Latvia’s unhealthy healthcare system

The Latvian government is working on one of the biggest healthcare reforms since the country gained its independence. Healthcare Minister Ingrida Circene says it will be fairer to taxpayers, fight the grey economy and bring more money into the healthcare system. But doctors and the Ombudsman argue that the change will not make people healthier, while leaving 100,000 uninsured.

Anita Biseniece, a 55-year-old self-employed guide in the Poikana forest in the Dobele region, is one of many who will lose her rights to state-funded healthcare if the Health Ministry has its way.
A contentious bill to change the way healthcare is funded has already passed a first reading in parliament. Under the new rules, state-funded healthcare will be available only to those who regularly pay income tax, and socially vulnerable people whom the state will insure. That category includes 19 groups such as pensioners, children up to the age of 18, the registered unemployed and others.

But those self-employed and underemployed people who do not pay enough tax would face a levy of 28 euros a month to insure themselves, or a one-off sum of 960 euros, equal to three minimum salaries, an impossible sum for many.
“I physically don’t have 28 euros that I can pay every month. I won’t do anything, I will simply die,” Biseniece told Re:Baltica.

Anita has four grown up children and the family lives off her 20-year-old son’s invalidity benefit and her husband’s invalidity pension. Anita’s husband is also self-employed, but his contract with the Latvian Forest Company, won during a competitive bidding process to process timber, will end this year.
She is worried that if her husband does not win another tender, he will have no work. Anita, a geographer by profession and a guide, earns money during the warmest parts of the year when school groups often travel to the famous and mystical Pokaina forest. But this income has also fallen because there are now far fewer people living in rural areas and fewer school children.

“There will only be a few people in the countryside [who have insurance], those who work for the district council or business people. People will not go and register themselves as unemployed because they do not have the money to travel 40 km every month to the local district center,” says Anita.
All experts agree that Latvia faces a healthcare crisis – government spending on healthcare as a share of GDP was just 3.6 percent in 2011, the second lowest in the EU, according to World Health Organization (WHO) data. It has high child mortality rates at birth and patient payments that are so high many pensioners cannot afford to go to hospital. The government has frozen funds for transplants, and for many with serious diseases the only chance of survival is to get money from private donations for treatments abroad.

All that in a country which has the most unequal distribution of income and spends the least of all on social welfare in the EU, according to 2012 Eurostat data. EU health indicators also show that some 12 percent of Latvians in 2012 did not go to the doctor because it was too expensive, too far or because they faced too long waiting times. For poorer people, that level was 22.4 percent, also the highest in the EU.

Family doctors have loudly protested against the planned reforms - they will be in the frontline when it comes to having to turn away people like Anita. Family Doctor Association head Pauls Princis worries that rather than improving health, the bill will have the opposite effect. He is so angered that he is threatening to call a referendum or file suit with the constitutional court should the proposed legislation become law. “This system will become even more complicated, it will worsen health levels in society,” he added.

The Ombudsman, in a letter to the Saeima in January, also warned about the risks from the law.
“Taking into account the high risk of poverty and social exclusion in Latvia and the very small size of social help, the law and the government’s planned concept are not judged to be socially just and disproportionately limit human rights,” Ombudsman Juris Jansons said in a letter in January to parliament.
But the main motor behind the changes and their initiator, Health Minister Circene, is unshakeable. At a news conference last month, responding to criticism of her plans, she said: “All change is difficult. Giving birth is also a hard process, most of the time.”

The minister sees the new system as being aimed at those who do not pay tax, with the reward a fairer system. She also promises that the new system will cut waiting times and reduce the joint payments which patients currently make for treatment, which are the third highest in the EU.
The government expects significantly to increase some of the services funded by the state, such as visits to specialists, tests, the availability of prosthetic limbs and rehabilitation. There are plans also to increase health workers’ salaries. To achieve all these goals, the government plans to increase the share of funding for healthcare so that it will exceed 4 percent of GDP by 2018.

But Ineta Rezevska, head of the division for Social, Economical and Cultural Rights at the Ombudsman’s office, noted that the government’s stated goal to increase healthcare funding to 4.5 percent of GDP by 2020 was not actually part of the law, but just in the footnotes, meaning the goal may or may not actually be reached.
“There is a risk that at least 100,000 people will fall out of the system, mainly people with irregular and low levels of income, who are, however, undeniably taxpayers,” she said.

The Health Ministry’s proposal means that from July 2015 state-funded healthcare will be given only to those whose employer declares their income to VID for 11 months in a calendar year, or who themselves declare an income to VID which is equal to at least 12 monthly minimum salaries.

