Lithuania’s private health providers expanded during COVID-19, then the system snapped back

In insurance-based Bismarck systems, where a compulsory social insurance fund purchases care from a mix of public and private suppliers, the crisis forced an unusually close embrace of the private sector.

The study, published in BMC Health Services Research, examines how public–private dynamics evolved during and after the pandemic in Lithuania’s compulsory health insurance system. Its central question is deceptively simple: were the crisis-driven adjustments to public–private cooperation a temporary response to exceptional circumstances, or the opening act of a longer-term structural transformation? The answer, according to the analysis, is firmly the former.

To reach that conclusion, the researchers adopted a theory-informed longitudinal descriptive case study design built on national administrative and documentary data. They drew on records from the Compulsory Health Insurance Fund and the Territorial Health Insurance Funds, tracking trends in financing, contracting arrangements, the composition of services and the regional distribution of private providers. Descriptive trend analysis and comparative regional analysis were then used to assess how the share of publicly financed services delivered by private providers changed over time.

The quantitative picture that emerges is one of expansion with firm limits. Their share of publicly financed healthcare funding increased modestly during the crisis.

Contracting tells a similar story of bounded change. Arrangements with private providers multiplied during the acute phase of the pandemic, as purchasing authorities mobilised additional capacity to cope with service disruptions and shortages. Yet these expanded contractual relationships did not translate into a sustained restructuring of purchasing.

Perhaps the most striking finding concerns geography. Regional variation in private sector participation persisted throughout the entire study period, and the study attributes this variation to pre-existing provider structures rather than to any uniform national expansion. In other words, the pandemic did not redraw the map of private healthcare in Lithuania; it temporarily amplified patterns that were already there.

The study’s conclusions are measured. Pandemic-driven changes in public–private arrangements, it finds, reflected selective and temporary adjustment rather than structural transformation of the compulsory health insurance system. At the same time, the authors draw a constructive lesson: controlled mobilisation of private providers can enhance health system responsiveness during crises without undermining the core institutional arrangements of insurance-based health systems.

As a longitudinal descriptive case study of a single country, the analysis cannot establish how generalisable these dynamics are to other Bismarck systems, and its descriptive design identifies patterns rather than causal effects.

Subject of Research: How public–private healthcare arrangements in Lithuania's Bismarck-style insurance system changed during and after COVID-19

Article Title: Public–private dynamics in a Bismarck health insurance system after COVID-19: a longitudinal case study from Lithuania

Article References: Kauzonė, H. M. (2026). Public–private dynamics in a Bismarck health insurance system after COVID-19: a longitudinal case study from Lithuania. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15915-y

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15915-y

Keywords: Lithuania, COVID-19, public–private mix, Bismarck model, compulsory health insurance, health system resilience, purchasing, ambulatory care, diagnostic services, regional variation, health policy, case study