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On the interpretation of the provisions of the Constitutional Court’s ruling of 16 May 2013 related to the right to healthcare

Case No. 47/2009-131/2010

 THE CONSTITUTIONAL COURT OF THE REPUBLIC OF LITHUANIA

 DECISION

ON THE CONSTRUCTION OF THE PROVISIONS OF THE RULING OF THE CONSTITUTIONAL COURT OF THE REPUBLIC OF LITHUANIA OF 16 MAY 2013

 26 February 2014
Vilnius

The Constitutional Court of the Republic of Lithuania, composed of the Justices of the Constitutional Court: Toma Birmontienė, Pranas Kuconis, Gediminas Mesonis, Vytas Milius, Ramutė Ruškytė, Egidijus Šileikis, Algirdas Taminskas, Romualdas Kęstutis Urbaitis, and Dainius Žalimas

The court reporter—Daiva Pitrėnaitė

Vytenis Povilas Andriukaitis, the member of the Seimas of the Republic of Lithuania acting as the petitioner, who filed the petition requesting a construction of the provisions of the ruling of the Constitutional Court of the Republic of Lithuania of 16 May 2013

The Constitutional Court of the Republic of Lithuania, pursuant to Article 61 of the Law on the Constitutional Court of the Republic of Lithuania, on 7 February 2014, at the Court’s public hearing, considered the petition (No. 1B-27/2013) of Vytenis Povilas Andriukaitis, the member of the Seimas acting as the petitioner, requesting a construction of certain provisions of the Ruling of the Constitutional Court “On the compliance of certain provisions of the Republic of Lithuania’s Law on State Social Insurance, the Republic of Lithuania’s Law on Health Insurance, and the Republic of Lithuania’s Law on Sickness and Maternity Social Insurance and the Law Amending It with the Constitution of the Republic of Lithuania” of 16 May 2013, which was adopted in constitutional justice case No. 47/2009-131/2010, in which Vytenis Povilas Andriukaitis, the member of the Seimas acting as the petitioner in this constitutional justice case, was a representative of the groups of members of the Seimas, the petitioners of the latter case.

The Constitutional Court

has established:

I

  1. On 16 May 2013, in constitutional justice case No. 47/2009-131/2010, the Constitutional Court adopted the Ruling “On the compliance of certain provisions of the Republic of Lithuania’s Law on State Social Insurance, the Republic of Lithuania’s Law on Health Insurance, and the Republic of Lithuania’s Law on Sickness and Maternity Social Insurance and the Law Amending It with the Constitution of the Republic of Lithuania” (Official Gazette Valstybės žinios, 2013, No. 52-2604; hereinafter referred to as the Constitutional Court’s ruling of 16 May 2013).
  2. Vytenis Povilas Andriukaitis, the member of the Seimas acting as the petitioner, requests a construction of whether:

– the provision “[t]he provision of Paragraph 1 of Article 53 of the Constitution that the state takes care of people’s health expresses the constitutional principle that is reflected in various aspects also in other provisions of the Constitution (first of all, in those of the same paragraph, but also in those beyond that paragraph). Upon this principle, the entire state activity related to people’s health must be grounded” of the third paragraph of Item 1.1 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 means that “the function of the state to take care of people’s health is applicable to the entire activity of the state, i.e., institutions that form and implement a certain state policy (either health or another policy) are obliged in all cases to assess an impact of their activity (including decisions adopted by them) on people’s health; and the legislature, before deciding to regulate certain public relations, is in all cases obliged to assess an impact that the legal regulation to be adopted may have on people’s and/or society’s health”;

– the provisions “Paragraph 1 of Article 53 of the Constitution consolidates the guarantee of medical aid to citizens free of charge at state medical establishments. This guarantee obligates the state to ensure the necessary conditions for its implementation, i.e., not only to create the required network of state healthcare establishments, but also to cover the costs of rendering such medical aid by state budget funds. Thus, while implementing its discretion of forming the state health policy and that of choosing a model of healthcare funding, the legislature may not disregard the fact that a certain part of healthcare services, namely, free-of-charge medical aid guaranteed to citizens, must be funded by state budget funds” of the first paragraph of Item 1.4 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that “the state, which is under the duty to ensure free-of-charge medical aid to citizens at state medical treatment establishments as well as under the duty to create the required network of state healthcare establishments, is obliged not only to provide for the payment of this aid by state budget funds but also to create and maintain the required network of state healthcare establishments namely by state budget funds”;

– the provision “[t]his relation between the constitutional values implies the fact that free-of-charge medical aid to all citizens must be ensured insofar as it is necessary to save and preserve the life of a human being” of the second paragraph of Item 1.4 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood in such a way that “the Constitution permits the legislature to expand the scope of free-of-charge medical aid to the extent that the state would guarantee not only the rendering of medical aid to citizens insofar as it is necessary to save and preserve the life of a human being but also to the extent that free-of-charge medical aid would include such rendering of medical aid whereby the state would ensure the proper protection of human dignity, the right to life, and the right to the best possible health, i.e., vitally important free-of-charge medical aid would be extended not only to saving and preserving the life of a human being but would also include human health preservation related to all medical aid services to be rendered, which would be rendered to a human being from the moment when a state dangerous to the life of the human being emerges until the health of the human being is preserved, i.e., until full recovery (e.g., the moment of release from a medical treatment establishment), i.e., whether ‘medical aid to save and preserve the life of a human being’ may be equated with medical aid to save and preserve the health of a human being”;

– the provisions “<...> the guarantee of free-of-charge medical aid to citizens at namely state medical establishments determines the duty of the state to ensure the rendering of vitally important medical aid at state medical establishments, inter alia, the continuous operation of the required network of state healthcare establishments rendering such aid; however, such a guarantee may not be construed as meaning that free-of-charge medical aid financed by state budget funds should be confined only to those establishments. The striving for the ensuring of the best possible accessibility to vitally important medical aid is also determined by the fact that in the situations where, due to some circumstances, such aid cannot be rendered, in a timely and quality manner, in state medical establishments, it may also be rendered in other healthcare establishments that are able to render such aid in a quality and safe manner; the costs incurred by the latter establishments in the course of rendering such aid must be covered by state budget funds” of the third paragraph of Item 1.4 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 and the provisions “[t]he specific character of healthcare as a sphere of economic activity is determined by the fact that most healthcare services are funded by public funds <...>. The state, which has the duty to create a system of healthcare funding by public funds based on social solidarity, must, <...> take care of the fact that those funds should be used in a responsible and rational manner. <...> the legislature is faced with the duty to establish the legal regulation governing the funding of healthcare services by compulsory health insurance funds that would create preconditions for the state so that it could plan the funding and distribute the funds among healthcare establishments in a manner where, without denying the obligation of the state to support the economic efforts and initiative that are useful to society and are based on private ownership, fair competition between healthcare establishments, and the right of the consumer of healthcare services (patient) to choose a healthcare establishment, one would ensure high quality of healthcare services funded by those funds and sufficient accessibility to the said services, i.e. their adequate distribution, as well as the continuous operation of the required network of state healthcare establishments. Thus, while being bound by the duty to ensure rational distribution of the limited funds of compulsory health insurance among the establishments rendering healthcare services, the legislature may establish the conditions and limitations of the funding of such services, inter alia such a procedure for the distribution of those funds, according to which they would be allocated to cover the costs of the healthcare services rendered only by those institutions that have concluded a corresponding agreement with an institution authorised by the state, under conditions established by law, regarding the rendering of the services funded from the compulsory health insurance funds. The procedure for concluding such agreements should be grounded on objective and non-discriminatory criteria, known in advance, which would not deny the freedom of fair competition and other principles of Lithuania’s economy, consolidated in the Constitution” of the sixth and seventh paragraphs of Item 1.7 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that, “in order to ensure the continuous operation of the required network of state healthcare establishments, the Constitutional Court’s ruling consolidates the priority of distributing the funds of the budget and the funds of the Compulsory Health Insurance Fund among, first of all, state medical treatment establishments, as well as that, only in cases where medical aid, due to certain circumstances, cannot be rendered in a timely and quality manner at state medical treatment establishments, it may be rendered at other healthcare establishments able to render such aid in a quality and safe manner, allocating in this case for the latter establishments the funds of the state budget and/or the funds of the Compulsory Health Insurance Fund, i.e., whether, in the aforesaid conclusions drawn in the Constitutional Court’s ruling of 16 May 2013, the Constitutional Court stated the rule of the priority of state medical treatment establishments, which means priority (precedence) in implementing the certain right—the right to receive distributable public funds, in the same manner as the Constitutional Court formulated in its Ruling of 22 December 2011 ‘On the compliance of the provisions of the Republic of Lithuania’s Law on Science and Studies <...>’, i.e., that non-state schools of higher education may receive state-funded student places only in cases when specialists of certain areas (fields) cannot be prepared in state schools of higher education due to objective circumstances”;

