Chapter 3. Health care system in Lithuania: Efficiency and quality

Lithuania has achieved a substantial reconfiguration of its hospital system

The current configuration of the hospital system represents progress in shaping the hospital sector. In 2015, there were 119 public hospitals (legal entities), which represents a considerable drop from the 1991 level of 202. The number of monoprofile hospitals has substantially decreased (from 39 in 2001 to 14 in 2015), through closures or administrative integration with general hospitals (there is only one self-standing TB facility and no administratively independent infectious diseases hospitals). The MoH manages 10 “republican level” facilities which are generally large (700 beds) and there are 49 smaller municipal hospitals (180 beds on average). The private sector includes 10 small inpatient facilities, a handful of specialised facilities and seven outpatient surgery centres (Table 3.1).

Many countries have been more effective in consolidating hospital infrastructure. Despite the progress noted, Lithuania still has a very large number of hospitals, with at least one in almost every municipality and a high number of beds. Since 1992, more than half of the beds have been closed through administratively planned downsizing and application of incentives such as shifting the funding to an output based reimbursement. However, most of this reduction took place in the 1990s. The number of beds has continuously declined. Nevertheless, Lithuania’s fast shrinking population led to increases in number of beds per capita during the years 2000s, so today Lithuania remains with Germany, Austria and Hungary among the European countries with the most hospital beds. Compared to neighbouring Baltic countries, the pace of change in reducing hospital capacity has been relatively slow: between 2000 and 2015, the number of beds in Latvia dropped by 54%, in Estonia by 42% and in Lithuania 27% (Figure 3.2).

Figure 3.2. The number of hospital beds has slowly declined and remains high

Hospital beds per 1 000 population, 2000 and 2015

Source: OECD Health Statistics 2017, https://doi.org/10.1787/health-data-en.

There is still room to further rationalise the hospital sector

Average lengths of stay average are relatively short with a notable exception. The average length of stay (ALOS) for curative care, at 6.3 days (2015), compares well internationally and is below the OECD average (6.7). But this number has not progressed the last five years. Tuberculosis stands out as one diagnostic area in which Lithuania has distinctively long treatment lengths. Long length of stays corresponds to a traditional and some would argue outdated inpatient mode of treatment for TB which characterises many former Soviet countries. Nonetheless, at 102 days (2015), Lithuania ALOS is twice as high as most Baltic neighbours and Central European countries, and compares poorly with the OECD average of 24 days.

The low and very variable bed occupancy rate indicates the hospital sector remains in overcapacity. In 2015, among the 65 public general hospitals, the average bed occupancy rate was 73.5% (or 268 days per year), which is below the OECD average of 77%. There are however large variations among general hospitals (Figure 3.3) with predominantly small hospitals reporting very low rates. This means that many beds are not used at all. The current health system development plan aims to increased bed occupancy levels and sets a target of 300 days per year (above 82%). In 2015, only 4 of the 65 public general hospitals in Lithuania met this target. In fact, the bed occupancy rate was lower than 60% in 13 public hospitals.

Figure 3.3. The acute care bed occupancy ratio is lower than the OECD average in 85% of Lithuanian hospitals

Bed Occupancy rate of public general hospital, 2015

Source: Ministry of Health, Lithuania.

Payment systems and contracting methods have been increasingly leveraged to encourage more efficient modes of delivery

DRGs combined with volume caps seek to encourage efficient delivery and lower volumes of inpatient hospitalisations. In 2012, a DRG system based on the Australian coding and diagnosis grouping was introduced and continues to be fine-tuned. For example, Lithuania is developing new cost weights to ensure relative prices reflect more closely the local cost structure of service production. The DRG system allows payments to hospitals to mirror their patients’ case-mix and incentivises the more efficient production of treatment episodes. It can also potentially encourage increases in the number of hospitalisations. In order to counteract this incentive, contracts between the NHIF with individual facilities include volume ceilings for in-patient services which are decreased year-on-year. Some services, such as the care of children under age three, obstetrics and specific acute procedures are not capped though. Additionally:

• To encourage reductions in volumes without penalising hospitals with proportionally reduced budgets, if the volume of a specific inpatient service is below the amount agreed in the contract, the price index for the service is increased and the hospital can receive at least part of the initially planned budget for the given year (but no more).

