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

The COVID-19 pandemic intensified debates about the role of private healthcare providers in publicly financed health systems, particularly in insurance-based Bismarck models. Governments across Europe temporarily expanded cooperation with private providers to address service disruptions and capacity shortages. However, it remains unclear whether such crisis-driven public–private adjustments represent temporary responses to exceptional circumstances or indicate longer-term structural transformation of health systems. This study examines how public–private dynamics evolved during and after the COVID-19 pandemic in a compulsory health insurance system and assesses whether these changes reflected temporary adaptation or structural change. This study adopts a theory-informed longitudinal descriptive case study design based on national administrative and documentary data. The analysis combines descriptive quantitative assessment of financing, contracting and regional patterns with documentary interpretation of institutional and policy arrangements governing public purchasing during and after the COVID-19 pandemic. Data from the Compulsory Health Insurance Fund and Territorial Health Insurance Funds were analysed to examine trends in financing, contracting arrangements, service composition, and regional distribution of private healthcare providers. Descriptive trend analysis and comparative regional analysis were used to assess changes in the share of publicly financed services delivered by private providers over time. Private healthcare providers played an expanded but bounded role during the pandemic, particularly in ambulatory and diagnostic services. Their share of publicly financed healthcare funding increased modestly during the crisis but remained limited overall and stabilised in the post-pandemic period. Contractual arrangements with private providers expanded during the acute phase of the pandemic but did not lead to sustained restructuring of purchasing relationships. Regional variation in private sector participation persisted throughout the study period, reflecting pre-existing provider structures rather than uniform national expansion. Pandemic-driven changes in public–private arrangements reflected selective and temporary adjustment rather than structural transformation of the compulsory health insurance system. The findings suggest that controlled mobilisation of private providers can enhance health system responsiveness during crises without undermining core institutional arrangements in insurance-based health systems.