20 years of transition: experience and challenges in ... years of transition: experience and challenges in health financing in Lithuania ... 34% AMW before tax) 2010 745 Lt vs 2125

20 years of transition: 20 years of transition:

experience and challenges in experience and challenges in

health financing in Lithuaniahealth financing in Lithuania

L. L. MurauskieneMurauskiene

ASSPRO CEE 2007 meetingASSPRO CEE 2007 meeting

Budapest, May 2011Budapest, May 2011

ASSPRO CEE 2007

Collaborative Focused Research Project

FP7-SSH-2007 Grant Agreement no.: 217431

ASSPRO CEE 2007, Budapest 2011ASSPRO CEE 2007, Budapest 2011

Public health expenditure (Public health expenditure (mlnmln. Lt). Lt)

0

1000

2000

3000

4000

5000

6000

1993

1995

1997

1999

2001

2003

2005

2007

2009

Value in current prices

Value in constant 1993

prices


Total health expenditure (2)Total health expenditure (2)

1035

1223

1493

1789

21422008

1035 1019 994 949867 836

0

500

1000

1500

2000

2500

2004 2005 2006 2007 2008 2009

in current prices

in 2004 prices

-12,00

-10,00

-8,00

-6,00

-4,00

-2,00

0,00

2,00

4,00

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Change in current prices

Real change

MlnMln EurEur %%


THE THE -- private & publicprivate & public

Shares of GDP (%)Shares of GDP (%)

4,1 4,2 4,4 4,6 4,7 4,5 4,6 4,8 5

3,9 44,3 4,5 4,5

1,41,8

1,7 1,51,6 2 1,7 1,6

1,6

1,81,9

1,9 1,7 1,7

0

1

2

3

4

5

6

7

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Share of private health care expenditure in

GDP (%)

Share of public health care expenditures in

GDP (%)


Public health expenditure (3)Public health expenditure (3)

mlnmln. Lt. Lt

4,1 4,24,4

4,6 4,74,5 4,6

4,85

3,9 4

4,34,5 4,5

0

1000

2000

3000

4000

5000

6000

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

0

1

2

3

4

5

6

Value in current prices

Share of public health care expenditures

in GDP (%)


Health related public expenditure Health related public expenditure

(%)(%)

28

6

65

28

7

66

30

6

64

32

7

61

34

8

58

38

8

55

0

20

40

60

80

100

2004 2005 2006 2007 2008 2009

Health care

Sickness

Disability


THE 2009 (NHA, THE 2009 (NHA, mlnmln. EUR, %). EUR, %)

Private insurance, 13,

1%

Direct OOP, 519, 26%Others , 1, 0%

SHIF, 1226, 61%

Public over SHIF, 247,

12%


The SHIFThe SHIF

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

-100

-50

0

50

100

150

revenue

expenditure

surplus/deficite


SHIF sourcesSHIF sources

0

500

1000

1500

2000

2500

3000

3500

4000

4500

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Other

State budget

State contribution

Income tax/Sic

Payroll 1


Who is in charge?Who is in charge?

State contributionState contribution

(2008 (2008 -- 27%, 2011 27%, 2011 --

34% AMW before tax) 34% AMW before tax)

2010 2010

745 Lt 745 Lt vsvs 2125 Lt2125 Lt

2 109 423 (1 880442 in 2 109 423 (1 880442 in

2009)2009)

713

372350269314

357 382 385470

560

701 742831

1001

1132

12561270

874

730

468

0

200

400

600

800

1000

1200

1400

0-4 10-

14

20-

24

30-

34

40-

44

50-

54

60-

64

70-

74

80-

84

90-

94

amžius

Lt


Health InsuranceHealth Insurance

Social insurance contribution or tax basedSocial insurance contribution or tax based

Obligatory inclusionObligatory inclusion

Autonomy Autonomy -- not consolidatednot consolidated

Tripartite management Tripartite management –– under the MOH, under the MOH,

Supervisory Board (role & presentation) Supervisory Board (role & presentation)

Single fund (central & 5 territorial Single fund (central & 5 territorial

branches)branches)

Responsibilities in financing Responsibilities in financing


Territorial allocation (deviation per Territorial allocation (deviation per

capita in capita in LitasLitas))

37

14

2

59

6

7

1

16

14

13

4

47

0 10 20 30 40 50 60 70

Health care

Pharmaceuticals

Rehabilitation

Total

Litas

2009

2005

2000


Contracting/PaymentsContracting/Payments

↑↑ No of servicesNo of services

↑↑ targeted targeted programmesprogrammes

↑↑ contractscontracts

Reference pricesReference prices

Points and volumesPoints and volumes

““GameGame”” stories: stories:

PHC PHC

Hospitals Hospitals

Medicines, etc.Medicines, etc.


Reforms agendaReforms agenda

WagesWages

Restructuring of the services (III stage)Restructuring of the services (III stage)

-- Requirements & standardsRequirements & standards

-- Prioritization in purchasingPrioritization in purchasing

-- ReRe--allocation of the funds (reserve)allocation of the funds (reserve)

-- InvestmentsInvestments


Public expenditure (%)Public expenditure (%)

46 46 49 48 49 48

4 44 4 4 3

4 44 6 7 94 45 6 6 6

37 38 35 32 30 30

2 2 1 2 1 12 2 2 2 3 33 3 6 7 4 1

0

20

40

60

80

100

120

2004 2005 2006 2007 2008 2009

Capital

Administration

Prevention & public health

Supplies

Anxcillary

Long-term care

Rehabilitation

Treatment


Public health expenditure in 2009 Public health expenditure in 2009

((mlnmln. EUR, %). EUR, %)

Hospitals, 728, 36%

Nursing & long-term

care institutions, 31,

2%

Outpatient care

providers, 449, 22%

Suppliers, 586, 29%

Administration, 72,

4%

Other activities, 138,

7%


Main toolsMain tools

RegulationsRegulationsLegislation Legislation ““boomboom””

By lawsBy laws

FundingFunding

ContractingContracting

PaymentsPayments

PricingPricing

LOST INLOST IN

Professional/expertProfessional/expert

Ownership/GovernanceOwnership/Governance

OPERATIONAL OPERATIONAL

ISSUES?ISSUES?


ImplicationsImplications

PowerPower--driven driven

BureaucracyBureaucracy

Reality? (e.g. statistics)Reality? (e.g. statistics)

3700 3700 –– 800800

epidemiologyepidemiology

Experience Experience


NormsNorms

ExperienceExperience

Experience + Theory = KnowledgeExperience + Theory = Knowledge

Documents

20 years of transition: experience and challenges in ... years of transition: experience and challenges in health financing in Lithuania ... 34% AMW before tax) 2010 745 Lt vs 2125