• If the volume of a specific inpatient service is more than 10% above the national average in a given area, no new contracts can be signed with additional providers (conversely, new contracts can be signed if the exiting volume is 10% below the national average).

• For all services, if volumes exceed the contractual volumes, additional cases are reimbursed at a lower rate.

Contracting and payments have also effectively encouraged the development of day-cases and outpatient surgery. The Ministry has introduced and regularly updates a list of surgeries and procedures which can be performed as day-cases since 2007 and outpatient surgery since 2013. In Lithuania, outpatient surgeries are those performed without general anaesthesia, and they are paid based on a price-list established by the Ministry. “Day-cases” include hospitalisation which are typically less than 24 hours but can be extended up to 48 hours if necessary. In order to encourage their development, since 2012, they are paid at the DRG full price. In addition, for individual hospitals, day-cases volumes are not capped. Among the 71 main procedures eligible to be performed as day-cases, the proportion actually performed as day-cases was 58% in 2016, an increase of 20 percentage points compared with 2012. In 2016, tonsillectomies were included in the day-case list and around 45% were performed as day cases that same year. In other words, hospitals are actively developing the day-case activity.

Due to Lithuania’s definition of day-cases, its progress in developing shorter surgeries is probably underestimated in international comparisons. International standards define day surgery as care provided to patients formally admitted to a hospital and discharged the same day. By this measure, Lithuania is very much lagging behind in developing modern approaches to hospital treatment, but the picture looks very different if the local definition of “day case” is used. For instance, while 0.3% of Laparoscopic cholecystectomy were carried out on an ambulatory basis by international statistical standards, a level similar to most Central European countries, nearly 36% were conducted in day-surgery – and patients released within 48 hours (Figure 3.4).

Figure 3.4. Lithuania has probably been better at developing efficient surgeries than international statistics suggest

Share of Laparoscopic cholecystectomy carried out as day-surgery cases, 2015 (or nearest years)

Source: NHIF and OECD Health Statistics, https://doi.org/10.1787/health-data-en.

Further consolidation of service delivery is warranted on efficacy and safety grounds and steps have been taken in that direction.

Surgeries are carried out in the vast majority of hospitals in Lithuania, which is inefficient and also carries a risk for patients. Of the 65 hospitals with a general profile contracted by the NHIF, 52 provided at least one surgical procedure in the year. Among them 22 carried out less than 250 procedures, which is roughly one per (business) day. Moreover, the number and complexity of these procedures varies considerably across hospitals, and many carry out major surgeries at very low frequency, for instance:

• 45 hospitals undertook appendectomy, but 23 of these performed appendectomies less than once a week;

• 37 hospitals conducted hysterectomies or C-sections, but among them 15 undertook any one of these major obstetric intervention less than once a week;

• 24 hospitals performed hip surgery, but while 5 performed them less than once a week, the 7 busiest one did more than 11 such surgeries per week.

In the vast majority of cases, these surgeries can be programmed. Concentrating their delivery in a few places could allow a more efficient use of staff and equipment. More importantly, the fact that so many facilities carry out few surgeries raises serious concerns about their capacity to deliver good outcomes.

The decision to use minimum volume thresholds for contracting is a bold step in the right direction. Lithuania intends on concentrating services in fewer places and is using volume targets for obstetrics and common surgeries in contracting to that effect. Since 2016, the plan is that unless a hospital is more than 50km away from the nearest one, or it has recently received specific investments, it will no longer be contracted by the NHIF when if carries out fewer than 300 births per year or less than 400 major surgeries. In 2015, half of the public general hospitals in Lithuania (31 of 65) had an obstetric department. In 14 of these, less than 300 deliveries were conducted.

There is evidence that concentration can be achieved in Lithuania: transluminal coronary angioplasties are only carried out in 5 public hospitals, on a very large scale, and less than two times a week in a private facility. Cataract surgery is also concentrated: 12 hospitals provide the service and only 4 of those in low volumes (less than 150 in a year).

The proposed leveraging of contracting to foster concentration is both innovative and welcome. The actual implementation of the measure could be monitored and its impact including on access and outcomes should be evaluated.

