Author: Ilona Bērziņa
Does our healthcare system finally has a hope of breaking away from the insufficient funding curse, or does the medical sector truly has changes ahead? What can we do on our own to watch our health – these and other topical questions were discussed by BNN with the leading specialist for public health from the Latvian Ministry of Health Dr.med.h.c. Pēteris Apinis.
– The state of Latvia’s medical sector of the past dozen years can best be described by the word “shortage” – shortage of money, doctors, nurses. If the healthcare budget for 2024 is EUR 1.88 billion and the sector itself is marked as one of the priorities, does this mean that it’s the end of the “shortage”, so to speak?
– The world is arranged in such a way that no country will ever escape from the shortage of money for healthcare. People live longer lives, people get cancer, people suffer various cardiovascular diseases or get dementia. Age-related diseases have expensive treatment and expensive social care. Every year global and national healthcare-related expenses go up 3-5%.
Medicine is becoming more expensive. Here’s an example – CSL Behring and uniQue have created the world’s most expensive medicine Hemgenix. It’s price is USD 3.5 million. This medicine treats haemophilia B patients who are currently receiving factor IX prophylaxis. Patients with this blood disease usually require regular administration of factor IX to replace or supplement low blood clotting factor levels. This process is extremely expensive throughout life, with injuries and joint haemorrhages leading to additional complications.
Hemgenix allows patients to generate factor IX on their own. The medicine is very expensive, and Latvian National Health Service is unlikely to pay for the first Hemgenix injection in the country anytime soon, nor will it be possible to compensate this medicine for Latvian haemophilia patients in the next 20 years.
Currently an average person in Baltic States spends on average EUR 1 700 on medicine every year. The EUR 1.88 billion you mentioned – EUR 1 000 per person a year from the state budget – the money we’ve all paid in taxes. It’s important to mention that medical costs are the highest the older a patient is.
The people who pay a lot of money in taxes but do not spend their “thousand” have to understand – they will spend a lot more on healthcare in the last two to five years of their lives.
But like I said – Latvian, Estonian, Polish residents spend EUR 1 700 on healthcare every year.
This means the average Latvian resident pays EUR 700 on their own – for examinations, consultations, medicine and treatment in private clinics. It would be simpler for everyone to pool their money (pay in taxes) some EUR 700 more every year to cover the main expenses of healthcare. I don’t think [Minister of Finance] Arvils Ašeradens is prepared to raise taxes again to get this additional EUR 700 from every Latvian resident or approximately EUR 2 500 from every employed person.
Politicians don’t want to say or understand the truth – that healthcare is an investment into national economy, but then it needs to be viewed in a complex manner – as jobs, pharmaceutical industry, as well as better work results, smaller delays, etc. But there will never be a single country in the world to complete satisfy all the needs of the healthcare sector. For example, some billionaire in the US had a heart transplantation for the seventh time last year. Public health and US residents’ health have nothing to do with that, but general health expenses of this particular patient are comparable to half of Latvia’s healthcare budget.
– Minister of Health Hosams Abu Meri promised “important changes to the organisation of healthcare services to make sure healthcare services are accessible to Latvian residents and the healthcare system is sustainable.” I cannot recall a single minister who didn’t promise something like that alongside a promise to reform one sector or the other. What should be done to implement this vision?
– I don’t recall Viņķele, Pavļuts, Veldre or other politicians in the healthcare sector promising something at least as logical as that. The good news is that Hosams Abu Meri views the field strategically, and he understands development. But we should read politicians’ promises in a simpler manner. If a politician says “healthcare services are acceptable and of high quality, and the system is sustainable”, then we should read it as “services will be accessible and of better quality than now, and the system will be more sustainable”. Then there is there truth. To look to the future, we can look back. Thirty years ago hospitals had a shortage of medicine, doctors’ pay was less than EUR 100 a month, Latvia had a single, privately owned mobile MRI machine, blood transfusion vials and elastics were sterilised and re-used again and again, and the blood itself wasn’t even tested for HIV/AIDS or C hepatitis. Latvia’s medical field has made great steps forward since the restoration of independence. Latvian residents now live 13 years longer on average. The biggest life extension is for women with higher education, whereas the lowest is for men with poor education.
– No matter the budget, nothing really changes from the perspective of patients – long queues to receive state-paid medical services are still a thing, the list of compensated medicines is still shorter than the ones in Lithuania and Estonia, people are afraid to call an ambulance because they fear a possible refusal and the potential bill – the list goes on. What is the main problem with Latvia’s healthcare sector – the shortage of money or poor management?
