. © 2017 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Attribution—Please cite the work as follows: “Aleksandra Posarac and Jerome Bickenbach. Disability Policy and Disability Assessment System in Lithuania © World Bank.” All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org Report No: AUS0001815 . Lithuania Disability Policy and Disability Assessment System Aleksandra Posarac and Jerome Bickenbach . May 2020 . SPL . Table of Contents An overview with key messages ............................................................................................................. 1 Background ............................................................................................................................................. 1 Context .................................................................................................................................................... 1 Disability assessment system .................................................................................................................. 1 Support provided to persons with disabilities ........................................................................................ 4 Persons with disabilities and labor market ............................................................................................. 5 Disability data ......................................................................................................................................... 6 Disability Policy and Disability Assessment System in Lithuania ............................................................ 7 1.1 Introduction ..................................................................................................................................... 7 1.2 A snapshot of disability statistics in Lithuania .................................................................................. 7 Key messages ................................................................................................................................ 10 1.3 Disability Assessment in Lithuania .................................................................................................. 11 1.3.1 Legal Framework .................................................................................................................. 11 1.3.2 How is disability assessed? .................................................................................................. 13 1.3.3 Assessing disability in children ............................................................................................. 13 1.3.4 Assessing special needs and the level of special needs ....................................................... 16 1.3.5 Work capacity assessment ................................................................................................... 18 1.3.6 Disability and work capacity assessment information system ............................................ 30 1.3.7 Key messages ....................................................................................................................... 35 1.4 Benefits for persons with disabilities .............................................................................................. 37 1.4.1 An overview and public spending ........................................................................................ 37 1.4.2 Social assistance disability pension...................................................................................... 42 1.4.3 Social insurance disability pension ...................................................................................... 43 1.4.4 Orphan’s pension ................................................................................................................. 45 1.4.5 Financial support for persons with disabilities raising a child ............................................. 45 1.4.6 Financial support for students with disabilities ................................................................... 46 1.4.7 Targeted compensation (care allowances) .......................................................................... 46 1.4.8 Reimbursement of the costs of purchasing and adaptation the car ................................... 47 1.4.9 Subsidized transport ............................................................................................................ 48 1.4.10 Medical rehabilitation ........................................................................................................ 48 1.4.11 Subsidized medication ...................................................................................................... 49 1.4.12 Provision of technical aid and compensation of expenses ................................................ 49 1.4.13 Support for housing ........................................................................................................... 50 1.4.14 Income tax exemptions ...................................................................................................... 51 1.4.15 Legal aid ............................................................................................................................. 51 1.4.16 Key messages ..................................................................................................................... 52 1.5 Labor market inclusion of persons with disabilities........................................................................ 54 1.5.1 Statistics on the labor market participation of persons with disabilities ............................ 54 1.5.2 Legislative framework on disability and employment in Lithuania ..................................... 56 1.5.3 Active labor market policies for people with disabilities in Lithuania ................................. 57 1.5.4 Other initiatives to assist labor market participation of persons with disabilities .............. 61 1.5.5 Education and skills development for children with disabilities ......................................... 62 1.5.6. Services to support labor market participation of elderly persons .................................... 62 1.5.7. Key messages ...................................................................................................................... 63 Annex 1: Understanding Disability and Disability Assessment ............................................................. 64 ANNEX 2: Disability in Lithuania – Legal Framework ............................................................................ 73 ANNEX 3: List of legal acts pertaining to disability with active links .................................................... 86 ANNEX 4: Data on Disability Assessment.............................................................................................. 89 ANNEX 5: Examples of Application Forms for Disability Assessment ................................................... 96 ANNEX 6: Activity and Participation Questionnaires .......................................................................... 102 ANNEX 7: Amounts of the social assistance disability pension, based on the Law on Social Assistance Pensions of the Republic of Lithuania as off 2019 .............................................................................. 122 ANNEX 8: DWCAO Information System (IS) Views.............................................................................. 124 List of Tables and Figures Table 1: Persons self-reporting long standing limitations in usual activities due to health problems in EU in 2018 ............................................................................................................................................... 9 Table 2: An example of basic work capacity assessment ..................................................................... 26 Table 3: Public spending on social protection in Lithuania 2014-2018 as % of GDP ............................ 38 Table 4: Composition of public spending on social protection in Lithuania 2014-2018 (%)................ 38 Table 5: Expenditure on social protection benefits in EU in 2017 ........................................................ 40 Table 6: Social assistance disability pension – number of beneficiaries and expenditures ................ 42 Table 7: Social Insurance Disability Pension: Beneficiaries and Expenditure ....................................... 44 Table 8: Orphans receiving pension and total public spending on it.................................................... 45 Table 9: Employment status at the time of disability assessment 2017-2018 ..................................... 54 Table 10: Employment of persons with disabilities in Lithuania 2017-2018. ....................................... 54 Table 11: Statistics of job seekers with disabilities 2018. ..................................................................... 55 Table 12: Spending on Active Labor Market Programs 2016-2018 ...................................................... 57 Table 13: Social enterprises in Lithuania 2016-2018. ........................................................................... 58 Table 14: Students with special educational needs in general education in Lithuania 2015-2019. .... 62 Table 15: Students with disabilities in educational institutions 2015-2019. ........................................ 62 Figure 1: Persons with disabilities in Lithuania 2012-2018..................................................................... 8 Figure 2: Assessing disability in children: a flow of administrative processes...................................... 14 Figure 3: Disability assessment in children 2013-2018 ......................................................................... 15 Figure 4: Process flow for assessing special needs and level of special needs of elderly persons ...... 17 Figure 5: Assessment of special needs by age ...................................................................................... 17 Figure 6: Assessment of work capacity 2013-2018............................................................................... 18 Figure 7: Work capacity assessment flow chart ................................................................................... 19 Figure 8: Impact of the assessment of activities and ability to participate on work capacity ............. 27 Figure 9: Spending on disability benefits as % of total social benefits in EU in 2017 ........................... 39 Figure 10: Spending on disability benefits as % of GDP in EU in 2017 ................................................. 39 Figure 11: SSIF – Average social insurance pensions in Lithuania in 2019 (in EUR per month) .......... 44 Figure 12: Unemployment rates of disabled and non-disabled population in select countries.......... 55 Figure 13: Vocational rehabilitation providers in Lithuania by type of disability ................................. 60 Abbreviations DG REFORM - Directorate-General for Structural Reform Support of the European Commission DWCAO – Disability and Work Capacity Assessment Office EU – European Union EU SILC - European Union Survey on Income and Living Conditions GDP – Gross Domestic Product ICF - International Classification of Functioning, Disability and Health ILO – International Labor Organization IS – Information System MOH – Ministry of Health MSSL - Ministry of Social Security and Labor SSIF – State Social Insurance Fund WHO – World Health Organization WHODAS – World Health Organization Disability Assessment Schedule WHO HALE - World Health Organization’s Health Adjusted Life Expectancy Acknowledgements This report was prepared by a joint team from the World Bank (WB), Directorate-General for Structural Reform Support of the European Commission (DG REFORM) and the Ministry of Social Security and Labor (MSSL) of the Republic of Lithuania. The team was led by Aleksandra Posarac, Lead Economist and Task Team Leader (WB) and comprised Professor Jerome Bickenbach, Lead Technical Expert (Swiss Paraplegic Society and University of Luzern), Marc Vothknecht and Claudia Piferi (DG REFORM), Marijana Jasarevic, Social Protection Specialist (WB), Professor Gordana Matkovic, Technical Expert (Belgrade University), Eglė Čaplikienė, Chief Advisor (for People with Disability Issues) (MSSL), Viktorija Vasiljeva-Gringienė and Jolanta Vyšniauskienė (MSSL) and Rasa Noreikyte - Ustinaviciene and Natalja Markovskaja from the Valakupiai Rehabilitation Centre, Vilnius. The team has benefited from comments and advice provided by Alvydas Juocevičius and Genovaite Paliusiene, project advisors. Useful comments on the draft report were provided by the MSSL staff: Daiva Zabarauskienė, Head of the Targeted Assistance Division, Jurgita Jurgita Čiuladaitė- Pritulskienė, Senior Advisor to the Targeted Assistance Division, Irma Mituzienė, Advisor to the Targeted Assistance Division, Inga Barauskaitė, Senior Advisor to the Pension Division, Rita Babianskaitė, Senior Advisor to the Pension Division, Daiva Liugienė, Chief Specialist in the Labor Market Division, and Kristina Maksvytienė, Head of the Labor Market Division. The team is thankful to Cem Mete (World Bank Manager), Lars Sondergaard (World Bank Program Leader) and Geraldine Mahieu from DG REFORM for their continuous overall guidance and support. Finally, the team wishes to extend its deep gratitude to the Ministry of Social Security and Labor, without whose commitment and enormous engagement, this study would not have been possible. This Final Report was written by Aleksandra Posarac and Jerome Bickenbach and edited in cooperation with Claudia Piferi, Marc Vothknecht. An overview with key messages Background This Report was prepared as part of the “Technical support to reform the disability assessment system” provided by the World Bank with funding from, and in collaboration with, the Directorate- General for Structural Reform Support of the European Commission (DG REFORM). The Project’s aim is to support the Ministry of Social Security and Labor (MSSL) of the Republic of Lithuania in enhancing disability assessment through (i) strengthening of the assessment of functioning (a lived experience of disability) following the principles and approaches of the World Health Organization’s International Classification of Functioning, Disability and Health (WHO ICF), and (ii) improvements in the related administrative processes. In order to provide a base for the design of the envisaged functioning assessment pilot, a mapping of the current disability assessment system was undertaken, including detailed description of the assessment criteria, the administrative/ business processes through which disability assessment is conducted and the underlying information system that supports them. With a view to better understanding the policy environment in which the disability assessment system operates, the mapping also includes an overview of available disability data, as well as a description and assessment of both (i) support benefits provided to persons with disabilities; and (ii) labor market and other programs to support participation of persons with disabilities. Context According to administrative data from 2018, there were about 231,000 persons with disabilities in Lithuania - 8.2 percent of all population. The prevalence of disability in the population over 16 years of age is estimated at about 10 percent. The administrative data reflects persons with disabilities of all ages who have been formally assessed for disability. United Nations Population Projections point to a significant drop in the Lithuanian population during the next 30 years. This decline is coupled with rapid aging of the population, which in turn is associated with increased disability prevalence. The pool of the working age population is projected to decline by more than half a million people by 2050. This profound change in the labor supply calls for a strong emphasis on healthy living and healthy aging policies. It also calls for policies and programs, including a disability assessment system, that would focus on optimizing functioning of persons experiencing disability, including rehabilitation, accommodation, care services, etc., to maximize the quality of their life, as well as their participation in the labor force. Disability assessment system Disability assessment trends. Lithuania has a well-established disability assessment system and a well-organized administrative structure that implements it - Disability and Work Capacity Assessment Office (DWCAO). DWCAO assesses disability in children, work capacity for working age adults, special needs (irrespective of age), and a level of special needs for the elderly (i.e. persons of retirement age and over). In 2018, DWCAO assessed for disability about 88,000 persons of all ages. The majority, about 51,000 or 58 percent, were work capacity assessments in working age population. Assessment of childhood disability represented 7.0 percent of the total. The rest, about a third, represented the assessment of the level of special needs in the elderly population (over 65 years of age). Most of the assessments – over 70 percent - are reassessments of persons who have already been assessed for their disability. Over the last decade, the number of assessments has significantly fallen, as has the number of persons with disabilities. It is believed that these trends are driven by outward migration, decreased fertility, 1 healthier lifestyle and better health care services. However, only an empirical analysis could shed light on the factors behind these trends. Legal framework. Disability assessment is regulated by the Law on Social Integration of Persons with Disabilities. Article 20 of this Law establishes that working capacity is determined by assessing the state of health of the individual and her/his ability to perform earlier obtained professional competences or to gain new skills or to be engaged in jobs that do not require professional qualifications, after having exhausted all available medical and vocational rehabilitation and special assistance measures. This approach is a very important feature of the disability policy and disability assessment system in Lithuania, as it envisages that a person should be provided the full range of available interventions to restore or stabilize health, maximize functioning and ensure her/ his labor market participation. However, this is yet to be realized in practice: in most cases a person is directly referred to DWCAO by a treating physician after the medical treatment. Assessment methodology. The assessment of disability is based on medical and so-called activities and participation criteria (the assessment of functioning). Medical criteria follow a classic Barema grid comprising a list of diseases and bodily impairments, where an impairment is assigned a certain percentage of disability/work capacity. Activities and participation criteria are based on a series of questions related to difficulties in functioning in several domains; a home-grown effort to implement the World Health Organization International Classification of Functioning, Disability and Health. The algorithm used for the application of the functioning score is such that it has almost no impact on the final decision on disability, rendering the assessment essentially based on medical criteria. Besides, occupational diseases and work injuries are exempt from it. It is recommended to apply functioning assessment across the board as it provides invaluable, objective information on how people experience disability in their everyday life. The activities and participation criteria and related instruments have been revised continuously, to link them better to the WHO ICF and the bio-psycho-social (interactional) model of disability and to make the assessment process more objective by including functioning assessment into disability assessment. To that end, MSSL is currently preparing to pilot a World Health Organization’s psychometric tool (World Health Organization Disability Assessment Schedule or WHODAS) for the assessment of functioning to inform any future adjustments in the disability assessment criteria and procedure through empirical evidence using a standardized, extensively tested, internationally validated and scientifically robust and reliable instrument. Transition from long-term sick leave to permanent disability. The paid sick leave provision is another very important feature of the Lithuanian social security system. It enables not only that a person gets needed medical treatment and medical rehabilitation, including assistive devices s/he might need, but also provides time for vocational rehabilitation and other measures to optimize a person’s health and functioning and ensure her/his return to work to be implemented. While Lithuania’s disability policy calls for such an approach legally, as noted above, it is yet to be fully operationalized and implemented in practice. A more integrated action and collaboration from various stakeholders - medical doctors, DWCAO, employment services, medical and occupational rehabilitation specialists, employers, municipal social services, and others - is needed. This would require changing the sequencing of the sick leave to disability trajectory. For employed persons experiencing sickness, once the acute medical treatment is completed, a medical rehabilitation phase provides an opportunity for a collaboration between a patient, his/her employer, rehab professionals, employment service, and local social services. The purpose of this collaboration would be to provide all available measures to help the patient maximize her/ his functioning and stay in employment. If this window is missed and a person leaves the labor market, as empirical evidence from Lithuania and many countries shows, the person is very likely to leave the labor market permanently. 2 Hence, only after all measures to restore health and optimize functioning have been exhausted, as stipulated by the above-mentioned Article 20 of the Law on Social Integration of Persons with Disabilities a person should be assessed for work capacity. While the full implementation of the Article 20 would require time and effort, Lithuania has an excellent foundation to build on it: in addition to the paid sick leave provision, Lithuania has an excellent network of rehabilitation facilities, which could collaborate with other government agencies (labor offices, employers, local social care services, DWCAO offices, etc.) and serve as a nodal point in implementing Article 20 requirements. Staff situation and training needs. DWCAO has difficulties hiring and retaining staff with a medical education background. To ensure that the assessment is conducted by medically trained staff, DWCAO may consider (i) expanding the engagement of medical staff on a part time basis; and (ii) changing administrative procedure to require that a well-trained medical rehabilitation specialist conducts a functioning assessment (could also be on a part time basis). A medical doctor could then review both the medical and functioning information and propose the work capacity decision. This would be made even easier if, as envisaged by Article 20 of the Social Integration Law, applicants would be presented at DWCAO only after a complete assessment at a rehabilitation clinic and once all measures for optimizing functioning and participating in the labor market have been exhausted. Streamlining administrative procedures. A combination of improved medical information and standardized functioning assessment with an evidence based, automated algorithm for medical and functioning assessment of work capacity (based on the WHODAS pilot) would contribute to streamlining administrative procedures. Moreover, such an automated algorithm could be used to flag any functioning score beyond what could be expected for a given health condition, thereby decreasing opportunities for fraudulent behavior. Manual handling of information during the assessment process is not insignificant. DWCAO should consider (i) reviewing the mandatory list of documents to streamline the needed documents (and examinations), but also to add information on medical and vocational rehabilitation undertaken and assistive devices received (preferably though real time electronic link to the e-Health information system, once it is operational; as well as links to the employment service, etc.), and (ii) populating information into the electronic file at the registration. While the registration phase may take longer to complete, it will save time of the assessors who will have all information in electronic format. Currently, the DWCAO assessor fills in manually the necessary information on (i) the person`s need for vocational rehabilitation, and on (ii) the nature and conditions of work and recommends assistance measures. These two aspects of the assessment could be improved by introducing - at the beginning of the disability assessment process - a standardized procedure to assess the needs for vocational rehabilitation and to provide recommendations regarding work conditions. Likewise, recommendations related to assistive devices are not based on objective information in the current process. In fact, there is no information on which DWCAO assessor would be able to objectively assess whether a person would need vocational rehabilitation and/or work-place adjustment and/or assistive devices/ assistance to stay in the current job, or a different job with the same employer or a new job. Besides these assessments require specific professional skills. Hence, most of the employed persons undergoing work capacity assessment leave employment and very few are referred to vocational rehabilitation. DWCAO Information System: The DWCAO Information System was designed in 2002-2004 and was deployed in 2004. It has been continuously updated to meet the requirements of the latest legislation and the needs of users and customers. The system development immediate needs are: (i) introduce electronic signature for all documents; (ii) introduce a smart disability certificate card instead of the current laminated card; (iii) ensure automatic, real time information update on applicants’ and beneficiaries’ socio-economic, civil and labor market status from SSIF, civil registry, employment service, tax authorities, etc.; (iv) introduce e-referrals across the board (DWACO’s information system is ready to receive e-referrals; there should be a time bound plan – say 3-5 years to make e-referrals 3 mandatory and universal); (v) system integration: all activity and participation questionnaires should be filled in electronically and automatically transferred to DWACO, including for special needs and level special needs. Furthermore, the information system needs a major technology update. The DWACO system was developed in 2004, using then up to date technologies. These technologies are now outdated, which severely limits the opportunities for system development and maintenance. Most of the modules in the system are manufactured using technologies that are not any longer supported (e.g., Referrals and document submission via BizTalk server). Integration solutions developed in 2004 are also technologically obsolete and do not provide the requirements, reliability and speed necessary for today's information systems. Considering that the system handles highly sensitive personal data, their storage, transmission and receipt of personal data to and from other information systems do not fully comply with the General Data Protection Regulation (GDPR). Hence, a medium-term information system plan is needed that would create a system based on the latest technology, which would be more secure, manageable, user-friendly, and functional. Support provided to persons with disabilities Support available to persons with disabilities. Today, Lithuania provides a range of benefits to persons with disabilities through social insurance, social assistance, social services, health insurance and labor market programs (details are provided in the main body of this report, section on disability benefits). Support programs range from benefits in cash, to services, including medical and vocational rehabilitation, employment support, care allowance, support for housing, etc. Benefits in cash dominate, especially social insurance disability pensions (87.0 percent of all adults with disabilities receive this benefit), social assistance disability pensions (19.0 percent of all persons with disabilities receive this benefit) and care allowances (41.0 percent of all persons with disabilities receive these allowances). Most benefits in cash are provided at the national level, while service provision and some benefits in cash are the responsibility of municipalities. Labor market participation (employment) has no impact on eligibility for benefits, except for social assistance disability pension, which cannot be received while a person is working. Overall, this is a good feature of the disability system in Lithuania: in many countries people with disabilities must choose between disability pension and labor market participation. The Government may consider extending this policy also to disability social assistance pensions in order to encourage persons receiving this pension to seek employment. Only if the employment is stable and say lasts for more than two years, the benefit could be gradually reduced/ tapered off. Public spending on disability benefits. Lithuania spends about 15.5 percent of GDP on social protection of which disability benefits constitute about 9.0 percent, or 1.4 percent of GDP (in 2018). Relative to other EU countries, Lithuania’s spending on disability benefits as a share of social spending is above the EU-28 average: only six EU countries spend more than Lithuania. However, relative to GDP, Lithuania’s spending on disability benefits is below the EU-28 and belongs to the lower end of spending among the EU members. Procedures to access benefits: To receive disability benefits a person must be assessed by DWCAO. However, the decision of DWCAO does not determine the right of the persons with disabilities to receive a benefit. Each benefit has its own assessment process and requires an application to the provider of the benefit/service and often a submission of documents, many of which, should be available online. The lack of an integrated process and the lack of coordination between institutions cause another problem as well: persons with disabilities are not well informed about available benefits/services and their requirements and, thus, many do not benefit from them. MSSL may consider the following steps to improve access to and efficacy of support to persons with disabilities. 4 • Better information is needed: To address this, MSSL, in collaboration with municipalities, should compile an inventory of disability benefits with their basic eligibility requirements and administrative procedures with a link to legal and administrative regulations and made it available electronically and in printed and accessible formats across the country. This inventory should be advertised widely, and each person registering for disability assessment at DWCAO should be given a copy and instructed on how to access information online. • Aligning access to medical rehabilitation with Article 20 of the Law on Social Integration of Persons with Disabilities. Access to these benefits starts when a person with assessed work capacity or level of special needs requires a special treatment and the treating physician fills in a form. To better align medical rehabilitation with the provision of Article 20, medical rehabilitation (and other rehabilitation and assistance measures) should precede work capacity assessment. Medical treatment and medical rehabilitation are integrated phases in restoring patients’ health and functioning. Should a person need continuous medical rehabilitation treatment after the assessment, such recommendation should be made by rehabilitation professionals to DWCAO and be taken into account during the assessment. The MSSL may wish to discuss this issue with the Ministry of Health and change related legal provision to ensure full implementation of the Article 20. • The procedures around care allowances should be reviewed. Targeted compensation (care allowances) could be further strengthened. The description of needs and content of the assistance would need to be precisely and minutely described, to allow for better decision making. This benefit is an open-ended commitment for the state budget. The eligibility and award are decided on by municipalities, while the financing is provided by the state budget. Potential policy considerations may include options to consolidate the benefit into a single benefit; differentiate it by hours of service needed and have DWCAO’s assessment and recommendations play a decisive role in the decision on eligibility. A regular audit of decisions would help ensure that the benefits are received by those who need them the most. • Assistive devices and technical aids are another area where integration between a treating physician, rehabilitation professionals and benefits administration need to be stronger. This is crucially important for the adequacy of assistive aids, which need to be tailored to the functioning needs of a person with disabilities. Assistive technology is one of the key contributing factors for helping persons with disabilities stay at work. Persons with disabilities and labor market Labor market participation and employment rates of persons with disabilities in Lithuania are low, well below those for the overall working age population. In 2018, out of 160,000 working age persons with disabilities, 47,200 persons were employed (29.4 percent) and 13,200 (8.2 percent) were looking for a job. A majority - 62.3 percent were out of the labor force. Following a standard ILO approach to calculate labor market indicators (where the denominator is labor force – employed plus those looking for a job), employment rate of persons with disabilities would be 78.1 percent and unemployment rate would be 21.9 percent – more than double that in the general population. Labor market policies and programs for persons with disabilities. Juxtaposed to this is a myriad of labor market policies and programs for persons with disabilities supporting both persons with disabilities and their employers. They include vocational rehabilitation and training, flexible working hours, labor market services, case management, wage subsidies, workplace accommodation, subsidies for job creation, social enterprises, etc. In combination with support persons with disabilities provided in general (benefits in cash and services), one would expect a higher labor force participation of persons with disabilities than observed. In fact, Lithuania has a higher unemployment rate of persons with disabilities than other EU countries for which comparative recent data is available. 5 Obstacles to labor market participation of people with disabilities. Most people with disabilities are capable of working and wish to work. However, they face difficulty in finding employment or remaining at the same workplace. They are more likely to become long-term unemployed or inactive. Breaking this situation requires a profound change in disability policy in Lithuania on two fronts: first, keeping people employed, even though they have been assessed as disabled, and providing opportunities for unemployed persons with disabilities to get a job commensurate with their work capabilities (e.g., a paraplegic architect or a government clerk would not need a to leave her/his job because of paraplegia). Keeping disabled people at work would require that all efforts be made to keep employed people experiencing health issues at work, prior to being assessed as having low work capacity. Even then, they should be supported to stay in employment. This would require a strong collaboration between a person with a possibly permanent health problem, her/his employer, the treating physician, medical rehabilitation professionals, occupational rehabilitation, employment services, and local social services. A more nuanced and tailored approach is needed to ensure opportunities for labor force participation of persons who have been disabled since childhood, persons who have acquired disability as adults and elderly persons experiencing disability who wish to work. For this to happen, a shift is needed in disability policy, its implementation, in the way how disability is assessed, and how support and assistance are provided, as discussed above and throughout this report. Disability data The administrative data in the area of disability policies is considered somewhat incomplete and not fully up to date. Accurate, up to date information is crucially important for policy development, planning, budgeting and implementation. MSSL may consider conducting a census (biometric if feasible) of persons with disabilities and task Disability and Work Capacity Assessment Office (DWCAO) with the data base updates and maintenance. Alternatively, data could be collected through the disability reassessment process that is conducted by DWCAO, but it may take several years to complete the census. Further, electronic exchange of information with the State Social Insurance Fund (SSIF), civil registry, health care system, employment services and other government entities involved in the implementation of the Government disability policies and programs would enable a regular update of information on benefits received by individuals with disabilities. Such a system would enable close monitoring of the implementation of disability policies and programs, provide information on service and benefit gaps and serve as a base for policy and programs development and planning. Empirical evidence on labor market participation of persons with disabilities is needed. MSSL should consider a survey of a sample of working age persons with disabilities to better understand who they are (education, qualifications, last job, distance form employment, etc.), and what their labor market situation is, as well as the reasons behind it. Alternatively, DWCAO’s assessment/reassessment of disability/ work capacity could be used to collect this information. It could be done at the registration for (re)assessment. MSSL should also start closely monitoring whether employed persons whose work capacity is assessed stay in employment or not and why. Unemployed working age persons who are assessed for work capacity should also be surveyed about their work history and attempts to get a job. Referral to the employment services should be a common practice. Implementation of the Article 20 of the Law on Social Integration of Persons with Disabilities, which stipulates that all support measures should be implemented prior to an individual being assessed for work capacity, as discussed above, would be a significant step forward in supporting employment and labor force participation of persons with disabilities. 6 An assessment of active labor market programs to support labor market participation of persons with disabilities should be conducted. Programs that do not perform well should be discontinued, and those that do work should be expanded. Disability Policy and Disability Assessment System in Lithuania 1.1 Introduction This Report was prepared as part of the “Lithuania - technical support to reform the disability assessment system” provided by the World Bank with funding from, and in collaboration with, the Directorate-General for Structural Reform Support of the European Commission (DG REFORM). The Project aims at supporting the Ministry of Social Security and Labor (MSSL) of the Republic of Lithuania in enhancing disability assessment through strengthening of the assessment of functioning and through related improvements in the administrative processes. This report, hence, provides a detailed description of the assessment criteria, the administrative/ business processes through which disability assessment is conducted and the underlying information system that supports them. To better understand the policy environment in which the disability assessment system operates, the Report also looks at disability data, support (benefits) provided to persons with disabilities and labor market programs and participation of persons with disabilities. The Report begins with a snapshot of disability statistics, followed by detailed mapping of the disability assessment system. Sections on disability benefits and labor market and persons with disabilities follow. Each section is concluded by key messages. The Report is accompanied by an Annex, which provides a short brief on Understanding Disability and Disability Assessment, as well as more detailed information on the legal framework for disability assessment, disability assessment statistics, examples of forms and assessment instruments and illustration of information system supporting disability assessment system business processes and decision making. 1.2 A snapshot of disability statistics in Lithuania According to the administrative data from the Ministry of Social Security and Labor (MOSSL), it is estimated that in 2018 there were 230,609 persons with disabilities in Lithuania - 8.2 percent of all population.1 As presented in Figure 1, year on year, this number has been slightly decreasing. It is believed that emigration, low fertility, healthier lifestyle and improved health services, have contributed to this trend. The prevalence of disability in the population over 16 years of age is estimated at about 10 percent.2 The administrative data in Lithuania capture the population of persons with disabilities of all ages (children, working age persons, and the elderly) who have been in contact with the government disability benefits system: have been assessed for their childhood or adulthood disability, work capacity, or special needs level and who are beneficiaries of publicly funded disability benefits. 