Seimas of the Republic of Lithuania Resolution No XII-964 of Approval of the Lithuanian Health Strategy 2014-2025


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Translated by the Ministry of Health
 
SEIMAS OF THE REPUBLIC OF LITHUANIA
RESOLUTION NO XII-964
of approval of the LITHUANIAN health strategy 2014–2025
 
26 June 2014 Vilnius
 
Seimas of the Republic of Lithuania, in accordance with Article 46 of the Law of the Republic of Lithuania on the Health System and paragraph 1 of Article 10 of the Law of the Republic of Lithuania on Public Health, decides:
 
1 article.
To approve Lithuanian Health Strategy 2014–2025 (as appended).
 
 
Speaker of the Seimas                                                                       Loreta Graužinienė
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ADOPTED
By the Resolution of 26 June, 2014 No XII-964
by the Seimas of the Republic of Lithuania 
 
LITHUANIAN health strategy 2014–2025
 
I CHAPTER
GENERAL PROVISIONS
 
1. The Lithuanian Health Strategy 2014–2025 (hereinafter – Strategy) sets goals and objectives  of health care activities and target indicators needed to achieve the level of health set out in the goals of the National Development Strategy: Lithuania 2030, adopted 15 May, 2012 by Resolution No XI-2015 of the Seimas of the Republic of Lithuania „Regarding adoption of the National Development Strategy: Lithuania 2030 (hereinafter  – National Development Strategy: Lithuania 2030), in the National Development Program 2014–2020 adopted 28 November, 2012 by the Decision No 1482 of the Government of the Republic of Lithuania  „Regarding adoption of the National Development Program 2014–2020 “ (hereinafter – National Development Program), and in the National Reform Agenda, adopted 27 April, 2011 by the Decision No. 491 of the Government of the Republic of Lithuania  “Regarding the Lithuanian Convergence Program of 2011 and National Reform Agenda (hereinafter - National Reform Agenda).   
2. Health is a human value and the foundation of life, and as such, it must be strong enough to allow conditions for everyday issues to be coped with successfully and overcome social and economic challenges.  Public health is both an asset and capital and as such its protection and fostering should be the main goal of the State, thereby ensuring the country’s social and economic development. Healthy and able people are a guarantee for sustainable development and economic growth. Therefore, in order to contribute to achieving the goals stated in European Commission's Communication of 3 March, 2010 Europe 2020-  A European strategy for smart, sustainable and inclusive growth (hereinafter – European Commission Communication Europe 2020), special consideration must be given  to the protection and promotion of the public health. Public health is directly linked to productivity of a population.  A healthier society can contribute to improvements in work efficiency, economic growth and competitiveness whilst reducing social deprivation and health inequalities.
3. The Constitution of the Republic of Lithuania enshrines the foundations of health care in the first paragraph of Article 53: The State shall take care of people’s health and shall guarantee medical care and services for persons in the event of sickness. The procedure for providing medical care to citizens free of charge at state medical institutions shall be established by law. The doctrine of the Constitutional Court of the Republic of Lithuania (hereinafter – Constitutional Court) emphasizes that “individual and public health is one of the main human values” (inter alia the ruling  of the 11 July, 2002 of the Constitutional Court regarding compliance with the Constitution of the Republic of Lithuania  of „The Law on the health care system of the  Republic of Lithuania Article 39, the Law on long-term funding of science and education of the Republic of Lithuania Articles 1, 2 and 3, the Law on the Structure of the state budget of the Republic of Lithuania chapter 2 of the Article 18 and the 1chapter of the  Article 172 of the Statute of the Seimas of the Republic of Lithuania, the Decision of 29 September, 2005 “Regarding the compliance of the pharmaceutical practice Law  4 paragraph of the Article 17 (edition of the 4June, 2002), the Decision of 21 June, 2011 “Regarding the constitutional compliance of the Gambling Law 2 paragraph of the Article 10(edition of the 25November, 2003)“, the Decision of 16 May, 2013 „Regarding constitutional compliance of certain provisions the Law on social security, Law on social security in case of illness and motherhood, and their amendments“. In the explanatory notes regarding the constitutional provision in which “the state takes care of the health of the people” the Constitutional Court has stated repeatedly that “health of the people is an important constitutional objective, as well, as a public interest, and taking care of the people's health is a function of the state” (inter alia Decision of 26 January, 2004 by the Constitutional Court „Regarding the constitutional compliance of the Alcohol control Law 4 part of the Article 1 (version of 2 July, 1997), 1 part of the Article 2 (version of 18 April, 1995), 2 item of the 3 paragraph of Article 1, 4  paragraph of Article 2 (version of  10December, 1998), Article 13 (version of 18July, 2000), 1 paragraph of Article 30 (version of 2 July, 1997) and 4th paragraph of Article 44 (version of 20 June, 2002) and Decision No 67 of the Government of the Republic of Lithuania (version of 22 January, 2001) „Regarding adoption of the regulation of the alcohol production licencing and constitutional compliance of the adopted items 7 and 9 of the Regulation”, Decision of 29 September, 2005 „Regarding constitutional compliance of the Law on the pharmaceutical practice 4 paragraph of Article 17 (version of 4 June, 2002)“, Decision of 21June, 2011  „Regarding the constitutional compliance with the Gambling law of the Republic of Lithuania 2 paragraph of the Article 10 (version of 25 November, 2003)”, the Decision of  16 May, 2013  „Regarding the constitutional compliance with certain provisions of the Law on social security of the Republic of Lithuania, The Law on social security in the event of illness and motherhood and amendments to the latter”).
4. The Strategy is based on the results of an analysis of the health care system reforms which was completed during the implementation of the Human Resource Development Program approved by the Decision of the European Commission No K (2007) 4475 of 24 September, 2007, with the last amendments introduced by Decision of the European Commission No C (2013) 6262 of 26 September, 2013, focusing on priority No 4: „Improving administrative skills and effectiveness in public administration sector”.
5. The Strategy is based on provisions and values inherent in the following: the World Health Organization (hereinafter – WHO) policy document  for the European region Health 2020: a European policy framework supporting action across Government and society for Health and wellbeing; best practices of the European Union (hereinafter – EU) member states; principles recognized by the doctrine of the Constitutional Court: universal coverage, solidarity of the society, social cohesion, equality of individual rights, participation of civil society in decision making, elimination of discrimination, assertion of dignity in all stages of health promotion and service provision, quality and accessibility of health care, continuity and sustainability of health care, responsible management, transparency and objectivity in decision making and implementation, responsible, rational and effective use of resources, and accountability.
6. A healthy society is a precondition for a smart, sustainable and inclusive economy and thus the Strategy contributes to the implementation of the European Commission Communication ‘Health 2020’ by embracing values representative of a democratic and civil society.
7. In order to achieve the main goal, fixed in 12 subparagraph of the Strategy, it is necessary to, involve the country as a whole – the Government of the Republic of Lithuania (hereinafter – Government), and unite all economic sectors, communities and families in this process for health. The majority of the population supports such an initiative.
Representative opinion polls of the Lithuanian population confirmed in 2011 that 92% of the population concurred with the statement, that “health should be the most important or one of the most important issues for the state”, thus health could and should be actively promoted during the period 2014–2025.
8. Article 46 of the Law on the Health Care System of the Republic of Lithuania (hereinafter – Law on the Health Care System) is the legal foundation of the Strategy and stipulates that the Lithuanian Health Strategy is to be proposed by the Government and adopted by the Seimas of the Republic of Lithuania (hereinafter – Seimas), in accordance with paragraph 1 of Article 10 of the Law of the Republic of Lithuania on Public Health, The Seimas approved, that Lithuanian health strategy sets the goals, tasks, anticipated health indicators of the Lithuanian residents.
 
