retaining physicians in lithuania: integrating research and health policy
TRANSCRIPT
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Health Policy 110 (2013) 39– 48
Contents lists available at SciVerse ScienceDirect
Health Policy
j ourna l ho me pag e: ww w.elsev ier .com/ locate /hea l thpol
etaining physicians in Lithuania: Integrating research and healtholicy
iudvika Starkienea,∗, Jurate Macijauskieneb,1, Olga Riklikienec,2, Marius Strickaa,2,ilvinas Padaigaa,3
Department of Preventive Medicine, Faculty of Public Health, Lithuanian University of Health Sciences, Eiveniu str. 4, LT-50161 Kaunas, LithuaniaGeriatric Clinic, Faculty of Nursing, Lithuanian University of Health Sciences, Josvainiu str. 2, LT-47144 Kaunas, LithuaniaDepartment of Nursing and Care, Faculty of Nursing, Lithuanian University of Health Sciences, Eiveniu str. 2, LT-50161 Kaunas, Lithuania
r t i c l e i n f o
rticle history:eceived 29 May 2012eceived in revised form 14 January 2013ccepted 18 January 2013
eywords:ealth policyealth workforcetrategic planninghysiciansesearch studies
a b s t r a c t
Many of the strategic planning studies worldwide have made recommendations to thepolicy makers on the steps to be taken in eliminating the perceived shortages of physi-cian workforce or in improving their distribution and retention. Policy makers have alsoconsidered various policy interventions to ensure adequate numbers of physicians. Thisstudy reviewed the research evidence and health policy decisions taken from 2000 to 2010in Lithuania and evaluated the chronological links over time between scientific recom-mendations and policy decisions. From the analysis it would seem that Lithuania’s successin retaining physicians between 2000 and 2010 was influenced by the timely implemen-tation of particular research recommendations, such as increased salaries and increasedenrolment to physician training programmes. In addition were the health policy inter-ventions such as health sector reform, change in the legal status of medical residents andestablishment of professional re-entry programmes.
Based on this evidence it is recommended that policy makers in Lithuania as well as in
other countries should consider comprehensive and systematic health policy approachesthat combine and address various aspects of physician training, retention, geographicmal-distribution and emigration. Implementation of such an inclusive policy however isimpossible without the integration of research into strategic decision making in workforcetive he
planning and effec. Introduction
Training adequate numbers of physicians and retaininghem in the medical workforce are global concerns [1,2].
∗ Corresponding author. Tel.: +370 37 327328; fax: +370 37 37 220733.E-mail addresses: [email protected],
[email protected] (L. Starkiene),[email protected] (J. Macijauskiene),[email protected] (O. Riklikiene),[email protected] (M. Stricka),
[email protected] (Z. Padaiga).1 Tel.: +370 37 327234; fax: +370 37 37 220733.2 Tel.: +370 37 797328; fax: +370 37 37 220733.3 Tel.: +370 37 396065; fax: +370 37 37 220733.
168-8510/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.healthpol.2013.01.013
alth policy interventions.© 2013 Elsevier Ireland Ltd. All rights reserved.
This is essential to ensure effective functioning of a healthcare system and the quality of health care services in par-ticular.
Since 1992, the first year for which data is available onHealth For All database, Lithuania has had one of the highestnumbers of physicians per population in Europe at 358.3per 100,000 [3]. This ratio has remained remarkably stableduring the last two decades with slight increase reach-ing 372 per 100,000 per population in 2010 [4], althoughthe increase in relative number of physicians was mainlycaused by more than a 5% decrease of overall population
(from 3.5 to 3.3 million). Overall the number of physi-cians slightly decreased by 3.7% from 12,692 to 12,226 [4,5].Despite a seemingly sufficient number of physicians, geo-graphic inequality remains a problem: the urban ratio was
alth Poli
40 L. Starkiene et al. / He492 per 100,000 in 2000, and reached 606 in 2010. Duringthe same period, the ratio in rural areas slightly decreasedfrom 188 to 172, and the difference between urban andrural ratios was 2.6 times in 2000 and 3.5 in 2010 [4].
Many workforce planning studies worldwide, includ-ing those in Lithuania, have made recommendations topolicy makers on the steps required to eliminate theshortages of the medical workforce and for improvingtheir geographical distribution and retention. As a resultof these studies and other government initiatives, pol-icy makers in many countries have considered variousinterventions to ensure that there is an adequate num-ber of physicians depending on the economic nature ofthe shortage: needs-based, demand-based, or both. Onthe other hand, success of implemented interventions isdependent upon the health care and education systems,health-worker skill mix, development of health informa-tion technologies including telemedicine, and countrywidedemographic trends.
