GOVERNMENT OF THE REPUBLIC OF LITHUANIA

GOVERNMENT OF THE REPUBLIC OF LITHUANIA Official translation 11 November 2008 Government of the Republic of Lithuania Resolution No 647 of 29 June 2006 Vilnius Amendments to the item: Resolution No 1229 of the Government of the Republic of Lithuania of 13 November 2007 (in force since 28 November 2007) Valstybės žinios (Official Gazette) No 122-5008, 2007). Amendments:

1. Resolution No 772 of 4 August 2006 of the Government of the Republic of Lithuania (in force since 13 August 2006) (Valstybės žinios (Official Gazette) No 88-3458, 2006).
2. Repealed by Resolution No 1229 of 13 November 2007 of the Government of the Republic of Lithuania (in force since 28 November 2007) (Valstybės žinios (Official Gazette) No 122-5008, 2007). ON THE APPROVAL OF THE STAGE II STRATEGY ON The restructuring OF healthcare institutions Acting pursuant to item 525 of the measures implementing the Programme of the Government of the Republic of Lithuania for 2004-2008, approved by Resolution No 315 of the Government of the Republic of Lithuania of 24 March 2005 (Valstybės žinios (Official Gazette) No 40-1290, 2005), and paragraph 3 of the Resolution No 335 of the Government of the Republic of Lithuania of 18 March 2003 (Valstybės žinios (Official Gazette) No 28-1147, 2003) of the Government of the Republic of Lithuania on the Approval of the Strategy on the Restructuring of Healthcare Institutions, the Government of the Republic of Lithuania has resolved:
3. To approve the Stage II Strategy on the Restructuring of Healthcare Institutions (as appended).
4. To instruct county governors: 2.
5. by 1 December 2006, to draft stage II county healthcare institution restructuring plans (2007-2008) and submit them for approval by the Ministry of Health following agreement with regional development councils; 2.
6. to report annually on 1 February, to the Ministry of Health on implementation progress of stage II of county healthcare institution restructuring plans, ensuring reliability and objectivity of the information.
7. The Ministry of Health shall: 3.
8. analyse and approve the submitted drafts of stage II county healthcare institution restructuring plans by 30 December 2006; 3.
9. oversee the implementation of stage II county healthcare institution restructuring plans; 3.
10. recommend that investment projects designed for restructuring of county healthcare institutions are included, on priority basis, into the annually drafted Law on Approval of Financial Indicators of the State Budget and Municipal Budgets, and the Public Investment Programme; 3.4.
11. To earmark funding from the Compulsory Health Insurance Fund in 2006 for healthcare institution restructuring programmes which were approved by the founder and endorsed by the Ministry of Health and the Compulsory Health Insurance Council. Acting Prime Minister Zigmantas Balčytis Acting Minister of Health Žilvinas Padaiga APPROVED by Resolution No 647 of the Government of the Republic of Lithuania of 29 June 2006 STAGE II STRATEGY ON THE restructuring OF healthcare institutionS I. General provisions
12. The Stage II Strategy on the Restructuring of Healthcare Institutions has been developed with a view to rationalizing the network of healthcare institutions and improving service structure to meet healthcare needs of the population.
13. The stage II of the restructuring of healthcare institutions (hereinafter referred to as “stage II restructuring”) shall be carried out in 2006-2008, and it shall ensure continuity and integrity of the implementation of the following major strategic documents regulating the development of healthcare system: 2.
14. The National Health Concept of the Republic of Lithuania, adopted by Resolution No I-1939 of the Supreme Council of the Republic of Lithuania of 30 October 1991 (Valstybės žinios (Official Gazette) No 33-893, 1991); 2.
15. The Health Programme of the Republic of Lithuania, adopted by Resolution No VIII-833 of the Seimas of the Republic of Lithuania of 2 July 1998 (Valstybės žinios (Official Gazette) No 64-1842, 1998); 2.
16. The Long-Term Development Strategy of the State, adopted by Resolution No IX-1187 of the Seimas of the Republic of Lithuania of 12 November 2002 (Valstybės žinios (Official Gazette) No 113-5029, 2002); 2.