1 The estimate is based on the number of persons with disabilities receiving disability benefits. See: Ministry of Social Security and Labor (MSSL): https://socmin.lrv.lt/lt/veiklos-sritys/socialine-integracija/neigaliuju-socialine-integracija/statistika-2 and the MSSL’s annual reports: https://socmin.lrv.lt/uploads/socmin/documents/files/veikla/veiklos%20ataskaitos/SADM%202018%20metu%20veiklos%2 0ataskaita.pdf 2 It would be useful if one would be able to compare the statistics internationally. Unfortunately, such data is not available. Moreover, such comparisons could only be illustrative, because administrative data reflect disability assessment systems, as well as benefits provided to persons with disabilities, which differ widely. 7 Figure 1: Persons with disabilities in Lithuania 2012 -2018 270,000 240,000 210,000 180,000 150,000 120,000 90,000 60,000 30,000 0 2012 2013 2014 2015 2016 2017 2018 All Children Adults Source: MSSL Eurostat data from the European Union Survey on Income and Living Conditions (EU SILC) based on the self-reported “long-standing limitations in usual activities due to health problems”, show much higher prevalence of disability in Lithuania (Table 1).3 The table shows that in 2018, compared to the EU-28 average, Lithuania had about one forth higher percentage of persons 16 years and over reporting experiencing “long-standing limitations in usual activities due to health problems”: 30.6 percent (24.0 percent “some” and 6.6 “severe” limitations) vs. 24.7 percent (17.7 percent and 7.0 percent), respectively. Like other European Union (EU) countries, prevalence of self-reported limitations is higher among female than male, it sharply increases with age and it is inversely related to the income level. It should be noted that administrative data on persons with disabilities (children, adults and elderly who have been assessed as persons with disabilities sand are benefiting from at least one disability program) and the EU SILC self-reported data on “long-standing limitations in usual activities due to health problems” are not directly comparable. 3 https://ec.EURopa.eu/EURostat/statistics-explained/index.php?title=Functional_and_activity_limitations_statistics 8 Table 1: Persons self-reporting long standing limitations in usual activities due to health problems in EU in 2018 Distribution of persons by self-reported long-standing limitations in usual activities due to health problems, by sex, 2018 (% share of the population aged 16 and over) Total Males Females Some Severe None Some Severe None Some Severe None EU-28 (1) 17.7 7.0 75.3 15.9 6.4 77.8 19.4 7.6 73.0 EA-19(1) 17.8 7.1 75.1 16.0 6.5 77.5 19.4 7.7 72.9 Belgium 16.5 8.9 74.7 15.5 7.5 77.0 17.4 10.2 72.5 Bulgaria 13.0 3.7 83.4 10.8 3.3 85.9 14.9 4.0 81.1 Czechia 20.2 7.7 72.0 18.3 6.9 74.7 21.5 8.3 70.2 Denmark 23.2 5.8 71.0 20.4 5.0 74.7 25.9 6.6 67.5 Germany 15.1 7.1 77.7 14.4 6.8 78.7 15.8 7.4 76.8 Estonia 26.8 12.7 60.5 25.7 10.4 63.8 27.6 14.4 58.0 Ireland (2) 11.4 5.6 83.0 11.0 5.4 83.6 11.7 5.7 82.6 Greece 13.6 10.2 76.2 12.5 9.3 78.2 14.6 11.0 74.5 Spain 16.2 4.4 79.4 13.9 3.8 82.2 18.4 4.9 76.7 France 15.9 9.3 74.8 14.7 8.6 76.8 17.0 10.0 72.9 Croatia 23.3 10.1 66.6 22.2 9.0 68.7 24.4 11.0 64.6 Italy 18.2 5.5 76.3 16.2 4.7 79.1 20.1 6.3 73.7 Cyprus 16.4 7.6 76.0 15.7 7.6 76.7 17.0 7.7 75.3 Latvia 30.3 9.7 60.0 27.1 8.6 64.3 32.7 10.6 56.7 Lithuania 24.0 6.6 69.4 20.5 5.6 73.9 26.7 7.4 65.9 Luxembourg 17.9 9.2 72.8 17.1 8.0 74.9 18.8 10.5 70.8 Hungary 18.0 7.4 74.6 16.1 6.3 77.6 19.6 8.4 72.0 Malta 9.4 2.5 88.1 8.6 2.2 89.2 10.3 2.8 86.9 Netherlands 25.7 5.5 68.8 22.2 5.1 72.7 29.1 6.0 64.9 Austria 25.2 8.9 65.9 23.8 8.4 67.7 26.4 9.4 64.2 Poland 16.4 7.5 76.0 14.7 7.4 77.8 17.8 7.6 74.6 Portugal 25.0 8.6 66.5 20.7 7.6 71.8 28.7 9.4 61.8 Romania 20.6 5.9 73.5 17.4 4.6 78.1 23.6 7.1 69.3 Slovenia 26.4 9.0 64.6 24.2 8.6 67.3 28.7 9.4 62.0 Slovakia (2) 22.8 9.1 68.1 19.8 8.1 72.1 25.7 10.1 64.3 Finland 26.9 7.3 65.8 23.3 6.7 70.1 30.6 7.9 61.5 Sweden 8.5 4.5 87.0 6.6 3.4 90.0 10.5 5.5 84.0 United 14.3 10.9 74.8 12.8 9.7 77.5 15.7 12.0 72.3 Kingdom (2) Iceland (3) 8.6 11.6 79.8 6.1 8.5 85.3 11.1 14.7 74.2 Norway 11.7 5.2 83.1 9.1 4.1 86.8 14.4 6.3 79.4 Switzerland 24.9 5.5 69.6 22.5 4.7 72.8 27.2 6.3 66.5 North 8.4 5.5 86.1 7.1 4.8 88.0 9.7 6.1 84.2 Macedonia Serbia (2) 13.0 5.7 81.3 11.2 5.1 83.7 14.6 6.2 79.2 Turkey (2) 17.7 6.5 75.7 14.4 5.5 80.1 21.0 7.6 71.4 (1) Estimates. (2) 2017 data (3) 2016 data Source Eurostat (online data code hlth_silc_12) UN Population Projections point to a significant drop in the Lithuanian population during the next 30 years: from an estimated 2,722,289 people in 2020 to 2,121,387 in 2050. This decline is coupled with rapid aging of the population and the share of the population over 65 in the total population is projected to increase by 41.0 percent: from 20.6 percent in 2020 to almost 29.0 percent in 2050. 9 Consequently, the pool of the working age population is projected to decline by more than half a million people by 2050, i.e. from 64 percent of the population in 2020 to 57 percent in 2050. This profound change in the labor supply calls for a strong emphasis on healthy living and healthy aging policies. Here, Lithuania has significant room for improvement. According to the World Health Organization’s (WHO) Health Adjusted Life Expectancy (HALE) at birth indicator, Lithuania’s HALE in 2016 was 66.1 years (61.9 for men and 70.0 for women). In comparison, HALE for France was respectively 73.4, 71.8 and 74.9 years.4 It also calls for policies and programs that would focus on optimizing functioning of persons experiencing disability, including rehabilitation, accommodation, care services, etc., to maximize the quality of their life, as well as their participation in the labor force. The administrative data presented here is considered somewhat incomplete and not entirely up to date. As accurate data is crucial for policy making, planning and budgeting and monitoring of policy implementation, the MSSL may consider conducting a census (biometric if feasible) of persons with disabilities and task Disability and Work Capacity Assessment Office (DWCAO) with the data base updates and maintenance. As soon as the disability assessment decision is made, the data base would be updated. DWCAO already has information exchange with the civil registry office, enabling real time updates in the civil registry status. Furthermore, electronic information exchange with the State Social Insurance Fund (SSIF) and other government agencies would enable collection of information and real time updates about benefits/ assistance people with disabilities have received. This would not only ensure accuracy of information but would facilitate integration of services provided to persons with disabilities and enable case management with the objective of ensuring that people with disabilities have access to available disability assistance programs. Alternatively, this data base could be compiled over several years using the process of disability reassessment, through which a majority of persons with disabilities must go through periodically. In this case, only persons with disability status for 10 years and for life would need to be surveyed. Key messages In 2018, according to administrative data, there were about 230,609 persons with disabilities in Lithuania - 8.2 percent of all population. The prevalence of disability in the population over 16 years of age is estimated at about 10 percent. The administrative data is considered somewhat incomplete and not fully up to date. MSSL may consider conducting a census (biometric if feasible) of persons with disabilities and task DWCAO with the data base updates and maintenance. Alternatively, data could be collected through the disability reassessment process that is conducted by DWCAO, but it may take several years to complete the census. UN Population Projections point to a significant drop in the Lithuanian population during the next 30 years. This decline is coupled with rapid aging of the population. The pool of the working age population is projected to decline by more than half a million people by 2050. This profound change in the labor supply calls for a strong emphasis on healthy living and healthy aging policies. It also calls for policies and programs that would focus on optimizing functioning of persons experiencing disability, including rehabilitation, accommodation, disability assessment system, care services, etc., to maximize the quality of their life, as well as their participation in the labor force. 4 See: https://www.who.int/gho/mortality_burden_disease/life_tables/hale/en/ 10 1.3 Disability Assessment in Lithuania In this section we look at the disability assessment system in Lithuania: the legal framework, assessment criteria, administrative processes and management information system. While disability assessment system is influenced by the larger environment set up by the overall disability policy and system, it also has a profound impact on them, as it ultimately plays an important gate-keeping role for persons with disabilities to access disability benefits. 1.3.1 Legal Framework5 The main legal act regulating disability assessment systemin Lithuania is the Law of the Republic of Lithuania on Social Integration of Persons with Disabilities (hereafter the Law on Social Integration).6 The government body tasked with disability assessment is Disability and Work Capacity Assessment Office (DWCAO) under the Ministry of Social Security and Labor (MSSL). DWCAO comprises central office in Vilnius and territorial divisions across Lithuania (21 territorial divisions). The Law on Social Integration came into force in 2005 introducing significant changes to the disability assessment system at the time. In particular: • A new definition of disability was introduced. Article 2 defines disability “as a long-term deterioration in health, reduced participation in the life of the community, reduced functioning through exposure to a combination of body structure, disfunction and environmental factors”. • The existing grouping of disability into three groups (Categories One, Two and Three) was replaced by new categorization, introducing notions of severe, moderate and mild disability, percentages of work capacity in working age individuals and special needs and level of special needs (the later for persons in retirement age). • The assessment methodology, which until 2005 was exclusively conducted based on medical criteria, was amended to include information “on the individual’s activities and ability to participate”. This information is collected through a face to face interview. Article 207 establishes that work capacity is determined by assessing the state of health of the individual and her/his ability to perform earlier obtained qualification, to obtain new qualification, or to be engaged in jobs that do not require professional qualifications, after having exhausted all available medical and vocational rehabilitation and special assistance measures. This is a very important provision of this law, because it sets favourable conditions for setting up disability policies and disability assessment system that prioritizes optimization of functioning, wellbeing and labor market participation of persons with disabilities. This article also establishes that the criteria and procedures for the assessment should be determined by the Minister of Social Security and Labor jointly with the Minister of Health. “The Order of the Minister of Social Security and Labor of the Republic of Lithuania and the Minister of Health of the Republic of Lithuania No. A1-78/V-179 on the Approval of Criteria for Work Capacity and the Procedure for the Assessment of Work Capacity”8 (hereafter the Order No. A1-78/V-179) is the main administrative act that regulates criteria and administrative process for the assessment of work capacity. 5 A brief summary of relevant legal acts is provided in Annex 2. Active links to those acts is provided in Annex 3 to this Report. 6 The Law of the Republic of Lithuania on Social Integration of Persons with Disabilities, https://www.e- tar.lt/portal/lt/legalAct/TAR.199156E4E004/cWWgldtkIu 7 Ibid, Article 20. 8 Order of the Minister of Social Security and Labor of the Republic of Lithuania and the Minister of Health of the Republic of Lithuania No. A1-78 / V-179 on The Approval of Criteria for Work Capacity and the Procedure for the Assessment of Work Capacity, https://www.e-tar.lt/portal/lt/legalAct/TAR.D1F619C285A0/asr 11 Detailed descriptions of the administrative process, and the instructions on how to perform it, are stipulated in orders of the Director of the Disability and Work Capacity Assessment Office (DWCAO) under the MSSL: • No. V-110 On the Determination of Assessment Procedure for the Level of Disability, Work Capacity, Special Needs and Vocational Rehabilitation Services in the Territorial Division of DWCAO9, • No. V-13 On the Determination of Assessment Procedure for the Level of Disability, Work Capacity, Special Needs and Vocational Rehabilitation Services in the Decision Control Division10, and • No. V-10 On the Determination of Control Procedure for Decisions Made by DWCAO Territorial Divisions.11 The Order No. A1-78 /V-179 comprises two detailed sections: (i) Criteria and (ii) Procedure. Paragraph 3 of the Criteria defines medical criteria (a typical Barema grid with a list of medical diagnoses/ impairments and a percentage values for work (in)capacity)12 assigned to each one of them and activities and participation criteria (interview instruments13, score values14, and coefficients related to score values15). Paragraph 11 of this Order establishes a method on how to combine the two scores and coefficients. The activities and participation criteria and related instruments have been revised continuously, to link them better to the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) and the bio-psycho-social (interactional) model of disability,16 to make the assessment process more objective by including functioning assessment into disability assessment, and to assess more comprehensively an individual’s capacity to participate in the labor market. This openness to adjust enables MSSL and DWCAO to keep abreast with the scientific advancements in the assessment of functioning. To that end, it is currently preparing to pilot a WHO-developed and extensively tested psychometric tool17 for the assessment of functioning to ensure that any future adjustments in the disability assessment criteria and procedure are based on empirical evidence using a standardized, extensively tested, internationally validated and scientifically robust and reliable instrument. The Procedure regulates in detail, step by step, process for disability assessment (rules, roles and controls) - from the submission of required documents and application (registration) for the assessment, to the decision concerning work capacity and appeals and reassessment procedure. Further guidance and instructions to the assessors are provided through the orders of a DWCAO director. 9 Order of the DWCAO’s director No V-110 on the Determination of Assessment Procedure for the Level of Disability, Work Capacity, Special Needs and Vocational Rehabilitation Services in the Territorial Division of DWCAO, https://www.e- tar.lt/portal/lt/legalAct/49be52803a8211e99595d005d42b863e 10 Order of DWCAO’s director No V -13 On the Determination of Assessment Procedure for the Level of Disability, Working Capacity, Special Needs and Vocational Rehabilitation Services in the Decision Control Division: https://www.e- tar.lt/portal/lt/legalAct/fa98a2503a8111e99595d005d42b863e 11 Order of DWCAO’s director No. V-10 On the Determination of Control Procedure for Decisions Made by DWCAO Territorial Divisions: http://ndnt.lrv.lt/uploads/ndnt/documents/files/SKS20130702%20(2).pdf 12 Ibid, Annex 1. 13 Ibid, Annex 2. 14 Ibid. 15 Ibid. 16 WHO (2001), International classification of functioning, disability and health, Geneva ; Bickenbach B, Posarac A, Cieza A, Kostanjsek N. (2015) Assessing Disability in Working Age Population - A Paradigm Shift: from Impairment and Functional Limitation to the Disability Approach, Report No: ACS14124, World Bank, Washington, D.C. 17 TB Üstün, N Kostanjsek, S Chatterji, J Rehm, editors (2010). Measuring Health and Disability, Manual for WHO Disability Assessment Schedule, WHODAS 2.0, WHO 2010, Geneva. 12 1.3.2 How is disability assessed? Prior to focusing on the question posed above, some key definitions and terms, from Lithuanian legislation and other official documents, are provided below. • Disability is defined as “the long-term deterioration in health, reduced participation in the life of the community, reduced functioning through exposure to a combination of body structure, disfunction and environmental factors”. This definition applies to disabled children, adults and elderly, i.e. there is no age restriction. • Disability level is determined in children up to 18 through an assessment of the degree of the loss of a child’s health, independence in daily activities and opportunities for education. In order words, the assessment of the disability level pertains to children only. • Capacity for work is defined as ability of an individual to implement previously acquired professional competence or to acquire new professional competence or to perform work requiring lower professional competence. It is expressed as a percentage value and is pertains to working age people (18-64). • Special need is the need for special assistance due to a person's congenital or acquired long-term medical conditions and adverse environmental factors (no age restriction). • Level of special needs is determined based on the reduction of person’s autonomy, with reference to the person's special needs or previously (before the retirement age) assessed working capacity. It pertains to people who have reached retirement age. • A person with disabilities is a person who has been assessed a disability level (mild, moderate or severe) or a work capacity of 55 percent or less or has been determined a level of special needs. Although disability assessment is carried out by DWCAO, the procedures for the assessment of disability level in children, work capacity for persons of working age, the assessment of special needs (no age differentiation), and the assessment of the level of special needs in the elderly all differ in medical criteria, as well in the application of activity and participation criteria and concerning authorized institutions to collect this information by filling in the activity and participation questionnaire. This is an issue since the same person may lose disability status due to age transition (from childhood to adulthood and from working age to retirement age). While some differences are natural, particularly in the case of children and their special needs, standardization and uniformity are important for credibility, validity, reliability and transparency of disability assessment. (For definition of these terms see Annex 1 to this Report.) For example, work capacity assessment in cases of occupational disease or work accident does not require the assessment of activities and participation – i.e. it is based solely on medical/impairment criteria. The rational for this is not clear, as the lived experience of disability is as important in the case of occupational diseases/ work accidents as in the case on any other health condition. Furthermore, filling in multiple questionnaires may actually not add value to the assessment process. Using one well designed and empirically tested instrument is more cost effective than using multiple instruments that are difficult to interpret and combine into a consistent, meaningful indicators. 1.3.3 Assessing disability in children The main regulation that establishes procedures for disability level assessment is the Order of the Minister of SSL, the Minister of Health and the Minister of Education and Science of the Republic of 13 Lithuania Nr. V-188/A1-84/ISAK-487: Approval of Criteria and Procedure for Determining Disability Level.18 The Ministerial Order defines some key terms in the following way19: • Basic level of disability – determined based on a person's state of health: all diseases, injuries, pathological conditions affecting the person's disability and related disorders of bodily functions. • Ability to participate – the ability of a person to take part in daily physical, social and educational life, consistent with his or her age group. • Special educational need – the need for assistance and service in the educational process resulting from exceptional personal abilities, congenital or acquired disorders, and unfavorable environmental factors. • Mild disability level – a person's condition when due to illness, trauma, injury, congenital or childhood health disorders, negative influence of environmental factors, the possibilities to develop, participate, and act have slightly decreased. • Moderate level of disability – a person's condition when due to illness, trauma, injury, congenital or childhood health problems, and negative influence of environmental factors a reduced ability to develop, participate, and function has occured and constant care and helo from other people is needed. • Severe disability - a condition whereby, due to illness, trauma, injury, congenital or childhood health disorders, and adverse effects of environmental factors, a significant reduction has occured in access to education, participation, and functioning and continued care, assistance and support from others is needed. Figure 2: Assessing disability in children: a flow of administrative processes Source: Author’s visualization based on administrative processes. Figure 2 presents a visualization of the administrative processes flow. A physician, after having received an application from parents, fills in a DWCAO form (see Annex 5) and prepares a medical file with relevant medical information.20 In addition to this information, DWCAO conducts a face to face 18 Order of the Minister of Social Security and Labor of the Republic of Lithuania and the Minister of Health of the Republic of Lithuania and the Minister of Education and Science of the Republic of Lithuania No: V-188/A1-84/ISAK-487 on the Approval of Criteria and Procedure for Determining the Disability Level: https://www.e-tar.lt/portal/lt/legalAct/TAR.95F9283BB46A/gOVaaGAwWa 19 Ibid. 20 These include: lab and other tests, diagnosis, the description of the severity of the disease, the description of bodily dysfunction; health history, etc.; Barthel Index, Functional Independence Test, Pain Rating Scale, Muscle Condition Assessment, Degree of Movement Impairment in Motion Impaired, IQ test results, Mini mental test, psychological personality test, confirming the degree of dementia, behavior, emotions, and other disorders in case of mental illness and 14 interview to collect information on the child’s activities and participation. The questionnaire is age specific (see Annex 6). A certificate from the Pedagogical-Psychological Service or the Educational Assistance Service regarding the Special Education and/or Educational Assistance Award may be provided as well. The level of disability is decided by using medical criteria (health conditions are assigned point values), based on the documentation submitted, and a coefficient that is assigned to scores from the activity and participation survey, as well as a special education need coefficient. The weight given to the health condition points dominates the formula. The point values assigned to medical conditions, the activity and participation scores and related coefficients and coefficients assigned to special education needs all reflect historical practice and expert opinion and it is hard to determine their scientific or empirical foundation: it may be that the number of points reflect objectively differences in health status, or that the chosen questions for activity and participation capture adequately age-specific growth benchmarks and variance in functioning and in any event it is not possible to determine what the empirical basis was for transforming scores into coefficients. Given how important it is to ensure that a child with a health condition develops up to her/his full potential, the MSSL and other relevant government agencies may consider an integrated approach to assessing disability/difficulty in functioning in children. They should consider where a case conference will be organized with participation of the child’s pediatrician, teachers, and other relevant professionals, and parents/ guardians. The objective would be to comprehensively assess the state of child’s development, health and functioning and to determine the child’s needs and support interventions/ assistance in order to maximize her/ his development potential. The assessment would need to be updated in regular intervals or as needed to ensure that adequate and timely support. Figure 3 below presents data on the number of children for whom an application for disability assessment was made and who were assessed as having a disability. Figure 3: Disability assessment in children 2013-2018 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 2013 2014 2015 2016 2017 2018 Applied to be assessed Assessed as having a disability Source: data from DWCAO Information system. disorders; tests confirming the degree of visual and / or hearing impairment in case of visual and hearing impairment; speech assessment in the case of speech disorder, etc. 15 The data21 show that the number of children for whom an application was made has decreased by almost 20 percent in a short span of six years. Most of the decline was on the account of the reassessment of disability status, because the number of children being assessed for the first time increased by 7.1 percent (from 1,795 in 2013 to 1,923 children in 2018). Reassessment of disability makes 2/3 of all assessment cases. Boys are more likely to be assessed for disability than girls. In 2018, boys represented 2/3 of all assessment cases. Looking at severity of assessed disability: moderate disability dominates (55.0 percent), followed by mild disability (30.0 percent) and severe disability (15.0 percent). The data also show a very high success rate for applicants: in 2018 – 97 percent. This could be due to a strict triaging process at the medical doctors’ level, or due to the softness of disability assessment criteria. Either way, a clinical assessment of a sample of cases would be needed to understand better this high success rate. For more data on disability assessment in children, see Annex 4. 1.3.4 Assessing special needs and the level of special needs Special needs could be assessed in the case of any applicant for disability assessment. For children, this assessment is to be part of the disability assessment process. For working age persons, it is to be part of the work capacity assessment. For elderly (retirement age plus), special needs and the level of special needs (elderly specific notion) are assessed separately.22 The assessment process considers: (i) Base Disability Level - A medical criterion, expressed as a score, that is based on the individual's state of health: illness, trauma, pathological condition and related bodily dysfunction. The scoring is done based on the point system where a certain number of points is asigned to each listed medical condition/ impairment, and (ii) Autonomy coefficient is a measure of a person's functioning in everyday life (mobility, nutrition, personal hygiene, social relationships) and his or her cognition, perception and behavioral abilities. The information is collected through an instrument especially designed for the elderly. In this case, the information is collected by a municipal officer, not DWCAO. The municipal officer visits the applicant. The collected information is transferred to DWCAO that reviews the information and decides on special needs and the level of special needs of the applicant. As in the case of childhood disability assessment, the formula for decision making is strongly biased towards medical part of the assessment. Figure 4 illustrates the assessment process flow. A treating physician upon receiving a request from her/his patient, fills in the DWCAO’s form, prepares required medical data and sends them to DWCAO. A municipal officer collects information on the person’s activity and participation through a face to face interview, which is used by DWACO to determine the applicant’s autonomy coefficient. The interview could be performed at the applicant’s home, should the circumstances warrant so. Upon receiving needed information, DWCAO designated officer reviews the documents and proposes the decision on the level of special needs to her/ his supervisor. 21Source of data: DWCAO Information System. 22Procedures are described in the Order of the Minister of SSI and the Minister of Health of the Republic of Lithuania No. A1-765/V-1530: Approval of the Procedure for Determining the Requirements for the Compensation of the Expenses for the Special Permanent Care, Special Permanent Care (Assistance), Special Car and its Technical Adaptation: https://www.e- tar.lt/portal/lt/legalAct/ef7052500aa811e9a5eaf2cd290f1944/asr 16 Figure 4: Process flow for assessing special needs and level of special needs of elderly pers ons Source: Authors’ visualisation based on administrative processes. Figure 5: Assessment of special needs by age 60,000 50,000 40,000 30,000 20,000 10,000 0 2013 2014 2015 2016 2017 2018 Children Working age persons Elderly (retirement age and above) Source: Figure 5 presents data on assessed special needs 2013-2018, by year and by all three different age groups: children, working age individuals and elderly. In all groups the numbers have fallen between 2013 and 2018: in the case of children by about 13 percent, in the case of working age people by 26 percent and in the case of elderly by 43 percent. 17 It is hard to speculate about the reasons behind the downward trend without a proper empirical analysis, particularly considering that the reasons may be group specific. It could also be that data is incomplete. It could be that applicants refuse the assessment of needs (their consent is needed for this assessment to be conducted). In the case of children and working age adults, given that the needs assessment is included into disability/work capacity assessment, the assessment likely reflects the fact that fewer children and working age adults are applying for disability benefits. However, of 5,628 children who were assessed for disability in 2018, only 983 (17.5 percent) were assessed as having a special need. The situation is similar for working age adults. This warrants further investigation, as it is difficult to imagine that a child, working age person or elderly person would be assessed and issued a certificate as disabled/ with low work capacity or having a special need level (elderly) without having a special need. A more detailed statistics on determination of special needs and level of special needs is provided in Annex 4. 1.3.5 Work capacity assessment Work capacity assessment is regulated by the Law on Social Integration of Persons with Disabilities23, detailed in the ministerial order No. A1-78/V-17924 and methodologically described with instructions for every officer of DWCAO in the DWCAO Director’s Order No. V-11025. (A summary of key legal provisions is provided in Annex 2, and the list of relevant legal acts with active web links is provided in Annex 3 to this Report.) Figure 6: Assessment of work capacity 2013 -2018 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 2013 2014 2015 2016 2017 2018 All applications Assessed work capacity 60-100 percent (not disabled) Assessed work capacity 0-55 percent (disabled) Source: Data from DWCAO Information System. 23 Law of the Republic of Lithuania on Social Integration of Persons with Disabilities, https://www.e- tar.lt/portal/lt/legalAct/TAR.199156E4E004/cWWgldtkIu 24 Order of the Minister of Social Security and Labor of the Republic of Lithuania and the Minister of Health of the Republic of Lithuania Nr. A1-78/V-179 Approval of the Procedure for the Assessment of Work Capacity, https://www.e- tar.lt/portal/lt/legalAct/TAR.D1F619C285A0/asr 25 Order of the DWCAO Director Nr. V-110 on the Determination of Assessment Procedure of the Level of Disability, Work Capacity, Special Needs and Vocational Rehabilitation Services in the Territorial Division of DWCAO, https://www.e- tar.lt/portal/lt/legalAct/49be52803a8211e99595d005d42b863e 18 Work capacity is assessed in working age adults, which is defined as 16-65 years of age in Lithuania. In the case of occupational disease or accident at work, there is no upper age limit. Figure 6 presents data on the work capacity assessment: applications, successful applications and those that were not successful. The figure shows a notable decline in the number of applicants for work capacity assessment during the last 5 years (26 percent between 2013 and 2018). The figure also shows a very high success rate – 91.9 percent in 2018. As a comparison, in the United States, this rate is at about 45 percent. It would be hard to speculate about the reasons behind this very high success rate without empirical evidence. (The reasons could range for a robust triaging at the medical doctors’ level, to soft, easy to meet criteria.) Acquiring such evidence would entail an audit of a sample of successful applicants using a fully-fledged clinical assessment of functioning and work capacity. More data on work capacity assessment is provided in Annex 4. The assessment processes The processes are similar to the above described processes applied for children and elderly. Figure 7 charts the flow of administrative processes. They comprise 9 distinct phases. Each is described in detail below. Figure 7: Work capacity assessment flow chart Source: Authors’ visualization. (i) Preparation of documents for DWCAO DWCAO is a government agency that conducts the assessment and decides on work capacity.26 Article 20 on the Social Integration Law stipulates that the assessment should be based on documents submitted by a treating physician, and vocational rehabilitation and other specialists. As noted previously, the Law also establishes that the assessment should be carried after all needed medical and professional rehabilitation and special aid measures have been undertaken.27 This approach is a welcome one, as it envisages that a person should be provided a full range of available interventions to restore or stabilize health, maximize functioning and ensure her/ his labor for participation. However, this is yet to be realized in practice: in most cases a person is referred to DWCAO by a treating physician after the medical treatment has been completed. 26 Ibid. Article 18. 27 Ibid, Article 20. 19 For employed individuals, after s/he has fallen ill or has been involved in an accident, a temporary incapacity for work (paid sick leave) is determined for up to 122 days by a treating physician. In cases where more time for a person to recover is needed, the sick leave can be extended, for as long as it is needed28 by the medical advisory commission in the presence of a representative from SSIF.29 The sick leave is paid to formal sector employees covered by social insurance. The first two days are paid by the employer (62.06 – 100 percent of the beneficiary's average wage). From the third day onwards, it is paid by SSIF: 62.06 percent of the beneficiary's average wage. There are minimum and maximum limits - for example, in Q4 of 2019, the minimum SSIF temporary incapacity (sick leave) benefit was EUR 139.21 per month, and the maximum benefit was EUR 1,855.61. Once the health condition has become “permanent, immutable and all available remedies have been exhausted”, the physician fills in an official form for the work capacity assessment. The paid sick leave provision is a very important feature of the Lithuanian social security system. With it not only does a person gets needed medical treatment and medical rehabilitation, including assistive devices s/he might need, but the person gets time for vocational rehabilitation and other measures to optimize health and functioning and ensure return to work. While legally Lithuania’s disability policy calls for such an approach, it is yet to be fully operationalized and implemented in practice. A more integrated action and collaboration from various stakeholders (medical doctors, DWCAO, employment services, medical and occupational rehabilitation specialists, employers, municipal social services, etc.) is needed, with the objective of enabling a person with a health condition to stay in employment. In this case, a person would be assessed for work capacity only after all measures to restore health and optimize functioning have been exhausted, as stipulated by the above-mentioned Article 20 of the Law on Social Integration of Persons with Disabilities. This should not be very difficult to implement as, in addition to the paid sick leave provision, Lithuania has an excellent network of rehabilitation facilities, which could collaborate with other government agencies (labor offices, employers, local social care services, and DWCAO offices) and serve as a nodal point in implementing Article 20 requirements. Also, a good practice to look at is the Dutch Social Security System. The DWCAO form should be filled in by a treating physician.30 The form is described in Annex 1 to the Order No. A1-78/V-179 and comprises general data such as contact information, work status, job description; and detailed medical information: comprehensive anamnesis, treatment, condition and course of treatment, description of health status by listing specialists’ consultations and short content of each, Barthel index, duration of temporary incapacity during the last 12 months; primary and secondary and diagnoses in ICD-10 codes. The physician should also indicate if a person is referred to DWCAO for the first time and if the referral is based on an individual’s request (this would indicate that a doctor does not find that the person’s state of health warrants a referral to DWCAO). A referring physician is also obliged to attach supporting medical documents to the form. There is a binding list of medical examinations that must be provided, including Barthel Index, Functional Independence Test, Pain Rating Scale, Muscle Condition Assessment for movement disorder, IQ and 28 The duration of sick leave is not limited. When person’s work capacity is decreased temporarily and her/his state of health does not meet the criteria for disability certification, the sick leave may be extended for as long as it is needed. Up to 90 of sick leave per year are paid for persons receiving disability benefit. During the sick leave, these persons continue to receive their disability benefit as well. 29 Paragraph 42 of the Order of the Minister of Health of the Republic of Lithuania V-533/A1-189 Approval of regulation regarding sick leave electronic certificates and electronic certificates of pregnancy and maternity leave. 30 Paragraph 7 of the Order No. A1-78 / V-179. In practice, sometimes there is a problem when a person gets treated in different institutions and a doctor who fills in the form does not have access to full medical information and cannot provide required information to DWCAO. A similar problem is faced by DWCAO’s assessors, when a doctor fills in the form based on her/his specialization only (for example condition after vertebral fracture) and does not include other diseases (eye diseases, cardiological pathology, etc.), which may have an impact on functioning and work capacity. These problems are supposed to be solved by E-health, but this system is yet to be fully operational. 20 Mini mental test, psychological personality profile, the degree of dementia, behaviour, emotional or mental disorders in case of mental illness, tests confirming the degree of visual or hearing impairment and speech test for speech impairment. The DWCAO form is valid for 60 days. The medical documentation is either carried personally to DWCAO in paper format or is transferred electronically to DWCAO. The latter, which is convenient and cost efficient, is yet to become universal practice. Either way, the applicant must register at the DWCAO for disability assessment. Overall, this phase may take as many as 100 days to be completed. In some cases, a specialist’s examinations can be scheduled only several months in advance. This is the phase where some changes may be introduced, in a sense that a complete set of documents should include documents related to medical rehabilitation that was carried out and conclusions/ recommendations of medical rehabilitation professionals concerning the person’s functioning status and needs, as well as evidence of efforts to ensure that a person continues with her/ his employment. (ii) Application for disability assessment The person or his/her representative must apply for the assessment of work capacity at DWCAO; the application form could be submitted personally or could be sent by post or courier. The visit to submit documents can be pre-registered,31 however, this option is used only by 4 percent of all applicants. Most of the applicants come personally to their territorial division of DWCAO and wait in line to register for the assessment and to submit necessary documents. The whole process is formally regulated.32 The application submission normally takes about one hour, but it could take longer, depending on the number of people submitting the application. (iii) Acceptance and verification of submitted documents, registration and assignment of DWCAO territorial division The officer of DWCAO’s Document Registration Division receiving applications reviews and verifies the submission and registers the case into the register module of DWCAO’s Information System (IS). An e- case is open automatically. DWCAO’s information system is electronically linked with the Population Registry data base. As soon as an applicant’s unique identification number is entered into DWCAO registry, relevant demographic information from the Population Registry is automatically pulled into DWCAO IS, including information whether the applicant is alive. (The registrar window view is provided in Annex 8.) After registering a person, the documents brought by an applicant are scanned and attached (in PDF format) to the person’s case in the IS. Paper copies of these documents are attached to the paper case file. The paper documents are then physically carried to the assigned territorial division33 (which could be in the same building where the registration has taken place). The assignment of the DWCAO territorial division that would perform the assessment is done in the following way: (i) if a person comes for the first time, the registrar manually selects the territorial division which has the lowest workload at that moment (the registrar could see the current day’s workload in each territorial division in her/his IS window; (ii) if a person comes for a re-assessment, the IS automatically assigns her/him to a territorial division that is different from the previous one. This is done to minimize bribes and rent seeking behavior. 