Present and future Challenges in Lithuanian
Mental Health Policy: shifting from deinstitutionalization
towards community integration

2004 Fellowship issue area: Public Health, Mental Health Initiative (MHI)

People with mental disabilities[1] are one of the most disadvantaged groups of people in Europe. Historically, society has tended to isolate and segregate them and, despite some improvements, discrimination against individuals with mental disabilities continues to be a serious and pervasive social problem. Prevailing negative attitudes towards people with mental disabilities mainly arises through a lack of information about this group of people, as well as misleading information about their supposed "danger" to society. In Central and Eastern European countries people with mental disabilities are generally considered dependents, not full members of society. The care for this group is most often provided in isolated and inhumane closed institutions. This system of service provision is still seen by most political decision-makers as the most efficient. The continuing existence of illegal discrimination and prejudice denies people with mental disabilities the opportunity to integrate fully into the community and to enjoy the same rights and possibilities as all other individuals. Lithuania is not an exception in this field.

This research paper aims to set out the essential steps that are necessary to put an end to the social exclusion and violation of the human rights of people with mental disabilities and, in particular, highlight the need to end the practice of placing people with mental disabilities in closed residential institutions.

· to analyze Lithuanian legislation and government policy on mental health and social care systems, to provide an overview of the current situation with regard to deinstitutionalization and the provision of housing for people with both intellectual disabilities[2] and mental health problems[3] in the community (supportive housing);

· to provide an overview of the relevant international norms and standards (United Nations’ declarations and resolutions, European documents) and their interpretation and implementation in the domestic legislation;

· to devise recommendations based on the research on developing an effective strategy to further encourage the deinstitutionalization process and promote positive changes in Lithuanian mental health and social welfare policy. Specific focus will be on the provisions that are necessary for adequate support for people with mental disabilities within the community, their implementation and functioning in Lithuania.

A system of in-patient social care institutions still prevails in Lithuania. Great numbers of people with mental disabilities live in these large residential institutions (social care institutions, psychiatric hospitals) that do not comply with the principles of modern social care standards which aim to ensure that people can wherever possible receive care and support in the community. Closed care institutions usually do not meet the hygienic, building adaptation requirements and standards of accommodating disabled people. Premises of many residential care institutions and psychiatric hospitals are overcrowded; the number of residents exceeds the set norm by two or three times. Large residential institutions usually provide only accommodation; social services are hardly implemented.

The data obtained from the research will help to form an impartial opinion about the current life situation of people with mental disabilities and the barriers they face in exercising their fundamental human rights to community integration and safe and proper living conditions within the community. Analysis of the international references and deinstitutionalization trends will help induce the shift from segregated institutional care to social inclusion in Lithuania. It will draw recommendations to address relevant and effective strategies for positive changes in Lithuanian mental health and social welfare policy which will be the basis for creating living conditions for people with mental disabilities in the least restrictive environment. In this way, the research also aims to affect deinstitutionalization policy in Lithuanian.

II. Legal Framework
1. Human rights approach: non-discrimination principle and right to community integration (including housing).
1.1.Worldwide international norms and standards.

International human rights law is built on the fundamental principle that all people should be protected equally under the law. Article 1 of the Universal Declaration of Human Rights (UDHR), adopted by the United Nations in 1948, provides that “all people are free and equal in rights and dignity”. Although not legally binding, the UDHR has inspired numerous and wide-ranging international instruments of human rights, including two legally binding UN treaties: the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR).

Yet the rights of people with disabilities have long been overlooked by the international community. Both the ICCPR and the ICESCR protect all people against discrimination on the basis of "race, colour, sex, language religion…or other status," but the language of neither convention specifies that discrimination on the basis of disability is unlawful. It was many years before the international community recognized that people with disabilities were affirmatively included in the anti-discrimination provisions of both covenants^{^[4]}.

Four other core UN human rights treaties are specialized to protect especially vulnerable groups such as women, children, workers, and racial minorities: the Convention on the Elimination of All Forms of Racial Discrimination (1965), the Convention on the Elimination of All Forms of Discrimination against Women (1979), the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (1984) and the Convention on the Rights of the Child (1989). But there is still no specialized UN convention on the rights of people with disabilities, although recently this is being considered by the UN[5]

Without specific language in international conventions the international human rights framework is rarely used to protect people with disabilities. Countries continue to subject people with disabilities to de jure discrimination - the arbitrary denial of rights that are afforded to all other citizens. People with disabilities have been locked away in institutions, considered "unfit for citizenship," and blamed for many of society's most unsolvable problems — such as crime and homelessness. Persons with disabilities were, and are, in many countries today, believed simply not to have the same "rights and liberties of normal people."

“Despite the shift towards a human rights perspective of disability over the last decade or so [...] many individuals who have been institutionalized remain ‘marginalized and forgotten’. In Central and Eastern Europe, government policies are still focused on placing people with mental health problems and/or intellectual disabilities in large remote institutions while those individuals who have not been institutionalized are also likely to be socially excluded due to the lack of available services in the community. Concerns about human rights abuses within institutions were a major factor contributing to the shift in policy from institutional care to the provision of community-based services in many western European countries.”[6]

Recently, there is a growing international recognition that, in addition to protecting rights within institutions, international human rights law provides a right to be free from institutionalization and to community integration. At present, there is no specific protection for the "right to community integration" as such in international human rights conventions, though article 23 of the Convention on the Rights of the Child recognizes the right to education, services, and support in the community. The right to community integration for people with disabilities has been recognized, however, in UN General Assembly resolutions on the rights of people with disabilities: the 1971 Declaration on the Rights of Mentally Retarded Persons, the 1991 Principles for the Protection of Persons with Mental Illness (The MI Principles), and the 1993 Standard Rules on Equalization of Opportunities for Persons with Disabilities[7].

In 1971, the UN General Assembly recognized as a general principle in the Declaration on the Rights of Mentally Retarded Persons that "wherever possible, the mentally retarded person should live with his own family or with foster parents and participate in different forms of community life. In the 1991 Principles for the Protection of Persons with Mental Illness (The MI Principles) it expanded the definition of this right to community integration and recognized not only the right "to live and work, as far as possible, in the community" but also "the right to be treated and cared for, as far as possible, in the community in which he or she lives." This preference for community living is reinforced by the duty to treat in the least restrictive environment and to preserve and enhance autonomy. Further, the Principles specifically prohibit all discrimination on the grounds of mental illness and define discrimination as "any distinction, exclusion or preference that has the effect of nullifying or impairing equal enjoyment of rights." Resulting that an individual who is institutionalized may be unable to exercise his or her rights to live and work in the community, or to be free from discrimination.

In 1993, the World Conference on Human Rights meeting in Vienna reemphasized the fact that people with mental and physical disabilities are protected by international human rights law and that governments must establish domestic legislation to realize these rights. In what has come to be known as the “Vienna Declaration,” the World Conference declared that “all human rights and fundamental freedoms are universal and thus unreservedly include persons with disabilities.”[8]

Pursuant to the recommendations of the World Conference on Human Rights, the United Nations General Assembly adopted a new resolution, the “Standard Rules on Equalization of Opportunities for Persons with Disabilities” (“Standard Rules”), which seek to ensure that all disabled people, ‘as members of their societies, may exercise the same rights and obligations as others’. The Standard Rules apply to all people with mental or physical disabilities, and recognize the right to community integration and community-based services to make such integration possible.

Although not legally binding, MI Principles, Declaration on the Rights of Mentally Retarded Persons and the Standard Rules can provide a useful guide on the implementation and interpretation of the legally binding treaties. Besides, they ‘imply a strong moral and political commitment on behalf of States to take action for the equalization of opportunities for people with disabilities’^{^[9]} At the same time, as it is indicated in the report of the Special Rapporteur of 2005 “a range of conceptual frameworks, and other insights, arising from the treaty-based rights provide useful guidance regarding the non-binding international instruments relating to mental disabilities. Properly understood, the generalized international human rights treaties and specialized international instruments relating to mental disabilities are mutually reinforcing[10].

Although the United Nations binding human rights treaties do not specifically address the concerns of individuals with mental disabilities, as a recent report of the Secretary General to the General Assembly makes clear, they are ‘entitled to the same protection that human rights law affords in general to all persons’. They “provide persons with mental disabilities with the right to liberty and security of person, to fair trial and to recognition everywhere as a person before the law, and the right to the highest attainable standard or physical and mental health, to education and to work, respectively.” ^{^[11]},

Following the arguments laid down by the Special Rapporteur, the right to community integration is derivative from the right to health and other human rights. „Community integration supports the dignity, autonomy, equality and participation in society, helps prevent institutionalization, which can render persons with mental disabilities vulnerable to human rights abuses and damage their health on account of the mental burdens of segregation and isolation. Community integration is also an important strategy in breaking down stigma and discrimination against persons with mental disabilities“^{^[12]}.

The World Health Organisation’s has also repeatedly criticised the institutionalization of people with disabilities. In the report of 2001, Mental Health: New Understanding, New Hope, it urged Governments to give priority to mental health in their health planning and made ten recommendations for action. In Recommendation 3 – ‘Give Care in the Community’ it states that “Community care has a better effect than institutional treatment on the outcome and quality of life of individuals with chronic mental disorders. Shifting patients from mental hospitals to care in the community is also cost-effective and respects human rights”[13].’

Ultimately, in the Mental Health Declaration for Europe 2005 WHO recognized “that the promotion of mental health and the prevention, treatment, care and rehabilitation of mental health problems are a priority for WHO and its Member States”[14]. Endorsing the statement that there is no health without mental health, which is central to the human, social and economic capital of nations and should therefore be considered as an integral and essential part of other public policy areas such as human rights, social care, education and employment. Following the Declaration, the Mental Health Action Plan for Europe 2005 was prepared. Proposing ways and means of developing, implementing and reinforcing comprehensive mental health policies in the countries of the WHO European Region, it requires specific actions to Offer effective care in community-based services for people with severe mental health problems.

WHO states that „there is no place in the twenty-first century for inhumane and degrading treatment and care in large institutions“, and that „it is essential to acknowledge and support people’s right to receive the most effective treatments and interventions while being exposed to the lowest possible risk, based on their individual wishes and needs“ [15]. WHO calls its member states for actions to consider: empower service users and carers to access mental health and mainstream services; plan and implement specialist community-based services, accessible 24 hours a day, seven days a week; provide crisis care, offering services where people live and work, preventing deterioration or hospital admission whenever possible; offer comprehensive and effective treatments, psychotherapies and medications with as few side effects as possible in community settings; etc.

