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• W2026148679 abstract "A decade ago, Lithuania emerged from the shadow of Soviet rule and ran straight into an economic collapse. Now, the health system is finally getting back on its feet. But, says Ben Aris, it will take a lot of improvements to change Lithuania's pessimistic outlook.The Vilnius Emergency Hospital (VEH) stands at the edge of Lithuania's capital surrounded by pine trees. The off-white paint is peeling from the exterior of the run down building, but as the city's main emergency treatment centre and home to one of the country's few neurosurgeries, the hospital has fared better than most.After a decade of chaos, Lithuania's health system is functioning again and health-sector financing is back in the black. But the tiny Baltic republic is now embarking on the second, more difficult, phase of improving the quality of health care.“The development of our hospital is independent from the main political process”, says Tomas Saladis the VEH's deputy director. “Accession to the EU (on May 1 this year) was positive, but we have yet to feel the impact of change in the health-care sector.”VEH is typical of facilities in Lithuania. It was half finished in 1990, when the country regained independence, but construction stalled during the subsequent economic collapse. Today it has 500 beds, from a planned total of 750, and employs over 1200 people.Thanks to the recent economic boom—the economy grew by 10% during the first half of this year—construction of a new wing has been completed. Walking through the corridor to the new wing is like stepping across the divide between past and a future still to be realised.Blue ceramic tiles line the walls in the tatty old building and most of the lights in the corridor are off either to save power or because no one has bothered to replace the bulbs. Patients lie in simple iron beds while nurses sit at the cheap chipboard tables that dominated Soviet institutional furniture.However, a few steps away through the connecting passage to the new, but as yet empty, building the change is complete. Lights burn, the paintwork is so fresh it looks wet, and the duty nurse on the only function floor sits at a stylish pine and metal desk. Huge milk-glass sliding doors hide the doctors' examination rooms equipped with comfortable faux leather couches and the few patients housed on the seventh floor enjoy modern rooms. The rest of the rooms are empty, waiting for more money to be found.Vilnius Emergency Hospital in Lithuania's capital has fared better than most other institutions, but still lacks essential equipmentView Large Image Copyright © 2004 Ben ArisNearly all the hospitals dozen X-ray machines were installed when the hospital was first opened more than a decade ago, and are in use day and night. The SSF came up with the money for three new machines last year, but Saladis says they still rely on the old equipment, which often breaks down and needs constant maintenance.The VEH may not be very impressive, but the fact that it is functioning at all—and even improving a little—is a great achievement. Reforms nipped a looming public-health crisis in the bud and put the sector back on its feet, even if it remains a little wobbly.“Lithuania was hit hard by the recession that followed the collapse of the Soviet Union. The collapse of the economy is clearly reflected in the public health statistics”, says Gediminas Cerniauskas, the deputy minister of health. “But in the last 5 years there has been a general recovery and public health has stabilised in the last 3 years. Life expectancy has started to rise again and the decline in the birth rate has halted. We hope that we have now reached the turning point.”Challenges for healthAll three of the tiny Baltic States face similar health problems to their new cousins in the EU. Like western Europe, diseases of the circulatory system are the most common cause of death in Lithuania, followed by cancer and accidents, together accounting for 86% of all deaths in 2002.The average life expectancy has increased although there is still a big difference between the sexes: while Lithuanian women live to 77·6 years (longer than nearly all other women in Europe) the men died at an early age of 66·2 years—twice as many men die each year as women.Likewise, infant mortality rates have fallen rapidly from about 12–14 per 1000 live births at the end of the Soviet-era to 7·9 per 1000 live births in 2002, against the EU average of 4·8 per 1000.