– Let’s start with emergency medical services. Statistics are unforgivable – the number of ambulance calls are up, including to assist with less important problems. NMPD is a service Latvian residents trust more than the police, municipal government, Saeima and the Cabinet of Ministers put together. Social networks do create bubbles. To get information I have learned to infiltrate patient and drug user groups, or bubbles. I haven’t found a real bubble of ambulance users or deniers, but globally in English there are some.
The situation with compensated medicines is much worse here. Hosams Abu Meri struck the table with his fist in the Cabinet of Ministers, yelled at the Ministry of Finance, and even led half-hour lectures in the Saeima committee to finally secure the additional EUR 50 million for compensated medicines.
Once he had accomplished this, we had to give away EUR 20 million to pay for debts left from Pavļuts.
A large portion was used to pay for medicines that, until now, were compensated at 50% or 75%. It seems to me that a large portion of this amount will go towards coverage of other debts (left from Covid-19 pandemic). Information regarding Kariņš’s – Pavļuts’ useless vaccines, iodine tablets an infectology gear procurements are still kept secret from me, but they definitely reach hundreds of millions of euros. We will not only receive all that but will also bury and otherwise dispose of using state funding.
I don’t want to sound like a populist, but I will say one more thing politicians and the people may not want to hear. The wider the range of services, the longer the queues. For example – there was a situation during Pavļuts’ term when some mother in a Zemgale hospital caused a scene when she wasn’t allowed to stay with her 30-year-old son in the intensive therapy ward. The situation could have been resolved locally, but Pavļuts got involved and announced that from there on the stay of relatives in hospitals will be paid for. This didn’t mean anything more than one more day spent in a queue for state-paid medical examination or specialist consultation. But if politicians find some service the state could pay for every week or so, queues will become one or two days longer every time.
– Is there any hope for the list of compensated medicines to become longer and that new and innovative medicines to be added to it?
– Yes, there is hope. Europe is moving towards a unified system to make sure prescribed medicines are paid for by the central budget. I truly believe Latvia’s Ministry of Health will work with specialists and will find a way to review the list of compensated medicines and expand it, especially with biological medicines and new cancer medicine.
As I’ve said, I follow different patient “bubbles” and I study their needs and general mood. Most of them are worried about the high prices of medicines and nutritional supplements. I would also like to say the confusion is usually about medicines that are recommended in misleading news.
We read misleading news in the banking, financial, postal sectors every day. News like that seem topical for journalists and news agencies. People rarely write about medical misleading news, because this means putting people’s lives at risk. Imagine – a person reads misleading news on some social network from a professor-looking person, and this professor recommends dropping all blood pressure or cholesterol medicines and instead use some miracle aid – nutritional supplement that will solve all health problems in a week. Even if one-tenth of older Facebook users, patients suffering from chronic diseases, believe this information, their life expectancy will become shorter, the risk of heart attack and stroke goes up. Misleading medical information on social networks is a big problem that preys on our residents’ health problems and secures income for unknown scammers living in foreign countries.
In the second half of 2022 we saw a rise of new, aggressive advertisements for nutritional supplements on Facebook. These miracle cures promised relief from hypertension, excess cholesterol, diabetes, arthritis, eye diseases and many other health problems. These advertisements had photos of professors Andrejs Ērglis, Viļnis Dzērve, Kārlis Trušinskis, Andris Skride, Romāns Lācis, Jānis Eglītis attached. And, yes, my photo was attached to some of them as well.
The majority of those advertisements used the name and photo of Andrejs Ērglis. He is the most popular doctor in Latvia at the moment. He often appears on TV and radio, press publications and various portals. There is a magical power to his name, similarly to Pauls Stradiņš, Ilmārs Lazovskis or Viktors Kalnbērzs. People trust Ērglis – simple as that. He is not only the most published Latvian scientist in world-famous scientific literature, but also a national doctor who has invested years in teaching people how to check cholesterol levels and take statins (now a combination of modern statins ezetimibe), teaching the way to take oral anticoagulants for patients with arrhythmia, teaching ways to keep track of blood pressure and take medication – so that arterial blood pressure is in the range of up to 130 mmHg.
Unfortunately in cardiology it often means that a prescribed medicine or combination of medicines will need to be taken for the rest of a patient’s life,
and it needs to be done in parallel to physical activities, healthy diet and a complete cessation of smoking. But all of the aforementioned – remaining life expectancy for Prof. Ērglis’ patients often means twenty to thirty years, during which it will be necessary to use statins, anticoagulants, beta blockers, etc. prescribed by the cardiologist or general practitioner. And the lion’s share of these medicines are compensated by the state.