“In Europe, the most important documents on human rights are the European Convention on Human Rights (1950), (‘the ECHR’) and the European Social Charter, 1961 (revised 1996). The ECHR sets out a range of civil and political rights while the European Social Charter addresses economic, social and cultural rights”[16]. The European Convention on the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, 1987 is also significant. In accordance with the requirements of the Convention, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (the CPT) was established, which examines ‘the treatment of all categories of persons deprived of their liberty by a public authority, including persons with mental disabilities’.

The European Union Charter of Fundamental Rights (2000), setting out a range of civil, political, economic and social rights, has an important provisions in providing a means for Community action to prohibit discrimination on the grounds of disability (art. 21) and justification for positive developments on behalf of disabled persons as a means of ensuring equal opportunities (art. 26). Although future legal status of the Charter is indeterminate yet.[17]

The first step towards advancing disability rights and recognizing disability as human rights issue on the European level was made on 1997, adopting the Treaty of Amsterdam (in the European Union framework)[18]. The Treaty of Amsterdam added a new Article 13 to the Treaty, reinforcing the principle of non-discrimination, which is closely linked to equal opportunities. The Treaty of Amsterdam for the first time mentions specifically disability as being the ground for non-discrimination, and makes the protected rights accessible to the individuals. Signing the Treaty European institutions and the EU Member states agree and oblige themselves to provide appropriate measure and to ensure that disability laws and policies do indeed contribute to the equal rights and equal opportunities of people with disabilities.

The Commissioner for Human Rights has also expressed his concern over the respect for the human rights of persons with mental disabilities^{^[19]}. Within the conclusions the provision for development of effective support and community care services is to be encouraged as a preferable alternative to unnecessary prolonged institutionalisation.

1.4. Precedents on the promotion of the community based services versus institutions

The European Commission and Court of Human Rights have heard numerous cases on the rights of institutionalized people with disabilities. As a result of this process, it has been established that treatment practices within institutions raise fundamental human rights concerns[20]. The practice of American legal system gives an example of the first such kind court decision, which provides the direction for further efforts to establish the right to community integration and inclusion for all people with disabilities in the United States, and as an example for other counties and the United Nations as well.

The United States Supreme Court in Olmstead v LC (1999) held that the unjustified segregation of individuals with ‘mental disabilities’ constituted discrimination under the Americans with Disabilities Act (antidiscrimination legislation). This was because the Court reasoned that undue institutionalization is discriminatory because it results in dissimilar treatment settings for individuals with mental disabilities vis a vis individuals without disabilities. It treats disabled individuals differently than non-disabled individuals by requiring people with disabilities to forego their life in the community in order to receive needed mental health treatment, inside an institution, while imposing no such requirements on people who are not disabled. Furthermore, the unnecessarily institutionalized because such confinement itself perpetuates unwarranted assumptions that the individual is incapable of participating in community life. Moreover, this unnecessary confinement diminishes the individual's ability to have a social life, family relations, to receive an education, or become economically independent through employment. Thus, undue institutionalization is discriminatory not only because it treats people with and without disabilities differently in terms of their access to mental health treatment, but also because it perpetuates the negative stereotypes of people with mental disabilities as "incapable or unworthy of participating in community life," depriving them of "everyday life activities" such as "family relations, social contacts, work options, economic independence, educational advancement and cultural enrichment"[21].

One of the human rights that should be afforded to all the persons equally, is the right to adequate housing. It has received a wide recognition as a fundamental human right in a number of international instruments and declarations, regional instruments and national laws. The significance of a secure place to live for human dignity, physical and mental health and overall quality of life, which enables one's development, begins to reveal some of the human rights implications of housing. With the adoption of the Universal Declaration of Human Rights in 1948, the right to adequate housing joined the body of international, universally applicable and universally accepted human rights law. Since that time this right has been reaffirmed in a wide range of additional human rights instruments, each of which is relevant to distinct groups within society. Many of the instruments that recognize the right to adequate housing phrase this right as one to which everybody is entitled. Article 25 of the Universal Declaration on Human Rights proclaims that: Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. Article 11 of the International Covenant on Economic, Social and Cultural Rights contains perhaps the most significant foundation of the right to housing, including the obligations of the States Parties to take appropriate steps to ensure the realization of this right. Both the United Nations Declaration of the Rights of the Child (1959) and the Convention on the Rights of the Child (1989) address the special housing rights of children.

Adequate housing is universally viewed as one of the most basic human needs[22]. Since having access to adequate, safe and secure housing substantially strengthens the likelihood of people being able to enjoy certain additional rights. Housing is a foundation from which other legal entitlements can be achieved. For example: the adequacy of one's housing and living conditions is closely linked to the degree to which the right to environmental hygiene and the right to the highest attainable level of mental and physical health can be enjoyed. The World Health Organization has asserted that housing is the single most important environmental factor associated with disease conditions and higher mortality and morbidity rates.

The right to adequate housing does not automatically imply that Governments are duty-bound to provide free housing to all citizens. It does, however, require Governments to take necessary measures which are aimed at enabling individuals to have access to adequate, affordable and safe dwellings.

2. Interpretation and implementation of the international norms in the domestic legislation – governmental obligations

“Lithuania has ratified most major international human rights instruments, including those with provisions relating specifically to the rights of people with disabilities. International treaties take precedence over national legislation.^{^[23]} Lithuania acceded to the International Covenant on Economic, Social and Cultural Rights[24] (CESCR) and the International Covenant on Civil and Political Rights[25] (CCPR) in 1992. Lithuania ratified the Convention on the Rights of the Child[26] in 1992. Lithuania ratified the ECHR in 1995, but has not signed or ratified Protocol No.12 to the ECHR. Lithuania ratified the Revised European Social Charter^{^[27]} of 1996 in 2001, and is bound by Article 15 on the right of persons with disabilities to independence, social integration and participation in the life of the community”[28].

The United Nations Standard Rules on Equalization of Opportunities for People with Disabilities[29] served as a source of reference for the preparation and adoption, in 2002, of the National Program for Social Integration[30].

Within the Single Programming Document (hereafter SPD)[31] for the period of 2004-2006, Lithuania took an obligation and outlined various measures to ensure equal opportunities and full integration of the disabled (though not explicitly referring to individuals with mental disabilities, it ensures the same rights to all the disabled).

Taking into account the Decision of the Council of the European Union of 3 December 2001 On the Declaration of the Year 2003 the Year of Persons with Disabilities, the Seimas of the Republic of Lithuania[32] adopted resolution declaring the year 2003 as the Year of the Persons with Disabilities of Lithuania[33]. The Action Plan of the Year of Persons with Disabilities in Lithuania, adopted in 2003, established the main policies of the State to ensure the rights of people with disabilities[34].

In line with the Council Directive 2000/78/EC of 27 November 2000, establishing a general framework for equal treatment in employment and occupation (hereafter the “Employment Directive”) and Council Directive 2000/43/EC of 29th June 2000 implementing the principle of equal treatment between persons irrespective of racial or ethnic origin (hereafter the “Race Directive”), the legislative framework for anti-discrimination has recently been significantly strengthened with the adoption of the new Law on Equal Opportunities 2003[35], which entered into force on 1 January 2005. This law was formulated as the general multi ground non-discrimination law that prohibits discrimination on various grounds including disability. The non-discrimination principle on the grounds of disability is set explicitly in the Law of equal opportunities which states that it strives to “ensure the realization of equal rights established by the Constitution of the Republic of Lithuania, as well as prohibit any direct or indirect discrimination on the grounds of age, sexual orientation, disability, racial or ethnic origin, religion or convictions”. Provisions of this law do not cover the spheres of family and private life, and explicitly regulates the implementation of equal opportunities in such areas as: 1) state and municipal institutions’ and offices’ activity in adopting legislature, preparing various programs and means for guaranteeing equal opportunities; 2) education; 3) employment; 4) access to goods and services.

Following the WHO European Ministerial Conference on Mental Health, by an Order of Minister of Health the committee for consideration of questions on mental health was composed to implement the provisions of declaration and action plan and to frame the strategy of Lithuanian mental health. The committee will perform an analysis of Lithuanian mental health programs, indicators of society’s mental health and activity of mental health care system and give recommendations on the Lithuanian mental health strategy and implementation of Helsinki Ministerial Conference Action Plan in Lithuania.

III. General current situation of people with mental disabilities in Lithuania

According to the current Lithuanian legislation, concerning the definition of “disability”, different terms of general nature are used in different legal acts: “invalidity”, which refers to the loss of the capability to work;[36] Persons with disabilities”[37]“person with mental disabilities”;[38] and, for educational purposes, “person with special education needs”.[39]: The term “intellectual disabilities” is not precisely defined in the laws of the Republic of Lithuania. Government regulations describe intellectual disability as a separate type of “disorder” and establish three levels of disability, including intellectual disability, for children: slight, moderate and severe.^{^[40]} For adults, the individual’s assessed level of intellectual disabilities is used as a basis for assigning one of three disability groups[41]: I, II or III, where group III is the least severe degree of disability. “However, the offensive term “imbecility” is still used in the Civil Code 2002”[42].

The Law on Mental Healthcare 1995 specifically focuses on the area of mental health and mental patients. It uses such terms as: “mental (psychiatric) patient (patient)” which is perceived as the person, who has psychiatric illness; and the “patient” who is understood as the psychiatric patients or any other person, who makes use of mental health care.

There are different procedures used in the assessment of children with disabilities, for educational, social care purposes; and in the assessment of adults with disabilities, for disability status and access to social benefits.^{^[43]} Until recently^{^[44]} the Law on Social Integration of People with Disabilities 1991^{^[45]} established the functioning system of determining disability. The Law regulated the establishment of disability, medical, vocational and social rehabilitation for disabled persons, the adjustment of conditions for the disabled, as well as the development and education of the disabled. It established legal, economic and organizational guarantees for the occupational, vocational and social rehabilitation of the disabled. The disability assessment procedures for adults (age 18 and over) established an individual’s disability according to one of three disability groups, I, II or III[46]. Indicated group of disability provided the right to receive state social insurance and other pensions, benefits, privileges.