– the provisions “[t]he specific character of healthcare as a sphere of economic activity is determined by the fact that most healthcare services are funded by public funds <...>. The state, which has the duty to create a system of healthcare funding by public funds based on social solidarity, must, <...> take care of the fact that those funds should be used in a responsible and rational manner. <...> the legislature is faced with the duty to establish the legal regulation governing the funding of healthcare services by compulsory health insurance funds that would create preconditions for the state so that it could plan the funding and distribute the funds among healthcare establishments in a manner where, without denying the obligation of the state to support the economic efforts and initiative that are useful to society and are based on private ownership, fair competition between healthcare establishments, and the right of the consumer of healthcare services (patient) to choose a healthcare establishment, one would ensure high quality of healthcare services funded by those funds and sufficient accessibility to the said services, i.e. their adequate distribution, as well as the continuous operation of the required network of state healthcare establishments. Thus, while being bound by the duty to ensure rational distribution of the limited funds of compulsory health insurance among the establishments rendering healthcare services, the legislature may establish the conditions and limitations of the funding of such services, inter alia such a procedure for the distribution of those funds, according to which they would be allocated to cover the costs of the healthcare services rendered only by those institutions that have concluded a corresponding agreement with an institution authorised by the state, under conditions established by law, regarding the rendering of the services funded from the compulsory health insurance funds. The procedure for concluding such agreements should be grounded on objective and non-discriminatory criteria, known in advance, which would not deny the freedom of fair competition and other principles of Lithuania’s economy, consolidated in the Constitution” of the sixth and seventh paragraphs of Item 1.7 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that “the funds from the budget of the Compulsory Health Insurance Fund may be allocated to healthcare establishments only for the healthcare services being rendered, i.e., the operation of the network of state healthcare establishments must be ensured only by state budget funds, and the operation of this network cannot be ensured by the funds of the budget of the Compulsory Health Insurance Fund allocated in order of priority; as well as whether the procedure for distributing funds among personal healthcare establishments may be established only by means of a law”, in a similar manner as the conditions for concluding agreements regarding the rendering of services financed by compulsory healthcare insurance funds;

– the notion “economically grounded tariffs for healthcare services”, used in the seventh paragraph of Item 1.7 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013, includes “exclusively free-of-charge medical aid services paid for from the state budget, or exclusively services paid for from the budget of the Compulsory Health Insurance Fund, or whether it includes all services financed from either the state budget or the budget of the Compulsory Health Insurance Fund, as well as whether tariffs for the said services must be based on the calculation of costs or on any other method”;

– the provisions “[w]hen it regulates the relations of compulsory health insurance, the legislature is bound by the requirement, stemming from Paragraph 1 of Article 53 of the Constitution, for ensuring accessibility, equal to all, to quality healthcare services <...>. It implies, among other things, that compulsory health insurance must be universal, i.e. it must cover all members of society, the amount of the contributions must depend on the income of persons, this amount must be such so that preconditions could be created for the accumulation of the necessary funds ensuring the sufficient accessibility to quality healthcare services. It needs to be emphasised that after the legislature has chosen compulsory health insurance, the obligation to pay the compulsory health insurance contributions as established by law is a constitutional duty; in itself, such a duty cannot be treated as a limitation of the rights of a person” of the first paragraph of Item 1.6 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that “the amount of the insurance contributions paid by a person depends on all the income received by the person, i.e., not only on the income related to remuneration for work or service but also on any other type of income received by the person, while those persons who do not receive any such income and are not insured by the state are obliged, in the manner prescribed by law, to pay the contributions set by the legislature (9 percent of the minimum monthly wage); as well as whether, depending on the amount of the contributions paid by a person, the person may receive more personal healthcare services compensated by compulsory health insurance, while a person the amount of whose contributions is inconsiderable may receive less personal healthcare services compensated by the said insurance, i.e., whether the number of compensated personal healthcare services depends on the amount of the compulsory health insurance contributions paid by a person, and whether, the legislature may, by means of a law, establish different legal regulation with regard to the aforementioned categories of persons”;

– the provisions “<...> the duty of the state to create a system of healthcare funding by public funds based on social solidarity, where such a system would make it possible to ensure sufficient accessibility to healthcare, may not be construed in such a way that, purportedly, society should bear the burden of funding all possible personal healthcare services. In this sphere it is necessary to find decisions ensuring the balance between the interests of the person as a consumer of healthcare services (patient) and those of the whole society. <...> the principle of solidarity in a civil society does not deny personal responsibility for one’s own fate; the recognition of the mutual responsibility of a person and society is important in ensuring social harmony <...>. The legal regulation governing the funding of healthcare of persons should create incentives for everyone to take care of his health, to assume the obligation to contribute, as far as possible, to the health funding and to use the healthcare services in a responsible and rational manner. Thus, under the Constitution, the legislature also has the powers to establish that certain healthcare services must be paid for from the private sources of funding, as, for instance, by voluntary health insurance funds, direct payment by the persons themselves, etc.” of the fourth paragraph of Item 1.5 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that, “on the one hand, under the Constitution, the legislature has the powers, after assessing the burden of funding personal healthcare services, to adopt decisions providing that a certain part of a service paid for by funds from the budget of the Compulsory Health Insurance Fund is paid for by territorial patient funds (compulsory health insurance), while another part of such a service is paid for from the private sources of funding, as, for instance, by voluntary health insurance funds, direct payment by the persons themselves, etc., but, on the other hand, having chosen such a decision, the legislature is equally bound by the duty not to deny the purpose of compulsory health insurance based on social solidarity—to ensure sufficient accessibility to healthcare services, i.e., whether personal healthcare services (with the exception of free-of-charge medical aid guaranteed by the state) may be paid for by using a combined model, according to which a certain part of a service is paid for by compulsory health insurance funds, while another part of the service is paid for from the private sources of funding”;

– in relation to the latter question, the provisions “[h]aving chosen compulsory health insurance as one of the sources of healthcare funding, the legislature must clearly define the scope of personal healthcare services financed by the funds of the said insurance. This can be done by specifying the services that may be rendered to the insured persons for the funds of this insurance, or, conversely, by specifying those services the rendering of which is not paid for by the said insurance funds and which must be paid for from private sources, whereas in cases where it is impossible to indicate this precisely, sufficiently clear criteria must be established enabling one to decide in every concrete situation” of the fourth paragraph of Item 1.6 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that “the legislature is bound by the duty to define the scope of services financed by compulsory health insurance funds; thus, after specifying which services are paid for by the funds of this insurance, the legislature is not allowed to establish that the said services may be paid for by other funds, i.e., it is not allowed to demand any additional payments from persons for the services paid for by the funds of the said insurance, while, where it is established that particular services are not paid for by compulsory health insurance funds, these services must be paid for only from private sources”.

  1. The Constitutional Court also received the letter of 1 October 2013 from Vytenis Povilas Andriukaitis, the then Acting Minister of Health of the Republic of Lithuania, in which it is noted that the Constitutional Court is requested to construe the provisions of its ruling of 16 May 2013 due to the fact that, in order to properly and timely implement this ruling, it is necessary to systemically review, assess, and amend the laws related to the budget of the Compulsory Health Insurance Fund as well as those related to the whole system of health.

II

At the Constitutional Court’s sitting, Vytenis Povilas Andriukaitis, the member of the Seimas acting as the petitioner, explained the reasoning giving rise to the petition requesting a construction of the aforementioned provisions of the Constitutional Court’s ruling, answered the questions of the justices of the Constitutional Court, and provided additional material.