31 The pre-registrationmay be done on the website www.ndnt.lt or via e-system of the State (“elektroninės valdžios vartai”): https://www.epaslaugos.lt/portal/login. An applicant also has an opportunity to register and log in to his/her profile to review the history of her/his assessments; to request copies of documents; to requests duplicate documents. 32 Government Resolution No. 875 on the Approval of Rules for Processing Requests, Complaints and the Services of Public Administration Institutions: https://www.e-tar.lt/portal/lt/legalAct/TAR.6565D97B9AA2/JSMqazjaWO and Order of DWCAO director No. V-82 on Approval of Description of Procedure for Reception and Servicing of Persons' Requests at DWCAO, http://ndnt.lrv.lt/uploads/ndnt/documents/files/Gautuasmenu(1).pdf 33 Located in the same DWCAO office building, as several territorial divisions are physically located in one DWCAO office location. 21 Overall, this phase takes about 15 minutes to complete. (iv) Appointment of assessors The Head of the assigned territorial division, upon receipt of personal documents (electronic and paper files) reviews them and appoints not less than two assessors.34 The assessors are appointed based on the workload35 and the nature of the assessment. One of the appointed assessors should have a university degree in biomedical sciences. In practice, it is difficult to find the medical doctors willing to work in DWCAO for several reasons: work at DWCAO is an administrative job and does not count as medical practice, so the medical doctors working at DWCAO must work in another medical job in order to be able to extend their doctor’s license; the remuneration is uncompetitive; and residents often work at DWCAO, however once they graduate, they opt for higher paid clinical jobs. Hence the turnover is high. If there is a need for a specialized knowledge, more than two assessors may be appointed. In practice, the head of the department briefly reviews the medical documents and chooses the main assessor based on the specialization or experience in dealing with specific cases. To avoid conflict of interest, at least one of the assessors should not have participated in the previous assessment of the applicant (in cases of a reassessment). An assessor cannot assess the individual whose documents s/he prepared for DWCAO’s assessment (it often happens in smaller cities where the same doctors work in the healthcare institutions as physicians and as assessors in DWCAO). An assessor must not be related to the applicant in any way. The duties of the first and the second assessor are not regulated separately. The assessors examine the documents and: 1) decide whether additional documentation and medical tests are needed, 2) decide on the place and time for a face to face interview, 3) conduct the interview, and 4) fill in the assessment act and submit it to the head of the division. In practice, the first assessor usually conducts all steps and before completing the act, consults with the second assessor. This is a common procedure if the first assessor has a bio-medical education. If the first assessor has no medical education, then he organizes the interview, fills the questionnaire, fills some parts of the assessment act, but medical criteria are chosen and filled in by the second assessor, i.e. the one, who has a bio- medical education. To minimize rent seeking behavior and fraud, it is recommended that during the interview the person and the assessor are not left alone in the room. DWCAO may consider a streamlined procedure to ensure that the assessment is conducted by medically trained staff. First, it could rely more on engaging medical staff on a part time basis (for a certain number of hours per week, allowing them to conduct their medical practitioners’ job, as their main job). This may require reaching an agreement with clinics/ hospitals but would enable DWCAO to improve its staff complement regarding medical education of the assessors. Second, it could consider changing administrative procedure where a well-trained rehabilitation specialist would conduct a functioning assessment (this could also be on a part time basis) and a medical doctor would review both medical and functioning information and propose work capacity decision. This would be made even easier if, as envisaged by Article 20 of the Social Integration Law, applicants would be presented at DWCAO only after a complete assessment at rehabilitation clinic and all measures for optimizing functioning and participating in the labor market have been exhausted. A combination of improved medical information and standardized functioning assessment with an evidence based 34 DWCAO regulations require that employees of territorial divisions who assess work capacity must be of impeccable reputation, have higher education in biomedical or social sciences and must sign declarations of impartiality and confidentiality. The education requirement, particularly regarding medical educational background, is difficult to fulfil, because private sector is more attractive than public. 35 A territorial division employee who logs in into the IS as the head of the territorial division must appoint the assessors from the assessors list. Once the assessors have been appointed, an assessment act is automatically created with the appropriate fields for the purpose marked in the registration window. The view of the window for appointing assessors in the DWCAO Information System is presented in Annex 8. 22 automated algorithm for combining medical and functioning information for objective assessment of work capacity (based on the WHODAS pilot) should facilitate the streamlining of administrative procedure. Moreover, based on empirical evidence, an algorithm could be developed to flag any functioning score beyond what could be expected for a given health condition. The appointment of assessors takes about 15-20 minutes. (v) The interview After the assessors have been assigned, the first assessor within three working days decides on the place and time for a face to face interview. The invitation for an interview is automatically generated by IS, printed, signed and hand delivered or mailed to the applicant. In practice, if the flow of applicants allows, the interview is arranged the same day of the submission of the application. At the beginning of the activity and participation interview the assessor must inform the applicant about the purpose and content of the interview. (For the interview form, see Annex 5.) The interview is carried out only after the person signs a confirmation that s/he was informed about it. The IS generates a questionnaire based on the age of the applicant. The assessor asks questions, the person answers them, and the assessor marks the answers (the values are 0-4) in the electronic file. At the end of the interview, the score is generated and recalculated into a coefficient automatically. The questionnaire with answers and names of the assessor and the applicant is generated in PDF format, printed and the applicant is asked to review and sign it. Once the person agrees and signs, the assessor notes that in the IS and the coefficient derived from the score is automatically applied to the medical score for a final determination of disability, work capacity or special needs. In the case of a simultaneous assessment of work capacity and special needs for working-age individuals, only one questionnaire needs to be completed (the other is filled in automatically), the scores of which are subsequently transformed into the coefficients for work capacity and special needs respectively. Attending a face to face interview is mandatory; if applicant is not able to attend in person for valid reasons, her/his representative should attend. The only exceptions are: (i) a person is visited at home or hospital in cases when predicted basic capacity for work is 0-25 percent (medical assessment part); (ii) when predicted basic capacity for work is 0-15 percent. Otherwise, if an applicant does not show up for an interview, the assessment is cancelled, unless valid explanation is provided. The interview takes about 34-40 minutes to complete. (vi) Review of documentation and work capacity percentage determination After the interview, the assessor fills in the evaluation act in IS.36 The act includes primary, secondary diagnoses (this information is automatically pulled in from the form a physician sends to DWCAO), anamnesis, medical information to support the severity of impairment (by medical consultations, examinations or lab tests). The assessor then chooses the most appropriate medical criteria. The information system contains several windows for filling in medical information. In these windows, the assessor selects criteria from the list of criteria and fills in other required parameters based on the provided medical documentation. If a referral has been submitted on paper, the assessor manually enters the information from the paper documents. The paper documents are then scanned and attached to the electronic personal case. If an electronic referral has been submitted, the assessor can access the medical documents in the PDF format automatically. Also, the assessor may copy some information from the electronic referral. However, some other needed information must be completed manually, based on the medical documentation provided. Overall, manual handling of information is a problem. DWCAO should consider minimizing it by instituting standardized list of medical information that must be provided, including information on medical and vocational rehabilitation undertaken and assistive devices provided (preferably though 36 For a screenshot, see Annex 8. 23 real time electronic link to the e-Health information system, once it is operational) and by populating information into electronic file at the registration. While the registration phase may take longer to complete, it will save time of the assessors who will have all information in electronic format. All document scanning should be done only once at the registration. (For scanning of DWCAO’s decision, see discussion below.) In the case of reassessment, the assessor can copy some information from the previous assessment by clicking appropriate button. The assessor can also check the data from the National Health Insurance Fund, such as when and where the person went for treatment, what medication s/he was prescribed, etc. The assessor also fills in the necessary information on the person`s need for vocational rehabilitation. This data is filled in manually to the system. The assessor also fills in information concerning the nature and conditions of work and recommends assistance measures. These two aspects of the assessment need some rethinking and strengthening, because the need for vocational rehabilitation and recommendations regarding work conditions should be based on an assessment prior to disability assessment, which is currently not the case. Likewise, for recommendations related to assistive devices. In the current process, there is no information on which DWCAO assessor would be able to objectively assess whether a person would need vocational rehabilitation, work place adjustment, or assistive devices or assistance to stay in the current job, or a different job with the same employer or a new job. Most of the employed persons undergoing work capacity assessment leave employment and very few are referred to vocational rehabilitation. The logic of the process needs to change. For employed persons experiencing sickness, once the acute medical treatment is completed, a medical rehabilitation phase provides an opportunity for a collaboration between a patient, his/her employer, rehab professionals, employment service, and local social services. The purpose of this collaboration would be to provide available measures to help the patient maximize her/ his functioning and stay in employment. If this window is missed and a person leaves the labor market, as empirical evidence from many countries shows, the person is very likely to leave the labor market permanently. To maximize chances of persons experiencing disability continuing labor market participation, Lithuania should consider allowing a person with disability to continue working and receiving disability benefit(s). Hence, he/she could be assessed for work capacity, while keeping her/ his job. The approach should be similar for the unemployed working age adults – prior to being assessed for work capacity, they should undergo a similar process. In this way, Article 20 of the Law on Social Integration will be implemented, with much higher chances for labor market participation of persons with disabilities. In cases when an assessor finds the medical information insufficient or unclear, including from the E- health system (ESPBI IS), s/he, within three working days can request additional examination or consultations.37 In special cases, where opinion of external experts is needed, DWCAO can engage external specialists or experts from an approved list of consultants.38 If necessary, DWCAO may also request additional examination at the tertiary health care institutions.39 These services are payed from DWCAO budget. Overall, this assessment step would take about 60-90 minutes. 37 The request for additional information is signed and approved by the head of the division. 38 Approved by the Order of Minister of Health of the Republic of Lithuania No. V-688 on the Approval of the List of Special Advisers of the Ministry of Health of the Republic of Lithuania: https://www.e-tar.lt/portal/lt/legalAct/TAR.B201648C88F8/asr 39 The assessor prepares the request in the IS, but only the Head of territorial Division has the right to complete the request for additional documents. If a paper dorm to DWCAO was provided, the system generates a paper request for additional documents in PDF format, which is printed and manually signed. In the case of electronic form to DWCAO, the request for additional documents is submitted electronically and signed by an electronic signature. The view of IS window for additional information may be seen in annex nine, picture 4. 24 (vii) Decision by the head of the territorial division After the act of evaluation is completed by the assessors, it is submitted to the head of the division to validate and sign it.40 This step takes about 20-25 minutes to complete. In case, when the opinions of assessors differ, the opinion of the head of the division is decisive. The head of the division can return the act for corrections or finalize the evaluation in the IS. The decision should be made within 15 working days after all necessary documents were received. If a person is entitled a status of a disabled, the beginning of a term is set from the date that all necessary documents were received (in order to protect the individual’s right to a benefit independently of the period that took DWCAO to make the decision). The head of the territorial division is responsible for organizing the assessment process and making the decision. The correct evaluation is the responsibility of the assessors. (viii) Issuing documents to the applicant After the evaluation has been completed by the head of the division, the IS automatically generates the following documents: (i) an evaluation act, (ii) an evaluation decision, (iii) a certificate of work capacity,(iv) a certificate of disability and nature and conditions of work and (v) recommendations on the need for assistance (the last four documents are applicable if the assessed work capacity is 55 or less percent).41 An employee of the territorial division prints the documents, submits them to the division head for signing and then mails them to the applicant. The decision must be sent to the person within three working days after the decision is made. (ix) Closing the case and transferring it to the archive After the decision has been sent, an employee of the territorial division scans all paper documents and transfers them to the IS; the paper file is sent to the Archive. The need for scanning can be eliminated by the introduction of electronic signature. Disability assessment criteria and application method The guidelines for work capacity assessment are established in the Law on Social Integration of Persons with Disabilities. Detailed criteria and how to apply them are set up by the previously referred to joint order of the ministers of social security and labor and health (hereinafter referred to as the Criteria). Work capacity is evaluated in 5 percentage points intervals, ranging from 0 to 100 (where 0 – 25 percent indicates total incapacity for work; 30 – 55 percent indicates partial capacity for work; and 60 – 100 percent means a person is capable for work). The assessment comprises two sets of criteria: (i) medical criteria (basic work capacity) and (ii) person’s activity and ability to participate. 40 The system automatically calculates the required scores based on all parameters entered by the assessors (both questionnaire and medical section). After the Head of Territorial Division checks all the information and presses the “Finish” button in the IS, the act is locked and cannot be changed. 41 All documents automatically generated in the system are printed by employees with a Document Manager login. They are printed on plain A4 paper except for disability certificate, which is printed on a secure document form, each with a unique serial number and special safety watermark. The system automatically displays the serial certificate number before printing it. This number must match the number on the paper secure document form. The IS window for printing may be seen in Annex 8. 25 (i) Medical criteria - basic work capacity Basic work capacity depends on person’s state of health: all diseases, injuries, pathological conditions that affect his/her work capacity and related medical disorders and impairments are considered. It is a traditional Barema table where each medical condition/ impairment is assigned a percentage value. (See Table 2 as an illustration; see also Annex 142 to the Criteria.43) Table 2: An example of basic work capacity assessment Person’s impairments Percent Coefficient Diabetes mellitus (E10-E14) with mild single organ system 70% 0.9 damage Second year after kidney transplant with normal transplanted Base 40% organ function 40 percent (because the smallest value) Arterial insufficiency - stage I No 90% (because >80) Organic amnesic syndrome (F04), assessed by psychological 55% 0.8 memory test, mild disorder Source: DWCAO. If a person’s impairment is caused due to two or more diseases or injuries, a work capacity percentage is determined in the following way: the medical condition with the lowest minimum percentage value is taken as a base; other medical conditions percentages are converted into coefficients and applied to the base percentage (70–80 percent: 0.9; 50–65 percent: 0.8; 30–45 percent: 0.7; and 0–25 percent: 0.6). These coefficients have been changed several times. At some point the lowest maximum value to which a coefficient would be applied was set up at 60 percent. It was reversed by the court as lacking scientific evidence. (ii) Activities and participation Criteria for the assessment of a person’s activities and ability to participate (the assessment of functioning) are set up in the Annex 2 to the Criteria.44 The questionnaire comprises 26 questions grouped under the following headings: mobility, independence, interaction, application of knowledge and daily activities. Each answer is scored from 0 to 4 points (see annexes 5 and 6 for an unofficial translation of the activity and ability to participate questionnaire, and other formal documents). The scores are then transformed into coefficients in the following way: (i) score of 93-101 points: coefficient 0.7 (ii) core of 84-92 points: coefficient 0.8 (iii) score of 68-83 points: coefficient 0.9 42 Ibid, Annex I. 43 There are 16 sections for each group of functions: diseases of the nervous system; mental and behavioural disorders; diseases of the eye, ear, nose and throat diseases; cardiovascular system diseases; digestive system diseases; diseases of the urogenital system; endocrine, nutritional and metabolic diseases; skin and sub-cutaneous diseases; diseases of the blood and hematopoietic organs and certain disorders related to immune mechanisms; infectious diseases; diseases of connective tissue and motor apparatus; illness, trauma and other consequences of external causes; diseases and lesions of other organs; oncological diseases. 44 Ibid, Annex Two. 26 (iv) score of 23-67 points: coefficient 1.0 (v) score of 10–22 points: coefficient 1.1 (vi) score of 0-9 points: coefficient 1.2. These coefficients are automatically applied to the medical assessment score for the final work capacity percentage. Figure 8 presents data on the impact of the assessment of functioning on the final work capacity assessment. In the figure, blue columns represent the percentage of applicants (excluding students up to 26 years, occupational diseases and injuries at work for whom the functioning assessment is not required), for whom the functioning assessment made no change, i.e. it had no impact on their work capacity status. Orange columns present the percentage of applicants whose basic work capacity score (medical assessment) was changed upwards of 55 percent due to the functioning score coefficient and they did not pass the cut off percentage for work incapacity. Grey columns reflect the percentage of applicants for whom the opposite was the case. Clearly, the impact of the functioning assessment on work capacity is only marginal and that the assessment is essentially based on medical criteria. In 2018, only in 1.74% of cases the activity and participation score changed the medical score meaningfully (see orange and grey sections of the columns in Figure 8). Figure 8: Impact of the assessment of activities and ability to participate on work capacity 100 0.25 0.26 0.26 0.18 0.25 0.24 0.37 0.36 0.37 0.36 0.41 0.39 0.70 0.55 0.58 0.44 0.52 0.50 0.21 0.25 99 0.41 1.09 1.24 1.18 1.35 1.10 1.19 1.55 1.70 1.87 2.84 2.92 2.61 2.79 98 3.25 3.40 97 96 95 94 Total Total Total Total Total Total Reassessment Reassessment Reassessment Reassessment Reassessment FT assessment Reassessment FT assessment FT assessment FT assessment FT assessment FT assessment 2013 2014 2015 2016 2017 2018 No impact Disability status not granted Disability status granted Source: DWCAO. Note: FT assessment: First Time Assessment. No impact: activities and participation score had no impact on disability status. Disability status not granted: activities and participation score has increased the work capacity percentage based on medical criteria above the threshold of 55 percent. Disability status granted: activities and 27 participation score has decreased the work capacity percentage based on medical criteria below the threshold of 55 percent. After the work capacity percentage is determined, two decisions also must be made: duration of the limited work capacity and the reason for it. The duration options are listed in the Law of Social integration45 and the Procedure46 and are: 6 months, 12 moths, 24 months, till the retirement age and for life (the last option can only be given in the cases of limited work capacity due to occupational disease or an accident at work). These options seem arbitrary and it is not clear based on what methodological guidance the decisions are made. Six, 12 or even 24 months is a short period that one can hardly expect to see a significant change in the work capacity status after they have lapsed. The Ministry should make an analysis of the work capacity re-assessment by each duration option. If majority of the decisions remain the same, then it should consider awarding limited work capacity status for a minimum of 3 years with another two options: 5 and 10 years and with mandatory reassessment after the duration has lapsed. Detailed criteria should guide the choice of the period. Disability due to occupational diseases and work accidents should be subject to general rules. In this way, the DWCAO assessors’ workload would decrease significantly, with potential for non-trivial cost-savings. Paragraph 27 of the Order No. A1-78/V-179 establishes the following 14 reasons for limited work capacity: 1) diseases or conditions, 2) diseases or conditions determined before the age of 24, 3) accident at work, 4) occupational disease, 5) disease acquired during service or training, 6) disease due to the acts of aggression and subsequent events of 11th and 13th January, 7) disease due to work to eradicate the effects of the Chernobyl nuclear power plant accident, 8) disease acquired during the course of the actions of resistance to the occupations of 1940- 1990, 9) diseases acquired during illegal detention and exile 10) diseases acquired during World War II by serving in active armies, guerrilla squads and units of anti-Hitler coalition states, 11) diseases acquired in ghettos, concentration camps or other types of forced camps, 12) diseases acquired through forced labor, 13) diseases resulting from a citizen's duty, 14) diseases acquired during military service or military training in the Soviet Army. The amount of disability benefit depends on the reason; assessment procedures are the same in all cases, although different documents may be required. Duration and cost of assessment On average, one assessment approximately takes four working hours of a DWCAO’s officer.47 The most time consuming is the filling in of the evaluation act, which together with the review of medical documentation needed for it takes about 1–1.5 hours. The activity and participation interview is the second; it usually takes 30–45 minutes. In economic terms, given how little impact on work capacity assessment this interview has, its marginal cost is rather high. 45 Ibid, Article 20, Paragraph 8. 46 Ibid, Paragraph 32. 47 Calculation provided by DWCAO. 28 According to the budget report for the fiscal year 2018,48 4,057,300 EUR was spent on disability assessment, of which 3,271,900 EUR was spent on staff salaries and taxes. In 2018, 144,660 assessments were performed, at the average cost of 28.05 EUR per assessment. Appeals All DWCAO’s decisions can be appealed. Below is a short summary of the appeal’s procedures. An individual not satisfied with the decision or social security fund or government agency financing disability benefits may appeal DWCAO territorial division’s decision during respectively 30 and 90 days after having received the decision. If an appeal is made, a new assessment is performed, and the decision is made anew. If the decision is appealed by an anonymous person, or after the term of appeal has expired, the application is reviewed by processing an unplanned control. Appeal of the territorial division’s decision: This appeal is addressed to the DWCAO director and carried out by DWCAO Decision Control Division. After the appeal has been received, it is registered and submitted to DWCAO director or his/her authorized officer, who directs it to the Decision Control Division, where a new evaluation act is created in the information system. Head of the Decision Control Division appoints minimum two assessors to the case. Depending on the content of the appeal, educational background of the first assessor may vary (an assessor with education in social sciences would be appointed as first assessor when duration, cause of disability or other legal issues are contested; when medical issues and medical criteria are appealed, then an assessor with educational background in bio-medical sciences is appointed as first assessor). The assessor examines the e-case, the decision of the territorial division, the assessment act of the territorial division, as well as all personal medical information contained in the E-health system (ESPBI IS). S/he must also decide whether the attendance of the individual is necessary (this is usually the case when the appellant disputes the activity and participation questionnaire or the assessor has questions pertaining to it, or when a person demands to participate). In the cases when the appellant is the Social Insurance Fund, both the individual and the representative of the SSIF are invited to the interview. The Decision Control Division can also request further examinations and additional information. After the assessment has been completed, the assessment act is drafted in the IS and submitted to the head of the Decision Control Division for review and finalization. The following decisions can be made: not to change the decision of the territorial division; not to change the decision of the territorial division, but to correct a technical error, or modify the conclusion regarding the nature and conditions of work; change the decision of the territorial division; or make a new decision. During 2018, DWCAO received 2,379 appeals, of which 2,146 from persons whose disability was assessed (about 3.0 percent of all individuals who were assessed in 2018). In total, 389 decisions were changed (16.35 percent of all appeals). Appeal of DWCAO director’s decision: The decision made by the Decision Control Division may be appealed to the Dispute Commission under the Ministry of Social Security and Labor, within 30 calendar days after it has been received. This Commission is the pre-trial litigation authority that determines whether a contested DWCAO decision was made in accordance with legal requirements. The Commission consists of 7 members, one of whom is the chairman.49 During the case investigation, the Commission can invite a person for an interview or apply for additional examination. The decision options are leave the DWCAO’s decision unchanged or grant the complaint or request and order DWCAO to amend the decision within a time limit set by the 48DWCAO Report for 2018, https://ndnt.lrv.lt/uploads/ndnt/documents/files/2018m_veiklosataskaita%20(1).pdf 49 The chair and members of the Commission are appointed and dismissed by the Minister for Social Security and Labor for a term of five years. The chairman and members of the Commission are prohibited from performing any duties other than scientific or teaching ones. The Commission employs 10 more specialists on a contract basis. 29 Commission. The Commission does not assess work capacity. After the decision of the Commission has been sent to DWCAO, the Decision Control Division executes it. Further appeals: The decision of the Commission may also be appealed to the Vilnius Regional Administrative court and, in final instance, to the Supreme Administrative Court of Lithuania. DWCAO control mechanism As part of the quality control efforts, DWCAO conducts random control of decisions made by DWCAO Territorial Divisions.50 During this random control, the head of the Decision Control Division appoints 1 chief specialist, who examines the e-case, the decision of territorial division, the assessment act of the territorial division, as well as all personal medical information contained in the E-health system (ESPBI IS). Decisions of territorial divisions are also reviewed by planned annual control. The procedure is the same as in the case of random control. In 2018, the planned review checked 6,684 cases. Only 19 (0.28 percent) were found not in order and the decisions were changed. This very low percentage raises flags about the effectiveness of the planned control. 1.3.6 Disability and work capacity assessment information system Registration and application. There are two ways to register for the work capacity assessment: pre- registering online or in person at the nearest DWCAO territorial division. Application must be done in person. DWCAO employee with the registrar login registers the person in IS: the registrar enters into IS a person’s unique personal identification number. IS then automatically checks the number automatically connecting to the Population Register. If a person whose number is checked is deceased, the system informs the registrar. If a person is alive, the following fields are automatically filled in in the registration window: name, surname, date of birth, and address. The registrar fills in other fields by hand or by selecting answers from a menu. If an applicant comes for the first time, IS assigns to him a new case number. If a person comes for re- assessment repeatedly, s/he will be given a previously assigned case number (one person can have only one case number in DWCAO IS, but different registration IDs). If a person had been issued a case number in another territorial division, the receptionist is notified that the case is stored in another territorial division and needs to be sent. Each territorial division has its own reception and case numbering, except for Vilnius, Kaunas, Klaipėda and Šiauliai: several divisions in these cities belong to the general DWCAO reception: Vilnius has 5 divisions belonging to Vilnius reception, Kaunas has 4 divisions belonging to Kaunas reception, Klaipėda has 3 divisions belonging to Klaipėda, Šiauliai also has 3 divisions belonging to Šiauliai. If a person applies for the assessment for the first time, the registrar manually selects the territorial division which has the lowest workload at that moment (the registrar sees the current day's workload in each territorial division in her IS window). If a person has come to be reassessed, IS automatically assigns him/her to a territorial division that is different from the previous. The objective is to minimize rent seeking behavior. The registrar also notes the purpose for which the client has come to DWCAO: to establish disability level, work capacity and/or special needs. The purpose can only be marked based on the applicant’s age: IS checks the age based on the unique personal identification number and it allows only a valid purpose. After an applicant is registered, the documents s/he has brought are scanned and attached (in PDF format) to her/ his personal case/file in IS. Paper version of these documents are attached to the paper version of the case. Appointment of assessors. In order to start the assessment, the territorial division employee who logs in as the head of the territorial division must appoint the assessors from the list of assessors (only the 50Order of the DWCAO Director No V-10 on the Determination of Control Procedure of the decisions made by DWCAO Territorial Divisions, http://ndnt.lrv.lt/uploads/ndnt/documents/files/SKS20130702%20(2).pdf 30 assessors currently working in the territorial division are displayed on it). Once the assessors have been appointed, an assessment act is automatically created with the marked purpose of the assessment. At least two assessors must be appointed. Assessment. The assessment consists of two parts: a medical part and the activity and participation questionnaire. Both must be completed in IS. Activity and participation questionnaire: Questionnaire content depend on the age of the applicant and it is generated by DWCA IS based on her/his age. As already described above, the assessor asks questions, the person answers them, and the assessor marks the answers in IS. IS automatically calculates the score and transforms it into a coefficient. After the interview has been completed, the questionnaire with answers is generated in PDF format, printed, the applicant reviews and signs it. The assessor notes this in IS. The coefficient would be then automatically applied to the medical assessment percentage for the final calculation of disability, work capacity or special needs. In the case of a simultaneous assessment of work capacity and the special needs for working age individuals, only one questionnaire needs to be completed (the other is filled in automatically), the scores of which are subsequently transformed into respective coefficients. It should be noted that needs assessment is performed only for those applicants who apply for it. While submitting the application for work capacity assessment a person may also – at the same time and based on the same medical documents ask to be assessed special needs. If the person does not submit application for special needs, only work capacity assessment is conducted. The registrar as well as the assessors may ask if s/he is sure that s/he does not need an assessment of special needs. This is another aspect of work capacity assessment that needs rethinking and strengthening. The needs assessment should not be elective, but mandatory for all applicants. The objective of this assessment is to determine which available services a person may benefit from to optimize her/ his functioning with a view of her/ him staying in employment or getting a job. The information required by DWCAO for disability assessment should also include all relevant facts about the rehabilitation measures undertaken and services provided (see discussion above). The assumption is that in the case of working age adults, all relevant and available rehabilitation interventions and other services would be provided prior to a person being assessed for work capacity. The needs assessment carried out by DWCAO would serve to identify additional needs and available services that could improve the wellbeing of a person. Medical condition assessment: DWCA IS contains several windows for filling in medical information. In these windows, the assessor selects criteria from the list and fills in other information from the medical documentation provided by the applicant. If an application has been submitted in a paper form, the assessor manually enters information from the paper documents into IS. If an electronic referral has been submitted, the assessor can find medical documents in PDF format in IS. Also, the assessor may copy some information from the referral, e.g. health description by clicking appropriate button. However, other information in the system must be completed manually, based on the medical documentation provided. In cases of a reassessment, the assessor can copy some information from the previous assessment by clicking appropriate button. The assessor can also access data from the National Health Insurance Fund (e.g. when and where the person went for treatment or what medication s/he was prescribed). The assessor also fills in (manually) information on the person`s need for vocational rehabilitation Final assessment result: The system automatically calculates disability or work capacity percentage based on all parameters entered by the assessors. When the assessors complete the assessment, the evaluation act is checked by the head of the territorial division. If everything is in order, s/he presses the "Finish" button. The evaluation act then becomes locked and cannot be changed. The system automatically generates several evaluation documents in the PDF format. These documents are printed by employees with a Document Manager login and signed manually signed by the head of the territorial division. 