4.2 Human resources
4.2.1 Health workforce trends
The main trends for the health workforce in Lithuania are shown in Table4.1 and Fig4.6–Fig4.10. Overall, the health workforce has decreased by approximately 18%: from 65 000 in 1990 to 47 000 in 2010, mostly through a large decrease in nursing personnel (Health Information Centre, 2013). The overall number of physicians per 100 000 population in Lithuania fluctuated between 360 and 375 in the period between 1992 and 2010 (Fig4.6). In 2010, it was 372 – higher than in Estonia, Latvia and the EU averages. The number of nurses per 100 000 population over that period has decreased from 944 to 722 – higher than in Estonia, Latvia and the EU12 (Fig4.7) and lower than the average for the EU15 (Fig4.8). The number of dentists has increased from 55 to 75 per 100 000, a figure similar to the EU15 average (Fig4.9). The number of pharmacists increased from 52 to 66 per 100 000 in the period from 1994 to 2003 (Fig4.10). The reporting then changed from physical persons to pharmacists licensed to practise, resulting in a break in the series (data not shown because of this lack of comparability). In 2010, there were 88 licensed pharmacists per 100 000 population (European Commission, 2013).
Unequal distribution of medical personnel throughout the country presents a serious problem. Countrywide in 2010, the density of practising physicians ranged from 906 to 54 per 100 000 population, but even within regions the density varies by up to a factor of 7; a similar situation is found for nurses and midwives. Moreover, the Lithuanian health workers’ trade union stresses that health system reforms, particularly hospital network reorganization (e.g. declining functions of hospitals in rural areas), are leading to increased unemployment among health professionals, mostly nurses.
Another cause of physician shortages in Lithuanian provinces is the absence of a centralized model for medical personnel planning and training. At present, universities have de facto control over physician training because of the lack of comprehensive, national-level human resource planning. The dominant position of university clinics in physician training inevitably results in imbalances in physician availability throughout the country.
Forecasts indicate that 40–60% of medical professionals currently working will exit the health workforce before 2025 because of their age; they will need to be at least partially replaced by newly trained specialists (Starkiene, 2012).
Ongoing human resources issues in Lithuania are the availability of trained health-care workers and migration. Other problems include ageing of physicians (currently, the average age varies from 49.6 years for family doctors to 56.2 years for internal medicine specialists), lack of medical residents in some specialties (obstetrics–gynaecology, neurology and ENT), high (about 20%) student drop-out rates and shortcomings in workload management.
4.2.2 Professional mobility of health workers
The issue of health worker migration has been the subject of broad debate in Lithuania, particularly since joining the EU in 2004. A study conducted in 2006 showed that the main drivers for emigration among health and social care workers were low wages, excessive workload, poor working arrangements and unsatisfactory work environment (Public Policy and Management Institute, 2006).
Health worker migration data showed that the number of doctors requesting professional certificates valid abroad was 357 in 2004 as Lithuania entered the EU, 186 in 2005 and 139 in 2009. For nurses, it was 107 in 2004, 166 in 2005 and 267 in 2009 (Padaiga, Pukas & Starkiene, 2011a). However, the number of certificates does not reflect the number of health workers actually leaving the country. A study showed that in the first two years since joining the EU about 0.6% of nurses, 0.5% of physicians and almost 2% of dentists left Lithuania annually (Starkiene et al., 2008). Their main destination was the United Kingdom, followed by the Nordic countries. By contrast, the numbers of work permits issued to foreign nationals were negligible: in 2005–2008; only 15 medical doctors, 6 nurses and 2 dentists sought permission to practise in Lithuania (Padaiga, Pukas & Starkiene, 2011b).
A more recent analysis (Lithuanian University of Health Sciences, 2011) reported that 3% of health professionals left the country between 2004 and 2010. Among surgeons, gynaecologists and obstetricians, these percentages are higher: 8.5%, 4.7% and 6%, respectively. Nevertheless, Starkiene et al. (2013) suggest that human resource policy in health care during the 2000s has followed evidence-based recommendations and that policy actions (increase in salaries, increase in enrolment for training programmes, change in medical residency status and professional re-entry programmes) have prevented major outflows of physicians from the health sector and country. In spite of this, the ageing workforce will increasingly pose a challenge.
4.2.3 Training of health workers
Physicians are trained at the Lithuanian University of Health Sciences (known as Kaunas University of Medicine until 2010) and the Faculty of Medicine at Vilnius University. The number of graduates from these schools has been increasing annually and in 2010 reached around 1500, with another 500 completing residency training. Since 2001, Klaipeda University and the Lithuanian Sports University are included on the list of higher education institutions providing training for health professionals (e.g. public health, nursing and physical therapy). There are also six colleges providing vocational training for nurses and other health-care personnel.
In 1992, formal training for physicians was extended to include residency training programmes following the six-year undergraduate period, and in 1995 it was harmonized according to EU standards. According to the Government Resolution of 2003, current medical training programmes cover undergraduate and postgraduate levels: six years for the diploma (five years for odontology and pharmacy and four years for public health, nursing, midwifery and rehabilitation) and three to six years for residency training programmes depending on specialty. A master’s degree in public health, nursing or rehabilitation can be obtained in two years, and doctoral studies span a four-year period. Non-university training programmes last from two to three and a half years. Since 1995, a proportion of students have had to pay for studies.
Specialist training for GPs, lasting 33 months, was first implemented in 1991, while retraining courses (lasting up to 52 weeks) started in 1993. The Ministry of Health planned to retrain the majority of GPs by 2010, with a target of 2500 trained or retrained GPs (Minister of Health, 2003). However, only 1849 GPs were actively employed in that year (Health Information Centre, 2012). A number of obstacles impeded the achievement of the target: a lack of teachers, difficulties for practising physicians to leave their jobs and families for retraining, and the significant financial burden of living expenses despite the government financing the costs of courses.
There are six vocational training institutions for nursing, midwifery and social care in Lithuania, teaching around 3500 students annually. There are also university degree programmes in nursing, with around 300 graduates annually. There have been a number of recent changes to improve nursing training. The curriculum now places greater emphasis on health promotion activities and community care. Nursing students also gain more practical skills, in part thanks to a larger role for qualified nurses in training. Nurses are increasingly promoted as semi-independent health practitioners.