Country and population

Latvia is one of three Baltic states in northern Europe with a territory of 64 589 km² and a population of 2.25 million (2010) composed of 46% men and 54% women. The average population density is 34.8/km² and the urban population accounts for 68% of the total population. The population is ageing: the proportion of children (aged 0–14 years) has decreased (from 21.4% in 1990 to 13.7% in 2008) and the proportion of people aged 65+ has increased (from 11.8% in 1990 to 17.3% in 2008). In 2008, the birth and death rates per 1000 inhabitants were 10.6 and 13.7 respectively (Statistics Latvia, 2011; WHO Regional Office for Europe, 2010).

Development and economy

Latvia is a parliamentary republic. The Parliament (Saeima) consists of one chamber whose 100 members are elected every four years. The country is divided into 109 administrative regions and 9 republic cities. Latvia restored its independence in 1991, after which a number of economic and political reforms were implemented in the economic, social and health sectors. In the period 1990–2008 the gross national income per capita (PPP int. $) more than doubled – from US$ 7810 in 1990 to US$ 16 740 in 2008 (WHO, 2010a). Following the years of economic stagnation in the early 1990s, Latvia posted Europe-leading GDP growth figures during the period 1998–2006. In the global financial crisis of 2008–2010 Latvia was the hardest hit of the EU Member States, with a GDP decline of 26.54% (WHO, 2010b). Since 2006, the GDP growth rate has dropped from 12.2% to – 18.0% in 2009, and it is forecast to be – 3.5% in 2010. In March 2010 the unemployment rate was 20.1% – the highest in the EU (Eurostat, 2010).

Between 1990 and 2007 Latvia’s Human Development Index rose by 0.44% annually from 0.803 to 0.866, which in 2007 gave the country the rank of 48th out of 182 countries with data, and the adult literacy rate is 99.8% (UNDP, 2010).

Population’s health

In the early 1990s, together with rapid changes in society, Latvia, like other central and eastern European countries, experienced a rapid worsening in the indicators of public health. The life expectancy started to decrease and reached its lowest level by 1994–65.5 years (59.0 years for male and 72.9 for females in 1995). Since 1995, however, life expectancy has been increasing, reaching 72.5 (67.0 for males and 77.8 for females) in 2008 (WHO Regional Office for Europe, 2010). Healthy life expectancy at birth in 2007 was 64 years (59 for males and 68 for females) (WHO, 2010b). The infant mortality rate per 1000 live births has decreased from 18.9 in 1995 to 6.7 in 2008 (WHO Regional Office for Europe, 2010). The total fertility rate has increased from 1.2 in 2000 to 1.4 in 2008 (WHO, 2010b).

Cardiovascular diseases, neoplasms and accidents are the most common causes of deaths. The mortality rates of the five most common causes of deaths in 2008 were as follows (all ages per 100 000 population): (1) atherosclerotic heart disease – 275.1; (2) neoplasms – 261.7; (3) cerebrovascular disease – 216.0; (4) accidents and poisonings – 108.1; and (5) acute myocardial infarction – 69.8 (Health Statistics and Medical Technologies State Agency, 2009).

Characteristics of health care system

Total health expenditure as a percentage of GDP has increased over the years to 7.5% (in 2008) and total health expenditures per capita were increasing until 2008 (see Table A16.1). The Latvian health care system is funded mainly through general taxes, which accounts for 58% of total health expenditure. Health expenditure makes up 10% of total government expenditure (2007) (WHO, 2010b). The Health Payment Centre is the institution that allocates state financing through contracts for provision of the state-guaranteed basic health care services with each health care provider, and also for reimbursing pharmaceutical expenditures. Ambulatory health care is guaranteed to receive at least 38%, hospital services no more than 52% and emergency medicine at least 9% of the total government financing for health care (Cabinet of Ministers of the Republic of Latvia, 2006b). Ambulatory health care includes primary care and secondary care – specialized outpatient care. Primary care is organized as the first level of contact with the health system and provided by independently contracted family doctors who practise on the basis of a patients’ list. Secondary care is provided mostly by health centres and specialists practising independently, and also by inpatient care provided by the hospital and its outpatient departments.

Table A16.1

Development of health care resources and utilization.