And then suddenly – an image of Prof. Andrejs Ērglis appears on Facebook or some portal with notes like: “Prof. Andrejs Ērglis: Noise or ringing in the head – it’s the onset of a stroke! Drink a strong drink before the container bursts”, “Prof. Andrejs Ērglis: pensioners, clean your blood vessels at home! 2 kg of clots come out in the morning”, Cardiologist: “Don’t destroy your heart with chemicals if your blood pressure is above 140/77, instead eat bitter…”.
This is where I want to ask all residents in Latvia – don’t believe advertisements, only believe the prescription from your doctor!
Latvian residents spend EUR 200 million on various pointless supplements and medicine-like products. This means every one of us – every Latvian resident – pointlessly spends EUR 100 every year on the internet, pharmacy or specialised supplement store on various supplements that cause more harm than good.
– Somehow, the notion is ingrained in our collective minds that there should be a professional manager at the helm of a hospital who, although doesn’t really understand how this whole complex organism – the hospital – functions and interacts in terms of treatment, but is well-versed in management knowledge and the production of countless papers. The same applies to hospital councils. Meanwhile patients don’t understand how it can be that there is a shortage of money to pay for state-paid medical services and yet there is enough money to pay council member large wages?
– World practice proves that a person with medical education and understanding of the field is the best suited to manage a hospital or other medical institution. For a long time politicians in Latvia have been pushing the opinion that a pub musician can work as a minister of health and a person close to a political clan can work as the head of a hospital.
One major development happened during Anda Čakša’s term as Minister of Health. First a ream management team was removed from the management of the Eastern Clinical University Hospital – one of the best medical organisers, surgery Prof. Viesturs Boks and Dr. Anita Štokenberga. Then the emphatic manager, Dr. Egita Pole (currently manages the State Donor Centre, and its work results are great) was removed. In their place the ministry appointed car locksmith Imants Paeglītis to the hospital’s management, who failed to fully grasp what medicine is in the years he spent managing the hospital. Shortly after that all municipalities decided to appoint people close to political organisations in important management posts in local hospitals.
I won’t speak for the Ministry of Health, where, aside from the minister, only three other people have a medical diploma.
To further reinforce this mess, then the minister Ilze Viņķele created well-paid hospital councils (more like troughs). At least one council member was selected by Viņķele from abroad. We had to translate all documents into English, but none of the foreigners contributed anything significant to Latvia in the end.
My advice to Hosams Abu Meri – if council are necessary because of EU regulations, then no one prohibits composing a single professional council for all hospitals.
– Lately people’s stories about long queues in hospitals, ambulances “throwing people out” at night because hospitalisation was not needed, indifference from medical workers and general lack of interest in treating patients have been popping up more and more often in the news… Like everyone else in our society, we are interested in preventing such situations, but – how can we do this? Will increased financing volumes be enough to prevent this morality problem?
– I will say that for every one accident in communication, logistics or organisation there are 100 stories of success. I see success every day. The cancer that would have meant death in two months fifteen years ago now means 5 to 10 more years of life for patients. But this does mean that cancer treatment will be more expensive. Last Saturday the mother of an acquaintance of mine was brough to Stradins Hospital. Half an hour later there was angiography performed, clots were removed from coronary arteries, stents were put in. The woman was discharged from hospital the next Thursday and drove her car home on her own.
I allow that we are living in the midst of negative information circulation – portals and newspapers gladly public negative news, people on social media tell about failures and ignore positive results.
– Another painful topic is the general practitioners institute. It’s not secret that the number of general practitioners in the country is small, many are already of or above pension age. Unfortunately, younger doctors are not in a hurry to work in the countryside area. What will we do when rural medical centres start closing down one after another simply because there is no one to work there? Will we urge people from, say, Preiļi to travel to Riga just to visit a family doctor?
– The question should be put in the same pile as the closure of rural schools, regional postal offices, the attitude of banks (indifference) toward doing business outside of Riga. If general practitioners are paid for the number of patients they process, and they still have to pay their nurse and secretary wages and social guarantees, pay for office rent, heating, medicine for emergency medical services, devices, PC software, transportation fees, then it turns out that this is not sustainable in a parish in which population numbers go down year after year, where there are less than 800 people in a 30 km radius. If no additional funding is provided to sustain general practitioners in those areas, there won’t be any practices, and the nearest doctor will be at least 50 km away. I know several places in Latgale in which it is now possible to maintain practice without additional indexation – bordering parishes between counties. The same applies to the Russian border, where the number of residents has gone down sharply in recent years.