The Constitutional Court

holds that:

I

  1. The purpose of the institute of the construction of the rulings and other final acts of the Constitutional Court is to disclose the content and meaning of certain provisions of a ruling or another final act of the Constitutional Court more broadly and in more detail where this is necessary in order that the proper execution of the ruling or another final act of the Constitutional Court would be ensured and the ruling or another final act of the Constitutional Court would be followed (inter alia, the Constitutional Court’s decisions of 22 December 2010, 5 September 2011, 29 November 2012, and 16 January 2014). The construction of a ruling or another final act of the Constitutional Court might be significant not only in seeking to ensure the proper implementation of the decision consolidated in the operative part of the act but also to ensure that proper consideration be given in the law-making process to the official constitutional doctrine formulated by the Constitutional Court; the purpose of the construction of a ruling or another final act of the Constitutional Court is to explain more comprehensively those provisions and formulations of the Constitutional Court’s ruling or its another final act due to the meaning of which there have been some uncertainties, but not to explain how to implement the said ruling or another final act in a concrete situation, inter alia, in the area of the application of law (the Constitutional Court’s decisions of 29 November 2012, 13 March 2013, 3 July 2013, and 16 January 2014).
  2. The Constitutional Court has emphasised on more than one occasion that the consideration of a petition requesting a construction of a ruling or another final act of the Constitutional Court does not imply any new constitutional justice case.

In this context, it should be noted that, under Paragraph 3 of Article 61 of the Law on the Constitutional Court, the Constitutional Court must construe its ruling without changing the content of the ruling. The Constitutional Court has held on more than one occasion that the said provision, among other things, means that, while construing its ruling, the Constitutional Court may not construe the content of the ruling in such a way that the meaning of its provisions, inter alia, the notional entirety of the elements constituting the content of the ruling, and the arguments and reasons upon which that ruling of the Constitutional Court is based would be changed. A ruling of the Constitutional Court is integral, and all its constituent parts are interrelated; the operative (resolving) part of a ruling is based upon the arguments of the reasoning part; while construing its ruling, the Constitutional Court is bound by the content of both the operative part and reasoning part of its ruling. When construing Paragraph 3 of Article 61 of the Law on the Constitutional Court, the Constitutional Court has stated in its acts on more than one occasion that the Constitutional Court may not construe what it did not investigate in the constitutional justice case in which the ruling, a construction of which is requested, was adopted; this would imply a matter for a separate investigation.

The Constitutional Court has also held on more than one occasion that the constitutional doctrine is not corrected when the rulings and other final acts of the Constitutional Court are officially construed; the correction of the official constitutional doctrine should be related to the consideration of new constitutional justice cases and creation of new precedents therein by the Constitutional Court but not to the official construction of the provisions of the rulings or other final acts of the Constitutional Court (inter alia, the Constitutional Court’s decisions of 6 December 2007, 1 February 2008, 18 December 2009, 13 March 2013, and 16 January 2014).

  1. In its decisions of 13 March 2013 and 16 January 2014, the Constitutional Court held that the Constitutional Court is a legal but not political institution; the Constitutional Court decides legal questions falling within its competence under the Constitution exclusively by invoking legal arguments, inter alia, the official constitutional doctrine and precedents that have already been formulated by it.

As the Constitutional Court has held on more than one occasion, no official constitutional doctrinal provision of a ruling or another final act of the Constitutional Court may be construed in isolation, by ignoring its meaning and systemic links with other official constitutional doctrinal provisions set forth in the relevant ruling, another final act of the Constitutional Court, or in other acts of the Constitutional Court, as well as with other provisions (either explicit or implicit) of the Constitution (inter alia, the Constitutional Court’s decisions of 6 December 2007, 28 October 2009, 13 March 2013, 3 July 2013, and 16 January 2014).

II

  1. It has been mentioned that the consideration of a petition requesting a construction of a ruling or another final act of the Constitutional Court does not imply any new constitutional justice case; the Constitutional Court may not construe what it did not investigate in the constitutional justice case in which the ruling, a construction of which is requested, was adopted; nor does the Constitutional Court explain how concretely its particular ruling should be implemented.

The Constitutional Court decides legal questions falling within its competence under the Constitution, thus, it also construes its rulings and other final acts, exclusively by invoking legal arguments, inter alia, the official constitutional doctrine and precedents that have already been formulated by it.

  1. Vytenis Povilas Andriukaitis, the member of the Seimas acting as the petitioner, requests, inter alia, a construction of whether the provision “[t]he provision of Paragraph 1 of Article 53 of the Constitution that the state takes care of people’s health expresses the constitutional principle that is reflected in various aspects also in other provisions of the Constitution (first of all, in those of the same paragraph, but also in those beyond that paragraph). Upon this principle, the entire state activity related to people’s health must be grounded” of the third paragraph of Item 1.1 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 means that “the function of the state to take care of people’s health is applicable to the entire activity of the state, i.e., institutions that form and implement a certain state policy (either health or another policy) are obliged in all cases to assess an impact of their activity (including decisions adopted by them) on people’s health; and the legislature, before deciding to regulate certain public relations, is in all cases obliged to assess an impact that the legal regulation to be adopted may have on people’s and/or society’s health”.

It should be noted that, in its ruling of 16 May 2013, the Constitutional Court did not investigate the question raised by the petitioner in relation to the duty of the legislature and other institutions forming and implementing the state policy to assess an impact of their activity (adopted decisions, established legal regulation) on people’s (society’s) health. It needs to be emphasised that, in the aforesaid ruling, the issue of the assessment of an impact made by state activities on people’s (society’s) health was not discussed at all.

Taking account of the arguments set forth, the Constitutional Court will not construe the aforementioned provision of the third paragraph of Item 1.1 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013.

  1. Vytenis Povilas Andriukaitis, the member of the Seimas acting as the petitioner, requests a construction of whether the notion “economically grounded tariffs for healthcare services”, used in the seventh paragraph of Item 1.7 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013, includes “exclusively free-of-charge medical aid services paid for from the state budget, or exclusively services paid for from the budget of the Compulsory Health Insurance Fund, or whether it includes all services financed from either the state budget or the budget of the Compulsory Health Insurance Fund, as well as whether tariffs for the said services must be based on the calculation of costs or on any other method”.

It should be noted that the petitioner’s request to construe how concretely tariffs for healthcare services should be calculated, so that they would be economically grounded, should be assessed as a question of economic purposefulness as well as a request to construe how concretely the aforementioned Constitutional Court’s ruling should be implemented.

Taking account of the arguments set forth, the Constitutional Court will not construe the notion “economically grounded tariffs for healthcare services”, as used in the seventh paragraph of Item 1.7 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013.

III

  1. Vytenis Povilas Andriukaitis, the member of the Seimas acting as the petitioner, inter alia, requests a construction of whether the provision “[t]his relation between the constitutional values implies the fact that free-of-charge medical aid to all citizens must be ensured insofar as it is necessary to save and preserve the life of a human being” of the second paragraph of Item 1.4 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood in such a way that “the Constitution permits the legislature to expand the scope of free-of-charge medical aid to the extent that the state would not only guarantee the rendering of medical aid to citizens insofar as it is necessary to save and preserve the life of a human being but also to the extent that free-of-charge medical aid would include such rendering of medical aid whereby the state would ensure the proper protection of human dignity, the right to life, and the right to the best possible health, i.e. vitally important free-of-charge medical aid would be extended not only to saving and preserving the life of a human being but would also include human health preservation related to all medical aid services to be rendered, which would be rendered to a human being from the moment when a state dangerous to the life of a human being emerges until the health of the human being is preserved, i.e., until full recovery (e.g., the moment of release from a medical treatment establishment), i.e., whether ‘medical aid to save and preserve the life of a human being’ may be equated with medical aid to save and preserve the health of a human being”.
  2. In its ruling of 16 May 2013, the Constitutional Court held that the provisions of Paragraph 1 of Article 53 of the Constitution may not be construed without, inter alia, taking account of their relation to the duty of the state to protect the life of a human being, as consolidated in Article 19 of the Constitution; the right to preserving and saving life when the life of a person is in danger is an inseparable and fundamental part of the innate human right to the best possible health; this relation between the constitutional values implies the fact that free-of-charge medical aid to all citizens must be ensured insofar as it is necessary to save and preserve the life of a human being; if a smaller extent of such aid were established, i.e. if even no minimal vitally important free-of-charge medical aid were established, its constitutional guarantee would in general become meaningless, and, at the same time, the constitutional obligations of the state to protect the life of a human being and to take care of people’s health would be violated; free-of-charge medical aid guaranteed to citizens must be in line with the requirements of accessibility and quality raised for healthcare services, and such aid must be rendered under the conditions and procedure heeding human dignity.

