Working for more and better primary care in the Baltic Sea Region

Twenty years have passed since the first contacts were made between Scandinavian GPs and colleagues in Estonia, Latvia, Lithuania, Poland, and Russia. Today these Baltic and Nordic colleagues are project partners in ongoing EU projects or have built up a close collaboration between their universities. One of the earliest initiatives was Forum Balticum, a research-methodological workshop, aimed to stimulate the development of primary care research [1]. In the Baltic countries, academic and clinical family medicine has advanced strongly since then [2].

However, there are huge and even growing health differences between the countries in the Baltic Sea region. While the gap in life expectancy between the countries has slowly been revised for a few countries, some striking differences are persistent. The average Swedish man will live 20 years longer than a Russian will. Russia also has the widest gap in life expectancy between men and women, [3], which, at 12.8 years, is the highest figure globally. Further, even though Russian women live much longer than Russian men, their health status is poorer for several more years than in the Nordic countries. Also for the Baltic countries, where general public health data look better than a few years ago, the difference between men and women does not seem to be converging. In Estonia and Lithuania, women live 11 years longer than men [3]. A similar picture of large and persistent, or very slowly closing differences in maternal, infant, and child mortality data, can be shown.

What can be done to target these significant health disparities? Simply adding more resources would probably not do the trick. The authors have participated in many projects for developing primary health care (PHC) in the Baltic Sea region, of which ImPrim is one: ‘Improvement of public health by promotion of equitably distributed high quality primary health care systems’. ImPrim is an EU flagship project in the Baltic Sea region where 12 partners from seven countries develop strategies, and pilot new tools and education programmes. The participating countries are Belarus, Estonia, Finland, Latvia, Lithuania, Sweden, and the Kaliningrad region of Russia. Three pillars form the work of ImPrim: (1) improving PHC funding and reimbursement; (2) enhancing PHC professional development; (3) PHC as a pillar of regional development. The first ImPrim report concludes that 20 years of reform have improved PHC systems in terms of efficiency and patient responsiveness. Also, the differences in financial resources between the countries do not explain differences in quantities of services, and not necessarily quality either. Countries with limited resources produce as many services as the more affluent countries (Figure 1), and accessibility is as good. Therefore, the potential for PHC and general health systems improvement is good, even with limited resources.

Figure 1. Outpatient contacts and inpatient admissions in the Baltic Sea region countries. Out-patients contacts per person and year and in-patient care admissions per 100 000 people.

One crucial development for PHC may be to strengthen the role and impact of nurses. Reimbursement systems and legal restrictions on nurses’ professional role impede the rational use of qualified staff. Networking across the Baltic on a collegial basis stimulates mutual learning and should include PHC nurses [4]. In ImPrim, nurses are trained in state-of-the-art family medicine models of comprehensive work. Nurses in all countries can have more individual responsibilities. A clinical audit is a bottom-up method of quality development [5]. Within ImPrim, Lithuanian nurses have registered over 7000 consultations in a clinical audit to acquire baseline data on workload and working conditions.

Another issue is irrational use of antibiotics. In Lithuania, a project to combat antibiotic resistance resembling the Swedish STRAMA has been developed in collaboration between Klaipeda and Lund universities.

Smoking and alcoholism cause great gender mortality differences in Russia and the Baltic countries [6]. Smoking is responsible for 40–60% of male mortality in Russia and the Baltic countries. A focus on how to reduce smoking would also affect the gender mortality gap.

Most of our challenges need to be tackled both at the grass-roots level with changes in PHC, and on a policy level including public health policies. Therefore, ImPrim has two action levels in many of its components. The first is to tackle health care problems such as lifestyle with simple advice and motivational interviewing. The second concerns advocacy for public health awareness and national policies supporting clinical procedures.

Conclusions

We have seen great gains in health system efficiency and health outcomes through 20 years of reform in all countries in the Baltic Sea region, many of these led by strong PHC development. However, we do need continued innovation and progress. This includes research, education, quality development, financial incentives, and implementation of new technology. Hence, we have a lot to learn from each other via established and future Baltic Sea region networks. PHC needs to continue to develop its scope and content, and health promotion is essential to reduce the gender gap in life expectancy.

Declaration of interest

The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

The ImPrim is a transnational project financed from the Baltic Sea Region Programme 2007–2013.