“More can be done to lower the infant mortality rate, but the problem is no longer with the care hospitals provide, as this is at European standards; most of the infant deaths occur after the babies have gone home”, says Rita Gaidelyte, a statistician at the Lithuanian Health Information Centre.Public health reached its nadir between 1995 and 1996: things like measles, tuberculosis, and sexually transmitted diseases all peaked before falling back to pre-independence levels during the following couple of years.However, Lithuania has not completely shaken its transition aches and some health problems from the mid-90s are lingering. The incidence of cancer was already increasing in Soviet times and the pace has picked up since independence: between 1960 and 2002, the number of people dying from cancer per 100 000 doubled from 200 a year to 400, although the incidence of cancer may be beginning to slow now— 3% fewer cases were reported in 2003 than in 2002.HIV/AIDS infections are also on the rise due to an explosion in the easy availability of narcotics in northeastern Europe, but there is a lot of confusion over the real extent of the problem. A total of 25 people have already died from virus-related complications, but the total number of cases remains in the hundreds out of a population of 3·4 million.Still, it seems the official figures seriously underestimate the extent of HIV infection, which is sweeping through the region. For example, the official headcount doubled in 2002 after all the inmates of the Altyus Penal Colony had blood tests and more than 300 were found to be infected. As of January 1, 2003, the government had registered 735 people infected with the virus, but health officials believe that the real number could be ten times as high.Negative notionsLithuania's mortality profile may be largely similar to western Europe's but two trends have health professionals baffled: Lithuania has the highest suicide rate in Europe and despite boasting the fastest growing economy in the EU, birth rates have failed to recover to their traditional high levels.Tabled 1Health statistics for LithuaniaTotal population3 465 000GDP per capita (Intl $, 2001)7978Total health expenditure per capita (Intl $, 2001)478Total health expenditure as % of GDP6·0Life expectancy at birth, male (years)66·2Life expectancy at birth, female (years)77·6Child mortality, male (per 1000)11Child mortality, female (per 1000)9Adult mortality, male (per 1000)303Adult mortality, female (per 1000)103Physicians per 100 000395·0Nurses per 100 000884Midwives per 100 00043·5 Open table in a new tab All three Baltic states saw a rapid increase in suicides during the 1990s, but while the number of suicides in Latvia and Estonia have fallen from a high of 40 per 1000 people a year to about 25 in 1995, Lithuania's suicide rate has remained stuck at the same high level, but no one is quite sure why.“It can't be easily explained”, says Gaidelyte. “Maybe there is something in our mentality that makes it harder to accept change. Maybe it is connected to the fact that this is a predominantly Catholic country whereas out Baltic neighbours are Protestant. Surveys show that the people are generally very pessimistic.”The minister says that pessimism is to be expected because, unlike neighbouring Poland and the other Central European countries that became independent with functioning governments, Lithuania was little more than a region in the Soviet Union.“The suicide problem is related to the speed of change. When we began we had no national government, but were simply a part of the Soviet empire so unlike countries like the Czech Republic or Poland we had to create everything from scratch”, says Cerniauskas. “But opinion polls suggest that people's attitudes began to change about 2 years ago and they were becoming more positive about the future.”The negativity is also reflected in the extremely low birth rates. Again, this has been common to all the transition countries, but traditionally Lithuania's 60 000 births a year were the highest in the region. Birth rates have fallen from 180 babies a year per 1000 people in Soviet times to under 100 per 1000 people by 2002. Last year saw the first increase, but only 500 more babies were born than the year before.“The low birth rate is a big problem as life expectancy is increasing and the population is aging so there will be difficulties in the future”, says Gaidelyte.Money money moneyThe corridors at the VEH maybe dark but at least its employees are being paid. As the focus turns to improving quality, the state is still facing huge challenges, but the prospects for overcoming them are good.“The small size of the country makes reform easier and Lithuania has already moved very fast”, says Marc Danzon, the WHO regional director for Europe. “There is a tremendous political determination to bring the health-care system in line with that of the EU … the country has been aiming at EU integration from the very start.”However, early efforts at reform actually made things worse rather than better. The entire pharmaceutical indutry was sold off in the first half of the 90s sending the cost of medicine skyrocketing. By the middle of the decade government was running up huge debts as drug prices exceeded even western levels.The revamp of funding health began in May 1996 with the creation of the State Health Insurance Fund, a mandatory insurance scheme, funded by workers' personal income tax, a flat 3% social tax and government top-ups to cover groups like children and pensioners. The SSF actually spends the money.Drug prices are still high but 2 years ago the state introduced a list of “basic” drugs and used its position as a monopoly buyer to bring down the prices of the most important. Still, the population is still asked to foot at least part of the bill for many drugs.