4.2 Human resources
4.2.1 Planning and registration of human resources
All health professionals must be certified under the pertinent professional association, which are the Latvian Medical Association, the Latvian Nursing Association or the Latvian Confederation of Professional Organizations of Health Care Personnel (responsible for allied sciences, such as speech therapists, dental technicians, etc.). Certification requirements are regulated by Article 26 of the Medical Treatment Law (1997) and specified in the Cabinet Regulation Procedures for the Certification of Medical Persons No. 943 (Cabinet of Ministers, 2012a). The organizations determine examination programmes and establish examination committees for each specialty, subspecialty or subsidiary specialty. Certification and recertification is defined in the regulatory enactments for regulated professions. Certification can be performed if a medical practitioner is registered in the state register of medical practitioners and medical support persons. All health care practitioners are listed in a nationwide information system, the Register of Medical Persons, maintained by the HI in accordance with the Cabinet Regulation on the Procedure for Establishing, Supplementing and Maintaining the Register of Medical Persons and Medical Support Persons (No. 317, Cabinet of Ministers, 2016a). Registered professionals receive the certificate of a “Medical Person”. The certificate has to be renewed once every five years and contains information regarding the right to practise a specific profession. Every health care practitioner has a personal registration number.
Medical practitioners wishing to undergo a recertification must apply to the Certification Authority or the Certification Commission no later than three months before the end of the certification period. The application includes a report on the professional activity approved by the head of the medical treatment institution, which reflects the volume, intensity and quality of the work performed during the period of validity of the certificate. Doctors, dentists and physiotherapists during the period of validity of the certificate should collect 250 further education points by attending different professional and scientific activities. Other medical practitioners require 150 education points, and specialists in medical or diagnostic methods need 100 further education points. The Cabinet Regulation No. 943 (Cabinet of Ministers, 2012a) determines the description and amount of further education points. The Certification Councils for the Latvian Medical Association, the Latvian Nursing Association or the Latvian Association of Medical Professionals can decide to suspend or revoke the issued certificate.
Training of health professionals in Latvia conforms to EU standards for mutual recognition. Study programmes are developed by professors, associate professors, assistant professors, study programme councils, as well as academic structural units involving student representatives and employers, in accordance with standards for the profession of health care professionals concerned and the requirements of the Law on Higher Education Institutions, the Law on Vocational Education, the State Standards of Higher Education, the Study Programme Licensing Regulations and the Regulations of Study Institutions Study Programmes. New study programmes need to be licensed by the Higher Education Center in accordance with the Cabinet of Ministers Regulations for Licensing Study Programmes. The MoH determines the number of training places at universities and for residencies (specialist training). The Latvian Medical Association monitors specialists moving to other countries and provides the Certificate of Conformity to physicians who are interested in working abroad.
For the period 2006–2015, the Basic Statement on Development of Human Resources for Health Care (Cabinet of Ministers, 2005c) was adopted for the coordination and adjustment of health care personnel remuneration to promote recruitment of new doctors and retain existing staff. However, due to the economic crisis, the document was abandoned in 2010 and salaries of health professionals were generally reduced rather than increased.
The most recent planning document is the conceptual report On the Health System Reform (Cabinet of Ministers, 2017a). It envisages an increase in wages for medical staff, and the adoption of personnel requirements by the number of beds and specialties.
As part of the WBG Reimbursable Advisory Services agreement with the Latvian NHS, the Health Care Facilities Master Plan for 2016–2025 by the World Bank (World Bank with Sanigest Internacional, 2016) aims at restructuring Latvia’s health facility network and provides standards for the planning of medical personnel based on the estimate of future demand for health care services in primary, secondary, tertiary and long-term care. The Master Plan recommended strengthening the primary care level and the expansion of coverage of outpatient services nationwide. It suggested replacing individual GP offices by health centres or team oriented multi-GP practices that could provide a variety of services. Using risk-adjusted population projections, the plan suggested recruiting an additional 568 primary care physicians to ensure their equal distribution by 2020. This reconfiguration however entails adequate human resources, training programmes and continuous education in place.
A full GP practice starts from 1800 patients (or 800 children, as there are GPs who take only children). If the number of patients registered by the GP exceeds the number of patients who constitute full practice, GPs have to ensure that at least two other medical practitioners are employed (nurse, assistant doctor or midwife) (Regulation No. 555).
