Health Policies: Latvia (2015)

Introduction

The Soviet period
The Soviet health care system, or the ‘Semashko’ system (named after the founder of the Soviet health care system), was vertically organised and centrally administered and planned. It focused on large hospitals and high-level specialisation. The system provided comprehensive coverage for the entire population, but the quality of care began to drop in 1970s, when it became difficult to  sustain the large and costly health care system.[1]

Reforming the Soviet system
After regaining independence in 1991, Latvia began to build a social health insurance type system as it made a transition to a market-based economy, privatisation, the development of entrepreneurship, and a new approach to social insurance. The Ministry of Welfare was established in 1991 and assumed responsibility for both health and social policies. The bank crisis in 1995 negatively influenced not only the wellbeing of Latvians but also the financing of social programmes and health care expenditure.[2] In 2003, the Ministry of Health was established, and certain long-term health care policies were delegated to the newly established ministry. Reforms, a lack of financing, and the decentralisation of the expensive-to-run centralised Soviet health care system led to the establishment of a National Health Service-type system in 2011. The central government is responsible for financing the statutory health care system through tax revenue. The funds are distributed by the State Compulsory Health Insurance Agency (SCHIA), which acts as a purchaser of health services on behalf of the entire population[3]. Latvia has one of the highest rates of out-of-pocket expenditure on health in the European Union (EU).[4]
During the economic crisis between 2007 and 2012 it again witnessed a number of reforms focused on:

1. further centralisation and consolidation of the state-run hospitals and financial mechanisms; 
2. the establishment of one central institution for distributing health care services and funding (the NHS); 
3. primary and ambulatory care, reducing the rate of stationing patients;
4. substantially fewer hospitals.

Long-term care policies

Long-term care policies: fragmentation between health and social sectors[5]
There is no one comprehensive long-term care policy, including for the elderly, although the experts (Zvidriņš 2003; Ilves & Plakane 2011) and policy documents (National Strategy Report on Social Protection and Social Inclusion 2008-2010 - Latvia (2008)) clearly voice the growing need for this. The organisation of long-term care varies greatly in different Latvian municipalities. A study on the Vidzeme region shows a great variety of approaches in municipalities, ranging from comprehensive coverage with integrated mobile brigades to few or no care options available or giving preference to institutional care. In most cases medical and social care are two separate care options with different funding sources and tracks for reference.

Long-term care does not fall within the health care sector in Latvia[6]. Therefore long-term care, even that which deals with health issues, falls under the social security system. The law “On social security” (7 September 1995) established the foundation of the social security system. The law on “Social assistance” (26 October 1995) established the division of responsibility between the state and the municipalities in providing social care. During the Soviet period, residential homes for seniors, persons with mental disorders, and seniors with specific disabilities were available.

Additionally, responsibility for the long-term care provision is split between municipalities and the state structures (Ministry of Welfare and the Ministry of Health). Legislation, policy developments, and care standards, as well as monitoring service providers, are provided by the state. The Ministry of Welfare registers social services providers. Health inspectors monitor health care and hygiene standards in the health care departments of long-term care institutions and in home-based nursing care. At present there is excess demand for social care services and clients wait in queues for long-term care institutions for up to 30 months[7]. Municipalities ensure the availability of social services – social care, care in LTC institutions, at home, and in day-care centres.

Long-term care policies: fragmentation between local and national levels
Smaller hospitals and some larger regional hospitals are usually owned by municipalities, while larger tertiary hospitals (university hospitals) and specialised (monoprofile) hospitals (e.g. psychiatric hospitals) are owned by the state. This split also influences the organisation of long-term care, care for persons with disabilities, and care for elderly, making it fragmented and dependent on local solutions and the capacity of local governments. During the economic crisis of 2007-2009, more hospitals were converted into social care or day-care centres (Mitenbergs et al. 2012: 88-89). As Mitenbergs et al. (ibid: 90) observes, “bed numbers in long-term care institutions increased greatly between 1995 and 2000 and again between 2009 and 2010”, showing the transit of health care infrastructure to the social care area. As Mitenbergs et al. claim, during the health care system reform in the 1990s smaller hospitals were reformed into care hospitals, providing nursing services but not medical treatment. The reason was the relatively high number of acute beds per 1,000 population – a legacy of the Soviet period – which was twice EU27 average at that time (ibid: 90). Since the implementing the reforms, the average length of stay has also decreased. Thus, transferring long-term care to social care sector led to decreasing health care costs.