Further restructuring will require planning and organising service delivery at a higher level of government. Overall, Lithuania needs to further consolidate hospital infrastructure on efficiency and safety grounds. The reconfiguration of hospital service delivery is difficult in all countries. Progress in Lithuania has been hampered by the fact that municipalities, which own and manage hospitals, have a natural tendency to protect local interests, in terms of perceived access to services or simply employment. Many countries in the wider Europe region have realised that the distribution of hospitals services needs to be decided at a higher level than the municipality. In Finland, hospital boards jointly manage several municipal hospitals, and the soon to be created counties will actually be responsible for jointly planning and coordinating service delivery across all health and social care previously delivered by municipalities. Austria, Denmark and Croatia have also re-concentrated the responsibility for planning and organising hospital service delivery at increasingly higher levels of government. Sweden is considering a consolidation of administrative levels. Similarly, the reorganisation of hospital service delivery will also need to be decided and governed across sets of municipalities. This might require a formal national service plan to be formulated. In addition, the governance and ownership framework of hospitals may need to be adapted to enable and incentivise reorganisation of service delivery across municipal and possibly regional boundaries.

Measures to reduce harmful alcohol consumption have been considerably strengthened recently and their effectiveness will need to be monitored

The main challenges with regard to the state of public health are well recognised. The populations’ health status and behaviours indicate a sizeable room for improvement. The 2014-2025 Lithuanian Health Strategy specifies concrete goals with regard to reducing harmful alcohol consumption, tobacco, drugs and psychoactive substances, as well as encouraging healthy nutrition and physical activity. The Strategy has an impressive cross-sectorial framework (involving nearly all Ministries), and the MoH is responsible for monitoring of the implementation. The intermediate evaluation of the progress is due in 2020.

Lithuania has intensified measures to tackle the exceptionally high alcohol consumption. At the national level, the alcohol control law was amended in 2014, and new restrictions were introduced in 2016, for instance, banning the sale of alcohol products in gas stations. The tightening of alcohol legislation was one of the priorities of the government elected in 2016. In June 2017, the parliament approved the introduction of multiple alcohol restrictions, which came into effect 1^st of January 2018. From this date Lithuania has a full ban on alcohol advertisement on TV, radio and internet. Alcohol sales hours were shortened by two hours in the morning and two in the evening and are now only allowed from 10 a.m. to 8 p.m. Monday to Saturday, with further restrictions Sundays. The minimum legal age for buying and consuming alcoholic beverages has been extended from 18 to 20 years. In the new legislation, retailers are responsible for controlling the age of buyers, and local governments given increased authority to limit and control sales hours in both shops and restaurants. Caterers, bars and restaurants are not limited by the time restrictions, but from 2020 further restrictions on sales come into effect, including limitations of out-door sales, for example a ban of sales on beaches, and a 7.5% alcohol limit on beverages sold during public events.

Tax increases were modest until 2017 and alcohol has become more affordable over time. Alcohol taxes (excise rates per hectolitre of pure alcohol) have been raised several times since 2000 but the increases have been low and sporadic. Between 2001 and 2008 the excise rate was even kept constant in nominal terms on beer and high alcohol-content beverages and from 2008 until 2016 increases were marginal. The prices of alcoholic beverages in Lithuania are 9% below the EU average (2016) and while food prices in Lithuania have tended to converge with average EU prices, the prices of alcohol have been more slow to do so and in fact diverged from the EU average between 2008 and 2015 (Eurostat, 2017). To put another perspective on this question of affordability, Lithuanians have experienced large increases in real wages over the last two decades, with the exception of a few years around the financial crises, while the prices of alcohol have increased much more slowly (Figure 3.7). As a consequence, alcohol affordability in Lithuania has increased substantially. Between 1996 and 2004 Lithuania had the largest increase in alcohol affordability among today’s EU countries, mostly driven by a real wage increase (Rabinovich, L. et al., 2009). However, in parallel with other restrictive policies on alcohol, Lithuania raised most alcohol excise rates in March 2017 substantially, e.g. from 336 to 711 Euros per hectolitre pure alcohol on beer (MoH).

Figure 3.7. Wage in Lithuania have increased much faster than the prices of alcoholic beverages

Price indices for food, alcohol beverages and wage rates 2000-2017 (2000=100).

Source: Wage rates; International Financial Statistics, IMF. Food and alcohol; Eurostat (Harmonised Index of Consumer Prices).

