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 335 of 18 March 2003 Vilnius (Amendments: Resolution No 1495 of the Government of the Republic of Lithuania of 2 December 2003 on Amending Resolution No 335 of the Government of the Republic of Lithuania of 18 March 2003 on the Approval of the Strategy on the Restructuring of Health Care Institutions” (in force since 6 December 2003) (Valstybės žinios (Official Gazette) No 114-5132, 2003). ON THE APPROVAL OF THE STRATEGY ON The restructuring OF health care institutions For the purpose of implementing the provisions of the Programme of the Government of the Republic of Lithuania for 2001-2004 approved by Resolution No IX-455 of the Seimas of the Republic of Lithuania of 12 July 2001 (Valstybės žinios (Official Gazette) No 62-2244, 2001), the Government of the Republic of Lithuania has resolved:

1. To approve the Strategy on the Restructuring of Health Care Institutions (as appended).
2. To recommend to the municipalities: 2.
3. in accordance with the provisions of the Strategy on the Restructuring of Health Care Institutions approved herein, revise the Primary Health Care Development Programmes (plans) and submit them to the Ministry of Health by 1 June 2003; 2.
4. to allocate for an upgrade of health care institutions and technologies at least 60% of the proceeds generated from the privatization of buildings owned by municipalities, vacated as a result of restructuring.
5. To instruct county governors, in accordance with the provisions of the Strategy on the Restructuring of Health Care Institutions approved herein, to specify the County Health Care Institution Restructuring Plan and submit it to the Ministry of Health by 1 September 2003, following agreement with municipalities.
6. To instruct the Ministry of Health: 4.
7. to approve Health Care Institution Restructuring Plans: 4.1.
8. of Vilnius and Kaunas counties by 10 December 2003; 4.1.
9. of other counties by 30 December 2003; 4.
10. to oversee the implementation of County Health Care Institution Restructuring Plans; 4.
11. within six months from the date of approval of Health Care Institution Restructuring Plans of all the counties, to draft a National Health Care Institution Restructuring Programme, make appropriate allocations for its implementation, and submit it for approval to the Government of the Republic of Lithuania; 4.
12. to recommend that investment projects designed for restructuring of county health care institutions are included, on priority basis, into the annually drafted Law on the Approval of Financial Indicators of the State Budget and Municipal Budgets , and the Public Investment Programme. Prime Minister Algirdas Brazauskas Minister of Health Juozas Olekas APPROVED by Resolution No335 of the Government of the Republic of Lithuania of 18 March 2003 STRATEGY ON restructuring OF health care institutionS I. General provisions
13. The Strategy on Restructuring of Health Care Institutions (hereinafter referred to as “the Strategy”) drafted for the purpose of implementing the health-related provisions of the Programme of the Government of the Republic of Lithuania for 2001-2004 which was approved by Resolution No IX-455 of the Seimas of the Republic of Lithuania of 12 July 2001 (Valstybės Žinios (Official Gazette) No 62-2244, 2001).
14. The restructuring of health care institutions shall be carried out in the following two stages: 2.
15. Stage I (2003-2005); 2.
16. Stage II (2006-2008).
17. The Strategy shall lay down the restructuring criteria and achievable outputs for stage I exclusively. Stage II criteria and outputs, as well as the schedule, shall be established in the second half of 2005, following the follow-up evaluation of Stage I.
18. The basic provisions of the Strategy shall rest on a thorough analysis of the latest developments in Lithuania, as well as the assessment of performance of health reforms in the Baltic and EU countries. II. aims, objectives and priorities of the strategy
19. The major aims of the Strategy shall be as follows: 5.
20. improving health care quality and accessibility; 5.
21. adjusting the range and structure of health care services to public needs.
22. The major objectives shall be as follows: 6.
23. restructuring health care institution network; 6.
24. building an effective health care institution system at county and municipal levels. 6.
25. transferring relevant state and municipal property for the management and disposition of health care institutions under the right of trust; 6.
26. raising efficiency of health care institutions;
27. The restructuring priorities shall be as follows: 7.
28. achieving a faster development of outpatient services over the reduction of inpatient services. 7.
29. starting health network restructuring with larger cities; 7.
30. making the development of rural family practice a priority in terms of service accessibility.
31. Strategy outcome assessment indicators shall be as follows: 8.
32. changes in morbidity and mortality; 8.
33. development of outpatient services; 8.
34. reduction of inpatient services; 8.
35. changes in the structure and arrangement of health care services to meet public demand; 8.
36. reduction of wait times; 8.
37. changes in the structure of health care spending; 8.