In addition, in the aforesaid ruling, the Constitutional Court held that the provision of Paragraph 1 of Article 53 of the Constitution, according to which the procedure for providing medical aid to citizens free of charge at state medical treatment establishments must be established by law, is a constitutional guarantee of the citizens’ right to receive, in a timely manner, vitally necessary free-of-charge quality medical aid at state medical treatment establishments, the implementation of which must be ensured by state budget funds; this guarantee is not identical to the right to healthcare, which is ensured, with regard to citizens as well as other persons, in the course of the implementation of the obligation of the state, as consolidated in Paragraph 1 of Article 53 of the Constitution, to take care of people’s health and to guarantee medical aid and services to a human being in the event of sickness.

In its ruling of 16 May 2013, the Constitutional Court also held that the constitutional provision that the procedure for providing free-of-charge medical aid to citizens at state medical treatment establishments must be established by law does not expressis verbis define the scope of the guaranteed aid, but in no way does it mean that, purportedly, all medical aid (let alone other healthcare services) rendered to citizens at those establishments must be paid for by state budget funds unconditionally and without paying heed to the financial capabilities of the state; the state may assume bigger financial obligations than it is implied by the constitutional guarantee of free-of-charge medical aid to citizens, however, the state budget cannot bear the burden mismatched with the financial capabilities of the state, due to which the state would be unable to discharge its other functions or the discharging of such functions would be much more difficult; having assessed, inter alia, the financial capabilities of the state, which are not and cannot be limitless, and paying heed to the balance of constitutional values and the constitutional principles of social harmony, responsible governance, reasonableness, the equality of the rights of persons, and other constitutional imperatives, the legislature must specify the scope of free-of-charge medical aid rendered to citizens by state budget funds; however, while doing so, the legislature may not deny the substance of this constitutional guarantee and the obligation of the state to take care of people’s health.

  1. Thus, in the context of the questions raised by the petitioner, it should be noted that:

– the Constitution consolidates the guarantee of vital (necessary to save and preserve the life of a human being) free-of-charge (financed by state budget funds) medical aid to citizens at state medical treatment establishments, which is related to the duty of the state, as consolidated in Article 19 of the Constitution, to preserve the life of a human being and the right of human beings to preserving and saving their lives in the event of danger; this aid guaranteed to citizens must be in line with the requirements of accessibility and quality raised for healthcare services, and such aid must be rendered under the conditions and procedure heeding human dignity;

– the guarantee of vitally necessary free-of-charge medical aid to citizens at state medical treatment establishments is not identical to the right to healthcare, which, with regard to citizens as well as other persons, is ensured by implementing the obligation of the state to take care of people’s health and to guarantee medical aid and services for a human being in the event of sickness, as consolidated in Paragraph 1 of Article 53 of the Constitution; thus, medical aid to save and preserve the life of a human being should not be equated with medical aid to save and preserve the health of a human being;

– bigger financial obligations compared to those implied by the constitutional guarantee of free-of-charge medical aid to citizens may be assumed by the state only in cases where these obligations would correspond with the financial capabilities of the state, i.e., where the state budget is not subject to a burden mismatched with the financial capabilities of the state, due to which the state would be unable to discharge its other functions or the discharging of such functions would be much more difficult.

  1. In the light of the foregoing arguments, the conclusion should be drawn that the aforementioned provision of the second paragraph of Item 1.4 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013, inter alia, means that the Constitution consolidates the guarantee of vital (which is necessary to save and preserve the life of a human being but which should not be equated with medical aid to save and preserve the health of a human being) free-of-charge (financed by state budget funds) medical aid to citizens; a bigger scope of free-of-charge medical aid to citizens, compared to that implied by the said constitutional guarantee, may be established by the legislature only in cases where this corresponds with the financial capabilities of the state, i.e., where the state budget is not subject to a burden mismatched with the financial capabilities of the state, due to which the state would be unable to discharge its other functions or the discharging of such functions would be much more difficult.

IV

  1. Vytenis Povilas Andriukaitis, the member of the Seimas acting as the petitioner, requests, inter alia, a construction of whether the provisions “Paragraph 1 of Article 53 of the Constitution consolidates the guarantee of medical aid to citizens free of charge at state medical establishments. This guarantee obligates the state to ensure the necessary conditions for its implementation, i.e., not only to create the required network of state healthcare establishments, but also to cover the costs of rendering such medical aid by state budget funds. Thus, while implementing its discretion of forming the state health policy and that of choosing a model of healthcare funding, the legislature may not disregard the fact that a certain part of healthcare services, namely, free-of-charge medical aid guaranteed to citizens, must be funded by state budget funds” of the first paragraph of Item 1.4 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that “the state, which is under the duty to ensure free-of-charge medical aid to citizens at state medical establishments as well as under the duty to create the required network of state healthcare establishments, is obliged not only to provide for the payment of this aid by state budget funds but also to create and maintain the required network of state healthcare establishments namely by state budget funds”.

The petitioner also requests a construction of whether the provisions “<...> the guarantee of free-of-charge medical aid to citizens at namely state medical treatment establishments determines the duty of the state to ensure the rendering of vitally necessary medical aid at state medical treatment establishments, inter alia, the continuous operation of the required network of the state healthcare establishments rendering such aid; however, such a guarantee may not be construed as meaning that free-of-charge medical aid, which is financed by state budget funds, should be confined only to those establishments. The striving for the ensuring of the best possible accessibility to vitally important medical aid is also determined by the fact that in the situations where, due to some circumstances, such aid cannot be rendered, in a timely and quality manner, in state medical establishments, it may also be rendered in other healthcare establishments that are able to render such aid in a quality and safe manner; the costs incurred by the latter establishments in the course of rendering such aid must be covered by state budget funds” of the third paragraph of Item 1.4 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 and the provisions “[t]he specific character of healthcare as a sphere of economic activity is determined by the fact that most healthcare services are funded by public funds <...>. The state, which has the duty to create a system of healthcare funding by public funds based on social solidarity, must, <...> take care of the fact that those funds should be used in a responsible and rational manner. <...> the legislature is faced with the duty to establish the legal regulation governing the funding of healthcare services by compulsory health insurance funds that would create preconditions for the state so that it could plan the funding and distribute the funds among healthcare establishments in a manner where, without denying the obligation of the state to support the economic efforts and initiative that are useful to society and are based on private ownership, fair competition between healthcare establishments, and the right of the consumer of healthcare services (patient) to choose a healthcare establishment, one would ensure high quality of healthcare services funded by those funds and sufficient accessibility to the said services, i.e. their adequate distribution, as well as the continuous operation of the required network of state healthcare establishments. Thus, while being bound by the duty to ensure rational distribution of the limited funds of compulsory health insurance among the establishments rendering healthcare services, the legislature may establish the conditions and limitations of the funding of such services, inter alia such a procedure for the distribution of those funds, according to which they would be allocated to cover the costs of the healthcare services rendered only by those institutions that have concluded a corresponding agreement with an institution authorised by the state, under conditions established by law, regarding the rendering of the services funded from the compulsory health insurance funds. The procedure for concluding such agreements should be grounded on objective and non-discriminatory criteria, known in advance, which would not deny the freedom of fair competition and other principles of Lithuania’s economy consolidated in the Constitution” of the sixth and seventh paragraphs of Item 1.7 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that “in order to ensure the continuous operation of the needed network of state healthcare establishments, the Constitutional Court’s ruling consolidates the priority to distribute the funds of the budget and the funds of the Compulsory Health Insurance Fund among, first of all, state medical treatment establishments, as well as meaning that, only in cases where medical aid, due to certain circumstances, cannot be rendered in a timely and quality manner at state medical treatment establishments, it may be rendered in other healthcare establishments able to render such aid in a quality and safe manner, by allocating in this case for the latter establishments the funds of the state budget and/or the funds of the Compulsory Health Insurance Fund, i.e., meaning that, in the aforesaid conclusions drawn in the Constitutional Court’s ruling of 16 May 2013, the Constitutional Court stated the rule of the priority of state medical treatment establishments, which means priority (precedence) in implementing a certain right—the right to receive distributable public funds, in the same manner as the Constitutional Court formulated in its ruling of 22 December 2011 ‘On the compliance of the provisions of the Republic of Lithuania’s Law on Science and Studies <...>’, i.e., that non-state schools of higher education may receive state-funded student places only in cases when specialists of certain areas (fields) cannot be prepared in state schools of higher education due to objective circumstances”.