Policy implications regarding work-force planningwhich are derived from the academic community arecountry-specific. Researchers face methodological prob-lems not only in forecasting the numbers of physicians,which is a very complex phenomena, but also in collectingretrospective data due to limited access to databases, lackof compatibility between different databases, periodicityand completeness of data, although attempts at linkage areperformed [6,7]. The links between the recommendationsby the researchers and the decisions taken by the policymakers in most of the cases remain unknown.
In our study we reviewed, using a retrospective method-ology, the research evidence and health policy decisionstaken from 2000 to 2010 in Lithuania and evaluated thelinks over time between studies and policy decisions onretention of physicians. This paper presents the analysisand findings from the most significant studies and healthpolicy decisions which focused specifically on the physicianworkforce during the last decade in Lithuania.
2. Materials and methods
Given that both policy and research documents wereessential to inform the review, two types of data sourceswere searched: scientific journal publications as well as“grey” literature (such as scientific non-commercial/lessaccessible publications) and legislation literature suchas policy decisions, policy documents, and governmentalreports.
Search for studies published in 2000–2010 aboutLithuanian physician workforce were carried out usingPubMed (www.ncbi.nlm.nih.gov/pubmed) and Aleph(www.aleph.library.lt) databases. Searching PubMed onlyfree full-text articles were revealed and the followingcombinations of keywords were used “physicians ANDLithuania”, “physician resources AND Lithuania”, “humanresources AND Lithuania”, “health professionals ANDLithuania”, “planning AND Lithuania”.
The Aleph database includes all publications publishedby Lithuanian researchers who are working and research-ing internationally and globally. Databases of all Lithuanianuniversities were searched separately. The search engine
cy 110 (2013) 39– 48
is not equipped with the option of choosing only full-text articles, therefore all publications were searched. Thefollowing keywords were used: “physicians’ planning”,“physicians’ human resources”. Only studies which weredirectly relevant to these topics and could be accessedin full text online and paper based in the library wereincluded.
Two unpublished scientific reports, which were deliv-ered to the Lithuanian Ministry of Health (MoH) as a resultof research carried out in the framework of the Programmefor Strategic Planning of Health Workforce in Lithuania forthe 2003–2020 [8], were received upon request from theMoH in September 2012. Thirteen documents (11 articles[9–19] and 2 unpublished reports [20,21]) were included.The flow diagram of literature search strategy, which isbased on the work of Moher et al. is shown in Fig. 1 [22].
The search of legislation issued in 2000–2010 wascarried on in March 2012, using the database main-tained at the Lithuanian Parliament (www.lrs.lt). Keywords“human resources for health”, “physicians”, “health carespecialists”) were used. The search resulted in 93 records.Eighty-two documents were excluded as being irrelevantto planning of physician workforce. Twelve documentswere included into the content analysis [8,23–33]. Also, thestakeholder group at the MoH was contacted to find otherdecisions that were not included in the online legislationdatabase. As a result of this investigation four additionalunpublished documents (policy decisions) were identifiedand included [34–37].
The final result from all databases meant that there were29 documents that were included in the content analysis.
3. Results
It was concluded that there have been a number ofstudies, which analyzed various aspects of the physicianworkforce, have been conducted in Lithuania between2000 and 2010 [Table 1]. Different policy interventionswere taken at the same time [Table 2]. In this results sectionthe main recommendations from research and policy inter-ventions are summarized according to the main themes(these are highlighted in bold) that were found. Any sim-ilar outcomes which appeared at different periods of timewere also noted.
3.1. Summary of research and policy interventions
During the 1990s, the number of places for medicalstudies was reduced by almost 50% (about 200–250 medi-cal students annually [9]. According to this study, in orderto achieve an appropriate supply of physicians in the future,the annual average enrollment to undergraduate medicalstudies should be immediately increased to 400 studentsannually.