For objective, but often subjective reasons, ever since Ivars Eglītis’ term the family doctor practice has been left to fend for itself – already a quarter of family doctors in Latvia are of pension age, and young doctors are reluctant to study this field. Young people do not see any perspective to work as family doctors because the system is inefficient, excessively bureaucratic and bloated. Family doctors have no opportunity to go on vacation, get sick or retire, handing over their practice to their trained successor. I won’t try to explain Latvia’s legislation, but the entire section of regulations regarding the financing of family doctors is one big nightmare.
The average financing of the medical field in European countries is significantly higher than financing in Latvia. Europe diverts 12% of medical budget towards primary healthcare on average. Latvia, on the other hand, diverts 6.8% towards primary care. As a result – according to ESAO “Health at a Glance. OECD indicator” health report – the life expectancy of Latvian residents is the shortest among economically developed countries. A child born in Latvia has a life expectancy of 73.1 years, and this is the shortest life expectancy among ESAO countries. The longest one is in Japan – 84.5 years.
One important issue for general practitioners is finding a way to reduce bureaucracy. Currently family doctors spend more than 80% of their time on bureaucratic entries, tables, tickets, journals, phone calls, responses to inquiries from the police, courts of law, orphan courts, the ombudsman, National Health Service, State Agency of Medicines, Health Inspectorate and other institutions. At the same time, the minister of finance and Saeima deputies use the argument that general practitioners perform additional indicators to prove on paper that they work better, that their patients live longer, are sick less often, work harder, pay more taxes before politicians give them more money.
It’s possible general practitioners would be prepared for such a conversation if the same criteria applied to the Saeima, the government and officials in general. So – if the government’s actions has resulted in the country having the last place in Europe, billions worth of debts, the poorest demographic situation in the last 100 years (wartime included), then this Saeima and the government, according to their own indexes, should have their pay cut by 20-30%. For unknown reasons deputies, ministers and leading officials will see a raise of an average of EUR 450 this year. At the same time, general practitioners, whose expenses, utilities, energy and other costs have increased by 20-30%, saw a drop in state funding – the pay for every individual patient is down by 17%.
In any case, Hosams Abu Meri is well-aware that the first order of business to improve the general healthcare situation is the de-bureaucratisation and continued support of general practitioners. However, it would seem there are no ears in the coalition that would listen.
– Are all these papers really that important to the treatment process. If not, how can we put an end to this plague? What are the estimates for the time doctors spend on paperwork, how much time is spent on actual patient treatment and how much money is left for professional growth, since the medical field continues rapidly developing.
– In accordance with the law, general practitioners in rural areas have to send information to 28 state and municipal institutions. Together with other regulations – I would some there are some forty institutions. They constantly send letter, make requests, perform inspections and control. All this prevents general practitioners from performing their direct duties. In hospitals the number of accountants and public relations specialists will soon exceed the number of practising doctors. When I was still in charge of Latvian Medical Association, we regularly studied doctors’ work together with SKDS and the bureaucratic load there are subjected to. This load first appeared back then. Currently it seems the medical association no longer does this. Ilze Aizsilniece isn’t interested in doctors’ problems, but the interest to issue certificates for money, acquire credit points for certification in exchange for money, meanwhile increases the bureaucratic load for doctors.
– Is there room for hope that the rapid development of technologies means in the near future we may see AI an important player in Latvia’s medical sector?
– The breakthrough in AI for healthcare and medicine is in first place in all global strategic medical documents for 2024. I am more sceptical about this because I have experienced the development of e-health in Latvia, for which ministers have been predicting a major breakthrough for the past twenty years. To this day this system is called e-catastrophe or e-nightmare. This is why I believe AI will enter the medical field this year indirectly here in Latvia.
In biotechnologies artificial intelligence can speed up discovery of medicines by analysing extensive sets of genomics, proteomics and other data, identifying promising drug targets and predicting their effectiveness. Artificial intelligence algorithms can facilitate the development of new drug molecules with precise properties, optimizing effect while reducing toxicity, thus creating safer and more effective drugs with less side effects. Global assumptions suggest that by 2030 nearly all biopharmaceutical estimates will be done by AI.
The AI analyses a patient’s DNA, and soon enough AI will be developing individual medicines and treatment strategies, which suggests a major breakthrough for precision medicine. This approach promises not only better results for patients but also more efficient use of resources. But I should say – precise medicine is a very expensive pleasure. Every one of us wants a tablet prescribed to us, not a tablet the global pharmaceutical sector has programmed to sell to each resident of the planet.