Others who do not have regular employment or earn less and who do not belong to any of the 19 groups that will get state-funded healthcare will only get emergency care and other narrowly defined services.
Anita says that she does not fall into any of the specially protected groups. She might be able to apply for the status of a person who has low income, but has not looked into that possibility. “I do not want to exist on welfare, I want to work. While I have breath left in my body I will not ask anything from anyone,” she says. She earns a bit of extra money by selling herbal teas, writing educational materials and leading excursions. Even having the special status of being on a low income would not change anything, because that category of person is not included in the 19 groups that will continue to get state-funded healthcare.

The government, even according to its own calculations, cannot count on too much money from voluntary payments into healthcare. Its calculations show that just 5 percent of the 145,000 people who are able to work, but who for some reason are not paying tax, would make voluntary insurance payments. That would mean that about 2.4 million euros would come into the system a year, a tiny share of a budget, expected to be 873 million euros next year.

Why has the ministry proposed a reform that would leave 100,000 people without healthcare? “It is not accurate to say that people will be left without healthcare,” said Circene. She said that the state would continue to ensure a healthcare minimum and that the people not paying tax are probably Latvians living abroad, who get their healthcare there. She adds that the ministry has already proposed adding provisions to the law which would allow local authority social services to support people who, through no fault of their own, had low income and were not included in the health insurance system.
“If we talk about social justice then the system now is just as unfair. Due to high patient  co-payments many cannot get access to health services, even if people are employed,” added Osis in response to criticisms about risks from the new system.

One of the reasons Circene often gives for the planned changes is that emigre Latvians continue to get state-funded healthcare, even though they do not pay tax in Latvia anymore. The ministry does not have figures for how many people that includes. Her opponents counter that most of the Latvians living abroad do not have time to wait in queues to see a doctor in Latvia and pay the full price for medical care.

That is what Anita’s older daughter does. She lives in England and gets healthcare there as a resident of that country. When she visits Latvia, she pays to go and see the doctor and does not queue for treatment.
The government can point to many countries where a system of obligatory healthcare insurance exists. That includes neighboring Lithuania and Estonia, which have had such systems since the 1990s. But a key healthcare indicator, life expectancy, is similar in all three Baltic States, being 76 in Estonia and about 73 in Latvia and Lithuania. All three remain below the EU average.

The Lithuanian experience has also shown that its health indicators have not improved since a 2008 reform of the system, and total healthcare financing fell during the 2009 crisis, from 5.5 percent of GDP in 2009 to 4.7 percent in 2011.
In Estonia, about 5 percent of the population remain outside the obligatory health insurance and about 9 percent in Lithuania (latest data show 280,000 people, but some of those are people who have left the country). They can join the system, making voluntary payments. In Estonia that sum is 13 percent of the average salary, or about 120 euros a months. In Lithuania, the amount is 9 percent of the minimum wage, or 35 euros a months. At the same time, the impact of such voluntary payments on the healthcare system is small. For example in Lithuania, the state took in 9.2 million euros from such payments, less than one percent of the total healthcare budget.

Family doctors on the front line
As in many other European Union countries, the family doctor is the front line and first port of call for patients. The design of the system, switched over from the centralized polyclinic system of the Soviet era, is that family doctors act as the gateway to care, either helping the patient themselves or sending them to a specialist.
The World Health Organization has stressed that primary healthcare is vital – it should catch illnesses early on, particularly vital for cancer, and help people lead healthier lifestyles, like reducing smoking or drinking, which can lead to lower levels of heart disease, the biggest killer of people in the EU.

Research by Barbara Starfield of the John Hopkins Hospital in the United States has found that a rise in the number of U.S. primary care doctors has gone hand in hand with a fall in the number of outpatient hospital visits, hospitalizations and surgical interventions, thus decreasing health expenditure for all tax payers.
Family doctors in Latvia are symbolic of the problems facing the system – they are overworked and face insufficient financing. WHO data show that most of Latvia’s 1,374 family doctors have between 1,000 and 2,000 patients. About 15 percent, or 193 doctors, have more than 2,000 patients and four have more than 3,000.

Family doctors say that Latvia’s poor health statistics are due to low levels of financing and an inefficient use of the available resources, where the emphasis is not on primary care, but on the financing of various medical specialists.
In our survey, doctors conceded they did not have enough time to carry out preventive healthcare because they have too many patients. The number of tests they can do is also limited by the quotas set by the state for free diagnostic procedures.