17. The Strategy on the Restructuring of Healthcare Institutions, approved by Resolution No 335 of the Government of the Republic of Lithuania of 18 March (Valstybės žinios (Official Gazette) No 62-2244, 2001). II. OUTCOMES OF THE STAGE I STRATEGY (2003 – 2005) ON THE RESTRUCTURING OF healthcare institutionS
18. Stage I of the Strategy on the Restructuring of Healthcare Institutions covers 2003-
20. The aims, objectives, priorities, criteria and achievable outcomes of stage I have been laid down in the Strategy on the Restructuring of Healthcare Institutions. Concrete actions, measures, timeframe and responsible executing authorities as regards the implementation of the provisions of the strategy have been set forth in county healthcare institution restructuring plans of Vilnius and Kaunas counties approved by Order No V-804 of the Minister of Health of 31 December 2003 (Valstybės žinios (Official Gazette) No 30-999, 2004). According to paragraph 3 of the Strategy on the Restructuring of Healthcare Institutions, stage II criteria and achievable outcomes will be directly related to the stage I restructuring performance.
21. The outcomes of stage I restructuring of healthcare institutions demonstrate the following changes in health system across the country: 5.
22. a number of visits to primary healthcare physicians per inhabitant has increased from 3.7 to 3.9; 5.
23. hospitalisation rate per 100 inhabitants has reduced from 23.2 to 20.
24. More than 23 out of 100 inhabitants were treated annually in hospitals before the restructuring. Stage I restructuring has brought the figure down by 3; 5.
25. A patient stays in hospital on average two days fewer, as an average stay in hospital has reduced from 10 to 8 days; 5.
26. bed occupancy has increased from 284 to 308; 5.
27. bed turnover has improved from 28 to 35 patients.
28. Health service delivery structure has become more efficient: 6.
29. a number of beds in general and specialized hospitals have come down by one fifth, which accounts for 5000 beds; 6.
30. inpatient service volume has reduced by 8 %; 6.
31. outpatient services have gone up by 6 %; 6.
32. nursing service volume has increased by 15 %; 6.
33. 600 day care places have been established;
34. The reorganization of the healthcare network has reduced a number of hospitals in Lithuania by 22: 7.
35. Šv. Jokūbo Hospital in Vilnius has been reorganized by way of dividing its services between Vilnius University Hospital and Vilnius University Emergency Hospital; 7.
36. Vilnius Centre Hospital has joined with Vilnius University Hospital Santariškių Klinikos; 7.
37. The National Hospital of Tuberculosis and Lung Diseases, the National Santariškės Hospital of Tuberculosis and Lung Diseases, Vilnius Hospital of Tuberculosis, Vilnius County Vyžulionys Hospital of Tuberculosis and Vilnius University Hospital of Infectious Diseases have merged into a new legal entity National Tuberculosis and Infectious Diseases University Hospital; 7.
38. The Child Development Centre of the National University Hospital has joined with Vilnius University Children Hospital; 7.
39. Kaunas Clinical Infectious Hospital has joined with Kaunas 2nd Clinical Hospital; 7.
40. P. Mažylis Maternity Hospital in Kaunas has joined with Kaunas 2nd Clinical Hospital; 7.
41. Viršužiglis Rehabilitation Hospital and Kaunas Romainiai Tuberculosis Hospital have been affiliated to the Clinics of Kaunas University of Medicine; Kulautuva Tuberculosis Hospital has become a structural unit of the Affiliate of Romainiai Tuberculosis Hospital; 7.
42. Garliava Hospital has joined with Kaunas County Hospital; 7.
43. The Oncological Hospital of Kaunas University of Medicine has been affiliated to Clinics of Kaunas University of Medicine; 7.
44. Kaunas Psychiatry Hospital has joined with Kaunas County Hospital; 7.
45. Skuodas Hospital has been affiliated to Klaipėda County Hospital; 7.
46. Palanga Hospital has been affiliated to Klaipėda Seamen’s Hospital; 7.13 Klaipėda Children Tuberculosis Hospital “Smiltelė” has been incorporated into Klaipėda Tuberculosis Hospital as a structural unit. 7.
47. Šilutė Children Tuberculosis Hospital “Eglutė” has been affiliated to Klaipėda Tuberculosis Hospital; 7.
