Current health care reform in Lithuania: real change or simply damage limitation?

For 19 years patients and doctors in Lithuania have been waiting for a major shift in the governmental attitude towards health care and, even more importantly, a well-designed and considered reform to address the inherited Soviet-style problems. The government and health care leaders kept saying: give us money and we will reform our health care.
A lot has been given through various international funds. Nothing major has happened. Quite the contrary. Most of the latest health care statistics show that the situation is unchanged or is becoming even worse.

Over the last decade the amount of monies poured into Lithuanian health care has nearly tripled. Has it changed the system? Has it helped the system as a whole? Has it addressed the main challenges of corruption and the inability to deliver health care reform? Has it led to prosperous and thriving health care?
Perhaps the best way to answer these questions would be through a case scenario study based on current health care reform in Lithuania, in order to understand the hidden meanings behind the eloquent words and to look beyond what political slogans state.

With the credit crunch-induced crisis and the lack of public money, the medical community was presented with the long awaited news that reform was on the way. On April 4, 2009, the Lithuanian health minister announced the start of health care reform. The first impression on hearing the news was thrilling: great!!! Finally it had arrived.
Health Care Minister Algis Caplikas stated that the main impetus was the newly released report from the World Bank. According to the minister, the report suggests that there are too many hospitals in Lithuania and that the number of hospitals should be reduced. This sounds logical. More importantly, the minister announced to the mass media that the World Bank report would be available in one week. That was in April 2009. It is now January 2010. The reform plan has been released but the World Bank report is still hidden from public view.

The major platform of the plan is an administrative division of the country. There are five administrative regions in Lithuania, so there will be five health care regions: Vilnius (the capital), Kaunas, Klaipeda, Panevezys and Siauliai regions.  Each region will have three levels of hospitals: national, regional and local. Based on this, the Minister has named the reform ‘3R’ to reflect this concept (in Lithuanian, the word ‘local’ starts with the letter ‘R’).
However, and more significantly, he often forgets to mention that there will be two other hospitals which will receive state support. They are the University Hospitals of Vilnius and Kaunas. So in essence, this is not a 3R reform but a 5R3R2U reform (5 regions, 3 different levels of hospitals, and two university hospitals).

The European Council at the meeting in Luxembourg in 2006 adopted the document named ‘Council Conclusions on Common values and principles in EU Health systems.’ This document has been signed by all the then 25 member states of the EU, including Lithuania. The document states that the overarching values of the health care systems in Europe should be universality, access to good quality care, equity and solidarity.

The current reform proposal basically makes it almost impossible to comply with these values. Creation of three regions with 3R level hospitals, and two regions with 3R2U hospitals will mean that 60 percent of the population will not have, or will have difficult, access to the university type of services and they will be quite distant from their homes (values of access to good quality care and equity will be undermined). The 2U concept involves exceptional financing of the university hospitals thus widening the existing significant gap in the specialist working environment in different regions, and makes it difficult to implement the value of solidarity.

Since each stage of health care development since independence in 1990, the leading academics of these hospitals have been able to devise the means and tools to direct more finances to their hospitals, whether the funds be national, international or European. As a result of these policies, the regional hospitals are deprived not only of facilities but also, and more importantly, of specialist care and input. With the implementation of the current reform the problem of the lack of specialists in the regions will be further exacerbated.

The intended reduction of the hospitals, without involving specialists in management of the hospitals, will mean further concentration of power by fewer individuals. This in turn will enhance the existing hierarchy and will lead to an even higher spread of corruption with the direction which is opposite to the value of universality.
The next question concerns the way the 5R3R2U reform is carried out. All strategic planning experts state the simple rule, that every reform should be conducted based on the principles of strategic planning. These principles state that the most important aspect is not the essence of the reform, but the way in which it is conducted.

So, how is the 5R3R2U reform conducted? The restructuring plan was announced on Sept. 8, 2009, and all stakeholders were given one week to express their views, concerns and suggestions. After 19 years and 7 months (1,019 weeks) of waiting, frustration and anticipation, the minister gave one week for debate.
Interestingly enough, no changes were introduced after the ‘public debate.’ The way the public debate was handled leads to another fundamental question: was it not a pre-planned concept, formally thrown open to the public in order to tick the democracy rules box? Is it just a cosmetic adjustment to satisfy the government budget requirements and to give the impression to international organizations that change is underway?

Or is it just simple damage limitation due to the fact that for the last 20 years very little, if anything, has happened in the medical field. An English proverb says: no news is good news. In the context of the current reform, this has proved to be completely the opposite.

Dr. Simaitis is a Lithuanian Cardiologist working in the United Kingdom.