9. The Strategy complies with the provisions of the Constitution of the Republic of Lithuania, the National Development Strategy: Lithuania 2030, the National Development Program, the Program of the 16 Government 2012–2016, adopted by the Seimas Decision No XII-51 of 13 December, 2012 „Regarding the Program of the Government of the Republic of Lithuania”, Lithuanian health system development framework document 2011–2020, adopted by Seimas Decision No XI-1430 of 7 June, 2011 “Regarding adoption of the framework document for the development of the Lithuanian health care system 2011–2020”, provisions of the WHO Framework Convention on Tobacco Control, ratified by the Law „Regarding the ratification of the WHO Framework Convention on the Tobacco Control”.
10. The Strategy also implements provisions of the Law on National Security Framework and National Security Strategy, adopted by the Seimas Decision No IX-907 of 28 May, 2002 “Regarding adoption of the National Security Strategy”, which is equivalent to the long-term national security enhancement program.
11. Terminology used in the Strategy:
11.1. Electronic health (hereinafter – eHealth) – is the use of information and communication technologies (ICT) combined with organisational change in healthcare systems and new skills in order to improve health care services (individual, public, pharmaceutical) by the immediate delivery of comprehensive personal health information to ensure entirety of health care, medical informatics and health care management.
11.2. External causes of death – fatal transport incidents, falls, mechanical impact by biological and natural forces, accidental drowning and asphyxiation, effect of electricity, radiation, temperature and pressure extremes, impact of smoke and fire, effect of heat and burns, contact with poisonous animals and plants, effect of natural forces, accidental poisonings, self-harm (suicides), attempted murders and actual murders, deaths of undetermined intent, legal use of force and military action, medical and surgical complications.
11.3. Chronic non-communicable diseases– long-term and usually slow progressing illnesses such as cardiovascular illness, cancer, diabetes, chronic respiratory diseases and mental disorders.
11.4. Standardized mortality – mortality indicator per 100 thousand of population, if the Lithuanian population structure by age corresponds to the established European standard.
11.5. Health technologies – medication, medical equipment and/or medical and surgical procedures, including disease prevention, diagnostics or treatment procedures, used in provision of healthcare services.
II chapter
GOALS AND oBJECTIVES OF THE strategy
 
1 image. Main goal of the program, main indicator, goals and objectives.
MAIN GOAL
The main goal of the Lithuanian Health Strategy 2014-2025 is the attainment of improved health of the Lithuanian population by 2025 as well as longer life and reduced health inequities.
MAIN INDICATOR 
Average life expectancy of the Lithuanian residents (to achieve that until 2025 average life expectancy for Lithuanian residents would be 77.5 years)  
GOAL
1. Create safer social environment, reduce  health inequities and social exclusion
2. Create health promoting working and living environment
3. Foster healthy lifestyle and its culture  
4. Ensure high quality and effective health care focused on population needs.
OBJECTIVES
1.1.Reduce level of poverty and unemployment
2.1. Create safe working conditions and healthy household conditions, increase consumer safety of goods and services.
3.1. Reduce consumption and accessibility of alcoholic drinks, illegal use of narcotic and psychotropic substances, also accessibility of gambling, computer games and such.
4.1. Ensure sustainability and quality of health care system through development of evidence based effective health technologies.
1.2. Reduce social and economic  disparities  at the national and community level
2.2. Create conditions promoting safe leisure.
3.2. Promote healthy eating habits
4.2. Develop health care infrastructure and improve health care service quality, safety, accessibility and patient centred-health care.
2.3. Reduce number of injuries in road traffic incidents.  
3.3. Develop habits for optimal physical activity.  
4.3. Improve maternal and child health.
    2.4. Reduce air, water and soil pollution, noise.
3.4. Promote oral hygiene and preventive habits for oral care.
4.4. Strengthen measures for prevention and control of chronic non-communicable diseases.
4.5. Develop Lithuanian e-health system (development of the e-health infrastructure, solutions and integration into EU e-health space).
4.6. Ensure health care in crisis and emergency situations.
 
12. The main goal of the Strategy is to achieve better population health, increase life expectancy, improve citizens' health and reduce health inequities by 2025.
13. Healthy people have a greater potential to work and grow, attaining a better quality of life, while sick people risk unemployment and social exclusion, since ill-health reduces productivity and generates treatment and health care costs.
14. Important determinants of public health are the following: demographic indicators, social and health inequalities, physical living and work environment, individual lifestyle and health care system.  
15. Best international and national practices demonstrate that sustainable improvement in population health can be achieved by combining major health promoting factors.  Therefore the Strategy sets the following 4 goals:
15.1. To build a safer social environment, to reduce health inequities and social deprivation;
15.2. To create health promoting physical environment for work and living; 
15.3. To foster healthy lifestyles of the population and a culture of promoting it;
15.4. To guarantee provision of high quality and effective health care focused on the needs of the population.
16. The conclusions of the assessment of the Lithuanian Health Program, adopted by the Seimas Decision No. VIII-833 of  2 July, 1998 „Regarding the adoption of the Lithuanian Health Program” (hereinafter – the Lithuanian Health Program 1998–2010), the achievements and failures of the Program implementation for 1998-2010, stipulates that during the period 1998–2010 a continuity of the health policy was ensured, a legal framework for health care was secured and substantial improvements of patient right protection were achieved.
17. The main achievements of the Lithuanian Health Program 1998–2010:
17.1. The main goal was achieved – in that the average life expectancy of the population was increased  from 71.39 years in 1998 to 73.45 years in 2010;
17.2. Major progress was made in pregnancy and new-born care, resulting in a reduction in new-born mortality rate from 9.3 per thousand live births in 1998 to 4.3 per thousand live births in 2010;
17.3. A reduction in tuberculosis morbidity was achieved: in 1998 active tuberculosis morbidity without relapses was 79.6 cases per 100 thousand inhabitants, while in 2010 – 49.7 per 100 thousand inhabitants. It is however important to note that this indicator is still among the worst in the EU;
17.4. A reduction in preventable death rate. Measures implemented to reduce trauma and accidents, combined with alcohol consumption control provided key contributions to this achievement. Implementation in 2008–2010 of the State Program for Road Traffic Safety 2005–2010 adopted 8 July, 2005 by the Government Decision No. 759  “Regarding adoption of the State Program for Road Traffic Safety 2005–2010” is an appropriate example of the successful health promotion  program. This significant initiative by the Ministry of Transport and Communications of the Republic of Lithuania proved the importance of intersectoral cooperation for the sake of the health of the population. On the other hand, the significant lag between Lithuania and old EU member states until 2004 (hereinafter – old EU member states), confirm that the potential solutions for this problem are not yet fully exhausted.
18. Main failures of the implementation of the Lithuanian health program 1998–2010 were:
18.1. A lack of awareness of sustainable development and cooperation aspects not only prevented progress in solving economic, social, well-being, environmental and public health problems, but also occurred at a time when the public health sector was tackling major public health issues. Consequently, several health indicators are considerably poorer than in other countries: e.g. high external mortality rates, mostly due to alcohol consumption. Suicide rates remain a major public health issue;
18.2. A failure to reduce the level of cardiovascular morbidity – the results of the specialized prevention program initiated in 2004 are expected only in the next ten years;
18.3. A number of health care services, such as odontology, sanatorium treatment became less accessible for citizens in the lower income group, children, and the disabled; consequently indicators  of oral health worsened;   
18.4. A delayed reform of the public health sector hindered public health specialists to take leadership in bringing together different sectors, institutions and citizens for the strengthening of health promotion activities;  
18.5. The remaining issue of shortcomings in rational distribution of health care resources – human, financial, material and information;
18.6. Mental health, social deprivation and health inequities among population remain a challenge to the public health policy;
18.7. Education for healthy lifestyle did not prove effective enough to positively influence healthy life expectancy;
19. Despite public health promotion failures in particular years or fields, the overall public health indicator trends were positive during the implementation period. Major mortality causes and demographic changes in Lithuania are similar to those of the new EU member states (hereinafter – new EU member states), which joined the EU between 2004 and 2013.
20. Three main mortality causes – cardiovascular diseases, cancer and external causes of death in 2012 accounted for 85.1% of all causes of death.  Cardiovascular disease caused more than half of the deaths – 56.6%, cancer  – 19.5%, external causes  – 8.9% of all deaths (Table 1).
 