“In Soviet times we had money, but no medicines to buy. Today we can choose from any medicine but we don't have the money to pay for them”, says Gaidelyte. “The problem is the price of drugs is the same as in western Europe, but our salaries are not.”By the mid-90s the system was facing a financial catastrophe but the reforms coupled with recent strong economic growth has put health-care budgets back into the black. Officially the state spent 4·9% of GDP on health care in 2002, but adding in nascent private care real spending is closer to 5·8% of GDP. The SSF ran a surplus of €30 million ($36·5 million, £20 million) for the first time last year and already has €20 million surplus over the first 6 months of this year.“Thanks to economic growth of 10% a year revenues are much higher, making the budget realistic as the assumptions last year were less than the reality this year”, says Cerniauskas.Money in the budget doesn't mean there is enough money to go round, however. The VEH is working, but Saladis could happily spend several tens of millions of dollars before he would say his hospital was up to EU scratch.Drugs in Lithuania cost as much as in western Europe, but salaries are nowhere near equivalentView Large Image Copyright © 2004 Ben ArisSaladis would like more money to buy more X-ray machines, but at least the old ones can be fixed if they go wrong. He is even more worried about loosing the people to operate them—a commodity that can't be replaced so easily.Lithuania's highly qualified doctors are leaving the country in search of better pay abroad. Migration of health workers is already an EU-wide problem. Nurses are the most mobile, but since accession in May the trickle of highly qualified eastern European doctors emigrating threatens to turn into a flood.“We have lost about six of our best doctors—a few surgeons, a urologist, an anaesthetist, and a toxicologist, who went to Norway, the UK, and several to Germany”, says Saladis. “They say that what they earn in a month here they can earn in a day there. In general things are getting better and I am optimistic about the future, but we are afraid of the brain drain and could have big problems soon.”Cerniauskas says the government is aware of the problem but simply does not have the money to bring wages up to western European levels overnight: wages have been hiked regularly but the increases are running only slightly ahead of inflation.Ironically, Danzon says that the government's pessimism gives the rest of the population cause for optimism. The government is not shirking the problems but facing them head on. It is this transparent focus on what needs to be done that is the best guarantee it will get done. Danzon says he is confident that Lithuania's health system will improve to EU standards quickly.Cerniauskas does not pull any punches when assessing the task ahead: “The emphasis is changing to improving the quality of the service. Now we have stabilised the system, but what we have now it is only stable stagnation.” A decade ago, Lithuania emerged from the shadow of Soviet rule and ran straight into an economic collapse. Now, the health system is finally getting back on its feet. But, says Ben Aris, it will take a lot of improvements to change Lithuania's pessimistic outlook. The Vilnius Emergency Hospital (VEH) stands at the edge of Lithuania's capital surrounded by pine trees. The off-white paint is peeling from the exterior of the run down building, but as the city's main emergency treatment centre and home to one of the country's few neurosurgeries, the hospital has fared better than most. After a decade of chaos, Lithuania's health system is functioning again and health-sector financing is back in the black. But the tiny Baltic republic is now embarking on the second, more difficult, phase of improving the quality of health care. “The development of our hospital is independent from the main political process”, says Tomas Saladis the VEH's deputy director. “Accession to the EU (on May 1 this year) was positive, but we have yet to feel the impact of change in the health-care sector.” VEH is typical of facilities in Lithuania. It was half finished in 1990, when the country regained independence, but construction stalled during the subsequent economic collapse. Today it has 500 beds, from a planned total of 750, and employs over 1200 people. Thanks to the recent economic boom—the economy grew by 10% during the first half of this year—construction of a new wing has been completed. Walking through the corridor to the new wing is like stepping across the divide between past and a future still to be realised. Blue ceramic tiles line the walls in the tatty old building and most of the lights in the corridor are off either to save power or because no one has bothered to replace the bulbs. Patients lie in simple iron beds while nurses sit at the cheap chipboard tables that dominated Soviet institutional furniture. However, a few steps away through the connecting passage to the new, but as yet empty, building the change is complete. Lights burn, the paintwork is so fresh it looks wet, and the duty nurse on the only function floor sits at a stylish pine and metal desk. Huge milk-glass sliding doors hide the doctors' examination rooms equipped with comfortable faux leather couches and the few patients housed on the seventh floor enjoy modern rooms. The rest of the rooms are empty, waiting for more money to be found. Nearly all the hospitals dozen X-ray machines