Pricing policies and advertising regulations can be effective and cost-saving strategies to reduce harmful use of alcohol. However, restrictions in alcohol advertising are increasingly challenged by the spread of advertising on Internet, including social media (Sassi, 2015). More broadly, the degree to which alcohol use-related policies are enforced in practice is of utmost importance. After the recent changes in legislation and increase in excise rates, Lithuania should carefully monitor and evaluate enforcement level of these policies already in place before designing and implementing any new solutions. If enforcement is weak, restrictions on access and raised legal purchase age from 18 to 20 years can be inefficient at best, or at worst, lead to further development of the black market, already very high in Lithuania.

Additional gains in health and life expectancy can be obtained through interventions targeting heavy drinkers. Brief interventions typically targeting high-risk drinkers in primary care settings have been found the most effective in other OECD countries (Sassi, 2015). Although they are expensive to implement, they become cost-effective several years after their implementation. Similarly, drug and psychosocial therapy of alcohol dependence and worksite-based interventions are also effective, with favourable cost-effectiveness profiles in the long run. So far, targeted interventions at primary care level have received little attention in Lithuania.

Public health interventions need to become more effective and better embedded

In general, evidence that highly effective public health interventions are actively pursued is limited at all levels. Concrete initiatives have been few or remain described in general terms. At the local level, the responsibility for public health mainly lies with municipalities, who are encouraged to set up and run (or contract if they do not have one) Public Health Bureaus (Kalediene et al. 2011). Lithuania currently has 47 such institutions across the 60 municipalities. However, municipalities are for the most part free to choose the activities they implement and decide on their level of effort. No framework is in place to help ensure that local-level stakeholders implement evidence-based interventions or are accountable for progress on results (as opposed to simply implementation).

A programme has nevertheless been set-up to develop joint health promotion efforts between public health bureaus and PHC providers. Since 2015, once a year, PHC providers can order free of charge diagnostic tests for patients (men aged 40 to 55 and women aged 50 to 65 years) with risk factors for CVDs (obesity, smoking, harmful alcohol consumption). The intervention consists in setting up an individual CVD prevention plan, a suggestion to attend a programme of a health promotion lectures at a Public Health Bureau, and a referral to a secondary care specialist if necessary. Around 1500 people were registered in 2015. In 2017, a similar programme is being launched for people at risk of diabetes. Outside these programmes, the Public Health Bureaus decide on their activities quite freely depending on available budget, with most initiatives focussing on alcohol abuse.

Overall, most public health efforts are geared towards small initiatives which are insufficiently evaluated. Most interventions, such as information sessions on harmful alcohol use or benefits of healthy diet at the Public Health Bureaus, are assessed in terms of process indicators, such as a number of participants, and not with regard to outcomes. Project design, including monitoring and evaluation, must focus also on the effectiveness of these actions. This could improve results, which has been below expectation in many programmes, notably those targeting harmful alcohol consumption. The above-described prevention programmes for patients at risk of CVDs included a comparison of health outcomes (mostly self-reported data) before and after the intervention but it has not been evaluated. Evidence on the effectiveness and cost-effectiveness of public health policies could support decision-makers in implementing the most suitable actions, especially to reduce the alarmingly high alcohol-related harm.

Further priority can be given to increased and stable funding for public health services. Lithuania allocates 1.9% (2016) of health spending to preventive services, noticeably below the OECD average, although this number does not include the ambitious intersectoral collaboration, and prevention efforts in primary care. Many development initiatives and research projects are conducted within time-limited EU funded projects. While project based testing and piloting is good to find effective approaches, there is a risk that many good projects will not be sustained without a more robust financing framework for these functions. The Public Health Strengthening Fund, operational since 2016, is founded to finance disease prevention, social advertising campaigns and health research. The funding comes from an ear-marked share of the alcohol tax and can mitigate dependence on EU grants. But its resources are limited. In 2016, 1.3 million euro was allocated to this fund (MoH). The fund is also, just like EU funding, set up to support projects, not institutionalise services.