The number of nursing personnel increased to a maximum of 544 per 100 000 inhabitants in 2006, but then decreased to 465 in 2009. The number of physicians increased to 311 per 100 000 inhabitants in 2008, but decreased to 300 per 100 000 inhabitants in 2009. The number of family doctors increased in the period 1995–2009 from 7.5 to 58.5 per 100 000 inhabitants, indicating the replacement of the previous district doctors for adults, district paediatricians and other polyclinic-based specialists with trained general family doctors (WHO Regional Office for Europe, 2010). The average number of outpatient visits per person dropped from 8.1 in 1990 to 4.3 in 1996, although it has slowly started to increase again and reached a level of 6.0 visits per person in 2008. In 1990, there were 188 hospitals in Latvia, although by 2009 the number of hospitals had decreased to 69 and the number of hospital beds had also decreased from 1344 per 100 000 inhabitants in 1990 to 642/100 000 in 2009. The number of acute hospital admissions per 100 persons has been about 20 over the years, but the average length of stay in the hospitals has dropped by more than half, from 17.3 days in 1990 to 8.5 days in 2009 (WHO Regional Office for Europe, 2010). The average number of pharmaceutical prescriptions was 1760 per 1000 registered patients in 2008 (Health Payment Centre, 2010).

2.1. Primary care governance

The legal aspects of the primary care system are provided in a number of legal acts, but the common vision and goals of future primary care have not been reflected in any policy documents. The distribution of primary care providers and facilities is defined by two regulations (Cabinet of Ministers of the Republic of Latvia, 2006b, 2009c). Practices in rural areas receive extra payment based on the patient density in the area, the distance to the hospital and payment for the salary of a nurse based on a population density formula. For three years after finishing their residency young doctors have to work under a contract with the Health Payment Centre, providing care in place where a doctor is required (i.e. under-doctored areas) or they must pay back the cost of their studies to the state within five years.

Primary care has a budget that is established at a national level and can be distinguished from other sectors. It was set in legislation until 2007 that the primary care budget should be at least 20% of payment for health care services, and that the ambulatory care budget should be at least 38% of payment for health care services. Currently the fixed primary care budget percentage has been abolished and the budget for primary care depends on the prices for different elements (for example, capitation payment, fixed payment for maintenance of the practice, tariffs for medical manipulations, payment for nurses, etc.) and is distinguished from the budget for laboratory tests and specialist consultations (Ministry of Health of the Republic of Latvia, 2010; Cabinet of Ministers of the Republic of Latvia, 2004, 2009c).

The inspection of health services provision (including primary care services) is coordinated by the Health Inspectorate of Latvia. The requirements for health personnel, rooms and equipment are set out in several legislative acts (Cabinet of Ministers of the Republic of Latvia, 1997, 2002, 2004, 2006b, 2009a). Physicians have to complete a three-year postgraduate programme to be certified in family medicine. There are obligatory continuing medical education or examination requirements for doctors to be recertified every five years. The major providers of primary care are family doctors, but 6% of the primary care workforce in 2010 still consists of “old” primary care physicians (district doctors) – paediatricians and internists – who have been contracted by the state to provide primary health care services. From 2010, the Health Payment Centre once again has to register new paediatricians in the primary health care providers list, and can finalize the contract for providing primary care services, but this contract will be cancelled from 2011. Dentists are also included in the primary care providers’ list in Latvia.

Until 2008, each practice had to be certified once in every five years, and have all the items on a list of mandatory equipment for family physicians, but from 2009 requirements have been eased (Cabinet of Ministers of the Republic of Latvia, 2009a).

There are 16 clinical guidelines for family physicians, prepared by family physicians and other specialists and confirmed by the Ministry of Health, as well as guidelines for good family physicians’ practice developed by the Latvian Family Physicians Association.

Community influence on a national level is expressed by patient satisfaction surveys. Also, medical professionals and representatives of patients contribute to primary care policy development informally. A Law on Patients’ Rights came into force in 2010. Before then, patients’ rights were laid down in the Law of Cure. There are no exact procedures for patient complaints in primary care regulated in normative acts, but it is laid down that patient complaints have to be submitted to the Health Inspectorate of Latvia or in the Court of Justice (Saeima of the Republic of Latvia 1997; Saeima of the Republic of Latvia, 2009).