Table 1.Cause of death in 2012
No
Cause of death
Proportion of mortality from specific cause in %
1.
Diseases of the circulatory system
56.6
2.
Cancer
19.5
3.
External causes of death
8.9
4.
Disease of the digestive system
5.0
5.
Diseases of respiratory system
3.1
6.
Infectious and parasitic diseases
1.5
7.
Other causes of death
5.4
 
21. The population in Lithuania has been decreasing between 1997–2010 due to reduced birth rates and increasing emigration, with a trend towards population ageing – in the period 2001-2014 the proportion of children under 14 decreased by 37.4%, while the proportion of adults over 65 increased by 13.8%. In 2014 adults over 65 years of age accounted for 17.4% of the Lithuanian population. There is an increasing burden of morbidity due to chronic non-communicable diseases in the country and correspondingly an increasing demand for human and financial resources to treat and nurse this patient group.
22. Standardized mortality indicators per 100 thousand populations are highly divergent in Lithuanian municipalities.  In 2010 only 3 municipalities exhibited mortality lower than average of the new EU states, and in 2012 only 24 municipalities had lower mortality than the Lithuanian mortality average. 
23. Inequities in mortality standardized per 100 thousand population in Lithuanian municipalities are provided in Image 2.
 
Image 2. Standardized mortality indicator per 100 thousand in Lithuanian municipalities
 
24. According to research there is no decrease in health inequities between male and female populations, city and rural areas, different educational levels. In Lithuania, populations with higher levels of education live healthier and longer, while populations with lower levels of education experience greater health related problems, such as:
24.1. The average life expectancy of Lithuanian men is nearly 11 years less than it is for women. Moreover, this gap is markedly greater than in most other EU member states;
24.2. Persons attaining university education live on average 11.3 years longer than persons with only secondary or lower education;
24.3. Persons living in the cities have an average life expectancy 3 years longer than those inhabitants living in rural areas; 
24.4. Women with lower income report on average 3.2 times more health problems, than women in a higher income group. Among men this difference is on average 2.3 times higher than in the high income group.
25. Conditions and settings for Strategy implementation: development of a legal framework, creating direct associations between competencies of the state and municipalities and health promotion goals, increasing material and financial resources necessary for achieving these goals.
26. Increase in average life expectancy should result primarily from a consistent decrease in early onset deaths (before the age 65), accompanied by an increase in healthy life expectancy and delaying illness incidence and related deaths.
27. The Lithuanian average life expectancy is mostly lowered by external causes of death which can’t be reduced by isolated efforts and actions by health sector (Image 3). Standardized mortality rates per 100 thousand population for external causes of death among the productive age group in Lithuania is significantly higher than in old and new EU member states. 
 
