5. Provision of services
- The NHS is the main institution responsible for the implementation of state health policies and for ensuring the availability of health care services in the country. The CDPC is the main institution for coordination of public health activities, and infectious and non-infectious disease control.
- Almost all Latvians are registered with a GP, who acts as the main point of entry into the health care system and as the gatekeeper to secondary ambulatory and hospital care, with some exceptions so patients can access a specialist without a referral from the GP. In rural areas, physician’s assistants and midwives still provide a considerable share of primary care. A patient with a referral from a GP can freely choose any ambulatory or inpatient care provider (institution) that has a contract with the NHS. Secondary ambulatory care is provided in a range of institutional settings, including self-employed specialists, health centres and hospital outpatient departments.
- Following budget cuts and the restructuring of the hospital sector since 2009, there have been efforts to promote a shift in use from inpatient to outpatient or day care settings. However, the system remains rather hospital-centric.
- Provider choice in the statutory system is often limited, in particular in rural areas, because of waiting lists and limited providers’ alternative. If waiting lists are substantial, and if providers have exceeded the number of treated patients according to their contracts with the NHS, patients have the option to pay directly (100% of costs) for the treatment at contracted or non-contracted providers.
- The pharmaceutical market is growing steadily and pharmaceutical consumption has reached €430 million in 2018. The NHS covers pharmaceuticals with varying degrees of co-insurance (100%, 75% or 50% coverage) amounting to €149 million in 2018. Patients pay the full price for a significant share of prescribed pharmaceuticals and the full price of all non-prescription drugs in the outpatient sector.
- Long-term care in Latvia falls within the scope of social care, which is administratively and financially entirely separate from the health system. Long-term care and other social care are the responsibility of the Ministry of Welfare.
5.1 Public health
Under the governance and supervision of the MoH, the CDPC (a state authority established in 2012 and financed by the national budget) plans, performs and monitors most public health activities. The CDPC took over the functions and tasks of nine different institutions and is responsible for prevention of communicable and noncommunicable diseases, health statistics and monitoring, health promotion, methodological support to health care institutions for patient safety and health care quality. The CDPC operates at two levels – national and regional – with nine structural units in Rīga, Daugavpils, Rēzekne, Valmiera, Gulbene, Jelgava, Jēkabpils, Liepāja and Ventspils. These units are responsible for epidemiological surveillance and monitoring, outbreak investigation of infectious diseases and antimicrobial resistance, surveillance of the immunization programme, emergency management and epidemic threat prevention. The Epidemiological Safety Act (1997), Procedures of Registrations of Infectious Diseases; Regulation No. 7 (Cabinet of Ministers, 1999) and other regulations define epidemiological surveillance. Communicable disease surveillance follows the requirements of the EU. Primary health care services and laboratories play an important role in the notification of communicable diseases. Legislation requires immediate notification of a single suspected case of a dangerous infectious disease, of three or five cases of some other particular infectious diseases or reasonable suspicions, as well as suspicion of quarantine diseases at state borders, and two or more cases of adverse events following immunization. Individuals living with HIV and AIDS patients, as well as patients with tuberculosis and STIs, are also reported to the CDPC (Cabinet of Ministers, 1999, 2008).
Originally within the competences of the CDPC, the MoH took over health promotion in 2012 after the centralization of health promotion activities due to the economic crisis. The MoH continued to lead health promotion projects financed by the ESF, delegating the work to local municipalities. The CDPC is involved in planning health promotion projects particularly in municipalities lacking health promotion capacity. The CDPC also runs an HIV/AIDS prevention office and supports NGOs in other regions with community-based, low-threshold programme (see Box5.1). Furthermore, the CDPC regularly disseminates an epidemiological bulletin and provides main health statistical information on its official webpage (www.spkc.gov.lv).
The CDPC collaborates with the European Centre of Disease Control (ECDC), Early Warning and Response System (EWRS), European Monitoring Centre for Drugs and Drug Addictions (EMCDDA), and WHO. Key partners of the CDPC are NGOs (e.g. the Latvian Red Cross, Association HIV.LV, Dia+logs, Papardes zieds, etc.) and state and local government organizations outside the traditional health system (see section 2.3).