In accordance with the Law on Social Integration 1991, statistics on people with disabilities should be collected regularly.[51] However, until recently the data collected and published by government agencies and institutions concerning people with disabilities was not comprehensive, and it did not contain specific information on people with intellectual disabilities. The most comprehensive official data on people with disabilities comes from the 2001 population census[52]. The other main sources of data are the Ministry of Social Security and Labor (on the number of people receiving disability pensions) and the State Mental Health Centre (on the number of people assessed as having mental disability and determined as being legally incapacitated due to the intellectual disabilities or mental health problems).

Within the present system of disability classification, the large group of “people with mental disabilities” is separated in Lithuania, which includes both people with intellectual disabilities and people with mental health problems and behavioural problems. In the daily practice there is an identification problem of these two groups of people[53], and it may constitute an important barrier in tackling the problem of establishing and meeting needs for social services, since it is not a homogenous group and support provided for them should not be unified.

For the first time the 2001 census specifically included questions on disability, data was collected on people with disabilities according to their disability group (I, II or III); cause of disability (for example, a congenital condition or accident); and type of disability. This allows for a differentiation of people with disabilities according to various demographic criteria, such as their socio-economic group or living conditions.

The evaluation of the results from the census towards the category of “people with mental disabilities” are compound, since it is still not possible to extract precise data on people with either intellectual disabilities or mental health problems from the census results. Furthermore, some caution is required in interpreting the statistics, which was based on the self-declaration. Many people with intellectual disabilities and mental health problems may be “missing” because they did not declare themselves for various reasons, including shame on the part of their families, or because they are in institutions.

According to the census there were 22,121 people with mental disabilities in Lithuania[54][55]. A total of approximately 19,584 adults with disabilities indicated mental disabilities as the main cause of their disabilities (or 7.4 per cent of all adults with disabilities)[56]. The majority of these (67.5 per cent) were diagnosed as being in disability group II. A total of 2,537 children (18.6 per cent of all children with disabilities) indicated mental disabilities.

Statistics from the State Mental Health Centre indicate a higher number of people with mental disabilities in Lithuania than was indicated in the 2001 Census. According to the centre, the number of people of all ages with established mental disabilities has gradually increased over the last decade, from 18,937 in 1990 to 28,697 in 2003, and 31,201 in 2004.^{^[57]} The center’s statistics provide data specifically on people with intellectual disabilities and people with mental health problems. In 2001, of the 27,640 people with mental disabilities, 8,202, or 30 per cent, were people with intellectual disabilities; in 2003 - 8,436 people and in 2004 – 9089 persons, again approximately 30 per cent of the total, were people with intellectual disabilities.

The Ministry of Social Security and Labor does maintain disaggregated statistics on the people with disabilities. However, as with the census, these statistics mention only the broader category of people with mental disabilities. According to the ministry, in 2002, 31,351 people were designated as having a disability for the first time. Out of this group, approximately 2,540 people, or 8.1 per cent of the total, had mental disabilities as their primary disability.^{^[58]}

4.General overview of the situation of persons with mental disabilities within the institutions

The international practices and trends on deinstitutionalization provide the arguments that provision of community care produces better outcomes, such as quality of life, that it better respects human rights and that it is more cost–effective than institutional treatment[59]. But due to the lack of national evidences and upon the influence of specific interest groups, Lithuania still follows the historic principle and allows further to dominate stigmatizing services and exclusively bio medical attitude.

Reliance on residential institutions and the lack of community-based alternatives to care is harmful, costly and intractable legacies that were inherited form the command economy of former Soviet Union. The key barriers to change the harmful legacies of the command economy of the Former Soviet Union and reduce reliance on residential institutions include: financial and organizational pressures to maintain residential institutions; public acceptance of this form of care as appropriate; and the absence of a national social welfare infrastructure, of systematic monitoring and oversight, and of a legislative framework that focuses on protecting the rights of vulnerable individuals[60].

Residential institutions absorb much of the limited governmental and nongovernmental resources that are needed to assist vulnerable groups. “In Lithuania, for example, 1.75 percent of the national budget is used for institutional care of vulnerable individuals”^{^[61]}. Since up to now the institutional care has a monopoly of services for vulnerable groups of people, the huge amount of financial resources were and still are allocated for renovation of buildings, improving comfort and living conditions, etc. Besides currently social care homes are the biggest employers in their regions[62]. Changing the system to support community-based care involves significant changes both to the existing funding and structural mechanisms within the system. Huge financial input and the problem of redeploying staff (ie finding other jobs for the vast numbers of people who are employed in the institutions) are arguments put forward by ‘specific interested groups’ (authorities, responsible for providing services at place, directors of the institutions, etc.) to support their view that the institutional care services is the only option for caring for people with mental disabilities. But these are not good grounds for doing nothing to change the current system of institutionalization and prevent human rights violations of people with mental disabilities.

Big residential institutions (psychiatric hospitals, social care homes) are usually functioning as a “separate republics”, maintaining the close intercourse within the system, i.e. with other mental health care institutions, and are closely related. Sometimes the patients of the psychiatric hospitals are moved on to social care homes, if they do not have the residential place or family members do not want him to return. “Problematic” social care homes residents are sent to psychiatric hospitals in cases of acute condition; as a mean of discipline for disobedience. In some cases psychiatric hospitals sometimes serve as residential institutions, since some category of patients (acute ones) are in fact “living” in the hospital several months or even more[63].

Such reticence of the institutions prerequisite the public opinion, which supports the existing system and stigmatizing attitude towards the mentally disabled people. One-third of Lithuanians believe that the human rights of the disabled received insufficient attention in 2004[64] and that the disabled were thought to be the second most discriminated social group[65]. The situation of the mentally disabled has been notably problematic. Opinion polls have shown that every other Lithuanian would prefer to isolate individuals suffering mental disabilities in institutions caring for mental patients on a regular basis. Sadly, only 30,8 % of respondents answered that above mentioned disabled persons should live in community, at home, together with people without disabilities, guaranteeing for them appropriate social services, thus integrating them into the society, eliminating stigmatizing factors. It has been widely believed that mentally disabled people are dangerous for others and that restrictions on their rights can be justified[66]. Notwithstanding this an antiquated attitude, since it is clearly demonstrated, that “healthy” people and not those suffering with mental health problems commit the absolute majority of crimes[67].

According to the data of the Social Institutions Supervision and Audit Department[68] for 2004 under the subordination of district administrations there are 22 special boarding homes for adult people with intellectual disabilities in Lithuania and 3 special boarding homes for children and young people with intellectual disabilities under the age of 21.

In Lithuania, according to the 2001 Census, a total of 6,095 people with mental disabilities, or approximately 27.5 per cent of the 22,121 people who declared themselves as having mental disabilities, were living in social care institutions. This group included 5,217 adults living in social care institutions and 878 children living in social care institutions for children and young people with disabilities. By the January 1, 2005 in state social care homes were residing 5349 persons (2882 male and 2467 female) and 659 children (373 boys and 286 girls)^{^[69]}. For 10 000 population there were 15,3 places in social care homes (data for 1 January 2005)[70].

Most of those institutions are located in remote parts of a country far from population centers. Residents of social care homes are commonly detained in those closed, segregated institutions and kept out of public view. People may remain in these custodial facilities for life, living cut off from family, friends, and community. The statistical data for the first half of year 2004 presents that there were 227 new residents that arrived at social care homes for adults with mental disabilities: 8,8 % - from other social establishments; 70,1 % - from home, 16,7 % - from hospitals and 4,4% - from lodging-house. For the same period 228 residents left social care homes: 3,9 % - to other social establishments, 7,9 % - to relatives or living at home; 88,2 % - died. There is no information available on the reasons of their death, but these figures obviously show the one-way movement of social care homes’ residents.

The international practices show that only few of these individuals need to be confined to institutions^{^[71]}. A small percentage of institutionalized populations are made up of individuals who present a danger to themselves or others or who are in need of treatment that must be provided in an institution. For example, 1407 (26,3 %) adults and 244 (37 %) children (data for 1st of January 2005) are intensively nursed in social care homes^{^[72]}. Many people in social establishments have mild or moderate disabilities (sometimes no disabilities at all), and are placed in institutions because they are marginalized in society and have no community support network: medication, social services meeting their individual needs.

From the Picture one can see, that the majority (more than 80 %) of residents are having disability group II, which in most cases does not require constant care and nursing[73]. Only approximately 18 percent of social care homes residents are in disability group I (which represent the most severe level of disability).

Because of the lack of community support and alternative services network in the municipalities and the growing numbers of vulnerable people that require them, there is a phenomenon of waiting lists for getting to the social establishments. According to the data from the Department of Audit and supervision of social establishments, in the waiting list to get to the state social care homes for adults with mental disabilities – there were 369 persons (201 male and 168 female). 91 of which have Disability group I, 263 – Disability group II, 15 – having no disability group (data for 1st of January 2004). The phenomenon of waiting list both promote the placement of persons into the social care homes (people are afraid to refuse the future place in institution), overstate the number of persons waiting for the place (the same individual is inscribed in two or more waiting lists in different counties), and defend an argument that the only way to guarantee medical and social support for those people is to place them into institutions.

According to Mental Health in Lithuania, Report of Assessment mission[74], 18% of the residents of social care homes could live in the community if appropriate services were available^{^[75]}. This means that people get to the social care home without considering their social abilities and deficiencies. At the same time, the loss of social skills within the social institutions is inevitable, and reintegration of such residents back into society requires additional efforts for recovery of their social abilities.

Authorities in various municipalities indicated similar problems in organizing services for people with intellectual disabilities and persons with mental health problems: most municipalities still orient to institutional care services provided in the county’s social care homes and do not establish community based services; the range of services provided in municipalities is not expanded enough; undefined functions and activity of different departments within the municipality in providing services for this social group of persons, lack of financial resources for establishing such institutions, lack of qualified specialists, absence of system of services, that could help person to live as long as possible in community ^{^[76]}. This illustrates the tendency of using of the most expensive and least user participation and activity requiring services and still undeveloped infrastructure of community based services in Lithuania[77].