Image 3. Indicator of standardized mortality from external causes per 100 thousand population in 2010 per age groups
28. Circulatory system related diseases account for most deaths (in absolute number of deaths) in Lithuania as well as in other EU member states. Potentially most lives will be saved due to prevention and control of cardiovascular mortality, once the 2009 level of mortality indicators of the new EU states is achieved during the Strategy implementation.
29. To successfully achieve the outlined goals and objectives of the Strategy, the health promotion process should become more effective and other sectors of the state economy should focus increasingly on health needs of the population. 
30. It is possible to involve citizens and different economic sectors more effectively through improvement of legal regulation, creating direct links between competencies bestowed upon state and municipalities and health promotion goals, and increasing available material and financial resources. 
31. State and municipal institutions seeking to improve effectiveness of the health care system management should assume responsibility for:
31.1. Developing public management, seeking to improve effectiveness of public management and satisfying population health needs;
31.2. Improving level of  public employees’ qualifications, strengthening capacity to implement best practice experience, improving skills required for searching national and international data-bases for the evidence based health promotion measures (if there is lack of information, to be able to order/tender research), utilize information technology.
32. Both the Government and the Ministries during 2014-2025 need to focus on increasing overall investment for health care by households, businesses and the State. Additional investment would result in longer and healthier lives of the Lithuanian population. In turn a healthier population would mean increased productivity, more competitive business and strengthening of human capital. Improvements in population health, lower death rates (especially among the working population) are one of the major responses to the demographic and economic challenges of modern Lithuania.  
33. State spending for health care services and medical goods are significant throughout all stages of the health promotion process: i.e. health promotion, disease prevention, diagnostics, and treatment, as well as rehabilitation.  Experience of EU member states shows that even in a growing economy, health care spending as a whole (state and private) grows faster than economic growth, reflected in the gross domestic product (hereinafter GDP). The increase in GDP is slower than the increase in health expenditure, due to the changes in the nature and extent of the needs of the ageing population. It is important to note that healthcare funding in the State budget structure was stable for the period of 2004–2012 and covered 65–72% of overall health care expenses in Lithuania. The 2014–2025 Program should ensure that health care costs proportion of GDP is similar to those of most of the EU member states.
34. Overall investment for health care by households, business and state during 2014-2025 should grow consistently by combining several streams of funding:  state funding through planning annual budgets and contributions to Mandatory Health Insurance Fund, supplementary insurance, direct payments from inhabitants, and business investments to health care. 
35. The first goal of the Strategy is to create a safer social environment, reduce heath inequities and social deprivation.
36. The Lithuanian social welfare system guarantees social stability and calm, but does not necessarily foster confidence in the future for all Lithuanian inhabitants.  In 2000–2010 an increasing social disparity was reflected by an increasing gap between health indicators of populations with stable and large incomes and those with irregular and small incomes, as well as between those living in stable family relationships and those who were single, and between individuals living in the cities and those living in rural areas. 
37. Increase in personal income and improvements in social status are often accompanied by health improvements. Persons from low income and low social status groups experience economic deprivation, have more psychological and social security problems, as well as fewer opportunities for acquiring healthy lifestyles, especially when the country’s social welfare system does not ensure dignified (adequate) living conditions.
38. One of the main assets of health promotion is reduction of poverty and other forms of social deprivation. Overall, in Lithuania poverty levels in the rural areas reached 28.5% of the population in 2012 - significantly higher than in the cities. One fifth of the Lithuanian population lives at risk of poverty, material deprivation or in families with unemployed members. Such individuals are unable to invest sufficiently in quality housing or health promotion.
39. The National Reform Agenda notes that one of the main ways to reduce poverty and social deprivation is by implementing a health care policy that promotes equal rights of individuals.
40. Article 4 of the Law on health systems states the main goal of the health care activity is to reduce health inequities between different social and professional groups while avoiding a reduction of the overall level of health of the citizens. This statement is an integral provision of the Strategy.
41. Safer social environment, reduction of the health inequities and social deprivation are the main contributions made by the state, municipal institutions, nongovernmental organizations (hereinafter– NGO) and business towards health promotion.  
42. Ensuring multisector contributions to health promotion is the main political commitment from all levels of government defined in international documents as “health in all policies” and “whole of Government approach”.
43. To achieve the first goal of the Strategy – i.e. create safer social environment, reduce health inequities and social exclusion – the following objectives are being set: 
43.1. To reduce poverty and unemployment;
43.2. To reduce social and economic disparity at the population and community level;
44. Sustainability of the social welfare system, as well as poverty, unemployment, work-related and everyday stress impact on the dynamics of chronic non-communicable diseases, also on trauma and suicide rates.
45. Suicide rates in Lithuania are the highest amongst EU member states.  According to Eurostat in Lithuania the suicide mortality per 100 thousand was 32.1 in 2006, 34.7 in 2008, and 32.9 in 2010. The suicide rate is almost 3 times higher than the EU average (11.7 in 2010). The rate of violence is reflected in the rate of homicides and other crimes, bullying among schoolchildren is also high in Lithuania.
46. According to epidemiological research 13% of Lithuanian schoolchildren have been diagnosed with mental disorders. The rate of bullying among schoolchildren is also very high: approximately 60–70 % of children report having experienced bullying as victims and/or as perpetrators.
47. As previously mentioned, suicide mortality in Lithuania has been the highest in the EU for many years. Therefore there is a need to unite society to solve the suicide problem. According to evidence based research, by implementing suicide prevention measures, such as reducing rates of ill-health (depression, anxiety, post-traumatic stress and behavioural disorders) determined by poverty, social deprivation and unemployment – it is possible to achieve significant progress in a relatively short time-frame.
48. Issues of safe childhood, adulthood and elderly in Lithuania are coordinated by 5 ministries: Ministry of Social Affairs and Labour, Ministry of Health, Ministry of Environment, Ministry of Education and Science, Ministry of Internal Affairs. In the past years these ministries have been instrumental in producing positive changes in key areas of suicide prevention: a significant expansion of social security, achieving adequate results (comparable with international practice) in the drug treatment of mental illness, accomplishing a breakthrough in bullying prevention in schools. However, there is an absence of leadership in producing comprehensive solutions for the problematic issue of suicide.
49. To achieve suicide prevention it is necessary:
49.1. To ensure a safe childhood. Measures minimising psychological conflict within families, preventing violence between family members will help protect the mental health of babies and children. Increased competency in recognizing potential violence in a child’s environment among specialists in education and social work will help act and secure timely and adequate assistance. Social skills acquired by children in education and social care institutions ensure full participation of children in society.  Informal education opportunities are providing additional special competencies, involving children in educational activities and shape a child’s outlook on the world, value system and creativity; 
49.2. To ensure safe adolescence. Harmonizing relations between schoolchildren and teachers, controlling bullying in schools and streets, reducing psychological conflict within families, preventing violence against family members protects the mental health of the adolescent. Accessibility to professional services (psychologists and health care specialists) reduces the risk that young persons will choose suicide as the solution to their accumulated problems. It is appropriate to create a repeat socialization system for underage offenders;
49.3. To ensure safe adulthood. There was a significant (nearly 1.5 times) drop in suicide rates in the working age population (45–59 years of age) in Lithuania from 2000–2007, which can be explained by increased employment stimulated by economic growth. According to analysis from other countries, the psychological state of the population is affected not only by the situation of the employment market, but also by unemployment benefits and social protection system. In countries where the social welfare system is more favourable towards the unemployed, there is less of a correlation between suicide and unemployment indicators, than in countries providing more modest unemployment benefits. For example, in Lithuania in 2010 less than 20% of individuals registered in the State Unemployment Office received unemployment benefits. Accessibility to professional psychological and health care services, collaboration between health care systems, education and cultural systems, supporting adult participation in informal education and continued adult learning programs, as well as measures to control alcohol, tobacco, psychoactive substance use, and gambling dependency disorders are very important in achieving safe adulthood. A significant element of suicide prevention are comprehensive and coordinated activities involving the medical community, representatives from the church, culture, arts and mass media. The highest suicide rates in Lithuania are among the working age population (45–59 years), therefore it is reasonable to focus on healthy and safe psychosocial environment at work. The European survey of enterprises on new and emerging risks – ESENER in 2009 has shown that up to 27.9% of employees report psychosocial factors that negatively affect their mental health and approximately 14% of employees report work related health problems, specifying anxiety and depression; 
49.4. To ensure healthy ageing. Combinations of factors determine the level of health at retirement age: how advanced the pension, psychological and clinical health care systems are, and the social life and learning opportunities for the elderly. It's important to note that in the old EU member states individuals over the age of 75 years commit suicide more frequently. Increased participation of persons older than 65 years in health promotion programs has direct impact towards increasing life expectancy and improving functional capability;
49.5. To ensure cooperation of the various sectors and institutions of education, health care, culture, social care, improving creative partnerships, especially those focusing on shaping holistically healthy young personalities and creating conditions favourable for the process, as well as stimulating persons with low motivation and encouraging their participation in cultural activities and social life, involving cultural establishment and artists.
50. Support of family, friends and community has a positive effect on health. Social networks, trust in society and people, provides resources to cope with problems, helps people to feel included as an important member of the community, increase life satisfaction, influences choice for a healthy lifestyle, helps avoid health problems and might reduce preventable mortality.
51. To establish/develop a child mental health strategy. It is important to develop psychological services for children, especially in education and health care systems.
52. To reduce social and economic (income) inequity; reduce the number of homeless persons and strengthen solidarity within the community.
53. The level of community solidarity affects trends of chronic non-communicable diseases, trauma, especially disorders due to effects of cold. The number of cold conditions related health problems is considerable. In Lithuania more than 300 people die from the cold every year, despite the Lithuanian climate not being particularly harsh. For example, in 2012 there were 331 deaths due to natural cold (76% of cases were people of working age), whilst in the same year there were 392 deaths due to transport incidents. While there is much awareness and focus on transport deaths in Lithuania, the effects of cold are largely ignored. However, this is a problem requiring urgent and radical solutions. Moreover, in addition to the aforementioned problem, other health issues, determined by the social-economic disparity of the population and community also need to be solved.
54. To reduce the rates of illness and deaths resulting from natural cold it is necessary:
54.1. To reduce consumption of alcoholic drinks and the illegal use of psychoactive substances; 
54.2. To draw the community and public employees’ attention concerning homeless and uncoordinated persons;
54.3. To develop social and health care services for socially vulnerable persons, especially clients of overnight shelters (temporary residence) and sobering services;
54.4. To develop services for the integration of persons returning from places of incarceration.
55. The second goal of the Strategy – is to create health promoting physical environment for work and living.
56. To achieve the second goal of the Strategy – create health promoting physical environment for work and living–the following objectives are set: 