In addition, the petitioner requests a construction of whether the aforementioned provisions of the sixth and seventh paragraphs of Item 1.7 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that “the funds from the budget of the Compulsory Health Insurance Fund may be allocated to healthcare establishments only for the healthcare services to be rendered, i.e., the operation of the network of state healthcare establishments must be ensured only from state budget funds, and the operation of this network may not be ensured by the funds of the budget of the Compulsory Health Insurance Fund allocated in order of priority; as well as whether the procedure for distributing funds among personal healthcare establishments may be established exclusively by means of a law”, in the same manner as the conditions for concluding agreements regarding the rendering of services financed by compulsory healthcare insurance funds.

It should be noted that the aforementioned provisions of the Constitutional Court’s ruling and the questions raised by the petitioner in relation to those provisions are related, therefore, the said provisions should be interpreted in conjunction.

  1. In its ruling of 16 May 2013, the Constitutional Court noted that the legislature is not allowed not to pay heed to the fact that free-of-charge medical aid guaranteed to citizens must be financed by state budget funds; the constitutional guarantee of free-of-charge medical aid to citizens at namely state medical treatment establishments determines the duty of the state to ensure the rendering of this aid, inter alia, the continuous operation of the needed network of state healthcare establishments rendering this aid.

It has been mentioned that free-of-charge medical aid guaranteed to citizens must be in line with the requirements of accessibility and quality raised for healthcare services, as well as that such aid must be rendered under the conditions and procedure heeding human dignity.

In its ruling of 16 May 2013, the Constitutional Court also noted that the striving for ensuring the best possible accessibility to vitally necessary medical aid is also determined by the fact that, in the situations where, due to some circumstances, such aid cannot be rendered in a timely and quality manner at state medical treatment establishments, it may also be rendered at other healthcare establishments able to render such aid in a quality and safe manner, and the costs incurred by these establishments as a result of the said rendered aid are covered by state budget funds.

It has also been mentioned that the guarantee of free-of-charge vitally necessary medical aid to citizens at state medical treatment establishments, as consolidated in Paragraph 1 of Article 53 of the Constitution, is not identical to the right to healthcare, which is ensured by implementing the obligation of the state, as established in the said paragraph, to take care of people’s health and to guarantee medical aid and services to a human being in the event of sickness; all medical aid rendered to citizens in state medical treatment establishments (let alone other healthcare services) must not be paid for by state budget funds unconditionally and without paying heed to the state’s financial capabilities; as regards a bigger scope of free-of-charge medical aid to citizens, compared to that implied by the constitutional guarantee of free-of-charge medical aid to citizens, the legislature may establish it only in cases where this would correspond with the financial capabilities of the state, i.e., where the state budget is not subject to burden mismatched with the financial capabilities of the state, due to which the state would be unable to discharge its other functions or the discharging of such functions would be much more difficult.

In its ruling of 16 May 2013, the Constitutional Court also pointed out that, after the legislature has chosen the model of healthcare funding based, inter alia, on compulsory health insurance (the purpose of which is to ensure adequate accessibility to healthcare services), the funds of this insurance may be used to finance those healthcare services for the insured persons that are not covered by the free-of-charge medical aid that must be rendered from state budget funds to all citizens, regardless of whether they are insured by compulsory health insurance.

  1. In the aforesaid ruling, the Constitutional Court also held that the specific character of healthcare as a sphere of economic activity is determined by the fact that most healthcare services are funded by public funds, which can also be accumulated if the legislature chooses compulsory health insurance; the state, which has the duty to create a system of healthcare funding by public funds based on social solidarity, must, under the Constitution, inter alia, the constitutional principle of responsible governance, take care of the fact that those funds should be used in a responsible and rational manner; because of the fact that, due to the increasing demand for healthcare services and their increasingly higher quality standards, due to more complex and more expensive healthcare technologies, the costs of rendering these services are continually increasing, while public funds allocated for covering such costs are limited, the legislature is faced with the duty to establish the legal regulation governing the funding of healthcare services by compulsory health insurance funds that would create preconditions for the state so that it could plan the funding and distribute the funds among healthcare establishments in a manner where, without denying the obligation of the state to support the economic efforts and initiative that are useful to society and are based on private ownership, fair competition between healthcare establishments, and the right of a consumer of healthcare services (patient) to choose a healthcare establishment, one would ensure high quality of healthcare services funded by those funds and sufficient accessibility to these services, i.e., their adequate distribution, as well as the continuous operation of the required network of state healthcare establishments.

In the Constitutional Court’s ruling of 16 May 2013, it was also held that, while being bound by the duty to ensure the rational distribution of the limited funds of compulsory health insurance among establishments rendering healthcare services, the legislature may establish the conditions and limitations of the funding of such services, inter alia, such a procedure for the distribution of those funds according to which they would be allocated to cover the costs of healthcare services rendered only by those establishments that have, under the conditions established by law, concluded a corresponding agreement with an institution authorised by the state regarding the rendering of services funded by compulsory health insurance funds; the procedure for concluding such agreements should be grounded on objective and non-discriminatory criteria, known in advance, which would not deny the freedom of fair competition and other principles of Lithuania’s economy consolidated in the Constitution; the legal regulation governing the funding of healthcare services by compulsory health insurance funds should induce not only fair competition between healthcare establishments but also their cooperation in order to ensure the continuity of healthcare, high quality services, and the rational and efficient use of resources.

  1. It should also be noted that the Constitutional Court, while construing Paragraph 1 of Article 53 of the Constitution, which establishes the foundations of health protection, did not relate it to Paragraph 3 of Article 41 of the Constitution, which consolidates the right of citizens who are good at their studies to free-of-charge higher education at state schools of higher education.
  2. Thus, in the context of the questions raised by the petitioner, it should be noted that:

– state budget funds must be allocated to pay for the services of free-of-charge vitally necessary medical aid rendered to citizens at state healthcare establishments as well as to ensure the continuous operation of the network of these establishments that is needed to render such aid; where the said aid, due to certain circumstances, cannot be in a timely and quality manner rendered at state medical treatment establishments and, as a result, is rendered at other healthcare establishments, the costs incurred by the latter establishments for rendering such aid must similarly be covered by state budget funds;

– after the legislature has chosen compulsory health insurance as one of the sources for the funding of healthcare, the funds of this insurance must be used to pay for only healthcare services not covered by free-of-charge medical aid services; however, in order to ensure the adequate rendering of free-of-charge vitally necessary medical aid to citizens at state medical treatment establishments as well as the continuous operation of the network of establishments that is needed to render such aid and, at the same time, the continuity of healthcare, high quality of services, and the rational and effective use of resources, it is necessary (expedient) that a certain extent of healthcare services related to the said aid be also rendered in these establishments and be paid for by compulsory health insurance funds; the said should be taken into account when healthcare services are financed by compulsory health insurance funds, inter alia, when an institution authorised by the state concludes agreements with healthcare establishments (including state healthcare establishments) regarding the rendering of services financed by the funds of the said insurance; at the same time, it is not permitted to deny the obligation of the state to support the economic efforts and initiative that are useful to society and are based on private ownership, the freedom of fair competition between healthcare establishments, and other principles of Lithuania’s economy consolidated in the Constitution;

– the creation and maintenance of the required network of state healthcare establishments must be based on an actual demand for services rendered by these establishments and the responsible and rational distribution and use of limited public funds; it is necessary to continually assess whether the network of state healthcare establishments is optimal and whether the healthcare services rendered by these establishments meet, inter alia, the criteria of accessibility and quality;

– the relevant law must establish the fundamentals of funding healthcare services by compulsory health insurance funds, inter alia, the essential conditions for concluding, in observance of the freedom of fair competition and other constitutional principles Lithuania’s economy, agreements between an institution authorised by the state and healthcare establishments regarding the rendering of services paid for by compulsory health insurance funds; based on these fundamentals, sub-statutory acts may provide for a detailed procedure for paying for the services in question, inter alia, the procedure for concluding the aforesaid agreements.

  1. In the light of the foregoing arguments, the conclusion should be drawn that the aforementioned provisions of the first and third paragraphs of Item 1.4 and the sixth and seventh paragraphs of Item 1.7 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013, inter alia, mean that:

– state budget funds must be allocated to pay for the services of free-of-charge vitally necessary medical aid, rendered to citizens at state healthcare establishments, as well as to ensure the continuous operation of the network of these establishments, needed to render such aid;

– when healthcare services are financed by compulsory health insurance funds, consideration should be given, inter alia, to the fact that, in order to ensure the adequate rendering of free-of-charge vitally necessary medical aid to citizens at state medical treatment establishments as well as the continuous operation of the network of these establishments that is needed to render such aid, it is necessary (expedient) that a certain extent of healthcare services that are related to the said vitally necessary medical aid and are paid for by compulsory health insurance funds be also rendered in these establishments; at the same time, it is not permitted to deny the obligation of the state to support the economic efforts and initiative that are useful to society and are based on private ownership, the freedom of fair competition between healthcare establishments, and other principles of Lithuania’s economy consolidated in the Constitution;

– the legislature must, by means of a law, establish the fundamentals of healthcare services funding by compulsory health insurance funds; based on these fundamentals, sub-statutory acts may provide for a detailed procedure for paying for the said services.