48. Priekulė Nursing Hospital has been reorganized by way of distributing its services between Klaipėda and Gargždai Hospitals; 7.
49. Pagryžuvis Tuberculosis Hospital has been incorporated into Šiauliai Hospital of Tuberculosis and Lung Diseases; 7.
50. Panevėžys Tuberculosis Hospital has been incorporated into Panevėžys Hospital of Infectious Diseases.
51. Certain hospitals where service volume failed to ensure the needed security to the patient have closed or merged the units of neurology, tuberculosis, cardiology, infectious diseases and others.
52. Regional hospitals failing to achieve an annual minimum of 300 births set forth in the Strategy on the Restructuring of Healthcare Institutions have had to transfer delivery services to obstetric units in other regions, thus ensuring higher level of services and patient security. Obstetric units have been closed in the following hospitals: 9.
53. Druskininkai; 9.
54. Ignalina region; 9.
55. Kupiškis; 9.
56. Molėtai; 9.
57. Naujoji Akmenė; 9.
58. Pakruojis; 9.
59. Plungė; 9.
60. Prienai; 9.
61. Skuodas; 9.
62. Šilalė; 9.
63. Varėna; 9.
64. Zarasai.
65. Problems related to the restructuring of healthcare institutions in large cities of Lithuania are additionally dealt with at the sittings of the Government Committee for Strategic Planning, with a view to patient concentration in larger facilities and reduction of redundant premises owned by hospitals. A wide representation of different stakeholders and analysis of positive/negative impact of proposed alternatives lead to most rational decisions: 10.
66. On 13 April 2005, the sitting of the Government Committee for Strategic Planning examined continued restructuring of Vilnius healthcare institutions and took a decision providing for three hospital clusters with different subordination: the Ministry of Health, the Governor of Vilnius County, and Vilnius City Council. The implementation of this decision and hospital clustering is expected to vacate 92 thousand square meters of premises currently in use by the hospitals. 10.
67. Analogous decision was taken at the sitting of the Government Committee for Strategic Planning, on 9 November 2005, with regard to continued restructuring of Kaunas healthcare institutions. 10.
68. A task force was set up by Resolution No 189 of 15 July 2005 of the Prime Minister of the Republic of Lithuania to make an enquiry into restructuring expediency of the Oncological Hospital of Kaunas University of Medicine and the Clinics of Kaunas University of Medicine. A meeting with the Prime Minister held on 16 March 2006 resulted in the decision to make a call for independent experts to measure the changes in accessibility and quality of medical services for oncological patients following the merger of the Oncological Hospital of Kaunas University of Medicine and the Clinics of Kaunas University of Medicine. 10.
69. A plan for continued restructuring of Klaipėda healthcare institutions is being worked out to be subsequently submitted to the Government Committee for Strategic Planning.
70. The outcomes of stage I restructuring of healthcare institutions show the improvement of major indicators of healthcare performance. However, three years period is not sufficient to identify major changes in health indicators in Lithuania. Furthermore, irrespective of improving inpatient care performance, inpatient mortality remains on the rise, i.e. from 1.97 % to 2.28 %. Growing outpatient services and aging population with characteristic multiple pathology determine relatively higher number of more complicated inpatient cases, which naturally raises a hospital mortality indicator. The analysis of changes in inpatient and general mortality rate by age groups shows that inpatient mortality in age group 15-44 and over 65 has changed more (8.3% and 15.1% respectively) compared to general mortality (3% and 6.5% respectively). This proves to the fact that reducing inpatient services and their accessibility do not pose problems either to the young or to the elderly patients.
71. Stage I restructuring of healthcare institutions has saved LTL 154m to be invested in the improvement of healthcare access and quality as well as working conditions for medical personnel: 12.
72. Two days shorter stay in hospital of one patient has saved LTL 40m; 12.
73. A partial substitution of inpatient care by outpatient care has saved LTL 61m; 12.
74. A substitution of intensive treatment by treatment in nursing hospitals has saved LTL 14m; 12.
75. A substitution of inpatient treatment by day care has saved LTL 39m;
76. The positive outcomes of stage I restructuring of healthcare institutions have been determined by the following factors: 13.
