Public Health Strategy for 2011-2017

2002-2010 Strategy.1;2;3;4;5;6 Positive developments have taken place as regards reaching some objectives, morbidity levels LPA – Latvian Pharmaceutists’ Association with vaccine-preventable diseases have decreased significantly, and breast-feeding indicators have improved; however, the LPS – Latvian Physicians’ Society objectives have not been reached. Negative trends have been observed with regard to other objectives; for example, adiposi- LSAA – Latvian Sports for All Association ty and morbidity with diabetes have increased. The aims and objectives included in this Strategy, as well as the specific points of progress being offered, should be known LSMSA – Latvian Sports Medicine State Agency and accepted not only by those who are implementing health policy, but by anyone who is doing the same with policies in MA – Ministry of Agriculture other sectors, since the aims set in the Strategy can be achieved only through joint effort. ME – Ministry of Economics MES – Ministry of Education and Science MEPRD – Ministry of Environmental Protection and Regional Development MF – Ministry of Finance MH – Ministry of Health MI – Ministry of the Interior MJ – Ministry of Justice MRDLG – Ministry of Regional Development and Local Government MT – Ministry of Transport MW – Ministry of Welfare NGOs – non-governmental organisations RSS – Rural Support Service 1 “Taisnīgums un solidaritāte veselības jomā” Sabiedrības veselības stratēģijas 2.mērķa sasniegšanas ziņojums, v/a „Sabiedrības veselības aģentūra”, 2008 PYLL – potential years of life lost [“Justice and Solidarity in Health Sector”. Report on achieving the 2nd aim of the Public Health Strategy”, state agency “Public Health Agency”, 2008]. 2 „Zīdaiņu un pirmsskolas vecuma bērnu veselība” Sabiedrības veselības stratēģijas 3.mērķa sasniegšanas ziņojums, VEC, 2008 [“Health of Infants and Pre- RSU – Riga Stradins University School Children”. Report on achieving the 3rd aim of the Public Health Strategy”, CHE, 2008]. RSU ILSEH – an agency of Riga Stradins University, entitled “Institute of Labour Safety and Environmental Health” 3 „Skolas vecuma bērnu un pusaudžu veselība” Sabiedrības veselības stratēģijas 4.mērķa sasniegšanas ziņojums, v/a „Sabiedrības veselības aģentūra”, 2008. SAM – State Agency of Medicines [Health of School Age Children and Teenagers”. Public Health Strategy. Report on achieving the 4 th aim of the Public Health Strategy, state agency “Public SCCD – State Centre for Curriculum Development Health Agency”, 2008]. 4 „Pieaugušo veselība, veselīgas un aktīvas vecumdienas” Sabiedrības veselības stratēģijas 5.mērķa sasniegšanas ziņojums, VEC, 2009 [“Adult Health, Healthy SLI – State Labour Inspectorate and Active Old Age”. Report on achieving the 5th objective of the Public Health Strategy, CHE, 2009] STI – sexually transmitted infection 5 Neinfekcijas slimību izplatības samazināšana” Sabiedrības veselības stratēģijas 8.mērķa atsevišķu apakšmērķu sasniegšanas izvērtējums, v/a „Sabiedrības TB – tuberculosis veselības aģentūra”, 2007. [Decreasing the prevalence of non-infectious diseases. Assessment of the achievement of some objectives of the 8 th aim of the Public Health Strategy, state agency “Public Health Agency”, 2007]. UL – University of Latvia 6 „Vardarbības un nelaimes gadījumu izraisītie veselības traucējumi” Sabiedrības veselības stratēģijas 10.mērķa sasniegšanas ziņojums, VEC, 2009 [“Health WHO – World Health Organisation Disorders Caused by Violence and Accidents”. Report on achieving the 10 th aim of the Public Health Strategy, CHE, 2009]. 8 9 1.Basic Principles and Aims of 2.Linking the Strategy with Public Health Policy Other Development Planning The Basic Principles of Public Health Policy: Documents The Strategy was prepared on the basis of the following documents: Human-centered health care - the public healthcare policy is implemented by making the individual person the focus • The Sustainable Development Strategy for Latvia, “Latvia 2030”,1 especially the point of progress covering in terms of prevention, diagnostics, treatment, rehabilitation and ensuring comprehensive information regarding, and the mo- the quality and accessibility of health and social services, as defined in Section 2: “Long-term Investments in Human Capital”. tivation of, people. • The Strategic Development Plan for Latvia 2010-2013, which proposes a healthy person in a sustainable society Human rights - every person is entitled to the highest level of physical and psychosocial health during the whole of his as a pre-condition for safe and stable development. or her lifetime. Effective policy and good governance - a health policy is founded upon evidence-based knowledge - scientific evi- Other policy planning documents with which the Strategy is connected: dence and cost effectiveness. Continuity, coordination and updating is ensured in terms of policy planning and implementa- In the field of employment and social policy: tion, as is the interconnectedness of policy planning documents. • Program for decreasing domestic violence 2008-2011 (aim: to monitor offences linked with domestic violence, achieving Participation - the involvement of society, public administration institutions, local government authorities, non-govern- a decrease in the number of such cases and their negative consequences);2 mental organisations, the representatives of private businesses, and foreign institutions in the process of planning, implemen- • Action plan for the implementation of Policy Guidelines for Decreasing Disability and its Consequences for 2005-2015 ting and assessing a public health policy, providing the opportunity for all of Latvia’s inhabitants to realise their “health poten- (aim: the complex development and implementation of disability prevention measures);3 tial” and facilitating as qualitative a functioning of the public health system as possible. Increasing the individual’s responsibili- • Guidelines on the national family policy for 2011-2017 (aim: to promote the establishment of families, and their stability ty for safeguarding and improving one’s health. and wellbeing, and to increase the birth rate, as well as to strengthen the institution of marriage and its value in society);4 Solidarity - all inhabitants of Latvia have the duty to cover the cost of maintaining the health system, by paying taxes, • Guidelines for the Development of the Field of Labour Protection 2008-2013 (aim: improving policy planning in labour fees and any other payments envisaged in legislation. protection, increasing the capacity and effectiveness of state monitoring and control mechanisms, and the practical im- Health in All Policies - other sectors, institutions and organisations should be involved and be co-responsible for ma- plementation of “the culture of prevention” in society and companies);5 intaining and improving public health, thereby ensuring a multisectoral strategy with regard to health determining factors • The “Latvia Fit for Children 2010-2012” Plan (aim: creating a world that will conform to the needs and interests of all (including physical, emotional, economic, social, cultural and other factors). children).6 Equal rights and opportunities for all - everyone bears an equal right to receive the necessary health promotion In the field of home affairs: and healthcare services within the limits of the human, technical and financial resources available within the state, within the • Guidelines for limiting drugs and psychotropic substances and the spread of addiction and controls for 2011 -2017 (aim: scope, and in accordance with the procedure defined by legal acts, irrespective of gender, age, race, skin colour, language, re- to decrease the acceptance by society of the illegal use of drugs and psychotropic substances and the harm caused by ligious beliefs, sexual orientation, political and other views, social background, ethnic background, education, social and mate- their use to society, and to decrease the availability of these substances).7 rial status, type of occupation and other conditions. In the field of education and science policy: • Guidelines on Education Development for 2007-2013 (aim: to ensure the option for all inhabitants to acquire a high level The aim of a public health policy is to prolong the healthy life years of the Latvian population and to of education through lifelong learning in accordance with individual interests, abilities and the economic development prevent untimely deaths, while maintaining, improving and restoring health. needs of the state, especially in relation to objectives that are linked with educating students on healthy nutrition, repro- ductive health and various dependencies, as well sports activities, etc);8 To be achieved by 2017: • National Sports Development Program for 2006-20102 (aim: to create conditions for the development of a healthy, physi- • to increase by two years the healthy life years of individuals cally and mentally developed personality);9 • (from 52.6 healthy life years for men in 2009 to 54.7 years in 2017, and from 55.8 healthy life years for women in 2009 to • National Youth Policy Program for 2009-2013 (aim: to improve the quality of life of adolescents by promoting their ini- 57. 8 years in 2017). tiative, involvement in decision taking, and in public life, supporting working with young people and ensuring that ado- • to decrease by 20% the potential years of life lost lescents enjoy an easier transition from the status of a child to that of an adult).10 • (from 85,338 potential years of life lost among men in 2009 to 68,270 in 2017, and from 35,793 potential years of life lost In the field of transport and communications policy: among women in 2009 to 28,634 in 2017). • Road Traffic Safety Program for 2007 -2013 (aim: to achieve a decrease in the number of fatal traffic accidents, especial- To reach the main aim of the public health policy, the following objectives have been set: ly by dealing with the following tasks - to guarantee the safety of the vulnerable participants in matters concerning road • To eliminate injustice in the field of health by implementing measures to ensure equal health opportunities for all Latvi- traffic use, increasing safety levels for children in road traffic use, and eliminating drink driving).11 an inhabitants. In the field of environmental policy: • To decrease morbidity and mortality from non-infectious diseases, and to decrease the negative impact of risk factors • Environmental Policy Guidelines for 2009-2015 (aim: to ensure that people have the option to live in a clean and well-or- upon the health. dered environment).12 • To improve the health of mother and child, and decrease infant mortality. In the field of a common agricultural policy: • To promote a healthy and safe living and working environment, and to decrease trauma and mortality from external cau- • Implementation plan for measures to supply fruit and vegetables to schools (2010-2013) (aim: to increase the consump- ses. tion of fresh fruit and vegetables by students in institutions of comprehensive education).13 • To decrease morbidity with infectious diseases among the population. • To ensure an effective management of the healthcare system and a use of resources, to ensure the optimisation of costs 1 Approved at 10 June 2010 sitting of the Saeima (Latvijas Vēstnesis No.101, 29.06.2010.). and the sustainability of the healthcare system, as well as ensuring equal access for all Latvian inhabitants to those heal- 2 Approved with the Cabinet of Ministers Order No. 343 of 18 June 2008. thcare services that are paid for from the resources of the state budget. 3 Approved with the Cabinet of Ministers Order No. 541 of 19 July 2006.

4 Approved with the Cabinet of Ministers Order No. 65 of 18 February 2011. The main points of progress for reaching the set aim: 5 Approved with the Cabinet of Ministers Order No. 213 of 17 April 2008. • Ensuring partnership and intersector cooperation, and promoting equal health opportunities for all inhabitants 6 Approved with the Cabinet of Ministers Order No. 324 of 9 June 2010. • Reducing the risk factors for non-infectious diseases 7 Approved with the Cabinet of Ministers Order No. 98 of 14 March 2011. • Improving the health of both pregnant women and children 8 Approved with the Cabinet of Ministers Order No. 742 of 27 September 2006. • Decreasing the impact of traumatism and environmental risks upon public health 9 Approved with the Cabinet of Ministers Order No. 838 of 31 October 2006. • Preventing infectious diseases 10 Approved with the Cabinet of Ministers Order No. 589 of 27 August 2009. • Developing a high quality system of healthcare services, and ensuring the equal accessibility of all services to all Latvian 11 Approved with the Cabinet of Ministers Order No. 209 of 13 April 2007. inhabitants. 12 Approved with the Cabinet of Ministers Order No 517 of 31 July 2009.

13 Approved with the Cabinet of Ministers Order No. 115 of 24 February 2010. 10 11 3. DESCRIPTION OF THE SITUATION AND IDENTIFIED PUBLIC HEALTH PROBLEMS The indicator, which proves inequality in health, is the difference between life expectancy for newborns in rural and urban populations. For rural inhabitants it is shorter by approximately two years.8 In Latvia, inequality in the health sector is caused also by socioeconomic factors, which are proven by different health indi- 3.1. Inequality in the Health Sector cators in various population groups. Poverty is an important factor, one which determines poor health, since the lack of finan- cial resources is a very significant factor in limiting the accessibility of healthcare services. In the EU SILC population survey of The main aim of the Strategy1 was to achieve an improvement of the health status of the Latvian population, approxima- 2008, 16% of respondents in Latvia indicated that they could not afford medical examinations, and this is the highest indica- ting it to the best EU health indicators, considering such quality of life aspects as the health and social security of inhabitants. tor amongst all the EU states.9 This shows that lower income households are more at risk of not receiving the necessary medi- The average life expectancy of newborns was used as the public health indicator. The general aim of the Strategy was to re- cal assistance than other households. ach 95% of the EU average life expectancy for newborns. The aim was not reached. However, in 2009 the average life expectan- The survey data covering comparisons of health self-assessment in individuals depending upon income levels indicate cy of newborns reached 92% of the EU average life expectancy of newborns. This indicator still significantly falls behind the EU that a smaller percentage of inhabitants with a lower income (52.2% of men, and 46.6% of women) characterise their state of average indicator, since the adjusted mortality indicators due to all causes of death in Latvia were still considerably higher than health as ‘good’ and ‘rather good’ compared to those with a higher income (66.7% of men, and 60.8% of women).10 the EU average. In 2009 the average life expectancy of newborns in the EU was 79.65 years, but in Latvia it was 73.28 years.2 A life lived in poverty is often linked with various forms of what can be termed risky behaviour, such as an increased use The gender differences within this indicator are worth noting. In 2010 the life expectancy of newborn males was 9.6 ye- of psychoactive substances (tobacco, alcohol), depression, anti-social behaviour and crime, with an increased risk of consu- ars shorter than for females.3 Also, within the EU, the life expectancy among males is shorter when compared to women, al- ming unsafe food, and a broad range of somatic problems.11 The CSB data for 2008 show that in Latvia the poverty risk in- though here the difference is only six years.4 This reveals male mortality indicators that are too high in Latvia. The lifestyle of dex, which characterises the proportion of the population that is exposed to poverty, was at 26%. Moreover, this indicator is Latvian men is typically less healthy, involving the use of dependency-inducing substances, an unhealthy diet, and risky be- higher among women (27%) then among men (24.2).12 haviour - men more often become the victims of traffic accidents and accidents at work, or commit suicide, which determines The accessibility of healthcare services (both in financial and regional terms, as well as the accessibility of specialists) cha- a higher mortality rate at a younger age for them.5 The adjusted mortality indicators show that in Latvia 48% men die below racterises the quality and effectiveness of the healthcare system. In Latvia a section of the population has no access to heal- the age of 65 (with women the figure is 28%). But in the EU only 29% of men die below the age of 65.6 thcare when this becomes necessary, due to financial conditions.13 The survey data indicates that 45.5% of respondents who However, the analysis of the healthy years of a typical lifespan, according to Eurostat calculations, shows that in Latvia needed healthcare services during the previous year and who rejected them did so due to financial considerations.14 in 2008 a total of 77% of the span of male life expectancy was spent in the healthy years of that lifespan, but for female life The studies on the accessibility of healthcare services reveal that almost one fifth (17.7%) of respondents believe that du- expectancy this figure was down to 70%. Therefore, women in Latvia have a longer life expectancy, but a smaller proportion ring the last twelve months they really needed a consultation with a specialist doctor, but this was not carried out due to of years in which they can expect to live a healthy life, which is in line with results from other EU states. constrained financial resources (23.7%), or due to waiting lists (12.8%), or due to distance or a lack of transportation (5.4%). This shows that accessibility problems in this sector are one of the most pronounced. Respondents from low income house- holds (below 100 LVL) approach specialist doctors with a frequency which is almost half that of people whose household in- come is medium or high.15 Likewise, inequality in Latvia can be observed when comparing the scope of healthcare services that are accessible to ge- neral society, along with the funding procedures used for it and the healthcare of prison inmates and the funding for that, so- Figure 1. The average life mething which causes serious problems, since both systems function in isolation. expectancy of newborns, by gender Identified problems: Source: CSB • The average life expectancy at birth significantly differs for men and women, which to a large extent is linked to an un- healthy lifestyle (using dependency-inducing substances, unhealthy nutrition) and risky behaviour, which is typical in men. • The accessibility of healthcare services differs for areas of the Latvian population, something that is influenced both by fi- nancial and geographical conditions. In Latvia, 11.3% of men and 15.2% of women rate the condition of their health as ‘poor’ and ‘rather poor’, and 48.3% of • The organisation of healthcare for prison inmates causes levels of inequality in the accessibility of healthcare. men and 41.2% of women rate it as ‘good’. With the general increase in age of the population, the numbers of inhabitants who assess their own health condition as being ‘good’ decreases.7 Objective: To eliminate inequality in the field of healthcare services, by implementing measures to ensure equal opportunities for all Latvian inhabitants to access healthcare services. 100% 90% Very poor To achieve the objective: 80% • Equal access to the promotion of good health, disease prevention, early disease diagnostics, and healthcare services, ir- 70% respective of a person’s place of residence, age, gender, or social and legal status, should be ensured; 60% Poor Percentage • Cooperation between public administration institutions, local government authorities, and non-governmental organisati- 50% 40% ons in order to improve the accessibility of health promotion measures is something that should be ensured; 30% Average • Monitoring the health status of the general public should be ensured. 20% 10% 0% Figure 2. Respondents’ self-assessment Good Total in all age 65+ of the condition of their health groups (proportion) 8 CSB data. Very good Source: CSB, EU-SILC Survey 2010 9 Taisnīgums un solidaritāte. v/a „Sabiedrības veselības aģentūra”, 2008. [Justice and Solidarity. State agency “Public Health Agency”, 2008].