56.1. To create safe and healthy conditions for work and living, increase safety of consumer goods and services;
56.2. To create conditions for safe leisure activities;
56.3. To reduce number of transport events and trauma in transport events;
56.4. To reduce air, water and soil pollution, noise.
57. To create safe and healthy conditions for work and living, ensure safety of consumer goods and services it is necessary:
57.1. To develop legal documents, regulating occupational health and safety, protecting from and reducing occupational risks;
57.2. To foster assessment of occupational risk, research into accidents at work and work-related illnesses;
57.3. To ensure accessibility of occupational medicine services;
57.4. To develop research into employee health and safety, focusing on prevention of accidents at work and occupational diseases, promotion of employee health and reduction of morbidity, improve monitoring system for work related accidents.
58. The second objective – to promote conditions for safe leisure.
59. The implementation experience during 2008-2010 of the National Trauma Prevention Program, adopted on 7 May, 2008 by Government Decision No 448 „Regarding change of the Decision No 423 of 14 April, 2000 „Adoption of the National Trauma Prevention Program 2000–2010” indicates that through demonstration of political will and use of the best international practices, Lithuanian institutions were capable of adequately responding and reducing trauma rates. A comprehensive implementation of the National Trauma Prevention Program (improved education of the public, targeted investment in the most effective measures for traffic incidents reduction, strengthening legal framework and enforcement, increasing penalties of legal violations [traffic regulations, special focus towards the quality of young drivers traffic performance, quality of driving]) for 2008–2010  achieved impressive results: a significant drop in number of deaths, injuries and cases of disability due to traffic accidents.   
60. To promote conditions for safer leisure it is necessary:
60.1. To ensure education of the population and encourage use of personal safety equipment;
60.2. To increase the number of swimming lessons for schoolchildren;
60.3. To improve first aid training;
60.4. To improve activity of the rescue services in public leisure places, increase   qualifications of rescue specialists and supply of material resources needed for carrying out their work; 
60.5. To reduce accessibility of alcoholic drinks and their consumption, strengthen implementation and control of the regulation for alcohol sale;
60.6. To support voluntary work and NGO efforts to develop opportunities for safe leisure.
61. To achieve reduction of traffic accidents and trauma in traffic accidents it is necessary:
61.1. To continue implementation and development of measures that have produced good results and broaden variety of road safety measures;
61.2. To reduce the legal level of alcohol in the blood to 0 for beginner drivers,  for vehicles with maximum mass of 3,5 tons or more than 9 passenger seats, for taxi and motorcycle drivers and encourage the population to more actively report violations of the regulation.
62. The fourth goal – reduction of air, water, soil pollution and noise.
63. Lithuania is a member of the UN Conventions for reducing pollution of atmosphere and implements EU environmental regulations for the control of air quality. Lithuania meets its obligations and does not exceed permitted levels of pollution. For the past several years the air quality in Lithuanian cities has been adequate, meaning that the number of days of excess pollution registered did not exceed the permitted number of non-compliance days.
However, whilst Lithuania has been meeting its obligations, it was noted that in 2010 the number of permitted non-compliance days was being exceeded in the world’s largest cities.
There is also an increasing risk that average target annual values for benzo[a]pyrene concentrations applicable since 31 December, 2012 could be exceeded. 
64. One of the major issues regarding water quality of Lithuanian rivers and lakes is pollution with food and organic substances, evidenced by high concentrations of nitrogen and phosphorus in the water. The main source of organic pollution in Lithuania is disseminated agricultural pollution and city wastewater. To achieve a high quality ecological standard for the water bodies it is necessary to reduce the level of river pollution from these substances. Lithuania has abundant underground water resources, but increasing consumption engenders the need to protect and save this resource. The problem of safeguarding the quality of the drinking water in wells still remains.
65. Lithuania has successfully implemented the first stage obligations of the  Directive 2002/49/EC of the European Parliament and of the Council of 25 June, 2002 relating to the assessment and management of environmental noise (OJ L 189, 18.7.2002, p. 12–25) (hereinafter – Directive 2002/49/EC) – European Commission had no warnings regarding the strategic noise maps and noise prevention action plan produced and delivered by Lithuania during the first stage of implementation of the Directive 2002/49/EC. In 2012, five years after the initial mapping, the maps were updated and new strategic noise maps for the agglomerations, major roads and railroads were drawn. The mapping reports were delivered to European Commission and received favourable reviews, yet the problem of environmental noise remains a serious problem in Lithuania:
65.1. In major cities the main source of environmental noise is road transport. Assessment of strategic noise map information for Vilnius, Kaunas, Klaipeda, Siauliai and Panevezys in 2012  determined that approximately 78 thousand (about 14% ) Vilnius city inhabitants live in buildings affected by day, evening and night noise with indicator values  exceeding Lden (65 dBA), in Kaunas city  – approximately 80 thousand(about 25%), in Klaipeda city – approximately 55 thousand (about 34%), Siauliai city – about  19 thousand (about 16%) and Panevezys city – about 1,2 thousand inhabitants;
65.2. In the buildings in Vilnius affected by night noise indicator  Lnight value limit (55 dBA) exceeding norm  approximately 67 thousand (about 12%) inhabitants, in Kaunas city– about 103 thousand (about 33%), in Klaipeda city – about 49 thousand (about 30%), in Siauliai city – about 22 thousand (about 18%) and in Panevezys city – about 1 thousand inhabitants;
65.3. The noise due to everyday human activity still poses a significant problem and is confirmed by the statistical data of Eurostat population surveys:  in 2010  14.1% of the Lithuanian population reported suffering from  neighbour or street produced noise (air or other type of pollution bothered 12.1% of the Lithuanian population in 2010).
66. To achieve reduction of air, water, soil pollution it is necessary: 
66.1. To reduce air, water, food or soil pollution, to prevent chronic non-communicable diseases and other health disorders;
66.2. To reduce impact of the ultraviolet radiation, prevent skin cancer cases or burns, damage to immune system.
67. The third goal of the Strategy – fostering healthy lifestyle and culture promoting it.
68. To achieve the third goal of the Strategy – fostering healthy lifestyle and promoting its culture, the following objectives are being set:
68.1. To reduce consumption and accessibility of alcoholic drinks, illegal use of narcotic and psychotropic substances, also accessibility of gambling, computer games and such;
68.2. To promote healthy eating habits;
68.3. To develop habits for optimal physical activity;
68.4. To promote oral hygiene and preventive habits for oral care.
69. The first objective is to reduce consumption of alcoholic drinks, tobacco use, illegal use and accessibility to narcotic and psychotropic substances.
70. There is a proven cause and effect relationship between the average amount of alcohol consumed and more than 60 illnesses.  Alcohol consumption is directly linked to alcoholic liver disease, accidental poisoning, mental disorders and alcoholic cardiomyopathy, it is also one of the risk factors for chronic diseases – cardiovascular, liver cirrhosis, cancer (especially the digestive system and breast cancer), pneumonia and pancreatitis and other. 
71. The majority of mortalities due to external causes are considered to be deaths partially caused by excessive use of alcoholic drinks.
72. Europe is the region with the highest consumption of alcohol per capita in the world, however there are large differences between countries varying from 0.5L to 21.0L per capita per annum. Research shows that reduced price and the expansion of sales outlet networks increases consumption and the number of deaths related to alcohol use.
73. Research also shows that alcohol is the third biggest harmful risk factor for premature death after elevated blood pressure and tobacco smoking, often more important than high cholesterol levels and overweight. It is estimated that it results in 3.2% of all deaths (1.8 million.) and 4.0% of DALYS (58.3 million.). A higher proportion of deaths and DALYS is attributed to males versus females. The indicators are also higher in certain regions: e.g. in East Europe alcohol consumption is involved in 16% of all deaths. In In addition to  direct intoxication, alcohol dependency, 20-30% of oesophageal cancer, liver cancer and cirrhosis, murders, epilepsy, traffic accidents, drownings are due to alcohol use.
74. In 1995 progressive Law on Alcohol Control was adopted in Lithuania, however it underwent several revisions up to 2007, mostly towards liberalizing advertising, sales and production of alcoholic drinks. Alcohol production was privatized, VAT reduced, tax discounts introduced for some groups of drinks, unrelenting and aggressive alcoholic drinks advertising campaigns began, focusing on promoting drinks most popular among young people. Since 2007 additional measures to curb demand and supply were implemented: advertising and alcohol sales at night were restricted, VAT increased, stricter consequences for drinking and driving established, additional mandate to control alcohol sales were given to municipalities. There was a reduction in alcohol consumption in 2008–2009 due to these measures, but this trend is not stable.
75. To reduce alcohol consumption, demand and supply, it is necessary:
75.1. To prevent falsified drink production and smuggling;
75.2. To promote public rejection of counterfeit and smuggled drinks;
75.3. To reduce demand and supply of alcoholic drinks using effective, evidence based WHO recommended measures, that include restrictions on sales outlets, sales time and alcohol advertising restrictions;
75.4. To increase VAT on alcoholic drinks proportionate to real salary increases and inflation change, pursuing the conversion of alcohol into a luxury item;
75.5. To increase the age limit to 20 years for buying and consuming alcoholic drinks;
75.6. To increase the consequences for violations of alcohol sale  regulations, especially if violations include alcohol sales to minors, adopt option of permission (licence) removal for the specific outlet violating regulations immediately, without waiting for repeated violations;
75.7. To organize social preventive campaigns for the target groups in the population;
75.8. To involve NGOs in informing society about alcohol use related health harm, developing information and education for healthy lifestyles and health issues;
75.9. To implement early intervention programs in primary health care services;
75.10. To develop psychological, medical and social rehabilitation and integration services for persons with alcohol dependency;
75.11. To promote total adversity towards drinking and driving;
75.12. To organize support services for family members of persons with alcohol dependency;
75.13. To introduce information about standard alcohol units on alcoholic drinks packaging, and warnings for pregnant women to avoid alcohol.
76. Smoking is one of the main causes of mortality in the population of the European region. Tobacco increases the risk of death due to chronic non-communicable diseases – cardiovascular, cancer, diabetes, chronic respiratory diseases, etc.
77. Smoking harms people other than the smoker (passive smoking) and is considered a risk factor for lung cancer, as well as other respiratory diseases. It hazardously affects a baby during pregnancy. Cigarette smoking is mostly associated with negative effects of tobacco, but tobacco chewing, smoking of cigars and pipes, also increase the risk of oral cancer.  It is important to note that stopping smoking after a certain period reduces the risk of oral cancer to those levels of a non-smoker.
78. About 25% of the Lithuanian population smoke. In 2010 on average there were 34.2% of men and 15% of women were everyday smokers. 30.4% of men and 62.2% women never smoke, while 19% of men and 12% of women were ex-smokers. Following the ban on tobacco advertising between 2000 and 2010 the number diminished 1.5 times; while the number of female smokers which had been increasing during the period 1997–2001  stabilized. The number of female smokers remained virtually unchanged in the period 2002–2010. Men and women with higher education smoke less frequently. Women in rural areas smoke more often than those in cities. The proportion of inhabitants who work in an environment polluted with tobacco smoke among population with higher education has decreased, while for the population with secondary and lower education it remained unchanged.   Therefore, significant progress has been made in smoking prevalence and regulation, yet smoking among adolescence remains a persisting problem.
79. WHO emphasizes that there is an increasing and more aggressive tobacco marketing and advertising targeting young people, women and groups of lower socioeconomic status.
80. In order to achieve reduction in tobacco product demand and supply it is necessary: 
80.1. To reduce accessibility of tobacco products and their substitutes through price increases and restrictions on electronic trade;
80.2. To expand smoke-free environments;
80.3. To strengthen adolescents protection through tobacco product regulation measures ;
80.4. To implement early educational programs in school, including themes of tobacco harm.
81. Illegal use of narcotic and psychotropic substances has an impact on increasing rates of mental and behavioural disorders, intoxication, prevalence of infectious diseases, including HIV infection and AIDS, criminality, trauma and suicide, as well as related mortality.
82. In order to achieve reduction in illegal demand and supply of narcotics and psychotropic substances it is necessary:
 