“Psychiatric hospitals may be also considered as the practices of stigmatizing isolation of persons with mental health problems. The same as social care institutions, they are the part of complex health care system, which is based on the same principles of paternalism, social exclusion and stigma. The fact that the mental health patients are treated not within the general, but in the specialized psychiatric hospitals, is an obvious example of stigma. The system of isolated psychiatric care and treatment institutions prerequisite for the human rights violations and deepen the social exclusion and stigmatization of the patients”.[78]

According to data of the Lithuanian Health Information Centre[79], there are 11 psychiatric hospitals in Lithuania. The number of psychiatrists per 10 000 people is 1,6 (in 1999, it was 1,3).[80] The admission rate is 10,5 per 1000 population, and the average length of stay is 32,4 days, bed turnover is 9,1. In year 2002 there were 3816 beds in psychiatry, i.e. 11,0 per 10 000 population. Percentage of deaths is 0,39%. Registered in outpatient clinics per 1000 population (adults) in 2002 mental and behavioral disorders: incidence 24,9, prevalence 76,5.

Health specialists alert of growing number of people with mental health problems in Lithuania. The morbidity with psychiatric disorders increased from 2287,5 in 1999 to 2688,2 in 2004 per 10 000 residents. There might be an outbreak of mental illness in the future, since there is a growing number of children having various psychological problems. Actually one third of Lithuanian children experience violence – physical, psychological, sexual^{^[81]}. Surveys^{^[82]} report about great numbers of Lithuanian pupils, who had thoughts about committing a suicide (33%) and those who attempted one (5%). Not long time ago health specialist noticed that in

Lithuania

the number of young people who are recognized as not suitable for the military service is rapidly increasing. Conscripts lose the ability to serve in the army if they have insufficient intellectual development^{^[83]}or have psychiatric disorder. Last year from total 2,5 thousand tested conscripts even 42 percent were considered as not suitable for the service. 26 percent from which, residing in the capital or Vilnius County had psychiatric disorders[84].

“Over the past ten years, reports have highlighted serious human rights abuses within institutions in Eastern and Central Europe. The reports identify a range of human rights violations within institutions for people with mental health problems and intellectual disabilities”[85]. The financial investments put into the system[86] for modernizing and making the institutions better does not address the human rights abuses. In their own essence big institutions can not lead to respect and security of the most fundamental human rights, such as: the right to private life, information, least restrictive environment, right of movement and other[87]. On the contrary all the reports[88] on the monitoring of human rights of persons within the institutions highlight the failure to comply with the following standards: protection from arbitrary detention; adequate living conditions; adequate provision of care and treatment; individualized care plans; protections from harm and others.

In Lithuania it is common practice to circumvent the legal procedures for civil commitment in cases where people with mental disabilities are placed under the "guardianship" which is equivalent to the so called plenary guardianship[89]. Placement under guardianship functionally strips them of any legal right to make the most basic decisions about their own lives. A ward who is under guardianship loses all civil and political rights usually enjoyed by adults. The guardian represents the ward under law and is entitled to “enter into all the necessary transactions in the interests and on the behalf of the ward[90], including the cases of "voluntarily" committed to an institution (both psychiatric hospital and social care home) by their guardian[91]. The statistical data show, that in total in the social care homes there were 697 (13 %)[92] residents who have been declared as legally incompetent and placed under guardianship (for the 1 January 2005). The whole procedure of declaring person incompetent[93] raise some doubts on its transparency and the “best interest” approach towards persons with mental disabilities[94].

Human rights and freedoms of patients within psychiatric hospitals are determined by the attributed regime[95] that is selected in accordance with the mental status. “The use of such rights as the right to privacy, movement and to property, as well as possibility of using means of restraints or seclusion primarily depend on the regime attributed”[96].

In relation to admission to psychiatric hospitals the predominant practice is to make the decision on involuntary hospitalization (or its extension) [97] without patient’s participation in the court process[98]. This obviously violates first of all the patient’s right to access to justice, and also the right to get appropriate treatment, since implementing the court’s decision on the involuntary hospitalization, based exclusively on the single-sided information from the mental health specialist, not taking into account patient’s wishes and choice, means both the person’s compulsory stay in the hospital as well as his treatment there. Even more problematic may be hospitalization of incompetent persons, in case guardians do not give their consent. There are no mechanisms for obligating guardians to proper exercise their obligations (to the best interest of the ward) and monitoring[99] the implementation of their duties. Extremely faulty is the procedure for request of removal of a guardian, since the ward is not entitled to initiate the change of his or her guardian and can not complaint about his improper supervision[100].

In Lithuania health care system is organized on a national (state), regional (counties) and local (municipality) levels and health care services are provided on a primary, secondary and tertiary health care levels. The objectives of Lithuania's health care system are to create and implement health care policy that will ensure public health, high quality of health care services and the rational use of resources based on health insurance and the right for permanent residents to free basic treatment, as well as the right of the patients to choose their doctor or a medical establishment.

Mental health care is part of the whole health care system. Mental health care is a specialized health care, executed according to the standards approved by the Ministry of Health care. The purpose of this care – is to provide psychiatric assistance (to diagnose, treat psychiatric disorders, forewarn about flare up of psychiatric illnesses at time), to help person to adjust to the society life and return to it.

In Lithuania, since 1989, the creation of the modern and relevant to the international standards mental health care system began. Emerging mental health problems and increasing prevalence of suicides, violence and substance abuse has attracted attention from governmental and nongovernmental sectors First new mental health services, NGOs and professional associations were established in the early 1990s. The most important achievements of the period of 1994-1996 was the Law on the Mental Health Care adopted by the Lithuanian parliament (Seimas) in 1995. This law laid the foundations for the reforms in mental health care system as well as for prevention against the misuse in psychiatry. From 1997 further steps towards the formation of the state mental health policy were performed: the State Mental Health Centre was established, the State Program on Prevention of Mental Disorders was adopted.

The reform of mental health system encouraged the establishment of mental health centers[101] under the primary health care institutions in municipalities and the decrease in the indicators of in-patient mental care. Currently, 65 (with two private ones)[102] mental health centers are functioning in Lithuania.

Article 53 of the Constitution of the Republic of Lithuania specifies that the State takes care of people's health and guarantees medical aid and services in the event of sickness. The Law provides free medical aid to citizens at state medical facilities.

Being a part of the whole health care system mental health care is regulated by the number of different laws and other legislation, that encompass the health care of all Lithuanian residents, including persons with disabilities.

The Law on Social Integration 2004 indicates, that “in order to secure equal opportunities of persons with disabilities within the sphere of health care, the health care services to the persons with disabilities are provided of the same level and within the same system as for other society members”[103]

The rights of individuals within the health care system are regulated by the Law on the Rights of Patients and Compensation of the Damage to their Health. The Law provides patients with such rights: right to assessable health care, the right to select a physician, nursing staff member, health care institution, the right to information, right to refuse treatment, right of complaint, right to inviolability of Personal Privacy. New amendments[104] to the law, which came into effect in the beginning of 2005, focus on compensation for damage endured during the provision of treatment or services. Compensation is based on the culpable actions of healthcare specialists[105] and the actions of individuals conducting examinations who do not comply with biomedical research standards[106]. Besides, the law particulary stresses the importance of the patient’s choice and consent to his treatment.

The Law on Mental Health care of the Republic of Lithuania adopted in 1995 provides the priority of medical help for persons with mental disabilities and additional health care. Since intellectual disabilities are associated with mental disabilities in most legal acts, it follows that discrimination against people with intellectual disabilities is equally prohibited under this legislation. It secures the insurance of all political, economic, social and cultural rights to mentally ill patients and non-discrimination on the grounds of mental illness (past or existing). Patients have the right to receive appropriate, accessible and suitable health care. The conditions of a patient’s mental health care at the time of their hospitalization must not be inferior to the treatment and nursing conditions of any person being treated. The law specifies patients’ right to select the physician, nursing staff member, health care institution or to refuse treatment; no treatment shall be given to a patient without his consent. Patients are entitled to the treatment and care conditions least restrictive to their freedom and dignity. These rights maybe restricted in cases when involuntary hospitalization is needed, also when mental health care services are provided for convicted persons with mental health problems.

The Law on Mental Health care specifies cases when an involuntary hospitalization which restricts person’s freedom is legitimate. A person who has a severe mental illness and refuses hospitalization may be admitted involuntarily to the custody of the hospital only if there is real danger that by his actions he is likely to commit serious harm

· Up to 1 month from the beginning of hospitalization, with the court permission;

· Extension of involuntary hospitalization and treatment should be reviewed by the court every 6 month.

These conditions must be met in order for a person’s involuntary hospitalization to be lawful

V. Lithuanian social care system

The Program for development of social services infrastructure [107] yet from 1998 proclaimed that the main policy trend of social services is decentralization and development of ambulatory (community) services. The main tasks indicated in the Program for 2004-2006 are to further disperse and decentralize organization and provision of social services; decrease the differences of social services infrastructure in the regions; develop the network of social service institutions and the variety of services provided and stimulate the quality of social services[108].

The Ministry of Social Security and Labor is implementing a reform of the provision of social services, which aims at creating legal, administrative, and financial foundations for an effective planning, provision and organization of social services, thereby ensuring the basic human needs and encouraging an individual to search for ways of self-helping. Social Services aim at satisfying the needs of individuals and creating living conditions that do not debase human dignity, when the individual himself is incapable of accomplishing this. Social services are divided into general and special social services.

General social services are provided to help persons with disabilities to live independently at home and in the community.

Special social services are provided to persons with disabilities when general social services are ineffective. These are provided at inpatient and outpatient care institutions and in rehabilitation institutions (such as day-centers, temporary residences, in-patient care, nursing homes and centers providing different types of services. The main task for the social care homes is to provide social care services to those people who cannot fend for themselves: temporary or permanent residence for the disabled who are in need of care, nursing, and who cannot live in their homes or independently.

The Order of the Minister of Social Security and Labor[109] provides that inpatient care institutions under the subordination of counties are for adults[110] who due to intellectual disability cannot live at home, make use of other community services and who need constant care; and for children (4 - 21 years of age) - including children and young people with intellectual disability[111].

Social services in Lithuania were legally established in the Social Support Conception adopted by the Government of the Republic of Lithuania in 1994. Social services were identified as one of the three social support forms. Further development of social services to different groups of individuals was set forth in the Law on Social Services of the Republic of Lithuania.

On 4 September 1998 Ministry of Social Security and Labor issued an Order on Development of trends for providing social services at homes and regulations of increase of work efficiency of social care homes, that gave the priority for providing social services at homes within the community, and stated that the person must be referred to the social care home only in cases when social services provided at home are not efficient and do not secure for the person the level of independency needed.