31 Pre-registration and on-line access: A person can pre-register to access DWCAO online to review the history of his assessments; request copies of documents; and requests duplicate documents. Pre- registration and profile viewing are available at this link: https://epaslaugos.ndnt.lt/registracija/ DWACAO Information System is part of the Government Information System and has automatic data exchange possibilities with more than 180 institutions: • Healthcare institutions (162). They provide to DWCAO electronic referrals and associated medical records. DWCAO sends back to them brief information about the outcome of the assessment. DWCAO may also make electronic request for additional medical documentation, if any is missing. • Lithuanian Library for the Blind. DWCAO informs the Library about persons with visual impairments, so that they can have access to it. • Vilnius City Municipality. Alytus City Municipality. DWCAO provides information about children with disabilities and their parents in order for them to qualify for benefits and gain priority access to an educational institution. • Kaunas City Municipality. DWCAO provides information on persons with disabilities, so that they be granted a state land lease tax relief. • Lithuanian Road Administration. DWCAO provides information on persons with disabilities, for them to access subsidized ferry transport. • E-health information system. Assessors can connect to the Electronic Health System – E-health, using their logins to get access to the person's health card. But the two systems are not integrated, and the assessors can only view the data. Hence, the need to manually copy information from E-health into DWCAO assessment documents. DWCAO IS also provides data to the E-health system about a person's disability. • Civil Registry Centers. DWCAO has real time access to the following information from the Civil Registry: personal identification number, name, surname, date of birth, address, and indication of death, if the person was deceased at the time of the registration with DWCAO. • Institute of Hygiene. DWCAO provides data to the State Registry of Occupational Diseases. • Information Society Development Committee. DWCAO provides data on the installation of road signs for disabled people. • Ministry of National Defense of the Republic of Lithuania. DWCAO provides data needed for the administration of military service and military records, for health examination staff, and for the administration of the pension of officers. • The State Social Insurance Fund Board (SSIFB). DWCAO provides information pertaining to payment of sickness benefits, social security pensions, and compensations, work capacity control, etc. • Ministry of Social Security and Labor (MSSL). DWCAO provides data needed for the provision of assistive devices, social services and other benefits to people with disabilities. • Center of Technical Aid for Disabled People. The DWCAO provides the data needed to provide technical assistance facilities for the disabled people and to compensate them. • State Studies Foundation. The DWCAO provides information disabled students need to qualify for education loans. • National Health Insurance Fund. DWCAO provides information needed for the reimbursement of the costs of medicines and medical care. DWCAO receives information on persons’ visits to doctors and prescribed medication. • State Tax Inspectorate. DWCAO provides information needed to identify persons who do not have to pay land tax, as well as persons who need to pay lower income tax or no tax at all. • Central Electoral Commission. DWCAO provides information needed to compile a list of voters who are eligible to vote at home. 32 • Lithuanian Employment Service. DWCAO provides information on persons with disabilities who were granted a status of the unemployed, are receiving additional support in the labor market, and the establishment and closure of social enterprises. DWCAO IS auxiliary sub-systems: DWCAO IS comprises several sub-systems: Decision Control Division`s Subsystem: Grievance redress and planned and unplanned control. Parking Cards for People with Disabilities Subsystem: Issuance of parking card to people with disabilities. Statistics Subsystem: Generates statistical reports. Secure Document Forms Accounting Subsystem: Back up of data on security document forms (SDF) stored in the Resource Management Department, SDF balances in territorial divisions, and corrupt SDF and their causes. Archiving Subsystem: Storage of archived files. Technical specification Considering high system load, large size of uploaded files, and large number of institutions providing and receiving data online, and the expected future growth, virtual server development and management tools are implemented in DWCAO infrastructure to ensure system performance, reliability and security (see Annex 8). • Web server, • Database server, • Application server, • Statistical data aggregation server, • Integration platform server, • Electronic file storage server, • Electronic signature server. DWCAO information system logical architecture: DWCAO Information System is implemented on the principle of 3-layer architecture, separating the layer of stored data, business process processing and presentation to the user. Schematic diagram of the DWCA system logic architecture is presented in Annex 8. Patient assessment data, electronic files, classifications, registers, and archived data are stored and processed on Microsoft SQL Server 2008 R2 database server. The agility and functionality of aggregated information processing in query and interactive reporting is provided by Microsoft Analysis Services and Microsoft SQL Server Reporting Services (MS OLAP). The system was implemented using Service Oriented Architecture (SOA). It enables different systems, applications, and tools to interact with web services. System user interface and application server components required for its operation are implemented on the basis of Microsoft.NET technology, making maximum use of server resources (Microsoft IIS and system components linking user interface, MS OLAP and Microsoft SQL Server 2008 R2). All data exchange with external systems is done through an integration component based on SOA principles. Only the following system web services are accessible externally: • Pre-registration web services, • Referrals and document submission web services, • Data exchange services with other institutions, 33 • External web applications (pre-registration, referrals and document submission portal) are based on ASP.NET technology, • The data exchange subsystem with healthcare institutions uses web services to exchange information with the system using the HL7 v3 standardized protocol, • Referrals and document submission subsystem is implemented based on the Microsoft BizTalk Server 2010. What needs to be improved? DWCAO IS was designed in 2002-2004 and was deployed in 2004. It has been continuously updated to meet the requirements of the latest legislation and the needs of users and customers. The system development and maintenance services are procured from private contractors. The current contract is for the duration of two years. The contract specifies maintenance work (paid as a monthly fee), and system development work (paid on an hourly fee basis). The contract also provides for additional hours for unforeseen works. The contract envisages the following system development work for the duration of the contract: • System component performance optimization, • System database optimization, • Development of new web services with other institutions for providing / retrieving data, • System security and collaborative server security assessment and assurance, • Realizing new secure ways of users informing. In addition to the work envisaged in the contract, the following is needed: • Introduce electronic signature for all documents, • Introduce smart disability certificate card instead of the current laminated card, • Ensure automatic, real time information update on applicants’ and beneficiaries’ socio- economic, civil and labor market status from SSIF, civil registry, employment service, tax authorities, etc., • Introduce e-referrals across the board (DWACO’s information system is ready to receive e - referrals, there should be a time bound plan – say 3-5 years to make e-referrals mandatory and universal), • System integration: all activity and participation questionnaires should be filled in electronically and automatically transferred to DWACO, including for special needs and level special needs. Furthermore, information system needs major technology update. The DWACO information system was developed in 2004. Many of technical solutions which were available then have become outdated, which severely limits the opportunities for system development and maintenance. Most of the modules in the system are manufactured using technologies that are not any longer supported (e.g., referrals and document submission via BizTalk server). Integration solutions developed in 2004 are also technologically obsolete and do not provide the requirements, reliability and speed necessary for today's information systems. Considering that the system handles highly sensitive personal data, their storage, transmission / receipt of personal data to / from other information systems do not fully comply with the General Data Protection Regulation (GDPR). Hence, a medium-term information system plan is needed that would create a system based on the latest technology, which would be more secure, more manageable, user-friendly, and more functional. 34 1.3.7 Key messages In 2018, Disability and Work Capacity Assessment Office (DWCAO) assessed for disability about 88,000 persons of all ages. The majority, about 51,000 or 58 percent, were work capacity assessments in working age population. Assessment of childhood disability represents 7.0 percent of the total. The rest, about a third, represents the assessment of the level of special needs in the elderly population (over 65 years of age). Most of the assessments – over 70 percent - are reassessments of persons who have already been assessed for their disability. Over the last decade, the number of assessments has significantly fallen as has the number of persons with disabilities. It is believed that these trends are driven by external migration, decreased fertility, healthier lifestyle and better health care services. However, only an empirical analysis could shed light on the factors behind these trends. The assessment of disability is based on medical and so-called activities and participation criteria (the assessment of functioning). Medical criteria follow a typical Bareme grid comprising a list of diseases and bodily impairments, where an impairment is assigned a certain percentage of disability (work capacity). Activities and participation criteria are based on a series of questions related to difficulties in functioning in several domains; a home-grown effort to implement the World Health Organization International Classification of Functioning, Disability and Health. The algorithm for application of functioning score is such that it has almost no impact on the final decision on disability, rendering the assessment essentially based on medical criteria. Besides, occupational diseases and work injuries are exempt from it. The activities and participation criteria and related instruments have been revised continuously, to link them better to the WHO ICF and the bio-psycho-social (interactional) model of disability, to make the assessment process more objective by including functioning assessment into disability assessment. To that end, it is currently preparing to pilot a World Health Organization’s psychometric tool (World Health Organization Disability Assessment Schedule or WHODAS) for the assessment of functioning to ensure that any future adjustments in the disability assessment criteria and procedure are based on empirical evidence using a standardized, extensively tested, internationally validated and scientifically robust and reliable instrument. Disability assessment is regulated by the Law on Social Integration of Persons with Disabilities. Article 20 of this Law establishes that working capacity is determined by assessing the state of health of the individual and her/his ability to perform earlier obtained qualification, to obtain new qualification, or to be engaged in jobs that do not require professional qualifications, after having exhausted all available medical and vocational rehabilitation and special assistance measures. This approach is a very important feature of the disability policy and disability assessment system in Lithuania, as it envisages that a person should be provided a full range of available interventions to restore or stabilize health, maximize functioning and ensure her/ his labor for participation. However, this is yet to be realized in practice: in most cases a person is referred to DWCAO by a treating physician after the medical treatment. The paid sick leave provision is another very important feature of the Lithuanian social security system. It enables not only that a person gets needed medical treatment and medical rehabilitation, including assistive devices s/he might need, but also provides time for vocational rehabilitation and other measures to optimize person’s health and functioning and ensure her/his return to work. While legally, Lithuania’s disability policy calls for such an approach, as noted above, it is yet to be fully operationalized and implemented in practice. A more integrated action and collaboration from various stakeholders -- medical doctors, DWCAO, employment services, medical and occupational rehabilitation specialists, employers, municipal social services, and others -- is needed. 35 In this case, a person would be assessed for work capacity only after all measures to restore health and optimize functioning have been exhausted, as stipulated by the above-mentioned Article 20 of the Law on Social Integration of Persons with Disabilities. This should not be very difficult to implement as, in addition to the paid sick leave provision, Lithuania has an excellent network of rehabilitation facilities, which could collaborate with other government agencies (labor offices, employers, local social care services, DWCAO offices, etc.) and serve as a nodal point in implementing Article 20 requirements. DWCAO has difficulties hiring and retaining staff with medical education background. To ensure that the assessment is conducted by them, it may consider expanding the engagement of medical staff on a part time basis and changing administrative procedure to require that a well-trained medical rehabilitation specialist conducts a functioning assessment (could also be on a part time basis) and a medical doctor reviews both medical and functioning information and proposes work capacity decision. This would be made even easier if, as envisaged by Article 20 of the Social Integration Law, applicants would be presented at DWCAO only after a complete assessment at rehabilitation clinic and all measures for optimizing functioning and participating in the labor market have been exhausted. A combination of improved medical information and standardized functioning assessment with an evidence based automated algorithm for combining medical and functioning information for objective assessment of work capacity (based on the WHODAS pilot) should facilitate the streamlining of administrative procedure. Moreover, based on empirical evidence, an algorithm could be developed to flag any functioning score beyond what could be expected for a given health condition, decreasing opportunities for fraudulent behavior. Currently, the assessor also fills in the necessary information on the person`s need for vocational rehabilitation. This data is filled in manually into the system. The assessor also fills in information concerning the nature and conditions of work and recommends assistance measures. These two aspects of the assessment need rethinking and strengthening, because the need for vocational rehabilitation and recommendations regarding work conditions should be based on an assessment conducted by specialized services/ professionals prior to disability assessment, which is currently not the case. Likewise, for recommendations related to assistive devices. In the current process, there is no information on which DWCAO assessor would be able to objectively assess whether a person would need vocational rehabilitation and/or work place adjustment and/or assistive devices/ assistance to stay in the current job, or a different job with the same employer or a new job. Hence, most of the employed persons undergoing work capacity assessment leave employment and very few are referred to vocational rehabilitation. Thus, the logic of the process needs to change. For employed persons experiencing sickness, once the acute medical treatment is completed, a medical rehabilitation phase provides an opportunity for a collaboration between a patient, his/her employer, rehab professionals, employment service, and local social services. The purpose of this collaboration would be to provide all available measures to help the patient maximize her/ his functioning and stay in employment. If this window is missed and a person leaves the labor market, as empirical evidence from many countries shows, the person is very likely to leave the labor market permanently. Manual handling of information during the assessment process is not insignificant. DWCAO should consider reviewing the mandatory list of documents and add information on medical and vocational rehabilitation undertaken and assistive devices provided (preferably though real time electronic link to the e-Health information system, once it is operational; the link to the employment service, etc.) and by populating information into electronic file at the registration. While the registration phase may take longer to complete, it will save time of the assessors who will have all information in electronic format. 36 DWCAO Information System: DWCAO Information System was designed in 2002-2004 and was deployed in 2004. It has been continuously updated to meet the requirements of the latest legislation and the needs of users and customers. The system development immediate needs are: (i) introduce electronic signature for all documents; (ii) introduce smart disability certificate card instead of the current laminated card; (iii) ensure automatic, real time information update on applicants’ and beneficiaries’ socio-economic, civil and labor market status from SSIF, civil registry, employment service, tax authorities, etc.; (iv) introduce e-referrals across the board (DWACO’s information system is ready to receive e-referrals; there should be a time bound plan – say 3-5 years to make e-referrals mandatory and universal); (v) system integration: all activity and participation questionnaires should be filled in electronically and automatically transferred to DWACO, including for special needs and level special needs. Furthermore, information system needs major technology update. DWCA system was developed in 2004, using then up to date technologies. These technologies are now outdated, which severely limits the opportunities for system development and maintenance. Most of the modules in the system are manufactured using technologies that are not any longer supported (e.g., Referrals and document submission via BizTalk server). Integration solutions developed in 2004 are also technologically obsolete and do not provide the requirements, reliability and speed necessary for today's information systems. Considering that the system handles highly sensitive personal data, their storage, transmission and receipt of personal data to and from other information systems do not fully comply with the General Data Protection Regulation (GDPR). Hence, a medium-term information system plan is needed that would create a system based on the latest technology, which would be more secure, more manageable, user-friendly, and more functional. 1.4 Benefits for persons with disabilities 1.4.1 An overview and public spending In this section we provide a brief overview of key disability benefits. Lithuania provides a range of benefits to persons with disabilities through social insurance, social assistance and labor market programs. Programs range from cash benefits, to services, including vocational rehabilitation and employment support, residential placement, etc. Cash benefits dominate, in particular social insurance benefit for work incapacity and social assistance disability pension. Cash benefits are provided at the national level, while service provision is responsibility of municipalities. (See Annex 2 for a more detailed information.) 37 Table 3: Public spending on social protection in Lithuania 2014 -2018 as % of GDP Social protect ion benefits, compared to gross domestic product | per cent 2014 2015 2016 2017 2018 Expenditure on family/child benefits 1.1 1.1 1.1** 1.2** 1.6* Expenditure on social exclusion benefits and other cases 0.4 0.3 0.3** 0.2** 0,3* Expenditure on old-age benefits 6.7 6.6 6.3** 6.1** 6.4* Expenditure on disability benefits 1.4 1.4 1.3** 1.3** 1.4* Expenditure on unemployment benefits 0.3 0.5 0.5** 0.5** 0.7* Expenditure on survivors' benefits 0.0 0.0 0.5** 0.0** 0.0* Expenditure on sickness and health care benefits 4.1 4.4 4.6** 4.5** 4.7* Expenditure on housing benefits 0.0 0.1 0.1** 0.1** 0.1* Social protection benefits 14.5 14.8 14.6** 14.4** 15.5* ** ·Revised. * Preliminary Table 4: Composition of public spending on social protection in Lithuania 2014 -2018 (%) Structure of social protection benefits | per cent 2014 2015 2016 2017 2018 Expenditure on family/child benefits 7.5 7.5 7.8** 8.3* 10.3* Expenditure on social exclusion benefits and other cases 3.0 2.2 1.9** 1.7* 1.8* Expenditure on old-age benefits 46.1 44.3 42.8** 42.6* 41.2* Expenditure on disability benefits 9.5 9.3 9.3** 9.3* 9.0* Expenditure on unemployment benefits 2.3 3.4 3.6** 3.7* 4,5* Expenditure on survivors' benefits 3.0 2.9 2.9** 2.6* 2.4* Expenditure on sickness and health care benefits 28.3 29.9 31.3** 31.3* 30.4* Expenditure on housing benefits 0.3 0.4 0.4** 0.4* 0.4* ** ·Revised·.* Preliminary Lithuania spends about 15.5 percent of GDP on social protection (Tables 3 and 4)51, of which, in 2018, disability benefits constituted about 9.0 percent, or 1.4 percent of GDP. Relative to other EU countries (Figure 9), Lithuania’s spending on disability benefits as a share of total spending on social protection is above the EU-28 average and this share is higher only in six EU countries. 51Statistics Department of the Government of the Republic of Lithuania, https://osp.stat.gov.lt/statistiniu-rodikliu- analize?hash=fe2f1e82-7e19-4a25-8903-334da41127b2#/. 38 Figure 9: Spending on disability benefits as % of total social benefits in EU in 2017 18 16 14 12 10 8 6 4 2 0 EU-28 Finland Latvia Romania France Hungary Italy Denmark Croatia Netherlands Bulgaria Poland Spain Austria Greece Cyprus Germany Ireland Estonia Slovakia Malta Luxembourg Belgium Portugal Slovenia Lithuania Sweden Czechia United Kingdom Source: Eurostat. Figure 10: Spending on disability benefits as % of GDP in EU in 2017 6 5 4 3 2 1 0 Luxemburg Latvia Romania Sweden Lithuania Bulgaria Austria Slovakia Greece Cyprus EU-28 Portugal Hungary Czechia Estonia Denmark Finland France Italy Poland Netherlands Germany Belgium Spain Slovenia Malta Croatia Ireland Source: Eurostat However, looking at spending on disability benefits as a percentage of GDP across EU (Figure 10 and Table 5), Lithuania’s spending on disability benefits as percent of GDP is below EU-28 (1.3 vs. 2.0 39 percent of GDP in 2017, respectively) and belongs among countries with the lower level of spending relative to GDP. Table 5: Expenditure on social protection benefits in EU in 2017 Housing and Old age and Sickness / Family / Disability Unemployment Social survivors Health Care Children Exclusion (% relative to (% relative to (% relative to (% relative to (% relative to (% relative to (% of social (% of social (% of social (% of social (% of social (% of social protection protection protection protection protection protection benefits) benefits) benefits) benefits) benefits) benefits) GDP) GDP) GDP) GDP) GDP) GDP) EU-28 45.8 12.3 29.6 7.9 7.6 2.0 8.7 2.3 4.4 1.2 4.0 1.1 Euro area 46.1 12.8 29.5 8.2 7.4 2.0 8.3 2.3 5.2 1.4 3.5 1.0 (EA-19) Belgium 46.5 12.6 26.9 7.3 8.7 2.4 7.6 2.1 6.9 1.9 3.4 0.9 Bulgaria 49.3 8.1 28.2 4.6 7.5 1.2 10.7 1.8 3.1 0.5 1.2 0.2 Czechia 47.2 8.5 32.7 5.9 6.4 1.1 8.8 1.6 2.6 0.5 2.4 0.4 Denmark 39.2 12.1 21.3 6.6 16.5 5.1 11,1 3.4 4.5 1.4 7.4 2.3 Germany 38.6 11.0 35.0 10.0 8.5 2.4 11.5 3.3 3.4 1.0 3.0 0.9 Estonia 41.7 6.6 29.9 4.7 11.6 1.8 13.1 2.1 2.7 0.4 1.0 0.1 Ireland 33.6 4.8 39.2 5.6 5.6 0.8 8.5 1.2 8.8 1.3 4.3 0.6 Greece 62.8 15.6 20.3 5.1 5.9 1.5 5.7 1.4 3.7 0.9 1.6 0.4 Spain 51.6 11.9 26.7 6.1 7.2 1.6 5.4 1.2 7.7 1.8 1.4 0.3 France 45.5 14.4 28.7 9.1 6.5 2.0 7.6 2.4 6.1 1.9 5.7 1.8 Croatia 43.5 8.9 33.7 6.9 10.7 2.2 8.6 1.8 2.1 0.4 1.4 0.3 Italy 57.8 16.2 23.1 6.5 5.8 1.6 6.3 1.8 5.8 1.6 1.2 0.3 Cyprus 55.9 10.1 18.3 3.3 4.4 0.8 6.7 1.2 5.6 1.0 9.1 1.6 Latvia 49.0 7.2 25.4 3.7 9.1 1.3 10.9 1.6 4.5 0.7 1.2 0.2 Lithuania 45.2 6.5 31.3 4.5 9.3 1.3 8.3 1.2 3.8 0.5 2.1 0.3 Luxemburg 39.6 8.5 24.9 5.4 10.8 2.3 15.3 3.3 5.4 1.2 4.0 0.9 Hungary 49.7 9.0 27.7 5.0 6.0 1.1 12.1 2.2 1.7 0.3 2.8 0.5 Malta 52.6 8.4 34.3 5.5 3.5 0.6 5.5 0.9 2.2 0.4 1.9 0.3 Netherlands 42.1 11.6 33.7 9.3 9.2 2.5 4.2 1.2 4.0 1.1 6.9 1.9 Austria 50.0 14.3 26.0 7.4 6.2 1.8 9.5 2.7 5.8 1.6 2.5 0.7 Poland 54.1 10.6 22.8 4.5 7.3 1.4 13.4 2.6 1.6 0.3 0.8 0.2 Portugal 58.3 13.7 25.5 6.0 7.1 1.7 4.9 1.2 3.2 0.8 0.9 0.2 Romania 56.3 7.9 28.0 3.9 6.5 0.9 7.7 1.1 0.5 0.1 1.1 0.2 Slovenia 47.4 10.5 34.0 7.6 4.8 1.1 8.3 1.8 2.4 0.5 3.1 0.7 Slovakia 45.8 8.1 31.7 5.6 8.8 1.6 9.1 1.6 2.9 0.5 1.7 0.3 Finland 45.1 13.6 22.5 6.8 9.6 2.9 9.8 2.9 7.3 2.2 5.8 1.7 Sweden 44.2 12.5 26.1 7.4 10.9 3.1 10.2 2.9 3.5 1.0 5.2 1.5 United 43.4 11.3 32.6 8.5 6.7 1.7 9.4 2.5 1.3 0.3 6.7 1.7 Kingdom Iceland 30.6 7.1 36.2 8.4 16.4 3.8 10.2 2.4 2.1 0.5 4.5 1.0 Norway 36.6 10.2 29.5 8.2 16.3 4.5 11.6 3.2 2.4 0.7 3.7 1.0 Switzerland 47.1 12.3 31.7 8.3 8.1 2.1 6.0 1.6 3.6 1.0 3.5 0.9 Serbia 55.7 10.6 25.3 4.8 6.1 1.2 6.5 1.2 3.2 0.6 3.2 0.6 Turkey 61.2 7.4 27.5 3.3 3.6 0.4 4.0 0.5 2.3 0.3 1.6 0.2 Bosnia and 48.2 8.6 29.6 5.3 15.7 2.8 2.6 0.5 2.5 0.4 1.5 0.3 Herzegovina Source: Eurostat (online data code: spr_exp_sum) 40 Two main benefits in cash for persons with disabilities are pensions: (i) social assistance disability pension (financed from the state budget), and (ii) social insurance disability pension (contributory). A person can receive only one pension.52 Labor market participation has no impact on disability social insurance pension eligibility. However, a person cannot receive social assistance disability pension, unless the person is disabled since childhood. Other cash benefits for persons with disabilities include: financial support for persons with disabilities raising a child; orphan’s pension; financial support for disabled students; targeted compensations (attendance and assistance allowance); reimbursement of the costs of medicines; reimbursement of the costs of medical treatment; transport subsidy; reimbursement of the costs of purchasing a car and its adaptation cost; provision of assistive devices; financial support for housing adaptation, a subsidy for buying, renting and adapting the house; income tax reduction; landowner tax exemption and legal aid. Social insurance disability pension and social assistance disability pension are administered by the State Social Insurance Fund (SSIF). SSIF also monitors decisions made by the Disability and Work Capacity Assessment Office (DWCAO) and can request additional health examination should any doubts arise concerning the validity of the information submitted by a treating physician to DWCAO or concerning the decision made by DWCAO. Other benefits are administered by various state agencies and municipalities. Most of the benefits listed above are funded from the state budget (except for contribution based social insurance benefits). In addition to cash benefits, there is also a wide range of services, including: providing information53, consultations, counselling, representation, organization of catering, providing clothing and footwear, organizing transportation, socio-cultural services, organization of personal hygiene and care services, home help, development of social skills, independent living, intensive crisis management, psychosocial assistance, sheltered accommodation, day care, short-term residential care and long- term social care. All these services are organized by the municipalities, according to the assessed needs of persons with disabilities. The assessment of needs is performed by municipalities. Here, a case for better coordination between DWCAO and municipalities could be made. Assessment of needs to optimize functioning and recommendation and referral to available benefits and services should be an integral part of DWCAO’s disability assessment process. The assessment should automatically be transmitted to social services in municipalities where a person with disabilities resides. While municipalities may need to check additional eligibility requirements, needs assessment, services recommendations and referral by DWCAO assessment will save time and money both to beneficiaries and the state. To receive any of the benefits mentioned above, a person must be assessed for disability, or work capacity, or a special need, or a level of special needs. The assessment of disability level (for children), work capacity (for working age persons), special needs (any age), and level of special needs (for elderly) is carried out by DWCAO. However, the decision of DWCAO does not determine the right of the persons with disabilities to receive a benefit. Each benefit has its own assessment process and requires an application of the person to the provider of the benefit/service and even a submission of documents that institutions might and in fact are able to gather by themselves. The lack of an integrated process and the lack of coordination between institutions cause another problem as well: anecdotal evidence suggests that persons with disabilities sometimes lack knowledge and are not well informed about available services and their requirements and, thus, many do not benefit from them. 52 People receiving disability pension can chose between disability and old age pension when they reach mandatory retirement age (whichever is higher). 53 Information to persons with disabilities, their family members or their representatives about planned and under implementation social integration programs, and available services and material support. Information to persons with hearing and visual disabilities must be provided in accessible formats and technologies, appropriate to their disability. 41 This problem is relatively easy to address. Ministry of Social Security and Labor (MSSL), in collaboration with municipalities, should compile an inventory of disability benefits with their basic eligibility requirements and administrative procedures and make it available electronically and in printed and accessible formats across the country. Each person registering for disability assessment at DWCAO should be given a copy and instructed on how to access information online. Moreover, as suggested above, DWCAO assessment process should include a comprehensive functioning and needs assessment and a referral to relevant national and municipal agencies/ bodies. Below, we briefly describe key disability benefits in Lithuania 1.4.2 Social assistance disability pension This is a monthly non-contributory cash benefit whose objective is to provide minimum income for persons who meet the requirements in cases of disability and incapacity for work. Social assistance disability pension is granted and paid to persons who are not entitled to social insurance disability pension. It is financed by the state budget. In 2018, 43,958 people, or about 20.0 percent of persons with disabilities in Lithuania, received this benefit. The expenditure share in GDP was 0.22 percent (Table 6). Table 6: Social assistance disability pension – number of beneficiaries and expenditures Number of persons with disabilities, % Year that received a social assistance Total spending GDP disability pension 2016 46,079 81,636,898.85 EUR 0.21 2017 46,463 85,588,565.66 EUR 0.2 2018 43,958 99,994,316.95 EUR 0.22 Source: Social Support Information System54 Eligibility requirements and related administrative procedures are set by the Law on Social Assistance Pensions of the Republic of Lithuania.55 Persons with disabilities may be granted a social assistance disability pension if they are: (i) Persons with severe, moderate or mild disability assessed by DWCAO, (ii) Persons who become incapable or partially capable for work until the day they reach the age of 24, as well as persons after the age of 24, who become incapable or partially capable for work due to an illness or trauma which had occurred before the age of 24, but no later than the day (inclusive) when they reach the age of 26, (iii) Parents or careers, who are recognized as incapable or partially capable for work, who have lost 60 or more percent of work capacity and who have provided care to a person with disabilities – with a special need for permanent nursing or permanent care (assistance) – at home for at least 15 years. For care of one person with disabilities, the social assistance pension can be granted to one person only, 54 http://vitrinos.spis.lt:8080/ 55 The Law on Social Assistance Pensions of the Republic of Lithuania: https://www.e-tar.lt/portal/lt/legalAct/TAR.2CE6CFE9E2EE/djrYRKXgRc 42 (iv) Mothers, who are recognized as incapable or partially capable for work, having lost 60 percent or more of their work capacity who have born and raised five or more children at least until the age of 8, (v) Persons recognized as incapable or partially capable for work who have lost 60 percent or more of their work capacity (also recognized as Group I or II invalids before the 1st of July 2005). The amount of the social assistance pension paid to a disabled child depends on the assessed disability level, whereas the amount paid to a working age persons depends on the percentage of the work capacity lost, as well as on the date from which the person was recognized as a persons with disabilities for the first time (see Annex 2). In general, social assistance disability pensions range from 2.25 social assistance pension base (as of January 1, 2020, the base is equal to 140 EUR – so the pension amount is currently 315 EUR per month) for persons who have lost 100 percent of their work capacity (severely disabled) to 140 EUR (1 social assistance pension base) for persons who have lost 45% work capacity.56 As a comparison, the national minimum monthly wage in 2020 in Lithuania is 607.0 EUR, and basic social insurance pension57 was 164.59 EUR in 2019. (See Annex 7 for amounts in 2019.) After the work capacity or disability level has been assessed by DWCAO, to qualify for this benefit a person must apply separately at SSIF. DWCAO decision is automatically transferred to SSSIF. The decision by SSIF should be made during 10 working days.58 The benefit is paid monthly for the duration of working capacity or disability.59 As noted, unless disabled since childhood, a person receiving social assistance disability pension can either work or receive this benefit. Having to choose between social assistance disability pension and working may deter people with disabilities from seeking employment (which may only be temporary/ seasonal, etc.). To encourage persons receiving this benefit to seek employment, the Government may wish to review this policy and allow them to work, while continuing to receive this benefit. Only if the employment is stable and say lasts for more than two years, the benefit could be gradually reduced/ tapered off. 1.4.3 Social insurance disability pension This is a social insurance benefit granted to a person whose work capacity was assessed by DWCAO60 and who meets minimum required length of service to obtain a disability pension. This pension is paid irrespective of the person’s employment and income status. In 2018, 186,802 persons with disabilities received social insurance disability pension – 87.0 percent of all adults61 with disabilities. Figure 3 provides data on average social insurance pensions in Lithuania.62 Table 7 provides data on disability social insurance pensioners and related annual expenditures. 56 MSSL, https://socmin.lrv.lt/lt/veiklos-sritys/socialine-statistika/pagrindiniai-socialiniai-rodikliai 57 Basic Social Insurance Pension is a benchmark indicator used to calculate pensions, social benefits, etc. The Law on Social Insurance Pensions of the Republic of Lithuania determines that the amount of the Basic State Social Insurance Pension may not be less than 110 per cent of the minimum standard of living/ consumption basket. The amount of the state social insurance basic pension is approved by the Government of the Republic of Lithuania on the proposal of the State Social Insurance Council. 58 Until 2019, social assistance disability pensions were paid by municipalities. 59 Duration of social assistance disability pension is set according to the duration of disability/work (in)capacity which was determined by DWCAO. 60 The Law on Social Integration of Persons with Disabilities: https://www.e-tar.lt/portal/lt/legalAct/TAR.199156E4E004/cWWgldtkIu 61 Includes retired persons. It should be noted that at retirement age, persons receiving disability social insurance pension may decide to receive an old-age pension, if higher than disability pension. 62 https://www.sodra.lt/lt/socialinis-draudimas/statistika 43 Figure 11: SSIF – Average social insurance pensions in Lithuania in 2019 (in EUR per month) Old Age Pension 308 Invalidity Pension 258 Retirement Pension 228 Early Retirement Pension 222 Disability Pension 208 Compensation for Special Work Conditions 203 Survivors' Pension 202 Widow's and Orphan's Pension 35 0 50 100 150 200 250 300 350 Source: State Social Insurance Fund (SSIF). Note: Invalidity pension pertains to disability pension granted before 2005. Disability pensions refers to disability social insurance pension granted after 2005. The main legal act that regulates social insurance disability pension is the Law on Social Insurance Pensions of the Republic of Lithuania63, which defines eligibility requirements, benefit calculation formula, etc. The pension consists of a defined-benefit and a defined contribution component. Defined benefit part is financed by the state budget, the defined- contribution part is financed by SSIF. Table 7: Social Insurance Disability Pension: Beneficiaries and Expenditure Number of persons with disabilities, that received Year a social insurance disability pension (including the Total spending % GDP ones, who were determined an invalidity group) 2017 198,610 500,243,000 EUR 1.19 2018 186,802 540,636,300 EUR 1.20 Source: SSIF budget report 201864 As a comparison and to get a sense of replacement rates, the average net monthly salary in Lithuania in 2019 III quarter was 834.4 EUR (gross 1,317.6) and minimum monthly wage was 555 EUR.65 63 Ibid, https://www.e-tar.lt/portal/lt/legalAct/TAR.A7F77DF94F5D/MmAdMhouCq 64 https://www.sodra.lt/uploads/documents/files/2018%20m_%20ataskaita.pdf 65 MSSL: https://socmin.lrv.lt/lt/veiklos-sritys/socialine-statistika/pagrindiniai-socialiniai-rodikliai 44 After her/his work capacity has been assessed by DWCAO, to receive this benefit, a person must apply at SSIF. DWCAO’s decision is automatically transferred to SSIF. The decision by SSIF should be made during 10 working days. The benefit is paid monthly for the duration of work incapacity.66 1.4.4 Orphan’s pension This is a monthly cash benefit for a person who has lost one or both parents. It is regulated by the Law on Social Insurance Pensions of the Republic of Lithuania. It can be obtained by persons who have become work incapable or partially incapable before 24 years old, as well as those who have been declared permanently incapable or partially incapable for work after the age of 24, but not later than the day when they reached the age of 26 (inclusive) and have lost one or both parents. These persons continue to receive this pension for life (Article 3867). For non-disabled children, an orphan’s pension may be granted until the age of 18 (24, if a person studies in general education programs or formal vocational training programs, or studies in a higher education institution under full-time study programs and has lost one or both parents). Table 8 presents data on orphan’s pensions and related expenditure. Table 8: Orphans receiving pe nsion and total public spending on it Total number Total number receivers of receivers of Year orphan’s pension (irrespective Total spending % GDP orphan’s pension of disability) (with disability) 2017 6,307 32,815 44,136,000 Eur 0.1 2018 5,621 31,814 47,743,900 Eur 0.11 Source: Annual report of Department for the Affairs of the Disabled under the Ministry of Social Security and Labor for 201868 In order to receive an orphan’s pension a child (young person) must be assessed by DWCAO. Upon the assessment, a person must apply at SSIF (DWCAO decision is automatically transferred to SSIF). The SSIF is obliged to decide in 30 days. The benefit, if awarded, is paid monthly for a duration of disability/work incapacity.69 1.4.5 Financial support for persons with disabilities raising a child This is a cash benefit for the persons with disabilities raising a child, to cover the costs of utilities, electricity, fuel or telephone. The requirements for eligibility and the procedures are set in the Resolution of the Government of the Republic of Lithuania No. 193 on the Guarantees of Services and Material Base for Persons with Disabilities.70 A person with disabilities must comply with the following requirements: 1) have her/ his work capacity assessed at 0-25 percent; and 2) having a child <18 years of age (24 if s/he is a student; and 3) no work 66 The duration of social insurance disability pension equals duration of work (in)capacity determined by DWCAO. 67 https://www.e-tar.lt/portal/lt/legalAct/TAR.A7F77DF94F5D/MmAdMhouCq 68 http://www.ndt.lt/wp-content/uploads/2018_Veiklos-ataskaita-pagal-priemones.pdf 69 The duration of orphan pension is set according to the term of working capacity which was determined by DWCAO. 70 https://www.e-tar.lt/portal/lt/legalAct/TAR.5CE87B8CDBD9/asr 45 capable family members. The benefit itself is equal to 20 percent of the Basic Social Benefit71. In order to receive this benefit, a person with disabilities must apply for it at the municipal Social Assistance Division. The decision is made during 30 working days. The number of beneficiaries counted only 66 in 2018 with the total spending of 2,800 EUR or 23.6 EUR per beneficiary. MSSL should consider consolidating small disability benefits into a more significant one for efficiency and efficacy reasons. 