82.1. To reduce the demand for illegal narcotics and psychotropic substances and their precursors by strengthening control on the turnover of these substances;
82.2. To strengthen promotion of healthy lifestyle skills in families and school;
82.3. To promote development of preventive measures for narcotics and psychotropic substance used at the workplaces and community;
82.4. To develop health care, social, rehabilitation and reintegration services for persons with behavioural and mental disorders resulting from use of narcotics or psychotropic substances;
82.5. To develop collaboration with civil society, social partners, NGO sector, organizing preventive measures and delivering services necessary for reduction of illegal use of narcotics and psychotropic substances; 
82.6. To strengthen multisectoral and international collaboration, coordination of drug control and drug abuse prevention;
83. The second objective is to promote healthy eating habits.
84. Currently there is sufficient evidence that unbalanced diet promotes obesity, lipid metabolism disorders, increases the risk of chronic non-communicable and other diseases, and is increasingly accepted as a common risk for these diseases. On the other hand diets compliant with recommendations for nutritional and energy values, as well as production and consumption of health promoting foods, can help prevent chronic non-communicable diseases related to poor diet. 
85. Research on dietary habits of European populations reflects a worsening nutritional situation over the past decades. WHO has adopted the Global strategy on Diet, Physical activity and Health, and members states are encouraged to implement all measures promoting healthy eating habits in the population and by doing this, reduce the prevalence of chronic non-communicable diseases and their risk factors.
86. In Lithuania, adult dietary research data determined that almost 18% of men and 20% of women are obese, while 45% of men and 34% of women are overweight. Even though Lithuanian eating habits are improving (increased consumption of vegetables and vegetable oil, reduced animal fat), the adult diet however remains unbalanced: diet contains too much fat, especially saturated fatty acids, sugar and products increasing blood cholesterol levels.
87. To achieve healthier eating habits it is necessary:
87.1. To increase compliance of Lithuanian diet nutritional values with WHO recommendations;
87.2. To increase education and information of the Lithuania population regarding healthy, balanced diet, incorporating these themes into school programs, increasing volume of thematic social advertising, and ensure accessibility of information that help to shape healthy dietary habits; 
87.3. To encourage Lithuanian companies to produce and supply internal market with health promoting foods, with special focus on health promotion needs of children and youth. Reduce the amount of salt, sugar and fat in food products. Wherever possible, information on the composition of the food products should be indicated clearly, and should be easily understandable and visible;
87.4. To support organizations and projects encouraging consumption of health promoting foods, support participation of municipalities in improving the quality of diets within communities;
87.5. To monitor the dietary habits of populations and regularly assess health risks associated with being overweight, diet changes in the population and related health problems;
87.6. To integrate healthy lifestyles into adult non-formal education programs.
88. The third objective is to foster optimal physical activity habits.
89. Four major areas in which people have the opportunity to be physically active are: at work (especially, if it is physical work), transport (e.g. walking, biking), household activities and leisure (sports). Lack of physical activity is defined as extremely limited or no physical activity in any of the aforementioned areas. Industrialization, urban development and the spread of mechanical transport significantly reduced physical activity in populations (even in developing countries), and as of today more than 60% of the world population have too little physical activity.  It has been established that physical activity reduces the risk of chronic non-communicable diseases. Various physical activities can improve the condition of the musculoskeletal system, help control body weight, and reduce symptoms of depression.   According to the WHO Global strategy on Diet, Physical Activity and Health 30 minutes of moderate physical activity every day, or nearly every day, should be enough to reduce the risk of cardiovascular disease.
90. Approximately 44% of the Lithuanian population do not engage in sports or physical training (the EU average is 39%). Data from the Lithuanian Adult Lifestyle Study has confirmed there is inadequate motivation for physical activity in the social environment and health care sector. Health care specialists are not sufficiently actively providing adequate recommendations to patients. However, there is a positive development in the expansion of private centres offering sport, physical training and health services, yet these services are mostly accessible to high income population. 
91. There is a lack of health promoting physical environments:  lack of adequate playgrounds for children, bike tracks, parks, green areas, relatively affordable and accessible to families from average income populations, subsidized by municipalities health and well-being services.
92. Decreasing physical activity in the population is one of the main causes of obesity.  Obesity is an increasing problem, since its prevalence has grown steadily and in the past two decades it has increased threefold – more than half the adults in the European region are overweight, while one quarter – are obese. The European Charter on Counteracting Obesity states that overweightness and obesity constitute one of the major public health challenges in the XXI century in the WHO European region, reaching epidemic levels due to changing social and economic environments; creating energy imbalance through reduced physical activity and increased availability of high energy food and drinks, changes in dietary habits and lifestyles of the population. The obesity epidemics stem from the aforementioned social changes, and cannot be blamed solely on genetic vulnerability that a section of the population may have.
93. Obese people have increased risk to ischaemic heart disease, hypertension. Obesity is the main cause of insulin-independent diabetes; obese people have increased risk of breast, uterus, colon, oesophagus and kidney cancer. Moreover, the mental health of obese persons is worse.
94. To achieve optimal habits of physical activity it is necessary:
94.1. To ensure conditions favourable for physical activity among children in preschools, primary and secondary, as well as vocational schools and public spaces;
94.2. To encourage training and physical activity among persons of working age (bike, walk in the parks, roller-skate, maintaining the environment);
94.3. To organize specialized health promotion projects fostering physical activity for the retired, the elderly and for disabled persons;
94.4. To invest in management and expansion of playgrounds, biking and pedestrian tracks, parks, green zones;
94.5. To encourage creation of programs for the optimisation of physical activity of the population in communities, municipalities and country as a whole, to include provisions regarding responsibilities of state and municipal institutions to create conditions promoting physical activity in the Law on Physical Culture and Sports.
95. The fourth goal of the Strategy is to ensure high quality and effective health care, focused on the needs of the population.
96. In order to meet the fourth goal of the Strategy – to ensure high quality and effective health care, focused on the needs of the population – the following objectives are set:
96.1. To ensure sustainability and quality of the health care system, developing health care technologies and efficiency based on scientific evidence;
96.2. To develop health care infrastructure and improve the quality of the health care services, safety, availability and patient-oriented health care;
96.3. To improve maternal health and child health;
96.4. To strengthen control and prevention of non-communicable diseases;
96.5. To develop the Lithuanian e-health system (development of Lithuanian e-health infrastructure and solutions, e-health integration into the EU e-health area);
96.6. To ensure health care in crisis and emergency situations.
97. The first objective is to ensure the sustainability and quality of the health care system and developing evidence based health care technologies.
98. Health must be viewed as an important economic growth factor and implementation of “health in all policies” requires closer inter-agency cooperation on public health issues.
99. In order to strike a balance between innovation and ensuring solidarity in the health care system, it is necessary to promote the assessment of health technologies and the improvement of health system efficiency.
100. There is a need to develop highly effective health technologies, of proven efficiency, to reduce the use of less effective health technologies and limit(?) their compensation from the Mandatory Health Insurance Fund or the State Budget.
101. In order to ensure sustainability and quality of the health care system, it is necessary:
101.1. To implement the principle of "health in all policies", to promote  inter-agency and public institutions collaboration, as well as a comprehensive NGO cooperation, focusing on the enhancement of the cohesion of social, cultural and health sectors, utilising cultural and artistic potential to promote activities contributing positively to mental and physical health and social welfare;
101.2. To increase the share of government spending on health care;
101.3. To increase investment in the health care sector; to increase the number of health programmes implemented by NGOs, and attract EU structural funds for these programmes;
101.4. To introduce evidence-based health technologies, modernize medical devices by providing state support for the training of health care professionals:
101.4.1. To include cost calculations in financing regulations for the budget of state funded institutions and the pricing of public health care services;
101.4.2. To develop health care services consistent with theoretical and practical achievements of medical science;
101.4.3. To assist in producing and implementing procedures and protocols based on the results of health technology assessment into health care practice;
101.4.4. To use results of health technology assessment in updating the Compulsory Health Insurance Fund lists of reimbursable medicines and services and drawing public investment priorities;
101.4.5. To introduce voluntary or mandatory accreditation of the health technologies and institutions using health technologies. information regarding accreditation should be publicly available;
101.4.6. To set up a centre of health technology assessment in order to collect, disseminate and adapt global health technology assessment research data for use in the Lithuanian health care system. The health technology assessment centre should be independent from existing academic and clinical practice; therefore it should be independent or part of the institution not having teaching and clinical practice as a main function;
101.4.7. To increase the reliability of health statistics data;
101.5. To approve and implement nationwide criteria and indicators for the evaluation of quality and effectiveness of  health care institutions; regularly perform comparative analysis of the quality and efficiency of the health care institutions; strengthen the link between funding of the institutions and  results of the assessment of the quality of their operations, efficiency and effectiveness;
101.6. To implement pharmaceutical care, strengthen the role of community pharmacies in the national health system.
102. In order to ensure sustainability and quality of the health care system, the state should commission training programs for health care professionals in the national health care system and subsequently ensure appropriate distribution of healthcare personnel among the municipalities.
103. The second objective is to develop a health care infrastructure and improve the quality, safety and availability of the health care services, and patient-centered health care.
104. Effective and innovative infrastructure models should be developed and implemented in order to provide public health care services executing comprehensive prevention programmes to reduce premature death and disability from non-communicable diseases and external causes, which contribute to major health inequities in different population groups and areas.
105. Primary health care infrastructure, specialized outpatient, rehabilitation and emergency services should be strengthened in order to reduce differences in quality of health care services, its availability throughout the country and increase accessibility of services closer to places of residence.
106. Delivery of services requiring complex technological equipment and highly specialized high-skilled professionals should be centralized, while health care services, which do not require complex technology should be decentralized and provided by agencies closer to patient place of residence. Nursing services should be developed in municipal health care institutions, integrating nursing and social service care and the provision based on patients' needs.
107. The number of doctors is currently sufficient to meet the health care needs of the Lithuanian population, yet the geographic spread of doctors in the country is very uneven:
107.1. The vast majority (over 71%) of doctors work in the cities, while 60% of health care needs are provided in the surrounding districts;
107.2. The community of health care professionals is rapidly ageing – in 2010, the average age among physicians of different specializations ranged from 49.6 years (family doctors) to 56.2 years (internal medicine doctors). The average age of nurses in 2010 was 45.3 years and for midwives it was 47.7 years;
107.3. A number of specialists with health care qualifications do not practice and are engaged in economic activities other than health care: up to 7% of persons with medical degrees do not practice or work in health care.
108. Public health care institutions lack the financial resources to provide health care services; they lack effective management and in some cases, lack sufficient health care professionals and equipment. Moreover, the primary health care network is unevenly distributed. These factors contribute to relatively long queues for quality medical care services.
109. In order to enhance development of the health care infrastructure, availability of health care services and improve patient safety, it is necessary:
109.1. To improve the organization of primary health care, ensure adequate distribution of primary health care facilities in municipalities, improve collaboration of primary health care professionals with other professionals in the health, social security, education, culture sectors, as well as artists, NGOs and local communities;
109.2. To promote cooperation between different levels of health care, while ensuring effective organization of public health services and patient flow management. This would guarantee more efficient use of human resources and a more balanced and rational use of equipment and laboratories, thereby enabling provision of a broader spectrum and  higher quality of medical services delivered in the rural areas;
109.3. To increase access to health care services for the most vulnerable groups of the population by developing dental, medical rehabilitation and health recovery services for low-income groups and persons without income, psychosocial support services to cancer patients, low-threshold diagnosis and prevention services of dependence disorders, etc.;
109.4. To increase efficiency in tuberculosis diagnosis and treatment procedures seeking to reduce tuberculosis morbidity and mortality in the Lithuanian population and contribute to reduction of social inequity in certain societal groups;
109.5. To increase patient safety, ensuring prevention of hospital infections, controlling indoor air quality in hospitals and adequate sterilization and hygiene of medical devices, introduce a monitoring system of undesirable events and improve the pharmacological vigilance system in order to effectively monitor adverse drug reactions;
109.6. To increase efficiency of diagnostic and treatment procedures for sexually transmitted infections, with particular focus on young people and adolescents.
110. The third goal is the implementation of the health care priority – improving maternal health and child health.
111. Improvement of maternal and child health is the most important target of the state and health care system. Research based evidence has demonstrated that improved health as a child has positive impacts on his/her health later in life as an adult.
112. In order to improve maternal and child health it is necessary:
112.1. To provide high quality, affordable health care services for protection and promotion of maternal and child health;
112.2. To provide infants and children with safe drinking water, adequate sanitation at home, social care institutions, child care centres, educational and medical institutions;
112.3. To ensure children have a safe and healthy living environment at home, kindergartens, schools and public spaces;
112.4. To implement the recommendations of the WHO European Healthy Nutrition Policy Action Plan;
112.5. To promote inter-agency cooperation in order to reduce the effects of noise, electromagnetic devices, transport and polluted air on infant and children’s health at home, children's social care institutions, children care centres, kindergartens, schools and medical institutions;
112.6. To expand immunization and subsidized vaccination programs;
113. The fourth objective is to strengthen the control and prevention of non-communicable diseases.
114. Chronic non-communicable diseases have become a global health problem, posing a growing challenge for every country, regardless of their socio-economic development in the XXI century.
115. Major causes of chronic non-communicable diseases are determined by human behaviour and can therefore be avoided. The main risk factors with the greatest impact on morbidity and mortality worldwide are the following: high blood pressure, smoking, high blood glucose, physical inactivity, overweightness and obesity, high blood cholesterol, unsafe sexual behaviour and alcohol abuse. The most effective tools to combat these risks focus on changing social norms through promotion of a healthy lifestyle and behaviours, reduction of risk factor prevalence and their impact. These strategies are implemented by introducing relevant legislation, taxation, financial incentives and health promotion campaigns.  However, even though the potential changes and achievements are obvious, challenges in the process are no less complex.
116. In order to strengthen prevention and control of non-communicable diseases, it is necessary:
116.1. To reduce cardiovascular morbidity and mortality;
116.2. To reduce malignant tumours morbidity and mortality;
116.3. To reduce diabetes morbidity and mortality;
116.4. To reduce chronic respiratory disease morbidity and mortality;
116.5. To reduce morbidity and mortality with mental disease and suicide;
116.6. To improve organization of screening programmes.
117. The fifth objective is to develop Lithuanian e-health system (development of Lithuanian infrastructure and solutions for e-health system, integration into the EU e-health area):
117.1. To enable professionals involved in health activities to have access to information about the patient and his/her condition in the right place and the right time;
117.2. To enable citizens to use electronic health services and solutions;
117.3. To enable health system management bodies to make effective policy-making decisions.
118. The sixth objective is to ensure health care in crisis and emergency situations.
119. Health care in crisis and emergency situations is organized and conducted in accordance with the laws of the Republic of Lithuania and other legal acts. The co-operation between the Ministry of Health, the Ministry of Defence and other institutions in this subject is very important.
120. In order to ensure health care in crisis and extreme situations it is necessary:
120.1. To improve the legislation in this area, taking into account the EU and the North Atlantic Treaty Organization (NATO) guidelines;
120.2. To consistently implement the provisions of the international preparedness and assistance standard “Major Incident Medical Management and Support – MIMMS”;
120.3. To make Lithuanian national health care institutions ready to act in crisis and emergency situations, as well as during military operations, and whilst carrying out functions of the host country;
120.4. Establish guidelines for national health care institutions on the use of their human and material resources, management and interaction with military units, and ensuring medical support to the Lithuanian army during military operations carried out in Lithuania.
III CHAPTER
INDICATORS OF THE STRATEGY IMPLEMENTATION ASSESSMENT
 