77. a systematic, consistent and widely discussed legal framework, problem deliberation at the sittings of the Committee for Strategic Planning of the Government of the Republic of Lithuania and the Committee on Health Affairs of the Seimas of the Republic of Lithuania, with the participation of the representatives from counties, municipalities, healthcare institutions, associations and other stakeholders; 13.
78. ensured restructuring continuity irrespective of political changes in the government; 13.
79. coordination and monitoring of all restructuring measures; preparation of methodical documents to guide each step of the restructuring; 13.
80. committed and vigorous participation in the restructuring process of all the levels involved: the Ministry of Health, county and municipal; 13.
81. continuous reporting of counties and municipalities on the progress of restructuring to the Ministry of Health;
82. LTL 55m have been used for stage I restructuring.
83. The amount has broken down as follows: 15.
84. severance pay LTL 14.4m; 15.
85. adjustment of premises to provide other type of healthcare services LTL 31m; 15.
86. outpatient care development LTL 9.6m. III. aims, objectives and MEASURES OF STAGE II RESTRUCTURING
87. The major aims of stage II restructuring shall be as follows: 16.
88. continuous improvement of healthcare quality and accessibility; 16.
89. building adequate structure of healthcare services; 16.
90. continuous restructuring of healthcare institution network; 16.
91. a more rational use of human and financial resources;
92. The major objectives of stage II restructuring shall be as follows: 17.1 with a view to developing primary healthcare and bringing it closer to the population, by 2008, achieve at least 60% primary healthcare delivery by private family physicians, who have an agreement with territorial patient funds regarding payment for healthcare services from the Compulsory Health Insurance Fund. This process shall be encouraged by the following measures: 17.1.
93. simplification of outpatient registration at healthcare institutions; 17.1.
94. differentiation of payment for services based on the population density (city, countryside) and age criteria; 17.1.
95. development of financial incentive system for preventive work and quality performance; 17.1.
96. bringing in a clause in the Law on State and Municipal Property Management and Use (Valstybės žinios (Official Gazette) No 54-1492, 1998; No 60-2412, 2002), which provides that private healthcare institutions, having concluded an agreement with territorial patient funds and as a result having service coverage from the Compulsory Health Insurance Fund, shall be entitled to use state or municipal-owned premises under the right of lending; 17.
97. treatment of most common diseases in healthcare institutions which are closest to the patient; concentration of latest technologies at university hospitals and hospitals with highest patient admission; structural improvement of inpatient care through the following measures: 17.2.
98. roll-out of county model of differentiated payment for services based on the established criteria (demand for service, population health indicators, number and age of the population, incoming and outgoing patient flows, healthcare institution performance, available financial, material and human resources, etc), county (regional) specificity; the opinion of municipalities and county administrations, proposals from the academic community, experts and public organisations: 17.2.1.
99. strengthening the infrastructure of consultation clinics and emergency units (ER), developing outpatient rehabilitation, day care and day surgery in the outpatient segment of each of the mentioned models; 17.2.1.
100. with a view to the rationalization of inpatient care, municipal hospitals shall strengthen the infrastructure for the treatment of most common and non-complicated diseases, leaving diagnosis and treatment of complicated diseases for university hospitals or large city hospitals which should be better equipped with up-to-date modern technologies; 17.2.
101. bringing to completion all the measures foreseen in county health care restructuring plans , which, due to subjective or objective reasons, failed to be implemented in stage I restructuring. These measures shall be provided for in stage II county healthcare institution restructuring plans; 17.
102. with a view to developing nursing and long term support treatment, it has been projected by 2008 to achieve at least 80% service delivery in general hospitals and at least 50% coupled with social (patronage) service delivery. This process shall be encouraged through the following measures: 17.3.
103. development and roll-out of a differentiated service system of nursing and long-term support treatment; 17.3.
104. development of nursing care services provided at patient’s home; 17.3.
105. increasing outpatient service volume; development of its forms; 17.3.
106. creating day nursing services; 17.
107. achieving better quality and higher response of emergency services through the reorganisation of emergency system. The following measures shall facilitate the process: 17.4.