1.4.6 Financial support for students with disabilities This is a monthly cash benefit for students with disabilities in order to partly compensate costs associated with their special needs or costs of education.72 It is calculated based on the Basic Social Benefit. The monthly payment of 50 percent of the Basic Social Benefit is for the reimbursement of special needs of students. In addition, there is also a payment of 3.2 Basic Social Benefits for every semester as the partial compensation for the costs of the studies (but only for students who study in non-state funded institutions). In 2017, there were 826 students receiving this benefit, down from 1,006 in 2015. The expenditure also went down: from 507,800 EUR in 2015, to 459,600 in 2017. The student may apply for this benefit, if: (i) s/he has been assessed as having work capacity of 45 percent or less or a severe or moderate level of disability; (ii) is enrolled in higher education for the first time (undergraduate/graduate/post graduate); (iii) is enrolled in a professional study program; (iv) is enrolled in a short study program.73 The application is submitted to the university that should decide within 20 working days. The benefit is awarded for the current semester, but not longer than for the duration of disability or work capacity. 1.4.7 Targeted compensation (care allowances) Targeted compensation is regulated by the Law on Targeted Compensation.74 It is a monthly cash allowance provided to persons assessed as in need of nursing care/ attendance and assistance. The Law recognizes two types of this support: permanent care and permanent care assistance. Each has two levels. (i) Permanent care: • 1st level permanent care – 304.2 EUR (2.6 times targeted compensation base); • 2nd level permanent care – 222.3 EUR (1.9 times targeted compensation base); (ii) Permanent care (assistance): • 1st level permanent care (assistance) – 128.7 EUR (1.1 times targeted compensation base); • 2nd level permanent care (assistance) – 70.2 EUR (0.6 times targeted compensation base). This is a revised provision introduced in January 2019. The benefit structure was changed, as well as the assessment criteria. Until January 2019, there were 3 types of benefits for special needs: i) permanent care (SP-1 - 280 EUR), ii) permanent care assistance (SP-2 - 112 EUR) and iii) reimbursement of transportation cost (SPT-4 – 9.5 EUR). Since the targeted compensation changed in 2019, no data on beneficiaries is available yet. Based on the old system, in 2018, 37,349 persons 71 Law of the Republic of Lithuania on Determining the Reference Indicators of Social Assistance Benefits defines a Basic Social Benefit as a benchmark for defining and calculating social assistance benefits. The law stipulates that this indicator may not be lower than 16 percent of the amount of the minimum consumption needs (MCN) in the previous year. The MCN is the amount in EUR needed to meet the minimum needs of a person for food and non-food expenditure per month. 72 Resolution of the Government of the Republic of Lithuania No 831 On Approval of the Procedure for Providing Financial Aid Measures to Persons with Disabilities Studying at Higher Education Institutions, https://www.e-tar.lt/portal/lt/legalAct/TAR.66E0CE6AE556/asr 73 https://www.e-tar.lt/portal/lt/legalAct/TAR.66E0CE6AE556/asr 74The Law on Targeted Compensation: https://www.e-tar.lt/portal/lt/legalAct/398a02704a6f11e6b5d09300a16a686c/asr 46 received SP-1; 57,158 SP-2 and 5,320 SPT-4. It total, about 41.0 percent of all persons with disabilities in Lithuania were receiving these benefits. The need for care is assessed by DWCAO according to medical and activity and participation information75; the payment is determined and executed by municipalities. The benefit is funded by the state budget. The Law on Social Integration of Persons with Disabilities76 defines that 1st level permanent care is determined for persons who need continuous care for 8 or more hours per day; 2nd level permanent care is determined for persons, who need continuous care for 6-7 hours a day, 1st level permanent care (assistance) is determined for persons, who need constant help from others for 4-5 hours a day; 2nd level permanent care (assistance) is determined for persons, who need constant care (help) of other persons for up to 3 hours a day. After the special need is assessed by DWCAO, a person must apply to the administration of municipality, submit the application, as well as the decision of DWCAO. The decision by the administration of municipality is made during 15 working days. The duration of this benefit is determined by DWCAO and it could be 6 months, 12 months, 24 months, and for life. There are several aspects of these benefits that could be streamlined. First, the number of beneficiaries appears relatively high (41.0 percent of all persons with disabilities in Lithuania) as compared to the numbers of persons with severe disabilities who would be the primary target group for this type of benefits. An audit of decisions would help ensure that the benefits are received by those who need them the most. A smaller number of beneficiaries would allow for higher benefits, within the same budget. The description of need and the content of the assistance would need to be described more precisely and in greater detail to allow for better decision making. Currently, it is not easy to differentiate between permanent care and permanent care assistance or determine a difference between 6 and 7 or 7 and 8 hours of care. Finally, this benefit is an open-ended commitment for the state budget. The eligibility and award are decided on by municipalities, while the financing is provided by the state budget. This is a typical situation where incentives are misaligned. Potential policy considerations may include options to consolidate the benefit into a single benefit; differentiate it by hours of service needed (e.g. 2, 4 and more than 4) and to have DWCAO’s disability/ needs assessment and recommendations play a decisive role in the decision on eligibility to better align incentives. 1.4.8 Reimbursement of the costs of purchasing and adaptation the car This is a cash benefit amounting to up to 32 Basic Social Benefits (1,216 EUR) once in 6 years to help with the purchase and adaptation of a car.77 A person with disabilities may apply to SSIF for this benefit, if s/he complies with the following: has a driving license and is assessed a special need by DWCAO of a reimbursement of the costs of purchasing and adapting a car (assessed only by medical criteria); or 2) is a parent of a disabled child under the age of 18 with a permanent care need (in this case, parents may apply).78 75 The criteria and assessment procedures are regulated by The Order of the Minister of SSL and the Minister of Health No. A1-765/V-1530 Approval of the Procedure for Determining the Requirements for the Compensation of the Expenses for the Special Permanent Care, Special Permanent Care (Assistance), Special Car and its Technical Adaptation, https://www.e- tar.lt/portal/lt/legalAct/ef7052500aa811e9a5eaf2cd290f1944/asr 76 Paragraph 4 of article 20 of The Law on Social Integration of Persons with Disabilities, https://www.e-tar.lt/portal/lt/legalAct/TAR.199156E4E004/cWWgldtkIu 77 It is regulated by the Law on Transport Relief of the Republic of Lithuania: https://www.e-tar.lt/portal/lt/legalAct/TAR.033D686E8F1B/asr 78 Parents of a disabled child who have received this benefit may continue to be entitled to it after the child turns 18 and needs permanent care (and has no ability to drive). 47 The application with the decision from DWCAO must be submitted to SSIF and the decision should be made within 10 working days. SSIF may appeal DWCAO’s decision with its director. The benefit is funded from the state budget. In 2018, about 600 persons were recipients of this benefit. The total spending was about 2,000,000 EUR. 1.4.9 Subsidized transport This benefit, regulated by The Law on Transport Relief, allows persons with disabilities to purchase discounted tickets for local (city and suburban) regular buses and trolley-buses, passenger trains (in Class 2 and 3 coaches, where the passenger departure and destination stations are within the territory of the Republic of Lithuania79), scheduled passenger ships and ferries.80 The State Road Transport Inspectorate under the Ministry of Transport and Communications monitors the implementation. 1.4.10 Medical rehabilitation This benefit pertains to the reimbursement of medical rehabilitation cost, including the rehabilitation treatment, when an eligible person81 is sent to complete the treatment following a serious illness or injury that is on a list approved by the Ministry of Health. It is regulated by The Law on Health Insurance of the Republic of Lithuania.82 The compensation is 100 percent and it is funded from the Compulsory Health Insurance Fund Budget. The benefit can be used once per year. The State Patient Fund administers the process. In 2017, medical rehabilitation services were provided to 916 persons and supportive medical rehabilitation to 1,707. The related Compulsory Health Insurance Fund’s expenditures were for medical rehabilitation services 899,854 EUR (0.0021 percent of GDP) and for supportive medical rehabilitation 1,034,738 EUR (0.0023 percent of GDP). The procedures for accessing medical rehabilitation benefits starts when a person with assessed work capacity or level of special needs requires a special treatment; the treating physician fills in a form. This sequencing is not aligned well with the requirement of the Article 20 of the Law of the Republic of Lithuania on Social Integration of Persons with Disabilities.83 Article 20 establishes that work capacity is determined by assessing the state of health of the individual and her/his ability to perform an earlier- obtained qualification, to obtain new qualification, or to be engaged in jobs that do not require professional qualifications after having exhausted all available medical and vocational rehabilitation and special assistance measures. In that sense, medical rehabilitation (and other rehabilitation and assistance measures) should precede work capacity assessment. Moreover, medical treatment and medical rehabilitation should not be viewed as separate, but as integrated phases in restoring patients’ health and functioning. Separating them may result in worse outcomes for person’s health and her/ his labor market participation. Should a person need continuous medical rehabilitation treatment such recommendation should be made by rehabilitation professionals to DWCAO and be taken into account during the assessment. The MSSL may wish to discuss this issue with the Ministry of Health and change 79 The discount for passenger trains and long-distance buses is funded by the state budged; the others by the municipalities’ budgets. 80 80 percent discount for disabled children, adults with work capacity 0 -25 percent, for individuals with high special needs level and their attendant. Persons with an average level of special needs and adults with 30-55 percent work capacity are eligible fora 50 percent discount. 81 A person, whose working capacity is 0-25 or a high level of special needs are determined by DWCAO. 82 The Law on Health Insurance: https://www.e-tar.lt/portal/lt/legalAct/TAR.94F6B680E8B8/asr 83 The Law of the Republic of Lithuania on Social Integration of Persons with Disabilities, https://www.e-tar.lt/portal/lt/legalAct/TAR.199156E4E004/cWWgldtkIu 48 related legal provision to ensure full implementation of the above-mentioned Article 20 (see also discussion in the section on Disability Assessment). 1.4.11 Subsidized medication The Law on Health Insurance84 provides that persons with disabilities with up to 40 percent of work capacity are eligible for a compensation for expenditure on medication.85 Territorial patient funds enter into agreements with pharmacies and reimburse them on a monthly basis. The compensation level is as follows: (i) 100 percent for persons with a work capacity of 0-25 percent or a high level of special needs; and (ii) 50 percent of the basic price for persons with a work capacity of 30 to 40 percent or an average level of special needs. To receive a compensation, a person must provide a prescription from the physician and her/his disability card to the pharmacy. The State Patient Fund is responsible for the compensation administration and monitoring.86 1.4.12 Provision of technical aid and compensation of expenses This program provides assistive devices for mobility, vision, hearing, communication or other needs of persons with disabilities or partially reimburses the cost of acquiring them.87 It is regulated by The Order of the Minister of Social Security No. A1-338 Approval of the Procedure for Providing Technical Assistance Measures for Persons with Disabilities and Reimbursement of Expenses. The need for an assistive device/ technical aid should be determined by a physician. It is provided free of charge; or in the form of down payment for purchasing it, or as a partial reimbursement of the cost of acquiring it. More costly aids, if issued free of charge, must be returned if not needed any longer. The application must be submitted to the territorial unit or the central Technical Assistance Center for Persons with Disabilities under MSSL or to the municipal administration. The decision must be made as soon as possible. The decision on compensation shall be made no later than within 10 working days. The benefit is financed from the state budget. In 2017:88 • 49,105 technical aids (new, returned, received through support) issued, • 1,353 compensations (323,747 EUR) were paid, • 24,652 individuals provided with technical measures. • Total spending: 2,415,000 EUR (0.006 % GDP89). In 201890: • 26,329 individuals provided with technical measures, • 55,350 requests received, 51,416 requests fulfilled, • 603 compensations paid (188,924.56 EUR). • 1,234 compensations paid (388,924.56 EUR). 84 The Law on Health Insurance: https://www.e-tar.lt/portal/lt/legalAct/TAR.94F6B680E8B8/asr 85 The medicine must be included in the list of medication that can be compensated. 86 In 2018, the Compulsory Health Insurance Fund spent 231,933,151 EUR (0.51 % GDP) on this program (for all beneficiaries, including persons with disabilities). 87 Examples of assistive devices: wheelchairs, orthotics, prosthetics, functional beds, sticks, toilets, etc. The benefit amount depends on the device/ aid provided: for a wheelchair for a tetraplegic person it is 1,450 EUR once in 5 years. 88 Annual reports of the Technical Assistance Center for Persons with Disabilities under MSSL: https://www.tpnc.lt/lt/apie- tpnc/veikla/veiklos-ataskaita/ 89 MSSL: “Indicators describing social integration of people with disabilities in the field of social security 2017” 90 Annual reports of the Technical Assistance Center for Persons with Disabilities under MSSL: https://www.tpnc.lt/lt/apie-tpnc/veikla/veiklos-ataskaita/ 49 In 2019: • 50,074 technical aids (new, returned, received through support) issued, • 1,125 compensations (394,182.25 EUR) were paid, • 25,991 individuals provided with technical measures, • Total spending: 2,395,300 EUR. This is another area where integration between a treating physician, rehabilitation professionals and benefits administration need to be stronger. This is crucially important for the adequacy of assistive aids, which need to be tailored to the functioning needs of a person with disabilities. Assistive technology is one of the key contributing factors for helping persons with disabilities stay at work. 1.4.13 Support for housing Support for housing for persons with disabilities comprises financial assistance for housing adaptation91 and a subsidy to rent/purchase/adapt the house. The support for housing is regulated by The Law on Assistance for Buying or Renting a Home, the Law of the Republic of Lithuania on Social Integration of Persons with Disabilities 92 and The Order of the Minister of Social Security and Labor of the Republic of Lithuania No. A1-103 on Approval of Procedure for the Adaptation of Housing for Persons with Disabilities.93 The person with disabilities may apply for adaptation of his/her house only if s/he is assessed as having a special need.94 There are two forms of this benefit: one is a means tested housing adaptation subsidy, the other is a special housing adaptation program, which is not. The former has a very low level of income threshold and, therefore, most of the persons with disabilities opt for the latter options. Municipal administrations establish the terms for submitting applications for housing adaptation every year. Applications are reviewed and decided on by a designated municipal commission composed of members representing municipal administration and members from disabled people organizations appointed by the Department of Disability Affairs. The benefit is funded from the state and municipal budgets. In 2017, 59,5 percent of applications for adaptation were approved: 412 houses were adapted to the needs of disabled individuals (total spending: 2,700,850 EUR, of which 1,450,000 EUR from the state budget).95 In 2018, 59 percent of applications for adaptation were approved: 381 houses were adapted (total spending: 2,242,610 EUR, of which 1,221,700 EUR from the state budget).96 In 2019, 56,1 percent of applications for adaptation were approved: 397 houses were adapted (total spending: 2,897,017 EUR, of which 1,453,100 EUR from the state budget). In 2017, a new program to adapt the living environment for families raising children with severe disabilities was introduced. In 2017, 88 housing units were adapted for 92 children; in 2018, 210 91 Includes, various types of mobility equipment, sanitary facilities, folding shower table or chair, bathroom bench, installation of electric water heater, lowering the door thresholds, dismantling, levelling slope installation, balcony door widening and floor levelling, adjusting exterior stairs, multiple signage stairs, and installation of gas leak detector. 92 The Law on Assistance for Buying or Renting a Home: https://www.e-tar.lt/portal/lt/legalAct/e944ee00600111e4bad5c03f56793630/asr 93 Order of the Minister of SSL No. A1-103 on Approval of Procedure for the Adaptation of Housing for Persons with Disabilities: https://www.e-tar.lt/portal/lt/legalAct/25069bc035df11e99595d005d42b863e/asr 94 Permanent care or first level and permanent care (assistance) due to mental disability or special need for technical assistance equipment (for any type of wheelchair or other measures). 95 MSSL: “Indicators describing the social integration of people with disabilities in the field of social security in 2017” 96 Department for Persons with Disabilities: http://www.ndt.lt/wp-content/uploads/JT_neigaliuju_teisiu_konvencijos_stebesenos_ataskaita_GALUTINE.pdf 50 housing units were adapted, and in 2019, 211 housing units were adapted for 180 children. The program also envisages the acquisition of sensory aids (a maximum of EUR 1,900 per beneficiary is allocated for the purchase of sensory aids). This program is financed from the state budget: 2017 - 290,800 EUR, 2018 – 384,000 EUR, 2019 - 458,600 EUR. One of the housing support measures is a partial97 reimbursement of a loan to purchase a dwelling. It may be provided to a person with disabilities once in a lifetime. A person must comply with the following requirements: 1) assessed as having a severe or moderate level of disability, or working capacity 0-40 percent, or level of special needs for the persons of a retirement age; 2) family annual net income meets the threshold (the threshold depends on the number of family members, but the lowest is 12,932 EUR); 3) meets the threshold for the value of property owned by a family (also depends on the number of family members; the lowest is 13,674 EUR). The application must be submitted to the administration of municipality, which gathers all the necessary documents. If the administration of municipality determines that a person who applied for housing support has not fulfilled the requirements, the housing support must be fully returned. This decision of the administration is an executive document. Another housing support measure is the financial support for renting homes for persons with disabilities (partial reimbursement of rent or renting a social house98). The application should be submitted to the administration of municipality, which gathers all necessary documents. After submitting the application to the administration of municipality, the list of persons and families entitled to rent social housing is established according to the date and time of registration (in case of social housing). In 2017, 215 families received support for renting a house, and 895 social flats were rented for persons with disabilities.99 1.4.14 Income tax exemptions These exemptions, including the exemption from the landowner’s tax,100 are regulated by The Law on Personal Income Tax of the Republic of Lithuania.101 The exemptions differ by the severity of disability: 353 EUR for persons with a work capacity of 0-25 percent/ persons of retirement age with a high degree of special needs/ persons with severe disability level; and 308 EUR for persons with a work capacity of 30-55 percent/ persons of retirement age with an average level of special needs/ persons with a moderate degree of disability.102 Tax Disputes Commission settles the disputes. 1.4.15 Legal aid Free of charge secondary legal aid (preparation of legal documents for litigation, consultation, representation in all legal disputes) is guaranteed to persons with disabilities who are: 1) assessed as having a severe disability or 2) assessed as having work capacity of 0-25 percent or 3) assessed as having a high level of special needs. This benefit is regulated by The Law on State Guaranteed Legal Aid.103 An application with all required documents must be submitted to the State-Guaranteed Legal Aid Office, which makes a decision immediately/ not later than within 5 working days. Ministry of 97 20 percent of the loan. The amount of state-reimbursed home loans cannot exceed: 1) 53,000 EUR for a single person; 2) 87,000 EUR for a family of two or more members; 3) 35,000 EUR for the renovation of existing dwellings, irrespective of the family status. 98 70 -80 percent of the rent or providing a social house. 99 Department for Persons with Disabilities: http://www.ndt.lt/statistiniai-rodikliai/ 100 Disabled persons: 1) assessed working capacity 0-40 percent and 2) there are no capable for work family members are exempt from the landowner tax. 101 The Law on Personal Income Tax: https://www.e-tar.lt/portal/lt/legalAct/TAR.C677663D2202/asr 102 General counting formula is 300 - 0.15 x (personal monthly earnings - minimum monthly wage). 103 The Law on State Guaranteed Legal Aid: https://www.e-tar.lt/portal/lt/legalAct/TAR.EAA93A47BAA1/asr 51 Justice of the Republic of Lithuania and State Guaranteed Legal Aid Coordination Board monitors the process. In 2017, secondary legal aid was provided in 810 cases.104 1.4.16 Key messages Lithuania provides a range of benefits to persons with disabilities through social insurance, social assistance, social services, health insurance and labor market programs. Programs range from benefits in cash, to services, including medical and vocational rehabilitation, employment support, care allowance, support for housing, etc. Benefits in cash dominate, especially social insurance disability pension (87.0 percent of all adults with disabilities receive this benefit), social assistance disability pension (19.0 percent of all persons with disabilities receive this benefit) and care allowances (41.0 percent of all persons with disabilities receive these allowances). Most benefits in cash are provided at the national level, while service provision and some benefits in cash is responsibility of municipalities. Labor market participation (employment) has no impact on eligibility for benefits. except for social assistance disability pension, which cannot be received while a person is working. Overall, this is a good feature of the disability system in Lithuania as in many countries people with disabilities must choose between disability pension and labor market participation. In that sense, to encourage persons receiving disability social assistance pensions to seek employment, the Government may wish to review this policy and allow them to work, while continuing to receive this benefit. Only if the employment is stable and say lasts for more than two years, the benefit could be gradually reduced/ tapered off. Lithuania spends about 15.5 percent of GDP on social protection of which disability benefits constitute about 9.0 percent, or 1.4 percent of GDP (in 2018). Relative to other EU countries, Lithuania’s spending on disability benefits as a share of GDP is above the EU-28 average: only six EU countries spend more than Lithuania. However, relative to GDP, Lithuania’s spending on disability benefits is below the EU-28 and belongs to the lower end of spending among the EU members. To receive disability benefits a person must be assessed for disability, or work capacity, or a special need, or a level of special needs. The assessment of disability level (for children), work capacity (for working age persons), special needs (any age), and level of special needs (for elderly) is carried out by Disability and Work Capacity Assessment Office (DWCAO). However, the decision of DWCAO does not determine the right of the persons with disabilities to receive a benefit. Each benefit has its own assessment process and requires an application of the person to the provider of the benefit/service and even a submission of documents, many of which, should be available online. The lack of an integrated process and the lack of coordination between institutions cause another problem as well: persons with disabilities are not well informed about available benefits/services and their requirements and, thus, many do not benefit from them. The Ministry of Social Security and Labor (MSSL), in collaboration with municipalities, should compile an inventory of disability benefits with their basic eligibility requirements and administrative procedures and made it available electronically and in printed and accessible formats across the country. This inventory should be advertised widely, and each person registering for disability assessment at DWCAO should be given a copy and instructed on how to access information online. DWCAO assessment process should include a comprehensive functioning and needs assessment and a referral to relevant national and municipal agencies/ bodies. 104 Department for Persons with Disabilities: http://www.ndt.lt/statistiniai-rodikliai/ 52 Targeted compensation (care allowances) could be further strengthened. The description of needs and content of the assistance would need to be precisely and minutely described, to allow for better decision making. This benefit is an open-ended commitment for the state budget. The eligibility and award are decided on by municipalities, while the financing is provided by the state budget. Potential policy considerations may include options to consolidate the benefit into a single benefit; differentiate it by hours of service needed and have DWCAO’s assessment and recommendations play a decisive role in the decision on eligibility to better align incentives. A regular audit of municipal decisions would help ensure that the benefits are received by those who need them the most. The procedures for accessing medical rehabilitation benefits starts when a person with assessed work capacity or level of special needs requires a special treatment and the treating physician fills in a form. The sequencing of this procedure is not aligned well with the requirement of the Article 20 of the Law on Social Integration of Persons with Disabilities. Article 20 establishes that work capacity is determined after having exhausted all available medical and vocational rehabilitation and special assistance measures. In that sense, medical rehabilitation (and other rehabilitation and assistance measures) should precede work capacity assessment. Moreover, medical treatment and medical rehabilitation should not be viewed as separate, but as integrated phases in restoring patients’ health and functioning. Separating them may result in worse outcomes for person’s health and her/ his labor market participation. Should a person need continuous medical rehabilitation treatment after the assessment, such recommendation should be made by rehabilitation professionals to DWCAO and be taken into account during the assessment. The MSSL may wish to discuss this issue with the Ministry of Health and change related legal provision to ensure full implementation of the Article 20. Assistive devices and technical aids are another area where integration between a treating physician, rehabilitation professionals and benefits administration need to be stronger. This is crucially important for the adequacy of assistive aids, which need to be tailored to the functioning needs of a person with disabilities. Assistive technology is one of the key contributing factors for helping persons with disabilities stay at work. 53 1.5 Labor market inclusion of persons with disabilities 1.5.1 Statistics on the labor market participation of persons with disabilities In this section, we are looking at the labor market status of persons with disabilities in Lithuania. As noted in section 1.1, in 2018, according to MSSL, there were 230,609 persons with disabilities in Lithuania (8.2 percent of the Lithuanian population). The number of children with disabilities was 14,894. Over the last ten years, the number of individuals certified as persons with disabilities for the first time has been decreasing steadily: from 27,200 in 2008, to 11,762 in 2018. In 2018, 55.7 percent of working age persons recognized as disabled were employed (Table 9). There is no information whether they continued being employed, or left employment, although, judging by the statistics presented here, majority is likely to have left their jobs. Table 9: Employment status at the time of disability assessment 2017 -2018 2017 2018 Working age persons recognized as disabled 12,208 11,762 Employed when recognized as disabled 6,761 6,554 Unemployed when recognized as disabled 5,447 5,208 Employed as % of the total 55,4% 55,7% Source: DWCAO. The labor force participation and employment rates of persons with disabilities are low in Lithuania. In 2018, out of 160,350 working age adults with disabilities, only 47,206 were employed and 13,200 were registered as job seekers (almost no change from 2017), resulting in the labor force participation rate of 37.7 percent and employment rate of 29.4 percent (relative to the total number of working age people with disabilities). A majority, 62.3 percent, was out of the labor force. These rates are well below those for the overall working age population, where labor force participation rate in 2019 was 62.0 percent, and employment rate 72.0 percent (in Lithuania employment rate is calculated as percentage of working age population with a job in total working age population). (Tables 10 and 11). However, following a standard International Labor Organization (ILO) approach to calculate labor market indicators ((where the denominator is labor force – employed plus those looking for a job), employment rate of persons with disabilities would be 78.1 percent and unemployment rate would be 21.9 percent (it was 6.1 percent in the general population in 2018). Table 10: Employment of persons with disabilities in Lithuania 2017 -2018. 2017 2018 Persons with disability (total) 241,861 230,455 Working age persons with disability (total) 162,632 160,350 Employed persons with disability (total) 47,133 47,206 Employment rate (as % of working age persons with 28,9% 29.4% disability) Source: Lithuanian Ministry of Social Security and Labor. International statistics on labor market participation of persons with disabilities is not readily available and the data is often rather old. Figure 12 presents the most recent available data from the ILO on unemployment rates among disabled and non-disabled population in select countries. In all countries included in the Figure, persons with disabilities experience higher rates of unemployment relative to non-disabled population. For Lithuania, data for 2012 and 2018 is included. While the rates have declined significantly between 2012 and 2018 (yellow bars), Lithuania’s rate of unemployment among 54 persons with disabilities is the second highest (only Spain has a higher rate). Also, the gap between the two unemployment rates is the highest in Lithuania. Figure 12: Unemployment rates of disabled and non-disabled population in select countries 35 34 31 30 25 21.9 21.9 20 19 18 16.4 15.9 14.5 15 12 12.3 9.7 9.5 9.5 10 7.5 7.5 7.3 6.1 6.1 5 3.6 0 Belgium Bulgaria Czechia Estonia France Hungary Lithuania Lithuania Slovakia Spain (2016) (2016) (2016) (2015) (2016) (2015) (2018) (2012) (2016) (2015) Disabled Not disabled Source: ILO. Table 11 presents data about job seekers with disabilities registered at the State Employment Service in 2018. Considering the number of the employed persons with disabilities and those seeking employment, there are about 100,000 persons with disabilities in Lithuania who are economically inactive. Table 11: Statistics of job seekers with disabilities 2018. 2018 Registered disabled job seekers 13,200 Employed 5,623 In the open labor market 5,200 In social enterprises 423 Employment support 3,300 Wage subsidy 1,600 Self-employed 1,100 Established new working place for employee with disability 81 Source: Activity Report of the Employment Services 2018. Most people with disabilities are capable of work and wish to work. However, they face significant difficulty in finding employment or remaining at the same workplace. They are more likely to become long-term unemployed or inactive. Changing this situation requires a profound change in disability 55 policy in Lithuania on two fronts: first, keeping people employed, even though they have been assessed as disabled, and secondly providing opportunities for unemployed persons with disabilities to get jobs commensurate with their work capabilities (e.g., a paraplegic architect or a government clerk does not need a to leave her/his job because of paraplegia). Keeping people at work would require that all efforts be made to keep employed people experiencing health issues at work, prior to being assessed as having low work capacity. Even then, they should be supported to stay in employment. This would require a strong collaboration between a person, her/his employer, treating physician, medical rehabilitation professionals, occupational rehabilitation, employment services, and local social services. A more nuanced and tailored approach is needed to ensure opportunities for labor force participation of persons who have been disabled since childhood, persons who have acquired disability as adults and elderly persons experiencing disability who wish to work. For this to happen a shift would be needed in disability policy, its implementation and in the way how disability is assessed, and support and assistance are provided, as discussed throughout this report. To start with, MSSL should consider a survey of a sample of working age persons with disabilities to better understand their labor market situation and reasons behind it. It should also start closely monitoring whether employed persons whose work capacity is assessed stay in employment or not and why. Unemployed working age persons who are assessed for work capacity should also be surveyed about their work history and attempts to get a job. Referral to the employment services should be a common practice. 1.5.2 Legislative framework on disability and employment in Lithuania Key provisions pertaining to labor market inclusion of persons with disabilities in Lithuania are provided in The Law of the Republic of Lithuania on Social Integration of Persons with Disabilities; The Employment Law of the Republic of Lithuania; and The Law of the Republic of Lithuania on Social Enterprises. The Law on Social Integration of Persons with Disabilities (2005 and subsequent revisions and amendments) aims to ensure equal rights and opportunities for persons with disabilities in the Lithuanian society. The Employment Law of the Republic of Lithuania105, envisages labor market services, employment support measures, and other economic and social measures to increase the rates of employment of job seekers, reduce unemployment, and mitigate negative consequences of unemployment. Persons with disabilities are systematically included in the provisions of this Law. The Law also provides for enhanced/ special employment support measures for persons with disabilities, including (i) subsidized employment, (ii) vocational rehabilitation/training, (iii) professional skills development, (iv) support for job creation, (v) and support for self- employment. Flexible working hours can be included in the rehabilitation plan. The Law also stipulates that persons with disabilities cannot be dismissed because of their disability. The Law on Social Enterprises106 aims to facilitate employment of persons with disabilities, particularly those facing difficulties to compete in the labor market under equal conditions, to promote their 105 21 June 2016, No XII-2470, Vilnius; Consolidated version as of 01/01/2020; The Law was published by the Register of Legal Acts (RLA) on 05/07/016, RLA ID 2016-18825. 106 Republic of Lithuania, Law, Amending the Law on Social Enterprises No. IX-2251, 19 September 2019 No XIII-2427; Vilnius; Consolidated version as of 01/01/2020; The Law was published by the Register of Legal Acts (RLA) on 09/10/2019, RLA ID 2019-16065 56 return to the labor market, their social integration, as well as to reduce social exclusion. A social enterprise could be of two types: general social enterprise, and social enterprise for persons with disabilities. Both are required to employ persons with disabilities, but the percentages are different (see below). A social enterprise employing persons with disabilities may receive the following state aid: (i) partial reimbursement of wages and state social insurance contributions for employees with disabilities; (ii) a subsidy for the creation of workplaces, adaptation of workplaces and acquisition or adaptation of work equipment for employees with disabilities; (iii) a subsidy for training of employees with disabilities. In addition to these, a social enterprise of persons with disabilities can receive the state aid for the following: (i) a subsidy to adapt the work environment, production premises and rest rooms; (ii) a subsidy for the reimbursement of additional administrative and transport expenses; and (iii) a subsidy for hiring an assistant (sign language interpreter or a guide). 