4.2.2 Trends in the health workforce
Over the past two decades the health workforce in Latvia has undergone considerable changes.
Family medicine was only introduced as a new specialty in Latvia in 1990 and considerable efforts were undertaken to retrain doctors to become GPs in order to build a stronger primary care.
About 52% of the GP practices are based in the Greater Rīga Area, and are also linked to the higher distribution of population in urban areas and around the capital, with primary care accessibility gradually decreasing with increasing distance from Rīga (see Box4.2). In 2018, the density of practising medical doctors was more than three times higher in the Rīga area than in Zemgale or Kurzeme. These regional differences persist for medical staff with secondary medical education (i.e. physician assistants, nurses, midwives): 109.9/10 000 inhabitants in Rīga; 48.7 in Zemgale and 48.5 in Kurzeme. However, the overall ratio of medical staff with secondary medical education per medical doctor remains very low and decreased from 2.1 in 2010 to even less than 1.7 in 2016. This could suggest that physicians assume some of the nurses’ duties, which could influence both the quality of physicians’ work and the care for patients.
In absolute numbers, there were about 9440 physicians in Latvia in 1990 declining to 6472 in 2018. Further, many GPs are reaching retirement without being replaced, an issue that is especially present in rural areas (see Box4.2). In international comparison, the number of physicians per 100 000 population in Latvia in 2017 was just below the EU28 average (Fig4.2), while the number of nurses is low in comparison to the other Baltic countries and the EU as a whole.
There has been a relatively continuous increase in the number of doctors since 2001 (Fig4.3), and in the period from 2009 to 2014, the proportion of doctor-trainees (including residents) in Latvia increased threefold, from 0.2 to 0.6 per 100 000 inhabitants. However, the number of nurses per population has been decreasing since 2010 and the nurse-to-population ratio is one of the lowest among EU countries.
To increase their incomes, doctors often work in multiple workplaces or perform several positions. From 2011 to 2016, the average number of positions per doctor increased from 1.9 to 2.0. This also leads to inequalities between institutions and specialties as, for example, doctors reduce the working hours in inpatient settings and increasingly work in ambulatory secondary care (including private health care). Recent improvements in remuneration for nurses in the primary care sector led to increasing numbers of nurses leaving hospitals. Both developments further exacerbate shortages in the hospital sector (OECD, 2016; World Bank, 2016b).
As indicated in Fig4.4, Latvia has very low number of practising nurses per population. The number of nurses increased slightly until 2006 before starting to decline again. In particular, there was a strong decline in 2009, when important budget cuts were implemented in the health sector, including reductions in salary levels and closing down of institutions. In 2017, there were 457 nurses per 100 000 inhabitants (484 per 100 000 if considering nurses and midwives). The absolute number of nurses practising in Latvia in 2018 was 8332.
In contrast, the number of physicians’ assistants is increasing, going from 1653 in 2005 to 2216 in 2017. Physician assistants are a particular feature of Latvia’s health care workforce as they relieve the shortages of nurses and family doctors especially in rural areas as they are trained in emergency care and outpatient care for diagnosis and prescribing (OECD, 2016).
The number of dentists began to increase steadily as of 1995 due to the privatization of nearly all dental practices, which raised the attractiveness of this profession. In 2017, there were 0.7 dentists per 1000 population, which was similar to the number of dentists in the EU28. The total number of practising dentists has decreased from 1456 in 2008 to 1361 in 2018. However, this decrease occurred simultaneously with the decrease of the population and thus does not affect the ratio per 1000 inhabitants, which remains stable at around 0.7.
The number of pharmacists has increased considerably over the past few years for which data are available and is considered to be sufficient to meet the country’s needs. In 2014 the number of pharmacists in Latvia (0.8 per 1000 population) was slightly below the European average (0.86) but far above the EU13 average (0.66).
Since 2000, Latvia has witnessed an increase in the overall number of graduates of health-related study and training. In particular the number of medical graduates increased more than four times between 2000 and 2015 and is above the EU28 average. Despite the continuous growth in the number of medical graduates, Latvia faces important shortages of health professionals as many graduates choose to work in different professions or move abroad.