“The 15 minutes we are allowed with patients is much too little to listen to our patients and understand their problems. People in this country are much sicker than in other countries,” said Jelena Gavrilova. Born in Riga, she arrived in 2009 in Skrunda. She has 871 patients and wants to keep the number below 1,000. She thinks that if her consultations last only a few minutes she loses her link to the patient, who cannot manage to talk about everything that is wrong with them.
Due to the fact that state financing for doctors is calculated based on the number of registered patients, the only way many doctors can balance the budget of their practice is to try to increase the number of patients. But that leads to more patient visits per day, longer queues and makes it more difficult to listen to each patient.

Many patients in Latvia do not trust their family doctor and often go directly to a specialist. When their health worsens, people often call an ambulance or go themselves to a hospital.
A 2010 FINBALT survey showed that more than a quarter of respondents are dissatisfied with their family doctor. Most people, 36 percent, see the doctor as being insensitive, while 33 percent are unhappy that the doctor does not send the patient for tests or to a specialist. Some 21 percent thought it was difficult to get an appointment with the doctor.

Guna Ozola, who works as a doctor at the emergency medical center at the Stradins Clinical University Hospital says she finds that about 60 to 70 percent of patients who come to hospital each day say they could not get to the family doctor.
“We are tired and do work which would normally fall to the family doctor and often have to deal with problems that need not have developed,” said Zane Putnina, Doctor Ozola’s colleague. Such a situation increases the load on the emergency care center, is wasteful of the limited resources available from the healthcare budget and reduces the ability of the team to react to emergency situations.

Of 1,200 emergency calls made each day, half of the patients are left at home, meaning they did not need to go to hospital and would have gone to the family doctor if there had been enough resources.
State Emergency Medical Service spokeswoman Ilze Buksa says that about 27 percent of calls are of a less serious nature. “These are patients who have insufficient communication with their family doctor and choose to solve their problems with the help of the ambulance service. But we are not a family doctor practice or an outpatient clinic, we are an intensive care unit on wheels and that [treating outpatients] is not really our work,” she added.

She said a system introduced two years ago whereby the service sends a letter to the family doctor of any person who calls out an ambulance more than five times a month had yielded some success. “We are getting fewer of these people, so obviously communication with their family doctor obviously got better,” she said.
Gunta Ancane, a board member of the Society of Latvian Doctors, says it is unacceptable that doctors are forced to take on as many patients as possible.

“In Norway, family doctors are not allowed to see more than 15 patients a day as it has been shown that it is not possible to give quality service to more than that and get to grips with their problems.” Family doctors in Norway have on average 1,111 patients registered with them, whereas the number is 1,559 in Latvia.
But Riga family doctor Ilze Aizsilniece adds: “A practice which has less than 1,800 patients is not economically viable. Some sort of viable business appears above 2,000 patients, and that is not normal.”

Doctor Gavrilova’s monthly income after all outgoings and covering the cost of a nurse is 200 lats. Asked how she can survive with 871 patients, she answers that her family has supported her all these years.
Inguna Locmele works as a family doctor in Rujiena, with three other colleagues. Her practice has slightly more than 1,700 patients, mainly children and elderly people, which is slightly more than the national average. 

Her morning begins at 6:30 a.m. at her house in Virkeni and she drives 10 minutes to Rujiena. Nurse Agnese Reute begins work at 8 o’clock and the doctor has another half an hour to finish off the paperwork from the day before. She takes emergency patients up to 9 o’clock and then up to 2 o’clock and longer she takes appointments. There are usually more patients than are listed for an appointment during the day and she often does not get time for lunch. She struggles to find the necessary two to three hours in the evening to do the paperwork.
“We try not to give appointments to more than 20 people, but usually there are about 30. The maximum we had was 50 patients,” she said.

“The better you work, the sicker the people who come to see you, because pensioners understand you are a good doctor and are gradually drawn to you. In the end, you get even older patients, which means more illnesses and more work,” she said.
The government has offered to pay for a second nurse to reduce doctors’ workloads, working mainly with preventive healthcare. Latvia has the fourth lowest number of nurses in the EU at five per 1,000 of population (the average in Europe is 8, while in Lithuania it is 7 and Estonia 6.5), meaning that doctors take on part of the work normally done by nurses, which in turns decreases the quality of medical care.