However it was not until 2002, in response to researchresults which recommended a need to increase the enrol-ment to medical studies, that the quota for state funded
university places for medical students was almost dou-bled by the MoES from 250 to around 400 [35]. Theaim of maintaining enrollment within this range was tomatch physician workforce supply with estimated future
L. Starkiene et al. / Health Policy 110 (2013) 39– 48 41
2 ad ditional records
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Fig. 1. The flow diagram
equirements [9]. The study, which forecasted a 14% lossn the physician workforce until 2010, also recommended
aintaining increased enrolment numbers [10]. Due toong training, the effect of increased enrolment was feltnly starting with 2008, when the number of graduatesncreased (322 students graduated in 2008, 395 in 2009nd 391 in 2010) [4].
Several studies emphasized the need to develop a com-rehensive plan in the long-term for physician workforceeeds. A study by Lovkyte et al. stated that the planas essential if adequate physician workforce was to be
vailable in the future. Input from all interested parties,ncluding government, universities, and physicians them-elves, was needed for a plan to be successful [11]. Anothertudy recommended that it was necessary to form consis-ent policies for undergraduate and postgraduate physicianraining [12]. It was also recommended that planning forhysician workforce and infrastructure indicators shoulde reconsidered in further plans and strategies [13]. Gov-rnment department of physician workforce planning, inne form or another, has been in place since 2000 inithuania and has survived frequent changes in the actualovernment itself. Fundamentals for development of austainable and consistent physician workforce planningolicy were laid down in 2000 when a group of stakehol-ers was formed.
In 2003, as a result of recommendations from research11,12], the MoH approved the Strategic Planning of
ealth Workforce in Lithuania for the 2003–2020 pro-ramme (amended in 2005) and appointed the Lithuanianniversity of Health Sciences (LUHS) as a supervisoryrganization for its implementation [8]. The physicianrature search strategy.
workforce planning system is not an institutionalized pro-gramme and there are no annual plans as such. Any datafrom this organization is however fed into policy consid-erations of the MoH, Ministry of Education and Science(MoES) and Ministry of Finance (MoF) on a project byproject basis only. At present, statistics on physician work-force are collected by several institutions and differentdatabases have to be linked in order to obtain comprehen-sive data.
Issue of mal-distribution of physicians by specialtieswas raised in 2004 and 2005. Based on the outflow projec-tions from the specialties, detailed recommendations weremade regarding how the overall number of entrants to res-idency programmes in medicine (residency being definedas a third cycle university studies in medicine, designed forthe physicians seeking to acquire or to change the special-ization of the professional qualification in medical practice)should be distributed between the specialties in order toprevent future shortages or surpluses [14,20]. Based onthese projections, the MoH issued recommendations touniversities in 2005 and 2006 [36,37]. These recommenda-tions stated how many medical residents should start eachof the residency programmes annually in order to preventshortages in the future. Geographical mal-distributionin the country was addressed by several studies whichhighlighted the need for consistent incentive policy toencourage physicians to move to rural areas [12,15–17,21].Despite that, a national incentive policy to address this
issue was never adopted in Lithuania. It is up to the munic-ipalities, which are the owners of regional hospitals andprimary health care centres, to create incentive packages toattract physicians. These packages include higher salaries,
42L.
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Health
Policy 110 (2013) 39– 48
Table 1Recommendations from research by category.
Category Study Methods/results Conclusion/recommendations
Increased enrolment Gaizauskiene et al. [9] Overview of changes in 1990–2000 and projections until 2015 Enrolment should be increased to 400 students annuallyLovkyte [10] Projections of supply and requirement for physicians until 2015 Increased enrolment should be maintained
Comprehensive plan in thelong-term for physician workforceneeds
Lovkyte et al. [11] Examination of changes in 1993–2000, review of previous studiesand reports
The plan is essential if adequate physician workforce was to beavailable in the future
Padaiga et al. [12] Retention study, emigration intentions study, projections Necessity to form consistent policies for undergraduate andpostgraduate physician training
Buivydiene et al. [13] Analysis of healthcare indicators comparing de facto data of majorand minor counties with planned indicators
Planning for physician workforce and infrastructure indicatorsshould be reconsidered in further plans and strategies
Mal-distribution by specialties Starkiene et al. [14] Projections of supply and requirement for family physicians (FPs)in 2006–2015