10 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums 2008, Rīga, 2010. [Study of the Health Affecting Habits of Latvian Population 2010, Riga, 2011].

1 Public Health Strategy (The Cabinet of Ministers meeting of 06.03.2001). 11 WHO, Health for All Policy Framework for WHO Region for Europe, “Health – 21”, 1999.

2 WHO European Health for all database. 12 Poverty risk index - the share of inhabitants (in percentage) below the threshold of the poverty risk, which is set at 60% of the available median income

3 CSB data. recalculated per equivalent consumer. The annual poverty risk threshold in Latvia in 2008 was 2295 LVL in one –person household and 4819 LVL for a

4 WHO European Health for all database, the data of 2008. household consisting of 2 adults and two children below the age of 14. The data are given with reference to the income reporting year. 5 „Paredzamā mūža ilguma atšķirības sievietēm un vīriešiem”. V/a „Sabiedrības veselības aģentūra”, Rīga, 2007 [“Differences in life expectancies of women 13 Access to health care and the financial burden of out-of-pocket health payments in Latvia. WHO, 2009. and men.” State agency “Public Health Agency”, Riga, 2007]. 14 Pētījums „Iedzīvotāju apmierinātība ar veselības aprūpes pakalpojumiem un to saņemšanas iespējām”, Veselības obligātās apdrošināšanas valsts aģentūra,

6 Latvia From Exuberance to Prudence (A Public Expenditure Review of Government Administration and the Social Sector), Europe and Central Asia 2008 [Study “Inhabitants’ satisfaction with health care services and the possibilities to receive them”, State Compulsory Health Insurance Agency, 2008]. Regional Office Human Development Department, 2010. 15 G. Briģis „Iedzīvotāju veselības apsekojuma analīze”, 2008 [G.Briģis “Analysis of Population Health Survey”, 2008].

7 EU-SILC survey 2010, CSB, 2011. 12 13 3.2. Non-infectious Diseases and their Risk Factors 3.2.1. Cardiac and Circulatory Diseases Cardiac and circulatory diseases form the most significant public health problem in Latvia and one of the most important in the A significant task to be faced in Latvia is that of trying to improve public awareness and to promote the development of whole world. The high mortality, morbidity and hospitalisation indicators serve as a proof of that. Even though the number of de- both personal skills and lifestyle and behavioural changes to ensure good levels of cardiac and circulatory results with simp- aths caused by circulatory diseases was smaller in 2010, it is still the most prevalent cause of death (causing 54.1% of all deaths).1 le and effective measures. The most effective source of prevention for cardiac and circulatory disease is stopping smoking and The indicators of mortality caused by circulatory diseases among the Latvian population are twice as high as the average EU indi- taking regular physical activity, as well as one’s choice of food, making sure it complies with the principles of rational or phy- cators. In 2009 the total adjusted mortality indicator in Latvia for circulatory diseases per 100,000 of the population was 479.5, whi- siological nutrition (increasing the consumption of fruit and vegetables and decreasing the consumption of salt and saturated le in Lithuania this was 496.78, in Finland it was 218.07, and in Austria it was 213.12, but the average in EU countries was at 232.77.2 fatty acids) and maintaining an adequate body weight. The total mortality rate from circulatory diseases is higher among women (749.0 per 100,000 people in the population) when com- pared to men (701.5 per 100,000 of the population). But in the 0-64 age group among males the mortality rate from circulatory di- 3.2.2. Oncological Diseases seases (237.0 per 100,000 inhabitants) is three times higher than among women (81.7 per 100,000 inhabitants).3 Even though, since 2001, the total adjusted mortality indicator from circulatory diseases in Latvia has been decreasing slightly every year (in 2001 it was For a long time malignancies have occupied second place in the reasons for causes of death, following on from cardiac 606.82 per 100,000 inhabitants), diseases of the circulatory system remain a significant public health problem in Latvia. and circulatory diseases. Comparing 2010 to 2009 shows that the mortality rate has increased - from 267.3 to 273.6 cases per 100,000 inhabitants.9 The total morbidity indicators in Latvia do not differ significantly from the average EU indicators (except 187.8 for lung cancer sufferers), but the mortality indicators are higher. Male morbidity rate from malignancies (314.0 per 100,000 165.9 177.1 180.1188.1 inhabitants) is higher than female morbidity rate (239.0 per 100,000 inhabitants). Data from the Latvian Register of Oncologi- 163.7174.4 169.9170.3 182.7 cal Diseases shows that in 2010, a total of 10,600 people were newly diagnosed with cancer, but the total number of registe- 157.01 red patients at the end of 2010 was 62,959. !"#$%&&$&&&$'($!'!)*+,'-$ 144.2 Figure 3. Untimely morbidity (0-64 Latvia years) from cardiovascular diseases 136.7 129.3122.8 117.1 111.1 in Latvia and in the EU (1998-2009) 120.7 113.8 106.6 EU‐15 108.6 103.3 99.896.96 Source: WHO Health for all database Figure 4. Morbidity from malignancies in 1999-2010, by gender Source: CSB Every year the number of newly diagnosed cardiovascular diseases increases, and in general the morbidity level from this in Latvia is very high. In 2010, hypertensive diseases had a leading role among all other cardiovascular diseases with a figure of 98 99 20 20 20 00 01 02 03 20 20 04 19 19 2020 05 06 40.2%, while cerebrovascular diseases were at 9.1%, angina was at 10.3%, and chronic ischemic heart disease was at 5.4%.4 20 20 20 07 08 09 The cardiac health of the Latvian population is significantly influenced by the prevalence of cardiac and circulatory disease risk factors among the population. The cross-section survey of cardiac and circulatory disease risk factors in the Latvian population,5 ser- ves to reveal that an increased arterial blood pressure above 140/90 mmHg is observed on average in 45% of population, reaching Latvia has a large proportion of primary, untreated, visually discernible malignancies (breast, cervical, mouth cavity, and rec- a frequency of between 60-70% in the over-55s. The prevalence of high cholesterol levels (above 5.0 mmol/l) is high - between 40- tal). In 2008 visually discernible cancer in stages III and IV was detected in 25.5% of cases, in 2009 it was 25.8, but in 2010 it was 50% in the 25-34 age group, reaching between 75-85% in the over-55s. Approximately 34% of the population have increased fasting higher, in 27.7% of cases.10 The high and unchanging prevalence of primary untreated cancers, in its turn, determines the com- glycaemia above 5.66 mmol/l, but 5.4% of them reach the diagnostic criterion for diabetes mellitus, which is 7.0 mmol/l. Prevalent paratively high first year fatality and low five year survival indicators. The statistical indicators that characterise morbidity in Lat- obesity is also observed, in more than 30% of the population the body mass index exceeds 30kg/m2. These points focus upon the via are comparable to the average EU indicators, but the mortality rates from this disease group are still comparatively higher, wi- attitude of inhabitants towards their own health and their ability to link the presence of risk factors with the possibility of develo- thout showing any positive changes over time. ping cardiovascular diseases in the future. The Latvian population is gradually taking better care of its health; however, this is not In accordance with acts of legislation,11 organised cancer screening has been introduced for breast, cervical and colorectal sufficient. In a survey that was carried out in 2010, a total of 66.9% of respondents admitted that they had had their blood pressure cancer in Latvia; however, screening for colorectal cancer can be classified as opportunistic. The coverage for the target group measured during the last year, while 30.2% had their blood cholesterol levels measured, and 32.8% had their blood sugar levels me- for breast and cervical cancer exceeds 95% (letters are sent to this section of the target group); however, the response (actual asured. Preventive activities increase with age; moreover, studies show that women are more active in this regard.6 For every third participation in screening) is not satisfactory - it is significantly lower than the internationally accepted minimum indicators (30.9%) inhabitant who had had their blood cholesterol levels measured, the result was elevated: for men in the 55-64 age group the (the coverage for the target group should reach 75% at least). The lowest coverage indicator is for colorectal cancer screening. figure was 42.6%, but for women in the same age group it was higher at 52.1%. The fact that the majority of the population - 84.3% Individual invitations to participate in screening are sent to the breast and cervical cancer target group, but are not sent to in cases of increased cholesterol levels - received advice on diet is a factor that must be assessed positively.7 the colorectal cancer screening target group (which does not comply with the definition of an organised screening process). An international study on secondary cardiovascular prevention,8 revealed that in Latvia, after suffering a myocardial infarction or People are not being informed sufficiently about the necessity of participating in the screening program or about the poten- heart surgery, coronary disease patients continue smoking (21.6%), or suffer from increased body weight (80.9%), elevated bloody tial benefits of this program. pressure (58.6%), or elevated cholesterol levels (64.0%), and 23.8% of patients have diabetes mellitus. This data shows that the preva- The program for Controlling Oncological Diseases for 2009-2015,12 has been developed to decrease the risk of oncological lence and elimination of risk factors is not only a problem for the healthy section of the population, but pertains also to patients. diseases, to increase the survival of oncological patients, and to improve their quality of life. Taking as a basis the situation in Lat- via, the global experience, and WHO recommendations, the program defines five points of progress: primary prevention, cancer

1 CHE database The Causes of Death of Latvian Population. screening that is organised by the state, treatment, palliative care, and methodological guidance for the sector. The aim of the

2 PVO Health For All database. program can be achieved through intersectoral and multi-disciplinary cooperation. The first and main approach to be emphasi-

3 CHE data. sed in cancer prevention is the restriction of smoking and the use of alcohol, promoting healthy nutrition and exercise in combi-

4 CHE data. nation with screening, early diagnosis, risk reduction, appropriate treatment, and palliative care. 5 „Latvijas iedzīvotāju kardiovaskulāro un citu neinfekcijas slimību riska faktoru šķērsgriezuma epidemioloģisks pētījums” (1.ziņojums) Latvijas Ārsts, sept. 2010 [A cross-sectional epidemiological study of the risk factors of cardiovascular and other non-infectious diseases among Latvian population” (1st Report), Latvijas Ārsts, September, 2010].

6 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums 2010. Rīga, 2011 [Study of the Health Affecting Habits of Latvian Population 2010. Riga, 2011]. 9 CSB data. 7 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums 2008. Rīga, 2010 [Study of the Health Affecting Habits of Latvian Population 2008, Riga, 2010]. 10 CHE data.

8 EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 countries, EuropeanJ. 11 The Cabinet of Ministers Regulation No. 1046 of 19 December 2006 “The Procedure of Organising and Funding Health Care”. Cardiovascular Prevention and Rehabilitation, 2009, 16,2,121-137. 12 Approved with the Cabinet of Ministers Order No. 48 of 29 January 2009. 14 15 3.2.3.Diabetes Mellitus The number of diabetes patients is growing with every year, both in Latvia and in Europe in general. The prevalence of diabetes has increased in Latvia from 1.5% of the total population in 2000 to 2.09% in 2005 and 3.2% in 2010.1 An especially rapid increase in the number of diabetes patients has been observed in recent years: in 2009 in Latvia 67,348 diabetes patients were recorded (or 2,995.4 patients per 100,000 inhabitants), but in 2010 this had increased to 72,654 patients (or 3,258.5 patients per 100,000 inhabitants).2 The majority of patients (93.9% of registered diabetes mellitus patients) in 2010 were Type II diabetes mellitus patients, while Type I diabetes mellitus patients numbered 5.4%, and other specific types of diabetes amounted to 0.7%. Since Type II diabetes mel- Figure 5. The dynamics of the litus patients are predominantly elderly people, the largest proportion of diabetes patients were in the over-60s age group (in 2009 number of suicides from 1990- this figure for this was 70.8% and in 2010 it was 71.4%).3 The development of Type II diabetes mellitus to a large extent is linked 2010, by gender with an unhealthy lifestyle and excess body weight. Source: CSB Currently the diagnostics, treatment and monitoring of diabetes patients in Latvia’s prisons and detention centres is very difficult and limited due to insufficient funding and deficiencies in legal regulation. It is economically more efficient to invest in the prevention of diabetes mellitus risk factors, preventive measures, a timely de- Isolated short-term campaigns and activities aimed at reducing prejudice against persons with mental health problems, tection of the disease, and treatment before the disease’s complications have developed. In the case of diabetes mellitus, preventi- decreasing the number of suicides, and supporting people in situations of crisis, have been carried out in Latvia.13 ve measures are very important - an adequate diet, increased physical activity, and abstaining from addiction-inducing substances, In 2008 the guidelines entitled “Improving the mental health of the population in 2009-2014”,14 were adopted with the including alcoholic beverages, and not smoking. aim of providing to the population high quality mental healthcare which could conform to their needs. An action plan for the implementation of the guidelines is needed in order to implement a consistent and continuously planned policy. To ensure 3.2.4.Mental (Psychic) Health the implementation of a successively planned policy, the Cabinet of Ministers has charged the Ministry of Health with drafting a plan for the implementation of the Guidelines,15 defining measures to improve the development of mental healthcare ser- Sound public mental or psychical health is an essential pre-condition for developing a stable, safe and prosperous society. The vices, promoting mental health, and improving the legislative basis. main aspect in improving public mental health is the prevention of mental diseases and suicides, improving mental health and well- being, improving somatic health, a realisation of human resources and human potential in full, decreasing prejudice and discrimina- 3.2.5. Factors influencing health (lifestyle and behaviour) tion, the accessibility of specialists, intersector cooperation, the attraction of resources, etc.4 In 2010 the most frequent mental and behavioural disorders for patients who have been entered into the Register of Patients A healthy lifestyle has an essential role in preserving and improving health. As mentioned before, the most significant with Particular Diseases, were schizophrenia, schizotypal disorders and hallucinations (26.6%), mental retardation (24.0%), organic public health problems in Latvia are cardiac and circulatory diseases. The main behaviour factors, which facilitate the develop- mental disorders, including symptomatic disorders (22.7%).5 An analysis of newly registered patients shows that, according to the ment of circulatory diseases, are unhealthy nutrition, insufficient physical activity and smoking. In 80% of cases circulatory di- method by which the disorder had been diagnosed, only 14.8% of cases involving all registered patients saw the disorder being di- seases are linked to the presence of these risk factors. The features of a healthy lifestyle are sufficient physical activity, a ratio- agnosed by a general practitioner. Most frequently, the patients themselves identified the disorder and approached a psychiatrist nal or physiological diet, and an absence of harmful habits (smoking and alcohol consumption). (18.2%) or the disorders were noticed by relatives or friends (24.7%), or they were identified by a psychiatrist (16.1%). In 8.4% of ca- ses the diagnosis was made at the psycho-neurological medical facility.6 3.2.5.1. Dietary Habits The proportion of inmates with mental and behavioural disorders is large (in 2010 a total of 6,795 had 5,896 registered cases of mental and behavioural disorders). The percentage of such persons in prisons or detention centres greatly exceeds this proportion Nutrition has a crucial role in improving and maintaining health indicators. A balanced diet with a high nutritional value is in society; therefore they need special attention. Inmates with mental and behavioural disorders pose a threat to other inmates and needed to ensure the growth and the development of the body, to promote a high capacity for work and wellbeing. Howe- staff; likewise, special methods for working with inmates are needed. ver, only 49% of Latvian inhabitants consider the food that they consume daily to be generally healthy, but 39% admit that In Latvia the indicators reflecting the mental health of the population have worsened. In general, 64.7% (58.4% of men and their daily diet is not healthy.16 In general men have poorer dietary habits such as, for example, a low intake of vegetables, or 70.7% of women) have noted that during the last month they have experienced tension, stress and depression. Feelings of stress a low proportion of full-grain and bran bread consumption.17 The WHO recommends that at least 400g of vegetables and fru- and depression are most frequently experienced by both genders in employable age, between 25 to 54 years of age. On average, it be consumed daily;18 however, only 35.3% of inhabitants consume fresh vegetables every day. Likewise, only 21.5% of in- 26.9% of the total, or 24.9% of men and 28.8% of women, indicate that during the last year they have experienced episodes of dep- habitants consume fruit and berries on a daily basis. Only 33.1% of men and 49.8% of women do not add salt to their food, ression.7 During the last year, 50.8% of boys and 64.2% of girls have experienced irritation or a bad mood more often than once per but almost one man in every ten (9.0%) adds salt to his food before tasting it, while women do this less frequently, amoun- week.8 It is worrying that 27% of school students between the ages of 15-16 admit that they have considered suicide, but 12% of ting to 4.3% of the total.19 The average amount of salt consumed by Latvian inhabitants every day is 7.1g per day, which ex- them have actually attempted to commit suicide.9 ceeds the recommended daily amount of 5g per day.20 Excessive consumption of salt is a very important risk factor in cardiac Latvia is one of the countries with the highest suicide rate in Europe. In 2010, a total of 435 people committed suicide, which and circulatory diseases, since it increases the risk of hypertension. constitutes 19.4 per 100,000 of inhabitants. Most often suicides are committed by men in the 45-59 age group.10 & 11 Suicides (in the 15-64 age group) rank as the fifth most frequent cause of death. Among men the mortality rate for attempted suicides (36.2 per 100,000 inhabitants) is up to seven times higher than among women (5.1 per 100,000 inhabitants).12 The consistent decrease in the number of suicides, which was observed over the last fifteen years, stopped in 2008-2009, possibly, under the impact of the econo- mic recession.