The Strategy for reorganization of state social care institutions 2002[112] foresees the trends of reorganization of state care institutions for 2003-2008 year. The necessity for such reorganization is conditioned by the facts, that: according to the data of Ministry of Social security and Labor state care institutions house approximately 30% (this number include both old age persons and persons with disabilities) of people who could live independently receiving social services in community. Quite often municipalities dissociate from financial obligations to organize social services for their community members, and dealing with problems of lone persons or persons without residential place, send them to the state care institutions. Social services for people with disabilities are in most cases provided in such institutions, since the infrastructure of community based services for persons with disabilities is not developed enough. The majority of state care institutions are overcrowded, with up to 550 residents^{^[113]} (see Appendix, Table 1). Upon implementation of the strategy it is foreseen to every year gradually expanding the network of social services provided in community, to decrease the number of places within institutions, improving the living conditions and quality of services provided. To seek, that in 2008 year the number of residents would not exceed 300 in one institution and not more than 4 persons would live in one room[114].

Special in-patient social services are provided to children and adults with intellectual disability in social care homes. The Requirements for In-patient Social Care Institutions and the Procedure for Sending Persons to In-patient Social Care Institutions (hereinafter referred to as the Order) were approved by the Order of the Minister of Social Security and Labour on 9 July 2002 . The Order regulates the organization of the work of in-patient social care institutions, norms of the personnel, defines the services provided, the rights and duties of residents, requirements for the building of care institutions and environment, acceptance and departure from these institutions and the contingent of accommodated persons.

Though social care homes are intended to provide with housing, catering, utilities, personal hygiene, social work, communication and consultation services those with intellectual disability who cannot live at home, make use of other community services and who need constant care. Only recently the Procedure 2000 was amended[115] with the provision that for those in Disability group II may be established the need for constant care[116]. Previously the constant care was only indicated for those in Disability group I. Such law provision contradicted with the existing practice that majority of social care home residents have disability group II (see Picture 1).

Persons are accepted into the care institutions on a voluntary basis, except of those under the guardianship[117]. The resident can leave the care institution for a short period of time (up to three months per year) or for good if he is recognized as capable and willing to do so. When releasing a resident, it must be secured that services will be ensured for him in the community; he will have proper living conditions and will be able to live independently. The resident who is recognized as incompetent or capable to a limited extent may only leave the institution permanently if they are going to live with a custodian or a guardian assigned to him by the court. Since there is a faulty practice of establishing guardianship to the persons after they are accepted to the social care home and usually administration of the social care home is assigned as a guardian, person is unable to leave the home at any occasion.

Requirements for the outpatient social services institutions of 2003^{^[118]} establish minimal requirements for such outpatient institutions which main activity is social work and provision of social services^{^[119]}. Description of organization of such institutions, requirements for personnel, social services, buildings, rights and obligations of clients are included.

Though the trend for decentralization of institutions and provision of social services within community was proclaimed yet in 1998, only in 2005 the definition of independent living homes was included into the Catalog of Social services^{^[120]}. Independent living home is defined as an outpatient social services institution, wherein old age persons or people with disabilities, who do not require intensive social care services, and who are able to live independently, only with part time support of social worker, are housed[121].

The newly adopted Law on Social Integration 2004 is intended to guarantee equal rights and opportunities for people with disabilities while establishing principles for the social integration of people with disabilities. The new law sets out rules for determination of disability and working capacity, provision of rehabilitation services, and principles for assessing and meeting the special needs of people with disabilities.^{^[122]}

The Law on equal opportunities 2003 is of great importance to the disabled, since it explicitly establishes the prohibition of discrimination on the grounds of disability. Covering the area of access to goods and services, the law indicates that “whilst implementing equal opportunities, the goods seller, producer or service provider is obliged to ensure irrespective of a person’s disability: equal conditions to get the same production, goods and services, including accommodation, and …guaranties for the adequate or of the same value products, goods or service…”[123].

VI. Trends in deinstitutionalization processes and providing housing for people with both intellectual and mental disabilities in the community (supportive housing) in Lithuania.

The World Health Organization in its Report of 2001 called for a continued shift away from the use of psychiatric hospitals and long-stay institutions to the provision of community care, arguing that such care produces better outcomes. The report recognized that community care implies providing a comprehensive range of services and points of contact, with contributions from different professionals and sufficient links to other sectors such as housing and employment (WHO, 2001a)^{^[124]}.

“Over the last 30 years major moves towards deinstitutionalization, that is, towards reducing the use of such institutions, have taken place in many European countries”[125]. Individuals have been transferred to other settings such as general hospitals or various forms of community-based supported living establishments, or have been returned to their family homes.

The challenges were particularly great in Central and Eastern Europe, where command economies of the former Soviet Union had the reliance on residential institutions[126].

Recently there has been seen a progress in terms of deinstitutionalization in Central and Eastern Europe. In Lithuanian, for example the number of psychiatric beds from 1991 was reduced by more than one third. The time spent in hospitals was shortened and trying to change it to the treatment at the ambulatory mental health centers.

The World Bank research suggests a strategy for making transition and reforming mental health care system. It includes: changing public opinion and mobilizing community support; strengthening community-oriented social welfare infrastructure; establishing community-based social service pilot projects; using pilot projects to reduce the flow of individuals entering residential institutions and to reintegrate individuals into the community; redesigning, converting, or closing facilities; creating a national system of community-based social services^{^[127]}.

Each country should make decision on the mix of mental health services that is necessary, taking into account a range of factors including population needs, level of resources, flexibility and coordination of organizational structures, as well as local culture, and include them in its national mental health policy and action plan.

“The extent to which services can be moved from institutions to the community and the appropriate model of care continue to be key questions for policymakers. The mixed results of the deinstitutionalization process experienced by some countries may dissuade policy-makers from further moves towards community-based care”[128]. Also administrators may be extremely reluctant to countenance change; they may be worried about losing their status and authority. Employees will also be understandably concerned about their own job prospects if, for instance, institutions are shut down and replaced by community services.

Nevertheless the positive changes within the region and membership in international organizations will induce to resign the monopoly of the closed institutions and to take action to organize and deinstitutionalize mental health care system, providing community care services as alternatives to institutional care. In Lithuania, as well as in other countries of the region, there is a continuing need to address human rights violations, stigma, discrimination and the consequent social exclusion that set mental health apart from most other health concerns. Ultimately there is a necessity to promote positive mental health and mental well-being. The World Health Organization has published evidence that mental health promotion and mental disorder prevention can help in maintaining or improving health, have a positive impact on quality of life and be economically worthwhile (WHO, 2004b, 2004c)^{^[129]}.

There are a key guiding principles recommended for organization of mental health services: protection of human rights (whether services are based in the community or in hospital settings); accessibility (services available locally); comprehensiveness (facilities and programs should meet all needs of the population); coordination and continuity of care; effectiveness (evidence of effectiveness or at least ongoing monitoring and evaluation of services); equity (services available across the whole country, not just in urban centers, on the basis of need); efficiency (developing of services and shifting resources based on evidence of cost–effectiveness)[130].

Evidence on the cost–effectiveness of community care versus institutional care suggests that community-based services do not necessarily reduce health system costs, but that the quality of life and satisfaction with services are improved, while the costs remain broadly the same. There is also evidence that quality of care is closely related to expenditure on services.

“There are no persuasive arguments or data to support a hospital-only approach, nor is there any scientific evidence that community services alone can provide satisfactory comprehensive care. Instead, it argued that a “balanced care” approach is required, whereby frontline services are based in the community with back-up from hospitals, which provide a limited amount of acute inpatient care. Where hospital stays are required, they should be as brief as possible, with services provided in normal community settings rather than in remote, isolated locations”[131]. One of the aims of social support is effectively reserving state resources to provide services in the community, and to exhaust institutional services only in cases of necessary indications.

Lithuanian Health Program describes such mental health priorities as stabilization of morbidity with mental diseases, reduction number of suicides up to average of European countries. Exclusively mental health priorities are nominated in the State mental disorders prevention program (1999)[132] and consider prevention of occurrence of mental disorders, early detection, qualitative active and supportive treatment stressing the importance of primary mental health care and social rehabilitation. It also emphasizes: assurance of effective and accessible composite help for persons with mental and behavioral disorders; rehabilitation and integration of mentally disabled people; decentralization of mental health care services in Lithuania; etc.

The National Program on Social Integration for People with Disabilities 2003-2012[133] is also aimed at seeking of equal opportunities in social integration of people with disabilities and planning activities that would correspond to the international and national policy aims and obligations. The principles for planning the state policy on social integration of people with disabilities are: continuity of means of rehabilitation; equal opportunities, accessibility, compensation for disability, decentralization, prevention of discrimination and participation of people with disabilities.

The Ministry of Social security and Labor reports that upon implementation of The Program for development of social services infrastructure through 1998-2004 years, more than 100 project on development of social services were financed with 29,75 mln. Lt.^{^[134]}. Meanwhile only over one year for financing of traditional social care homes the government allocates several times more resources than through the 6 years for financing development of modern alternative services^{^[135]}.

Nevertheless all these programs mentioned pay too little attention to the housing (independent living) problems of people with disabilities (especially people with mental disabilities). With an increasing number of disabled persons, growing children with disabilities, with the new generation of parents (who does not want to send their children to the institutions and raise them by themselves, but are not able to guarantee an appropriate care for them hereafter) the need for such services is constantly growing. Representatives of non-governmental organizations and other stakeholders negatively view the so called ‘old type’ care institutions and state a preference to small community type houses or small care institutions intended for persons with mental disabilities. These could facilitate development of their social skills, encourage independence and implementing other social rehabilitation programs. Parents (guardians) of children or adults with either intellectual disability or mental health problems are apt to take care of their family members themselves or send them to such institutions, which would resemble home environment.

The Council for the affairs of disabled to the Government of the Republic of Lithuania[136], seeking to develop the community based social services indicated in the Catalog of Social services and to increase the independence and decrease social isolation of people with disabilities is financing from the state budget the Program of Adaptation of accommodation (environment) to the disabled[137]. The aim of this program is to help people with disabilities to live independently within their own homes and secure environment. Nevertheless the priority is put to various categories of disabled people with moving difficulties.

The persons with mental disabilities are also discriminated re possibility to get the state assistance to purchase or rent the dwelling. Within the list of diseases that people suffer from serious forms, entitling them to the state assistance there are no mental illness or psychiatric disorders included[138].

