OECD Reviews of Health Systems Lithuania Publication Launch. Vilnius, May 25, Agnès Couffinhal Senior Economist, Health Division OECD

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1 OECD Reviews of Health Systems Lithuania 2018 Publication Launch Vilnius, May 25, 2018 Agnès Couffinhal Senior Economist, Health Division OECD

2 An in-depth review of the health sector Objective Evaluate Lithuania s policies and practices as compared to OECD best policies Progress and Remaining challenges Access and Sustainability Efficiency and Quality

3 Recognise progress and remaining challenges Socio-economic context Resources available in the health system Organisation and governance: key assets On balance, disappointing health outcomes 3

4 A very dynamic economy with considerable challenges Lithuania has one of the fastest growing economies in the OECD Average annual growth , % Real GDP Real GDP per capita But growth has not been inclusive enough: 20% of the population is at risk of poverty or social exclusion Population aged years, % change, main scenario Lithuania s working age population will decline rapidly over the next 30 years

5 Lithuania s spending on health is modest but broadly aligned with resources Total expenditure on health per capita PPP DEU NLD NOR 5000 FRA BEL SWE AUT JPN CAN AUS DNK 4000 NZL GBR FIN ISL 3000 PRT SVN ESP ITA GRC ISR 2000 CHL HUN SVK CZE KOR MEX EST LVA POL 1000 LTU TUR GDP per capita PPP USA CHE

6 Practising nurses per population, 2015 Lithuania has more human resources for health than many Practising doctors per population, UK 8 CZE LTU 6 LTV

7 Organisation and governance Lithuania stands out for its. Comprehensive transformation Health Insurance Fund Modern Primary Care Consolidation of hospitals Modern payment methods Consistency in policy directions Service delivery agenda Importance of prevention and public health Institutional stability A comprehensive approach to health embedded in government strategy Horizontal priority for Lithuania 2030

8 Poor health status Life expectancy In 45 years, life expectancy at birth has increased by four years only and is now lower than anywhere in the OECD

9 Poor health status An ECA-wide story Smith & Nguyen (2013)

10 Poor health status Comparison with OECD mortality patterns 8% 6% 5% 3% 2% Diseases of the circulatory system Cancer External causes of mortality Unsurprisingly, NCDs are the main causes of mortality 20% 56% Other causes Diseases of the digestive system Diseases of the respiratory system (2015) Ratio between standardized morality rates Lithuania vs OECD, Lithuania stands out on CVDs, external causes of death (suicide), liver diseases and TB All causes Diseases of circulatory system Ischemic heart diseases Cerebrovascular disease Cancer External causes Intentional self-harm Diseases of digestive system Chronic liver disease and cirrhosis Diseases of respiratory system Tuberculosis

11 Poor health status Slower decline in CVDs 950 Lithuania Latvia Hungary Slovak Republic Estonia Czech Republic Poland OECD

12 Poor health status Unhealthy behaviours are widespread Highest reported alcohol consumption in the OECD and rising Litres per capita (15 years and older) Additionally: Men are among the most frequent smokers in the OECD Obesity among women is average

13 Poor health status Among the highest levels of avoidable deaths in the EU Eurostat Database (standardised death rates per population, 2014)

14 Governance A missing ingredient? Data infrastructure reasonably strong Genuine efforts to avail information to the public User-friendly Data analytics (Independent) impact evaluation Are we getting the results which matter If not why? Data-driven performance discussions Accountability for results

15 Sustainability and access By and large, a positive story 15

16 A resilient system provides effective health coverage Social Health Insurance covers virtually all the population State explicitly contributes on behalf of the economically inactive population Coverage translates into effective access to services: 8.7 consultations per year (25% above OECD av.), 24 hospitalisations per (50% above OECD av.) Relatively low use of diagnostic tests

17 Consistent story of relatively low unmet needs Unmet need for medical examination for financial, geographic or waiting times reasons, by income quintile, 2015 High Total Low Income population Income Netherlands Austria Slov enia Germany Spain Czech Republic Lux embourg Sw eden Norw ay Sw itzerland (2014) France Denmark Slov ak Republic Belgium Hungary Ireland United Kingdom Lithuania Portugal OECD25 Finland Iceland Italy Poland Latv ia Greece Estonia % EHIS 2014 Unmet need for financial reason 2% of the population for medical care 5% for dental care 2% for prescribed pharmaceuticals SILC Survey