1 CHE data.

13 Erdmane A, Leimane-Veldmeijere I, Muciņš R, Veits U., Ziņojums par Pasaules Veselības organizācijas garīgās veselības deklarācijas un rīcības plāna

2 Ibid. ieviešanu Latvijā, Rīga, 2009 [Erdmane A., Leimane-Veldmeijere I., Muciņš R., Veits U., Report on the Implementation of World Health Organisation

3 Ibid. Declaration and Action Plan on Mental Health in Latvia, Riga, 2009].

4 WHO Regional Office for Europe, Mental Health facing the challenge, building solutions, Report from the European Ministerial Conference, Copenhagen, 2005.

14 Approved with the Cabinet of Ministers Order No. 468 of 6 August 2008. 5 CHE data.

15 Ibid.

6 Garīgā veselība Latvijā 2009. gadā, tematiskais ziņojums, VEC, 2010 [Mental Health in Latvia in 2009, thematic report, CHE, 2010]. 16 „Sabiedrības veselības analīze Latvijā 2006”. Veselības statistikas un medicīnas tehnoloģiju valsts aģentūra, Rīga, 2007[The Analysis of Public Health in

7 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums, 2010. Rīga, 2011 [Study of the Health Affecting Habits of Latvian Population 2010, Riga, 2011]. Latvia. State Agency of Health Statistics and Medical Technologies, Riga, 2007].

8 Velika B. u.c., Veselība un psihosociālā labklājība skolas vecuma bērniem Latvijā, HBSC, Rīga, 2008 [Velika B., et al. Health and psychosocial wellbeing of school

17 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums 2008. VEC, 2010 age children in Latvia, HBSC, Riga, 2008]. [Study of the Health Affecting Habits of Latvian Population 2008, CHE, 2010].

9 Koroļeva I. u.c., Atkarību izraisošo vielu lietošanas paradumi un tendences skolēnu vidū, ESPAD, Rīga, 2008 [Koroļeva I., et al. The habits and trends of using

18 Diet, nutrition and the prevention of chronic diseases. Report of a joint WHO/FAO expert consultation. Geneva, World Health Organization, 2003. addictive substances among school students, ESPAD, Riga, 2008].

19 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums, 2010. Rīga, 2011.

10 CSB data. [Study of the Health Affecting Habits of Latvian Population 2010 Riga, 2011].

11 Taube M, Damberga I, Pašnāvības Latvijā – situācija, perspektīvas, risinājumi, ziņojums par situāciju, Rīga, 2009 [Taube M., Damberga I. Suicides in Latvia –

20 Latvijas iedzīvotāju visaptverošais pārtikas patēriņa pētījums 2007-2009., Nacionālais diagnostikas centrs, PVD Pārtikas centrs, Rīga, 2009. [A the situation, prospects, solutions, report on the situation, Riga, 2009]. comprehensive survey of Latvian population food consumption patterns 2007-2009. National Centre of Diagnostics, FVS Food Centre, Riga, 2009].

12 CSB data. 16 17 Milk is a very important source of calcium for the body, and yet almost half of the Latvian population (54.3%) do not con- sume milk daily. Latvian inhabitants are similarly reluctant to use sour milk products.1 Inhabitants with a higher level of educa- tion, along with city dwellers, as well as women, are more prone to changing their dietary habits.2 During the teenage years the need for nutrients physiologically increases, and the nutritional value and the balance of food consumed is important. Educating students and their parents on issues of healthy nutrition is very important, thereby promo- ting the choice of a healthy diet among school students. A study shows that in general girls have healthier dietary habits: girls Childhood obesity causes extensive and serious health and social problems in the future life of the child. Due to incorrect consume chips and soft drinks less frequently than boys. A total of 39.8% of students eat sweets at least once per day. On ave- nutrition in the pre-school age, one fifth of first graders (22.9%) have excessive body weight or obesity (and in Riga this figu- rage only 23% of school students consume fruit and vegetables every day. Only approximately one third of girls and one fifth re is higher, at 28.2% of first graders). Moreover, its proportion among boys aged 7-8 is larger than among girls; however, du- of boys consume vegetables every day.3 ring the last two years the proportion of first grade girls aged 7-8 suffering from obesity has increased faster than the propor- tion of boys suffering from obesity. The greatest proportion of first graders with excessive body weight has been observed in 30 Riga and other large cities, as well as in schools with Russian as the language of instruction (especially for boys). However, the 28 28 26 greatest increase in excessive body weight and obesity (+4.5%) during the last two years has been observed in schools with 25 Latvian as the language of instruction. One in ten first graders in Latvia is underweight, most often in small towns and in the 21 countryside.7 Several studies performed in other countries proves that food product advertising influences children’s taste, 20 20 shopping habits and food consumption. Even an advertising spot that is just thirty seconds long significantly influences the choice of food for two year-old children.8 According to the Eurobarometer study, 17% of Latvian inhabitants believe that food 15 15 advertising fully influences children’s dietary habits and 53% indicate that advertising to a large extent influences dietary ha- bits.9 Studies have proven that TV advertising is linked with the obesity of children aged between two to eighteen.10 On ave- boys Percentage Figure 6. The percentage of 10 girls students who have consumed rage, Latvian school students spend 4.78 hours watching TV on weekdays and 5.48 hours over the weekends.11 fruit at least once per day Since 2003 it has been possible to study nutritional science at Riga Stradins University, and since 2006 it has been possible

5 Source: HBSC to acquire a health science master’s degree in nutrition (within the framework of the inter-institutional academic master level programme, “Nutritional science”). Nutrition specialists can participate in the processes of health promotion, education, treat- 0 ment and rehabilitation at hospitals, institutions of education, health centres, food production and catering companies, etc. 11 years old 13 years old 15 years old However, nutrition specialists have so far been insufficiently involved in performing these duties. To promote the consumption of healthy food in society, the Cabinet of Ministers has approved both the guidelines entit- led “Healthy Nutrition 2003-2013”,12 and a plan for implementing these guidelines,13 envisaging being able to inform society In almost every second Latvian comprehensive school (46.7%) there is a café or a shop, and in 12.4% of them there is a food about issues related to healthy nutrition and developing nutritional recommendations for different social groups, integrating and drink vending machine from which students can purchase items that are predominantly sweets and calorie-rich treats. The issues of healthy nutrition in comprehensive secondary education programmes, as well as other measures. students in Riga and in schools with Russian as the language of instruction have the greatest opportunity of purchasing sweets Unhealthy dietary habits involving the consumption of sweet drinks and sweets and insufficient care for oral hygiene can and calorie-rich treats from a café or shop that is located in the school or from food and or drinks vending machines.4 influence dental health. Dental caries is is still a significant problem in Latvia, affecting the population in all age groups. The In 2006, a Cabinet of Ministers Regulation was adopted,5 prohibiting distribution in institutions of education any drinks, su- prevalence of dental caries is characterised by the DMF index (the number of decayed, missing and filled teeth). The DMF in- gar confectionery and chewing gum that contains certain food additives, including colourings, sweeteners, preservatives and dex for permanent teeth in children of the age of twelve has decreased from 5.8 in 1993 to 3.08 in 2010; however, it is still other substances, as well as food products with a high concentration of salt. The regulation was developed with the aim of high according to WHO classification.14 restricting the availability of food products in the institutions of education that are unnecessary in the daily diet of children Thanks to active preventive measures, the dental health status of children and teenagers has significantly improved du- (including crisps, salty nuts, coloured sweets, or sweetened and coloured drinks). ring recent years. The work to provide information and to motivate people that has been carried out by dental health centres To ensure balanced nutrition for first grade pupils, beginning on 1 September 2007, pupils have been receiving a state- covers 74.6% of the country’s population in rural regions and cities, and partly also in Riga. Dental health centres regularly as- funded free lunch. Quality criteria have been set for free lunches such as, for example, excluding the use of potato chips, sau- sess children’s oral health status and the prevalence of dental and oral cavity diseases, and they inform the parents of children sages, and ketchup, but milk, fresh vegetables and lean meat must be included.6 In 2010 the subsidy for providing free lunc- about anything they discover in this area. In 2009, 15,959 children had their dental health evaluated. hes to first grade pupils was LVL 2,264,018 (0.80 LVL per pupil). To ensure balanced nutrition for primary school students of all The measures to inform and educate the public that have been carried out over the last ten years have lead to the im- ages, free lunches should also be introduced for pupils in the other grades, 2-9, if appropriate state budget funding becomes proved care of the oral cavity. In 2010, 40.4% of men and 65.1% of women brushed their teeth more than once per day, but available. 12.1% of men and 2.5% of women brushed their teeth less frequently than once a week. Caring for dental health, including To promote the accessibility of healthy food in institutions of education, in 2007 the Ministry of Health prepared a hand- regular visits to the dentist, is an indicative value that reveals the adult population’s general attitude towards their health. In book entitled “Preparing Balanced Menus for Pupils of Grades 1-4”, which was intended for free distribution to all catering bloc- 2010, 48.3% of population did not visit the dentist even once (56.0% of men and 41.0% of women).15 ks at institutions of education. The handbook contains practical recipes for making not only delicious, but also healthy school lunches, so that lunch will provide all students their necessary nutrients. Since 2004 the support program for supplying certain milk products to the students of institutions of comprehensive edu- cation, the so-called “School Milk” program, has been available in Latvia. The European Commission funds the program; and its basic aim is linked to the promotion of a healthy diet and milk consumption among school students. In the 2010-2011 school year the program for supplying fruit and vegetables to schools, or “The School Fruit”, was introduced, with the aim of promo- ting higher rates of consumption in fruit and vegetables among school students. In the 2010-2011 school year, 78% of the gra- de 1 State Agency of Medicines-6 students who were enrolled in schools were registered for participation in the program.

7 Bērnu antropometrisko paradumu un skolu vides pētījums Latvijā, 2010., Riga, 2011.

1 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums 2010. Rīga, 2011 [A study of children’s anthropometric habits and school environment in Latvia, 2010. Riga, 2011]. [Study of the Health Affecting Habits of Latvian Population 2010, Riga, 2011]. 8 “The challenge of obesity in the WHO European Region and the strategies for response” WHO, 2007.

2 Ibid. 9 Health and food, Special Eurobarometer, November 2006.

3 Uztura paradumi un ķermeņa masa skolas vecuma bērniem Latvijā., Rīga, 2007 [Dietary habits and body mass of school age children, Riga, 2007]. 10 “The challenge of obesity in the WHO European Region and the strategies for response” WHO, 2007.

4 Bērnu antropometrisko paradumu un skolu vides pētījums Latvijā. SVA, Rīga, 2008 11 Fiziskā aktivitāte un sēdošs dzīvesveids skolas vecuma bērniem Latvijā, Veselības veicināšanas valsts aģentūra [A study of children’s anthropometric habits and school environment. PHA, Riga, 2008]. [Physical activity and sedentary lifestyle among school-age children in Latvia, State Agency for Health Promotion].

5 The Cabinet of Ministers Regulation No. 693 of 22 August 2006 “An Amendment to Regulation No. 610 of 27 December 2002 “Hygiene requirements for 12 Approved with the Cabinet of Ministers Order No. 556 of 4 September 2003. institutions of comprehensive primary, comprehensive secondary and vocational education” and Regulation No. 692 of 22 August 2006 “Amendment to 13 Approved with the Cabinet of Ministers Order No. 856 of 10 November 2004. Regulation No. 596 of 27 December 2002 “Hygiene requirements for institutions of education implementing pre-school education programs””. 14 CHE data

6 The Cabinet of Ministers Regulation No. 1206 of 28 December 2010 “Procedure for calculating, allocating and using state budget resources for catering to 15 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums, 2010. Rīga, 2011. pupils of primary education institutions”. [Study of the Health Affecting Habits of Latvian Population 2010, Riga 2011]. 18 19 60 52.8 48.5 3.2.5.2. Insufficient Physical Activity 50 44.9 44 40 Physical activity is an important factor in influencing the levels of health in all ages. The consumption of energy levels of be- Percentage tween 1000-1500kcal per week or 250-350kcal per day, which can be achieved by intense body movements that cause additio- 28.8