The annual enrollment in FPs residency training programmesshould be increased by at least 20% for the next 3 years.Year-by-year monitoring is crucial in order to prevent futureshortages
Kaunas University ofMedicine [20]
The outflow projections from the specialties Recommendations regarding how the overall number ofentrants to medical residency programmes should bedistributed between the specialties in order to prevent futureshortages or surpluses
Geographical mal-distribution Padaiga et al. [12] Examination of changes in 1993–2000, retention study, emigrationintentions study, projections
Uneven geographic distribution across the country
Reamy et al. [15] Overview of attempts to plan the future physician workforce, andtheir impact on the current and the future workforce
Consistent incentive policy should be created to encouragephysicians to move to rural areas
Reamy et al. [16] Review of literature and legislation The geographical distribution of physicians is uneven, with themajority working in urban areasPadaiga et al. [17] Overview
Kaunas University ofMedicine [21]
Requirement projections for physicians by specialties in Siauliaicounty
Uneven geographic distribution in districts of Siauliai county
Better retention programme forphysicians
Lovkyte [10] Projections of supply and requirement for physicians until 2015 Better retention programme would be a solution for stabilizingthe training requirements in order to achieve the desiredworkforce supply
Starkiene et al. [14] Projections of supply and requirement for FPs in 2006–2015 Retention rates would increase, if reformed and significantlyimproved financial and non-financial incentive system wasimplemented
Kaunas University ofMedicine [20]
The outflow projections from the specialties Retirement and retention rates should be monitored
Frequently updated and completedatabase
Lovkyte [10] Projections of supply and requirement for physicians until 2015 Development of frequently updated database of physicians isessential for the successful planning of future workforceLovkyte et al. [11] Examination of databases in 1990–2000, review of previous
studies and reportsPadaiga et al. [12] Examination of changes in 1993–2000, retention study, emigration
intentions study, projectionsNo one database or registry can provide all the informationrequired in a timely manner
Starkiene et al. [14] Projections of supply and requirement for family physicians (FPs)in 2006–2015
Comprehensive registry or means to link the existingdatabases are essential in order to obtain completeinformation on the physician workforceReamy et al. [15] Overview of attempts to plan the future physician workforce, and
their impact on the current and the future workforceReamy et al. [16] Review of literature and legislationStarkiene et al. [18] Overview of previous studies The need to establish the linkages between databases not only
within Lithuania, but also with the other countries (in order tomonitor migration)
L. Starkiene et al. / Health PoliTa
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Lith
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ia
cy 110 (2013) 39– 48 43
as well as, coverage of accommodation and transportationexpenses. In 2008 the MoH issued an order enablingagreements between medical residents and health careinstitutions on covering medical residency costs as well asfull or partial subsistence costs. After finishing their resi-dency, medical residents commit to work at the sponsoringhealth care institution for a certain period of time, usuallyup to 5 years [30].
Introduction of better retention programme for physi-cians was recommended by several studies as a solution forstabilizing the training requirements in order to achieve thedesired workforce supply. Researchers also recommendedthat special attention should be paid to the monitoring ofretirement and retention rates in the physician workforce[10,14,20]. A professional re-entry programme has beenin place since 2009. Inactive physicians, whose licenseswere suspended or cancelled, can return to their profes-sion, while undergoing a professional traineeship, whichvaries in length from 1 to 12 months, depending upon theperiod of inactivity and specialty requirements. Once in aprofessional career, up to 90% of re-entry traineeship costsare covered by MoH [29]. The policy decision to ensuresocial guarantees to medical residents (who at that timewere considered as students, but not employees) and moreindependence (to delegate more duties to them) was takenin 2010 [27]. It introduced salaries in addition to scholar-ships; monthly gross salary for junior medical resident wasset at D 350, and for senior medical resident – D 445. Start-ing with 2013, the salaries are to reach D 389 and D 495,correspondingly [28].
Unfavourable retirement conditions, e.g., pensions areseveral times lower than salaries, also contribute to betterretention. Physicians are reluctant to retire immediatelyafter reaching retirement age (62.5 for men and 60 forwomen in Lithuania) and continue to work, on average, for15 years afterwards [6]. Even though the average pensionincreased more than twice (from D 90 in 2000 to 216 in2010), the difference between the average salary and thepension was 4.8 times in 2010 [5].