V

  1. Vytenis Povilas Andriukaitis, the member of the Seimas acting as the petitioner, requests a construction of whether the provisions “<...> the state’s duty to create a system of healthcare funding by public funds based on social solidarity, where such a system would make it possible to ensure sufficient accessibility to healthcare, may not be construed in such a way that, purportedly, society should bear the burden of funding all possible personal healthcare services. In this sphere it is necessary to find decisions ensuring the balance between the interests of the person as a consumer of healthcare services (patient) and those of the whole society. <...> the principle of solidarity in a civil society does not deny personal responsibility for one’s own fate; the recognition of the mutual responsibility of a person and society is important in ensuring social harmony <...>. The legal regulation governing the funding of healthcare of persons should create incentives for everyone to take care of his health, to assume the obligation to contribute, as far as possible, to the health funding and to use the healthcare services in a responsible and rational manner. Thus, under the Constitution, the legislature also has the powers to establish that certain healthcare services must be paid for from the private sources of funding, as, for instance, by voluntary health insurance funds, direct payment by the persons themselves, etc.” of the fourth paragraph of Item 1.5 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that “on the one hand, under the Constitution, the legislature has the powers, after assessing the burden of the funding of personal healthcare services, to adopt decisions providing that a certain part of a service to be compensated by the funds from the budget of the Compulsory Health Insurance Fund be paid for by territorial patient funds (compulsory health insurance) while another part of such a service be paid from the resources of private funding, as, for instance, voluntary health insurance funds, direct payment by the persons themselves, etc., on the other hand, having chosen such a decision, the legislature is equally bound by the duty not to deny the purpose of compulsory health insurance, based on social solidarity—to ensure sufficient accessibility to healthcare services, i.e., whether personal healthcare services (with the exception of free-of-charge medical aid guaranteed by the state) may be paid for by using a combined model, i.e. where a certain part of a service is paid for by compulsory health insurance funds, while another part of the service is paid for by the funds of private sources”.

The petitioner also requests a construction of whether, in relation to the latter question, the provisions “[h]aving chosen compulsory health insurance as one of the resources of healthcare funding, the legislature must clearly define the scope of personal healthcare services financed by the funds of the said insurance. This can be done by specifying the services rendered to the insured persons for the funds of this insurance, or, conversely, by specifying those services the rendering of which is not paid for by the insurance funds and which must be paid for from private resources, whereas in cases where it is impossible to specify this precisely, sufficiently clear criteria must be established enabling one to decide in every concrete situation” of the fourth paragraph of Item 1.6 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that “the legislature is bound by the duty to specify the scope of services financed by compulsory health insurance funds; thus, after specifying which services are paid for by the funds of this insurance, the legislature is not allowed to establish that the said services may be paid for by other funds, i.e., it is not allowed to demand any additional payments from persons for services covered by the insurance in question, while, after having established which services are not covered by compulsory health insurance, the latter services must be paid for only from private sources”.

It should be noted that the cited provisions of the Constitutional Court’s ruling as well as the questions raised by the petitioner in relation to those provisions are interrelated. In view of this as well as the petitioner’s request that the aforesaid provisions be related to the questions raised in relation to them, these provisions should be construed in conjunction.

  1. In its ruling of 16 May 2013, the Constitutional Court noted that, when regulating the relations of compulsory health insurance, the legislature is bound by the requirement, stemming from Paragraph 1 of Article 53 of the Constitution, for ensuring accessibility, equal to all, to quality healthcare services; the duty of the state to create a system of healthcare funding by public funds based on social solidarity, where such a system would make it possible to ensure sufficient accessibility to healthcare, may not be construed as meaning that, purportedly, society should bear the burden of funding all possible personal healthcare services; in this sphere, it is necessary to find decisions ensuring the balance between the interests of a person as the consumer of healthcare services (patient) and those of the whole society; the legal regulation governing the funding of personal healthcare should create incentives for all persons to take care of their health, to assume the obligation to contribute, as far as possible, to healthcare funding, and to use healthcare services in a responsible and rational manner; therefore, under the Constitution, the legislature also has the powers to establish that certain healthcare services must be paid for from the sources of private funding, as, for instance, by voluntary health insurance funds, the direct payment by the persons themselves, etc.

In the ruling in question, the Constitutional Court reiterated the provisions, set forth on more than one occasion in its other rulings, that the principle of solidarity in a civil society does not deny personal responsibility for one’s own fate; the recognition of mutual responsibility of a person and the society is important in ensuring social harmony, guaranteeing a person’s freedom and possibility of protecting himself or herself from the difficulties that could not be overcome by one person alone.

In the ruling in question, the Constitutional Court also pointed out that the legislature must clearly define the scope of personal healthcare services financed by compulsory health insurance funds; this can be done by specifying the services that are to be rendered to the insured persons for the funds of this insurance, or, conversely, by specifying those services the rendering of which is not to be paid for by the said insurance funds and which must be paid for from private sources, whereas in cases where it is impossible to specify this precisely, sufficiently clear criteria must be established enabling one to decide in every concrete situation.

It has been mentioned that, after the legislature has chosen the model of healthcare funding based, inter alia, on compulsory health insurance (the purpose of which is to ensure sufficient accessibility to healthcare services), the funds of this insurance may be used to finance those healthcare services for the insured persons that are not covered by free-of-charge medical aid, which must be rendered from state budget funds to all citizens, regardless of whether they are insured by compulsory health insurance. In the Constitutional Court’s ruling of 16 May 2013, it was also held that healthcare services rendered to persons not insured by compulsory health insurance (or to those that have not obtained such insurance themselves) may not be paid for by the funds of the said insurance.

  1. Thus, in the context of the questions raised by the petitioner, it should be noted that:

– the fact that the legislature, while being under the duty to provide for a method, based on social solidarity, for accumulating the necessary public funds to ensure sufficient accessibility to healthcare services not covered by free-of-charge medical aid guaranteed to citizens, has chosen compulsory health insurance does not deny the possibility of providing for also other forms of financing healthcare services; all persons must take care of their health and contribute, as far as possible, to healthcare funding; thus, inter alia, they may, on a voluntary basis, additionally insure their health or pay for certain healthcare services (part thereof), which are rendered at either state or other healthcare establishments;

– under the Constitution, the duty of the state to create a system of healthcare funding by public funds based on social solidarity, where such a system would make it possible to ensure sufficient accessibility to healthcare, may not be construed as meaning that, purportedly, society should bear the burden of funding all possible personal healthcare services; in this sphere, it is not permitted to violate the balance between the interests of a person as the consumer of healthcare services (patient) and those of the whole society; thus, the legislature must, by means of a law, clearly specify the scope of personal healthcare services financed by compulsory health insurance funds and define clear criteria based on which it could be determined which healthcare services are paid for by the funds of the said insurance;

– under the Constitution, the legislature has the powers to establish that certain healthcare services (with the exception of free-of-charge medical aid to citizens, which is financed by state budget funds) are to be paid for from private funding sources, as, for instance, by voluntary health insurance funds, the direct payment by the persons themselves, etc.;

– the legislature may, by means of a law, also establish such a procedure (method) for financing healthcare services according to which, in certain cases, either by choice or at the request of a patient, a certain part of a healthcare service financed by compulsory health insurance funds could be paid for from private funding sources; however, such a legal regulation may not deny the requirement, stemming from Paragraph 1 of Article 53 of the Constitution, that sufficient accessibility to quality healthcare services be ensured even in cases where persons do not wish to contribute to the payment for the healthcare services rendered to them.

  1. In the light of the foregoing arguments, the conclusion should be drawn that the aforementioned provisions of the fourth paragraph of Item 1.5 and the fourth paragraph of Item 1.6 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013, inter alia, mean that the legislature must, by means of a law, clearly define the scope of personal healthcare services financed by compulsory health insurance funds as well as specify clear criteria based on which it could be determined which healthcare services are financed by the funds of the said insurance; in certain cases, either by choice or at the request of a patient, a certain part of a healthcare service financed by compulsory health insurance funds could be paid for from private funding sources; however, such a legal regulation may not deny the requirement, stemming from Paragraph 1 of Article 53 of the Constitution, that sufficient accessibility to quality healthcare services be ensured.