were installed when the hospital was first opened more than a decade ago, and are in use day and night. The SSF came up with the money for three new machines last year, but Saladis says they still rely on the old equipment, which often breaks down and needs constant maintenance. The VEH may not be very impressive, but the fact that it is functioning at all—and even improving a little—is a great achievement. Reforms nipped a looming public-health crisis in the bud and put the sector back on its feet, even if it remains a little wobbly. “Lithuania was hit hard by the recession that followed the collapse of the Soviet Union. The collapse of the economy is clearly reflected in the public health statistics”, says Gediminas Cerniauskas, the deputy minister of health. “But in the last 5 years there has been a general recovery and public health has stabilised in the last 3 years. Life expectancy has started to rise again and the decline in the birth rate has halted. We hope that we have now reached the turning point.” Challenges for healthAll three of the tiny Baltic States face similar health problems to their new cousins in the EU. Like western Europe, diseases of the circulatory system are the most common cause of death in Lithuania, followed by cancer and accidents, together accounting for 86% of all deaths in 2002.The average life expectancy has increased although there is still a big difference between the sexes: while Lithuanian women live to 77·6 years (longer than nearly all other women in Europe) the men died at an early age of 66·2 years—twice as many men die each year as women.Likewise, infant mortality rates have fallen rapidly from about 12–14 per 1000 live births at the end of the Soviet-era to 7·9 per 1000 live births in 2002, against the EU average of 4·8 per 1000.“More can be done to lower the infant mortality rate, but the problem is no longer with the care hospitals provide, as this is at European standards; most of the infant deaths occur after the babies have gone home”, says Rita Gaidelyte, a statistician at the Lithuanian Health Information Centre.Public health reached its nadir between 1995 and 1996: things like measles, tuberculosis, and sexually transmitted diseases all peaked before falling back to pre-independence levels during the following couple of years.However, Lithuania has not completely shaken its transition aches and some health problems from the mid-90s are lingering. The incidence of cancer was already increasing in Soviet times and the pace has picked up since independence: between 1960 and 2002, the number of people dying from cancer per 100 000 doubled from 200 a year to 400, although the incidence of cancer may be beginning to slow now— 3% fewer cases were reported in 2003 than in 2002.HIV/AIDS infections are also on the rise due to an explosion in the easy availability of narcotics in northeastern Europe, but there is a lot of confusion over the real extent of the problem. A total of 25 people have already died from virus-related complications, but the total number of cases remains in the hundreds out of a population of 3·4 million.Still, it seems the official figures seriously underestimate the extent of HIV infection, which is sweeping through the region. For example, the official headcount doubled in 2002 after all the inmates of the Altyus Penal Colony had blood tests and more than 300 were found to be infected. As of January 1, 2003, the government had registered 735 people infected with the virus, but health officials believe that the real number could be ten times as high. All three of the tiny Baltic States face similar health problems to their new cousins in the EU. Like western Europe, diseases of the circulatory system are the most common cause of death in Lithuania, followed by cancer and accidents, together accounting for 86% of all deaths in 2002. The average life expectancy has increased although there is still a big difference between the sexes: while Lithuanian women live to 77·6 years (longer than nearly all other women in Europe) the men died at an early age of 66·2 years—twice as many men die each year as women. Likewise, infant mortality rates have fallen rapidly from about 12–14 per 1000 live births at the end of the Soviet-era to 7·9 per 1000 live births in 2002, against the EU average of 4·8 per 1000. “More can be done to lower the infant mortality rate, but the problem is no longer with the care hospitals provide, as this is at European standards; most of the infant deaths occur after the babies have gone home”, says Rita Gaidelyte, a statistician at the Lithuanian Health Information Centre. Public health reached its nadir between 1995 and 1996: things like measles, tuberculosis, and sexually transmitted diseases all peaked before falling back to pre-independence levels during the following couple of years. However, Lithuania has not completely shaken its transition aches and some health problems from the mid-90s are lingering. The incidence of cancer was already increasing in Soviet times and the pace has picked up since independence: between 1960 and 2002, the number of people dying from cancer per 100 000 doubled from 200 a year to 400, although the incidence of cancer may be beginning to slow now— 3% fewer cases were reported in 2003 