While not an explicit retention policy, the medicalcommunity (mainly physician and nurse associations) hasbeen pressing the MoH to increase salaries. In 2005 theMoH Committee of Health Affairs at the Parliament andthe medical associations signed a memorandum on salaryincreases, that is, 20% annually for physicians and nurses in2005–2008 [34]. The average annual gross salary of physi-cians has increased more than twice since 2005 (from D 464in 2005 to D 1035 in 2010) and in 2009 it was as high asD 1217. However, in response to the financial crisis, thepayment for health care services to health care institu-tions by the State Sickness Fund was reduced; payment formost of in-patient and specialized services was 11% lowerin 2012 than in 2008, although payment of family doc-tors remained almost unchanged (3% decrease). As a result,salaries of physicians also decreased by 15%. For compar-ison, the national average salary of all sectors grew fromD 370 in 2005 to D 612 in 2010 [5].
The MoH has concentrated on the overall reforming ofthe health sector, stating that the reform will also enableretention and motivation of Lithuanian health profession-als to practise in Lithuania. A government-approved health
44L.
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Policy 110 (2013) 39– 48
Table 2Policy interventions arranged by research recommendation categories.
Category Type of policy intervention Policy intervention, year Main outcomes
Increased enrolment Increased enrolment tophysician trainingprogrammes
On number of state-funded medical study places in 2002–2003; 2002 [34] Enrollment increased to 400 students annually
Comprehensive plan in thelong-term for physicianworkforce needs
Strategic planning ofphysician workforce
On approval of the programme for Strategic Planning of Health Workforcein Lithuania for the 2003–2020; 2004 [8]
Programme laid the basis for the development ofphysician workforce planning
Mal-distribution by specialties Improved distribution ofphysicians in specialties
Recommendations to the universities on distribution of state-fundedmedical residency places by specialty in 2005–2006 and in 2006–2007;2005, 2006 [35,36]
Improved distribution of state-funded medicalresidency places by specialty in 2005–2006 and in2006–2007
Geographical mal-distribution Improved geographicdistribution
On approval of order on covering students and medical residents’ trainingcosts by institutions of Lithuanian national health system; 2009 [30]
Coverage of students and medical residents trainingcosts
Better retention programme forphysicians
Professional re-entryprogramme
On scope and requirements for physicians’ continuing professionaldevelopment; 2009 [29]
Coverage of 90% of re-entry traineeship costs by MoH
Health sector reform On the Approval of the Strategy on the Restructuring of Health CareInstitutions; 2003 [23]On the Approval of the Stage II Strategy on the Restructuring of HealthCare Institutions; 2006 [24]On the Approval of the Stage III Programme on the Restructuring of HealthCare Institutions and services; 2009 [25]
Improved retention and motivation of physicians topractise in Lithuania
Financial incentives Trilateral agreement on increasing salaries for health professionals; 2005[33]
Increased salaries for physicians
Change in the legal statusof medical residents
On creation of working group for addressing issues in physician trainingand initiating corresponding changes in legislation; 2007 [27]. Decision onChanges the Training of Physicians; 2010 [28]
Social guarantees and more independence to medicalresidents
Unfavourable retirementconditions
NA Pensions, which are several times lower than salaries,contribute to better retention
Frequently updated and completedatabase
Frequently updated andcomplete database
On Reorganization of the Register of Physicians’ Licenses into the Registerof Health Care and Pharmacy Specialists’ licenses and on Approval ofRegulations of the Register of Health Care and Pharmacy Specialists’Licenses; 2011 [33]
Comprehensive and timely data on physicianworkforce
Model for projecting therequirement
Model for determiningrequirement for healthworkforce
On Approval of Model for Planning Requirement for Health Workforce;2007 [26]
Model for determining requirement for physicianworkforce was adopted
Establishment of well-managedmigration policy
Emigration preventionmeasures
On the Approval of the Strategy on the Economic Migration Regulation andthe Plan for Implementing Measures 2007–2008; 2007 [31]
Long-term economic migration control measures
Return programme On the Approval of the Programme on Reverse Brain Drain; 2008 [32] Reverse “brain drain” programme for physiciansinvolved in research
Financial incentives Trilateral Agreement on Increasing Salaries for Health Professionals; 2005[33]
Increased salaries for physicians
Health sector reform On the Approval of the Strategy on the Restructuring of Health CareInstitutions; 2003 [23]On the Approval of the Stage II Strategy on the Restructuring of HealthCare Institutions; 2006 [24]On the Approval of the Stage III Programme on the Restructuring of HealthCare Institutions and services; 2009 [25]
Improved retention and motivation of physicians topractise in Lithuania
Regular update of requirement andsupply projections
The analysis projectcommissioned by the MoH
Analysis of health workforce number, requirement and pilot “dayphotograph” measurement of workload, 2011 [6]
Detailed and good quality data on various physicians’workforce characteristics
Necessity to continue research
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are reform was started in 2003 and implemented in threetages (2003–2005; 2006–2008; the third stage, startedn 2009, is still on-going). The whole reform was aimedt improving quality and access to health care services,ptimizing the amount and structure of health care ser-ices according to patient needs, changing the structuref services, and restructuring the network of health carenstitutions [23–25]. The on-going reform made use ofnancial support from EU structural funds (2004–2006nd 2007–2013) that enabled renovation of most hospi-als and supply of new medical equipment, plus supportingmprovement to primary health care facilities [38]. There
ere particular indicators set relating to physician work-orce. The number of family physicians was planned toncrease in the country and the geographic distributionf specialist physicians was set to improve. According tohe study, which analyzed the change in indicators in003–2005, the planned increase in the number of familyhysicians was achieved. The number of specialist physi-ians decreased in major counties while in minor countiest increased [13].