30 Men nal sweating, is classed as being physical activities. The recommended amount of weekly physical activity is five times a week or th- 22.6 ree times per week for intensive movement. The WHO recommends that adults dedicate at least thirty minutes every day to physical Women 20 15 15 activities;1 however, only 12.2% of Latvian inhabitants comply with this recommendation. The 2010 survey on health-influencing ha- bits amongst the Latvian population shows that for the majority of the population this is insufficient - in 2010, 39.9% of inhabitants 10 were engaged in some form of physical activity for at least half an hour every day or two to three times per week and more often; Figure 6. Proportion of daily moreover, women were significantly less active (34.7%) than men (45.3%).2 0 smokers by gender and place of In accordance with data from the survey performed by the Market and Public Opinion Research Centre SKDS,3 almost half or Riga 0i1es Towns Rural territories residence (percentage) 49% of inhabitants responded that they dot not engage in any physical or sporting activities at all. Source: FINBALT In accordance with the Eurobarometer survey,4 in Latvia 44% of the population does not engage in any physical or sporting ac- tivities at all, while the average percentage in the EU is 39%. Likewise, it was found that in Latvia only 28% of inhabitants engage in physical or sporting activities one or two times a week, while the EU average is 40%. It must be noted that the use of tobacco products is a topical issue amongst adolescents. Study data shows that in gene- The ways in which leisure time can be spent are of a kind that predominantly involve little physical activity - the majority of in- ral 43% of school students (46.8% of boys and 38.8% of girls) aged 13 to 15 years are currently using tobacco products. A to- habitants (41.5%) spend their leisure time reading or watching TV. A total of 42.1% of inhabitants ride State Agency of Medicines bi- tal of 18.2% of students in this age group are daily smokers. Compared to the 2002 study data, smoking among boys and girls cycles or go for walks, but only 16.5% spend their leisure time jogging gently or engaging in other physical activities.5 has increased by more than 5%.14 The legal act provides that it is prohibited to sell tobacco products to persons below the Insufficient physical activity is one of the most significant factors that negatively affects the health of school-aged children. The age of eighteen,15 and their sale is also prohibited at educational institutions and in terms of installing vending machines proportion of school children whose general level of physical activity could be considered as being sufficient (involving activity taken that would make them easily accessible to children and adolescents. However, survey data shows that the majority of school at least five days a week and for least sixty minutes a day), is 46.3%. The proportion of girls with sufficient levels of physical activity is students who smoke (46.7%), also purchase their cigarettes from shops and kiosks, and of these 56.2% admit that during the on average 14% per cent smaller than that of boys.6 Quite often, the physical activities of children are restricted by insufficient oppor- last month no one refused to sell them these products because of their age.16 tunities to use the school’s sports hall or sports grounds, as well as by inadequate infrastructure in their place of residence. The proportion of households that are exposed to tobacco smoke is high. A total of 54.5% of men and 44.5% of women In 2006, with the aim of creating pre-conditions for the development of a healthy, physically and mentally developed personality, have noted that in the family someone smokes in the presence of others. The proportion of those exposed to smoking above the National Sporting Development Program for 2006 -2012 was approved.7 Starting with 2009, the state budget does not provide average levels for both genders is found in the 15-24 age group; likewise the impact of passive smoking is greater in groups sufficient resources for its implementation, i.e. at an amount that is sufficient to ensure the involvement of inhabitants in activities with a lower level of education. A total of 14.4% of men and 3.9% of women are forced to spend more than five hours in work which have been designed for promoting a healthy and active lifestyle. The objectives envisaged by the program are aimed at invol- premises that are filled with tobacco smoke. More than half (56.9%) of school students (13-15 years old) live in homes in whi- ving children and adolescents in sporting activities, including sports for all, or in promoting the development of high achievement ch someone smokes in their presence, and 73.3% of school students spend time outside their homes in places in which so- sports. To highlight the development of sports for all, as well as the provision of measures that are intended to reduce sports-related meone smokes in their presence.17 The ban on smoking in public premises has improved the situation; however, the require- injuries, following an assessment of the aims and objectives included in the Sporting Policy Guidelines for 2004-2012,8 and in the ments set out in legal acts are not fully complied with. National Sporting Development Program for 2006-2012,9 the Sporting Policy Guidelines for 2013-2020 should be elaborated. The popularity of the consumption of other types of tobacco products is growing in Latvia. In the youngest age group (15-24), 50.4% of men and 41.8% of women had smoked a water pipe during the last year. A total of 12.0% of men and 0.3% 3.2.5.3. Smoking of women in this age group admit having tried snuff or chewing tobacco, even though the sale of both snuff and chewing to- bacco is prohibited in Latvia.18 Smoking is a significant risk factor for several chronic diseases, such as oncological, circulatory, and respiratory tract diseases, and Healthcare staff have an important role to play in decreasing smoking. Even very brief and simple advice provided by a for diabetes. Smoking also has a long-term effect upon the ingestion and reproductive system and delivers an adverse impact to oral healthcare specialist may significantly help to increase the number of cases in which people quit smoking. However, as survey and dental health and pulmonary functional abilities.10 Thanks to extensive smoking restrictions in public places that have been laid data shows,19 a significant proportion of medical students are also smokers - from 19.6% of dentistry students up to as much down in legal acts, positive trends in the prevalence of smoking have been observed in Latvia. Moreover, Latvia is one of the few WHO as 49.6% of nursing students. European Region states in which legal acts require the placement of warnings and colour photos on the packaging of tobacco-rela- In practice it means that only a small number of smokers receive advice from their doctor to quit smoking. In 2010, only ted products and which prohibit the advertising of tobacco products on television and radio and in public places. The implementation 17.2% of daily smokers were advised by their doctor to quit smoking. Family members have been more actively urging to quit of these measures since 1998 has resulted in a gradual decrease of daily smokers both among men and women. The proportion of smoking - a total of 53.9% of them, as well as other persons amounting to 27.4%.20 men who smoke on a daily basis has decreased from 51.3% in 1998 to 45.0% in 2008, while the proportion of women who smoke on The majority of prison inmates smoke and have smoking-related health disorders, as well as other addictions. a daily basis has also decreased, from 19.2% to 15.6%.11 The 2010 survey shows that the overall proportion of daily smokers is 33.7% (47.4% men and 20.7% women). The proportion of daily smokers among women is larger in Riga and the other largest cities in Latvia 3.2.5.4. Alcohol consumption (28.8% and 22.6% respectively), but among men in the largest cities and rural territories it is 52.8% and 48.5% respectively.12 In Latvia the mortality rates for men from diseases that are related to smoking in the age group 35-45 is the highest in the European Union.13 Alcohol consumption is a significant indicator for assessing the prevalence of alcohol use and its consequences in a country, as well the general public health status. According to CSB data, in 2009 the consumption of absolute alcohol per capita was 6.1 litres, but when calculating per capita consumption among the population of fifteen year-olds and older, the figure was 7.01 lit-

1 Steps to health. A European framework to promote physical activity for health. Copenhagen, WHO Regional Office for Europe, 2007. res. The registered consumption of legal alcohol comprises all registered alcohol that has been produced and sold in the coun-

2 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums 2010. Rīga, 2011 [Study of the Health Affecting Habits of Latvian Population 2010. Riga, 2011]. try, as well as information concerning foreign alcohol trade.

3 Latvijas iedzīvotāju sportošanas paradumi, SKDS, 2007 [Sports habits of Latvian population, SKDS, 2007].

4 Survey on Sport and Physical Activity, Special Eurobarometer, March 2010.

5 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums 2010. Rīga, 2011[Study of the Health Affecting Habits of Latvian Population 2010. Riga, 2011]. 14 Starptautiskais jauniešu smēķēšanas pētījums 2007.gada aptauja Latvijā”. v/a „Sabiedrības veselības aģentūra”, 2007 6 „Fiziskā aktivitāte un sēdošs dzīvesveids skolas vecuma bērniem Latvijā”. VVVA [International study of smoking among adolescents, 2007 survey in Latvia”. State agency “Public Health Agency”, 2007]. [Physical activity and sedentary lifestyle among school-age children in Latvia. State Agency for Health Promotion]. 15 Likums „Par tabakas izstrādājumu realizācijas, reklāmas un lietošanas ierobežošanu”

7 Approved with the Cabinet of Ministers Order No. 838 of 31 October 2006. [Law “On restricting the sales, advertising and use of tobacco products”].

8 Approved with the Cabinet of Ministers Order No. 632 of 15 September 2004. 16 Starptautiskais jauniešu smēķēšanas pētījums 2007.gada aptauja Latvijā”. v/a „Sabiedrības veselības aģentūra”, 2007

9 Approved with the Cabinet of Ministers Order No. 838 of 31 October 2006. [International study of smoking among adolescents, 2007 survey in Latvia”. State agency “Public Health Agency”, 2007]. 10 „Smēķēšanas un alkohola lietošanas izplatība skolas vecuma bērniem Latvijā 1991.-2006.” SVA, Rīga, 2008 17 Ibid. [The prevalence of smoking and alcohol consumption among school-age children in Latvia, PHA, Riga, 2008]. 18 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums 2010. Rīga, 20101 11 „Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums” 2008. Rīga, 2010. [Study of the Health Affecting Habits of Latvian Population 2008,Riga, 2010]. [Study of the Health Affecting Habits of Latvian Population 2010. Riga, 2011]. 12 „Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums” 2010. Rīga, 2011. [Study of the Health Affecting Habits of Latvian Population 2010. Riga, 2011]. 19 Global Health Professional Student Survey (GHPSS), WHO, 2009.

13 Projekts „HEM – Novērst atšķirības starp Eiropas Savienības iedzīvotājiem”. v/a SVA. 20 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums 2010. Rīga, 20101 [Project “HEM - preventing differences between the inhabitants of the European Union”, state agency Public Health Agency]. [Study of the Health Affecting Habits of Latvian Population 2010. Riga, 2011]. 20 21 Identified problems: Figure 7. Consumption of • Latvia has high morbidity and mortality levels caused by non-infectious diseases (cardiac and circulatory diseases, onco- absolute alcohol in litres in logical diseases and diabetes), the progression of which to a large extent is influenced by the person’s lifestyle (nutritio- Latvia, 2000-2009 nal habits, physical activities and use of addiction-inducing substances). Untimely mortality caused by non-infectious di- Source: CSB seases is higher among men than among women. • The care for and knowledge about safeguarding their health and the available options for timely diagnosis and treatment of diseases is insufficient amongst inhabitants (especially males). Starting with 2009 the CSB uses only data on registered alcohol in calculating the rates of alcohol consumption per capita. Cal- • A large section of the Latvian population exhibits unhealthy nutritional habits - the insufficient consumption of vegetab- culating unregistered or illegal alcohol consumption is problematic, because it is not counted.1 According to the Eurobarometer les, fruit and berries, and the excessive use of salt; moreover, men have poorer nutritional habits than women. study in 2009, in Latvia a comparatively small number of respondents consume alcohol every day (2%); however, 33% of respon- • The majority of the Latvian population are insufficiently engaged in physical activities, since there is a lack of awareness dents consume alcohol between two to three times per month.2 in the role that physical activities can play in safeguarding the health, skills, abilities and resources for engaging in physi- During the last decade a stable trend has continued in Latvia - the decreasing number of traffic accidents caused by drivers who cal activities; likewise, the environment for promoting physical activities is underdeveloped and is not sufficiently acces- have been under the influence of alcohol. In 2010, a total of 317 road traffic accidents with injuries were caused by drunken drivers, sible (bicycle paths, and a sufficient number of sports halls and sports grounds). which is 7.9% of the total number of injuries caused by road traffic accidents and is 1.6% smaller that the figure for 2009. • Health indicators for adolescents are deteriorating, which is influenced by the growing prevalence of smoking and drug It is statistically proven that binge drinking is linked with criminal behaviour, especially among young males. In 2010, when com- use among young people, unhealthy nutritional habits and a lack of participation in physical activities. pared to 2009, the number of crimes committed whilst being under the influence of alcohol has decreased by 27% (In 2009, 4,586 • Prejudices against people with mental health disorders are still prevalent in society, which hinders the inclusion of these crimes were committed whilst being under the influence of alcohol, but in 2010 this figure had fallen to 3,349).3 persons in society. To decrease alcohol consumption in society, concerted intersectoral cooperation is needed, as well as concrete measures for • People with mental health disorders do not seek timely help in primary healthcare, as a result of which mental health decreasing the accessibility of alcoholic beverages, the illegal circulation of alcohol, and trade and advertising restrictions, which problems are predominantly diagnosed on an in-patient level. will be set out by the Action Plan for Decreasing Alcohol Consumption. • Under the impact of the economic recession, high mortality indicators (especially among men) from suicides continue, and the number of people feeling stress, tension and depression grows. 3.2.5.5. Drug consumption In Latvia so far, two large-scale representative surveys have been carried out, allowing the use of drugs amongst the population Objective: To decrease the rates of morbidity and mortality from non-infectious diseases, to be identified. The results of both surveys indicate that in 2007, when compared to 2003, the indicators for people trying drugs and to decrease the negative impact of risk factors upon the health. and the recent use of drugs (during the previous year) amongst the population have significantly increased in all age groups and for both genders. According to the results from the 2008 study, every fourth person amongst the students who took part in the To achieve the objective: survey (24.6%) in grades 9-10 in Riga has tried one of the illegal substances.4 • Continue implementing the policy for promoting a healthy choice in society and make a healthy choice the easiest choi- During the last years the number of newly treated drug users has gradually increased - in 2006 there were 390 first time pa- ce, using a taxation policy and raising public awareness. tients who were treated for drug or psychotropic substances addiction or abuse, but in 2007 a total of 611 persons were diagnosed • Continue implementing a united policy for the promotion of a healthy diet, improving the knowledge of inhabitants in with this, and in 2008 it rose again to 645 persons. In 2009 and 2010 this indicator significantly decreased to 435 and 429 patients regard to the significance of a balanced diet in maintaining and improving health levels, facilitating the availability of respectively.5 healthy and nutritious food in educational institutions, and ensuring that primary school students have access to free The number of inmates who have used drugs before sentencing and who continue to use them in places of imprisonment is lunches. large. According to one study,6 a total of 66.1% of the total number of the prison population used drugs, but 31.8% also continue • Continue implementing a united policy to promote physical activities in society, emphasising the promotion of people using them in places of imprisonment. Dependency treatment is not accessible in prisons or detention centres (only detoxification is sports, improving the opportunities for people to engage in physical activities, ensuring an environment and infrastructu- available), which increases the risk of repeated crime after the release of these untreated persons, as well as the risk of spreading in- re that promotes physical activities, and developing people’s skills and abilities to engage in physical activities. fectious diseases, typical of addicted persons (HIV, hepatitis viruses, etc), in society following their release. • Continue implementing a united policy to decrease the use of various addiction-inducing substances (tobacco products, The Cabinet of Ministers, with the aim of decreasing the public acceptance of the use of illegal drugs, and the harm caused by their alcohol, drugs) in society by improving the knowledge levels of inhabitants about the adverse effect of these substances use and accessibility, approved Guidelines for Restricting and Controlling the Spread of Narcotics and Psychotropic Substances and Ad- upon their health, by restricting advertising and accessibility, and by developing legal acts to regulate the distribution of diction to them for 2011-2017.7 These guidelines envisage a number of measures aimed at the prevention of drug addiction and drug new tobacco products. use, as well as an improvement of the healthcare for drug addicts and drug users. It provisions for providing around-the-clock medical • Continue implementing a united policy for promoting mental health, educating society about the issues of mental health assistance at multi-profile hospitals to addiction patients with acute health problems, considering the coverage provided by addiction promotion and prevention, training general practitioners to work with people with mental health disorders, and impro- medicine, and this is something that should be taken up in elaborating the Action Plan for Restricting Alcohol Consumption. ving the accessibility of mental healthcare services. • Ensure regular monitoring, research and analysis of the situation concerning the prevalence of risk factors for non-infec- tious diseases in society.

1 “Atkarību izraisošu vielu lietošanas izplatība un sekas Latvijā 2009. gadā”. VEC, 2010 [“The use of addiction inducing substances and its consequences in Latvia in 2009”. CHE, 2010].

2 “EU citizens’ attitudes towards alcohol”. Special Eurobarometer 331, 2010.

3 Data of Road Traffic Safety Directorate and the State Police, 2010.

4 Riska un aizsargājošo faktoru ietekme uz atkarību izraisošo vielu lietošanu. Ziņojums par pētījuma rezultātiem Rīgā. Rīga; Rīgas atkarības profilkses centrs, 2007 [The impact of risk and protective factors upon the consumption of addictive substances. Report on study results. Riga; Riga Addiction Prevention Centre, 2007].

5 CHE data.

6 “Narkotiku lietošanas izplatība ieslodzījuma vietās Latvijā, VEC, SIA “Socioloģisko pētījumu institūts”, 2010 [“The prevalence of drug abuse in Latvia’s places of deprivation of liberty”, CHE, Ltd.”Social Studies Institute”, 2010].