But many doctors do not take up the offer of a second nurse as that would mean they need to rent more space and, particularly in Riga, that would mean lower income for the practice. Doctor Aizsilniece says that state financing does not cover the real market cost of a doctor’s practice. “It is not possible to get suitable office space for yourself and two nurses for the 240 lats the state has calculated for the cost of office space,” she said.
Riga family doctor Iveta Feldmane, who has 900 patients at her practice, said she would like to take on a second nurse funded by the state for preventive medicine work, but she cannot afford it. After paying for her office at Riga’s ARS clinic, a nurse’s salary and for equipment and materials, she has 250 lats a month left. She has three children and the family is supported by her husband. If she took on another nurse, Dr. Feldmane would have no salary.

Better in Estonia?
In Estonia, things are different. Though total healthcare spending as a share of GDP is slightly lower than in Latvia, health indicators are slightly better and doctors’ salaries higher. People also pay less out of their own pocket than in Latvia.
How is that possible? One reason seems to be that nurses in Estonia play a much bigger role and primary healthcare is better. Indeed, in Estonian family doctor practices most of the work is done by nurses. They do not only take patients and carry out simple tests, but also issue prescriptions and hand out medical certificates for driving licenses. That means that the number of patients a doctor sees does not exceed 15 a day, said family doctor Triinu-Mari Ots of the Laagri district near Tallinn.

Ots’ one visit lasts 20 minutes and she has five hours of contact with patients. She works with two other family doctors, a pediatrician, who is part-time, six nurses and one administrator. The total number of patients is 5,800, which is split between the three doctors and which is higher than the average number of patients per doctor in Estonia. The turnover of the practice is about 20,000 euros a month.

It is difficult to compare the practice of Triinu-Mari Ots with a similar establishment in Latvia as Latvia does not have such joint practices. The Health Policy journal reported in 2012 that, according to 2009 data, the average monthly income for a practice in Estonia was 6,930 euros, including payment for laboratory tests). In Latvia, in the first six months of 2010, it was 3,568 euros and in Lithuania 5,520 euros.
Ots said that Estonia had little choice but to make improvements to its healthcare system as many specialists were heading to Finland to work. Given no extra funding, emphasis was put on the efficient use of financing and on primary care.

“The Estonians are without a doubt the most efficient when it comes to results achieved per euro spent,” said Peteris Apinis, president of the Latvian Doctors Association.
Triinu-Mari Ots said the introduction in 2009 of an e-health platform was a great step forward. She says the system cut ten fold the time she has to spend on paperwork and that writing electronic prescriptions takes a few seconds. She finishes taking patients at two o’clock and then spends another hour on the phone with patients. As she is the head of the practice, she sometimes has to stay at work to 5 o’clock to deal with organizational issues, but after that she picks up her daughter from pre-school and the rest of the day she spends with friends or exercising. Her monthly salary is about 1,800 euros while her nurses take home about 800 euros.

Estonians visit their family doctor for free, while Latvians have to pay one lat. Some doctors, seeing that some patients are poor, do not take even that lat and get a reprimand from the national health service authority.
“We got a letter saying that we were not meeting the terms of our contract because I have a duty to take the patient fee. If a patient comes and does not have any money then I have to sign a document to show the patient’s debt,” said family doctor Alise Nicmane–Aispure.

Some doctors fear the new insurance system will make such situations more common.
Doctor Locmele in Rujiena is aghast at the idea that she will have to become a ‘tax inspector’ and will help or turn away patients after having checked if they have paid their taxes.
“That is absurd. If an acutely ill patient comes to me and needs urgent care, I will not send the patient away, even if I see that I will not get my fee from the national health service (for treating the patient),” she said.
“Circene’s reforms show clearly that we are heading to privately funded medical care and society should be told that loud and clear. But the main problem is that people do not have the money for private medical care. In the end, the old generation of doctors will take on the burden of this situation because we will have to treat for free these people who cannot afford to pay. Our consciences will not allow us to let these people die just because they have no money,” she said.

Anita Biseniece agrees with such comments.
“The thing is that everyone who is healthy, strong and can get money has gone to England, Denmark or Ireland and is getting a better level of healthcare, or people do not have work and do not have these 20 lats. That means the attitude of state officials to their fellow man can only be described as a conscious attempt to exterminate them.”
The deadline for proposals ahead of the second reading of the healthcare insurance bill is past. Member of parliament Janis Reirs said there were a lot of proposed amendments and expected much work ahead. At the same time, the Latvian Association of Doctors has asked parliament to suspend its consideration of the bill and to send it back to the ministry for re-working. The Association wants primary healthcare and the most simple diagnostic tests to be guaranteed for all, whatever their insurance status, and for the law to be supplemented with clears goals on fair, transparent and predictable financing for healthcare in Latvia.