4.2.3 Professional mobility of health workers
Health professional mobility can contribute to human resource shortages if countries lose significant numbers of well trained professionals who decide to work abroad in search of better working conditions or salaries. Since the accession of Latvia to the EU, health professional mobility is thought to have increased considerably, although reliable data are limited. In 2005, when Latvia planned to increase the wages of health workers, one motivation was to prevent the potential emigration of health workers as a result of EU accession (WHO, 2006). However, the planned wage increase was delayed and only recently implemented. Yet, a large proportion of well trained and experienced specialists leave the public sector to work in the private sector, where incomes are much higher.
A higher number of doctors also decide to migrate to other EU countries requesting certificates of conformity of study from the Latvian Society of Physicians every year. Every year around 100 Latvian doctors hand in the necessary documents to go to work in other countries; for example, Germany and Sweden. In 2017, 85 doctors submitted the documents to the Latvian Medical Association. However, these certificates indicate only the intention to leave the country rather than actual migration, and they do not capture health workers who decide to work in countries outside the EU or Norway. There are no official statistics on the number of graduates that leave Latvia for good or the number of doctors that leave to work in other countries, as this information is not included in the registers of medical persons in Latvia. Also, a significant proportion of medical graduates pursue their residencies in other EU countries and pose a problem for the retention of medical graduates in Latvia.
Migration of nurses also presents an important challenge, given the already low numbers of nurses in Latvia. Low salaries and difficult working conditions have led many nurses to move to other EU countries with better work opportunities where the demand for specialized nurses is high (OECD, 2016). Acknowledging the need to restrain outward migration and increase the supply of health workforce, the Government of Latvia has taken steps to develop a human resources strategy and amended the remuneration system for health professionals (see sections 6.1and 3.7.2).
There are also some health workers from other countries, such as the Ukraine, who migrate to Latvia.
4.2.4 Training of health personnel
The medical training system in Latvia provides a good basis for professional medical education. Currently, physicians are trained at two universities in Latvia, both located in Rīga: the University of Latvia (under the responsibility of the Ministry of Education) and Rīga Stradiņš University (RSU; under the responsibility of the MoH). In particular, Rīga Stradiņš University offers a simulation-based approach using virtual environments to train medical students.
Undergraduate medical education lasts six years. The first two years are exclusively theoretical, while the practical training increases progressively starting in year 3. Medical students have to pass a state exam divided into medical and surgical parts and obtain the Diploma at the Highest Level of Medical Education. Subsequently, physicians must complete a three- to six-year postgraduate residency programme to obtain a specialty. Dentistry training lasts five years. Medical professional associations carry out certification of specialists. Continuous medical education is offered and organized by universities and medical professional associations. There are different forms of training: courses, seminars, etc. Physicians can choose the courses they wish to take. Proof of having participated and passed a certain number of continuous medical courses is required for recertification every five years, independent of the type of health care institution in which physicians work.
There are two separate nurse education tracks in Latvia. Firstly, a three-year vocational training programme at one of five colleges of medicine (former nursing schools) qualifies students to work as nurses. The programme entails at least one year of theoretical studies and at least 1.5 years of practical studies. Secondly, since 1990, nurses can train through a four-year Bachelor study programme at Rīga Stradiņš University or, since 2010, at the University of Latvia. These university programmes are intended to train nurses who wish to pursue supervisory roles or managerial tasks on specialized wards. Nursing students train in several specialties: anaesthesia, intensive and emergency care, child care, internal medicine, outpatient nursing, mental health care nursing, surgical nursing, as well as basic nursing training. All nurses have to be registered in the Register of Medical Persons and Medical Support Persons maintained by the HI. After finishing nursing school, nurses usually start working under the supervision of a specialized (certified) nurse or a certified physician (e.g. in a GP practice), and have to be certified by the Latvian Nurses Association, which is also responsible for recertification after five years.
For midwives, the same two training options exist and the duration of studies is the same as for nurses. Most midwives study at one of the colleges of medicine. If the midwives’ programme of education begins after finishing the nursing educational programme, the minimum duration of study is 18 months. Since 2007, Rīga Stradiņš University has also offered a first level higher professional education study programme “Midwife” and, from 2010, a four-year Professional Bachelor programme for midwives.