VI

  1. Vytenis Povilas Andriukaitis, the member of the Seimas acting as the petitioner, requests a construction of whether the provisions “[w]hen it regulates the relations of compulsory health insurance, the legislature is bound by the requirement, stemming from Paragraph 1 of Article 53 of the Constitution, for ensuring accessibility, equal to all, to quality healthcare services <...>. It implies, among other things, that compulsory health insurance must be universal, i.e. it must cover all members of society, the amount of the contributions must depend on the income of persons, this amount must be such so that preconditions could be created for the accumulation of the necessary funds ensuring the sufficient accessibility to quality healthcare services. It needs to be emphasised that after the legislature has chosen compulsory health insurance, the obligation to pay the compulsory health insurance contributions as established by law is a constitutional duty; in itself, such a duty cannot be treated as a limitation of the rights of a person” of the first paragraph of Item 1.6 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013 may be understood as meaning that “the amount of the insurance contributions paid by a person depends on all the income received by the person, i.e., not only on the income related to remuneration for work or service but also on any other type of income received by the person, while those persons who do not receive any such income and are not insured by the state are obliged, in the manner prescribed by law, to pay the contributions set by the legislature (9 percent of the minimum monthly wage); as well as whether, depending on the amount of the contributions paid by a person, the person may receive more personal healthcare services compensated by compulsory health insurance, while a person the amount of whose contributions is inconsiderable may receive less personal healthcare services that are compensated by the said insurance, i.e., whether the number of compensated personal healthcare services depends on the amount of compulsory health insurance contributions paid by a person, and whether the legislature may, by means of a law, establish different legal regulation with regard to the aforementioned categories of persons”.
  2. In its ruling of 16 May 2013, the Constitutional Court noted that, having chosen the model of healthcare funding based, inter alia, on compulsory health insurance, the legislature must, inter alia, establish the persons covered by this insurance, the amount (amounts) of the insurance contributions, the terms of payment, and possible special advantages; when regulating the relations of compulsory health insurance, the legislature is bound by the requirement, stemming from Paragraph 1 of Article 53 of the Constitution, that the accessibility, equal to all, to quality healthcare services be ensured, also by the constitutional imperatives of solidarity, social harmony, and justice, as well as by the constitutional principles of responsible governance, reasonableness, proportionality, and the equality of the rights of persons; this implies, among other things, that compulsory health insurance must be universal, i.e., it must cover all members of society, that the amount of the contributions must depend on the income of persons and that it must be such so that preconditions could be created for the accumulation of the necessary funds ensuring sufficient accessibility to quality healthcare services; after the legislature has chosen compulsory health insurance, the obligation to pay compulsory health insurance contributions as established by law is a constitutional duty; in itself, such a duty cannot be treated as a limitation of the rights of a person.

In that ruling, the Constitutional Court also noted that, while seeking to ensure healthcare accessibility to all persons, regardless of the income of persons, the legislature, inter alia, may place the burden of the compulsory health insurance of the most socially sensitive groups of persons upon the state; however, this must be done in a responsible manner, by not distorting the essence of social solidarity, without denying the incentives of persons to take care of their health and their duty to contribute, as far as possible, to health funding, thus, this must be done in such a manner that the social harmony and the balance between the interests and responsibility of the person and society would not be disturbed.

  1. Thus, in the context of the questions raised by the petitioner, it should be noted that:

– having chosen the healthcare funding model based, inter alia, on compulsory health insurance (one of social insurance types), which is universal (covering all members of society), the legislature must establish, inter alia, the persons covered by this insurance, the amount (amounts) of the insurance contributions, and possible special advantages, and it may place the burden of the compulsory health insurance of certain most socially sensitive groups of persons upon the state;

– the Constitution does not establish any amount of compulsory health insurance contributions that must be paid, nor does it prescribe any type of income based on which this amount must be calculated; it is the discretion of the legislature to establish a certain fixed or differentiated amount of compulsory health insurance contributions, depending on certain income of a person, as well as to specify the types of income based on which the amount of the said contributions would be calculated; while doing this, the legislature must pay heed to the principles of the balance of constitutional values, social harmony, responsible governance, reasonableness, the equality of the rights of persons, and other constitutional imperatives, and is not allowed to deny the obligation of the state to take care of people’s health;

– the principle of accessibility, equal to all, to healthcare services, upon which compulsory health insurance is based, means that, once the legislature establishes a differentiated, depending on certain income of a person, amount of compulsory health insurance contributions, the scope of healthcare services paid for by compulsory health insurance funds that may be rendered to a person may not depend on the amount of the said insurance contributions established for that person; the scope of healthcare services paid for by compulsory health insurance funds that may be rendered to a person is determined by the health needs of the insured, the amount of the accumulated compulsory health insurance funds, and the priorities in the funding of healthcare services; compulsory health insurance funds must be distributed in a responsible and rational manner, and the constant control over the use of these funds must be ensured.

  1. In the light of the foregoing arguments, the conclusion should be drawn that the aforementioned provisions of the first paragraph of Item 1.6 of Section IV of the reasoning part of the Constitutional Court’s ruling of 16 May 2013, inter alia, mean that, having chosen compulsory health insurance based on the principle of social solidarity, the legislature has the discretion to establish the amount of compulsory health insurance contributions depending on certain income of a person, as well as to specify the types of income based on which the amount of the said contributions is calculated; while doing this, the legislature must pay heed to the principles of the balance of constitutional values, social harmony, responsible governance, reasonableness, the equality of the rights of persons, and other constitutional imperatives, and is not allowed to deny the obligation of the state to take care of people’s health; the scope of healthcare services financed by compulsory health insurance funds that may be rendered to a person may not depend on the amount of the compulsory health insurance contributions paid by the person.

Conforming to Article 102 of the Constitution of the Republic of Lithuania and Articles 1 and 61 of the Law on the Constitutional Court of the Republic of Lithuania, the Constitutional Court of the Republic of Lithuania gives the following

decision:

  1. To construe that the provision “[t]his relation between the constitutional values implies the fact that medical aid free of charge to all citizens must be ensured insofar as it is necessary to save and preserve the life of a human being” of the second paragraph of Item 1.4 of Section IV of the reasoning part of the ruling of the Constitutional Court of the Republic of Lithuania of 16 May 2013 (Official Gazette Valstybės žinios, 2013, No. 52-2604), inter alia, means that the Constitution consolidates the guarantee of vital (which is necessary to save and preserve human life but should not be equated with medical aid to save and preserve human health) free-of-charge (financed by state budget funds) medical aid to citizens; a bigger scope of free-of-charge medical aid to citizens, compared to that implied by the said constitutional guarantee, may be established by the legislature only in cases where this corresponds with the financial capabilities of the state, i.e., where the state budget is not subject to a burden mismatched with the financial capabilities of the state, due to which the state would be unable to discharge its other functions or the discharging of such functions would be much more difficult.
  2. To construe that the provisions “Paragraph 1 of Article 53 of the Constitution consolidates the guarantee of medical aid to citizens free of charge at state medical establishments. This guarantee obligates the state to ensure the necessary conditions for its implementation, i.e., not only to create the required network of state healthcare establishments, but also to cover the costs of rendering such medical aid by state funds. Thus, while implementing its discretion of forming the state health policy and that of choosing a model of healthcare funding, the legislature may not disregard the fact that a certain part of healthcare services, namely, free-of-charge medical aid guaranteed to citizens, must be funded by state budget funds” of the first paragraph of Item 1.4 of Section IV of the reasoning part of the ruling of the Constitutional Court of the Republic of Lithuania of 16 May 2013 (Official Gazette Valstybės žinios, 2013, No. 52-2604), also the provisions “<...> the guarantee of medical aid free of charge to citizens at namely state medical establishments determines the duty of the state to ensure the rendering of vitally important medical aid at state medical establishments, inter alia, the continuous operation of the required network of state healthcare establishments rendering such aid; however, such a guarantee may not be construed as meaning that free-of-charge medical aid financed by state budget funds should be confined only to those establishments. The striving for the ensuring of the best possible accessibility to vitally important medical aid is also determined by the fact that in the situations where, due to some circumstances, such aid cannot be rendered, in a timely and quality manner, in state medical establishments, it may also be rendered in other healthcare establishments that are able to render such aid in a quality and safe manner; the costs incurred by the latter establishments in the course of rendering such aid must be covered by state budget funds” of the third paragraph of Item 1.4 of Section IV of the reasoning part of the ruling of the Constitutional Court of the Republic of Lithuania of 16 May 2013 (Official Gazette Valstybės žinios, 2013, No. 52-2604), and the provisions “[t]he specific character of healthcare as a sphere of economic activity is determined by the fact that most healthcare services are financed by public funds <...>. The state, which has the duty to create a system of healthcare funding by public funds based on social solidarity, must, <...> take care of the fact that those funds should be used in a responsible and rational manner. <...> the legislature is faced with the duty to establish the legal regulation governing the funding of healthcare services by compulsory health insurance funds that would create preconditions for the state so that it could plan the funding and distribute the funds among healthcare establishments in a manner where, without denying the obligation of the state to support the economic efforts and initiative that are useful to society and are based on private ownership, fair competition between healthcare establishments, and the right of the consumer of healthcare services (patient) to choose a healthcare establishment, one would ensure high quality of healthcare services funded by those funds and sufficient accessibility to the said services, i.e. their adequate distribution, as well as the continuous operation of the required network of state healthcare establishments. Thus, while being bound by the duty to ensure rational distribution of the limited funds of compulsory health insurance among the establishments rendering healthcare services, the legislature may establish the conditions and limitations of the funding of such services, inter alia such a procedure for the distribution of those funds, according to which they would be allocated to cover the costs of the healthcare services rendered only by those institutions that have concluded a corresponding agreement with an institution authorised by the state, under conditions established by law, regarding the rendering of the services funded from the compulsory health insurance funds. The procedure for concluding such agreements should be grounded on objective and non-discriminatory criteria, known in advance, which would not deny the freedom of fair competition and other principles of Lithuania’s economy consolidated in the Constitution” of the sixth and seventh paragraphs of Item 1.7 of Section IV of the reasoning part of the ruling of the Constitutional Court of the Republic of Lithuania of 16 May 2013 (Official Gazette Valstybės žinios, 2013, No. 52-2604), inter alia, mean that:

