Spotlight Interview
With Professor Žilvinas Padaiga Conducted November 2008
Professor Žilvinas Padaiga, currently at the Department of Preventative Medicine at Kaunas University in Lithuania, has enjoyed a diverse career which has encompassed clinical research, policy development and politics. After training as a medical doctor specializing in paediatrics, Professor Padaiga completed a PhD in public health and took an active role in health care reform, working in expert advisor roles with the Lithuanian Health Care Reform Bureau and the Parliament of Lithuania National Health Board. In 2004, he entered parliament and held the post of Health Minister. He has published extensively in the fields of diabetes, as well as co-authoring reports and articles on human resources for health and Lithuania's health workforce.
	ICHRN: What are the current key health workforce issues facing Lithuania?
Žilvinas Padaiga: The common features of the health workforce in Central and Eastern European countries, such as the maldistribution by gender, regions and specialties, can also be found in Lithuania. Women make the large portion of health workforce, and their share has remained relatively constant since independence in 1990; in 2007 99.4% of nurses, 85.5% of pharmacists, 81.6% of dentists and 70% of physicians were women. The geographic distribution of health workforce in Lithuania is very unequal. The majority work in urban areas, while in rural settings their numbers are lower. The percentage of physicians in cities has remained constant at about 70% over the last 20 years (66.8% of the population lived in cities in 2007). The percentage of dentists (63.0%) and nurses (58.2%) were also higher in urban areas. Another important issue is aging of health workforce – in 2006 19.3% of physicians, 12.5% of dentists, 12% of pharmacists and 4.3% of nurses were older than 60 years. Retention of health workforce, which reflects the number of practising specialists, is also of great concern. Two cohort studies of dentistry and medical graduates performed in 2003 indicated that only 62% of physicians and 83% of dentists were practising following 5-40 years from graduation. Migration of the health workforce is also considered as an urgent issue (see question 2). Also, as a result of decreased enrollment in medical studies back in 1990s, the number of graduates per year will continue to decrease until 2012. For example, there will be 210 graduates in 2009 compared to 281 in 2002. Together with the issues mentioned, this will result in the physician to population ratio dropping from 382.1 per 100,000 in 2008 to an anticipated 351.3 per 100,000 in 2015, as well as worsening geographic distribution. Nursing workforce will also be affected by shortages and the problem of geographic maldistribution in the coming years. Since 1990, the year of independence, nurses per population ratio in Lithuania has been constantly dropping from 958.7 to 737 per 100,000 in 2007. The ratio of nurses graduating annually per 100,000 has dropped more than two times and was 19.5 in 2006 – one of the three lowest ratios in the European Union countries. This drop will continue further, as the enrollment numbers of nurses have been substantially decreasing. Between 1990 and 2006 the number of nurses graduating each year fell from 1827 to 662. Decreases in new nursing students are also evident, with the number of new nurses enrolling falling from 700 to 344 between 2002 and 2006.
	ICHRN: Research you presented in 2002 suggested that accession to the European Union might result in increased migration of health professionals from Lithuania, leading to shortages. What has been the impact of EU accession on the health workforce in Lithuania?
Žilvinas Padaiga: The survey performed in 2002 and in 2004 (for pharmacists) indicated that 60.7% of medical residents, 26.8% of physicians and 26.5% of pharmacists intended to leave for the EU or other countries. It was a definitive decision of 2.5% of medical residents, 3.8% of physicians and 2.3% of pharmacists. To evaluate the impact of EU accession, a study was carried out in 2007 [6]. Data of 2004-2005 from the Ministry of Health, which issues the certificates for all health professionals who wish to practice abroad, were used for study purposes, which revealed that 0.4% of all Lithuanian nurses, 3.6% of all dentists and 2.7% of all physicians were issued the certificates. Checks in the databases of other countries and the State Patient Fund indicated that 0.3% of all Lithuanian nurses, 2.7% of all dentistry specialists and 0.7% of all physicians emigrated during this period. Even though the study found little evidence of large-scale migratory flows, the potential effects of migration should be addressed systematically and in a coordinated way. In order to observe further trends, the study should be expanded to later years.