2.2. Economic conditions of primary care

In 2005, expenditure on outpatient care was 23.4% of total expenditure on health (Eurostat, 2010). According to the Ministry of Health, expenditure on primary care was 9.7% of the total expenditure on health in 2009 (including dentistry for children ~1% of total expenditure on health) (Ministry of Health of the Republic of Latvia, 2010). In Latvia, the whole population is covered for costs of general practice office visits, except for a minimal co-payment (€1.40) for those who do not belong to any of the special groups of patients whose co-payment is covered by state (see below) (Cabinet of Ministers of the Republic of Latvia, 2006b), while only 27% of inhabitants are fully covered for the costs of home visits (including children up to the age of 18, persons > 80 years old, those with severe disabilities (invalids), those who are receiving home care, palliative care or long-term negative pressure ventilation of lungs). Another category is patients with influenza who have to pay a co-payment for home visits only if there is an influenza epidemic (Health Payment Centre, 2010; Health Statistics and Medical Technologies State Agency, 2009; Cabinet of Ministers of the Republic of Latvia, 2006b). There is a €2.80 co-payment for home visits.

Most (90%) family doctors are self-employed practitioners with a contract with the health insurance fund – the Health Payment Centre – while about 8% of family doctors are salaried with health authorities and 2% are self-employed practitioners without a contract and are paid by patients out of pocket (Health Payment Centre, 2010). Salaried family doctors are paid according to the number of their patients and indicators of performance. Contractors with the health insurance fund receive a mix of capitation and fee-for-service and other specific components. A family physician’s income is made up of the following:

1. 1. capitation sum (85% capitation + 15% bonus/quality payment for the performance of quality indicators), and a capitation coefficient is used depending on the age of the patient;
2. 2. additional fixed payments – for low patient density in the area, for long distance to the hospital, for maintenance of the practice, for family doctors’ certificate (correspondence of practice to the normal structure of family doctor’s practice);
3. 3. extra benefits are given for medical care of chronically ill patients and certain medical treatments, including vaccination and prevention.

For example, in 2009, the defined quality criteria included: coverage of at least 65% of adult patients registered in the practice; preventive visits of at least 90% of children registered in the practice; immunization of children over 95%; tests for HbA1C for patients with type II diabetes at least twice a year for 80% of patients registered with the practice; emergency medical help calls for bronchial asthma and primary hypertension patients (Cabinet of Ministers of the Republic of Latvia, 2006b).

In 2008, the average gross annual income of family doctors was estimated to be €45 000, which includes costs for running the practice (that is, premises, equipment, care, employed staff, etc.), but does not include costs for lab tests or other investigations. This is the overall sum received from the state and patients (co-payments and some paid services). Compared to other specialists the family doctor’s income is lower than for other medical specialists, but higher than the income of nursing staff and midwives (see Fig. A16.1).

Fig. A16.1

How does the average income of mid-career health professionals relate to that of a mid-career GP.

2.3. Primary care workforce development

The tasks and duties of family doctors are described and legally fixed by the regulation approved by the Cabinet of Ministers of the Republic of Latvia (2006b, 2009b). Family doctors provide comprehensive care irrespective of the patient’s age, gender and health problems. The average number of working hours per week of family doctors is at least 40 hours and it is set out in legislation that the practice should be open at least 40 hours per week, although there is no obligation to work in the evenings after 19:00 hours or during weekends (Cabinet of Ministers of the Republic of Latvia, 2006b).

Family doctors in Latvia are trained at Rīga Stradiņš University and at the University of Latvia. The three-year postgraduate training programme in family medicine was first introduced in 1993 and the trainees spend 11–12.5 months in a primary care setting. Family medicine is also a subject in the undergraduate medical curriculum. At present, there is no special professional training for community nurses or primary care nurses. Since 2009, there is only one specialty – the “ambulatory nurse” – but up till this time there were also some community nurses (Cabinet of Ministers of the Republic of Latvia, 2006c).

At present, there are no data available from forecasting studies on current and future primary care workforce capacity needs. In the period 2003–2007 the supply of family doctors and dentists has increased, but the supply of other directly accessible medical specialists has not changed much (see Fig. A16.2) (Eurostat, 2010). In 2008 the total number of family doctors in Latvia was 1304 with an average age of about 47 years – 6% of family doctors are younger than 35 years, 28% of family doctors are aged 35–44 years, 39% of family doctors are aged 45–54 years and 27% are aged 55 years or older (Latvian Family Physicians Association, 2010).

Fig. A16.2

The development in supply of primary care professionals per 100 000 inhabitants in the most recent available five-year period.

There are two family doctor associations in Latvia. The Latvian Family Physicians Association has 1225 members and the Latvian Rural Family Physicians Association has 503 members. Both societies work to defend the financial/ material interests of family doctors and the Latvian Family Physicians Association also deals with professional development (including guideline development) and education. There is no professional journal in the field of family medicine or general practice in Latvia. Primary care nurses are not represented by any professional organization.