121. Strategy implementation assessment indicators and their values are presented in the Strategy appendix.
122. For program implementation monitoring and evaluation, the official publicly available data generated by the Statistics Lithuania, Institute of Hygiene, Eurostat and WHO will be used. The data of sociological surveys and studies can also be used.
IV CHAPTER
STRATEGY IMPLEMENTATION
123. The Lithuanian Health Strategy is referred to in the Law on Health Care Systems as a foundation for the planning of health promotion activities at the Parliament level. The Parliament aims to reflect the population's needs for health promotion and increased life expectancy in its annual state budget planning, based on approval of the annual budgets for Social Security and Health Insurance.
124. Strategy implementation is coordinated by the Ministry of Health.
125. The strategy is implemented through the National Public Health Development Programme  2016–2023, adopted by the Government Resolution No. 1291 on 9 December, 2015 "Regarding adoption of the National Public Health Development Programme 2016–2023”, also the National Programme for the Advancement 2014–2020, adopted by the Government Resolution No. 1482 on  28 November, 2012 "Regarding adoption of the National Programme for the Advancement 2014–2020”,  The National Programme for the Advancement 2014–2020 horizontal priority "Health for All" inter-institutional action plan, adopted by the Government Resolution No. 293 on 26 March, 2014 "Regarding adoption of the National Programme for the Advancement 2014–2020 horizontal priority "Health for All" inter-institutional action plan”, The National Programme for the Advancement 2014–2020 horizontal priority “Regional development” inter-institutional action plan, adopted by the Government Resolution No. 172 on 19 February, 2014 "Regarding adoption of the National Programme for the Advancement 2014–2020 horizontal priority "Regional development " inter-institutional action plan”, Employment Growth Programme 2014–2020, adopted by the Government Resolution No. 878 on 25 September, 2013 "Regarding adoption of the Employment Growth Programme 2014–2020”, the National Programme for Development of Safe Traffic 2011–2017, adopted by the Government Resolution No. 257 on 2 March, 2011“Regarding adoption of the National Programme for Development of Safe Traffic 2011-2017”, the State Environmental Monitoring Programme 2011-2017, adopted by the Government Resolution No. 315 on 2 March, 2011 “Regarding adoption of the State environmental monitoring 2011-2017 programme”, National climate change management policy strategy adopted by the Seimas Resolution No. XI-2375 on 6 November, 2012 “Regarding adoption of the National climate change management policy strategy”, the National drug control and drug abuse prevention programme 2010-2016, adopted by the Seimas Resolution No. XI-1078 on 4 November, 2010 “Regarding adoption of the National drug control and drug abuse prevention programme 2010-2016”,  the inter-institutional Action Plan of the Republic of Lithuania to Prevent the Use of Drugs, Tobacco and Alcohol, approved by Resolution No. 217 of 25 February 2015 of the Government of the Republic of Lithuania “On Approving the Interinstitutional Action Plan of the Republic of Lithuania to Prevent the Use of Drugs, Tobacco and Alcohol”, as well as other strategic documents, contributing to a framework for the promotion of public health.
126. Ministries, government and municipal institutions, businesses, NGOs and communities contribute to the implementation of the Strategy according to their competences. Individuals are encouraged to take care of the health of their children and their parents.
127. The Strategy is implemented from the respective year’s Lithuanian state budget appropriations, municipal budgets, the Compulsory health insurance fund, the EU and other international financial aid funds and other legally obtained funds.
128. Progress of Strategy implementation will be assessed each year by monitoring indicator values and performing interim evaluations in 2020, with a final evaluation in 2025.
129. The Ministry of Health includes Strategy implementation information each year in its annual report to the Government, interim and final Strategy implementation evaluation reports propose for discuss to the Government. Submits annual reports on the implementation of the Strategy as well as producing interim and final implementation evaluation reports that the Government shall submit to the The Seimas.
130. The interim and the final evaluation reports on the implementation of the Strategy shall be made available to the public.
____________________________
 
