In this journal, we regularly publish national editorials from the five Nordic colleges of general practitioners Citation[1–5], as an important way of learning from each other. Just as important, is, of course, to learn from other countries, and the aim of this editorial is to give an overview of family medicine in Estonia, Latvia, and Lithuania.
History in brief
Historically the three small Baltic countries have a great deal in common with their Nordic neighbours on the other side of the Baltic Sea Citation[6], Citation[7]: Finnish and Estonian belong to the same Finno-Ugrian family of languages, and Scandinavian Vikings often visited the Baltic shores. Danes founded Tallinn, the Danish fortress, and according to the legend the Danish flag, “Dannebrog”, fell from the sky during a battle in Estonia. In Sweden's days as a great power in the seventeenth century, Estonia and Latvia were important parts of the Swedish empire, with Riga as the largest town, and the university in Dorpat, present-day Tartu, was founded by the Swedish king, Gustavus Adolphus.
Germans and Poles have also had interests in the Baltic area, but otherwise it was Russia that was the dominant power for a long time Citation[6], Citation[7]. For a couple of decades, between the world wars, the three Baltic countries were independent, after which they became republics of the Soviet Union. During Mikhail Gorbachev's period as secretary general at the end of the 1980s, characterized by “glasnost” and “perestroika”, the three countries regained their freedom and were recognized as independent states in the autumn of 1991.
From polyclinic to health centre
In the Soviet healthcare system there were plenty of low-paid doctors, all of whom were state employees Citation[8]. Primary care was provided in large polyclinics where many different specialists, chiefly in internal medicine, paediatrics, and gynaecology, helped each other to meet the basic needs of the population. The importance of narrow specialization was stressed, and there was no family medicine or general practice in the Western sense.
Almost immediately after independence, the three Baltic countries began a radical reform of their healthcare Citation[9], dismantling the old polyclinic system and aiming at a system of Western European type based on primary care. In this process they received support from many countries, including the Nordic states.
In Sweden the East Europe Committee, founded in 1991, contributed funds for the work of change in countries like Estonia, Latvia, and Lithuania. GPs in Blekinge County contacted Lithuanian colleagues for the first time in 1990, and from 1992 this resulted in several development projects.
One important project has been Forum Balticum Citation[10], a biennial workshop on research methods, in which the Blekinge R&D Unit has collaborated with the Department of Clinical Sciences, Malmö, at Lund University. Since 1994 the workshop has been held three times in Karlskrona, Sweden, twice in Klaipeda, Lithuania, once in Tartu, Estonia, and once in St Petersburg, Russia. Apart from Sweden and the three Baltic countries, the participants have mainly come from Russia, while some supervisors have been brought from the UK.
Through these different activities we in Sweden have been able to follow the multifaceted work of reforming primary care in the three Baltic countries. We have previously described the development of research in primary care from a global perspective Citation[11], and here, together with our Baltic colleagues, we wish to give an idea of where clinical and academic family medicine stands today in Estonia, Latvia, and Lithuania, more than 15 years after independence. All the data in the tables were provided by RK, GT, and AJ, respectively, except for the number of primary care articles, which was found by searching Pub Med in a standardized way Citation[11].
Clinical and academic family medicine
The change from the older Soviet polyclinic-based healthcare system towards a Western system based on primary care involved major challenges. Earlier organ specialists had to be retrained as general practitioners, and education for specialists in family medicine had to be introduced. This required an academic foundation, and simultaneously the health insurance system and the legislation of healthcare had to be reformed.
Clinical family medicine today seems fairly similar in the three countries (), although, from the outside, Estonian primary care gives the best overall impression Citation[12]. Specialist education lasts three years in all the countries, but the proportion of family medicine varies. The density of doctors in primary care is highest in Lithuania (1/1200) and lowest in Latvia (1/1600), while the proportion of specialists in family medicine is highest in Estonia and lowest in Lithuania. The old polyclinics are still noticeable only in Lithuania, and it is only in Latvia that patients have to pay when they consult a doctor in primary care.
Table I. Clinical family medicine in the Baltic countries.
Academic family medicine seems to have developed well in Estonia and Lithuania, while Latvia has lagged behind (). Latvia has neither university departments nor professors of family medicine, and they are still waiting for their first PhD in family medicine. Undergraduate education of doctors takes six years in all the countries, but it is only in Estonia that the proportion of family medicine is noticeable.
Table II. Academic family medicine in the Baltic countries.
Impressive development in a short time
In a relatively short time, just over 15 years, the Baltic countries have reformed their healthcare radically. Clinical family medicine is now the basis of healthcare, and in Estonia and Lithuania academic family medicine is well on the way. It has been an honour for us in Sweden to take part in this development, which has simultaneously taught us a great deal. The eighth meeting of our joint Forum Balticum will be held in Riga, Latvia, in September this year.
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