7 Approved with the Cabinet of Ministers Order No. 98 of 14 March 2011. 22 23 3.3.The Health of the Mother, Father and Child 3.3.1. Sexual and Reproductive Health The study shows that men less frequently take care of their reproductive health when compared to women. The majority of men have never visited an urologist, a venereologist or an andrologist. Only 12% of respondents had consulted these doc- The health and development of a child before birth and during the first year of life are mainly determined by the mother’s tors during the last twelve months. However, 63% of those women involved in the survey responded that they went for a pre- health, as well as the parents’ knowledge about their own and the expected baby’s health, and their care for the child. The re- ventive gynaecological examination once a year or more.9 productive health indicators are very important indicative indicators, ones which characterise the general state of public health. The health of a child is significantly affected by the mother’s health and her lifestyle habits during pregnancy. Any infec- Educating young people about reproductive health issues has an important role in improving the quality of life of adoles- tion of the sexual organs plays a significant role in the development of complications during pregnancy, which can cause ear- cents. Knowledge about contraceptives does not always guarantee that these means will be used during their first sexual rela- ly labour and hereditary infections. The risk of contracting infections is increased by an early start of an individual’s sexual tions, which shows that the education process does not sufficiently focus upon relevant problems in sexual relationships. The life, the frequent changing of sexual partners, and insufficient knowledge about preventing STIs and sexual hygiene. Smo- report on the population’s reproductive health shows that in the age group from fifteen to nineteen years a total of 73% of king, the consumption of alcohol, drugs and other addiction-inducing substances have a negative impact upon the health of men and 51% of women used contraception in their first sexual relations.1 pregnant women and also on foetal development. Approximately 10% of women giving birth have smoked during pregnan- Unwanted pregnancy is the most negative consequence of sexual activities amongst youths. Moreover, young peop- cy, 0.5% have used alcohol, and 0.1% have used drugs.10 Smoking, and the consumption of alcohol, drugs and other addicti- le should be considered as being one of the HIV infection risk groups, since 37.2% of newly infected cases are in the under- ve substances leave a negative impact upon the health of pregnant women and on foetal development, which can often lead thirties age group (2.6% of them are also below eighteen).2 The use of condoms protects both against STIs (including HIV in- to miscarriages, developmental disorders of the foetal organ systems, early labour, and the birth of premature babies, stillborn fection) and unwanted pregnancy. As the study data shows, condoms are the most frequently used means of contraception infants, and newborn mortality during the first week of life. among adolescents. Countrywide reports on the contraceptive means used by adolescents differ greatly. In accordance with The fact that since 2004 the number of women who have registered a pregnancy prior to the twelfth week of that preg- the available data on the situation in Latvia, 86% of boys and 77% of girls (aged fifteen years old) have indicated that they nancy has decreased is something that should be assessed in a negative light; in 2008 the proportion of such women was at used contraceptives during their last sexual relations, utilising condoms, but 7% of boys and 11% of girls have indicated that 90%, in 2009 it was 88.4%, but in 2010 it was 87.5%.11 hormonal contraceptives were used.3 In 2008, when compared to 2007, maternal mortality significantly decreased, reaching the indicator of 12.5 per 100,000 Condoms, intrauterine devices and hormonal contraception are the most popular known methods of contraception in Lat- live births (in 2007 it was 25.8). However, in 2009 maternal mortality dramatically increased, reaching the indicator of 46.1 per via. But the most frequently used ones are condoms, coitus interruptus, and hormonal pills. The study shows that women are 100,000 live births. The cause of death in eight out of ten deceased women was linked directly with pregnancy.12 In 2010 this better informed about contraceptive methods and means than men.4 People are better informed about the means of contra- indicator decreased (26.1 per 100,000 live births), and in four out of five mothers who died the cause of death was directly lin- ception; however, one of the obstacles to their use could be the accessibility of contraception, especially for persons with a ked with pregnancy. And yet this indicator is still the highest in the EU (in 2009 the average maternal mortality rate in the EU low income. was 6.33 per 100,000 live births).13 One of the most important indicators, characterising behaviour habits, is the number of abortions. During the last few ye- Compared to 2009, in 2010 the number of registered STI cases has decreased by 12% (1,807 cases in 2009 and 1,588 ca- ars the number of abortions has decreased in Latvia. In 2008 the number of abortions per 1,000 women of reproductive age ses in 2010). Even though, since 1999, morbidity with syphilis in Latvia has decreased by 6.2 times, still it is the highest among was 18.0, while in 2009 it was 15.6, and in 2010 it was 13.3. The number of abortions among young women is also decre- the EU countries after Romania (in Latvia in 2008 the figure was 10.3 cases per 100,000 of the population, while in Romania it asing. In 2010 the number of abortions among women aged between fifteen and seventeen was 5.7 per 1,000 women in this was 18.67 per 100,000 of the population). In 2008 as to morbidity with gonorrhoea, Latvia (with 21.5 per 100,000 of the popu- age group (in 2009 it was 6.1, and in 2008 it was 7.1), but among women aged between eighteen and nineteen it was 14.8 (in lation) ranked second among EU countries after the United Kingdom (31.29 per 100,000 of the population).14 Chlamydiosis is 2009 this was at 16.5, and in 2008 it was 24.2). the disease of people in the reproductive age group, with 69% of all registered cases being men and women in the 15-29 age The number of babies born to underage mothers (15-17 years) continued decreasing in 2010, constituting 1.4% of new- group. Since the chlamydia screening program in Latvia covers only pregnant women, the official figures for morbidity with borns (in 2009 it was 1.7%, and in 2008 it was 2.1%).5 chlamydia (21.6 per 100,000 of the population) is much lower than in other European countries, for example, Ireland (581.6 According to CSB data in 2010, in Latvia a mother’s average age at the time at which her first child is born was 26.4. Du- per 100,000 of the population), Norway (490.4 per 100,000 of the population), and Sweden (456.3 per 100,000 of the popula- ring the last few years the trend has been for this age to increase. Since 2004 a summary of the birth-rate coefficient has tion). Chlamydia usually proceeds asymptomatically (without symptoms) (in 70% of women and 50% of men), the untreated shown a gradual increase,6, reaching the indicator 1.453 in 2008; however, in 2009 and in 2010 it slightly decreased (1.319 infection frequently causes infertility and influences the reproductive health of both men and women. and 1.177 respectively).7 Statistical data on infertility is not available in Latvia; however, the experience of developed countries shows that approxi- Increased body weight and obesity leave a negative impact upon a woman’s health and fertility. In the case of obesity, fe- mately 10-15% of couples are infertile. Among women the most frequent causes of infertility is blocked fallopian tubes, whi- male reproductive functions suffer - a woman is unable to become pregnant or to carry the child. The fact that the level of ch occurs after infection (frequently after gonorrhoea infection), surgical interventions into the organs of the reproductive obesity is high among Latvia’s women is worrying. The survey indicates that in 2010, a total of 17.9% of the women surveyed system, as well ovary dysfunction, incorrect positioning of the uterus, uterine or ovary malignancies, metabolic disorders, etc. were obese.8 Male infertility can be caused by decreased sperm count or lack of it, as well in cases when the sperm count is normal, but the sperm is unviable, and by other causes. The National Family Policy Guidelines for 2011-2017,15 deal with infertility in a de- mographic context, envisaging the objective, which is to assess the possibility of introducing state support measures for infer- tility treatment and to inform society about the threats and risks to reproductive health, all of which increase infertility. To as- sess the possibility of introducing state support measures, the prevalence of infertility problem in Latvia should be assessed.

1 Iedzīvotāju reproduktīvā veselība. Pārskats par situāciju Latvijā (1997-2003) [Reproductive health of the population. An overview of the situation in Latvia (1997-2003)].

2 ICL data.

3 Inequalities in young people’s health. HBSC International report from the 2005/2006 survey. WHO, 2008. 9 Iedzīvotāju reproduktīvā veselība. Pārskats par situāciju Latvijā (1997-2003)

4 Iedzīvotāju reproduktīvā veselība. Vērtējums un ieteikumi. Rīga, 1998 [Reproductive health of the population. An overview of the situation in Latvia (1997-2003)]. [Reproductive health of the population. Assessment and recommendations”. Riga, 1998]. 10 Mātes un bērna veselība perinatālajā periodā. V/a „Sabiedrības veselības aģentūra”, 2009

5 CHE data. [The health of mother and child during the perinatal period. State agency “Public Health Agency”, 2009].

6 The average number of children, which could be born to one woman during her lifetime, if the birth-rate in each age group would remain on the level 11 „Latvijas veselības aprūpes statistikas gadagrāmata 2009” VEC, 2010 [The Year-Book of Latvian Health Care Statistics, 2009”, CHE, 2010]; CHE data. of the year when calculations are done. 12 „Latvijas veselības aprūpes statistikas gadagrāmata 2009” VEC, 2010 [The Year-Book of Latvian Health Care Statistics, 2009”, CHE, 2010].

7 CSB data. 13 WHO Health for All database.

8 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums 2010. Rīga, 20101 14 Ibid. [Study of the Health Affecting Habits of Latvian Population 2010. Riga, 2011]. 15 Approved with the Cabinet of Ministers Order No. 65 of 18 February 2011. 24 25 3.3.2. Healthy Start of Life The health and wellbeing of Latvian newborns, infants and children of pre-school age (between 1-5 years) is still lower According to the data in the CHE Register of Patients with Particular Diseases on hospitalised patients who had suffered when compared to other EU countries. trauma and injuries, in 2010, a total of 594 boys and 433 girls under the age of five had suffered trauma. Most often traumas Infant mortality is one of the indicators that characterises both the general health of mother and child and also healthcare occur at home, a total of 74.6% (766 cases). In 2010 the most frequently encountered injuries among children were bruises before and after birth, which indirectly characterises the socioeconomic conditions in the country in general. (196 cases), open wounds (219 cases), burns or scalding (205 cases), bone fractures (224), and in 140 cases, concussions. Perinatal mortality (the perishing of the foetus before birth or during labour, or the death of the newborn during the first Children under the age of five most frequently suffer injuries in connection with falls, or coming into contact with hot week of life) in Latvia has been decreasing over time; in 2009 this indicator was at 9.6 per 1,000 live and stillborn births, but liquids and hot surfaces. In this age group the accessibility of chemical substances that are hazardous for health also creates a in 2010 this indicator decreased to 8.2. This indicator in Latvia is higher than the average in the EU and the highest among all risk, as they can cause poisoning or chemical burns. The main cause of trauma among children is an unsafe environment and Baltic States. It is mainly caused by the comparatively large number of stillborn children.1 insufficient parental responsibility - children are not supervised and a safe home environment is not created. In 2005 the Saei- ma adopted amendments to the Law on the Protection of the Rights of the Child,7 envisaging penalties being imposed upon parents or guardians who leave a child without supervision. The analyses of the 154 cases of chemical burns of the oesophagus in 2003-2007, which was carried out by the state-ow- ned “Children’s Clinical University Hospital”, shows that most frequently chemical burns of the oesophagus occur at home in children in the 1-3 year age group (111 out of 154 cases). The most frequent agents that have caused burns or poiso- ning among children are household chemical products. The most important achievement in improving child safety were the amendments to Cabinet of Ministers Regulation No.334 of 20 April 2004: “Regulation on food pollution and requirements on the packaging and labelling of food products containing caustic chemical substances”,8 in 2009, prohibiting the retail sale of concentrated vinegar essence (above 10% of the unit’s total mass). To improve the health of mother and child, to decrease maternal and infant mortality, to ensure high quality pregnancy Figure 8. Perinatal mortality care and the care of newborns at a high level, a united implementation of the approach to mother and child healthcare must rates per 1,000 live and still born continue. births in 2000-2010 Source: CHE Identified problems: • Insufficient knowledge of the general public, including teenagers and adolescents, about issues relating to sexual and re- productive health and STI prevention. Since 2001 the infant mortality rate indicator (covering children who have died during the first year of life, with rates at • Insufficient parental knowledge about the negative effects of addiction-inducing substances upon the health of pregnant 11.0 per 1,000 live births) has decreased to 5.7 per 1,000 live births in 2010.2 In Latvia it is approximately twice as high as the women and the foetus, about the importance of starting pregnancy care in a timely fashion, and preventive measures to EU average. The main causes of infant mortality (approximately 50-60% of all children who die during the first year of life) are decrease child traumas. concrete perinatal conditions (for example, intrauterine hypoxia, hereditary and aspiration pneumonia, etc). Hereditary ano- • A lack of data about infertile couples, the infertility treatment and in vitro fertilisation procedures in Latvia does not allow malies are the cause of death for approximately one third of children who die during the first year of life, and also external for the production of a substantiated assessment of the available options for introducing state supported measures for causes continue to be the cause of infant death, even though they can be limited or even prevented.3 infertility treatment, and information about the accessibility of contraceptive means for various target groups, including Perinatal and infant mortality indicators can be influence both by the mother’s and by the father’s attitude towards preg- persons on low incomes, is also lacking. nancy, the lifestyle and health status of both parents, and the parents’ knowledge of childcare and injury prevention, as well as the quality of work performed by the respective healthcare service providers.4 Objective: To improve the health of mother and child, and decrease infant mortality. A mother’s milk is one of the most significant factors for promoting the health of newborns and infants and in the pre- vention of infectious diseases. Every year the proportion of children who have been breast-fed up to the age of twelve mon- To achieve the objective: ths is growing in Latvia (in 2006 it was 17.9%, in 2007 it was 18.2%, in 2008 it was 18.9%, in 2009 it was 20.8%, and in 2010 it • Continue implementing the united policy to promote maternal and child health, improving pregnancy and newborn was 21.7%). An increase has also been observed in the proportion of children who have been breast-fed for six months (from care, increasing the knowledge among pregnant women about the negative impact of addiction-inducing substances 45.8% in 2007 to 52.5% in 2010).5 To compare: in 2009 in Estonia this indicator was 53.2%, but in Lithuania it was only 35%.6 upon the health of the pregnant woman and foetus and promoting breast feeding and appropriate complementary food. The positive trend in breast-feeding indicators was influenced by the work done to educate and inform society and the deve- • Educate society in general (especially adolescents) about reproductive health issues and STI prevention, decreasing the lopment and implementation of measures to promote breast-feeding. During the previous planning period the “Baby Friendly number of unwanted pregnancies and cases of STIs. Hospital” initiative was launched and implemented with WHO support, and the Commission for Promoting Breast Feeding and • To assess the prevalence of infertility in Latvia by collecting data on infertile couples and on fertility treatment and in vit- various breast-feeding consultants were also active. However, currently, when the state has limited options for providing fi- ro fertilisation procedures being performed. nancial assistance for promoting breast feeding, NGOs have a significant role in promoting breast feeding, actively providing • To assess the accessibility of contraceptive means and their use among persons with low income or poor persons, and support and assistance to young mothers in solving breast feeding related problems. The activities of healthcare institutions their role in decreasing the number of abortions. and the competence of healthcare personnel also promote breast-feeding. To improve the quality of work of medical facilities, quality criteria for in-patient medical facilities (including those providing obstetric help) should be defined and introduced. The most frequent cause of death for children in the 1-5 year old age group is external causes of death. The information provided by the CHE database on the Causes of Death indicates that in this age group the most frequent causes of death are drowning, poisoning, suffocation, falls, and exposure to smoke, fire and flames.

1 Mātes un bērna veselība perinatālajā periodā. V/a „Sabiedrības veselības aģentūra”, 2009 [The health of mother and child during the perinatal period. State agency “Public Health Agency”, 2009].

2 CHE data.

3 Mātes un bērna veselība perinatālajā periodā. V/a „Sabiedrības veselības aģentūra”, 2009 [The health of mother and child during the perinatal period. State agency “Public Health Agency”, 2009].