Finally, on the public health front, it is worth noting that despite relatively low levels of antibiotic consumption, antimicrobial resistance is a concern in Lithuania. The consumption in the community of antibiotics in Lithuania stands at 16.9 DDD per 1 000 inhabitants per day (2016, ESAC-Net), considerably lower than the EU average (21.9). Yet, the levels of antimicrobial resistance (AMR) for most pathogens under surveillance by the European Centre for Disease Control are high (ECDC, 2017). In 2015, Lithuania introduced nation-wide regional AMR management groups in the regional public health centres, to coordinate expert from different sectors (Hygiene Institute), but further efforts to change clinical behaviour, in both PHC and the hospital sector, are needed.

Policies and institutions to improve quality of care are slowly developing.

The State Health Care Accreditation Agency (SHCAA) is the main institution in charge of quality assurance. The SHCAA, subordinated to the MoH, has long been in charge of licensing of health care organisations and most professionals. Public and private health care organisations must comply with certain input-related requirements – regarding facilities, medical devices, staff – as well as process requirements – regarding governance, quality management, medical audit, clinical care protocols, registration of adverse events, collection of patient feedback, and respect for patients’ rights. Health care professionals’ licencing requires a minimum number of hours of professional training. The SHCAA can inspect facilities either to investigate patients’ complaints or to verify that licencing criteria are met.

The SHCAA has recently launched an accreditation programme, but it seems to attract few providers. In March 2016, an accreditation programme was initiated to promote quality improvement, which is voluntary and currently limited to PHC providers. By the end of 2016, only five PHC organisations had applied for accreditation and ten more were in the preparation stage (Ministry of Health, Lithuania, 2016). In January 2017 a financial incentive in the form of a marginally higher capitation for accredited clinics was introduced, although it seems to be inadequate to substantially raise interest, possibly because of the accreditation fee clinics have to pay. By the end of 2017 only 16 institutions were accredited (SHCAA, 2018).

Some clinical guidelines exist but information about their effective use is lacking. The Ministry of Health has issued 123 diagnostic and treatment protocols (in cardiology, oncology, neurology, traumatology and paediatrics). Providers are encouraged to follow them, regardless of the ownership or level and volume of the services provided. If there are no nationally approved protocols, health care providers are required to prepare protocols themselves for the high risk diagnostic and treatment procedures (Ministry of Health, Lithuania, 2016). No mechanisms are in place to monitor compliance or support providers in implementation. To date, patient safety has received very little attention. Overall, Lithuania lacks a system-wide support for continuous health care quality improvement.

Some initiatives put greater emphasis on measuring and – at least for primary care – rewarding quality

Quality is increasingly monitored and Lithuania in 2017 reported data on a range of OECD-HCQI indicators. In 2012, a set of 15 quality indicators for hospitals was adopted, in line with the PATH (Performance Assessment Tool for Quality Improvement in Europe) recommendations. Quantitative indicators include for instance the frequency of Caesarean sections, mortality from myocardial infarction during active treatment, mortality from stroke during active treatment, and the frequency of development of pressure ulcers. Qualitative indicators pertain to patient satisfaction and the presence of some processes (for instance adverse event reporting system). However, the procedure for engaging hospitals in a quality discussion, limited to a yearly discussion of the results between the managers of the facilities and the NHIF, is weak. Hospital remuneration is not tied to quality. For primary care, a set of indicators is used to calculate a performance-based add-on to the capitation (see below). It is worthwhile highlighting though that in 2017 the MOH participated in the OECD HCQI data collection efforts, the results of which are analysed further below.

Information on quality is shared transparently in an effort to support an informed choice for patients. Quality indicators for hospitals are published annually on the website of the SHCAA. For primary care, many quality indicators are calculated to facilitate bench marking by clinics and municipalities. For example, the Hygiene Institute routinely produces avoidable hospitalisation rates for each municipality. For patients, data on individual facilities’ performance is readily available on-line, published by the five territorial insurance funds. While this is a very welcome step towards improving transparency, further steps could be taken to contextualise and make this information interpretation-friendly. For example, the five funds provide different level of detail and present the data in different ways on their respective websites.

PHC remuneration is organised to reward performance, through fee for service and a pay-for-performance component. Facilities receive an age and sex-adjusted capitation rate (72.9% of total PHC facilities’ revenue in 2016) with an additional per capita amount for rural facilities (7.1% of revenue). PHC providers also receive activity- or output-based payments for a list of specific services (10.7% of revenue). The list of 63 services which render additional payments includes immunisation, monitoring of pregnant women, early diagnosis of tumours, and home visits by nurses. The final element of remuneration is a result-based payment based on a list of performance indicators (9.3% of revenue). In recent years, the share of capitation in total revenue for PHC providers has declined in favour of higher performance payments.