1.5.3 Active labor market policies for people with disabilities in Lithuania Active labor market programs (Table 12) are implemented by the Employment Services (previously the Lithuanian Labor Exchange Office) under MSSL, and include: mainstream services, such as vocational training for unemployed and employees who have been given a notice of dismissal, competence recognition, apprenticeship and traineeship, technical skills training, and others, as well as specialized programs for specific groups of unemployed, including persons with disabilities, such as wage subsidies, subsidies for job creation, vocational rehabilitation and support for self-employment. Table 12: Spending on Active Labor Market Programs 2016-2018 2016 2017 2018 Active labor market programs (EUR mill) 67,1 71 67,5 Share of GDP (%) 0,17 0,17 0,15 Labor market services (EUR mill) 23,9 33,2 28,1 Social enterprises (EUR mill) 23,1 28,9 31,3 Vocational rehabilitation (EUR mill) 3,2 3,6 2,6 Source: Activity Reports of Employment Services 2016, 2017 and 2018. These programs target narrowly defined groups: working age persons with disabilities, unemployed working age persons with disabilities, unqualified unemployed persons, long-term unemployed under 25 years of age, unemployed older than 50 years of age, unemployed under 29 years of age, and others. The rationale for the program segmentation is unclear and the consolidation of programs should be considered, possibly into three groups: persons with disabilities since childhood, persons who have acquired disabilities during adulthood and elderly persons who wish to work. What matters is a comprehensive assessment of each client, including profiling and psychometric testing and offer of labor market mediation and job matching service. These programs seem to be more effective in labor market inclusion.107 Wage subsidies: State Employment Service provides wage subsidies to private or public companies to boost job creation. In the case of persons with disabilities, the aim is to support employment of persons with work capacity 0-40 percent, and to help employment or long-term labor market integration for persons with 45-55 percent work capacity. The subsidy is based on the salary from the person’s non terminated labor contract including taxes, and it is capped at 1.5 minimum wages. The 107See, for example: Jochen Kluve (2010), The effectiveness of European active labor market programs, Labor Economics 17 (2010) 904–918; Card, D., J. Kluve and A. Weber (2015), What works? A meta-analysis of recent active labor market program evaluations, NBER Working Paper 21431. Mckenzie, David J. 2017. How effective are active labor market policies in developing countries? A critical review of recent evidence (English). Policy Research working paper; no. WPS 8011; Impact Evaluation series. Washington, D.C.: World Bank Group. http://documents.worldbank.org/curated/en/256001490191438119/How-effective-are-active-labor-market-policies-in- developing-countries-a-critical-review-of-recent-evidence; 57 subsidy percentages and duration are as follows: (i) work capacity 0-25 percent: 75 percent; unlimited duration; (ii) work capacity 30-40 percent: 60 percent; up to 24 months; and (iii) work capacity 45-55 percent: 50 percent; up to 6 months. In total, in 2018, wage subsidy was provided to 6,800 employers (5,687 thousand in 2017) for employment of about 14,000 unemployed workers (9,000 in 2017). Of these, 1,600 were persons with disabilities. Subsidies for job creation: The goal of this measure is to support unemployed people, including unemployed people with disabilities to create a job for themselves (self-employment) or start a business. Persons with work capacity <40 percent may receive additional assistance for the workplace adaptation/accommodation and purchase of special equipment. Eligible for this subsidy are working age disabled persons with work capacity <40 percent and unemployed persons under the age of 29 years. The subsidy must be used for premises, equipment and tools. Established workplace must be sustained at least 36 months after creation. In 2017, there were 302 workplaces created using this program (at the cost of 2,401,275 EUR). Social enterprises: This program aims to stimulate employment of persons with disabilities and other disadvantaged groups. The status of “social enterprise” is granted by the Employment Services to any legal entity in Lithuania that meets required criteria. There are two types of social enterprises. The only difference between them is the percentage of persons with disabilities they are required to employ. In a social enterprise, persons with disabilities should make not less than 40 percent of the average annual employee number (a minimum number of disabled employees cannot be less than four). Social enterprise for disabled persons is required to employ not less than 50 percent, of which 40 percent must be employees with severe disability (0-40 percent work capacity). Other target groups for employment in social enterprises are long term unemployed, and persons older than 50 years. In practice, more than 90 percent of all employed in social enterprises are persons with disabilities. A company that wants to be established as a social enterprise must apply to the Employment Services, which after having reviewed required documents grants the status of the social enterprises or denies it. The State provides to social enterprises funding for the following: salaries and social insurance contributions, creation or adaptation of workplace, and training. Social enterprises for persons with disabilities can also get funding for the transportation of the disabled employees, for the recreation space in the workplace, for personal assistants (e.g. sign language interpreter). Persons with disabilities, who are willing to work in social enterprises must be registered and referred to this work by the Employment Services. In 2018 there was big growth in the number of social enterprises, there were 177 enterprises, that is 35 percent than compared to the previous years (Table 13). However, while the number of social enterprises jumped, the number of persons with disabilities actually decreased relative to 2017. Table 13: Social enterprises in Lithuania 2016 -2018. 2016 2017 2018 Number of social enterprises 131 131 177 Number of social enterprises with status of disability x x 60 social enterprise Employed persons with disability in social enterprises 6,800 8,500 8,000 Source: Activity Reports of Employment Services 2016, 2017, 2018. In recent years there have been discussions in the Parliament and society about the effectiveness of social enterprises. The main point of criticism has been the cost effectiveness of the program: the state allocates about 30 million EUR annually to help create and maintain jobs for persons with disabilities, while only 7-8 thousand people with disabilities work in social enterprises. Many social enterprises are found to misuse the system by employing people with light and moderate disability 58 who can perform as productively as employees without disabilities; they also tend not to employ people with mental and intellectual disabilities. Many social enterprises provide cleaning and similar services that do not require skills. Anecdotal evidence suggests that in some instances, employment is of short duration. The system of monitoring is not fully operational. The focus of monitoring is on finances and number of employees with disabilities; other important aspects of the program such as satisfaction and integration of persons with disabilities are yet to be systematically monitored. Working conditions are monitored by the Labor Inspectorate, which delivers monitoring reports the Employment Service. Vocational Rehabilitation Programs. These programs’ objective is to restore, increase or develop new work capacity and build and increase skills of persons with disabilities, so that they can participate gainfully in the labor market. Vocational rehabilitation includes educational, social, psychological, rehabilitation and other impact measures. Within the Vocational Rehabilitation Program, the following services are provided: (i) assessment of professional capacities; (ii) vocational guidance and counselling; (iii) restoration or training to acquire new vocational skills; (iv) assistance in finding a job; (v) support at the workplace. Vocational rehabilitation is implemented in several stages. First, the need for vocational rehabilitation services is established. This is done by DWCAO as part of the work capacity assessment (see section on Disability Assessment pertaining to this). After having received the conclusion of DWCAO confirming the need for vocational rehabilitation, the person applies to the Local Employment Services office at the place of residence. The office issues a reference to the institution providing vocational rehabilitation services, where an individual vocational rehabilitation program is drafted, and the scheduled services are provided. When the vocational rehabilitation program is completed, the person returns to DWCAO for the final assessment of the work capacity. Vocational rehabilitation services are publicly procured periodically by the Employment Services. The key selection criterion is the lowest cost, which does not guarantee the best quality services. Persons participating in a vocational rehabilitation program receive a vocational rehabilitation benefit. It amounts to 65.94 percent of the beneficiary’s income 3 months before the start of the program. The benefit cannot be lower than two basic social insurance pensions (361.90 EUR/ 2020) per month and it cannot exceed two average national salaries. It is paid monthly from the first day of participation in the program for a maximum of 180 calendar days. For persons covered by the State Social Insurance, vocational rehabilitation benefit is financed and paid by the State Social Insurance Fund and the payment procedures are regulated by the Law on Sickness and Maternity Social Insurance. If a person is not covered by the state social insurance, s/he receive a vocational rehabilitation benefit in the amount of two basic social insurance pensions, in accordance with the procedure set out by the Government. In 2018, there were 14 vocational rehabilitation providers (Figure 13) covering entire country and providing good access to vocational rehabilitation. 59 Figure 13: Vocational rehabilitation providers in Lithuania by type of disability Sensor disability Mental disability Movement disability Intellectual disability Source: Analysis of the Effectiveness of Vocational Rehabilitation Services 2011-2016, Valakupiai Rehabilitation Centre. Persons with disabilities could choose from 120 vocational training programs. The most popular were: accountant, florist-flower seller, carpenter, computer technician, nurse assistant, seller-cashier, leather artistic handicrafts producer, hairdresser, cook, company manager, kitchen assistant, jeweler, advertising layout operator, webpage designer, plumber, small business administrator, cleaner (adapted to persons with mental disability), text typing and desk-top publishing and editing operator, insurance consultant, decorative handicrafts producer. In 2018, 544 persons participated in the Vocational Rehabilitation Program; significantly less than in 2017 (805) and 2016 (768 persons).108 In 2018, the employment rate within 6 months after completion of the Vocational Rehabilitation Program was 45.6 percent.109 Vocational rehabilitation services serve only a fraction of working age persons with disabilities: in 2018, 11,281 persons were assessed as having a disability (first time assessment). As already discussed in the section on disability assessment, vocational rehabilitation should first and foremost be undertaken prior to a person being assessed as disabled. This by no means implies that working age persons with disabilities should not benefit from vocational 108 Source: Statistical Report 2018 of Employment Services Under the Ministry of Social Security and Labor of the Republic of Lithuania. 109 Source: Ministry of Social Security and Labor of the Republic of Lithuania. 60 rehabilitation. For higher coverage, however, DWCAO assessors would need to be furnished with proper evaluation and recommendations by vocational rehabilitation professionals (e.g. the Employment Services recommendations). Vocational rehabilitation services are financed by the State Employment Services. For the period 2018- 2020, it is planned that annually 900 persons will take part in vocational rehabilitation services. Both in 2018 and 2019 the target was not reached (in 2019, 594 disabled persons participated in the program). In 2018, the vocational rehabilitation budget was 2.6 million EUR. One of the reasons why people with limited work capacity might be hesitant to enrol in rehab programs is fear that due to vocational rehabilitation their work capacity percentage may change and the benefits they receive may be reduced. Uncertain job prospects may add to these concerns. This issue can easily be resolved by allowing a person a period during which s/he can search for a job while receiving the same amount of benefits, even with increased work capacity. In recent years there have been discussions in the Parliament and by disabled people organizations about the cost-effectiveness of vocational rehabilitation. The main criticism has been that the program is long and expensive. This perception is however contrasted by the fact that about 40 percent of participants remain employed one year after the program has ended, which is rather high success rate. Other critics have argued that vocational rehabilitation programs should be conducted in the mainstream environment were the programs cost several times less. However, one can only compare the programs in a meaningful manner based on empirical evidence and analysis – at a minimum, one would need to compare employment rates and job retention for persons with similar disabilities in vocational programs and mainstream training settings for any viable conclusions to be drawn. Case management: In 2018 Employment Service introduced case managers who serve unemployed persons with disabilities. They assess work abilities, education, health limitations, expectations and motivation, to help persons with disabilities find the best employment. After introducing this service in 2018, 47 case managers started their work all over the country. The serve over 10,000 registered unemployed persons with disabilities. It is planned to increase the number of case managers to 52; at least one per regional unit of Employment Service. 1.5.4 Other initiatives to assist labor market participation of persons with disabilities The Association of Deaf and Hard of Hearing Persons has initiated a project “Integration of hearing- impaired people into the labor market”. During this project specialists were trained as employment mediators and specialized employment office for deaf and hard of hearing persons was established. Employment mediator assesses the skills of the client, assists her/ him choose the job, helps them find the right job, prepares the client for a job interview, advises employers on employment of disabled people, helps with required employment documents and represent the interests of her/his client in the job contract negotiations. S/he also monitors the course of employment and helps solve any problem that may arise.110 To ensure quality of services, one employment mediator should not work with more than 10 clients at a time. Initiative of the restaurant “Pirmas blynas”: The first and only restaurant in Lithuania (Vilnius) that offers jobs to people with disabilities. On average, it employs 5-6 people with intellectual disabilities. It also offers job rotation and apprenticeship to people with intellectual disabilities. This restaurant has helped improve awareness of disability and has helped reduce stigma of people with intellectual disabilities to work in a service sector and be visible in Lithuania. One of the initiatives for young adults with disabilities is the project “Employment for Young Adults with Disabilities – LEAD”, implemented by the Valakupiai Rehabilitation Center. The project aims to facilitate employment of young adults with disabilities. Activities include collaboration with family 110 https://deaf.lt/en/about-project/ 61 members who often play an important encouraging/discouraging role. The services comprise soft and technical skills development, and employment facilitation. Once a young person finds employment, employment counsellors monitor developments and provide in-work and outside work support. 1.5.5 Education and skills development for children with disabilities Acquiring skills is as important for children with disabilities as for children without disabilities. Most children with disabilities in Lithuania are educated in mainstream schools (Table 14). Vast majority (88.0 percent) attends classes with their non-disabled peers, while 2.9 percent attends special classes in mainstream schools. The rest, 9.1 percent, attends special schools. Table 14: Students with special educational needs in general education in Lithuania 2015 -2019. 2015-2016 2016-2017 2017-2018 2018-2019 General class (full integration) 34,032 34,143 34,093 35,711 Special and developmental class (partial 986 1,023 1,110 1,159 integration) Special schools 3,638 3,680 3,656 3,686 Total 38,656 38,5846 37,860 40,556 Source: The Lithuanian Department of Statistics. After a pupil graduates from general education, there are several possibilities for continuing education and professional skills development: a vocational school, a college or a university. The statistics show that during the last 4 school years the number of students with disabilities has steadily been decreasing (Table 15). This is a trend that warrants investigation. Table 15: Students with disabilities in educational instituti ons 2015-2019. 2015-2016 2016-2017 2017-2018 2018-2019 Vocational school 1,346 1,359 1,332 1,283 College 301 242 181 141 University 419 362 314 279 Total 2,066 1,963 1,827 1,703 Source: The Lithuanian Department of Statistics. In 2017, financial support was provided to 826 students with disabilities studying in 36 universities and colleges). 1.5.6. Services to support labor market participation of elderly persons There are no such services in Lithuania. However, Lithuania should consider introducing such policies. Many elderly persons may be willing to work provided flexible working hours and adequate support for those experiencing difficulties in functioning. Elderly persons should be able to work as much and as long as they want to. This is not only sound welfare policy, but also prudent economic and labor market policy. 62 1.5.7. Key messages Labor market participation and employment rates of persons with disabilities in Lithuania are low, well below those for the total working age population. In 2018, out of 160,350 working age persons with disabilities, 47,206 persons were employed (29.4 percent) and 13,200 (8.2 percent) were looking for a job. A majority of 62.3 percent were out of the labor force. Following a standard ILO approach to calculate labor market indicators, employment rate of persons with disabilities would be 78.1 percent and unemployment rate would be 21.9 percent – more than double in the general population (where the denominator is labor force – employed plus those looking for a job). Juxtaposed to this is a myriad of labor market policies and programs for persons with disabilities supporting both persons with disabilities and their employers. They include vocational rehabilitation and training, flexible working hours, labor market services, case management, wage subsidies, workplace accommodation, subsidies for job creation, social enterprises, etc. In combination with support provided in general (benefits in cash and services – see section on Disability Benefits), one would expect higher labor force participation of persons with disabilities than observed. Lithuania has higher unemployment rate of persons with disabilities than other EU countries for which comparative recent data is available. Most people with disabilities are capable of work and wish to work. However, they face difficulty in finding employment or remaining at the same workplace. They are more likely to become long-term unemployed or inactive. Breaking this situation requires a profound change in disability policy in Lithuania on two fronts: first, keeping people employed, even though they have been assessed as disabled, and providing opportunities for unemployed persons with disabilities to get a job commensurate with their work capabilities (e.g., a paraplegic architect or a government clerk, does not need a to leave her/his job because of paraplegia). Keeping people at work would require that all efforts be made to keep employed people experiencing health issues at work, prior to being assessed as having low work capacity. Even then, they should be supported to stay in employment. This would require a strong collaboration between a person, her/his employer, treating physician, medical rehabilitation professionals, occupational rehabilitation, employment services, and local social services. A more nuanced and tailored approach is needed to ensure opportunities for labor force participation of persons who have been disabled since childhood, persons who have acquired disability as adults and elderly persons experiencing disability who wish to work. For this to happen a shift in disability policy, its implementation and in the way how disability is assessed, and support and assistance provided need to change, as discussed throughout this report. To start with, MSSL should consider a survey of a sample of working age persons with disabilities to better understand who they are (education, qualifications, last job, distance form employment, etc.), and what their labor market situation is as well as the reasons behind it. Alternatively, DWCAO’s reassessment of disability/ work capacity could be used to collect this information. It could be done at the registration for reassessment. MSSL should also start closely monitoring whether employed persons whose work capacity is assessed stay in employment or not and why. Unemployed working age persons who are assessed for work capacity should also be surveyed about their work history and attempts to get a job. Referral to the employment services should be a common practice. Implementation of the Article 20 of the Law on Social Integration of Persons with Disabilities, which stipulates that all support measures should be implemented prior to an individual being assessed for work capacity, as discussed throughout this report, would be a significant step forward in supporting employment and labor force participation of persons with disabilities. An assessment of active labor market programs to support labor market participation of persons with disabilities should be conducted. Programs that do not perform well should be discontinued, and those that do work should be expanded. 63 Annex 1: Understanding Disability and Disability Assessment111 What is Disability Assessment? Disability assessment is a gate through which anyone who claims any publicly or privately provided disability related benefit, service or product must pass. Every country has some form of disability assessment, some government authorized agency or agent charged with assessing whether a person is disabled or not, and to which degree. Most commonly and most visibly disability assessment is linked to social security benefits. But it also applies to eligibility for other social policy benefit: to access these benefits—from rehabilitation services, to care services, to assistive devices, to disability social pension, to social assistance in cash and in kind—people must be officially declared to have a disability. Disability assessment affects labor supply, government spending and individual welfare. Through the power vested in them, disability assessors make decisions that affect tens of millions of working age adults (on average 6 percent of working age population in OECD countries) and influence the allocation of national resources that often surpass 1 percent of GDP in any given year (on average 1.8- 1.9 percent of GDP in the OECD countries). It is estimated that aging of the population and increase in retirement age (in many countries the working age has been extended to well over 65 years of age) are bound to drive these percentages up. Disability assessment and determination Disability assessment is an authoritative determination about the kind and extent of disability a person has, as part of a larger administrative process usually called disability evaluation or disability determination. Disability assessment is part of a process that determines the eligibility of an applicant for some social benefit, service or protection that comprises a country’ disability policy. These programs include social security and disability pensions; health and rehabilitation services; general social benefits such as income support; and employment-related benefits, such as unemployment benefits and workers’ compensation. The work capacity or work ability assessment is the most prominent application of disability assessment, since being able to work is key to economic self-sufficiency and social standing. Historically, disability assessment, and especially work capacity assessment, has also been closely linked to medicine, for the source of criteria of assessment, and the medical profession for assessors and adjudicators of eligibility. Medical criteria—it is commonly believed—are objective and clear and medical professionals are socially respectable and reliable. Taken together, this meant that the medical professional made a good ‘gatekeeper’ to public benefits. But essential to understanding the challenges of disability assessment is the controversy over the concept of ‘disability’ itself. What is disability? Since roughly the 1970s on, it was common to speak about two ‘models’ of disability: The Medical Model of Disability and the Social Model of Disability. The Medical Model of Disability purportedly claimed that disability was essentially a medical problem located in an individual’s body that required a medical or rehabilitative response. This was contrasted to the Social Model of Disability that denied that disability was fundamentally a matter of the condition of a person’s body but was rather a social disadvantage experienced by an individual, a disadvantage created entirely by social, cultural and economic conditions and beliefs. In the last two decades or so these debates have resolved in favour of the consensus view that disability is a complex phenomenon that involves both biomedical features 111From Bickenbach B, Posarac A, Cieza A, Kostanjsek N (June 2015). Assessing Disability in Working Age Population - A Paradigm Shift: from Impairment and Functional Limitation to the Disability Approach. Report No: ACS14124, World Bank, Washington, D.C. 2015. 64 of a person’s body or mind and the impact of the overall, physical and social, environmental context in which the person carries out his or her life. This interactional view of disability is the dominant one today and the most common-sense one: disability clearly is not solely about how a person’s body functions, since two people can have exactly the same impairment while one experiences a severe disability and the other little or no disability because they live in very different contexts that make very different demands on them. On the other hand, disability is not just about these environmentally or socially created disadvantages, because the body and how it functions makes a difference as well. This interactional (or bio-psycho-social approach to disability) view of disability is at the heart of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF), formally endorsed by the World Health Assembly in 2001 and embraced in 2008 by the United Convention on the Rights of Persons with Disabilities (UNCRPD). The graphic presentation below illustrates this new understanding of disability and its implications for disability assessment. 65 66 67 68 The credibility of disability assessment The credibility and perceived legitimacy of a country’s disability assessment procedure depends on a few fundamental considerations. First, the assessments must be valid so there are no ‘false positives’ (people receiving benefits but are not disabled) or ‘false negatives’ (people who should be receiving benefits, but do not). Second, they must be reliable, in the sense that two assessors following the same rules and criteria, should come to the same assessment of the same person (often called ‘inter- rater reliability’). And third, the decisions must be transparent and standardized, so that the grounds for the decision-making are publicly known and their application in particular cases independently evaluated. In short, the legitimacy of the disability assessment process depends on it being, and be seen to be, impartial, fair and based on objective evidence. Nonetheless, depending on the social purposes and political objectives a policy or program is designed to serve, the criteria used for disability evaluation may extend beyond medical or even disability- relevant considerations to broader social considerations that may not be directly linked to the experience of disability. Historically, disability policy has been the most volatile and reactive to historical events (such as a dramatic increase in the number of returning war veterans with injuries who demand returning to their old jobs), demographic, economic and social factors. These forces have often dramatically changed the objectives of the policy, but without altering the social importance of securing accuracy in the assessment of disability. Models of disability assessment around the world Worldwide, strategies of disability assessment focus either on (i) health conditions and the impairments associated with them; (ii) functional limitations in basic or simple activities, understood independently of environmental or contextual differences; or (iii) disability fully understood as outcome of interactions between features intrinsic to the person (health conditions, impairments and functional limitations) and the full range of environmental factors that, possibly uniquely, characterize the overall lived-context of the individual. Each approach has its strengths and weaknesses. Impairment approach: Assessing work capacity, on this approach, is entirely a matter of measuring the severity of an underlying health condition and associated impairments. Although simple and straightforward, and by far the most common approach used worldwide, the Impairment approach has been strongly criticized both technically in terms of reliability and in terms of the underlying assumption that inferences from severity of impairments can validly be made to levels of work capacity, without in any way taking into account the impact that features of the work place 69 environment – how the job is structured, stress levels, the physical conditions, and the social and attitudinal conditions of employment. The interactional model, and evidence supporting it, strongly suggests that this approach is inadequate and distorts the assessment process. Functional Limitation approach: This approach arose in the 1970s in response to criticism of the Impairment strategy from rehabilitation professionals who argued that physical examination and medical history-taking are an insufficient evidentiary basis for assessing work disability. They argued that a person’s work capacity depended on the extent to which the person could perform very basic actions such as lifting, standing, walking, sitting, carrying, pushing, pulling, climbing, balancing, stooping, kneeling, crouching, crawling, reaching, handling, fingering, talking, feeling, hearing, and seeing. These ‘functional capacities’ were thought to be essential predictors of work capacity. To assess these capacities a range of Functional Capacity Evaluation (FCE) tools, mostly health condition specific, were developed and recommended for disability assessment. The Functional approach has been plagued with disappointing results in developing valid and reliable FCEs that have application, not only across health conditions, but internationally. There is also the concern that FCEs tend to focus on a person’s deficits—the capacities that the individual has lost— when it is commonly agreed a person’s physical and mental assets and strengths are equally important information for a work disability assessment. Finally, Functional approach suffers from the same problem as the Impairment approach: it only indirectly, by proxy, assesses work disability. Although both information about impairments and functional limitations in the performance of basic activities is essential for disability assessment, especially for work disability, equally important is information about the impact of the working environment on work disability. Disability approach: The Disability approach attempts to directly assess disability rather than indirectly infer disability from a proxy impairment or functional capacity assessments. Direct assessment, in principle, gives equal consideration to all determinants of disability—medical, functional, environmental and personal. The disability approach, in its purest form, would be fully individualized and based on direct evidence. It would strive to provide valid assessment directly on evidence, on the assumption that the true object of assessment must be the person-environment, interactive outcome rather than any intrinsic feature of the person (impairment or functional capacity). For many decades, although the Disability approach was acknowledged to be the theoretical optimal approach, it was argued that either the Impairment or the Functional Limitation approaches were preferable, because the very concept of ‘disability’ remained controversial and it was simply not practically feasible to collect and analyze information about the person (health condition, impairments, and functional limitations) and the person’s environment, in order to make a disability assessment. Because of the ICF, however, these objections can be overcome. Introduction to ICF In May 2001, the International Classification of Functioning, Disability and Health (ICF) of the WHO was endorsed by the World Health Assembly. The ICF provides a comprehensive and standardized framework and language for the description of Functioning and Disability. The ICF model is the clearest expression of the interactive model of disability about which there is worldwide consensus, as expressed by the World Health Assembly unanimous endorsement. As an international standard, the ICF provides separate classifications of the components of Functioning and Environmental Factors, each of which is composed of domains (chapters and blocks) and categories. Qualifiers are provided to describe the extent of the problems in Functioning, that is, the extent of Disability denoted by each domain and category variable. ‘Functioning’ in the ICF as an umbrella term including all aspects and dimensions of how human species function and act, from the concrete functions (and structures) of the human body and mind 70 to the variety of simple and complex actions that a person engages in. These simple and complex actions are conceptualized from the perspective of the intrinsic capacities of the person to perform actions (the perspective of Capacity), and in terms of the actual performance of these actions in interaction with the complete context in which the person lives (the perspective of Performance). Depending on the dimension of Functioning of interest, Disability is denoted as a matter of Impairments of Body Functions and Body Structures, Limitations in Activities and Restrictions in Participation. Functioning and Disability are thus overarching terms that identify these parallel dimensions. Although Functioning is conceptually linked to a health condition (a disease, disorder, injury or natural process such as aging), it is not a direct causal consequence but rather the overall experience of living with a health condition. The key issue is that Disability is created both by the underlying Health Condition and associated Impairments and by the lowered or raised levels of Capacity to perform Activities & Participation that result from Environmental Factors. Health state and environmental factors are therefore both determinants of Disability. Application of ICF to disability assessment There is a growing recognition that disability assessment should be based on the full, contextualized lived experience of health rather than merely on diagnosis, impairments or functional capacity evaluation. Increasingly, researchers and policymakers have turned to the ICF as a feasible design framework for reforming disability assessment procedures for social, health, and employment policy. The fact that ICF is a globally accepted, international standard classification generates three sources of added value in the application of the ICF as a design framework for disability assessment: ICF is an optimal data reporting structure: As ICF is a complete information collection structure, with an exhaustive and mutually exclusive list of domains of functioning, it offers the prospect of providing the full range and detail of information required for a complete disability assessment. Moreover, ICF not only coordinates existing data, it identifies informational gaps, in particular information about the work environment that, as has been shown, greatly enhances the validity and reliability of work disability determination. ICF is the basis for process legitimacy: Standardization of process, procedure and evidence is the administrative solution to challenges to legitimacy, and this is what the ICF can provide. Documentation of information in the language of ICF not only guarantees comparability, it also secures accountability. As the internationally accepted, scientific basis for describing the determinants and outcomes of functioning, disability and health, ICF is the optimal basis for making the case for the legitimacy of a disability assessment procedure. ICF is an international platform for assessment and measurement: Recent work on the development of ICF Core Sets and other breakthroughs in measurement strategies relying on ICF as an exhaustive, and consistent, classification of all domains of Functioning and Environmental Factors, have led to useable instrumentation with direct application to disability assessment. ICF and the paradigm shift in disability assessment The ICF can be seen as providing a profound paradigm shift in our understanding of the rationale for, and importance of disability assessment in the context of disability policy, worldwide. First, ICF makes it feasible to construct a complete functioning profile for the purposes of assessment, based not merely on what a person cannot do, but including their assets and strengths. Added to this is ICF’s capacity to systematically record the presence of environmental facilitators and barriers, and their impact on the person performance in his or her actual context, and ICF makes it possible to directly assess disability. 71 Second, ICF, for the first time, creates the conceptual and practical structure to predict disability trajectories over time in order to be able to flexibly respond to changing social circumstances. Predicting how disability plays out in a person’s life over time is not only beneficial for anticipating economic and social costs of disability, it also makes it possible to implement health and rehabilitation (including vocational) interventions that can, for example by building on a person’s assets and strengths, untouched by a chronic health condition, limit the overall impact of health problems. Essentially, it can help keep a person on the job, instead of leaving the labor market. With demographic ageing, it is becoming increasingly important to identify, and if possible, modify, ageing trajectories as individuals age into, or age with, chronic health conditions. Third, the fundamental ICF distinction between capacity and performance makes it possible to identify and target interventions that are key to programs such as return to work. An ICF-based disability assessment points us toward both sets of determinants of disability – intrinsic health conditions and impairments, on the one hand, and environmental factors on the other. Rehabilitation therapists have traditionally adopted this understanding of disability in their work, looking both at interventions that enhance a person’s capacity, and at ways of improving performance by means of environmental facilitators, from assistive technology to workplace modifications Finally, to complete the potential paradigm shift that ICF promises, an ICF-based design framework for disability assessment has clear social and ethical significance that reaches far beyond procedural and scientific adequacy. Specifically, the need for a complete—asset as well as deficit—profile and the requirement that information about the potential impact of environmental adjustment on improved performance, in the workplace and across all areas of social and personal life, are consistent with the human rights found in various Articles and provisions of the United Nations’ Convention on the Rights of Persons with Disabilities. The fundamental lesson that ICF teaches in the context of disability assessment is this: Ensuring equality of capacity across the citizenry is beyond human knowledge and ingenuity: people will always be intrinsically, and often irremediably, different in the health conditions they experience, their impairments and functional deficits and assets. People have different Functioning profiles and there is only so much humans can do medically and therapeutically to ‘equalize’ human capacity in general or work capacity in particular. Performance is a different matter. Although there are many practical reasons why achieving equalized work performance is also beyond our grasp, it is not an impossibility: the working environment, across the labor market, could in principle be made fully accessible to all workers, whatever their Functioning profile. If achieving this goal is unfeasible, striving for it is a plausible policy objective; indeed, according to the Convention on the Rights of Persons with Disabilities, it is a matter of basic human rights. Conclusion A design framework for disability assessment grounded in the model and classifications of the ICF provides the basis for realizing the Disability approach to disability assessment. The case for moving beyond the purely Impairment and Functional Limitation approaches to the Disability approach for disability assessment is clear and persuasive. There are strong procedural, conceptual and normative arguments for moving toward the Disability strategy. The ICF provides not only the conceptual and practical tools for implementing the Disability strategy, it does so on the basis of a globally accepted international standard. While there is no simple, one-size-fits-all ICF template that can transform a country’s disability assessment and evaluation procedures into those that implement the full Disability approach, the ICF provides the conceptual basis and standard language needed to design the required assessment instruments and documentation tools to bring this about. All that is required is the political will to move in what is clearly the scientifically and ethically proper direction in the reform of disability assessment. 