	ICHRN: What policies and HR practices did Lithuania implement to prepare its health workforce for accession to the European Union in 2004? What was their impact?
Žilvinas Padaiga: Starting in 2005, the Government has taken a commitment to increase the salaries of human resources for health. As a result of this long-term commitment, salaries are expected to grow by 3.8-4.6 times until 2015. The other ongoing reforms in the health sector were Restructuring of the Health Care Institutions (2003-2008) and the E-health Project (2005-2008). Restructuring of the Health Care Institutions focused on development of outpatient services, especially in primary health care; optimization of inpatient services and development of alternative types of activities; and development of medical nursing and long-term care. During the first stage, 50,000 m2 of hospital areas were renovated and supplied with new medical equipment. Almost 1,000 offices for GPs were established until 2004 and over 500 new offices will be established and appropriately equipped in 2006-2008. Improved distribution of services: growth of outpatient services, day care hospital services, day surgery, etc. was achieved. The main strategic aims of the E-health Project are improved quality and access to health care services and health information, improved competence and efficiency of health professionals, and improved management and planning possibilities for executives and administrators. Successful implementation of the project will ensure linkage and communication of existing human resources for health registers and classifiers and improve quality of data. It will ensure better working conditions for physicians (filling of documentation will take 30% less time, e-registration of patients, feedback, better and faster exchange of information between different providers of health services, etc.).
	ICHRN: You have experience as physician, academic, politician and as Minister of Health. What different perspectives have these varying roles given you on meeting HRH challenges?
Žilvinas Padaiga: The main perspective has remained unchanged - planning policy of human resources for health should be sustainable and consistent and close collaboration between the stakeholders and the policy makers should be ensured.
	ICHRN: In your view, what skill mix is required in Lithuania to deliver effective models of preventative medicine? What are the implications of this for the training and development of the health workforce?
Žilvinas Padaiga: In my view, more public health specialists should be employed by municipalities to ensure qualitative provision of preventive medicine services. This activity is still in process, since only few municipalities have established Bureaus of Public Health. On the other hand, training numbers of public health specialists are sufficient, but a large part of them choose to work in other areas than public health, since it is quite difficult to find a job.
	ICHRN: Student attrition amongst nurses and other health professionals is a significant workforce challenge for many countries. What can governments, educators and service providers do to help reduce student attrition?
Žilvinas Padaiga: Attrition from studies is a very important indicator for projecting future number of graduates and has to be carefully considered when planning future student enrolments. According to the findings of the cohort studies performed in Lithuania, 17.3% of medical students, 10.7% of public health students, 4.2% of dentistry students and 4% of pharmacy students never finished their studies. There is a big economical loss involved in this, since as study results have shown, most of the students dropped out during the third or even fourth year of studies. Most commonly, drop outs were associated with lack of motivation and the fact that studies did not meet the student's expectations. In Lithuania, only quantitative measures of secondary school performance are considered in student admission process to ensure that acceptable academic standards are maintained. However, in my view, personal attributes such as motivation, leadership, coping, and interpersonal skills may provide valuable additional indicators of future students performance during studies. Therefore, I would suggest that an enrollment process that integrates quantitative measures and personal attributes, collected during a structured interview, could enhance the quality and future performance of health students and subsequently result in more students graduating from health-related studies.
	ICHRN: What do you see as key areas of HR reform or strategic intervention that you believe would make a significant contribution to addressing health inequities and meeting the Millennium Development Goals?
Žilvinas Padaiga: In my view, the key area of health workforce reform would be management of the migration of human resources for health from poor to rich countries and implementation of ethical recruitment policies worldwide. Rich countries, which made mistakes in the past while projecting supply and requirement for human resources for health, should not be solving their problems of shortages while recruiting health professionals from poor countries, especially from Africa.