 
 
Annex to the Lithuanian Health Strategy 2014–2025
 
LITHUANIAN HEALTH STRATEGY 2014–2025:
IMPLEMENTATION ASSESSMENT INDICATORS’ VALUES
 
No. of goals
Goals
Assessment indicator, value unit, data source
Status (year)
Assessment indicator value for 2020
Assessment indicator value for 2025
Main goal
Attainment of improved health of the Lithuanian population by 2025 as well as longer life and reduced health inequities.
1. Average life expectancy, SL
73.98 years (in 2012)  
75.8 years
77.5 years
   
   
2. Reduction of difference between male and female average life expectancy, by increasing male average life expectancy (in years), SL
11.06 years (in 2012)  
9.5 years
8 years
1.
Create safer social environment, reduce health inequities and social exclusion
1. Suicide mortality per 100 thousand population, Eurostat
31.03 (2012)
19.5
12.0
2. Proportion of population at risk of or experiencing social exclusion, Xx percent, Eurostat
32.5 (2012)
Reduce by 15% the 2012 level  
Achieve same level as the EU Member States average
3. Proportion of population living in households experiencing financial difficulties  (afford to eat meat, fish or analogous vegetarian meal at least every other day), percent, SL
23 (2012)
Reduce by15% of the 2012 level
Reduce by 10% of the 2020 level
2.    
Create a health promoting working and living environment
1. Amount of greenhouse gas emissions   (CO2equivalent), thousand tons, Eurostat
21 622
Stabilize growth
Stabilize growth
2. Proportion of population reported to be suffering from noise (Xx percent), Eurostat
13.3 (2012)
Reduce by 5 % of the 2012  level
Reduce by 5% of the 2020 level
3. Mortality from external causes per 100 thousand population, IH
122.47 (2012)
77.3
51.7
3.          
Foster healthy lifestyle and its culture          
1. Annual consumption of legal alcohol, per capita, in litres of absolute alcohol, SL
13.0 (2012)
9.5
8.5
2. Annual tobacco use, per capita, in number of cigarettes, SL, Study
907 (2012)
Reduce tobacco consumption by  3% of  the 2012 level
Reduce tobacco consumption by  3% of the 2020 level 
3. Mortality due to use of narcotic and psychotropic substances (absolute number), IH, SL
95 (2012)
Stabilize growth
Stabilize growth
4. Proportion of obese males in the Lithuanian male population  20–64 years of age, percent, Study
18 (2012)
Stabilize growth
Stabilize growth
5. Proportion of obese females in the Lithuanian female population  20–64 years of age, percent, Study
19 (2012)
Stabilize growth
Stabilize growth
4.                
Ensure high quality and effective health care focused on population needs.
1. Infant mortality per 1 000 live births in Lithuania, IH
3.9 (2012)
Achieve same level as the EU Member States average
Achieve same level as the EU Member States average
2. Number of family doctors/General Practitioners (GPs) per 10 thousand population, IH
6.4 (2012)
7.0
7.54
3. Number of nurses (including midwives), per medical doctor, IH
1.75 (2012)
2,0
Achieve same level as the EU Member States average
4. Mortality from circulatory diseases, standardized mortality indicator per 100 thousand population, IH
451.1 (2012)
368.7
310.4
5. Mortality from neoplasms, standardized mortality indicator per 100 thousand population, IH
182.1 (2012)
172.8
165.5
6. Gross health expenditure, percentage of GDP,  LS
6.7 (2012)
7.5
8.0
7. Proportion of state expenditure compared with gross health expenditure, percent, SL
65.3 (2011)
75
78
8. Proportion of expenditure earmarked for prevention and public health care in the current health expenditure structure, percent, SL
1.1 (2012)
2.0
3.0
 
Abbreviations:
GDP                               – Gross Domestic Product;
„Europe 2020“                   – European Commission Communication “A strategy for smart,   sustainable and inclusive growth” (03.03.2010) ,
Eurostat                          – European Union Statistical Service;
IH                                   –Institute of Hygiene;
SL                                   – Statistics Lithuania;
SVEIDRA                     – Mandatory health insurance information system;
Study                              – Study on Lithuanian adult population behaviour.