4 Ibid. 7 The Law of 17 March 2005 “Amendments to the Law on the Protection of the Rights of the Child”.

5 CHE data. 8 The Cabinet of Ministers Regulation No.368 of 28 April 2009 “Amendments to the Regulation of the Cabinet of Ministers Regulation No.334 of 20 April

6 WHO Health For All database. 2004 “Regulation on food pollution and requirements on the packaging and labelling of food products containing caustic chemical substances”. 26 27 3.4. A Healthy and Safe Environment 3.4.1. Living and Working Environment In the European region more than 1.7 million of fatal cases (18% of all deaths) are connected to environmental factors.1 Physi- cal, chemical and biological environmental factors can significantly influence the quality of life and cause health disorders; however, it is frequently impossible to measure clearly the health impact of these factors, because the values of their impact are usually low; ag- ain however, they affect people throughout their lives and have a long latency period before health problems appear. Moreover, the 3.4.2. External Causes of Death and Trauma impact of these factors can be complex, ie. they act jointly with other lifestyle habits. One of the main tools for assessing the impact of environmental factors upon human health is human biomonitoring, which is not conducted in Latvia. The number of studies in the To a large extent trauma is caused by an unsafe environment. For example, it has been assessed that 25% of road traffic acci- field of environmental health, which would integrate various impacts to which people are subjected during their lifetime - environmen- dents in Western Europe are attributable to environmental conditions such as, for example, road infrastructure, pavement cove- tal factors, the quality of their living and working environment, heredity, lifestyle habits, etc - is insufficient in Latvia. rings, and equipment for pedestrians and cyclists.10 In Latvia mortality from external causes ranks third in the total structure of The EU and WHO strategic environmental health policy planning documents,2 highlights several priorities: safe drinking water causes of death. and swimming waters, sanitary conditions, especially in the climate change context; the quality of indoor and outdoor air; the pre- In Latvia, every year 40,000 potential years of life are lost below the age of 65 due to external causes of death. The greatest vention of diseases that are caused or could be caused by other physical, chemical and biological environmental factors, including number of potential years of life are still being lost in road traffic accidents, while drowning ranks second, and suffocating and noise, nanotechnologies, electromagnetic fields, as well as risks and trauma in the working environment, etc. other respiratory disorders occupy third place. The significance of various external causes differs in different age groups.11 The Eurobarometer survey shows that 80% of the Latvian population, when assessing their attitude towards the environment, Mortality from external causes is decreasing every year. In 2010 it reached the indicator 94.1 per 100,000 inhabitants (in 2009 identify the environment as the most important factor affecting their living environment.3 However, when assessing the impact of this was 95.7, in 2008 it was 108.2).12 The information from the CHE database on the Causes of Death in the Latvian Popula- concrete environmental factors upon health, 56% of the Latvian population believe that their health is influenced by the general tion in 2010 shows that the highest mortality rates from external causes per 100,000 of the population is in the employable age quality of housing, but 24% are worried about the hazardous effect of chemical substances. Another study shows that 28% of the group - 94.3 cases - but among children the highest indicators of mortality rates from external causes are in the 15-19 year age Latvian population perceive the surrounding air pollution as a hindrance, but for 37% of them noise is a hindrance in their places of group (38.0 per 100,000 of inhabitants). The second highest mortality rate is among children in the 1-4 year age group (16.3 per residence - especially in Riga, where 46% of inhabitants suffer from excessive noise.4 Traffic is the most often mentioned cause of 100,000 inhabitants), while among school age children this indicator fluctuates around twenty cases per 100,000 inhabitants. The noise by inhabitants (76% of cases). mortality rates for external causes differs significantly for women (39.9 per 100,000) and men (157.3 per 100,000). To set the basis for safeguarding and restoring the quality of the environment and for a sustainable use of resources, while at the In the group of external causes of death, both in the employable and school age, traffic accidents are the most frequent cau- same time limiting the adverse impact of environmental factors upon human health, the CM has approved the Environmental Policy se of death. Compared to 2004 the traffic accident mortality indicator has decreased in both these groups. In the 15-19 year age Guidelines for 2009-2015.5 The guidelines deal with environmental issues in five thematic sections: air, water, land, nature and climate. group this indicator was 24.9 per 100,000 of the population in 2004, but in 2010 it was 14.6 per 100,000 of the population. In the During recent years, slight improvements have been observed in regard to accidents at work (the number of registered acci- employable age group it was 27.6 per 100,000 of the population and 12.9 per 100,000 of the population, respectively.13 dents at work in 2008 was 1,781, in 2009 it was 1,203 accidents, and in 2010 it was 1187). The number of registered severe accidents Fatal cases due to external causes are those that can be prevented, by promoting environmental safety measures (road traffic, has significantly decreased, constituting 265 cases in 2008, but in 2009 this was at 175 cases, and in 2010 it was at 164 cases; likewi- home safety, etc), and also by carrying out an education society on the impact of lifestyle habits and behaviours upon the heal- se, the number of registered fatal accidents at work has also decreased - in 2008, 43 such cases were registered, in 2009 this was 32 th of people. The implementation of the Road Traffic Safety Program,14 proves that positive results in this field can be achieved, cases, but in 2010 it was down to 23 cases.6 However, as regards the total number of accidents and their decrease when compared and as a result of this the mortality rates caused by traffic accidents significantly decreased. to the EU states, in Latvia the total number of registered accidents is extremely low, which is mainly linked to the fact that no acci- dents at work are registered or investigated in Latvia.7 Therefore, the causes of accidents are not identified in order to prevent their reoccurrence. Hiding accidents, and failing to investigate and register them facilitates the development of disability and a lowered capacity for work for the victims, who are not entitled to receive state funded treatment and rehabilitation. In 60-70% of cases the victims of accidents are employees whose experience in the profession does not exceed one year or was between one and three years in length. It shows that employees who start performing new duties in companies do not receive adequate prior briefings and training.8 As regards the incidence of occupational diseases, it should be noted that the number of registered patients with occupational diseases has rapidly increased in the period from 2007 to 2009. Such an increase could be explained by the fact that with the wor- sening of the economic situation many inhabitants wanted to settle the formalities in order that they might receive official con- Figure 9. The number of firmation of their occupational disease, thereby entitling them to receive compensation. Only in 2010 was the stabilisation of the fatalities and injuries in number of newly registered patients with occupational diseases observed - it decreased by 17% when compared to 2009 (in 2010 it traffic-related incidents was 1,150; in 2009 it was 1,385); however, the general assessment of the situation shows that the number is very high. According to Source: Road Traffic Safety the data of the Latvian National Register of Patients with Occupational Diseases, in the period between 1993 to 1 August 2011, a to- Directorate tal of 10,140 patients with occupational diseases were registered, with the total number of registered occupational diseases exce- eding 25,000. Slightly more than 60% of all patients with occupational diseases are women. The statistics for occupational diseases show that the number of patients with occupational diseases is growing every year; mo- reover, the number of registered untreated occupational diseases is growing, which to a large extent means that people see an occupational disease specialist too late and that other healthcare personnel are not sufficiently informed about the impact of adver- se work environmental factors upon human health. The measures for ensuring a safe environment which poses no hazard to health are defined by the Guidelines of Labour Protec- tion for 2008-2013.9

1 The European Health Report 2009. Health and health systems, WHO 2009.

2 Children's Environment and Health Action Plan for Europe (CEHAPE)(2004); The Declaration of the European Environement and Health Ministers Conference in Parma on health and environment of 11 March 2010; The draft of European Second Environemtn and Health action plan (2010).

3 Eurobarometer survey, Special “Electromagnetic fields”, 2007.

4 Vides faktoru ietekme uz veselību. Latvijas iedzīvotāju aptaujas rezultāti. v/a „Sabiedrības veselības aģentūra”, 2008. [The impact of environmental factor upon health. Latvian population survey results”, state agency “Public Health Agency”, 2008].

5 Approved with theCabinet of Ministers Order No. 517 of 31 July 2009.

6 State Labour Inspectorate, Public Report of 2010. 10 The European Health Report. Health and health systems, WHO 2009.

7 Pētījums „Darba apstākļi un riski Latvijā, 2009-2010”, SIA „Inspecta Prevention”, 2011 11 Potenciāli zaudētie dzīves gadi Latvijā 2008.gadā. VEC, 2009 [Potential years of life lost in Latvia in 2008. CHE, 2009]. [Survey “Working conditions and risks in Latvia, 2009-2010”, Ltd. “Inspecta Prevention”, 2011]. 12 CHE data.

8 State Labour Inspectorate, Public Report of 2009. 13 Register of Causes of Death of Latvian Population.

9 Approved with the Cabinet of Ministers Order No.213 of 17 April 2008. 14 Approved with the Cabinet of Ministers Order No. 209 of 13 April 2007. 28 29 Identified problems: • The lack of research in the field of environmental health is an obstacle for conducting a comprehensive assessment of the environmental factors that have an impact upon human health. • Measures to decrease the impact of environmental factors have not been implemented in full, which significantly influen- ces the quality of life. Since 2001 there has been a significant decrease in the number of children below the age of five who have died in road • A lack of unbiased information on environmental risk factors can be observed in society, which is something that hinders traffic accidents, from 46 cases per 100,000 to 14.2 per 100,000 in 2010. This trend strongly correlates with the increased usage an objective assessment of the potential health risks of various environmental factors. of child seats in cars during the recent years. The survey carried out in 2010 showed that 36.8% of respondents have used child • A low level of awareness among the population about the risk factors in the work environment and the impact of these seats almost every time when transporting young children (40.4% of women and 33.0% of men).1 However, this indicator is not upon the health (this strategy does not deal with issues related to limiting and preventing risks in the working environ- sufficient and means that approximately 60% of the population still do not use child seats when transporting children. ment, since they are included in the policy planning documents for the relevant sector). Traumas are one of the most frequent causes of prolonged or permanent incapacity for work or disability. Many peop- • Healthcare personnel are insufficiently informed about factors that can cause occupational diseases and about the timely le who have suffered trauma of some kind feels the consequences of it for many years afterwards. The calculations performed diagnosis of occupational diseases. by the WHO show that traumas constitute 10% of all disability-adjusted life years, DALY, and it is estimated that this indicator • Living conditions for the population are not sufficiently safe to prevent trauma. Trauma is one of the most frequent cau- could increase to 20%. Therefore, the consequences of various traumas has a significant impact upon society. In Latvia every ses of long-term or permanent incapacity for work or disability. tenth case of first-time disability is caused by injury, poisoning or the impact of other external factors. In the structure of the causes of first-time disability, those disabilities caused by external factors rank in fourth place. The consequences of traumas Objective: To promote healthy and safe living and an equally safe working environment, leads to first-time disability among young people.2 and to decrease trauma and mortality from external causes of death. According to the WHO calculations, a total of 68%, or more than two out of every three trauma cases (including fatal ones), are preventable; and the proportion of preventable traumas is even higher among children.3 To achieve the objective: An unsafe environment and insufficient parental responsibility are the main causes of traumas in children. Child safety is li- • To identify the impact of environment risk factors upon health, to inform society about environment risk factors and pos- kewise influenced by the safety of toys and other daily household items such as, for example, various objects containing bat- sibilities they might have to decrease the hazardous effect of these factors upon their general health, also taking these teries and magnets, food-like objects, or lighters. Numerous measures in the field of product safety where this is linked to the factors into consideration in the planning process, and to inform the employees of healthcare institutions about the cor- protection of children are implemented in the EU.4 The goods which are included in the EC report on dangerous products rect management of medical waste. (RAPEX5) are not sufficiently identified in Latvia and are often accessible to children. The Consumer Rights Protection Centre • To inform healthcare personnel of the factors that cause occupational diseases and the timely diagnosis of occupational has contributed a great deal to the monitoring of product safety requirements, including that of toys,6 and in 2009 it establis- diseases. hed a hotline for reporting consumer injuries, with the financial support from the EU. • To facilitate the development of a safe environment, to improve general knowledge amongst population in regard to any Traumas suffered during physical activities are typical among teenagers. The survey showed that during the previous year possibilities there might be to avoid traumas in everyday life, during leisure activities and while engaging in physical acti- almost half of the school students who were included in the survey and who were aged eleven, thirteen and fifteen had suf- vities, on the correct course of action to take in the case of an injury in order to prevent trauma, and facilitating the crea- fered traumas.7 The greatest rate of traumas is observed during informal sporting activities and physical activities - cycling, tion of a safe environment. skating and roller-skating without protective measures, driving motor vehicles before acquiring a driver’s licence, swimming in • To implement the effective surveillance of the market for goods and services to ensure that only safe goods and services unsuitable locations, and playing various games in demolished buildings and on incomplete construction sites. are accessible to the consumer To implement a united and continuous policy for decreasing the number of traumas and deaths from external causes, a policy-planning document must de developed which defines measures for trauma prevention. Intentional harm - violence and self-harm - is also a cause of traumas, injuries and mortality. One of the most topical prob- 3.5. Infectious Diseases lems in contemporary society is domestic violence, which is linked with violence among intimate partners, along with violen- ce against children and the elderly. Domestic violence manifests itself both as physical and emotional violence. Neglecting In many countries around the world and in the EU, including Latvia, the prevalence of several infectious diseases has been in- children, which causes severe injuries in those children, is also considered to be violence. terrupted, restricted or fully eliminated by the introducing new and effective vaccines, improving the system of epidemiological CHE data shows that in 2010, 138 persons have died as the result of a violent attack. The greatest proportion of persons who supervision, and by effectively coordinating international action in terms of dealing with epidemics. At the same time the risk of have died from violence are in the 250-60 age group. Data from the Register of Patients with Particular Diseases on patients who epidemics occurring still exists, since today infectious diseases are spreading around the world with worrying speed, disregarding have suffered traumas and injuries shows that in 2010, 258 persons suffered injuries because of their husband, wife or partner. national borders and the standard of living in any particular country. The outbreak of SARS in 2003, the spread of the influenza The “Program for decreasing domestic violence in 2008-2011”,8 which was developed by MW, and the National Family Poli- pandemic in 2009, and the outbreak of poliomyelitis in Tajikistan in 2010 prove that infectious diseases can pose a significant th- cy Guidelines for 2011-2017,9 both deal with the issue of decreasing violence. reat to public health. The spread of infectious diseases (including TB, HIV and STIs) is facilitated by migration, drug abuse and li- Children suffer from violence not only in the family but also at their institution of education, where both physical and festyle (prostitution), the inaccessibility of hygiene and preventive means, socioeconomic factors, climate change, etc. emotional violence is typical among school students. The survey on the health habits of school students shows that bullying The survey information,11 showed that 1.7% of the Latvian population (1,714 per 100,000 of the population) are infected with is widespread in schools. Data from the 2005-2006 school year indicated that during the previous couple of months approxi- the C hepatitis virus (HCV). The average number of HCV patients for every single general practice could be 34, but in the majori- mately half of students had suffered at least once from bullying.10 ty of cases this is known neither by general practitioners or the patients themselves, because usually this viral infection exhibits The timely rehabilitation of patients who have suffered traumas is essential. It improves the quality of life of these patients, no specific symptoms. Patients with an asymptomatic course of hepatitis C pose the greatest threat of an epidemic. HCV is a seri- decreases their temporary incapacity for work and ensures disability prevention. Patients who have suffered traumas and do ous threat to public health and the most dangerous one among all hepatitis viruses, because in 80% of cases the condition beco- not receive timely rehabilitation run the risk of becoming disabled. mes chronic and the number of liver cirrhosis and/or liver cancer cases significantly increases. The number of people infected with hepatitis C who are living in Latvia exceed by ten times the number in other countries such as, for example, Sweden or the United Kingdom. It is impossible to carry out HCV tests among Latvia’s prison population; therefore, no objective data about the prevalen- ce of the disease is available. However, on the basis of expert opinion and the specifics of living conditions in prisons or detention centres, the rate of HCV infection among prison inmates could be very high, many times higher than in society in general. Foreign studies and statistical data also show that the HCV infection rate among prison populations is much higher than in society.