Pharmacists receive their education in the Faculties of Pharmacy within Rīga Stradiņš University and the University of Latvia. Following five years of professional education, students receive a Master’s degree in pharmacy. In the University of Latvia students receive a Bachelor’s degree after three years of academic study and a Master’s degree after two additional years. Pharmacist’s assistants are educated within the Rīga 1st Medical College and Stradiņš University Red Cross Medical College in cooperation with Rīga Stradiņš University. Since 2004, pharmacists and their assistants have had to register with the Latvian Pharmacists Association in order to be allowed to work in a pharmacy. For recertification, which is carried out by the Latvian Pharmacists Association, pharmacists have to submit proof of having obtained 60 credit points of postgraduate training every three years.
A Physician Assistant Professional Standard has been developed and approved since 2011. The qualification of physician assistant can be acquired in several medical colleges, Rīga Stradiņš University and University of Latvia. This is a three-year programme. It is possible to work as a physician assistant in various health care institutions.
The Faculty of Rehabilitation at Rīga Stradiņš University was established in 1993. Around 100 different specialists such as physiotherapist, logopedists, ergotherapists and nutrition specialists graduate each year. Since 1997, Rīga Stradiņš University has offered a four-year Bachelor programme in public health. Every year, approximately 20 students graduate. After their Bachelor’s degree, graduates as well as other health professionals (physicians, nurses, etc.) may continue with a two-year Master’s programme in public health, after which they may pursue a doctoral degree.
In 2014, Rīga Stradiņš University and Rīga International School of Economics and Business Administration (RISEBA) established a joint full-time Professional Master’s degree in Health Management and a Professional Business Establishment Executive, which lasts 1.5–2 years.
All study programmes in health care at Rīga Stradiņš University and at the Faculty of Medicine of the University of Latvia are accredited by the Ministry of Education and Science until the year 2022. Cabinet of Ministers Regulation No. 626, adopted on 9 October 2018 (prot. No. 46, § 15) Regulations on the List of Mandatory Occupational Standards and Professional Qualification Requirements and the Procedure for Publishing the Professional Standards and Professional Qualification Requirements Contained Therein determines the professions that need to develop professional standards, including all health care specialties.
The minimum professional qualification requirements for physicians have been defined in line with EU standards by the regulations of the Cabinet of Ministers No. 315 on the Minimum Requirements of the Educational Programme to Receive the Doctor’s Professional Qualification (in force since July 2002). The minimum requirements for dentists, pharmacists, nurses and midwives are defined by the regulations of the Cabinet of Ministers on the Minimum Requirements of Educational Programmes for the Acquisition of the Professional Qualification of Dentist, Pharmacist, Nurse and Midwife (in force since February 2002).
The specific content of postgraduate training courses and recertification requirements for medical doctors, pharmacists, nurses, etc., is produced and approved by the respective professional associations. There are no differences between public or private institutions in the training requirements for health professionals.
4.2.5 Physicians’ career paths
Doctors’ career paths depend very much on individual initiative, capabilities and choices. There is no standard procedure in Latvia regarding career development. After completing their basic studies and receiving a doctor’s diploma, graduates continue their education in the residency programme of the chosen specialty.
Each year, the MoH approves the number of resident places by specialty. After completion of postgraduate education, most physicians begin work as a specialist within different health care institution or privately. For sub-specialization, it is necessary to attend further training courses. After several years, it is possible to rise to positions of chief doctor or director, depending on professional knowledge and management skills. Decisions regarding promotions within the institution are made by the board of the institution, which is nominated by the owners, such as the MoH in the case of state institutions, municipalities or private institutions.
Physicians who choose to work in the public sector can also teach in university hospitals. Doctors are encouraged to pursue a PhD in medicine in order to strengthen research capacity and pursue a career in academia.
The NHS regulates the countrywide distribution of GPs through contracts with individual practices and the administrations of hospital outpatient institutions or health centres. The restricted public funding influences the number of vacancies available through contracts with the NHS.
4.2.6 Other health workers’ career paths
Other health workers’ career paths also depend on their individual initiatives, capabilities and choices, with no standard procedure in place regarding career development. Every health worker begins work within an institution or privately. There are opportunities to rise in any health career. Nurses and other specialties can pursue master’s degrees and apply for managerial positions, or within academia.