3.1. Access to primary care services

In 2008, the average number of family doctors per 100 000 population was 58 (Health Statistics and Medical Technologies State Agency, 2009). There are no data available about differences between urban and rural density of family doctors, nor about differences between the regions. However, shortages of family doctors exist in some regions.

All family doctor practices and primary care centres are obliged to be open at least 40 hours per week (Cabinet of Ministers of the Republic of Latvia, 2006b). The number of home visits is not very high – on average 3.6 visits per week per family doctor (private home visits are not included) (Health Payment Centre, 2010). Usually, family doctors do not provide an out-of-hours service. This service is provided by hospital emergency departments if the patient has emergency health problems outside the family doctor’s office hours (Cabinet of Ministers of the Republic of Latvia, 2006b). After-hours primary care centres are occasionally used. Telephone consultations are used frequently and there are appointment systems for the majority of patient contacts. Practices that have web sites, or that offer e-mail consultations or special clinical sessions for certain patient groups are not yet common (see Fig. A16.3) (Dobrev et al., 2008).

Fig. A16.3

The extent to which organizational arrangements commonly exist in primary care practices or primary care centres.

There is co-payment for family doctor’s services, but compensated medicines can be received according to a prescribed diagnosis. Compensation can be 100%, 75% or 50% depending on the diagnosis. There are patient groups that do not have to pay co-payments because it is covered by state (see section 2.2 above for details and there is a ceiling for co-payments (maximum €570 in a year).

In 2007, 5% of the patients rated family doctor care as not affordable, while 73% found that it is easy to reach and gain access to family doctors (European Commission, 2007).

3.2. Continuity of primary care services

All family doctors have a patient list, averaging 1585 people (in 2009) (Health Payment Centre, 2010). Over the years, about 80% of patients reported visiting their family doctor if they had health problems. To guarantee continuity of care, all family doctors routinely keep records for all patient contacts, except telephone and e-mail consultations (Cabinet of Ministers of the Republic of Latvia, 2006a). In 2007, 51% of family doctors reported having access to a computer in the consultation room and 67% of family physicians reported use of a computer in their work, although it is not known whether the computer is at their office or at home (Latvian Family Physicians Association, 2008). Computers are used mainly to keep patients’ records, but also to prescribe medicines, to produce financial and administrative documents, to book patients’ appointments and to search for expert information on the Internet (Dobrev et al., 2008). Clinical record systems are unable to generate lists of patients by diagnoses or by health risks, however. When family doctors refer their patients to a medical specialist they always use a referral letter, and specialists usually communicate with referring family doctors after an episode of treatment. However, family doctors usually do not receive information within 24 hours about contacts that patients have with out-of-hours services (Cabinet of Ministers of the Republic of Latvia, 2006b).

Patients are free to choose the family doctor they want to register with, but this choice is certainly limited in some areas where the population density is low and there is only one family doctor for the region (Cabinet of Ministers of the Republic of Latvia, 2006b). Patient satisfaction with family doctors is high (reported 2008); and the majority of the patients in 2010 reported being satisfied with their family doctor and explanations given by family doctors; patients also trust their family doctors and are satisfied with the available time during consultations with their family doctor (see Fig. A16.4) (Health Payment Centre, 2010; Toma, 2010).

Fig. A16.4

Patient satisfaction with aspects of care provision.

3.3. Coordination of primary care services

There is a partial gatekeeping system in Latvia. In general, people need a referral from a family doctor to see a specialist, with the exception of gynaecologists and sport medicine physicians (only for athletes). Paediatricians, ophthalmologists and children’s surgeons are directly accessible specialists since 2009. Psychiatrists, endocrinologists, oncologists, respiratory specialists, narcologists, dermatologists and STD specialists are directly accessible if patients have a specific diagnosis. Direct access to the dentist paid by the state is available only for children, so adults have to pay privately. Direct access to all specialists is possible if costs are paid privately (Cabinet of Ministers of the Republic of Latvia, 2006b).

Most family doctor practices (92%) are single-handed (solo practices), while 8% of practices are mixed practices with family doctors and medical specialists (Health Payment Centre, 2010). This refers to the legal status of practices and does not exclude the existence of shared locations among physicians (no data is available on this). Also, cooperation with medical specialists is not very close (e.g. joint consultations or replaced specialist care are uncommon), but it is quite common for medical specialists to give clinical lessons for family doctors. The closest cooperation within primary care is with the practice nurse, nurse practitioners, and also with other family doctors. Cooperation between family doctors and home nurses, social workers or other primary care specialists is not common. Nurse-led activities like health education or diabetes care are quite uncommon in primary care.