The performance based payment for PHC is well intended and monitored, and some indicators show improvements. Twelve indicators are taken into account to determine the payment. They include to the proportion of registered adults who visits the clinic at least once per year. For children, the same indicator is used plus one for the share of children who received a dental screening. Four indicators monitor cancer screening (breast, cervical, colorectal and prostate cancer screening) and four indicators relate to results achieved for chronic patients: hospitalisations of patients with asthma, diabetes, hypertension and schizophrenia. Given the burden of disease and the still relatively low screening rates (see below), the focus on non-communicable diseases of the pay-for-performance is welcome. Results are monitored by the NHIF, which for instance show that the cervical cancer screening rate for registered patients rose from 23 percent in 2008 to 35% in 2015. Other screening rates are also improving and hospitalisation rates for chronic diseases are decreasing, albeit slowly. There is however large room for improvement, as compared to other countries (see next section). In the absence of an evaluation framework, the impact of the scheme is difficult to ascertain.

A review and revision of the pay-for-performance component would be warranted. The knowledge base on indicators which should be used for adequately remunerating performance suggests a number of good practices (McColl et al., 1998, EXPH 2017). In particular, the performance criteria should point to results which can be directly influenced by the provider and are sensitive to their level of effort, reflect important clinical areas, but also more generally encourage the delivery of appropriate services. In this regard, the indicators used in Lithuania could be improved. For example, a high share of listed adults who visit PHC over one year, which generates a bonus payment, does not necessarily mean the clinic meets those in most need of a consultation. Furthermore, general check-ups for healthy adults are not shown to improve morbidity or mortality. Finally, access in Lithuania is well developed (previous chapter) and in 2016, 92% of PHC clinics reached the highest level of performance on this indicator. Therefore, the usefulness of this indicator in the performance scheme could – at this point – be debated. As another example, the indicators on avoidable hospitalisations which are certainly relevant to monitor the performance of PHC at a high-level, may not be so appropriate at the level of a single (especially small) facility as they are not only impacted by primary care. Additionally, the denominator (number of listed patients diagnosed with a certain chronic disease) can be affected – and potentially manipulated – in response to the performance scheme, calling its robustness in question. For chronic diseases, performance schemes typically use processes indicators to reward clinical excellence (for example, blood pressure checks for patients with hypertension, tests for HgbA1c for diabetic patient) or better intermediate outcomes (for example, cholesterol control in people with diabetes or controlled blood pressure). So, while monitoring and rewarding performance may be appropriate, the current system could be better calibrated.

Additional measures directly support the delivery of more effective services

In recent years, Lithuania has undertaken two interesting initiatives to strengthen specific services which have a strong potential to increase the effectiveness of service delivery and thus quality.

An EU-funded programme supporting the integration of health and social services has been the main initiative to encourage care co-ordination. In Lithuania, efforts to encourage the coordination of care across health providers are essentially limited to requirements made for providers to communicate with one another when patients move across different parts of the system. In 2013 however, the Ministry of Social Security and Labour launched the Integrated Assistance Programme to offer integrated health and social care to the disabled and elderly. In 21 municipalities, 70 mobile teams provide integrated services (nursing and social care) at home, including support to their informal care givers. Funding from the EU will support the expansion to all municipalities but funding is only secured until 2020. The project-based approach can help devise effective solutions to integrate services, but carry a risk that they may not be sustained. Given the increasing population at need for such services, the programME should be carefully evaluated and – if cost-effective – sustainably funded.

The recently introduced functional clustering can strengthen the quality of specific hospital services for which rapid access is needed. In 2013, a new wave of reforms established standardised pathways for patients who suffer from specific conditions for which a fast response is required, namely stroke and some types of myocardial infarction (with elevated ST). Under the “Integrated Health Care and Functional Cluster Systems”, depending on severity, patients are directed by emergency services either to the regional hospital or one of the six regional stroke treatment centres or five cardiology centres established by the programme. They receive an initial treatment and can be later transferred to a facility closer to their home. For strokes, the programme has essentially allowed the development of intravenous (IV) thrombolysis or thrombectomy in the country, two types of procedures used to treat and remove blood clots from the body.

