- We at LFMI do not call reform that which the Ministry of Healthcare does. In economic terms a reform is supposed to be related to economic concepts of ownership and competition. When we talk about competition in market terms, we have to think of the rise of the market and a tangible growth of the private sector; we have to think of the patient becoming a welcome client but not a pushed-around appendage to the system. True, the healthcare system is undergoing some restructuring today, but obviously this will not give any structural result. The restructuring of healthcare institutions is but a small element in the overall structural reform and, to our opinion, this element is not even necessary.

- The core of healthcare reform is to provide for the rise of service prices. And prices are not the same as compensations. We have prices on the pharmaceutical market and we can find out what the prices of medicines are by going to a pharmacy. But in the service market prices are still non-existent, and at the outpatient clinic we can learn the prices of additional services at best. So we cannot talk about effectiveness in today’s service market. Effectiveness can be achieved only when healthcare establishments charge competing prices. What we have today is ancillary economic constructs such as compensation and cost. But this is not a price.

How the prices of healthcare services should appear, statutorily or not, is a question of tactics. The result of the reform should be a system in which patients know what the prices of services are, what proportion of the price they are compensated for and how much they have to pay as a surcharge. As to compensations, they have to be applied not only in public healthcare establishments and not only in Lithuania. A situation like this would condition the rise of competition among service providers. Private healthcare institutions are an important element of the reform. And there should be more and more of them.

- No doubt, the private sector is too small. All over the world the private sector pushes healthcare establishments to improve the quality and effectiveness of their services. They lure away patients from public institutions by nothing but better quality. This is the way to spur the public sector. Public organizations in any sector, not only healthcare, are neither flexible nor innovative nor ready to respond promptly to customers’ requirements. Strengthening the private healthcare market would kill two birds with one stone: on the one hand, it would absorb a large proportion of patients and it would serve as a catalyst to increase the effectiveness of public service providers on the other. Unlike public establishments, private healthcare institutions have a stronger motivation to work effectively because they have to hold out.

- In terms of control, yes: it is much easier to control budgetary organizations. And the state wants to do that. The introduction of insurance medicine might have created an erroneous impression that insurance medicine handles people’s premiums and not budgetary funds. However, mandatory health insurance has very few features of insurance. There is not much difference whether healthcare services are financed by the Mandatory Health Insurance Fund or the state budget. After all, both sources rely on state funding.

We should go in another direction: healthcare institutions should be put up for auction and privatized. I do not see any other way out. The equivocal status of public healthcare institutions we have today is no good. Their directors are neither public officials who could be easily controlled by administrative methods nor private subjects who are controlled by the market. Accounting standards and practice in public organizations, not only healthcare institutions, are simply impenetrable, so it is very hard to manage them financially. I really do not think that public service providers are a salvation: they have many advantages but they also have many flaws. That is why I think they should turn towards the market but not the budget. What would we gain if public healthcare establishments went back to the budget? - Stricter control and nothing more. This would not create stronger motivations for better services or competition. A possibility of putting them into private ownership would be gone. As a result, we would remain at the same level, but this is not enough for today’s healthcare system.

- Judging from official statements it would seem that everything is getting better and salaries have been raised. However, every doctor would say that this was a very negligible increase. It is absurd for doctors to earn the salaries they do today.  Mind you, they are specialists who have alternatives in Europe. Our doctors are forced to win back that which they lose under the pressure exerted on private institutions by migrating and working in the West! How long do we think doctors will keep earning less than the country’s average?

- There are no resources to satisfy the demand for healthcare services. And it does not matter whether it is 5 percent of GDP or less. Not a single EU country can apportion as many resources as are required to meet their citizens’ healthcare needs. What differs is only the quality of services. Germans would certainly not tolerate the quality we in Lithuania do. We find it amazing but Germans would not think it funny if the rims of glasses which were covered by insurance last year would not be covered by insurance this year. Societies are aging all over Europe. People receive longer treatment, too, so the demand for services will keep growing in the future. We cannot expect to satisfy this demand with budgetary funding. We should set a limit on how much we can spend on healthcare. We have no other way out but to let consumers set this limit themselves. Every person should say how much he or she can spend on his or her health.

- I am sceptical of comparison. We lack much of what wealthier countries possess. Of course, the level of healthcare spending is a question of political agreement. But even if we set it, we should not close the door to additional, insurance money. And we already know what the ratio in Lithuania is: compensations from the Mandatory Health Insurance Fund cover 70 percent of services, and we pay, in one way or another, the remaining 30 percent. Unofficial payments comprise a large portion of these funds. The problem is that unofficial payments cripple the whole system and create a parallel one. The worst problem is that patients are baffled and do not know how they should behave when they get sick. There are two systems. One of them is official, but when patients have to deal with it, everything appears to be different as they are required to pay surcharges. Yet, information is unavailable because there are no prices. If this money remained in one system, we would have an absolutely different picture. We would have insurance that would alleviate the existing tension at least for the statistical average consumer.

- There are many myths about the American healthcare system, but this is not because there is too much market in healthcare provision there but because there is too little of it. The prices of healthcare services and insurance coverage are outrageous, but this is caused by state regulation because the state requires unrealistic terms of insurance which in turn push the prices up.

European countries have different healthcare models, but all of these models are in a crisis. EU countries are unable to maintain their extensive and generous systems, and they cannot satisfy the demand for healthcare services. Ensuing problems are reflected in different ways: the French healthcare system has a continuously high financial deficit, while England suffers heavily from a lack of doctors. There are long lines in all countries, so the patient is not welcome anywhere. Who is the winner in a system like this? We know from the Soviet experience that the winners are those who have access to services, through bribes or telephone calls to familiar doctors. This is corruption, a degenerated model, a prototype of a Soviet system if you wish.

- Civil society organizations find themselves in a difficult position because there is much antagonism between doctors themselves within this system. Who are the largest and the strongest group in the system? They are doctors who have authority, doctors who dispense money and have solid patients paying bribes, doctors who receive the latest equipment and, lastly, political protection. And they hold down the other part who cannot make careers or obtain better jobs or earn higher salaries.

These are two sides of the barricade, so to speak. One of them is interested in maintaining the system at the expense of the other. The other would welcome reforms I have talked about, but today the reform proponents do not belong to the elite of the system because they do not have authority. Those who attempt to change the system are promptly forced to quit. In this case we have a silent conspiracy of the medical elite with politicians, people who also fall ill and want quality treatment. The suppressed part of the medical world is afraid to change this system. The problem is the same as with lawyers whose salaries were raised for the very same reason. So the situation is double-edged. The flank of new-generation doctors - those who wish to work in Lithuania - should gain strength.  

- Thank you.