1 Latvijas iedzīvotāju veselību ietekmējošo paradumu pētījums, 2010. Riga, 2011 Latvia is still one of those EU countries that has high indicators of the prevalence of HIV infection: in 2009 the incidence [Study of the Health Affecting Habits of Latvian Population, 2010. Riga, 2011]. (the number of new cases) indicator was 12.2 per 100,000 inhabitants (in 2008 it was 15.8) or the second highest, exceeding 2 „Vardarbības un nelaimes gadījumu izraisītie veselības traucējumi”, VEC, 2009 [Health Disorders Caused by Violence and Accidents. CHE, 2009]. the average European indicator (50.3) 2.6 times. In some population groups the prevalence is very high (among the users of 3 „Traumatisms un ārējie nāves cēloņi bērniem un jauniešiem”, SVA, 2007 injectable drugs it is between 22-23%, close to the critical limits - 5% - among men who have sexual relations with other men, [Traumatism and external causes of death among children and adolescents, Public Health Agency, 2007]. and also among prison inmates a total of 7% of them are HIV infected), therefore placing Latvia among those countries in

4 General Product Safety Directive 2001/95/EC. which an HIV epidemic is not general, but is concentrated in some population groups with increased risky behaviour. The pro-

5 Rapid Alert System for Non-Food Products. portion of AIDS patients has increased rapidly (in 2009, 4.3 cases per 100,000 inhabitants were recorded, which is the highest

6 The Cabinet of Ministers Regulation No. 132 of 15 February 2011 “Regulation on the Safety of Toys”. morbidity rate in the EU countries). The percentage of prison inmates with AIDS is also high (1,074 cases per 100,000 of the

7 Skolēnu veselības paradumu pētījuma (HBSC pētījums) 2005./2006.gada aptaujas dati, VEC population). The measures for restricting HIV infection are defined by the Program for Limiting the Spread of Human Immuno- [A Survey of School Students’ Health Habits (HBSC survey). 2005/2006 survey data, CHE]. deficiency Virus (HIV) for 2009-2013.12

8 Approved with the Cabinet of Ministers Order No. 343 of 18 June 2008.

9 Approved with the Cabinet of Ministers Order No.65 of 18 February 2011. 11 “C vīrushepatīta izplatība Latvijā”, LIC, 2009 [The Prevalence of Hepatitis Virus C in Latvia, ICL, 2009].

10 Vardarbības un nelaimes gadījumu izraisītie veselības traucējumi. VEC, 2009 [Health Disorders Caused by Violence and Accidents. CHE, 2009]. 12 Approved with the Cabinet of Ministers Order No. 437 of 30 June 2009. 30 31 Table. The number of vaccine preventable diseases Until 2010, morbidity with TB was decreasing, reaching the indicator of 36.6 per 100,000 of the population in 2009 (and in 1960 and in 2010 in Latvia it was the same in 2010); however, at the end of 2010 and the beginning of 2011 a trend was observed which showed a Source: ICL growing number of TB cases. The mortality indicators also improve (4.5 per 100,000 of the population in 2009 and 3.5 per 100,000 of the population in 2010).1 However, according to the WHO Region for Europe data, Latvia belongs to the eighteen Year high priority countries in the European region for TB control and is one of 27 countries in the world with the highest level of Vaccine dependent disease 1960 2010 multi-resistant TB (MDR-TB). Several problems in the fight against tuberculosis are causes of concern, high mortality rates from Tetanus 12 0 tuberculosis, especially during the first year after diagnosing, which points to a belated detection of disease cases. In 2010, Diphtheria 209 2 35% of deceased TB patients died during the first month following diagnosis, and in 18% of those who had died, tuberculo- Whooping cough 2495 9 sis was detected during the post mortem. In 2008-2009 an increase in the number of multi-resistant cases has been registe- Measles 19744 0 red. The increase in the proportion of extensively resistant TB (MR/XR-TB) among MR-TB patients is a negative trend; in 2009 it Epidemical parotitis 11714 3 reached 14%, and was at 17% in 2010. The number of registered TB/HIV dual infection cases is increasing with every year. The Poliomyelitis 17 0 proportion of TB/HIV among newly diagnosed TB cases in 2009 reached 6.9%, and was at 7.6% in 2010, which according to WHO guidelines points to the situation of TB/HIV co-infection epidemics. Total: 34 191 14 The socio-economic situation is also an important factor, one which influences the spreading of infectious diseases. A study,2 has shown that an increase in TB morbidity and mortality can be expected, linked to the current global economic recession. During 2008-2009 the epidemiological situation regarding acute intestinal infections and hepatitis A became significant- ly worse in Latvia. During the last seven years a stable trend of increasing morbidity with acute intestinal infections with viral However, ICL monitoring results indicate that in 2009-2010 the immunisation indicators have significantly worsened. aetiology has been observed, and since 2004 the number of cases has increased more than 2.5 times (from 1,928 to 5,050 ca- In some age groups they no longer meet the objectives of the National Immunisation Program. To improve immunisation ses). The Hepatitis A outbreak in 2008 and 2009 affected more than 5,000 inhabitants (only 1,226 cases were registered during indicators and decrease the morbidity with vaccine preventable diseases, the activities launched in the framework of the the previous eight years), of which 85% were hospitalised. In 2007 in Latvia nine group cases of acute intestinal infections and National Immunisation Program should be continued, providing scientifically substantiated information on the importance of hepatitis A cases with five and more affected were registered, but in 2009, 63 outbreaks were registered. Group cases are pre- vaccination and implementing a united approach to immunisation promotion. dominantly linked with people getting infected at home and at children’s institutions of education. The hepatitis A epidemics, which is a comparatively easily controllable disease, proved once again that outbreaks of infectious diseases are possible if the system for preventing and controlling infectious diseases is not being constantly maintained and developed. Every year the epidemic activity of influenza, with smaller or greater intensity, is observed during autumn, winter period. Identified problems: Every year influenza causes severe complications for many patients and becomes the cause of death in tens of cases; it is es- • The number of HCV infected patients is high, but not all of them receive adequate healthcare services. Large number of pecially dangerous to patients with pulmonary diseases, cardio-vascular diseases, metabolic disorders and other chronic dise- group cases of acute intestinal infections. ases. The population immunisation level against influenza in Latvia is very low compared to other EU countries, during the re- • Latvia is among those EU countries with high indicators of HIV prevalence, moreover, the number registered TB/HIV dual cent years it reached only on average 0.8%. The vaccination level in the age group “65 and above” during the last seasons was infection is growing every year. one of the lowest in the EU countries - 2.4 - 2.6%. To compare - in the United Kingdom and the Netherlands 70% and more • The TB morbidity and mortality rates and resistant TB level are high in Latvia. The high mortality from TB, especially du- are vaccinated in this age group. ring the first year after diagnosing the disease, reveals belated detection of the disease. For several years already the National Immunisation Program3 has been public health priority in Latvia. Healthcare and pub- • The risk of outbreaks/ epidemics of vaccine preventable diseases is increasing, because the proportion of immunised po- lic health specialists have achieved the accessibility of high quality immunisation services on the local and the national level. pulation is decreasing. Notable achievements have been reached in preventing vaccine preventable diseases. By 2008 vaccination coverage in the fra- mework of immunisation program had been achieved for all age groups, which is the main cause for decreasing morbidity. Objective: To decrease morbidity with infectious diseases. Through the implementation of the program every year 30 000 cases of various infectious diseases and more than 100 death cases among children are prevented. The morbidity with several infectious diseases has decreased by 99.95% and even more. To reach the objective: Even though there has been an increase in the morbidity with various infectious diseases, which are linked to hygiene conditi- Continue implementing united policy for preventing infectious diseases and restricting their spreading by maintaining and im- ons and the quality of life during the last years (hepatitis A, acute intestinal infections), the incidence indicators regarding vacci- proving a prevention and control system of infectious diseases, by educating society about most effective preventive measures ne preventable diseases have remained unchanged due to the positive impact of the immunisation program (see Table). against infectious diseases, promoting timely detection of TB cases and decreasing the spread of multiresistant TB.

1 ICL data.

2 Arinaminpathy N, Dye C. Health in financial crisis: economic recession and tuberculosis in Central and Eastern Europe. J.R.Soc. Interface published online 28 April 2010 (rsif.royealsocietypublishing.org, access 9 February 2011).

3 The Order of the Cabinet of Ministers No. 43 of 31 January 2008 “On the National Immunization Program for 2008 - 2010”. 32 33 4. THE DESCRIPTION OF THE SITUATION AND PROBLEM The reimbursement system for medicines and medical equipment is an essential part of the healthcare system. A well- developed system of reimbursement allows the patient to be treated as an outpatient, it prevents cases of unnecessary hospi- DEFINITION IN HEALTHCARE talisation. Every year the list of reimbursement medicines is expanded, including diseases, for which the cost of medicines for their treatment is reimbursed from the resources of the state budget (the number of medicines in the reimbursement list of 2008 - 1094 and 146 items of medical equipment, in 2009 - 1125 medicines and 152 items of medical equipment).4 According to HPC data in 2009 482461 Latvian inhabitants (or 21.4%) received medicines reimbursed from the state budget. The funding allocated by the state was 29 lats per capita. In Estonia in 2009 64.7% of insured persons received reimbursed medicines, and 4.1. Funding of the Health System the expenditure of Estonian Health Insurance Fund for reimbursement medicines was 46 lats per capita.5 In Latvia at the end of 2009 the national funding for reimbursing the costs of medicines and medical equipment was 66.6 million lats, at the end In Latvia the greatest source of healthcare revenue are general, un-earmarked taxes. The budget of the MH is approximately of 2010 - 71.6 million lats, in 2011 (with budget amendments) - 73.0 million lats. 6% of GDP. In 2010 the proportion of national (public) funding according with the approved budget was 3.5% of GDP, at the The largest amount of resources of the state budget for reimbursement medicines in 2009 was spent for the treatment of end of 2010 3.9% of GDP and in 2011 in accordance with the budget amendments 3.7% of GDP, and the rest is private funding. endocrine, nutritional and metabolic diseases, treatment of circulatory diseases, treatment of tumours and the diseases of the The long-term aim is to re-allocate the proportion of public and private funding, decreasing the part of private funding. The RL nervous system.6 Saeima every year approves the health budget for the coming year. (The funding of the health system is depicted in Figure) The proportion of private payments for healthcare services, compared to the national funding, also reveals the scope of national support. Patients’ direct payments for healthcare services have increased from 23.9% in 2004 to 40.8% from the to- tal expenditure for healthcare services in 2006. The proportion of national funding has respectively decreased from 76.1% in Other income State budget 2004 to 59.2% in 2006.7;58 Patients’ direct payments include patients’ fees, payment for services, which are not covered from the national healthca- re budget resources, payments to service providers for which a receipt of payment is not provided, as well as expenditure for State Agencies (ICL, SAM, purchasing medicines. In Latvia the level of patients’ direct payments is high in all income groups, however, the probability of Taxes Health Payment Centre (HPC) MH LSMSA) facing proportionally high expenditure for healthcare is higher in low income households, compared to high income house- Institutions holds. Because of high patients’ direct payments households can end up in deeper poverty.9 It must be noted that the fun- (NEMAS, CHE, ding system should ensure a fair distribution of burden - the inhabitants’ financial contribution for healthcare should conform to their ability to pay.10 HI, etc.) According to CSB calculations regarding the structure of household expenditure, in 2009 expenditure for health constitu- Population ted 5.3% of the total expenditure. It is 124 lats annually per one member of household. The largest part of it (67%) was spent Patients Conclusion of for purchasing medications.11 According to the information provided by SAM the total turnover of medicines, which reached agreements / consumers, in 2009 was 195.69 million lats.12 Payment for services/ Reports on Patients’ fees/ Direct provided services payments Figure 10. The funding of the healthcare system in Latvia Source: The Ministry of Health Providers of health care services (institutions of health care, general practitioners) Figure 11. The breakdown of Institutions of health care that do not have contractual relationship with HPC household health expenditure, average per member of household in 2009 (in lats). Voluntary Health Insurance Source: CSB Identified problems: • • High level of patients’ direct payments for healthcare services, which significantly impacts the accessibility of healthcare. The budget of the Ministry of Health (including funding from the EU Structural Funds) at the end of 2010 was 496.1 mil- • Insufficient financial state support for the health system; lion lats,1, which is approximately 11.2% of the total state budget and 3.9% of GDP. In accordance with the amended budget • Large household expenditure for purchasing medicines. of 2011, in compliance with MF orders, MH budget expenditure is 499.1 million lats, which is approximately 10.5% of the total state budget and 3.74% of GDP. The proportion of national expenditure allocated for health in Latvia characterises the national support to the health system. The funding allocated for health in Latvia for many years already has been one of the lowest (in some years - the lowest) in the EU and fluctuates between 3.28% of GDP in 2005 till 3.9% of GDP in 2010, and has decreased till 3.7% of GDP in 2011. EU countries allocate from 4.6% to 7% of GDP for healthcare.2 In Latvia the resources of the state budget allocated for healthcare are (sectoral budget programme 33.00.00 “Ensuring hea- lthcare”) administered by the Health Payment Centre. The proportional allocation of resources for paying for healthcare servi- 4 Public Report of the State Agency of Medicine Prices for 2009, Riga, 2010. ces is defined in a legal act.3 HPC plans the allocation of resources in compliance with it: at least 45% for out-patient healthcare 5 Estonian Health Insurance Fund Annual Report 2009. services, no more than 53% for in-patient healthcare services. 6 HPC data.

7 E.Tragakes “Veselības aprūpes sistēmas pārejas periodā: Latvija. Pārskats par veselības aprūpes sistēmu.” WHO (2008.) [E.Tragakes “Health Care Systems in Transition: Latvia. A review of the health care system.” WHO, 2008].

8 World Health Statistics 2009, WHO (2009).

9 Access to health care and the financial burden of out-of-pocket health payments in Latvia. WHO, 2009.

1 The budget of 2010 with the Orders of the Cabinet of Ministers and the Ministry of Finance at the end of the year. 10 Estonia Health system performance assessment. WHO, 2010.

