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Chapter 6 | The impact of the crisis on the health system and health in Latvia
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which further increases dissatisfaction with the health system. A significant
proportion of the population either does not pay income tax or does not pay as
much as it should. The government hopes that it can increase the populations'
willingness to contribute financially to the health system if it links entitlement
to payment of a contribution, as is the case in social health insurance systems.
However, linking entitlement to payment of a contribution means a move away
from universal population coverage and this will need to be managed extremely
carefully to avoid adverse effects (Mitenbergs et al., 2012).
The benefits package
While universal population coverage was maintained, both service and cost
coverage deteriorated. Although no benefits were explicitly removed from the
benefits basket, certain services were implicitly removed through changes in the
benefits basket legislation (e.g. Regulation No. 1046, Government of Latvia,
2006) and in NHS contracts. Global budgets were introduced to control
hospital spending; at the same time, certain services (e.g. emergency assistance)
and population groups (e.g. children and pregnant women) were prioritized in
the contracts with providers. Consequently, as hospital budgets were used up
for prioritized care, patients were faced with substantial waiting times for nonprioritized
services, up to a point where these services can be considered to be
implicitly excluded.
User charges
Co-payments for specialist outpatient care and per diem charges for inpatient
care increased considerably in 2009, while co-payments for GP visits were kept
relatively unchanged (to steer patients away from inpatient care and specialist
outpatient care). In 2010, fees for specialist outpatient visits and per diem
hospital charges were reduced by 40% and about 21%, respectively (Table 6.4).
In addition, a co-payment of up to LVL 30 (€42.77) was introduced in 2009
for inpatient surgical interventions. Patients also have to co-pay up to LVL 25
(€35.64) for various diagnostic/therapeutic services. There are no user charges
for approved laboratory tests for which patients are referred by a physician;
however, patients may be charged for syringes, needles and collection of blood
samples for tests. Co-insurance for certain pharmaceuticals also increased in
2009, along with the change in the reimbursement system (see below). Most of
the co-insurance increases were applied to medicines for cardiovascular diseases
(the main cause of mortality in Latvia). In 2010, the co-insurance rate for
cardiovascular diseases was reduced from 50% to the previous level of 25%.
Several mechanisms exist to protect the population from catastrophic
expenditures or underuse of services, which could result from user charges.