Only on the initiatives of non governmental organizations representing people with mental disabilities and their families options for supported living for such people are emerging in Lithuania. There are few of such examples.

By the initiative of Lithuanian Welfare Society for Persons with intellectual disabilities “Viltis”[139] seven independent living homes are established for people with intellectual disabilities with 115 persons getting services there.

Text Box: Pašilaičiai living home in Vilnius (the capital).
The Living home is located in one of the living regions of Vilnius and occupies two ordinary apartments in the tenement house. 9 persons (5 in one apartment and 4 in another) with intellectual disabilities live and share the space there. 5 social workers are employed and work on a rota basis (one person being permanently) to help them. Most of the residents are orphans, being selected and referred here from social care homes by “Viltis” organization. All residents attends day care centers, 5 of them need assistance and transportation, 4 goes independently. Being at home, they prepare food for themselves, do housecleaning, laundry, watches TV, etc. For the living, food and other expenses they pay 80% from their disability pension. The left money is used either independently, or with the help of the social worker, depending on the person’s abilities.
In case there is a vacancy, the new resident is referred by “Viltis”.

By the initiative of Viltis organization and in collaboration with Vilnius municipality authorities the Plan of proposals and measures on developments of services for people with intellectual disabilities was drafted. The analysis of the demand for living services in Vilnius city shows, that in Vilnius city the housing services for people with intellectual disabilities above 18 year old is provided in two social services establishments mentioned above. They house 37 people with intellectual disabilities. Meantime there are 46 parents’ applications at the “Viltis” Vilnius branch due to the people from 16 years old included into the list, which at present requires social services within the establishment, but because of lack of places can not be provided.

The growing demand for stationary establishments providing social services for people with intellectual disabilities older than 18 year old is conditioned by the activity of special education establishments in Vilnius city. Every year the growing number of young people with severe or moderate intellectual disabilities leaves these institutions. Taking into account the existing integrated system of educational and day occupation services, it is necessary to plan the increase of places in living establishment. At present there are 259 children and teenagers attending education and day occupation centres in Vilnius. Some of them are orphans and need living places and constant social care.

The Plan proposes: to organize integral interdependent network of social services (secured housing program for people with slight intellectual disability, specialized living homes for people with severe and moderate intellectual disabilities, temporary care centres); to develop network of stationary social services for people with intellectual disabilities (independent living homes to 20 people with slight and moderate intellectual disability, care home for 40 people with severe intellectual disability).

At present there are no such housing services for people with mental health problems either. Only recently by the initiative of GIP Vilnius office in cooperation with Lithuanian society of people with mental disabilities "Giedra" and Lithuanian Welfare society for persons with psychiatric disorders there is a project on creating an independent living establishments for people with mental health problems.

In addition to protecting human rights within institutions, international human rights instruments, recognize and provide a right to be free from institutionalization and to have the right to community integration.

Residential institutions are harmful, costly and intractable legacies that not only create conditions for the perpetration of human rights violations, but institutions in themselves infringe the person’s right to liberty, freedom of movement, right to have a choice and to receive care and support in the least restrictive environment. Nor are they are effective, neither from a medical aspect nor from a social. This is because they perpetuate the myth that people with mental disabilities are “socially ignorant” and “useless” and become a financial burden for the state to take care about.

Following the international practice based on human rights approach, equality and nondiscrimination principles, countries are induced to make a transition and create alternatives to institutional care. It is recommended that the Lithuanian government shows a strong political will to make a shift from the institutional care towards community integration of people with mental disabilities.

Giving the priority to the area of mental health as an integral component of society‘s overall health in the national health policy should address the stigma, social exclusion and deeply entrenched prejudices towards people with mental disabilities in the Lithuanian society.

Setting the framework for the assessment and provision of mental health services, and their integration with general health and community services would guarantee parity with other health care services and ensure that what is provided is appropriate to people’s needs. Appropriate mental health services should be accessible, acceptable and of adequate quality.

The principle of the least restrictive alternative should be laid down in the legislative and other necessary measures that would prevent inappropriate institutionalization and provide appropriate facilities, services, programs, personnel and protection, as well as opportunities for people with mental disorders to thrive in the community.

Mental health system should not as exclusive as it is. Legislation should establish and guarantee the continuity of care, moving beyond health and social care, and protecting people with mental disabilities against discrimination and encouraging their social integration within all area of life.

A network of community based social services should be developed and expanded as much as possible to cover the geographical spread and the range of possible specific needs of people with intellectual disabilities and mental health problems.

It is recommended that people with mental disabilities, their family members and NGOs, representing their interests make use of the Law on equal opportunities 2003 as much as possible in ensuring nondiscrimination principles with respect to their access to services (including housing).

The right to adequate housing has received a wide recognition as a fundamental human right, enabling everybody to have access to adequate, affordable and safe dwellings. Legislation should incorporate provisions for giving people with mental disabilities priority in state housing schemes and for setting up subsidized housing schemes, as well as for establishing a range of specialized housing facilities such as halfway homes and long-stay supported homes. The implementation of such programs should be guaranteed to enable vulnerable people to enjoy the independent living to the fullest possible extent, with an appropriate support services.

The protected funding needed and safeguards should be put in place to ensure that funds are fully transferred as the balance of services shifts from institutions towards the community. “Money follows the persons” funding schemes might encourage the changes, providing persons with mental disabilities options to choose services best meeting their needs, and making the competitions between different service providers for the clients with the ensured money to come.

Different legal subjects administering separate parts of the complex institutional care system does not ensure the objective assessment of functioning of various institutions and continuity of care for people with mental disabilities outside the sphere of their competence. Independent monitoring structures are needed to guarantee the constant supervision of the whole system and its effective functioning, based on the respect and securing of the basic human rights standards with respect to people with mental disabilities.

[1] The umbrella term “mental disability” includes major mental illness and psychiatric disorders; more minor mental ill health and disorders, often called psychosocial problems; and intellectual disabilities. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Paul Hunt* Doc E/CN.4/2005/51, para 19.

[2] The term “intellectual disability” (also described as ‘learning disability’ or ‘mental retardation’) here refers to a lifelong condition, usually present from birth or which develops before the age of 18. It is a permanent condition that is characterized by significantly lower than average intellectual ability and results in significant functional limitations in intellectual functioning and in adaptive behavior as expressed in conceptual, social and practical adaptive skills.

[3] Mental health problems include depression, bipolar disorder (manic-depressive illness), attention-deficit/ hyperactivity disorder, anxiety disorders, eating disorders, schizophrenia, and conduct disorder.

[4] Eric Rosenthal and Arlene Kanter. People with Disabilities in Institutions and the Emerging Right to community Integration: Protections Under International and U.S. Law.

[5] Starting from July 29, 2002 the UN Ad Hoc Committee is working on the draft of the Comprehensive and Integral International Convention to Promote and Protect the Rights and dignity of Persons with Disabilities. Information accessible on the Disabled peoples‘ international website at http://www.dpi.org/en/resources/topics/topics-convention.htm

[6] Included in Society. Results and Recommendations of the European Research Initiative on Community-Based Residential Alternatives for Disabled People. p.20

[7] Eric Rosenthal and Arlene Kanter. People with Disabilities in Institutions and the Emerging Right to community Integration: Protections Under International and U.S. Law.

[8] Vienna Declaration and Program of Action, World Conference on Human Rights, Vienna, 14-25 June 1993, U.N. Doc A/CONF.157/24, para. 63.

[9] Standard Rules, paragraph 14.

[10] Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Paul Hunt* Doc E/CN.4/2005/51, para 30.

[11] United Nations General Assembly, ‘Progress of efforts to ensure the full recognition and enjoyment of the human rights of persons with disabilities’ Report of the Secretary General, 24^th July 2003, pages 4 & 5

[12] Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Paul Hunt* Doc E/CN.4/2005/51, para 85.

[13] The world health report 2001 - Mental Health: New Understanding, New Hope, WHO accessed on the WHO website at http://www.who.int/whr/2001/chapter5/en/index1.html

[14] European declaration on Mental Health, 2005. EUR/04/5047810/6. 14 January 2005. 52667

[15] Mental Health Action Plan for Europe, 2005. EUR/04/5047810/7. 14 January 2005. 52671.

[16] Included in Society. Results and Recommendations of the European Research Initiative on Community-Based Residential Alternatives for Disabled People. p.19.

[17] It was meant that the status of the not legally binding Charter will change when the European Constitution comes into force (on ratification by the Member States). Considering that the solid acceptance of this European document is breached (with the opposition by France and Holland), the future of the whole European Constitutions is under the question now.

[18] Richard Whittle. The Framework Directive for equal treatment in employment and occupation: an analysis from a disability rights perspective. 27 European Law Review. June 2002.

[19] The protection and promotion of the human rights of persons with mental disabilities. Seminar organized by THE COMMISSIONER FOR HUMAN RIGHTS, Copenhagen, 7 February 2003. Conclusions, paragraph 8.

[20] For example: case Van der Leer v. the Netherlands (compulsory confinement in a psychiatric hospital without a hearing was challenged), application No. 11509/85. Judgment 21 February 1990. Reported at (1990) 12 EHRR 567; case Johnson v. the United Kingdom (patient no longer with mental disability still detained), application No. 119/1996/738/937. Judgment 24 October 1997. Commentary at EHRLR 1998, 2, 224-226, etc. Information from the Mental disability advocacy center (MDAC) website accessed at http://www.mdac.info/resources/echr_cases.htm

[21] Olmstead v LC, 527 US 581 (1999)

[22]International norms and standards relating to disability. Part IV. Towards a Rights Based Perspective on disability.3/3, accessed at http://www.un.org/esa/socdev/enable/comp402.htm#2.5.1

[23] The Constitution (Article 138) and the Law on International Treaties 1999 define the main principles concerning the effect of international conventions, treaties and agreements. International treaties ratified by the Seimas become constituent parts of the legal system of Lithuania. If the standards defined by international treaties ratified by Lithuania differ from the ones set in its legislation, the standards of those international treaties must take precedence over Lithuanian legislation. Legislation and other legal acts of Lithuania must be coordinated with the norms set in these treaties. K. Jovaišo, Commentary of the Lithuanian Constitution (Part 1), Law Institute, Vilnius, 2000 (hereafter, Jovaiša, Commentary).