In general, clinical patient records of family doctors are not used routinely to produce health statistics at national and regional level in order to identify health needs and priorities for health policy. Nationwide health surveys are only conducted incidentally.

3.4. Comprehensiveness of primary care services

The minimum set of medical equipment of family doctor practices was specified by a regulation of the Cabinet of Ministers, and practice certification took place every five years according the regulation, but was cancelled in 2009 (Ministry of Welfare, 1999).

In 2008, 16% of total patient contacts were handled solely by family doctors without referrals to other providers (referrals to laboratory, visual and functional diagnostics and other auxiliary services are included in primary care) (Health Payment Centre, 2010). Patients visit their family doctor with a variety of health problems (such as lung diseases, heart diseases, peptic ulcer, diabetes type II, etc.), some mental health problems like mild depression as well as in cases of children’s health problems (see Table A16.2). Patients with mental health problems also can visit a psychiatrist or psychotherapy specialist; women with gynaecological problems and pregnancy usually prefer to see the gynaecologist or midwife. Routine paediatric surveillance for children up to 4 years, including the infant vaccination, is almost always performed by family doctors, as is immunization for tetanus and cholesterol checking, while family doctors usually perform influenza vaccination and allergy vaccination as well. Procedures like insertion of an IUD, removal of a rusty spot from the cornea, joint injection, strapping an ankle or fundoscopy are only performed by family doctors occasionally. Screening for breast or cervical cancer or testing for sexually transmitted disease is not a very common activity in family doctors’ practices, nor is groupwise health education usually provided, but individual counselling in the case of different health risks is provided almost always by family doctors.

Table A16.2

GPs’ involvement in delivery of various primary care services.

4.1. Quality of primary care

The average number of prescriptions annually provided by family doctors in 2008 was 1760 per 1000 registered patients (Health Payment Centre, 2010) and the use of antimicrobials for systemic use in ambulatory care in 2007 was 13 DDD/1000 inhabitants/day (ESAC, 2009).

The quality of diabetes care is described by following indicators (in 2008): (1) crude percentage of the population with diabetes aged > 25 with cholesterol 5>mmol – 65%; (2) crude percentage of the population with diabetes aged > 25 with blood pressure above 140/90 mm Hg measured in the last 12 months – 34.8%; (3) crude percentage of the population with diabetes aged > 25 with HbA1c – 45.5%; (4) crude percentage of the population with diabetes aged > 25 with overweight and obesity and BMI measured in last 12 months – 91.8%; (5) crude percentage of the population with diabetes aged > 25 with eye fundus inspection in the last 12 months – 72.3% (Cebolla & Bjornberg, 2008; Centre of Health Economics, 2010).

There are no data available about the quality of COPD and asthma care. The number of hospital admissions for people with a diagnosis of asthma per 100 000 population in 2008 was 160.6 (Health Payment Centre, 2010).

The percentage of infants vaccinated within primary care against various infections in 2008 was as follows: (1) diphtheria – 97.3%; (2) tetanus – 97.3%; (3) pertussis – 97.3%; (4) measles – 96.6%; (5) hepatitis B – 96.2%; (6) mumps – 96.6%; and (7) rubella – 96.6% (7). In 2008, the percentage of population aged 65+ vaccinated against flu was 2 (Infectology Centre of Latvia, 2010).

Latvia introduced organized cancer screening in 2009 and there is two-year mammogram programme in Latvia. During the years 2006–2008 20.1% of women aged 52–69 years had at least one mammogram in the past three years (Health Payment Centre, 2010; Cabinet of Ministers of the Republic of Latvia, 2006b). Organized cervical cancer screening was also introduced in 2009, and during 2006–2008, 46.4% of women aged 21–64 years received a Pap smear test (Health Payment Centre, 2010; Cabinet of Ministers of the Republic of Latvia, 2006b; Viberga & Engele, 2007).

4.2. Efficiency of primary care

In 2008, the number of family doctor consultations per capita per year was 3.0 (Health Payment Centre, 2010; Health Statistics and Medical Technologies State Agency, 2009) and the proportion of home visits of all family doctor–patient contacts was 3.8% in 2009. Private home visits are not included (Health Payment Centre, 2010). The estimated average consultation time is 12 minutes. At present, there are no data about the number of telephone consultations of all GP–patient contacts and about the number of new referrals from family doctors to medical specialists per 1000 listed patients per year.