108. reorganisation of 55 currently operating municipal emergency dispatch services; coordination of their activities with the Emergency Response Centre under the Ministry of Interior; 17.4.
109. emergency fleet renovation aiming at regular vehicle replacement after seven years in operation; 17.4.
110. equipping emergency dispatch and vehicles with up-to-date communication devices; 17.
111. improvement of rehabilitation services by setting up an outpatient rehabilitation unit at each municipal healthcare institution; and rationalizing inpatient rehabilitation; 17.
112. a more efficient use of healthcare resources and better management of health institution property through the following measures: 17.6.
113. transferring state and municipal owned property as shareholder contribution to public health institutions, thus increasing the capital of a public institution, if the state or (and) a municipality have their participatory presence, except expensive medical equipment, whose criteria shall be established by the Ministry of Health; 17.6.
114. factoring depreciation of immovable and movable property (except expensive medical equipment) in the basic price for healthcare services, i.e. raising the price by depreciation share; 17.6.
115. using state capital investment exclusively for the purchase of expensive medical equipment and construction of critical infrastructure; 17.6.
116. taking the decision of a wider implementation of successful pilot concession projects of property management; 17.6.
117. using proceeds from the sale of redundant premises of healthcare institutions for building and renovation of new healthcare facilities or new equipment; 17.
118. better service quality and adequate payment for services with better pricing system of healthcare institutions achievable through the following measures: 17.7.
119. gradual increase in basic price for healthcare services; 17.7.
120. encouraging competition through a possibility of medical service provision below the basic price fixed by the state 17.7.
121. provision of principles and procedures for the liberalization of prices for paid services in draft amendments to the laws regulating the delivery of paid services; 17.
122. promoting supplementary (voluntary) health insurance through a complex of relevant legal measures and financial levers: 17.8.
123. establishing a package of healthcare services to be covered by the voluntary health insurance or paid from compulsory health insurance funds. 17.8.
124. encouraging inhabitants, employers and insurance companies to develop the supplementary (voluntary) health insurance and improve its forms; 17.
125. upgrading facilities for science and training, projecting increased allocations, in as much as possible, for health research, focus on its wider application, professional training and development. IV. ASSESSMENT criteria OF STAGE II restructuring
126. Major assessment criteria for the aims and objectives of stage II restructuring shall be as follows: 18.
127. average life expectancy becoming at least a month longer on annual basis; 18.
128. outpatient service volume growth by at least 5%; 18.
129. nursing and long-term support service growth by at least 3-5%; 18.
130. day care and day surgery service growth by at least 10%; 18.
131. reduction of inpatient services in general and specialized hospitals by at least 3-5%; 18.
132. emergency fleet renovation by at least 10%. V. FINAL PROVISIONS
133. County governors shall engage municipalities, healthcare institutions and territorial patient funds in the preparation of stage II county healthcare institution restructuring plans (2007-2008). The preparation of stage II county healthcare institution restructuring plans shall be organized and methodically guided by the Ministry of Health and the State Patient Fund under the Ministry of Health. Amendments to the item: Resolution No 772 of the Government of the Republic of Lithuania of 4 August 2006 (in force since 13 August 2006) (Valstybės žinios (Official Gazette) No 88-3458, 2006).
134. Endorsed stage II county healthcare institution restructuring plans shall be launched for implementation following the signature of bilateral agreements between a healthcare institution and a territorial patient fund.
135. The Ministry of Health shall: 21.
136. during the first half of 2009, measure the outcomes of stage I restructuring, and subsequently submit them to the Government of the Republic of Lithuania during the third quarter of 2009; 21.
137. during the second half of 2009, work out Priority Areas for Healthcare Development 2009-2015;
138. The implementation of aims and objectives of stage II restructuring shall be funded from the EU financial support, the Compulsory Health Insurance Fund, the State Budget of the Republic of Lithuania, municipal budgets and other financial resources.
139. Healthcare savings resulting from healthcare restructuring shall be used for the healthcare purposes.
140. With a view to the implementation of the provisions of stage II restructuring, the Ministry of Health shall develop and submit to the Government of the Republic of Lithuania draft amendments to relevant legal acts and adopt necessary regulations.