72 ANNEX 2: Disability in Lithuania – Legal Framework Disability in Lithuania is regulated by a number of laws, starting with the Constitution, and by a large body of regulatory acts issued by government bodies and agencies responsible for the development of disability related policies and their implementation. Brief summaries of key acts as they relate to disability, are presented below. The Constitution of the Republic of Lithuania The Constitution ensures equal opportunities for all, protects human rights, guarantees medical treatment and financial benefits for persons with disabilities. The constitutional provisions comply with the requirements to protect and respect human honor and dignity, and prevent any discrimination, as it is established in the United Nations Convention on the Rights of People with Disabilities (hereinafter referred to as UNCRPD). In the Article 52, the Constitution stipulates: “The State shall guarantee its citizens the right to receive old-age and disability pensions, as well as social assistance in the event of unemployment, sickness, widowhood, the loss of the breadwinner, and in other cases provided by law.” It should be noted the term “disability pensions” is used just in translation, as in Lithuanian language the Constitution uses the term “invalidumo”. Terms “Invalidity” and “Invalid” (in Lithuanina “invalidas”) have been used in legal acts mostly until 2005. Since then, the terms have been changed to “disabled” persons and “person with disabilities”. While the Constitution does not mention directly persons with disabilities in other articles, their provisions pertain to them as well. The Law of the Republic of Lithuania on Social Integration of Persons with Disabilities The main law which pertains to disability is the Law of the Republic of Lithuania on Social Integration of Persons with Disabilities (hereinafter referred to as the Law on Social Integration). It came into force on July 1, 2005. Not only it defined new terms and definitions, it also modified the methods of disability assessment used for adults, as well as children, embedded equal rights and opportunities of persons with disabilities in the society and designated main institutions responsible for integration of persons with disabilities (Article 16). As per Article 16: (i) the Government of the Republic of Lithuania (GoL) sets the directions for the social integration policies; (ii) the Ministry of Social Security and Labor (MSSL) organizes, coordinates and monitors the implementation of the social integration policy for persons with disabilities; (iii) other government ministries, within their competences, also set relevant social integration policies for persons with disabilities and organize, coordinate and monitor their implementation; (iv) the Department of Disability Affairs under the MSSL organizes the implementation of social integration policy of persons with disabilities and participates in preparing reports on the implementation of the United Nation Convention on the Rights of Persons with Disabilities (UNCRPD); (v) the Disability and Working Capacity Assessment Office under MSSL (hereinafter – DWCAO), within its competences, participates in the development and implementation of social inclusion policies regarding disability, working capacity, vocational rehabilitation services, and special needs; (vi) municipalities carry out the activities of social integration of persons with disabilities, meeting their special needs, including carrying out the assessment of their individual independence in daily activities and providing general and special social services, and creating conditions for their integration into community; they also cooperate with disabled people organizations; (vii) associations of persons with disabilities represent their interests, assist in the implementation of the social integration policies, and organize delivery of 73 social rehabilitation services, recreation, sports, tourism, and cultural activities for disabled people, and participate in international cooperation. The Law on Social Integration consolidates major concepts regarding the system of disability policies and programs, disability assessment and integration of persons with disabilities into society. It also regulates who can be granted a status of a disabled person, which institutions participate in the assessment of disability and vocational rehabilitation and list the special needs. Some key definitions from the Law on Social Integration are provided below: Capacity for work: the ability of an individual to implement previously acquired professional competence or to acquire new professional competence or to perform work requiring lower professional competence. In the definition of working capacity, no age limitations are set. Disability: a long-term deterioration in health, reduced participation in the life of the community, and reduced functioning. Disability level: determined through a complex assessment of the degree of a loss of a person’s health, independence in daily activities and opportunities for education. Disabled person: a person who, according to the procedures established by this Law, has a disability or a working capacity level of 55 percent or less or required level of special needs. Special need: the need for special assistance due to a person’s congenital or acquired long-term medical conditions (disability or incapacity for work) and adverse environmental factors. Level of special needs: a reduction in autonomy of persons above retirement age. The law also sets different groups of disabled persons according to their age: disabled children (from birth till 18 years old; disabled adults (from 18 years (in some case of social insurance from 16 – working age) until retirement age (incapable or partially capable for work); persons with special needs (Article 20 stipulates that only persons at the retirement age can be granted the level of special needs. No age limitations are applied for persons, who apply for the assessment of level of working capacity due to an accident at work, on the way to or from work, or due to an occupational disease (Article 20). DWCAO decides on (Article 18): i. the level/severity of disability, the time of its occurrence and its duration, ii. the level of working capacity (i.e. percentage of incapacity for work), its cause(s), time of occurrence and duration, iii. the need for vocational rehabilitation services for working age individuals (16 years of age until mandatory retirement) and have been covered by state social insurance, iv. conclusions regarding the nature and needed conditions for a person with limited working capacity to work, v. special needs: permanent care, special care (assistance), the need for reimbursement of the costs of the purchase of a special car and its technical adaptation, iv. the level of special needs and its duration. Prior to 2005, a medical model was used to assess disability. The Law on Social Integration introduced the assessment of functioning along with medical conditions. The only exceptions, when working capacity is assessed just by medical criteria are: professional diseases, accidents at work, extremely severe health conditions (with the provision that in these cases, a person has the right to ask to be 74 assesses using a functioning criteria, as well), and in the case of young people until the age of 26, provided that they are still studying112. Reflecting on the exceptions above, it is hard to explain them. The purpose of the assessment of functioning is to assess, as objectively as possible, how a person with a health condition, experiences disability in her/his everyday life, in other words, to assess a lived experience of disability. In that sense, there is no reason to make exceptions. Quite the contrary. The criteria and procedures for determining the level of working capacity are determined by the Minister for Social Security and Labor together with the Minister for Health (Article 20). Article 20 establishes that working capacity is determined by assessing the state of health of an individual and her/ his ability to perform the current qualification, to obtain new qualifications, or engage in jobs that do not require professional qualifications, after having exhausted all available medical and vocational rehabilitation and special assistance measures. The Law stipulates that the level of working capacity is determined on the basis of documents submitted by the physician who treats the person and vocational rehabilitation and other specialists. However, this provision is yet to be implemented, as DWCAO is not submitted any information about individuals’ abilities to perform professional qualifications. The person whose working capacity is assessed and/or his/her representative has the right to participate in the determination of the working capacity. Article 20 stipulates options for the duration of working capacity: 6 months, one year, two years, until retirement age, and for life (for professional diseases and injuries at work). Articles 21 and 22 regulate vocational rehabilitation. DWCAO decides on the vocational rehabilitation following the criteria set by the Minister of SSL. Vocational rehabilitation is defined as rehabilitation or improvement of the individual’s capacity for work, professional competence and ability to participate in the labor market by using educational, social, and psychological rehabilitation and other measures. Vocational rehabilitation services include: professional guidance, counselling, assessment, rehabilitation or development of professional skills, re-qualification. The Law provides for a vocational rehabilitation benefit that is paid monthly from the first day of participation in the vocational rehabilitation program for a maximum of 180 calendar days. This benefit is granted and paid regardless of any other income the person receives. In practice, it is one of the most significant motivators for persons to attend vocational rehabilitation. Articles 24-28 regulate special needs as they pertain to domestic and private life, education, work, and social life. These needs are grouped as follows: a) technical support; b) financial assistance; and c) social services. To respond to special needs, the Law provides for the following: sign language interpretation, assistive devices, assistants, guides, housing adaptation, transportation, information and consulting, assistance at home, care homes, assistance benefits, meals, provision of necessities, etc. The Law on Equal Opportunities of the Republic of Lithuania This Law establishes the legal basis and powers of the Equal Opportunities Ombudsman and the Disability Rights Monitoring Commission under the Office of the Equal Opportunities Ombudsman, as well as the filing and investigation of complaints. The aim of this law is to ensure the monitoring and control of the implementation of the UNCRPD in Lithuania. Article 7 sets the obligation for the employer to take appropriate measures to facilitate access for persons with disabilities to work, career 112Paragraph 23 of the Order of the Minister of Social Security and Labor of the Republic of Lithuania and the Minister of Health of the Republic of Lithuania Nr. A1-78 / V-179: Approval of the Procedure for the Assessment of Working Capacity, https://www.e-tar.lt/portal/lt/legalAct/TAR.D1F619C285A0/asr 75 progression or education, including appropriate accommodation. The law forbids any form of discrimination and sets procedures for complaints. The Law on Social Assistance of the Republic of Lithuania The Lithuanian social protection system is comprised of: • Contributory Social Insurance System, • Non-contributory Social Assistance System, which consists of two main parts: financial assistance and social services. Social assistance is financed from the state or municipal budgets, • Supplementary social benefits for specific groups of the population for their extraordinary merits or injuries under special conditions. These are financed from the state budget. The Law on Social Assistance provides for monthly cash benefits (‘social pensions’) that guarantee minimum income to persons who meet stipulated conditions in cases of disability, old age, and survivorship, and provided that they are not covered by contributory social security system. These benefits are funded from the state budget. The Law on State Social Insurance Pensions of the Republic of Lithuania This law regulates benefits from the contributory social security system, namely contributory old age, disability and survivorship pensions. Regarding social insurance disability pension, it is a regular monthly payment granted to a person who has her/his working capacity established according to the provisions of the Law on Social Integration and meets minimum required length of employment service. This Law also recognizes the social insurance disability old-age pension – an old-age pension paid to a person who reaches mandatory retirement age while receiving disability social insurance pension. The Law stipulates that when a person receiving disability social insurance pension reaches mandatory retirement age, she/ he can choose between a disability or old-age pension – whichever is higher. Disability social insurance pension is not an obstacle for persons with disabilities to continue working. This is a positive feature of the Lithuanian disability policy: a person may continue working in the same job and progress in her/ his career, while receiving disability social insurance pension on the basis of her/ his reduced working capacity. To be eligible for a social insurance disability pension, a person Article 25 sets the range of working capacity, which may be granted a social insurance disability pension, a person should have lost at least 45 percent of working capacity (Article 25). Special conditions are envisaged for persons with dwarfism. The Law also regulates survivorship disability social insurance pension. The Law on State Social Insurance of the Republic of Lithuania The Law on State Social insurance of the Republic of Lithuania (hereinafter referred to as the SSI Law) establishes the basics of the social insurance system: types of state social insurance, categories of persons insured by state social insurance, principles and structure of the social insurance management system, rights, duties and responsibilities of participants, recovery of overpayments and the procedure for appealing against actions (inaction) and decisions of the administrative bodies of the State Social Insurance Fund (SSIF). The SSI Law focuses on sick leave, maternity benefits and unemployment benefits. The Law specifically mentions persons with disabilities in several instances. For example, individuals providing permanent care for disabled individuals are covered by state pension and unemployment 76 social insurance; persons with disabilities are freed from the obligation to contribute to social insurance, etc. The Law also authorizes SSIF to review decisions of DWCAO and to apply for the re-evaluation of the assessed capacity for work. Article 341 describes in detail the monitoring mechanism. DWCAO functions and authority per se are mainly set in bylaws. Law on Transport Subsidies of the Republic of Lithuania This Law defines categories of persons to whom passenger transport allowances are granted, the types of allowances, the reimbursement of passenger transport expenses and the procedures and sources of reimbursement. The ticket discount depends on the severity of disability. The Law on Social Services of the Republic of Lithuania This Law defines the concept, objectives and types of social services, regulates eligibility requirements and how services are allocated to beneficiaries, as well as management of services and licensing, financing, payment for social services and the settlement of disputes related to social services. Government bodies responsible for social services are: The Ministry of Social Security and Labor; municipalities; and The Department of Social Services Supervision under MSSL. The Law defines that the aim of social services is to create conditions for a person (family) to develop or to enhance the abilities and possibilities to independently solve his/her social problems, maintain social relations with the society, and overcome social exclusion. Social services provide assistance to a person (family) who, by reason of age, disability or social problems, partially or completely lacks, has not acquired or has lost the abilities or possibilities to independently perform private (family) life and participate in society. The main guiding principles in the provision of social services are co-operation, participation, complexity, accessibility, social justice, relevance, efficiency and comprehensiveness. The Law recognizes 2 groups of social services: i. basic (information, consultancy, mediation and representation, socio-cultural services, organization of transport, catering, providing basic clothing and footwear, other services) and ii. special (social care and social guardianship and permanent assistance of specialists and may be daily, short term and long term). However, social services are not linked to disability assessment, people with disabilities need to seek social services themselves and to prove that they need them (i.e. undergo a separate assessment). The Law thrust is a focus on family support and it thus provides for social services at home, as well as for a short-term/ temporary placement for elderly and disabled persons in institutional care. Currently, more than 6,000 people with disabilities reside in “centralized” institutional care. These residential care institutions are managed by MSSL. They are legacy of the previous system focus on institutional care. The government is committed to deinstitutionalization of care, but the process has been slow, reflecting challenges of deinstitutionalization that critically depends on the development of a robust system of community-based care services, which takes time and resources. The Labor Code of the Republic of Lithuania The Labor Code of the Republic of Lithuania (hereinafter referred to as the Labor Code) regulates the individual labor relations which arise upon the signing of an employment contract. It also regulates pre-employment, post-employment, collective agreements, labor disputes, grievance redress, etc. With regards to people with disabilities, the Labor Code considers them part of the labor force, with few distinct provisions. Article 57 protects employees from dismissal in cases when they care for a disabled child until the age of 18, for family members with less than fifty-five percent working capacity, 77 elderly, or members with a significant level of special needs. These employees should be given a priority to stay at work. These, as well as employees with disability should have an opportunity for a part time workday or a part time work week upon request (Article 40). The Labor Code sets a 20-working day annual holiday term for all employees (Article 126). The Law on Civil Service of the Republic of Lithuania sets a 22 working day annual holiday; 27 working days in the case of a disabled employee or the one who rises a disabled child. The Law of the Republic of Lithuania on Safety and Health at Work The purpose of this Law is to establish: legal provisions and requirements to protect or reduce employees’ occupational risks; general provisions for the assessment of occupational risk, the investigation of accidents at work and occupational diseases; the health and safety requirements applicable to persons under eighteen years of age, pregnant workers, workers who have recently given birth, breastfeeding mothers and persons with disabilities. Article 21 stipulates mandatory medical examination when a person with disabilities is employed and also when working conditions change. Article 33 lists duties of employees, with specific provisions for persons with disabilities. They have an obligation to submit the findings and conclusions of DWCAO to the employer, so that employer would accommodate the needs of such a person. Article 38 establishes that the conclusion of the health care institution regarding the disabled person’s abilities to perform a specific work is binding for the employer and the employee. It is also stated that disabled persons may be appointed to work overtime, to work at night shift, and to stand on duty only with their own consent and if their health care provider does not restrict it. The Law on Compensation for Accidents at Work or Occupational Diseases This law regulates procedures, amount of benefits and persons entitled to compensation because of accidents at work or occupational diseases. Articles 12 and 13 define that a person who has lost less than 30 percent of working capacity due to an injury at work or occupational disease is entitled to a lump sum payment; those who have lost 30 or more percent are entitled to a regular payment. Working capacity loss is assessed by DWCAO and the benefits are payed either by an employer or SSIF. Article 20 sets that where compensation is paid by employers its calculation and payment is controlled by the State Labor Inspectorate (SLI). Where it is paid by the territorial offices of SSIF, the SSIF controls its calculation and payment. Detailed procedure for working capacity assessment is regulated by a bylaw, namely The Order by Minister of Social Security and Labor of the Republic of Lithuania and Minister of Health of the Republic of Lithuania No. A1-1/V-2. The Law on Unemployment Insurance of the Republic of Lithuania The Law on Unemployment Social Insurance of the Republic of Lithuania establishes the system of unemployment social insurance, categories of persons covered by it, entitlements and eligibility conditions, the terms and conditions of payment, financing, administration, and liability of persons whose benefits have been wrongly calculated and paid. Article 13 sets the rule that persons with disabilities who are entitled to a disability pension due to their loss of working capacity can be entitled only a part of the unemployment insurance benefit that exceeds the amount of their pension. The Employment Law of the Republic of Lithuania This Law regulates employment relations and terms including main forms of employment, legal basis of employment support system for job seekers, its purposes, tasks, functions of entities implementing 78 employment support policy, organization and financing of the provision of labor market services and employment support measures, irregularities in employment, undeclared work and undeclared individual work. Article 12 names labor market services and employment support measures: 1) registration of vacancies and jobseekers; 2) information; 3) counseling; 4) assessment of employability; 5) recruitment mediation; and 6) planning individual employment activities. Employment support measures include: 1) active labor market policies (these are: learning support; support for mobility; sponsored recruitment – subsidies for employer; support for jobs creation); 2) programs to increase employment. Article 16 designates the Employment Service to be responsible for the organization and coordination of the vocational rehabilitation services for people with disabilities. Article 25 defines that people with disabilities who are unemployed, are of a working age and whose working capacity is 55 percent or less are entitled to additional support in the labor market. This includes subsidized employment, which is provided to: 1) persons with disabilities with up to 40 percent of capacity for work (severe or medium level of disability), in order to help them remain in the labor market, and 2) persons with disabilities with 45 – 55 percent of working capacity (mild level of disability), to help them consolidate their position in the labor market. Employers who recruit persons with disabilities receive a subsidy for disabled employees’ salary and related social insurance contributions. The amount of subsidy cannot exceed 1.5 minimum monthly wage and is calculated as a percentage of the salary plus social insurance contribution paid by the employer in the following way: • 75 percent for up to 25 percent working capacity or severe level of disability, • 60 percent in the case of 30–40 percent of working capacity or a medium level of disability, • 50 percent in the case of 45–55 percent of working capacity or a mild level of disability. Article 41 describes conditions for working place adaptation subsidy for a disabled employee. Also, the Law envisages subsidized job creation for persons with disabilities. The subsidy is capped at 31.03 minimum monthly wages. Employers bear 20 or 30 percent of the job creation cost, depending on the severity of disability oh the individual for whom the job is created and must maintain the job for no less than 36 months from the recruitment of individuals referred by the territorial labor exchanges. If disabled individuals whose working capacity does not exceed 40 percent (severe or medium level of disability) want to start their own business, the support for independent employment is provided. This support cannot exceed 31.03 minimum monthly wages as approved by the Government. Article 50 identifies that labor market services and employment support measures are financed from the State and municipal budgets, European Union structural and other funds and sources. The Law on Social Enterprises of the Republic of Lithuania This Law establishes the rights and obligations of legal persons having a status of a social enterprise. Article 3 defines the social enterprise and also notes that enterprises established by persons with disabilities are also a social enterprise, but not every social enterprise is an enterprise of disabled persons. Social enterprise should comply with the following requirements: employees belonging to a target group should constitute at least 40 percent of the annual average number of listed employees and the number of employees belonging to the target group should not be less than four. In the case of a social enterprise of persons with disabilities, disabled persons should make at least 50 per cent of its annual average number of employees. When employees are persons with severe or moderate disability level or with working capacity of 40 percent or with high or medium level of special needs, then they should account for at least 40 percent of the annual average number of listed 79 workers; the number of such employees should not be less than four. The average annual employee count should include disabled workers who work at least 80 hours a month. Article 13 establishes types of state aid to social enterprises: 1) a subsidy for wages and state social insurance contributions; 2) a subsidy for the creation of jobs and purchase of equipment for disabled workers; 3) a subsidy for the adaptation of workplaces and work equipment for disabled workers; 4) a subsidy for training targeted workers; 5) a subsidy for the adaptation of the working environment, and production and recreation facilities; 6) a subsidy for administrative expenses; 7) a subsidy for transport costs; 8) a subsidy for assistant expenses. The Law on Personal Income Tax of the Republic of Lithuania Article 20 of this law sets personal income tax-exemptions for people with disabilities. The exemption varies, depending on the severity of disability. The Law on Municipality of the Republic of Lithuania According to this law, municipalities are responsible to create conditions for social integration of persons with disability residing on their territory. They should develop and carry out local programs for social integration of persons with disabilities, including organizing and providing general and specific social services to meet special needs and for facilitating social integration of persons with disabilities. Also, they should cooperate with associations of persons with disabilities. The Law on Construction of the Republic of Lithuania This law regulates architectural requirements for structures under construction, reconstruction, repair and demolition, as well as requirements for the protection of the interests of third parties, etc. Article 6 sets, that buildings and civil engineering structures shall be adapted to special needs of persons with disabilities. The Law of the Republic of Lithuania on Assistance for Buying or Renting Homes The purpose of this Law is to establish principles, sources of financing, forms, rights and obligations of persons receiving support for buying or renting homes, as well as the conditions and procedure for social housing and municipal housing rent and sale of municipal housing. Article 2 stipulates that a person who, according to the procedure established by the Law on Social Integration, has a severe or average disability level or 40 percent or less working capacity, or a person who has reached retirement age and has a special needs level is eligible to benefit from the provisions of the Law. The Law on the Family Card of the Republic of Lithuania This law enables families with 3 or more children, those with a child with disabilities and those with a disabled family member whose assessed working capacity is 55 percent or less to benefit from discounts in various spheres of daily, social, cultural life by using the issued Family card. Resolution of the Government of the Republic of Lithuania No. 413 On Approving the Regulation on Granting and Payment of the Allowance for Vocational Rehabilitation Vocational Rehabilitation Allowance is granted and pad to persons permanently residing in Lithuania who have been granted vocational rehabilitation need by DWCAO. It is paid for the duration of a 80 person’s participation in a Vocational Rehabilitation Program provided by the Employment Service under MSSL. It is capped at 180 calendar days and financed by the state budget. Resolution of the Government of the Republic of Lithuania No. 831 On Approving the Procedure for Financial Aid Measures to Disabled Students in Higher Education Institutions This resolution determines financial aid measures, amounts of benefits and students eligible to receive them (with severe or moderate disability or working capacity of 45 percent and less). Order of the Minister of Social Security and Labor of the Republic of Lithuania No. A1-93 On Approving the Catalog of Social Services The catalog sets the types of social services and describes them by definition, purpose, recipients, place of delivery, duration / frequency of service provision, service providers, etc. The services are codified, and the code is used in the electronic information system of social support for the family and the types of social service institutions. Order of the Minister of Social Security and Labor of the Republic of Lithuania No. A1-103 On Approving Description for the Procedure for the Adaptation of Housing for Persons with Disabilities Persons with disabilities are eligible for housing accommodation once in ten years, provided that they comply with at least one of the following: have been determined a special need for permanent care, a special need for any type of a wheelchair; a special need for mobility technical aids (walkers, crutches, etc.); and a special need for permanent care (assistance) of first level due to mental disability (paragraph 4). The main administrative body for organizing and implementing housing adaptation are municipal administrations and their housing commissions. Housing adaptation is financed from the national and municipal budgets. When disability is assessed, the need for housing adaptation is not determined, which makes people with disabilities often unaware of this benefit. Order of the Minister of Social Security and Labor of the Republic of Lithuania No. A1-302 on Description of the Criteria for Determining the Need for Vocational Rehabilitation Services and Approval of the Rules for Provision and Financing of Vocational Rehabilitation Services This order defines criteria for determining the need for vocational rehabilitation services for persons who have applied to the Employment Service and DWCAO. Therefore, both Employment Service, when making a decision to provide individuals with determined working capacity with vocational rehabilitation, and DWCAO when determining a need for vocational rehabilitation are obligated to follow the criteria. Order of the Minister of Social Security and Labor of the Republic of Lithuania No. A1-98 on Approval of the Procedure for Payment of Disability Benefits This order determines payments from the State budget for people with disabilities who are assessed as incapable for work and in whose family nobody works. These allowances are subsidies for utilities and fuel expenses and could be used to pay utility bills, electricity, telephone and fuel purchases. 81 Order of the Minister of Social Security and Labor of the Republic of Lithuania and the Minister of Health of the Republic of Lithuania No. A1-78 / V-179 on Approval of Criteria for Determining Working Capacity and the Procedure for the Assessment of Working Capacity Article 20 of the law on Social integration stipulates that criteria and procedure for working capacity assessment should be determined by the Minister for SSI jointly with the Minister for Health. Therefore, this Order is the main bylaw which regulates the assessment of working capacity, including the percentage of working incapacity assigned to a concrete disease, coefficients applied for the second and other diseases, scores for psycho-social questionnaires, etc. This Order comprises 2 separate documents regulating (i) criteria for determining working capacity and (ii) procedure for it. Criteria defines the content of a disability assessment: medical criteria (percentage values for concrete diseases) and social criteria (questionnaires, score values), and sets the rules of their application as well as determines various coefficients. Procedure regulates step by step administrative process as it relates to working capacity assessment: from registration and submission of documents needed for determination of working capacity, to the final decision, as well grievance redress procedure. The procedure consists of examination of medical documents and filling in a questionnaire to assess psycho-social wellbeing. The analysis of medical documents allows to choose the appropriate medical criterion, if there is one. Otherwise, the procedure is aborted and working capacity is not assessed – the base of evaluation of working capacity is a health condition – medical diagnosis. In 2019 the Order was amended (paragraph 17.1) and stipulates that for persons who are granted disability status, as well as for those assessed as having a special need, a recommendation on the need for assistance is issued. The implementation of this rule would require that relevant services amend their own rules to reflect the recommendations. Order of the Minister of Social Security and Labor, the Minister of Health and the Minister of Education and Science of the Republic of Lithuania No. V-188/A1-84/ISAK-487 on Approval of Criteria and Procedure for Determining the Level of Disability This order regulates the assessment of disability level in children: medical criteria, assessment instruments, coefficients, procedures and other requirements. There are 4 different instruments/ questionnaires according to the child’s age; however, until the age of 4 disability level is assessed based on medical criteria. In addition to activity and participation questionnaire, which is filled by DWCAO assessor during the interview with parents, a questionnaire for special education needs may be submitted from the pre-school or school – a disability coefficient is also applied in this case. The procedure consists of examination of medical documentation and filling in a questionnaire. The former serves to choose an appropriate medical criterion, if there is one. Otherwise, the procedure ceases and a disability level is not assessed, because the base for evaluation is a health condition – medical diagnosis. The attendance of parents in the evaluation is necessary. They provide information needed to fill in the questionnaire. There are 3 levels of children disability: severe, medium and mild. DWCAO must decide during 15 working days. As medical criteria differ between adults and children, there are frequent disputes when child benefits are lost when a disabled child transition into adulthood. Moreover, according to working capacity assessment procedure (as noticed above), working capacity for students until the age of 26 is assessed based on medical criteria only, even when a disability level until the age of 18 is assessed taking into 82 account a psycho-social/ functioning information as well. This inconsistency in regulation would need to be addressed. Order of the Minister of Social Security and Labor and the Minister of Health of the Republic of Lithuania No. A1-765/V-1530 on Approval of the Procedure for Determining the Requirements for the Compensation of Expenses for the Special Permanent Care, Special Permanent Care (Assistance), Special Car and its Technical Adaptation This order empowers DWCAO to determine special need and related procedure for their determination. Different assessment procedures are applied for children, working age adults and people of retirement age. The procedure comprises examination of medical documentation and filling in a psycho-social questionnaire. The analysis of medical documentations serves to determine a medical criterion. If no medical criterion is established, the procedure is aborted, and special needs are not assessed – the base of evaluation of special needs is a health condition – medical diagnosis. In practice, special needs of children and working age adults are assessed during the assessment of disability or working capacity assessment. The same questionnaires are used for determining a psycho-social coefficient as for the disability or working capacity assessment (paragraphs 16, 17). For people of retirement age, the questionnaire is filled in by a municipal employee. DWCAO must make a decision during 20 working days. There are 4 species of special needs: special permanent care, special permanent care (assistance); reimbursement of the costs of the purchase and technical adaptation of a special car. Special permanent care and special permanent care (assistance) can be either level one or level two where level one pertains to a more severe disability and greater need for assistance. Order of the Minister of Social Security and Labor of the Republic of Lithuania No. A1-563 on Approval of the Procedure for Determining the Special Needs Level for Retirement Age Persons This procedure establishes that DWCAO assesses special needs of a person of retirement age and decides on the level of special needs. The Law on Social integration (Article 10) provides for 3 levels of special needs: 1) high level of special needs in the case when they are determined as level one or two permanent care special need; 2) average level of special needs, when a person is determined as a first level permanent care (assistance) need; and 3) minor level of special needs, which is determined for persons with level 2 permanent care (assistance). Persons, who are determined to have a special need for special car and its technical adaptation are not entitled for any level of special needs. However, the paragraph 13 sets the exceptions for the ones, who have not applied to the municipality for determination of the level of special needs until 2018- 12-31 (the date when DWCAO was empowered to make decisions on the level of special needs – before, the municipalities were in response): 1) the level of high special needs where a special need for permanent care or a need for permanent care (assistance) is identified; 2) the average level of special needs where the special need for reimbursement of the costs of purchasing and maintaining the passenger car is identified; 3) the level of minor special needs where the special need for reimbursement of transport costs is identified. This regulation creates an unequal position for persons of the same health impairments and age depending just on the time of application to DWCAO. 83 Order of the Minister of Social Security and Labor of the Republic of Lithuania and the Minister of Health of the Republic of Lithuania No. A1-1 / V-2 on Approval of Rules for Determining the Level of Incapacity for Work in Respect of Accidents at Work or the Consequences of Occupational Diseases Working incapacity due to accidents at work or occupational diseases is assessed based on medical criteria only. In the case of accidents, the incapacity is assessed for each accident separately, and if a person experiences more than one accident at work over his work life, incapacity will be assessed for each accident. Similar provision exists for occupational diseases, although in practice most individuals experience one occupational disease and, thus, the assessment is normally conducted only once. The assessment procedure is the same as in the case of general illness related incapacity for work assessment; the only difference is that the psychosocial questionnaire is not administered. In addition to medical documentation, a person undergoing assessment is required to provide an Occupational Disease Investigation and Approval Act/ an Act of an Accident at Work. There is no age limit for a person to be assessed for working incapacity because of an accident at work or occupational disease. The duration of incapacity could be half year, year, 2 years, and for life. DWCAO director's orders The director of DWCAO is empowered to issue regulatory acts pertaining to disability assessment. The main director’s orders concerning disability assessment are: a. Order of DWCAO director No. V-110 on the Determination of Assessment Procedure of the Level of Disability, Working Capacity, Special Needs and Vocational Rehabilitation Services in the Territorial Division of DWCAO This order sets step by step procedures for the assessment. It also requires that civil servants and employees of territorial units who determine the level of disability, working capacity, special needs, special needs level and need for vocational rehabilitation services must be of impeccable reputation, have a higher education in biomedical or social sciences and must sign declarations of impartiality and confidentiality. Assessment procedures described in detail as follows: acceptance and verification of submitted documents; registration and flow of submitted documents; appointing assessors; assessment of disability and decision making; assessment of vocational rehabilitation and decision making; closing the case and archiving it; and appeals. b. Order of DWCAO director No. V-13 on the Determination of Assessment Procedure of the Level of Disability, Working Capacity, Special Needs and Vocational Rehabilitation Services in the Decision Control Division This order regulates the appeal procedures as well as the enforcement of the decisions made by the Dispute Commission under MSSL and courts. The person that is not satisfied with the assessment decision, as well as the institution which is supposed to pay the benefits may appeal. In these cases, the assessment process is conducted anew. The attendance of the person or the institution is not necessary, but in cases when the institution appeals, the Decision control division must invite both – the person and the institution to attend the hearing. During the investigation of appeal new documents or evidence may be provided; questionnaires may be repeated. Decisions options are as follows: not to change the decision of DWACAO’s territorial division; not to change the decision, but to correct a technical error, modify the conclusion regarding the nature and conditions for work; change the decision of the territorial division; make a new decision based on new data that has had a significant impact on the decision. If the petitioner is not the person whose disability was assessed, nor the institution obligated to pay the benefits, the appeal is proceeded through the Control Procedure. 