Long-term care forms
There are two types of long-term care institutions:

1. Specialised long-term care institutions, financed by the state budget (Ministry of Welfare) (Ilves & Plakane 2011: 131), for adults with severe intellectual disability, persons with visual impairments (categories I and II), children with severe intellectual disabilities between age four and 18, orphans and children without parents until the age of two, as well as children without parents who have severe intellectual disabilities up to age four are all covered by the state budget. There are five state-owned social care institutions. Additionally, the state concludes agreements with nongovernmental organisations (NGOs) and private service providers. A similar ownership/contracting strategy is executed by the municipalities. 
2. Local governments provide social care services for retired persons and persons with disabilities as well as orphans and children without parents between ages of two and 18. These include residential homes for seniors and people with special needs and who require assistance. These institutions specialise in care for the elderly and persons with health problems. The facilities are funded by municipalities and residents themselves or their families. In 2013, there were 60 facilities serving 5,000 clients.

Zvidrins (2003: 20) states that in 1990 there were 8,472 beds in residential homes for seniors and persons with mental disorders. In the subsequent decade the number fluctuated, reaching its highest point in 1995 (8,799). With municipalities taking over the provision of institutional care for seniors, the number of beds declined but institutions themselves tended to become smaller (Zvidrins 2003: 20). Zvidrins estimates that 1.3 % of seniors received institutional care (ibid). Social care institution residents receive medical care and are registered with a primary care physician and secondary ambulatory care services as are other Latvian residents.

There are also alternative long-term arrangements available for elderly:

1. Home care which is provided by municipality social services or outsourced to providers contracted by social services.
2. Service apartments owned by the local government are let out to individuals with severe functional disorders. Service apartments offer individuals with disabilities the possibility to live independently, take care of themselves, and increase their social skills. Group houses (apartments) and halfway houses represent another form of assistance. A group house is a separate apartment or a house in which individuals with mental disorders can live securely and receive individual support addressing their social problems. A halfway house is a transition stage after a long-term care institution for persons with intellectual disabilities, who are taught to live independently before they move to a group house (Ilves & Plakane 2011: 3). Elderly persons who do not have an additional disability are entitled to group houses.

Inclusion and alternative care policies
The National Strategy Report on Social Protection and Social Inclusion 2008-2010 (2008) encourages promoting the development of alternative care services to institutional care and improving the social functioning capabilities of elderly people and their inclusion in society, as well as encouraging inclusion and employment opportunities for their family members. The plan also considers the fact that the number of old persons and single retired persons is increasing, the demand for social services is growing, yet similar to previous years there are long waiting times for receiving services in social care institutions. The report  highlights the link between the insufficiently developed network of municipal services alternative to institutional services and the increased demand for institutional care. At the same time, the accessibility of both institutional and alternative social care services is limited.

The targets of the plan include not only the elderly but also other groups in need of long-term care (e.g. persons with mental disorders) in the following areas:

1. to promote the development of alternative social care services for persons of retirement age, services at home;
2. to facilitate the access to services and equal employment opportunities, ensuring social care, the development of social skills, and possibilities to spend free time for children, persons with functional disorders, and retirees.

The National Strategy Report (2008: 54) identifies the following as the main challenges:

• Restricted access to social care and social rehabilitation services;
• Insufficient resources to ensure social services adequate to the particular needs of the
• person;
• Differing qualitative and quantitative indicators of the services offered in different 
• regions;
• Inadequately developed network of social services alternative to institutional care;
• Restricted opportunities to ensure succession of social services;
• Insufficient integration into society of persons living in long-term social care institutions;
• Lack of qualified personnel services.

Taking into consideration the fact that Latvia has no experience in provision of integrated services, it is necessary to develop the integrated service provision and financing scheme and improve coordination between health care and long-term social care services.

Qualifying for long-term care
The need for care in Latvian legislation is not clearly defined. According to the state-issued regulations[9], the client’s social care needs and material resources are first assessed. To determine the need for care, various documents proving one’s health status and financial situation are required. The social worker visits the applicant at home to gather information about the applicant’s living conditions and the ability of the applicant’s family members to provide care. Each client has to pay for most forms of the social care services. When the client or the family lacks the necessary funds, the services are covered from municipal budget[10]. The social worker decides on the most appropriate form of care. In case the client’s health requires the 24-hour presence of qualified personnel, services are offered in a long-term care institution. However, evidence shows (Putnina & Linde-Ozola 2014) that institutional care is offered when the municipality does not have other forms of care or does not have vacancies in long-term care institutions for clients. 

The assessment of the need for health care at home is performed by a family doctor or other medical specialist. An individual receives health care at home in cases in which there is a need for constant outpatient health care and the patient cannot receive this in a medical institution due to his or her particular health condition. There are several levels of dependency, which are assessed by the family doctor or specialist identifying the need for care. The doctor also determines the duration and level of the service (Ilves & Plakane 2011: 2-3).

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