38. changing economic efficiency in health care delivery. III. overview of current status
39. In 2001, Lithuania had: 9.
40. 195 hospitals, including 189 state and municipal hospitals (including112 general, specialized and rehabilitation hospitals, and 77 nursing and support hospitals) 9.
41. as per hospital founders, 112 state and municipal hospitals (excluding nursing and support hospitals) break down as follows: 10 hospitals founded by the Ministry of Health 46 by county governors and 56 by municipal councils. 9.
42. 894 outpatient care institutions, including 436 state and municipal and 458 private. 9.
43. 31628 beds, including 31523 in state and municipal hospitals (including 2914 in nursing and support hospitals), 105 beds in private facilities.
44. Major national health indicators: average length of stay in hospital (except nursing and support hospital) is 10.04 days; bed occupancy is 283.7 days; bed turnover is 28.25; hospitalisation rate per 100 inhabitants is 23.2 patients.
45. Current major trends in the development of health care system: 11.
46. decentralization of primary health care; 11.
47. development of family doctor institution; 11.
48. greater municipal independence in health care delivery; 11.
49. reduction in a number of beds; 11.
50. increased attention to disease prevention.
51. Major drawbacks of the current system preventing from ensuring secure service delivery and efficient utilisation of available resources are as follows: 12.
52. inpatient service share is too big as compared to the other health care services; 12.
53. health care institutions are concentrated in the cities, leaving most rural areas without adequate access to medical care; 12.
54. a number of patients and range of services at some hospitals is too low to ensure adequate quality, patient security and high professional competence of physicians; 12.
55. inadequate medical care for the elderly; 12.
56. inadequate level of the system of outpatient nursing and cooperation between medical and nursing personnel; 12.
57. treatment continuity is not fully ensured upon patient’s referral from one speciality medical institution to another. 12.
58. the condition of most of medical buildings and equipment is inadequate; while management under the right of trust does not provide for improvement. IV. prioritY AREAS for restructuring
59. Restructuring of health care institutions shall follow the three priority areas: 13.
60. the first area being development of outpatient treatment services with a particular focus on primary health care; 13.
61. the second area being rationalization of inpatient treatment services and the development of alternative activity forms; 13.
62. the third area being development of nursing and long term support with a particular focus on health care improvement for the elderly.
63. The implementation of the first area foresees: 14.
64. to encourage private practice of general practitioners working under contracts with territorial patient funds in order to decentralize primary health care; 14.
65. in line with the provisions of the Programme of the Government of the Republic of Lithuania for 2001-2004, to provide the same operating conditions for private health care institutions constituting a part of the national health system, as for state and municipal health care institutions; 14.
66. to widen the scope of tests and treatment at outpatient institutions; 14.
67. to pay more attention to disease prevention and improve its funding model; 14.
68. to develop outpatient services provided by specialist physicians; 14.
69. to develop a long-term patient follow-up system (dispanserization); 14.
70. to improve the system of payment for primary health care services by introducing leverages encouraging provision of more numerous, diversified and better quality services, and the development of preventative measures and a greater attention to rural medical care.
71. The implementation of the second area foresees: 15.
72. to rationalize the scope and structure of inpatient services to meet patient needs, and to intensify the process of treatment; 15.
73. to develop day treatment and day surgery; 15.
74. to improve coordination between inpatient and ambulance services; 15.
75. to improve outpatient rehabilitation services, and to work out inpatient rehabilitation unit requirements.
76. The implementation of the third trend foresees: 16.
77. to asses the needs of adults and children for medical nursing and long-term support, as well as the possibilities of their integration in public care system; 16.
78. to develop a nursing and long-term support system for children and adults with a special focus on differentiated service groups. 16.3.to establish possibilities of meeting needs for services based on respective groups, and funding resources, and to work out payment models; 16.
79. to develop outpatient nursing services of patient home care.
80. The three-area restructuring specified in paragraph 13 of the Strategy shall be effected through an optimal integration of all health care areas of activity, a roll-out of a voluntary health insurance as an extra scheme, transference of state and municipal property for the management and disposition of health care institutions under the right of trust with a view to an improved health care payment procedure. V. criteria for restructuring of health care institutions. achievable outcomes
81. With a view to the implementation of the provisions of the first priority area specified in paragraph 13.1 of the Strategy, the municipalities developing Primary Health Care Development Programmes (plans) shall be called upon to take into account the following criteria while planning the deployment of health care institutions: 18.
82. population density; 18.
83. age structure; 18.
84. health indicators; 18.
85. time required to access a health care institution; 18.
86. transportation network; 18.
87. distance to a health care institution; 18.
88. points of public attraction (churches, sails points, local authority office, public centres, etc.)