84 c. Order of DWCAO director No. V-10 on the Determination of Control Procedure of Decisions Made by DWCAO Territorial Divisions This Order regulates control, which is carried out by the Decision Control Division. There are 2 types of control: planned (a plan is drawn up at the beginning of the year, taking into account the results of the preceding years) and unplanned (organized on the basis of anonymous complaints, appraisal discrepancies, number of changed decisions of territorial divisions). The objective is to minimize fraud and corruption and apply as much as possible preventive measures against unlawful, low-quality decisions. d. Order of DWCAO director No. V-43 on Approval of the Procedure of Referral to Third Level Health Care Institutions or Independent Experts and Other Specialists and the Payment for Their Services This procedure allows DWCAO to engage external assessors when needed and to refer applicants to additional examination. e. Order of DWCAO director No. V-11 on Approval of Methodological Recommendations for the Determination of the Permanent Care, Permanent Care (Assistance) and Special Car and its Technical Adaptation for Special Needs There are many methodological recommendations and this one is provided as an example – it provides methodological guidance to assessors on how to conduct the psycho-social interview. Other methodical recommendations explain the assessment criteria, special cases, diseases, etc. These methodological guidance documents are very popular internal documents as they help assessors do their job and also to equalize the practice of assessment across DWACAO offices. Municipal acts related to disability There are 60 municipalities in Lithuania and territorial division is based on the principles of decentralization. Duties and powers of municipalities are briefly described above as regulated by The Law on Municipality of the Republic of Lithuania. According to this Law, municipalities are obliged to create conditions for social integration of persons with disabilities residing on their territory. Accordingly, municipalities issue numerous acts to implement national laws and ministerial orders. Examples of municipal orders: • Order of the Director of Palanga City Municipality Administration No. A1-541 on Housing Adaptation for People with Disabilities specifies in detail how the Order of the Minister for SSL Nr. A1-103: Approval of the Description of the Procedure for the Adaptation of the Housing for Persons with Disabilities is going to be implemented in municipality. • Order of the Director of Šilutė District Municipality Administration No. A1-996 On the Description of the Procedure for the Organization and Provision of Personal Assistant Services in Šilutė District Municipality establishes criteria for assessing the need for personal assistant services for persons with physical and/or complex disabilities in the implementation of the pilot project; • Order of the Director of Alytus District Municipality Administration No. D1-248 Approval of the Description of the Procedures for Organizing an Employment Promotion Program for the Selection of Employers: regulates conditions and procedure for the organization of the implementation of the Employment Growth Program and its financing. 85 ANNEX 3: List of legal acts pertaining to disability with active links 1 The Constitution of the Republic of https://www.e-tar.lt/portal/lt/legalAct/TAR.47BB952431DA/asr Lithuania 2 Law on Equal Opportunities of the https://www.e- Republic of Lithuania tar.lt/portal/lt/legalAct/TAR.0CC6CB2A9E42/iIhuBawnsA 3 The Law of the Republic of https://www.e- Lithuania on Social Integration of tar.lt/portal/lt/legalAct/TAR.199156E4E004/cWWgldtkIu Persons with Disabilities 4 Law on Social Assistance Pensions https://www.e- of the Republic of Lithuania tar.lt/portal/lt/legalAct/TAR.2CE6CFE9E2EE/djrYRKXgRc 5 Law on Social Insurance Pensions of https://www.e- the Republic of Lithuania tar.lt/portal/lt/legalAct/TAR.A7F77DF94F5D/MmAdMhouCq 6 Law on State Social insurance of https://www.e- the Republic of Lithuania tar.lt/portal/lt/legalAct/TAR.0F9036415DBD/SerhhpiDiF 7 Law on Transport Subsidies of the https://www.e-tar.lt/portal/lt/legalAct/TAR.033D686E8F1B/asr Republic of Lithuania 8 Law on Social Services of the https://www.e-tar.lt/portal/lt/legalAct/TAR.91609F53E29E/asr Republic of Lithuania 9 Labor Code of the Republic of https://www.e- Lithuania tar.lt/portal/lt/legalAct/f6d686707e7011e6b969d7ae07280e89/asr 10 Law on Civil Service of the Republic https://www.e-tar.lt/portal/lt/legalAct/TAR.D3ED3792F52B/asr of Lithuania 11 Law of the Republic of Lithuania on https://www.e-tar.lt/portal/lt/legalAct/TAR.95C79D036AA4/asr Safety and Health at Work 12 Temporary Law on Compensation https://www.e- for Accidents at Work or tar.lt/portal/lt/legalAct/TAR.AB0E44DE47D8/pyGNqZSYwO Occupational Diseases 13 Law on Unemployment Insurance https://www.e- of the Republic of Lithuania tar.lt/portal/lt/legalAct/TAR.FDF42614DE52/GvtibHnMPm 14 Employment Law of the Republic of https://www.e- Lithuania tar.lt/portal/lt/legalAct/422c8b5042b811e6a8ae9e1795984391/YM FgYWKTVP 15 Law on Social Enterprises of the https://www.e- Republic of Lithuania tar.lt/portal/lt/legalAct/TAR.EEC13A0B85BA/zXCvVywnNx 16 Law on Personal Income Tax of the https://www.e-tar.lt/portal/lt/legalAct/TAR.C677663D2202/asr Republic of Lithuania 17 Law on Municipality of the Republic https://www.e-tar.lt/portal/lt/legalAct/TAR.D0CD0966D67F/asr of Lithuania 18 Law on Construction of the https://www.e-tar.lt/portal/lt/legalAct/TAR.F31E79DEC55D/asr Republic of Lithuania 19 Law of the Republic of Lithuania on https://www.e- Assistance for Buying or Renting tar.lt/portal/lt/legalAct/e944ee00600111e4bad5c03f56793630/asr Homes 20 Law on the Family Card of the https://www.e- Republic of Lithuania tar.lt/portal/lt/legalAct/b17d5a5084cb11e8ae2bfd1913d66d57 21 Resolution of the Government of https://www.e-tar.lt/portal/lt/legalAct/TAR.12CA4299A3C7/asr the Republic of Lithuania On Approval of the Regulation of Granting and Paying the Allowance for Vocational Rehabilitation 22 Resolution of the Government of https://www.e-tar.lt/portal/lt/legalAct/TAR.66E0CE6AE556/asr the Republic of Lithuania No. 831 On Approval of the Procedure for Financial Aid Measures to Disabled Students in Higher Education Institutions 86 23 Order of the Minister of Social https://www.e-tar.lt/portal/lt/legalAct/TAR.51F78AE58AC5/asr Security and Labor of the Republic of Lithuania No. A1-93 on Approval of the Catalog of Social Services 24 Order of the Minister of Social https://www.e- Security and Labor of the Republic tar.lt/portal/lt/legalAct/25069bc035df11e99595d005d42b863e/asr of Lithuania No. A1-103 on Approval of the Description of the Procedure for the Adaptation of the Housing for Disabled People 25 Order of the Minister of Social https://www.e- Security and Labor of the Republic tar.lt/portal/lt/legalAct/TAR.C0890374F8E9/RdArsAbCGJ of Lithuania No. A1-302 on Description of the Criteria for Determining the Need for Vocational Rehabilitation Services and Approval of the Rules for Provision and Financing of Vocational Rehabilitation Services 26 Order of the Minister of Social https://www.e-tar.lt/portal/lt/legalAct/TAR.A2B2F7F5372F/asr Security and Labor of the Republic of Lithuania No. A1-98 on Approval of the Procedure for Payment of Disability Benefits 27 Order of the Minister of Social https://www.e-tar.lt/portal/lt/legalAct/TAR.D1F619C285A0/asr Security and Labor of the Republic of Lithuania and the Minister of Health of the Republic of Lithuania No. A1-78 / V-179 on Approval of Criteria of Working Capacity and the Procedure for the Assessment of Working Capacity 28 Order of the Minister of Social https://www.e- Security and Labor of the Republic tar.lt/portal/lt/legalAct/TAR.95F9283BB46A/gOVaaGAwWa of Lithuania and the Minister of Health of the Republic of Lithuania and Minister of Education and Science of the Republic of Lithuania No. V-188/A1-84/ISAK-487 on Approval of Criteria and Procedure for Determining the Disability Level 29 Order of the Minister of Social https://www.e- Security and Labor of the Republic tar.lt/portal/lt/legalAct/ef7052500aa811e9a5eaf2cd290f1944/asr of Lithuania and the Minister of Health of the Republic of Lithuania No. A1-765/V-1530 on Approval of the Procedure for Determining the Requirements for the Compensation of the Expenses for the Special Permanent Care, Special Permanent Care (Assistance), Special Car and its Technical Adaptation 30 Order of the Minister of Social https://www.e- Security and Labor of the Republic tar.lt/portal/lt/legalAct/21e33070cdfc11e8bea9885f77677ec1/asr of Lithuania No. A1-563 on Approval of the Procedure for Determining the Special Needs Level for Retirement Age Persons 87 31 Order of the Minister of Social https://www.e- Security and Labor of the Republic tar.lt/portal/lt/legalAct/TAR.A2474E417755/LcbyMrjJFx of Lithuania and the Minister of Health of the Republic of Lithuania No. A1-1 / V-2 on Approval of Rules for Determining the Level of Incapacity for Work in Respect of Accidents at Work or the Consequences of Occupational Diseases 32 Order of DWCAO Director No. V- https://www.e- 110 on the Determination of tar.lt/portal/lt/legalAct/49be52803a8211e99595d005d42b863e Assessment Procedure of the Level of Disability, Working Capacity, Special Needs and Vocational Rehabilitation Services in the Territorial Division of DWCAO 33 Order of DWCAO director No. V-13 https://www.e- on the Determination of tar.lt/portal/lt/legalAct/fa98a2503a8111e99595d005d42b863e Assessment Procedure of the Level of Disability, Working Capacity, Special Needs and Vocational Rehabilitation Services in the Decision Control Division 34 Order of DWCAO director No. V-10 http://ndnt.lrv.lt/uploads/ndnt/documents/files/SKS20130702%20( on the Determination of Control 2).pdf Procedure of the decisions made by DWCAO Territorial Divisions 35 Order of DWCAO director No. V-43 https://www.e- on Approval of the Procedure of tar.lt/portal/lt/legalAct/867d94a07df411e98436e02a0124fc68 Referral to Third Level Health Care Institutions or Independent Experts and Other Specialists and the Payment for their services 36 Order of DWCAO director No. V-11 https://www.e- on Approval of Methodological tar.lt/portal/lt/legalAct/3d3ef8803a8111e99595d005d42b863e Recommendations for the Determination of the Permanent Care, Permanent Care (Assistance) and Special Car and its Technical Adaptation Special Need 88 ANNEX 4: Data on Disability Assessment113 (i) Children 113 Data source for all tables: DWCAO complied for the purpose of this Report. “Total” pertains to a number of assessments. In some cases, the same person may be counted twice if s/he was assessed twice within the same year or was assessed for more than one special need. 89 (ii) Determination of Special Needs 90 91 (iii) Work capacity assessment 92 93 94 95 ANNEX 5: Examples of Application Forms for Disability Assessment 1. DWCAO form filled by a physician treating a person applying for work capacity assessment 96 97 2. Application form for work capacity assessment by an applicant to DWCAO 98 99 3. Application form for disability assessment in children __________________________________________________________________________________________ ____ (forename and surname – in capital letters) __________________________________________________________________________________________ ___ (address of the place of residence, tel. No, e-mail address) To: The Disability and Working Capacity Assessment Office under the Ministry of Social Security and Labor REQUEST FOR ESTABLISHING A DEGREE OF DISABILITY _/_/20_ I hereby request to establish a degree of disability of my child/foster child. _______________________________________________________________________ (forename, surname) Data provided: 1. Family status: lives together with (underline) parents, custodians, single, other (enter) _______________________________________________________________________ . 2. Education (underline): school not attended, elementary, lower secondary, secondary. 3. Attends ___________________________________________________________ . (enter the name of the educational establishment) 4. A degree of special educational needs (underline) established, not established (the certificate is enclosed hereto). 5. Please establish a degree of disability retroactively from ___________ (specify the reason) ______________________________________________________________________ ______________________________________________________________________ . I hereby request to assess/not assess (underline as appropriate) special needs of my child/foster child during the establishment of a degree of disability. I HEREBY CONFIRM that the information provided is correct. After completing assessment of a degree of disability, and after finding out that I meet the criteria established in the Description of the Procedure of issue of Disabled Parking Card, please issue a disabled parking card. 100 (tick a box if you wish to get the card) I have been notified that: - a photo of the child is required to be additionally provided for the issue of a disabled parking card. - in establishing a degree of disability, the DWCAO will process the special category data of my child/foster child and, when necessary, will receive additional medical or other documents (data) from personal healthcare or other establishments and institutions, will familiarize medical information available in the outpatient card of the individual in accordance with the legal acts. I will collect the documents prepared by the DWCAO / send the documents to the address specified in the application. (underline as appropriate) ____________ ____________________________ (signature) (forename and surname) 101 ANNEX 6: Activity and Participation Questionnaires 1. Questionnaire filled in by DWCAO assessor during an interview with an applicant for a work capacity assessment 102 103 104 105 106 107 108 109 110 111 Annex 2 to the Description of the Criteria for and Procedure of the establishment of a degree of disability 2. Questionnaire to assess activity and ability to participate in 4 to 6 years old children ______________________________________________________________________________ (forename and surname of the individual) ______________________________________________________________________________ (forename and surname of the individual’s parents (adopt ive parents), custodian (guardian) ______________________________________________________________________________ (forename and surname of the employee of the Disability and Working Capacity Assessment Office under the Ministry of Social Security and Labor who has carried out the assessment and completed the questionnaire) I have been made familiar with the procedure of the assessment of a degree of disability, I am aware of the significance of the Questionnaire of individual’s activity and ability to participate in assessing a degree of disability. Individual’s parent (adoptive parent), custodian or guardian _________________ ______________________ (signature) (forename and surname) _________________________ (date) Questions are answered by the individual and / or by the individual’s representative. Below are questions related to children’s daily activities. When completing the Questionnaire, please mark (by circling) how often each of the activities listed has been a concern during the last month: 0 points – when the individual experiences no activity related difficulties and difficulties of ability to participate; 1 point – when the individual experiences activity related difficulties and difficulties of ability to participate: is independent but technical assistance measures are sometimes required in daily activities and help by another individual is sometimes required; 2 points – when the individual experiences activity related difficulties and difficulties of ability to participate: is independent but technical assistance measures are always required in daily activities and help by another individual is sometimes required; 3 points – when the individual experiences activity related difficulties and difficulties of ability to participate: is not independent, technical assistance measures are always required in daily activities and help by another individual is always required; 4 points – when the individual experiences activity related difficulties and difficulties of ability to participate: cannot perform any action on his/her own, absolute help is required, in daily activities is completely dependent on technical assistance measures and other individuals. There are neither right nor wrong answers. 112 Activities have been a concern during the last month Activities and ability to participate (in points) 1. Cognition (learning and applying knowledge) 1.1. Does the individual have difficulty playing with 0 1 2 3 4 toys? 1.2. Does the individual have difficulty learning to 0 1 2 3 4 speak? 1.3. Does the individual have difficulty 0 1 2 3 4 understanding notions describing length, quantity, relation? 1.4. Does the individual have difficulty learning to 0 1 2 3 4 read? 1.5. Does the individual know letters? 0 1 2 3 4 1.6. Does the individual have difficulty learning to 0 1 2 3 4 count? 2. General tasks and requirements 2.1. Does the individual have difficulty carrying out 0 1 2 3 4 a simple (one) task? 2.2. Does the individual have difficulty carrying out 0 1 2 3 4 a task which requires several steps to complete (e.g. not enough strength, unable to focus attention, cannot concentrate, does not understand sequence of actions, etc.)? 2.3. Does the individual have difficulty carrying out 0 1 2 3 4 daily activities (e.g. to brush the teeth, to wash, put clothes on, etc.)? 3. Interaction 3.1. Does the individual have difficulty 0 1 2 3 4 understanding what others are saying? 3.2. Does the individual have difficulty 0 1 2 3 4 understanding the meaning of gestures and/or pictures? 3.3. Does the individual have difficulty speaking? 0 1 2 3 4 3.4. Does the individual have difficulty 0 1 2 3 4 pronouncing sounds? 3.5. Does the individual have difficulty using 0 1 2 3 4 gestures, pictures and / or drawings for interaction? 4. Mobility (moving) 4.1. Does the individual have difficulty sitting down 0 1 2 3 4 and/or standing up? 4.2. Does the individual have difficulty when sitting 0 1 2 3 4 and/or standing for a longer time? 4.3. Does the individual have difficulty controlling 0 1 2 3 4 the hand, the fingers and/or the thumb? 4.4. Does the individual have difficulty controlling 0 1 2 3 4 the shoulder and/or the arm? 4.5. Does the individual have difficulty walking? 0 1 2 3 4 5. Independence (self-service skills) 5.1. Does the individual have difficulty washing? 0 1 2 3 4 5.2. Does the individual have difficulty using the 0 1 2 3 4 toilet? 5.3. Does the individual have difficulty putting 0 1 2 3 4 clothes on and off? 5.4. Does the individual have difficulty eating? 0 1 2 3 4 113 Activities have been a concern during the last month Activities and ability to participate (in points) 5.5. Does the individual have self-protection 0 1 2 3 4 difficulties (e.g. avoiding burns, falls, cuts, slips, tumble, does he/she can safely cross the street, etc.)? 6. Interpersonal relationships and interactions 6.1. Does the individual have difficulty interacting 0 1 2 3 4 with those around him/her (e.g. to say hello, to thank others, to apologize when necessary, etc.)? 7. Basic areas of life 7.1. Does the individual have difficulty playing with 0 1 2 3 4 others? 7.2. Does the individual have difficulty participating 0 1 2 3 4 in pre-school education (e.g. at the nursery school or at home - to concentrate, to stay focused, to assimilate knowledge, to acquire new skills, etc.)? 7.3. Does the individual have difficulty 0 1 2 3 4 understanding what money is? Total of points 0 28 56 84 112 A sum of the Total of questions – 28 individual's points Total of the individual's points Evaluation of answers: Points Coefficient 112–76 0.9 75–38 1.0 37–0 1.1 The employee having performed __________ ____________________________ (signature) (position held, forename and surname) the assessment I have made myself familiar: Individual‘s parent (adoptive parent), custodian or guardian _________________ ______________________ (signature) (forename and surname) Notes ________________________________________________________________________ _______________________________________________________________________________ ___________________________________ Supplemented with an Annex: No V-304/A1-189/V-614, 06/04/2012, Official Gazette, 2012, No 43-2121 (12/04/2012), ID code 1122250ISAK89/V-614 Amendments to the Annex: No V-1219/A1-545/V-822, 25/10/2017, published in the Register of Legal Acts on 30/10/2017, ID code 2017- 17078 114 Annex 3 to the Description of the Criteria for and Procedure of the establishment of a degree of disability 3. Questionnaire to assess activity and ability to participate in 7 to 13 years old children ______________________________________________________________________________ (forename and surname of the individual) ______________________________________________________________________________ (forename and surname of the individual‘s parents (adopt ive parents), custodian (guardian) ______________________________________________________________________________ (forename and surname of the employee of the Disability and Working Capacity Assessment Office under the Ministry of Social Security and Labor who has carried out the assessment and completed the questionnaire) I have been made familiar with the procedure of the assessment of a degree of disability, I am aware of the significance of the Questionnaire of individual‘s activity and ability to participate in assessing a degree of disability. Individual‘s parent (adoptive parent), custodian or guardian _________________ ______________________ (signature) (forename and surname) _________________________ (date) Questions are answered by the individual and / or by the individual‘s representative. Below are questions related to children’s daily activities. When completing the Questionnaire, please mark (by circling) how often each of the activities listed has been a concern during the last month: 0 points – when the individual experiences no activity related difficulties and difficulties of ability to participate; 1 point – when the individual experiences activity related difficulties and difficulties of ability to participate: is independent but technical assistance measures are sometimes required in daily activities and help by another individual is sometimes required; 2 points – when the individual experiences activity related difficulties and difficulties of ability to participate: is independent but technical assistance measures are always required in daily activities and help by another individual is sometimes required; 3 points – when the individual experiences activity related difficulties and difficulties of ability to participate: is not independent, technical assistance measures are always required in daily activities and help by another individual is always required; 4 points – when the individual experiences activity related difficulties and difficulties of ability to participate: cannot perform any action on his/her own, absolute help is required, in daily activities is completely dependent on technical assistance measures and other individuals. There are neither right nor wrong answers. 115 Activities have been a concern during the last Activities and ability to participate month (in points) 1. Cognition (learning and applying knowledge) 1.1. Does the individual have difficulty playing with 0 1 2 3 4 toys? 1.2. Does the individual have difficulty using words, 0 1 2 3 4 phrases, sentences? 1.3. Does the individual have difficulty 0 1 2 3 4 understanding notions describing length, quantity, relation? 1.4. Does the individual have difficulty reading? 0 1 2 3 4 1.5. Does the individual have difficulty writing? 0 1 2 3 4 1.6. Does the individual have difficulty counting? 0 1 2 3 4 2. General tasks and matters 2.1. Does the individual have difficulty carrying out a 0 1 2 3 4 simple (one) task? 2.2. Does the individual have difficulty carrying out a 0 1 2 3 4 task which requires several steps to complete (e.g. not enough strength, unable to focus attention, cannot concentrate, does not understand sequence of actions, etc.)? 2.3. Does the individual have difficulty carrying out 0 1 2 3 4 daily activities (e.g. to do the necessary works in the morning: to brush teeth, to wash, put clothes on, to pack things that are needed at school, to tidy up the workplace, to reach an educational institution, etc.)? 3. Interaction 3.1. Does the individual have difficulty 0 1 2 3 4 understanding what others are saying? 3.2. Does the individual have difficulty 0 1 2 3 4 understanding the meaning of gestures and/or pictures? 3.3. Does the individual have difficulty speaking? 0 1 2 3 4 3.4. Does the individual have difficulty pronouncing 0 1 2 3 4 different sounds? 3.5. Does the individual have difficulty using 0 1 2 3 4 gestures, pictures and/or drawings for interaction? 4. Mobility (moving) 4.1. Does the individual have difficulty sitting down 0 1 2 3 4 and/or standing up? 4.2. Does the individual have difficulty when sitting 0 1 2 3 4 and/or standing for a longer time? 4.3. Does the individual have difficulty controlling 0 1 2 3 4 the hand, the fingers and/or the thumb? 4.4. Does the individual have difficulty controlling 0 1 2 3 4 the shoulder and/or the arm? 4.5. Does the individual have difficulty walking? 0 1 2 3 4 5. Independence (self-service skills) 5.1. Does the individual have difficulty washing? 0 1 2 3 4 5.2. Does the individual have difficulty using the 0 1 2 3 4 toilet? 5.3. Does the individual have difficulty putting 0 1 2 3 4 clothes on and off? 5.4. Does the individual have difficulty eating? 0 1 2 3 4 116 Activities have been a concern during the last Activities and ability to participate month (in points) 5.5. Does the individual have self-protection 0 1 2 3 4 difficulties (e.g. avoiding burns, falls, cuts, slips, tumble, does he/she can safely cross the street, etc.)? 6. Household 6.1. Does the individual have difficulty performing 0 1 2 3 4 simple housework (e.g. wash dishes, wipe dust, tidy up the things when ordered – to gather toys, drawing tools, etc.)? 7. Interpersonal relationships and interactions 7.1. Does the individual have difficulty interacting 0 1 2 3 4 with those around him/her (e.g. to say hello, to thank others, to apologize when necessary, to behave appropriately in a variety of situations, to understand and respond to other people's feelings, etc.)? 7.2. Does the individual have difficulty getting to 0 1 2 3 4 know his/her peers and continuing friendship? 8. Basic areas of life 8.1. Does the individual have difficulty playing with 0 1 2 3 4 others? 8.2. Does the individual have difficulty participating 0 1 2 3 4 in the educational process (e.g. at school during the lessons - to concentrate and focus attention, not disturb other children, to acquire expertise knowledge; if the child is taught at home – to concentrate, to maintain focus, to acquire expertise knowledge, to acquire new skills, etc.)? 8.3. Does the individual have difficulty using money 0 1 2 3 4 (e.g. when paying for goods at the store, realizing the value of things, etc.)? 9. Community, social and civic life 9.1. Does the individual have difficulty participating 0 1 2 3 4 in non-formal education activities for children (e.g. at music, art, sports, technical schools, in various groups, studios, clubs, societies, etc.)? Total of points 0 30 60 90 120 A sum of the Total of questions – 30 individual's points Total of the individual's points Evaluation of answers: Points Coefficient 120–81 0.9 80–41 1.0 40–0 1.1 The employee having performed __________ ____________________________ (signature) (position held, forename and surname) the assessment 117 I have made myself familiar: Individual‘s parent (adoptive parent), custodian or guardian _________________ ______________________ (signature) (forename and surname) Notes ________________________________________________________________________ _______________________________________________________________________________ ___________________________________ Supplemented with an Annex: No V-304/A1-189/V-614, 06/04/2012, Official Gazette, 2012, No 43-2121 (12/04/2012), ID code 1122250ISAK89/V-614 Amendments to the Annex: No V-1219/A1-545/V-822, 25/10/2017, published in the Register of Legal Acts on 30/10/2017, ID code 2017- 17078 118 Annex 4 to the Description of the Criteria for and Procedure of the establishment of a degree of disability 4. Questionnaire to assess activity and ability to participate in 14 to 17 years old children ______________________________________________________________________________ (forename and surname of the individual) ______________________________________________________________________________ (forename and surname of the individual’s parents (adoptive parents), custodian (guardian) ______________________________________________________________________________ (forename and surname of the employee of the Disability and Working Capacity Assessment Office under the Ministry of Social Security and Labor who has carried out the assessment and completed the questionnaire) I have been made familiar with the procedure of the assessment of a degree of disability, I am aware of the significance of the Questionnaire of individual’s activity and ability to participate in assessing a degree of disability. Individual’s parent (adoptive parent), custodian or guardian _________________ ______________________ (signature) (forename and surname) _________________________ (date) Questions are answered by the individual and / or by the individual’s representative. Below are questions related to children’s daily activities. When completing the Questionnaire, please mark (by circling) how often each of the activities listed has been a concern during the last month: 0 points – when the individual experiences no activity related difficulties and difficulties of ability to participate; 1 point – when the individual experiences activity related difficulties and difficulties of ability to participate: is independent but technical assistance measures are sometimes required in daily activities and help by another individual is sometimes required; 2 points – when the individual experiences activity related difficulties and difficulties of ability to participate: is independent but technical assistance measures are always required in daily activities and help by another individual is sometimes required; 3 points – when the individual experiences activity related difficulties and difficulties of ability to participate: is not independent, technical assistance measures are always required in daily activities and help by another individual is always required; 4 points – when the individual experiences activity related difficulties and difficulties of ability to participate: cannot perform any action on his/her own, absolute help is required, in daily activities is completely dependent on technical assistance measures and other individuals. There are neither right nor wrong answers. 119 Activities have been a concern during the last Activities and ability to participate month (in points) 1. Cognition (learning and applying knowledge) 1.1. Does the individual have difficulty reading? 0 1 2 3 4 1.2. Does the individual have difficulty writing? 0 1 2 3 4 1.3. Does the individual have difficulty counting? 0 1 2 3 4 1.4. Does the individual have difficulty making 0 1 2 3 4 adequate decisions (e.g. choosing the way and means of activities, anticipating the possible consequences of the behaviour and responsibility, etc.)? 2. General tasks and requirements 2.1. Does the individual have difficulty performing a 0 1 2 3 4 simple (one) order? 2.2. Does the individual have difficulty carrying out a 0 1 2 3 4 task which requires several steps to complete (e.g. not enough strength, unable to focus attention, cannot concentrate, does not understand sequence of actions, etc.)? 2.3. Does the individual have difficulty carrying out 0 1 2 3 4 daily activities (e.g. to do the necessary works in the morning: to brush teeth, to wash, put clothes on, to pack things that are needed at school, to tidy up the workplace, to reach an educational institution, etc.)? 3. Interaction 3.1. Does the individual have difficulty understanding 0 1 2 3 4 what others are saying? 3.2. Does the individual have difficulty understanding 0 1 2 3 4 the meaning of gestures and/or pictures? 3.3. Does the individual have difficulty speaking? 0 1 2 3 4 3.4. Does the individual have difficulty using gestures, 0 1 2 3 4 pictures and/or drawings for interaction? 4. Mobility (moving) 4.1. Does the individual have difficulty sitting down 0 1 2 3 4 and/or standing up? 4.2. Does the individual have difficulty when sitting 0 1 2 3 4 and/or standing for a longer time? 4.3. Does the individual have difficulty controlling the 0 1 2 3 4 hand, the fingers and/or the thumb? 4.4. Does the individual have difficulty controlling the 0 1 2 3 4 shoulder and/or the arm? 4.5. Does the individual have difficulty walking? 0 1 2 3 4 5. Independence (self-service skills) 5.1. Does the individual have difficulty washing? 0 1 2 3 4 5.2. Does the individual have difficulty using the 0 1 2 3 4 toilet? 5.3. Does the individual have difficulty putting clothes 0 1 2 3 4 on and off? 5.4. Does the individual have difficulty eating? 0 1 2 3 4 5.5. Does the individual have self-protection 0 1 2 3 4 difficulties (e.g. avoiding burns, falls, cuts, slips, tumble, does he/she can safely cross the street, etc.)? 6. Household 6.1. Does the individual have difficulty performing 0 1 2 3 4 more complex housework (e.g. to do laundry, room cleaning, cooking, etc.)? 120 Activities have been a concern during the last Activities and ability to participate month (in points) 7. Interpersonal relationships and interactions 7.1. Does the individual have difficulty interacting 0 1 2 3 4 with those around him/her (e.g. to say hello, to thank others, to apologize when necessary, to behave appropriately in a variety of situations, to understand and respond to other people's feelings, to accept criticism in an adequate manner, etc.)? 7.2. Does the individual have difficulty getting to 0 1 2 3 4 know his/her peers and continuing friendship? 8. Basic areas of life 8.1. Does the individual have difficulty participating in 0 1 2 3 4 the educational process (e.g. at school during the lessons - to concentrate and focus attention, not disturb others, to acquire expertise knowledge, to do homework; if the child is taught at home – to concentrate, to maintain focus, to acquire expertise knowledge, to acquire new skills, to perform tasks assigned, etc.)? 8.2. Does the individual have difficulty using money 0 1 2 3 4 (e.g. when paying for goods at the store, realizing the value of things, distributing petty cash that he/she receives – pocket-money, etc.)? 9. Community, social and civic life 9.1. Does the individual have difficulty participating in 0 1 2 3 4 non-formal education activities for children (e.g. at music, art, sports, technical schools, in various groups, studios, clubs, societies, etc.)? Total of points 0 27 54 81 108 A sum of the individual's Total of questions – 27 points Total of the individual's points Evaluation of answers: Points Coefficient 108–73 0.9 72–37 1.0 36–0 1.1 The employee having performed __________ ____________________________ (signature) (position held, forename and surname) the assessment I have made myself familiar: Individual‘s parent (adoptive parent), custodian or guardian _________________ ______________________ (signature) (forename and surname) Notes ________________________________________________________________________ _______________________________________________________________________________ 121 ANNEX 7: Amounts of the social assistance disability pension, based on the Law on Social Assistance Pensions of the Republic of Lithuania as off 2019 a. For a person with established severe, moderate or mild disability: 1. Severe disability: 2 basic social assistance pensions (BSAPs=132 EUR) = EUR 264. 2. Moderate disability – 1.5 BSAP (EUR 198). 3. Mild disability: 1 BSAP (EUR 132). b. Amounts of the social assistance disability pension for the persons recognized as persons with incapacity for work or partial incapacity for work before the day (inclusive) they reach the age of 24, as well as persons who, because of the effects of a sickness or injury suffered before the age of 24, have been recognized as persons with incapacity for work or partial incapacity for work after they reached the age of 24, but not later than before the day (inclusive) they reach the age 26 (since 1 January 2019): 1. 100 per cent loss of work capacity: 2.25 BSAPs (EUR 297). 2. 95 per cent loss of work capacity – 2.16 BSAPs (EUR 285.12). 3. 90 per cent loss of work capacity – 2.08 BSAPs (EUR 274.56). 4. 85 per cent loss of work capacity – 2 BSAPs (EUR 264). 5. For the persons who have lost 80 per cent of the capacity for work – 1.91 BSAP (EUR 252.12). 6. 75 per cent loss of work capacity – 1.82 BSAP (EUR 240.24). 7. 70 per cent loss of work capacity – 1.74 BSAP (EUR 229.68). 8. 65 per cent loss of work capacity – 1.65 BSAP (EUR 217.80). 9. 60 per cent of loss of work capacity – 1.43 BSAP (EUR 188.76). 10. 55 per cent loss of work capacity – 1.2 BSAP (EUR 158.40). 11. 50 per cent loss of work capacity – 0.98 BSAP (EUR 129.36). 12. 45 per cent loss of work capacity – 0.75 BSAP (EUR 99). c. Amounts of the social assistance disability pension: parents (adoptive parents), guardians who have been recognized as persons with incapacity for work or partial incapacity for work, who have lost 60% or more of the capacity for work and who have for at least 15 years taken care of a disabled family member at home for whom a special need for permanent nursing or permanent attendance (assistance) is established. Social assistance pension for taking care of a disabled person may be granted only to one person; to mothers who have given birth to and brought up five or more children until they reached the age of 8 and who have been recognized as persons with incapacity for work or partial incapacity for work, who lost 60% or more of the capacity for work. 1. 100 per cent loss of work capacity – 1.5 BSAP (EUR 198). 2. 95 per cent loss of work capacity – 1.48 BSAP (EUR 195.36). 3. 90 per cent loss of work capacity – 1.47 BSAP (EUR 194.04). 4. 85 per cent loss of work capacity –1.46 BSAP (EUR 192.72). 5. 80 per cent of loss of work capacity – 1.45 BSAP (EUR 191.40). 6. 75 per cent loss of work capacity – 1.31 BSAP (EUR 172.92). 7. 70 per cent loss of work capacity – 1.18 BSAP (EUR 155.76). 8. 65 per cent loss of work capacity – 1.05 BSAP (EUR 138.60). 9. 60 per cent loss of work capacity – 1 BSAP (EUR 132). 122 d. Amounts of the social assistance disability pension for persons who have been recognized as persons with incapacity for work or partial incapacity for work, who lost 60%+ of work capacity: 1. 100 per cent loss of work capacity – 1 BSAP (EUR 132). 2. 95 per cent loss of work capacity – 0.99 1 BSAP (EUR 130.68). 3. 90 per cent loss of work capacity – 0.98 1 BSAP (EUR 129.36). 4. 85 per cent loss of work capacity – 0.96 1 BSAP (EUR 126.72). 5. 80 per cent loss of work capacity – 0.95 1 BSAP (EUR 125.40). 6. 75 per cent loss of work capacity – 0.94 1 BSAP (EUR 124.08). 7. 70 per cent loss of work capacity – 0.93 1 BSAP (EUR 122.76). 8. 65 per cent loss of work capacity – 0.91 1 BSAP (EUR 120.12). 9. 60 per cent loss of work capacity – 0.9 1 BSAP (EUR 118.90). 123 ANNEX 8: DWCAO Information System (IS) Views Screenshot 1: The employee with the registrar login (Vilnius reception) registers the person to the DWCO IS Screenshot 2: Registration for working capacity window Registration for working capacity window Screenshot 3: The employee with the login of Head of territorial division appoints assessors Screenshot 4: Head of Territorial Division completes the request for additional documents, decision not to assess, or to issue an invitation for an interview request for additional documents decision not to assess invitation Screenshot 5: Assessors window in DWCO IS Screenshot 6: Registrar is printing the documents f rom documents list Figure 1: Visualization of technical architecture of DWCA automated information system Figure 2: Detailed scheme of the DWCA information system infrastructure Figure 3: The DWACO system logic architecture diagram *ASPĮ – Personal Healthcare Institution