The need for a frequently updated and completeatabase has been repeated throughout such studies. Thiseed was indicated as a prerequisite in 2003 and 200410,11]. It was stated that no one database or registry ofhysicians in Lithuania can provide all the informationequired in a timely manner [12]. Comprehensive registryr means to link the existing databases are essential inrder to obtain complete information on the physicianorkforce [14–16]. The need to establish these linkages
etween databases not only within Lithuania, but alsoith the other countries (in order to effectively monitorigration) was also emphasized [18]. This recommenda-
ion should be implemented sometime in 2013, when theomprehensive registry on physicians will start function-ng [33].
The need to adopt a model of projecting theequirement for physician workforce by specialties wasighlighted in a study in 2006 [21]. As a consequence, theodel was adopted by the MoH in 2007 [26]. While being
very positive development, it is of advisory nature onlynd has some severe limitations for practical implemen-ation (e.g. set of variables is incomplete, in some casesata is not available or cannot be obtained). Recommenda-ions by a national expert group were presented on reviewnd amendment of this model in 2011 [6], but so far thisocument remained unchanged.
Establishment of well-managed migration policy wasointed out to be important for avoiding shortage of physi-ians in the near future [18,19]. Emigration has been seens a threat to physicians’ retention in the workforce sincehe very beginning of this century. The biggest fears wereeen before accession to the European Union (EU) in 2004,hen a survey indicated that more than a half (60.7%) ofedical residents and over a quarter (26.8%) of physicians
ntended to leave for the EU or other countries [19]. A gen-ral migration policy was adopted in 2007, which aimed to
evelop long-term economic migration control measures,uch as regulating the economic factors that contribute toigration (i.e., better working conditions, social guaran-ees, higher salaries) [31]. No specific national policy for
cy 110 (2013) 39– 48 45
physicians has been adopted as yet. A reverse “brain drain”programme was started in 2008; however it concerns onlythose physicians who are involved in research activities[32]. However, health sector reform and financial incen-tives, which were described above, have also contributedreducing emigration rates.
Two studies stated that physician workforce require-ment and supply projections should be updated regularly(at least every 3 years) in order to respond if new trendsin any of the workforce characteristics emerge or pro-jection assumptions change [9,10,14]. Almost all studiesemphasized the necessity to continue research on variousaspects of physician workforce [9–12,14–17,20]. Recom-mendations from research were taken into account whilemaking policy decisions; temporal links between researchstudies and health policy decisions are presented in Table 3.
Some of the research recommendations were imple-mented the same or the next year, e.g. recommendationson increased enrolment, comprehensive plan for physi-cian workforce, mal-distribution by specialties, andmodel for projecting requirement. Other recommenda-tions remained unacknowledged for a few years andwere implemented later on (on necessity to continueresearch, update of projections) or were implemented onlyto small extent (better retention programme,geographicalmal-distribution). Policy intervention to address recom-mendation on frequently updated and complete data basewas taken in 2005, amended in 2011; however so far it onlyexists on paper [33].
4. Discussion
The research studies, conducted in Lithuania, includedcomprehensive strategic plans, needs for policies forphysician workforce with the projections for the futureand specific problem, as enrolment into medical studies.Various policy documents covered a wide spectrum ofphysician workforce aspects starting from enrolment tophysician training programmes till re-entry programmesand financial incentives. However, analysis of health pol-icy documents revealed that existing strategic planning forhealth workforce lacks comprehensive implementation onregular basis.