than in 2002. HIV/AIDS infections are also on the rise due to an explosion in the easy availability of narcotics in northeastern Europe, but there is a lot of confusion over the real extent of the problem. A total of 25 people have already died from virus-related complications, but the total number of cases remains in the hundreds out of a population of 3·4 million. Still, it seems the official figures seriously underestimate the extent of HIV infection, which is sweeping through the region. For example, the official headcount doubled in 2002 after all the inmates of the Altyus Penal Colony had blood tests and more than 300 were found to be infected. As of January 1, 2003, the government had registered 735 people infected with the virus, but health officials believe that the real number could be ten times as high. Negative notionsLithuania's mortality profile may be largely similar to western Europe's but two trends have health professionals baffled: Lithuania has the highest suicide rate in Europe and despite boasting the fastest growing economy in the EU, birth rates have failed to recover to their traditional high levels.Tabled 1Health statistics for LithuaniaTotal population3 465 000GDP per capita (Intl $, 2001)7978Total health expenditure per capita (Intl $, 2001)478Total health expenditure as % of GDP6·0Life expectancy at birth, male (years)66·2Life expectancy at birth, female (years)77·6Child mortality, male (per 1000)11Child mortality, female (per 1000)9Adult mortality, male (per 1000)303Adult mortality, female (per 1000)103Physicians per 100 000395·0Nurses per 100 000884Midwives per 100 00043·5 Open table in a new tab All three Baltic states saw a rapid increase in suicides during the 1990s, but while the number of suicides in Latvia and Estonia have fallen from a high of 40 per 1000 people a year to about 25 in 1995, Lithuania's suicide rate has remained stuck at the same high level, but no one is quite sure why.“It can't be easily explained”, says Gaidelyte. “Maybe there is something in our mentality that makes it harder to accept change. Maybe it is connected to the fact that this is a predominantly Catholic country whereas out Baltic neighbours are Protestant. Surveys show that the people are generally very pessimistic.”The minister says that pessimism is to be expected because, unlike neighbouring Poland and the other Central European countries that became independent with functioning governments, Lithuania was little more than a region in the Soviet Union.“The suicide problem is related to the speed of change. When we began we had no national government, but were simply a part of the Soviet empire so unlike countries like the Czech Republic or Poland we had to create everything from scratch”, says Cerniauskas. “But opinion polls suggest that people's attitudes began to change about 2 years ago and they were becoming more positive about the future.”The negativity is also reflected in the extremely low birth rates. Again, this has been common to all the transition countries, but traditionally Lithuania's 60 000 births a year were the highest in the region. Birth rates have fallen from 180 babies a year per 1000 people in Soviet times to under 100 per 1000 people by 2002. Last year saw the first increase, but only 500 more babies were born than the year before.“The low birth rate is a big problem as life expectancy is increasing and the population is aging so there will be difficulties in the future”, says Gaidelyte. Lithuania's mortality profile may be largely similar to western Europe's but two trends have health professionals baffled: Lithuania has the highest suicide rate in Europe and despite boasting the fastest growing economy in the EU, birth rates have failed to recover to their traditional high levels.Tabled 1Health statistics for LithuaniaTotal population3 465 000GDP per capita (Intl $, 2001)7978Total health expenditure per capita (Intl $, 2001)478Total health expenditure as % of GDP6·0Life expectancy at birth, male (years)66·2Life expectancy at birth, female (years)77·6Child mortality, male (per 1000)11Child mortality, female (per 1000)9Adult mortality, male (per 1000)303Adult mortality, female (per 1000)103Physicians per 100 000395·0Nurses per 100 000884Midwives per 100 00043·5 Open table in a new tab Tabled 1Health statistics for LithuaniaTotal population3 465 000GDP per capita (Intl $, 2001)7978Total health expenditure per capita (Intl $, 2001)478Total health expenditure as % of GDP6·0Life expectancy at birth, male (years)66·2Life expectancy at birth, female (years)77·6Child mortality, male (per 1000)11Child mortality, female (per 1000)9Adult mortality, male (per 1000)303Adult mortality, female (per 1000)103Physicians per 100 000395·0Nurses per 100 000884Midwives per 100 00043·5 Open table in a new tab All three Baltic states saw a rapid increase in suicides during the 1990s, but while the number of suicides in Latvia and Estonia have fallen from a high of 40 per 1000 people a year to about 25 in 1995, Lithuania's suicide rate has remained stuck at the same high level, but no one is quite sure why. “It can't be easily explained”, says Gaidelyte. “Maybe there is something in our mentality that makes it harder to accept change. Maybe it is connected to the fact that this is a