Although a more complete evaluation is required, results are encouraging. According to data provided by the Ministry, the rates of IV thrombolysis, a quality indicator monitored in stroke care which remain disappointingly low in many high income countries (Scherf et al, 2016), has increased dramatically in Lithuania. In 2012, 160 intravenous thrombolyses were performed and in 2016, 808. For thrombectomies the number rose from 4 to 276. Since the creation of Percutaneous Coronary Intervention Centres (open 24/7) for the cardiology patients, the time of access to the required intervention has dropped and hospital mortality in patients is decreasing2. The Government plans on expanding this clustering system to all people who suffer from a myocardial infarction. These measures, as well as selective contracting based on minimum volume, hold great potential for increasing the quality of inpatient services in Lithuania but it will be critical to demonstrate more rigorously that they lead to improvements in clinical outcomes.

The satisfaction of the Lithuanian population in the health system is increasing

A number of European surveys suggest that Lithuanians are more satisfied with their health system than in the past. According to Eurobarometer, the population’s view on the quality of health care improved dramatically between 2009 and 2013. Between these 2 years, the share of Lithuanians rating the overall quality of health care in the country as good increased from 40 to 65%, the largest increase among European Union countries, although this share is still below the EU average (71%) (European Commission, 2014). The European quality of life survey (Eurofound, 2017) also shows increased trust in the health care system. On a scale from 1 (very poor quality) to 10 (very high quality), the average rating of the quality of health services in Lithuania has increased from 5.1 to 6.3 between 2003 and 2016, the fourth highest increase in the European Union (Figure 3.8). Patient satisfaction is an important quality metric and the progress shown is surely encouraging. Yet, as the rest of the section will show, results on outcomes of care are not progressing as fast and lag at the bottom of the distribution.

Figure 3.8. The rating of health services quality has increased over time in Lithuania

Quality ratings of health services in European countries 2003 and 2016

Source: European quality of life survey 2016 (Eurofound, 2017).

Prevention and treatment at the primary care level must still improve

Immunisation rates could be higher. High rates of children immunisation were one of the hallmarks of soviet systems, which many countries have retained. Results in this regard in Lithuania are a bit disappointing and around or slightly below OECD averages: 93 percent of children are immunised against diphtheria, tetanus and pertussis, 94 percent against measles and 94 percent against Hepatitis B – the only rate at par with the OECD average (2015). Although Influenza vaccination coverage for people above 65 is much higher than in Latvia and Estonia, at 19.5% it remains well below the OECD average (Figure 3.9).

Figure 3.9. One of five people over 65 received a flu shot in 2015

Percentage of population aged 65 and over vaccinated for influenza, 2015

Source: OECD Health Statistics 2017, https://doi.org/10.1787/health-data-en.

PHC in Lithuania is increasingly effective in managing chronic diseases and keeping people out of the hospital. Hospitalisations for ambulatory care sensitive conditions are among the key quality indicators for primary care. Hospitalisations for these conditions have been declining in Lithuania since 2005, although from very high levels. The gains are however unevenly distributed across the country with more modest improvements in rural areas, possibly caused not only by differences in available PHC services but also differences in social conditions and support (Jurevičiūtė and Kalėdienė, 2016).

Lithuanian data submitted to the OECD for the years 2012–2015 confirms that the proportion of patients hospitalised for congestive heart failure, asthma and COPD has been decreasing. For Asthma and COPD, the rates are in fact converging with OECD averages, keeping in mind that this progress is only relative as many countries manage to achieve substantially lower rates of hospitalisations. On the other hand, despite progress, for congestive heart failure, the proportion of patients hospitalised still remains the highest among 32 countries reporting this indicator to the OECD, more than twice the average rate. Hospitalisation rates for diabetes are a third higher than the OECD average and do not seem to decline (Figure 3.10).

Figure 3.10. Hospital admissions for chronic conditions are declining in Lithuania

Age-sex standardised hospitalisation rates per 100 000 population aged 15 and above

Source: OECD Health Statistics 2017, https://doi.org/10.1787/health-data-en.