The Lithuanian physician workforce has remained sta-ble between 2000 and 2010. This is the result of successfullyimplemented recommendations of research studies thathave been discussed in this paper r as well as other externalfactors and conditions.
The best example of similar findings over a period ofyears is the research of possible physician emigration fromLithuania that attracted the attention of policy-makers,health-care managers, and professional organizations andenabled necessary and timely responses [18,19]. Anotherexample is that in order to meet the growing needs of thehealth care sector Lithuania, similarly to Poland, Slovenia,the United Kingdom, and Slovakia, has increased and main-tained physician training capacities since 2002 and the
main actions were also reasoned by research investigations[38].Increased salaries were likely to have had a positiveinfluence on attrition to other better paid professions and
46 L. Starkiene et al. / Health Policy 110 (2013) 39– 48
Table 3Chronological links between research studies and health policy decisions.
Year Researchrecommendations bycategory
Year Policy intervention
2002 Increased enrolment[9]
2002 On number of state-funded medical study places in 2002–2003[34]
2003 Comprehensive plan inthe long-term forphysician workforceneeds [11–13]
2003 On approval of the programme for Strategic Planning of HealthWorkforce in Lithuania for the 2003–2020 [8]
2004, 2005 Mal-distribution byspecialties [14,20]
2005, 2006 Recommendations to the universities on distribution ofstate-funded medical residency places by specialty in 2005–2006and in 2006–2007 [35,36]
2003, 2005, 2006 Geographicalmal-distribution[12,15–17,21]
2009 On approval of order on covering students and medical residents’training costs by institutions of Lithuanian national health system[30]
2004, 2005 Better retentionprogramme forphysicians [10,14,20]
2009 On scope and requirements for physicians’ continuing professionaldevelopment [29]
2003, 2006, 2009 On the Approval of the Strategy on the Restructuring of HealthCare Institutions [23]On the Approval of the Stage II Strategy on the Restructuring ofHealth Care Institutions [24]On the Approval of the Stage III Programme on the Restructuring ofHealth Care Institutions and services [25]
2005 Trilateral agreement on increasing salaries for health professionals[33]
2010 On creation of working group for addressing issues in physiciantraining and initiating corresponding changes in legislation [27]Decision on Changes the Training of Physicians [28]
2003, 2004, 2005, 2008 Frequently updatedand complete database[10–12,14–16,18]
2005 On Reorganization of the Register of Physicians’ Licenses into theRegister of Health Care and Pharmacy Specialists’ licenses and onApproval of Regulations of the Register of Health Care andPharmacy Specialists’ Licenses [33]
2006 Model for projectingthe requirement [21]
2007 On Approval of Model for Planning Requirement for HealthWorkforce [26]
2004, 2008 Establishment ofwell-managedmigration policy[18,19]
2007 On the Approval of the Strategy on the Economic MigrationRegulation and the Plan for Implementing Measures 2007–2008[31]
2008 On the Approval of the Programme on Reverse Brain Drain [32]2005 Trilateral Agreement on Increasing Salaries for Health
Professionals [33]2003, 2006, 2009 On the Approval of the Strategy on the Restructuring of Health
Care Institutions [23]On the Approval of the Stage II Strategy on the Restructuring ofHealth Care Institutions [24]On the Approval of the Stage III Programme on the Restructuring ofHealth Care Institutions and services [25]
2003, 2004, 2005 Regular update ofrequirement andsupply projections
2010 Analysis of health workforce number, requirement andpilot “day photograph” measurement of workload [6]
[9,10,14]Necessity to continueresearch [9–12,15,20]
emigration rates as it is supported by the evidence thatattractive payments systems work as a motivational fac-tor and a retention strategy [38]. In Latvia, the most alliedcountry to Lithuania, stability in physician numbers hasbeen reported due to a significant increase in physicians’incomes (a near doubling compared to earlier years), amarked slowdown in resignations from the health sector,and a return to the medical field from other sectors [39].
Establishment of re-entry programmes into the medicalprofession was a very positive development, however, it istoo early to measure its impact, as it has only been initiatedsince 2009 [29].
However, national intervention programmesaddressing the issues of increasing retention in the medicalprofession, and improving geographical distribution stillremain challenges for Lithuania.