18 Financial protection High OOPs by OECD standards, especially on pharmaceuticals % of spending out-ofpocket 32% of spending on health for an OECD average of..20% 42%.on outpatient care.27% 68%..on pharmaceuticals..42% More on this during WHO s presentation

19 Sustainability Health is not a very high priority Health as a share of public spending 26% 24% JPN CHE 22% USA DEU 20% NZL NLD 18% IRL SWE GBR AUS CAN NOR 16% ISL OECD DNK FRA CZE ESP 14% AUT BEL EST ITA KOR MEX SVN 12% LUX SVK PRT FIN ISR POL 10% LTU HUN TUR LVA GRC 8% 25% 30% 35% 40% 45% 50% 55% 60% Public expenditure as a share of GDP

20 Sustainability Bridging different perspectives Effective budget management Countercyclical financing of health Projected increases in contribution on behalf of inactive population NHIF balances its budget and builds provisions and reserves Facilities finances are overall sound Public spending projected to increase less than in most of Europe BUT Sustainability is not just about spending little Spending more will not solve all problems (next section). Nor will increasing salaries of health workers

21 Efficiency and quality: The crux of the matter to accelerate progress 21

22 The system could deliver more value for money Life expectancy in years Life expectancy at birth and GDP per capita, 2015 (or nearest year) 85 JPN FIN CAN ISR ESP ISL ITA FRA AUS CHE LUX KOR SWE NOR NLD IRL GRC NZL AUT PRT DNK 80 SVN GBR CRI DEU CHL CZE BEL USA TUR POL EST SVK CHN MEX HUN 75 BRA COL LVA LTU RUS 70 IDN IND R² = GDP per capita (USD PPP)

23 Efficiency The number of beds has slowly declined but remains high

24 Efficiency The acute care bed occupancy ratio is lower than the OECD average in 85% of Lithuanian hospitals Average Lithuania OECD 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

25 Efficiency Consolidation also warranted on quality grounds Many hospitals produce very low volumes of complex services 22 hospitals carry out less than one surgery a day 15 hospitals carry out a major obstetric surgery less than once a week Minimum volumes have been introduced Consolidation of the network remains insufficient and may require governance reforms (networking, mergers, joint ownership)

26 Efficiency Also about setting the right priorities Prevention Recent efforts go in the right direction Effective enforcement and impact Develop services in line with the burden of diseases Thrombolyses and thrombectomies Mental health

27 Quality Policies and institutions are in place to encourage quality Accreditation program in place More than 120 clinical protocols issued P4P and FFS in PHC encourage prevention Functional clustering Satisfaction with the quality of services is improving 1-10 scale EU Lithuania European Quality of Life Survey 2016

28 100 Quality Prevention One of five people over 65 received a flu shot in Cancer screening: progress remains insufficient

29 Quality Primary care Hospital admissions for chronic conditions are declining OECD-2013 Lithuania OECD-2013 Lithuania Asthma Diabetes Age-sex standardised hospitalisation rates per population aged 15 and above

30 Quality Hospital care Thirty-day mortality after admission to hospital for acute myocardial infarction based on patient data

31 Quality Improving safety and effectiveness Need to strengthen data quality on patient safety and increase transparency/use of quality data; Hold providers accountable for quality (prescription) Develop a continuous quality assurance culture, in particular a national adverse event reporting and learning system, set up a system to encourage and monitor compliance with guidelines.

32 In sum: OECD key recommendations Accelerate efforts to rationalise the use of hospital resources and rebalance service delivery, with greater emphasis on care co-ordination and mental health at PHC level; Invest effectively in public health to tackle risk factors, notably harmful alcohol consumption; Develop a quality assurance culture to better measure results and hold stakeholders more explicitly accountable for improving them; Scale up the system s capacity to evaluate the impact of policies and understand the reasons for their success or lack thereof.

33 Concluding remarks The Health Committee requested an update on reforms two years after accession. Since opinion formulated, positive developments on alcohol regulation and the development of the first medicines policy guidelines with explicit efforts to reduce the cost to patients. Step up efforts to demonstrate impact. Ultimately: cultural shift towards a more resolutely people-centred approach.

34 Ačiū a Agnès Couffinhal, Karolina Socha-Dietrich and Jens Wilkens agnes.couffinhal@oecd.org You may now download the Review at 34