[24] International Covenant on Economic, Social and Cultural Rights (CESCR), 3 January 1976, 993 U.N.T.S. 3, available on the UNHCR website at http://www.unhchr.ch/html/menu3/b/a_cescr.htm (accessed 5 May 2004).

[25] International Covenant on Civil and Political Rights, 23 March 1976, 999 U.N.T.S. 171, available on the UNHCR website at .http://www.unhchr.ch/html/menu3/b/a_ccpr.htm (accessed 5 May 2004).

[26] International Convention on the Rights of the Child, 2 September 1990, 44 U.N. GAOR Supp. (No. 49) at 167, U.N. Doc. A/44/49 (1989), available at http://www.unicef.org/crc/crc.htm (accessed 26 November 2004).

[27] Revised European Social Charter, 1 July 1999, C.E.T.S. 163, available at http://conventions.coe.int/Treaty/en/Treaties/Html/163.htm (accessed 22 October 2004).

[28] EUMAP report “Rights of People with Intellectual Disabilities. Access to Education and Employment. Lithuania”, Vilnius, 2005.

[29] United Nations Standard Rules on the Equalisation of Opportunities for Persons with Disabilities, A/RES/48/96, 20 December 1993.

[30] National Programme for Social Integration and Action Plan for the National Programme for Social Integration.

[31] Lithuanian Single Programming Document for the period 2004–2006 establishes the priorities and measures under which projects in Lithuania will be selected to receive funding from the EU Structural Funds. The SPD 2004–2006 includes various important measures aimed at promoting equal opportunities and the full integration of people with disabilities in general. However, it does not explicitly refer to people with mental disabilities.

[32] The Parliament of the Lithuanian Republic.

[33] This placed the State under the obligation to prioritise issues that concern people with disabilities in all aspects of their life; ensure their protection from discrimination; and grant them equal rights and opportunities aiming at strengthening their independence, social and economic integration and participation in the life of society.

[34] Government Decision „On Action Plan for the Year of People with Disabilities“ No. 159//State News, 2003, No. 14-558.

[35] Law on Equal Opportunities No. IX-1826//State News, 2003, No. 114-5115

[36] The term “invalidity” is still used in the Law on Social Integration 1991. However, the new Law On Social Integration 2004 no longer uses this outdated term.

[37] Law On Social Integration 2004//State News 2004, No. 83- 2983 (coming into force from 1 July 2005).

[38] Law on Mental Health Care 1995.

[39] The Law on Special Education 1998, in Article 3, defines “people with special needs” as “children and adults who, because of congenital or acquired impairments, have limited opportunities for participating in the educational process and social life”.

^{^[40]}Joint Order of the Ministry of Health and the Ministry of Social Security and Labour of 22 March 2004, on the List of Ailments and Conditions for Determining the Level of Disability (severe, moderate and slight) for Disabled Children, approved by, No. V-144/A1-69//State News, 2004, No. 44-1464; 2004, No. 47 (readjusted), para. 2, (hereafter, Order on determining disability level for children).

[41] After 1 July 2005, there will be no disability groups assigned, but the loss of working capacity determined in accordance with the new Law on Social integration 2004.

[42] EUMAP report “Rights of People with Intellectual Disabilities. Access to Education and Employment. Lithuania”, Vilnius, 2005.

[43] The Ministry of Social Security and Labour and the Ministry of Health Care are jointly responsible for disability assessment procedures related to health care, employment, social welfare entitlements, exemptions and rehabilitation. For the purpose of disability assessment, the health condition of a person with disabilities is evaluated according to a methodology designed by the Ministry of Health Care. The Ministry of Education and Science is responsible for assessing the special educational needs of children and young people with disabilities.

[44] The old version of the Law on Social Integration 1991 is valid until 1 July 2005. After this date the new Law on Social integration of people with disabilities 2004 comes into force. It changes the very concept of disability and establishes new procedure for its evaluation.

[45] The Law on the Social Integration of People with Disabilities 1991// State News 1991, No. 36- 969 (hereafter Law on Social Integration 1991).

[46] Up to now disability assessment procedure for adults was primarily based on inadequate and predominantly medical criteria, with little or no consideration given to the person’s actual capacity for work or the possibility of rehabilitation.

[47] The Law on the Social Integration of People with Disabilities, No. IX-2228//State News, 2004, No. 83-2983, (hereafter, Law on Social Integration 2004).

[48] Law On Social Integration 2004, art. 3.

[49] EUMAP report “Rights of People with Intellectual Disabilities. Access to Education and Employment. Lithuania”, Vilnius, 2005.

[50] According to the previous disability assessment procedures for people age 18 and over (including old age persons) disability group was indicated. The new procedure provides that for old-age people, who due to the long term health changes or their consequeances totaly or partially lost their independency and are not able to care for their personal and social life, special needs are established.

[51] Law on Social Integration 1998, art. 7.

[52] Department of Statistics, results of the 2001 Population and Housing Census, available in English and Lithuanian on the website of the Department of Statistics at http://www.std.lt (accessed 23 September 2004), (hereafter, 2001 Census).

[53] The research „Preparation of strategy on providing of social support for persons with intellectual disabilities and persons suffering from mental illness, and recommendations on optimal ratio of institutional care and community based services“ 2003 showed that not all municipality departments of social support and health had segregated data on those two groups of vulnerable people.

[54] Department of Statistics, Information circular No. 2, 20 November 2003 (hereafter, Department of Statistics, Information circular No. 2)

[55] According to the 2001 census, Lithuania’s population in 2000 was 3,620,756 people.

[56] The total number of persons with disabilities was 263 thousand, and constituted 7,5 percent of the total population of Lithuania. 2001 Census; and Department of Statistics, Information circular No. 2.

[57] Information from the website of the State Mental Health Centre, available at http://www.vpsc.lt. The State Mental Health Centre was established in 1999 by the Ministry of Health Care. The Centre organises the implementation of mental health care policy and strategy.

[58] Ministry of Social Security and Labour, Social Report 2002, Vilnius, 2003.

[59] David McDaid, GrahamThornicroft. Mental Health II. Balancing Institutional and community-based care. Policy Brief. WHO 2005, page 1.

[60] Tobis D. Moving from Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union. 2000, The World Bank.

[61] Tobis D., 2000. Moving from Residential Institutions to Community-based Services in Central and Eastern Europe and the Former Soviet Union. World Bank, Washington, DC

[62] Monitoring Human Rights in Closed Mental Health Care and Social care Institutions. Report, Vilnius, 2005, page 13.

[63] Monitoring Human Rights in Closed Mental Health Care and Social care Institutions. Report, Vilnius, 2005.

[64] .The Situation of Human Rights in Lithuania and Evaluation of Human Rights Protection System., representative public opinion survey (N = 1,000), conducted by Vilmorus Market Research within the framework of the National Human Rights Action Plan.

[65] .How Does the Community Rate the Situation of Human Rights in Lithuania?. Public opinion survey, Human Rights Monitoring Institute, 2004.

[66] Human right in Lithuania. Overview 2004. Human rights Monitoring Institute, Vilnius, 2005.

[67] Experts affirm, that every day rights of people with mental disabilities are infringed in Lithuania. Elta announcement, 25 May 2005.

[68] The Supervision and Audit Department at the Ministry of Social Security and Labor is a state institution, which caries out the supervision and assessment of social services institutions and social programs, available at http://www.sipad.lt/

[69] This number is increasing, since on 1 July 2004, there were 5344 persons (2865 male and 2479 female) living in social care institutions for adults with mental disabilities. Data received from Department of Audit and supervision of social establishments, accessed at website http://www.sipad.lt/main/index.php?act=menu&id=57.

[70] This number increased, since data for 1st of January 2004 showed that for 10 000 population there were 14,6 places in social care homes.

[71] Tobis D. Moving from Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union. 2000, The World Bank.

[72]. For 1st of July 2004, 1616 (30,2 %) adults and 241 (36,9 %) children had the need for constant nursing. Department of Audit and supervision of social establishments, accessed at website http://www.sipad.lt/main/index.php?act=menu&id=57

[73] Only in cases of acute psychiatric and behaviour disorders, the need for constant support and nursing may be established for persons with disability group II. Amendments of 25 May 2004 to the Order “On the Procedure for Determining the Loss (Disability) of Long-Term and Constant Capability to Work” No. V-387/A1-145//State News, 2004, No. 87-3184.

[74] Mental Health in Lithuania. Report of Assessment mission, 16-17 October 2000

[75] Authorities of social care homes report, that approximately 20% of residents could live in the community, receiving additional services (this number range in different establishments from 10 to 30 %). Monitoring Human Rights in Closed Mental Health Care and Social care Institutions. Report, Vilnius, 2005.

[76] The research „Preparation of strategy on providing of social support for persons with intellectual disabilities and persons suffering from mental illness, and recommendations on optimal ratio of institutional care and community based services“ 2003., the research covers various country regions.

[77] The research „Preparation of strategy on providing of social support for persons with intellectual disabilities and persons suffering from mental illness, and recommendations on optimal ratio of institutional care and community based services“ 2003

[78] Monitoring Human Rights in Closed Mental Health Care and Social care Institutions. Report, Vilnius, 2005, page 7.

[79] Lithuanian Health Information Centre website accessed at http://www.lsic.lt/html/en/lhic.htm

[80] http://www.lsic.lt/html/en/lhic.htm

[81] Results from international research "Teenagers attitude to sexuality and sexual violence”, information accessed at http://www.mip.lt/index.php/news,archive;97

[82] Data from the survey carried out by the State Mental Health Centre. Article “The nation “gets crazy”, Magazine “Veidas” of May 5, 2005.

[83] The youngster who makes less than 80 point in the IQ test is considered as inappropriate for the service.

[84] Rapidly increasing number of conscripts having psychiatric disorders. ELTA announcement of February 2 2005.

[85] Included in Society. Results and Recommendations of the European Research Initiative on Community-Based Residential Alternatives for Disabled People. p.20.

[86] During the past 15 years the situation in Lithuanian social care homes, in comparison to the other Baltic states, is the most improved.

[87] Monitoring Human Rights in Closed Mental Health Care and Social care Institutions. Report, Vilnius, 2005, page 7.

[88] For example Monitoring Human Rights in Closed Mental Health Care and Social care Institutions. Report, Vilnius, 2005.

[89] A person who “as a result of mental illness or imbecility is not able to understand the meaning of his actions or control them” may be by the court decision declared as legally incapable and placed under guardianship. Civil Code 2000, art. 2.10(1), art. 3.277(1).