This retrospective review has some limitations. Firstly,in order to establish the links between the recommen-dations by the researchers and the decisions taken bythe policy makers only full text online research papers
were used for the analysis that caused the potential miss-ing of relevant literature. Therefore, the authors madeefforts to compensate for this shortage by adding the“grey” literature sources. Secondly, temporal links between
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ecommendations and actions does not necessarily implytable causality. Despite the understanding that workforcelanning is a constant and continuous process, research andolicy-making activities relating to physician workforce in000–2010 in Lithuania were lacking coordination and aystematic approach. As it is shown in this paper, tempo-al links between recommendations from research studiesnd appropriate health policy decisions as well as reg-latory interventions exist. Although, without follow-uptudies and monitoring system firm and definite conclu-ions remain tentative.
From this study the fact has to be acknowledged thatven when countries have relevant workforce planningechanisms and competent researchers to work on those
ssues, serious methodological problems arise from the lackf data that makes it difficult to highlight the trends affect-ng the physician workforce. To overcome these barriersn one of the analysis projects (completed in June 2011),
hich was commissioned by the MoH and funded by theU Structural Funds, the authors of this paper created aink between four databases, which collect data on physi-ian workforce [6,7]. This constitutes very detailed andood quality data on various physicians’ characteristicsi.e., active versus practicing, losses due to death, actualetirement age, actual emigration rate). However this was
cross-sectional evaluation only and the data will becomeut-dated in 3–5 years. Therefore a unified and comprehen-ive register of physicians and other health professionals,hich is scheduled to start functioning in Lithuania in 2013,
s expected to be an effective managerial tool for achievingealth workforce planning objectives.
Even though this study also focused on single countryase, it is also of significance to the wider internationalommunity. It is encouraging that many of the activitiesisted in this paper correspond to the developments andhanges in physician workforce planning in other Europeanountries and relatively “new” member states in particu-ar. The Lithuanian experience is an example of a country
ith a growing interest and experience in health workforcelanning and the application of different sophisticatedorecasting methodologies during the last decade. Similarractice is observed in Belgium, Estonia, Finland, Latvia,pain, and the United Kingdom. Lithuania is active in devel-ping a variety of activities, and like Austria, our countryas no nation-wide planning and recruitment programme,ut use procedures at the sector level. It also replicateshe German practice of dispersing planning across differ-nt institutions (e.g. universities, MoH) and organizationalevels [38]. The Finish experience with extended workforcelanning beyond the health system and which introduced aomprehensive system including other sectors, remains anmbition for Lithuanian health policy-makers, researchersnd professionals [38].
. Conclusions
The lessons learned during the decade of integrating
esearch and policy actions for retaining physicians inithuania are several. First, research results gave quiteew specific recommendations, e.g. to increase intakento universities up to 400 students annually. We notecy 110 (2013) 39– 48 47
that all specific research recommendations were takeninto account as they were relatively easy to imple-ment (increased enrolment, migration surveys, salaryincrease). Non-specific recommendations (e.g. incentivespolicy encouraging physicians to move to rural areas orwell managed migration policy) will take time to be con-verted into fast policy action because additional effortis needed to create functioning financial and monitoringsystems. Therefore, researchers in the future should takeresponsibility to formulate at least draft policy papers withseveral implementation scenarios.
Second, all research studies on health workforce carriedout in Lithuania except the latest one (2011, commissionedby the MoH) [6,7] were initiatives of researchers them-selves. This approach took considerable time and effort tokeep convincing frequently changing governments to con-vert research results into policy action. The latest studygave a very positive experience – obtaining of the neces-sary data was fast, researchers had several opportunitiesto discuss results with the officials and by administrativeorder results of the study have to be used for policy update.Based on this experience we recommend that MoH shouldhave long-term strategic operational research areas whichhave to provide regular data for policy making.
Third, the major obstacle in doing research still remainslack of adequate and timely provided data which wouldcover all areas of workforce development and function-ing and would enable policy makers and others to makefast analyses and recommendations. Without the linkedNational database, research studies will remain cross-sectional giving just a glimpse into complicated system ofLithuanian health workforce situation.
Acknowledgements
Authors wish to thank Associate Professor, Patricia A.Cholewka, EdD, MPA, MA, RN, NE-BC, Department of Nurs-ing, New York City College of Technology, CUNY, U.S.A. andKaren Holland, MSc, BSC(Hon) RN, RNT, Research Fellow,School of Nursing, Midwifery & Social Work, University ofSalford, UK for editing support.
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