Global forecasts are very optimistic when it comes to AI revolutionising doctor/patient communication, as well as patient’s attitude toward their health and use of medicines. At the same time, I can see the opposite happening – inequality of treatment, mistrust of certain groups of medicines is increasing in the world.
It has already showed signs in 2024, but chatbots and chronic health management applications based on generative AI algorithms will not reach Latvia for another five years. Such solutions will likely help patients in their daily lives, answer their questions and provide translations from medical jargon to everyday language. I am not a fan of chatbots and virtual assistants, but it seems that even in medicine these digital assistants will be available 24 hours a day, 7 days a week, offering preliminary medical diagnostics and health advice.
Artificial intelligence will most definitely become multi-modal in medicine this year. While at the moment almost everything is linear – for example, in the radiology department of the Latvian Hospital of Traumatology and Orthopaedics, artificial intelligence processes one type of data – X-ray and visual diagnostics images and very accurately reads bone fractures. Next year, in the world’s largest hospitals, multimodal models will try to process and interpret text, images, audio and video at the same time, in fact – become the interface that will bring the doctor into the age of artificial intelligence. Medicine in its deepest essence is multimodal, where the diagnosis is determined not only by laboratory and visual diagnostics examinations, but also by the doctor’s experience and intuition. However, it seems to me that it is precisely these qualities that artificial intelligence will not have in the near future.
Moreover – we have to mention AI avatars, which are developing with incredible speed. These are mainly tools for businesses. One example is HeyGen’s AI-based translation service, which not only translates your recorded video into (for example) the language of Ur (an Indian tribe in Peru that lives on islands in Lake Titicaca), but also synchronizes lip movements with that other language. Of course, telecommunications with the head of the Ur tribe about his blood pressure or bowel movements would be an interesting medical experiment, but I do not think that in the near future it will enter the GP’s practice to communicate with the descendant of a Russian military person who wants to live in Latvia, but categorically does not want to learn Latvian.
Literature from around the world claims that AI will soon start helping people deal with mental problems – AI will be able to help identify behaviour models that could indicate mental problems. This will mean a major breakthrough for health technologies. The combination of virtual reality and artificial intelligence with good success is already being used in innovative therapies for children with autism, helping them develop problem-solving skills in a controlled and safe environment.
– Experts did warn us not long ago that the country is not ready to provide residents with medicines in a crisis. Factors such as disruptions in international supply chains or delivery quotas set by foreign manufacturers cannot be influenced by us, so the question is: should the state create a national reserve fund for medicines and what can we do ourselves? Especially for patients suffering from chronic illnesses.
– This is a question for a six-hour or 28-page answer. Latvia does have medical reserves, but they are rather chaotic. Hospitals keep stores of medicines to last three months. This is good, but if we are unable to receive medicines from other European countries in peacetime for one reason or another, then in wartime we would go through our stores of painkillers, infusions, sterile dressings within hours. Ukraine’s experience shows – the most important medicines should be spread out across the country, as close to hospitals as possible. The European Union has named 200 drugs that, at best, countries must be able to produce on their own, but at worst, must be created for a 6-month reserve in case of war. I think that Latvian pharmaceutical factories are able to start the production of at least 120 of these medicines within a year or two, provided that the state undertakes to purchase these medicines for reserves. The problem comes from the conditions under which medicines in Ludza or Zilupe can be stored by wholesale traders and pharmacies. Stores of medicines and storage in general means expenses which the state should compensate to wholesale traders and pharmacies. But is seems that with activity from Minister of Economy Viktors Valainis, the matter of reserves in Latvia has finally started moving forward.
As for each individual resident’s ability to invest resources into their health, I’m not a big fan of home medkits. Medicines in them frequently expire. The best investment into one’s health is dropping smoking immediately – cigarettes and e-cigarettes. The other investment is sports activities – spend at least 30 minutes every day doing sports to warm up, stretch, move around in general.
Eating less, consuming less sugar, salt, trans-fats, sweetened beverages and alcohol is a good investment as well.
A third good investment would be improving one’s health literacy – learn basic first aid, cardio-pulmonary reanimation, hygiene. Moreover, people should love their family doctor (urologist, gynaecologist, ophthalmologist, pediatrist, etc.). People should trust medical specialists. For all the 50% of Latvian residents who are not equal in examinations, diagnosis or treatment, I can repeat the world’s simplest paradigm – the drug helps only if it is taken at the right time, in the right dose and according to the specified course.
Also read: BNN ASKS | Ideological opponents: what’s the opinion on EU’s asylum and migration reform?
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