Public health laboratories provide essential services including disease and outbreak detection, emergency response, environmental monitoring and disease surveillance. State and local public health laboratories serve as a focal point for the national system, through their core functions for human, veterinary and food safety, including disease prevention, control, and surveillance; integrated data management; reference and specialized testing; laboratory oversight; emergency response; public health research; training and education; and partnerships and communication. The national reference laboratory (NRL) covers all registered (communicable) infectious diseases.
The National Immunization Council determines the State Immunization Programme, based on WHO guidelines, including the vaccination calendar for child immunizations. The up-to-date national immunization schedule is in line with the Global (European) Vaccine Action Plan. Vaccination is comprehensive and mandatory, and is provided free of charge at the primary health care level by family doctors, paediatricians and doctors’ assistants (Cabinet of Ministers, 2000). Adults receive vaccination against diphtheria, tetanus (with specific indications) and influenza (specific age and high-risk groups). In general, vaccination coverage in Latvia is relatively high (>90%) and morbidity from vaccine-preventable diseases is low. Immunization data show increased coverage since 2012, which is now at the EU average for a number of vaccines and for routine childhood vaccinations even higher than WHO’s general target of 95%.
The HI is also involved in public health activities. It carries out evaluations of health care premises, equipment, personnel and documentation to assess compliance with government regulations. The HI controls compliance with permissible noise limits and levels of vibration in the premises of residential and public buildings and some other standards for environmental safety. It disseminates findings to the public, considers complaints, applications and proposals. It also creates and maintains a cosmetic ingredients database, organizes and performs monitoring of the quality of drinking-water and water in public swimming places. In the cases specified in regulatory enactments or at the request of a natural or legal person, it assesses the conformity of a construction project and an object with hygiene requirements, and evaluates the risks of chemicals to human health. The HI, together with the MoH, the CDPC and the SEMS, participates in the implementation of the International Health Regulations (IHR) and in the management of emergencies involving threats to public health. The SEMS is the national focal point in assurance of the IHR and is operational 24/7. The capability for timely and accurate disease reporting to international organizations, according to WHO requirements, is generally good in Latvia.
Other institutions, such as the Food and Veterinary Service (under the Ministry of Agriculture), the Road Traffic Safety Directorate (under the Ministry of Traffic) and the State Environmental Service (SES; under the Ministry of Environmental Protection and Regional Development) are important for the successful implementation of the intersectoral approach for health improvement, which is included in the Public Health Strategy 2014–2020 (see section 6.1). In order to facilitate the development of human biomonitoring and intersectoral collaboration, a Human Biomonitoring Council was established in 2016, with participation of members from the MoH and its public health institutions, Rīga Stradiņš University, the Ministry of Environmental Protection and Regional Development, the Ministry of Agriculture, the Ministry of Education and Science, the Ministry of Welfare, the Latvian Medical Association and the Environmental Consultative Council.
The occupational health services in Latvia are not government financed but employers are obliged to establish an organizational structure for labour protection and provide financing for occupational health. There are several laws and more than 20 regulations related to occupational health and safety. The State Labour Inspectorate under the Ministry of Welfare monitors developments in this scope. Research on this issue exists at Rīga Stradiņš University in the Institute of Occupational and Environmental Health. There are three population-based screening programmes in Latvia: one is for neonates to detect congenital phenylketonuria and hypothyroidism; another for pregnant women; and the third is a breast, colorectal and cervical cancer screening programme, launched in 2009. The NHS finances all three. Under the cancer screening programme, women between 25 and 70 years of age are eligible to receive Pap smear screening for cervical cancer once every three years, and mammography screening every other year between age 50 and age 69. The entire population above age 50 should receive faecal occult blood tests once a year. The NHS sends out invitation letters to eligible females for cervical and breast cancer screening. Colorectal cancer screening is the responsibility of GPs (opportunistic screening). In the first year of the programme, the population response was relatively low; according to NHS internal data, only 6.95% of the eligible population received colorectal screening, 14.9% Pap smear screening and 21% breast cancer screening. In 2017, the eligible population response reached 13.4% for colorectal screening (from 2014 it has been limited to both women and men from age 50 to 74), 39% for Pap smear and 44% for breast cancer screening.