Hospital mortality for acute conditions is stubbornly high

The quality of acute health care services also needs to improve. Mortality after hospitalisation for acute conditions is the most common indicator for measuring hospital care quality and is collected by the OECD for international comparison purposes. For the first time, Lithuania provided 30 day mortality data for AMI, haemorrhagic stroke (caused by bleeding) and ischemic stroke (caused by blood clotting) in 2017. In all cases, Lithuania’s figures considerably exceed OECD averages. Figure 3.11 for instance shows that Lithuania has the second highest mortality rates of all OECD countries that are able to link mortality data across health providers for AMI and ischaemic stroke. Although Lithuanian data is only available for four years (2012–2015), results have not improved over this period. It will be all the more important to monitor the impact of on-going clustering of stroke and cardiac services. In addition, Lithuania should expand the number of quality indicators reported to the OECD, particularly on patient safety to better benchmark its performance.

Figure 3.11. Thirty-day mortality after admission to hospital for AMI and ischemic stroke are the second highest in the OECD

1. Three-year average. 2. Results for Canada do not include deaths outside of acute care hospitals.

Note: Based on patient (linked) data.

Source: OECD Health Statistics 2017, https://doi.org/10.1787/health-data-en.

Cancer care, which relies on both effective PHC and hospital services, is improving although results still lags behind most OECD countries

This section concludes with a disease-oriented perspective on quality by looking at results on cancer care.

Despite progress, PHC providers struggle to ensure better coverage of cancer screening. Lithuania has set up publicly funded population-based screening programmes for common cancers: breast, prostate, colorectal and cervical cancer and coverage of the target population has increased over the last 10 years. In 2015, 45% of targeted women had been screened for breast cancer compared to only 12% in 2006, a significant improvement from very low levels. For cervical cancer, the national screening programme started in 2004 and coverage has increased more slowly, from 43% in 2010 to 48% in 2015. However, these screening rates still lag behind most OECD countries and in both cases, the numbers put Lithuania among OECD’s poorest performers (Figure 3.12). According to NHIF data, in 2016, 46% of targeted men were screened for prostate cancer. Colorectal cancer screening, first piloted in 2009 and nation-wide since 2014, is now reaching 43% of the target population.

Figure 3.12. Cancer screening rates for women are low

1. Programme data 2. Survey data * Three-year average

Source: OECD Health Statistics 2017, https://doi.org/10.1787/health-data-en.

Primary care is given a large responsibility in the management of the screening programmes but national governance can be tightened to increase coverage and secure equity. Primary care providers have the responsibility to inform patients about the screening programmes and refer eligible patients. They are also incentivised to reach a high uptake through the primary care reimbursement system. All four screening programmes are included in the primary care quality indicators list with a graded payment scale depending on the number of screened people as share of eligible people listed with the clinic. Unlike most other countries with population based programmes, invitations to eligible target groups are not sent through central screening registries, but from the individual primary care centres. Consequently, invitations and follow up for positives are not systematically managed the same way across the country, and take up is to a large extent dependent on the primary care clinic. This also means it is potentially more difficult to automatically link screening data to cancer and other health registries and there is still no screening registry in the country (European Commission, 2017). The National Cancer Prevention and Control Programme (2014–25) is aiming for both improved quality of screening tests and development of the national cancer register, including data linkages to providers and diagnose facilities, among other results. To reach acceptable coverage and equity across the country in this decentralised screening system, more national level steering in addition to the current incentives is probably needed.

Overall, the effectiveness of cancer care quality has improved considerably but still lags behind most OECD countries. Five-year survival rates after cancer diagnosis for most forms of cancer have increased substantially over the past decade and faster than in many other countries, but remain among the lowest in the OECD. Breast cancer survival has increased from 65 to 74% between 2000-04 to 2010-14, but it remains behind those of neighbouring Baltic countries Latvia and Estonia. Similarly colorectal cancer treatment is increasingly successful and at par with neighbouring countries. Colon cancer survival has increased from 45 to 57% in the same time period (CONCORD programme, LSHTM, 2018). For prostate cancer, survival has doubled between the late 1990s and the late 2000s. However, much of the increase in cancer survival is driven by earlier detection, which increases survival also without decreasing mortality (Krilaviciute et al., 2014). All in all thus, from diagnostic to treatment, progress is still needed.