predominantly Catholic country whereas out Baltic neighbours are Protestant. Surveys show that the people are generally very pessimistic.” The minister says that pessimism is to be expected because, unlike neighbouring Poland and the other Central European countries that became independent with functioning governments, Lithuania was little more than a region in the Soviet Union. “The suicide problem is related to the speed of change. When we began we had no national government, but were simply a part of the Soviet empire so unlike countries like the Czech Republic or Poland we had to create everything from scratch”, says Cerniauskas. “But opinion polls suggest that people's attitudes began to change about 2 years ago and they were becoming more positive about the future.” The negativity is also reflected in the extremely low birth rates. Again, this has been common to all the transition countries, but traditionally Lithuania's 60 000 births a year were the highest in the region. Birth rates have fallen from 180 babies a year per 1000 people in Soviet times to under 100 per 1000 people by 2002. Last year saw the first increase, but only 500 more babies were born than the year before. “The low birth rate is a big problem as life expectancy is increasing and the population is aging so there will be difficulties in the future”, says Gaidelyte. Money money moneyThe corridors at the VEH maybe dark but at least its employees are being paid. As the focus turns to improving quality, the state is still facing huge challenges, but the prospects for overcoming them are good.“The small size of the country makes reform easier and Lithuania has already moved very fast”, says Marc Danzon, the WHO regional director for Europe. “There is a tremendous political determination to bring the health-care system in line with that of the EU … the country has been aiming at EU integration from the very start.”However, early efforts at reform actually made things worse rather than better. The entire pharmaceutical indutry was sold off in the first half of the 90s sending the cost of medicine skyrocketing. By the middle of the decade government was running up huge debts as drug prices exceeded even western levels.The revamp of funding health began in May 1996 with the creation of the State Health Insurance Fund, a mandatory insurance scheme, funded by workers' personal income tax, a flat 3% social tax and government top-ups to cover groups like children and pensioners. The SSF actually spends the money.Drug prices are still high but 2 years ago the state introduced a list of “basic” drugs and used its position as a monopoly buyer to bring down the prices of the most important. Still, the population is still asked to foot at least part of the bill for many drugs.“In Soviet times we had money, but no medicines to buy. Today we can choose from any medicine but we don't have the money to pay for them”, says Gaidelyte. “The problem is the price of drugs is the same as in western Europe, but our salaries are not.”By the mid-90s the system was facing a financial catastrophe but the reforms coupled with recent strong economic growth has put health-care budgets back into the black. Officially the state spent 4·9% of GDP on health care in 2002, but adding in nascent private care real spending is closer to 5·8% of GDP. The SSF ran a surplus of €30 million ($36·5 million, £20 million) for the first time last year and already has €20 million surplus over the first 6 months of this year.“Thanks to economic growth of 10% a year revenues are much higher, making the budget realistic as the assumptions last year were less than the reality this year”, says Cerniauskas.Money in the budget doesn't mean there is enough money to go round, however. The VEH is working, but Saladis could happily spend several tens of millions of dollars before he would say his hospital was up to EU scratch.Saladis would like more money to buy more X-ray machines, but at least the old ones can be fixed if they go wrong. He is even more worried about loosing the people to operate them—a commodity that can't be replaced so easily.Lithuania's highly qualified doctors are leaving the country in search of better pay abroad. Migration of health workers is already an EU-wide problem. Nurses are the most mobile, but since accession in May the trickle of highly qualified eastern European doctors emigrating threatens to turn into a flood.“We have lost about six of our best doctors—a few surgeons, a urologist, an anaesthetist, and a toxicologist, who went to Norway, the UK, and several to Germany”, says Saladis. “They say that what they earn in a month here they can earn in a day there. In general things are getting better and I am optimistic about the future, but we are afraid of the brain drain and could have big problems soon.”Cerniauskas says the government is aware of the problem but simply does not have the money to bring wages up to western European levels overnight: wages have been hiked regularly but the increases are running only slightly ahead of inflation.Ironically, Danzon says that the government's pessimism gives the rest of the population cause for optimism. The government is not shirking the problems but facing them head on. It is this transparent focus on what needs to be