[90] Civil Code 2000, art. 3.240(1) and (2).

[91] A ward who is under guardianship loses all civil and political rights usually enjoyed by adults. The guardian represents the ward under law and is entitled to “enter into all the necessary transactions in the interests and on the behalf of” the ward.

[92] This number is increasing, since according to the data for the 1 July 2004, 663 (12.4%) residents of the social care homes were under the guardianship.

[93] Although the Lithuanian legislation provide for opportunity to the courts to limit the active capacity of individuals who “abuse alcohol, drugs or other toxic substances” and place them under curatorship which is equivalent to so called “partial guardianship”, this is not the applied to the individuals with mental disabilities, where the courts have the only option to fully remove the individual’s active legal capacity. Civil Code 2000, art. 2.11(1), art. 3.279.

[94] Many people are declared as incompetent without legal representation or due process protections. For example, wards do not have the right to appeal the court’s final decision that determines their incompetence and places them under guardianship. Code of Civil Procedure 2002, art. 469.

[95] Presently there are four types of regimes: regime of intensive supervision (the most strict one, whit the prohibition for the patient to leave the ward); regime of medium intensity supervision (the patient can leave his ward, but can not leave the psychiatric department); regime of non intensive supervision (when the short walking in the territory of hospital is allowed to the patient); and free regime (the patient is allowed to leave the territory of the hospital).

[96] Monitoring Human Rights in Closed Mental Health Care and Social care Institutions. Report, Vilnius, 2005, page 26.

[97] See section IV.2.

[98] According the conclusion of psychiatrist, that “the patient is not able to show in front of the court due to his health condition” the court may decide on the involuntary hospitalizations (or its extension) without the patients participation.

[99] Guardianship institutions (municipal or regional institutions concerned with the supervision and control of the actions of guardian) are responsible for the continuous supervision of designated guardians in matters relating to the proper performance of their duties. Civil Code 2000, art. 3.241(1).

[100] This is undertaken by the authorities at a care institution or by the prosecutor. Civil Code 2000, art. 3.246(3).

[101] Organisation and functioning of mental health centers are regulated by the 1996 year Government Order on confirming Regulation of Mental health care center. They are accredited by the State to provide mental health care and social support to patients with mental health problems and other persons.

[102] Data from the State Mental Health Centre website accessed at http://www.vpsc.lt/centrai2.html

[103] The Law on the Social Integration of People with Disabilities, No. IX-2228//State News, 2004, No. 83-2983, (hereafter, Law on Social Integration 2004).

[104] Law on the Amendment of the Law on Patients Rights and Compensation for the Damage Caused to the Health, No. IX-2361//State News, 2004. No. 115-4284.

[105] Healthcare institutions and relevant staff are deemed at fault when a patient’s health is partially or fatally impaired as a result of failure to comply with legal regulations governing provision of health care services and treatment and/or in the methods used for diagnosis and treatment. Healthcare institutions and relevant staff are further at fault when a patient’s health is impaired due to deliberate actions of health care providers which may not necessarily violate legal requirements and/or when healthcare providers have been negligent in their duty.

[106] The respective law issued on 13 July 2004 amended the Law on Ethics of Biomedical Research by focusing responsibility on the technician conducting biomedical research for liability in physical damage due to impairment or death and moral damage resulting from the research, unless evidence shows that the damage occurred to reasons unrelated to the biomedical research or the deliberate actions of the examined person.

[107] Government decision on approving of The program for development of social services infrastructure 1998-2003//State News, 1998, No. 19-478

[108] Government decision on approving of The program for development of social services infrastructure 2004-2006//State News, 2003, No. 90-4075

[109] Order of the Minister for Social security and Labor on the Requirements for the stationary social care institutions and order for relegating persons to stationary social care institutions 2002//State News, 2002, No.: 76-3274

[110] Persons who due to intellectual disability have Disability Group I and II.

[111] Disabled children (with highly significant, significant and medium mental retardation) and persons who due to an intellectual disability have Disability Group I and II.

[112] Order of the Minister of Social security and Labor on approval of the Strategy for reorganization of state social care institutions 2002//State News 2002, No.: 71-2991.

[113] Items 5.2, 5.3, 5.4. Order of the Minister of Social security and Labor on approval of the Strategy for reorganization of state social care institutions 2002//State News 2002, No.: 71-2991.

[114] Despite of the decrease of the total number of places in state social care institutions from 5363 on the 1 January 2004 to 5359 on 1 July 2004 and to 5316 on 1 January 2005, the total number of individuals residing in institutions is yet not decreasing but balancing between 5348, 5344 and 5349 accordingly. Data received from Department of Audit and supervision of social establishments, accessed at website http://www.sipad.lt

[115] Joint Order of the Minister of Health and the Minister of Social Security and Labour of 25 May 2004 on Amendments to the Procedure for Determining the Loss (Disability) of Long-Term and Constant Capability to Work 2004, No. V-387/A1-145//State News 2004, No. 87-3184, (entered into force on 2 June 2004), Items 28.12, 29.5, 31.18, 33.30-3, (hereafter, Procedure 2004).

[116] “Disability group II is established for those people who, due to their condition, are partially incapable of taking care of their private or social lives and who need temporary nursing, care and support from others. In some cases, the need for constant support and attendance may be established” Procedure 2004, item 30. Previously the law only indicated the need for temporary care for people with Disability group II.

[117] See section III.4.2

[118] Order of the Ministry of Social security and labor on Requirements for the outpatient social services institutions//State News 2003, No. 43-1990

[119] Requirements ar applied to such types of institutions: establishments for day social services (family support centers, day social care centers) and temporal living establishments.

[120] Order of the Minister of Social security and Labor on approval of Catalog of Social services 2000//Styate News 2000, No. 65-1968.

[121] Item 19-1. Amendments to Social services Catalog 2005// State News, 2005, No. 15-481

[122] Law on Social Integration 2004, art.1(1).

[123] Law on Equal Opportunities No. IX-1826//State News, 2003, No. 114-5115

[124] David McDaid, GrahamThornicroft. Mental Health II. Balancing Institutional and community-based care. Policy Brief. WHO 2005.

[125] Ibidem, page 1.

[126] Psychiatric hospitals and long-stay social care homes (internats) continue to be the mainstay of mental-health service provision in most of these countries.

[127] Tobis D. Moving from Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union. 2000, The World Bank.

[128] David McDaid, GrahamThornicroft. Mental Health II. Balancing Institutional and community-based care. Policy Brief. WHO 2005, page 6.

[129] David McDaid. Mental Health I. Key issues in the development of policy and practice across Europe. Policy Brief. WHO 2005.

[130] David McDaid, GrahamThornicroft. Mental Health II. Balancing Institutional and community-based care. Policy Brief. WHO 2005.

[131] David McDaid. Mental Health I. Key issues in the development of policy and practice across Europe. Policy Brief. WHO 2005.

[132] Government Decision on adoption of the State mental disorders prevention program//State News 1999, No. 109-3186.

[133] Government Decision on adoption of National program for 2003-2012 on social integration of persons with disabilities 2002//State News, No. 57-2335.

[134] For the year 2005 2.3 mln. Lt. from the state budget was allocated for the Program for development of social services infrastructure. Selected 26 project, with only 3 designed for people with disabilities.

[135] Monitoring Human Rights in Closed Mental Health Care and Social care Institutions. Report, Vilnius, 2005.

[136] The Council acts according to the Law of the Social integration of the Disabled of the Republic of Lithuania and contributes to the Government of the Republic of Lithuania in forming social policy corresponding to the needs of the disabled. Funding from the national budget is allocated for the execution of the Law of the Social integration of the disabled. The Council is responsible for managing these resources and financing programs for the integration of the disabled, announcement of tenders for implementation of such programs and contracting expert evaluations.

[137] Program of Adaptation of accommodation (environment) approved by the Council for the affairs of disabled to the Government of the Republic of Lithuania on February 10, 2005. Protocol No. 1.

[138] Order of Minister of Health care on approval of the List of diseases that people suffer from serious forms, entitling them to the state assistance according to the law on the state assistance for purchase or rent of the dwelling 2003//State News, No. 81-3719.

[139] The Lithuanian Welfare Society for Persons with Mental Disability Viltis is a non-governmental organization which encourages the universal integration of persons with mental disabilities in the society, is acting in their and their families’ interests and protecting their rights. The organization has its branches in all the regions of Lithuania and is representing interest of people with intellectual disabilities all over the country.

Back to Home page

No.	Name of the social care home		Plan of beds	Residents	Disability				Incompetent

					I gr.	II gr.	III gr.	Without group

1.	Kėdainių		130	132	29	100	-	3	27
2.	Strėvininkų		252	250	55	194	-	1	43
	Total:		382	382	84	294	-	4	70

3.	Šilutės		550	551	99	452	-	-	54
	Total:		550	551	99	452	-	-	54

4.	Didvydžių	300		299	35	258	-	6	149
5.	Ilguvos	75		75	11	64	-	-	23
6.	Suvalkijos	120		118	25	74	-	19	7
7.	Kalvarijos	211		209	43	160	-	6	51
	Total:	706		701	114	556	-	31	230

8.	Kupiškio	105		104	16	82	-	6	10
9.	Lavėnų	100		101	17	84	-	-	13
10.	Jotainių	205		205	46	158	-	1	13
11.	Skemų	400		399	56	338	-	5	27
	Total:	810		809	135	662	-	12	63

12	Aukštelkės	257		256	63	189	1	3	30
13.	Jurdaičių	360		369	57	312	-	-	12
14.	Linkuvos	370		378	61	317	-	-	23
	Total:	987		1003	181	818	1	3	65
15.	Adakavo	200		199	26	164	-	9	37
	Total:	200		199	26	164	-	9	37

16.	Duseikių	275		275	38	237	-	-	11
17.	Stonaičių	201		199	30	169	-	-	1
	Total:	476		474	68	406	-	-	12

18.	Aknystos	340		343	28	313	2	-	29
19.	Visagino	175		176	28	144	2	2	30
	Total:	515		519	56	457	4	2	59

20.	Jasiuliškių	330		336	52	283	-	1	58
21.	Strūnos	210		220	57	163	-	-	22
22.	Prūdiškių	150		155	89	66	-	-	27
	Total:	690		711	198	512	-	1	107
*In total:*		*5316*		*5349*	*961*	*4321*	5	62	*697*