89. With a view to the implementation of the provisions of the second priority area specified in paragraph 13.2 of the Strategy, the following interrelated achievable outcomes shall be set out: 19.
90. hospital admissions per 100 municipal population – 18 hospitals (which do not provide intensive care, nursing and support services); 19.
91. average length of stay all over Lithuania – 8 days; 19.
92. achievable outcomes according to major specialities in hospitals and structural units (Annex to the Strategy).
93. Inpatient health care institutions shall be restructured according to the following criteria: 20.
94. a number of inpatient services provided for the population in health care institutions located in the territory of their residence; 20.
95. a number of inpatient services provided for patients in health care institutions located outside the territory of their residence; 20.
96. a umber of inpatient services provided for patients from other municipalities; 20.4.a reduction in inpatient services achieved through substitution by primary outpatient and specialist physician services. 20.
97. self-sufficiency indicator of a health care institution for the last 2 years (debit/credit balance);
98. With a view to the implementation of the provisions of the third area specified in paragraph 13.3 of the Strategy as regards nursing and support, the following shall apply: 21.
99. the achievable outcome being bed occupancy 330 days; 21.
100. the criterion being a number of beds per 1000 population 0.8 – 1.2 beds. V. strategy implementation
101. With a view to the implementation of the provisions of the Strategy, amendments to relevant legislation shall be submitted and a national health care institution restructuring programme shall be worked out, which shall specify measures to be taken, responsible institutions and delivery dates,
102. The restructuring of health care institutions at national, county and municipal levels shall be effected in line with the principles, achievable outcomes and criteria laid down in the Strategy. Restructuring plans shall be developed for the respective period. County governors and municipal councils may take into account the specifics of the area and make relevant adjustments as regards the criteria and the requirements, while implementing county and municipal restructuring plans.
103. The restructuring shall be implemented through merger or separation of relevant medical institutions. While taking decisions regarding the size, structure and location of health care institutions, regions and counties shall be considered a basic unit for the evaluation of the needs of territorial inpatient health services. Continuity of hospital activities according to disease treatment specialities shall be based on morbidity indicators, as well as material, financial and human resources of health care institutions and performance indicators.
104. State and municipal investments into health care shall be planned and allocated in line with the plans for the restructuring of health care institutions.
105. The restructuring of health care institutions provided by the Strategy shall be implemented in the following way: 26.
106. The management of a health institution shall work out restructuring projects in accordance with the criteria and achievable outcomes laid down in the Strategy. 26.
107. The development and adjustment of health institution restructuring plans shall be guided by county governors and Territorial Patient Funds in line with the methodological requirements issued by the Ministry of Health and the State Patient Fund. 26.
108. Health institution restructuring projects shall be implemented following the signature of bilateral agreements between a health care institution and a Territorial Patient Fund. FINAL PROVISIONS
109. The implementation of this Strategy shall be funded from the state budget of the Republic of Lithuania and the Compulsory Health Insurance Fund.
110. To oversee and evaluate the ongoing restructuring, the State Patient Fund and county governors shall annually report the achievements to the Commission on Restructuring of Health Care Institutions, set up by Order No 274 of the Minister of Health of 12 June 2002 (Valstybės žinios (Official Gazette) No 62-2524, 2002), as well as to the Minister of Health.
111. Economic and social implications of the restructuring of the health care network shall be measured and subsequently published in the National Programme for the Restructuring of Health Care Institutions.
112. The effects of the first stage restructuring of health care institutions are expected to improve access and quality of health services as well as major performance indicators of the health system: reduced total number of beds and hospitalizations, shorter average stay in hospital, increased bed occupancy, etc. The economic effect achieved will provide the possibility of raising health care fees by approximately 20 %.
113. A significant part of restructuring-related savings shall be used for a partial settlement of credit installments. The remainder shall be used for the development of outpatient services, increased salaries and service fees. Annex to the Strategy on the Restructuring of Health Care Institutions ACHIEVABLE OUTCOMES BY MAJOR SPECIALITIES IN HOSPITALS AND THEIR STRUCTURAL UNITS No. Speciality Average length of stay (days) Bed occupancy (days) Minimum annual number of births (pcs) Maximum length of stay before operation (days) Minimum annual number of surgical procedures (pcs)
114. Therapy* 7 300–320 x x x
115. Paediatrics 7 280–300 x x x
116. Surgery 7 300–320 x 3 established by order of the Minister of Health
117. Obstetrics 4 230–250 300 x x
118. Psychiatry 28 300–320 x x x
119. Tuberculosis 48 300–320 x x x
120. Rehabilitation 23 300–320 x x x __________________ * Bed occupancy at infectious diseases hospitals or units is 280-300 days.