– state budget funds must be allocated to pay for the services of free-of-charge vitally necessary medical aid rendered to citizens at state healthcare establishments as well as to ensure the continuous operation of the network of these establishments that is needed to render such aid;

– when healthcare services are financed by compulsory health insurance funds, consideration should be given, inter alia, to the fact that, in order to ensure the adequate rendering of free-of-charge vitally necessary medical aid to citizens at state medical treatment establishments as well as the continuous operation of the network of these establishments that is needed to render such aid, it is necessary (expedient) that a certain extent of healthcare services that are related to the said vitally necessary medical aid and are paid for by compulsory health insurance funds be also rendered in these establishments; at the same time, it is not permitted to deny the obligation of the state to support the economic efforts and initiative that are useful to society and are based on private ownership, the freedom of fair competition between healthcare establishments, and other principles of Lithuania’s economy consolidated in the Constitution;

– the legislature must, by means of a law, establish the fundamentals of healthcare services funding by compulsory health insurance funds; based on these fundamentals, sub-statutory acts may provide for a detailed procedure for paying for the said services.

  1. To construe that the provisions “<...> the state’s duty to create a system of healthcare funding by public funds based on social solidarity, where such a system would allow one to ensure sufficient accessibility to healthcare, may not be construed in such a way that, purportedly, society should bear the burden of funding all possible personal healthcare services. In this sphere it is necessary to find decisions ensuring the balance between the interests of the person as a consumer of healthcare services (patient) and those of the whole society. <...> the principle of solidarity in a civil society does not deny personal responsibility for one’s own fate; the recognition of the mutual responsibility of a person and society is important in ensuring social harmony <...>. The legal regulation governing the funding of healthcare of persons should create incentives for everyone to take care of his health, to assume the obligation to contribute, as far as possible, to the health funding and to use the healthcare services in a responsible and rational manner. Thus, under the Constitution, the legislature also has the powers to establish that certain healthcare services must be paid for from the sources of private funding, as, for instance, voluntary health insurance funds, direct payment by the persons themselves, etc.” of the fourth paragraph of Item 1.5 of Section IV of the reasoning part of the ruling of the Constitutional Court of the Republic of Lithuania of 16 May 2013 (Official Gazette Valstybės žinios, 2013, No. 52-2604) and the provisions “[h]aving chosen compulsory health insurance as one of the sources of healthcare funding, the legislature must clearly define the scope of personal healthcare services financed by the funds of the said insurance. This can be done by specifying the services rendered to the insured persons for the funds of this insurance, or, conversely, by specifying those services the costs of rendering which are not paid for by the said insurance funds and which must be paid for from private sources, whereas in cases where it is impossible to specify this precisely, sufficiently clear criteria must be established enabling one to decide in every concrete situation” of the fourth paragraph of Item 1.6 of Section IV of the reasoning part of the ruling of the Constitutional Court of the Republic of Lithuania of 16 May 2013 (Official Gazette Valstybės žinios, 2013, No. 52-2604), inter alia, mean that the legislature must, by means of a law, clearly define the scope of personal healthcare services financed by compulsory health insurance funds as well as specify clear criteria based on which it could be determined which healthcare services are financed by the funds of the said insurance; in certain cases, either by choice or at the request of a patient, a certain part of a healthcare service financed by compulsory health insurance funds could be paid for from the private sources of funding; however, such a legal regulation may not deny the requirement, stemming from Paragraph 1 of Article 53 of the Constitution, that sufficient accessibility to quality healthcare services be ensured.
  2. To construe that the provisions “[w]hen it regulates the relations of compulsory health insurance, the legislature is bound by the requirement, stemming from Paragraph 1 of Article 53 of the Constitution, for ensuring accessibility, equal to all, to quality healthcare services <...>. It implies, among other things, that compulsory health insurance must be universal, i.e. it must cover all members of society, the amount of the contributions must depend on the income of persons, this amount must be such so that preconditions could be created for the accumulation of the necessary funds ensuring the sufficient accessibility to quality healthcare services. It needs to be emphasised that after the legislature has chosen compulsory health insurance, the obligation to pay the compulsory health insurance contributions as established by law is a constitutional duty; in itself, such a duty cannot be treated as a limitation of the rights of a person” of the first paragraph of Item 1.6 of Section IV of the reasoning part of the ruling of the Constitutional Court of the Republic of Lithuania of 16 May 2013 (Official Gazette Valstybės žinios, 2013, No. 52-2604), inter alia, mean that, having chosen compulsory health insurance based on the principle of social solidarity, the legislature has the discretion to establish the amount of compulsory health insurance contributions, which depends on certain income of a person, as well as to specify the types of income based on which the amount of the said contributions is calculated; while doing this, the legislature must pay heed to the principles of the balance of constitutional values, social harmony, responsible governance, reasonableness, the equality of the rights of persons, and other constitutional imperatives, and is not allowed to deny the obligation of the state to take care of people’s health; the scope of healthcare services financed by compulsory health insurance funds that may be rendered to a person may not depend on the amount of the compulsory health insurance contributions paid by the person.
  3. To refuse to construe the provision “[t]he provision of Paragraph 1 of Article 53 of the Constitution that the state takes care of people’s health expresses the constitutional principle that is reflected in various aspects also in the other provisions of the Constitution (first of all, in those of the same paragraph, but also in those beyond that paragraph). Upon this principle, the entire state activity related to people’s health must be grounded” of third paragraph of Item 1.1 of Section IV of the reasoning part of the ruling of the Constitutional Court of the Republic of Lithuania of 16 May 2013 (Official Gazette Valstybės žinios, 2013, No. 52-2604).
  4. To refuse to construe the notion “economically grounded tariffs for healthcare services”, as used in the seventh paragraph of Item 1.7 of Section IV of the reasoning part of the ruling of the Constitutional Court of the Republic of Lithuania of 16 May 2013 (Official Gazette Valstybės žinios, 2013, No. 52-2604).

This decision of the Constitutional Court of the Republic of Lithuania is final and not subject to appeal.

Justices of the Constitutional Court:                         Toma Birmontienė
                                                                                             Pranas Kuconis
                                                                                             Gediminas Mesonis
                                                                                             Vytas Milius
                                                                                             Ramutė Ruškytė
                                                                                             Egidijus Šileikis
                                                                                             Algirdas Taminskas
                                                                                             Romualdas Kęstutis Urbaitis
                                                                                             Dainius Žalimas