done that is the best guarantee it will get done. Danzon says he is confident that Lithuania's health system will improve to EU standards quickly.Cerniauskas does not pull any punches when assessing the task ahead: “The emphasis is changing to improving the quality of the service. Now we have stabilised the system, but what we have now it is only stable stagnation.” The corridors at the VEH maybe dark but at least its employees are being paid. As the focus turns to improving quality, the state is still facing huge challenges, but the prospects for overcoming them are good. “The small size of the country makes reform easier and Lithuania has already moved very fast”, says Marc Danzon, the WHO regional director for Europe. “There is a tremendous political determination to bring the health-care system in line with that of the EU … the country has been aiming at EU integration from the very start.” However, early efforts at reform actually made things worse rather than better. The entire pharmaceutical indutry was sold off in the first half of the 90s sending the cost of medicine skyrocketing. By the middle of the decade government was running up huge debts as drug prices exceeded even western levels. The revamp of funding health began in May 1996 with the creation of the State Health Insurance Fund, a mandatory insurance scheme, funded by workers' personal income tax, a flat 3% social tax and government top-ups to cover groups like children and pensioners. The SSF actually spends the money. Drug prices are still high but 2 years ago the state introduced a list of “basic” drugs and used its position as a monopoly buyer to bring down the prices of the most important. Still, the population is still asked to foot at least part of the bill for many drugs. “In Soviet times we had money, but no medicines to buy. Today we can choose from any medicine but we don't have the money to pay for them”, says Gaidelyte. “The problem is the price of drugs is the same as in western Europe, but our salaries are not.” By the mid-90s the system was facing a financial catastrophe but the reforms coupled with recent strong economic growth has put health-care budgets back into the black. Officially the state spent 4·9% of GDP on health care in 2002, but adding in nascent private care real spending is closer to 5·8% of GDP. The SSF ran a surplus of €30 million ($36·5 million, £20 million) for the first time last year and already has €20 million surplus over the first 6 months of this year. “Thanks to economic growth of 10% a year revenues are much higher, making the budget realistic as the assumptions last year were less than the reality this year”, says Cerniauskas. Money in the budget doesn't mean there is enough money to go round, however. The VEH is working, but Saladis could happily spend several tens of millions of dollars before he would say his hospital was up to EU scratch. Saladis would like more money to buy more X-ray machines, but at least the old ones can be fixed if they go wrong. He is even more worried about loosing the people to operate them—a commodity that can't be replaced so easily. Lithuania's highly qualified doctors are leaving the country in search of better pay abroad. Migration of health workers is already an EU-wide problem. Nurses are the most mobile, but since accession in May the trickle of highly qualified eastern European doctors emigrating threatens to turn into a flood. “We have lost about six of our best doctors—a few surgeons, a urologist, an anaesthetist, and a toxicologist, who went to Norway, the UK, and several to Germany”, says Saladis. “They say that what they earn in a month here they can earn in a day there. In general things are getting better and I am optimistic about the future, but we are afraid of the brain drain and could have big problems soon.” Cerniauskas says the government is aware of the problem but simply does not have the money to bring wages up to western European levels overnight: wages have been hiked regularly but the increases are running only slightly ahead of inflation. Ironically, Danzon says that the government's pessimism gives the rest of the population cause for optimism. The government is not shirking the problems but facing them head on. It is this transparent focus on what needs to be done that is the best guarantee it will get done. Danzon says he is confident that Lithuania's health system will improve to EU standards quickly. Cerniauskas does not pull any punches when assessing the task ahead: “The emphasis is changing to improving the quality of the service. Now we have stabilised the system, but what we have now it is only stable stagnation.”" @default.
• W2026148679 created "2016-06-24" @default.
• W2026148679 creator A5082739618 @default.
• W2026148679 date "2004-08-01" @default.
• W2026148679 modified "2023-10-14" @default.
• W2026148679 title "Little by little" @default.
• W2026148679 doi "https://doi.org/10.1016/s0140-6736(04)16956-0" @default.
• W2026148679 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/15338565" @default.
• W2026148679 hasPublicationYear "2004" @default.
• W2026148679 type Work @default.
• W2026148679 sameAs 2026148679 @default.
• W2026148679 citedByCount "2" @default.
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