2 Eurostat data. 11 CSB data.

3 The Cabinet of Ministers Regulation No. 1046 of 19 December 2006 “The Procedure of Organising and Funding Health Care”. 12 Public Report of the State Agency of Medicines for 2009. 34 35 4.2. Organisation of Healthcare Primary healthcare is the first stage, when a person encounters healthcare system. It is provided by the team of a ge- The institution of a clinical pharmaceutist should also be developed and strengthened, involving them in decision taking neral practitioner (general practitioner, doctor’s assistant (flesher), nurse and receptionist), dentists, pharmaceutists and mi- on selection of medicines and their use during the in-patient stage, ensuring also the surveillance of medicinal therapy and dwives. General practitioners ensure to the patients registered with them general healthcare (treatment of acute and chronic the continuity in the use of medicines also in the out-patient stage. diseases), including surgical operations provided on out-patient basis, rehabilitation, pregnancy care and post-partum care, prescribe medicines, refer for diagnostic examinations and specialists to receive secondary healthcare services, and they also At the day clinic a patient, who does not need round the clock monitoring and care provided by medical personnel, can work on prevention (including immunisation), as well as ensure the monitoring of chronically ill patients (for example, pa- receive diagnostic and healthcare services. The patient is referred to the day clinic to receive services paid for by the state by tients with mental health disorders). A general practitioner’s field of activities includes cooperation with the local government the general practitioner or a specialist. For cases when a patient is brought to an institution of healthcare, but is not hospita- and the social service of a local government, ensuring multisectoral approach to dealing with patient’s health problems. lised, patient hotels have been set up and will be set up in the future at the hospitals, providing an opportunity for the pa- The situation still remains when there is no primary healthcare nurse or receptionist working at the GP’s practice, two ge- tient to stay overnight, if it is impossible return home or if the patient cannot arrive at the healthcare institution at the sche- neral practitioners share one consulting room in shifts, the nurse has not been provided with a separate room for working duled time. with patients. These shortcomings make the services provided by the general practitioner and nurse less accessible, create waiting lists for receiving services, causes patients’ dissatisfaction with the way general practitioners’ work is organised and Home healthcare is the healthcare provided to the patient by a nurse or a doctor’s assistant (feldsher) at his or her pla- with the quality of services. It must be noted that legal acts do not set out sufficiently detailed requirements on the way ge- ce of residence. It is provided in those cases, when the patient does not need to be at a hospital, but because of medical indi- neral practitioners should organise their work, so such deviations from the understanding of best practice are possible. So- cations, for example, restricted mobility, the patient is unable to reach the general practitioner or other specialist. The general lutions should be found to improve the territorial accessibility of general practices, to build the capacity of practices and to practitioner takes the decision on the necessary home healthcare and its estimated length. The patient receives home health- expand the competence of a general practitioner and motivation to participate in health promotion work. It is important to care, if the patient has a chronic disease and restricted mobility, because of which the patient is unable to come to the institu- achieve conceptual changes in the understanding of the general practitioner’s role in the health system - from “gatekeeper” to tion of healthcare, as well as in cases when the patient has been discharged from an in-patient facility or a day clinic following “healthcare manager”. I.e., a general practitioner should be the central person, who guides the patient through health system surgical manipulations. and coordinates the treatment process, dedicates more time to the patient and aspects of health promotion and prevention, Healthcare includes disease prevention, treatment during the period of illness, and also medical rehabilitation to restore and is also responsible for effective, timely and economical treatment. the patient’s capacity for work. Medical rehabilitation provided timely and in optimum scope and, if necessary, further de- At the same time the potential of the professionals in pharmaceutical field to support the general practitioner’s team is velopment of the results achieved through rehabilitation in the framework of social and professional (vocational) rehabilita- underused. Pharmaceutical care should be harmonically included in the healthcare system, creating an optimum infrastructu- tion allows to decrease or fully prevent functional disorders and their consequences, therefore preventing or decreasing tem- re of service providers (pharmaceutists, pharmacies) and to develop criteria for providing pharmaceutical care. Special atten- porary incapacity for work, providing disability prevention or decreasing the severity of disability. This, in its turn, improves tion should be paid to using the potential of pharmacies in territories with low population density and insufficient accessibi- the quality of life of these persons and the retaining or regaining of the social role for persons with functional restrictions; it lity of healthcare specialists. This would ensure the quality of services and promote their accessibility, regardless of patients’ also decreases the long-term financial burden to the healthcare and social system. place of residence. In accordance with legal acts2 the healthcare of persons deprived of liberty is organised by the Ministry of Justice. It is se- parated from the general healthcare system of Latvian population. Therefore, as soon as a person arrives at a place of depriva- Latvian inhabitants can receive secondary out-patient healthcare at out-patient and in-patient institutions of healthcare tion of liberty, he or she no longer has access to the general practitioner, reimbursement medicines, preventive health check- with a general practitioner’s referral or without it from directly accessible specialists, or as a service for a charge from other spe- ups and examinations in full scope. The primary healthcare of persons deprived of liberty is provided by the healthcare per- cialists (in the absence of a referral). Medical specialists specialising a concrete field provide these services. The general practitio- sonnel at the prisons or detention centres, the institutions of healthcare belonging to the healthcare system provide secon- ner helps the patient to select among the offered healthcare services and refers the patient to the most appropriate specialist. dary healthcare. The healthcare of persons deprived of liberty is funded from the budget of the Ministry of Justice, except me- In developing a healthcare system, in which the general practitioner fulfils the function of “a healthcare manager”, it is es- dicines for treating TB and HIV/AIDS, which are funded from the healthcare budget. Funding for the healthcare of persons sential to ensure feed-back between the specialists of secondary out-patient care and the general practitioner, therefore en- deprived of liberty is envisaged in the state budget, however, the amount is insufficient. suring the use of complete and credible information in the treatment process. Continuity in primary and out-patient care will To re-direct the healthcare system from hospital treatment to the primary and out-patient level, the principles of planning improve the quality of services, facilitate trust in the doctor, as the result the number of untreated illnesses will decrease, the in-patient and out-patient services should be defined on policy planning level, drafting a development plan for healthcare person will regain capacity for work sooner and in the long-term improvement in public health indicators can be expected. system, criteria for planning territorial distribution and the amount of services to be provided, as well as criteria for assessing the quality of the services provided, i.e., the competencies of healthcare personnel involved in the treatment process should In-patient healthcare services are provided by university hospitals, multi-profile hospitals, specialised hospitals and be defined for all levels of care. care hospitals.1 To ensure healthcare sector with human resources and their development in the long-term, the Cabinet of Ministers in A patient may be referred to a hospital by the specialists of primary care, secondary out-patient care and EMA service. 2006 approved the program “The Development of Human Resources in Healthcare in 2006 -2015”.3 It sets out the following Healthcare services of secondary and tertiary level are provided in the framework of in-patient services. main objectives - an effective human resources planning, providing the sector with a sufficient number of personnel in the The number of acute beds (at university and multi-profile hospitals, specialised hospitals) remains fragmented across diffe- necessary distribution and with adequate qualifications, the development of the system of education and improving the rent hospitals, providing services to administrative territories with a small number of inhabitants and ensuring hospitalisation system of remuneration. In 2010 MH prepared an informative report on the implementation of the Guidelines “The Deve- on a small scale. According to the recommendations of the World Bank the number of hospital beds should be decreased for lopment of Human Resources in Healthcare” and the program “The Development of Human Resources in Healthcare in 2006 more efficient use of the available resources. -2015” in 2006 -2009,4 which reflects the objectives that have been, have not been or have been partially met. On the basis of To develop the out-patient healthcare and promote economical use of healthcare budget, in 2009 the activities of day cl- the data and the results of analysis obtained while preparing the report, as well as through analysing the situation in connec- inics and the range of services provided by them were significantly expanded, and new healthcare service funded by the re- tion with the changes introduced into the healthcare system in recent years, linked with the reorganisation of hospitals, out- sources of the state budget - home healthcare - was introduced. patient facilities, specialists’ practices and day clinics, a new, updated document on the development of human resources in Since during the period, when the funding for healthcare system and the per capita expenditure were increasing, the ef- healthcare should be developed. fectiveness of healthcare system did not improve, for example, the number of episodes of care implemented by general prac- titioners and out-patient care specialists, the patients’ satisfaction with the accessibility of healthcare services did not impro- ve, measures to improve the effectiveness of healthcare system should be implemented, i.e., rational concentration of hospital services and decentralisation and regional development of out-patient services should be continued. Moreover, cooperation with social services providers, local government authorities should be promoted, to develop integrated long-term care, espe- cially for elderly patients, patients with mental health disorders, allocating for this purpose the necessary funding.

2 The Cabinet of Ministers Regulation No. 199 of 20 March 2007 “ On the health care of detained and sentenced persons in pre-trial prisons and institutions of deprivation of liberty”.

3 The Cabinet of Ministers Order No. 870 of 6 November 2006.

1 The Cabinet of Ministers Regulation No. 60 of 20 January 2009 “Regulation on the Mandatory Requirements for Medical Facilities and their Structural Units.” 4 http://polsis.mk.gov.lv.view.do?id=1774 36 37 Identified problems: • Healthcare system deals with timely untreated health problems. Patients do not always have the possibility to see a doctor. • Integrated, continuous and successive healthcare is not provided, which is fostered by the fact that persons providing healthcare are paid for the manipulations performed, not for the end result (quality) of the treatment. • During the period when the funding for healthcare system and per capita expenditure were increasing, the effectiveness of the healthcare system did not improve, for example, the patient satisfaction with the accessibility of healthcare servi- ces did not increase. Therefore, when increasing the funding for the healthcare sector according to the state budget pos- sibilities, it is important to introduce measures for increasing the effectiveness of the healthcare system. • The possibility to conclude contracts only with most efficient (efficiency of work and cost efficiency) providers of out-pa- tient services is underused. Therefore, the number and the structure of healthcare service providers are not optimal. To limit the spread of infections connected with healthcare and to provide an insight on the measures of prevention and • Prison inmates are not provided with reimbursement medicines and items for out-patient treatment. epidemiological control at the institutions of healthcare, guidelines on the best public health practice regarding actions, when cases of MRSA, Clostridium difficile, vancomycin resistant Enterococcus faecalis, Enterococcus faecium (VRE), hepatitis B, hepa- titis C, HIV infection and viral aetiology acute intestinal infections are conformed at institutions of healthcare, have been pre- pared. The guidelines offer a summary of evidence-based practice regarding monitoring and control of healthcare related in- 4.3. Quality and Safety of Healthcare Services fections at the institutions of healthcare. To ensure compliance with requirements of hygiene and anti-epidemics regime at medical facilities and to prevent noso- The most important elements of the healthcare quality is consistency in ensuring healthcare services, applying evidence- comial diseases, the management of medical waste at medical facilities should be regulated. Special attention should be paid based practice, coordinated care in all stages of healthcare, prevention of possible mistakes in the care process (safety) and to the disinfection of infected medical waste, to prevent spreading of infectious diseases and ensure disposal of medical was- improving clinical effectiveness.1 te in an environmentally safe way, since landfills may accept only waste, which is not infectious. Various indicators are used to assess the quality of healthcare: the indicators of clinical outcomes (patient’s assessment of the treatment outcomes, the level of hospitalisation with out-patient sensitive diagnoses, five year survival rate for concrete oncological diseases, etc.), patient safety indicators (the level of surgical infections, other healthcare related infections, the in- Identified problems: cidence of bacterial infections with resistance against antibiotics) and quality indicators of the care process (the development • There is no comprehensive quality system for all healthcare services providers, which would allow the patient to make a and implementation of evidence-based clinical guidelines, the scope of compliance with evidence-based clinical guidelines).2 motivated choice. To improve the quality of healthcare in Latvia evidence-based clinical guidelines should be developed and implemented. • The quality criteria set for the work of primary and secondary healthcare service providers are not sufficient to ensure ef- The procedure for developing, assessing, registering and approving of guidelines is set out in the Cabinet of Ministers Regula- fective and safe treatment process and long-term improvement of public healthcare indicators. tion.3 The list of approved guidelines is available on the CHE webpage. Currently quality criteria for general practitioners are defined in a legal act.4 They are used to assess the work of a general Objective: To ensure effective management of healthcare system and use of resources, to ensure optimisation practitioner; the amount of annual payment is calculated according to the rate of quality criteria met. of resources and long-term sustainability of the healthcare system, as well as equal access for all Latvia’s In Latvia the Health Inspectorate controls the quality of healthcare provided to the patients. HI controls the legal compli- inhabitants to those healthcare services, which are paid for from the state budget. ance of the institutions of healthcare, including the spending of budget resources; it reviews patients’ complaints and carries out appropriate control measures at the institutions of healthcare. The greatest number of complaints deals with the quality of To reach the objective: expertise on the incapacity for work, including the substantiation of the issued certificates on the incapacity for work. Compla- • Creation of a sustainable health system, ensuring stable and predictable funding for healthcare. ints of persons from prisons or detention centres rank as second, but the third type of most frequent complaints concerns the • Facilitating the decrease of patients’ direct payments, improving the accessibility of healthcare services and shortening work of general practitioners, as well as complaints regarding surgery/ traumatology/ obstetrics/ gynaecology and dentistry. the waiting time. Healthcare related infections and microbial resistance is one of the main public health problems in the world, including • Strengthening of primary healthcare, including pharmaceutical care as the most cost effective and comprehensive level the EU. Every year approximately 4 million patients in the EU member states are infected during the healthcare process, and of healthcare. for approximately 37 000 patients the outcome is fatal. • Increasing the activities of the general practitioner’s team in providing care to oncology, addiction patients and patients A number of measures to ensure the monitoring and control of healthcare related infections and microbial resistance have with mental health disorders. been implemented in Latvia, legal acts related to infection control and rational use of antibacterial agents have been developed. • Introducing the principle “money follows the patient” in the out-patient sector. Since 2004 the majority of Latvian microbiological laboratories have become part of the European Antimicrobial resistance • Planning of a cost and resources effective system of in-patient healthcare. surveillance system - EARSS, in the framework of which regular monitoring of antibiotics resistance is performed. • Developing of out-patient care and decreasing hospitalisations time of patients. In 2007 systematic epidemiological surveillance of laboratory confirmed methicillin resistant Staphylococcus aureus (he- • Ensuring healthcare to prison inmates in conformity with the healthcare in society (reimbursement medicines, the rights reinafter - MRSA) cases was started, this function is performed by ICL, but the quality of hygiene and anti-epidemic regime at for prison doctors to prescribe them, tests paid for by the state budget). healthcare facilities is controlled by HI. • Ensuring the implementation of best practice principles in treatment, facilitating the development of clinical guidelines and their implementation in practice. • Developing of integrated long-term care, defining, which long-term care services are paid for from the healthcare budget and which - from the social budget. • Improving the accessibility of reimbursement medicines and the quality of pharmaceutical care.

1 Estonia Health system performance assessment. WHO, 2010.

2 Estonia Health system performance assessment. WHO, 2010.

3 The Cabinet of Ministers Regulation No. 469 of 25 May 2010 “The Procedure of Developing, Assessing, Registering and Implementing Clinical Guidelines”.

4 The Cabinet of Ministers Regulation No. 1046 of 19 December 2006 “The Procedure of Organising and Funding Health Care”. 38 39 5. Policy Outcomes, Action Results and their Performance Indicators Defined policy objective: To eliminate inequality in the field of health, by implementing measures to ensure Defined policy objective: To decrease morbidity and mortality from non-infectious diseases, decreasing the equal opportunities for health to all Latvian inhabitants. negative impact of risk factors upon health. Reference level Performance indicator: mortality from circulatory 2014 2017 diseases (per 100000 of the population) Indicator Year (source: CHE) Performance indicator: the average life expectancy at birth for men (in years) 68.8 2010 69.1 71.1 including men 237.0 2010 250.9 241.7 (source: CSB) including women 81.7 2010 70.1 59.8 Policy outcome A1: Performance indicator: average life expectancy at birth Policy outcome B1: Performance indicator: mortality from oncological The life expectancy at for women (in years) 78.4 2010 79.1 79.6 Mortality from non- diseases (per 100000 of the population) 106.4 2010 102.5 102.0 birth has increased. (source: CSB) infectious diseases (source: CSB) Performance indicator: average life expectancy at birth below the age of 64 including men 123.2 2010 117.6 117.0 close to the average indicator of the EU states (%) 91 2008 93 95 has decreased. including women 90.2 2010 89.0 88.8 (source: Eurostat) Performance indicator: mortality from diabetes (per 100,000 of the population) 5.6 2010 5.4 5.0 Action result A1: (source: CHE) Guidelines on health including men 6.9 2010 6.0 5.8 promotion measures in local government Performance indicator: guidelines developed - 2010 x including women 4.2 2010 3.1 3.0 authorities Performance indicator: The consumption of absolute developed and Action result B1: alcohol per one inhabitant older than 15 years (in litres) 7.0 2009 6.9 6.7 forwarded to all An action plan for (source: CSB) local government restricting alcohol authorities consumption has Performance indicator: Proportion of school students, Performance indicator: proportion of local government - 2010 65 85 been elaborated and who during the last month have drunk more than 5 units authorities involved in implementing the guidelines (%) 29 2007 25 20 implemented of alcohol on one occasion (%) Action result A2: (source: ESPAD) Performance indicator: Regular, updated information on Annual intersectoral health promotion, disease prevention, negative impact Action result B2: public health of environmental factors upon health and possibilities - 2010 x x The amount of trans- communications plan Performance indicator: Restrictions to the use of trans- to decrease it, possibilities of early disease diagnosis and acids in the products - 2010. x x has been developed acids defined in legal acts. healthcare services is accessible to society. distributed in Latvia and implemented has been restricted 40 41 Defined policy objective: To improve the health of mother and child, decrease infant mortality. Defined policy objective: To promote healthy and safe living and working environment, to decrease Performance indicator: Infant mortality traumatism and mortality from external causes of death. (per 1000 live births) 5.7 2010 5.0 4,6 Policy outcome C1: Performance indicator: The number of children aged (source: CSB) The health condition 0-14 years who are discharged from in-patient institutions of children improves Performance indicator: Proportion of children (15yrs), with the diagnosis injuries, poisoning and consequences 1696.7 2010 1687.1 1677.4 who assess their health status as good (%) 76.4 2010 78 80 of the impact of other external factors (per 100,000 of the (source: HBSC) population) Policy outcome D1: (source: CHE) Action result C1: Performance indicator: Proportion of pregnant women Child traumatism has 10.2 2010 9 8 Performance indicator: The number of children aged 15- Parents informed who smoke (%) decreased about the impact of 17 years who are discharged from in-patient institutions addiction-inducing with the diagnosis injuries, poisoning and consequences 2091.1 2010 2055.6 2019.8 substances upon the of the impact of other external factors (per 100,000 of the population) health of a pregnant Performance indicator: Proportion of infants who are 52.5 2010 53.7 56.7 (source: CHE) woman and foetus breast-fed till the age of 6 months (%) and the importance Action result D1: Performance indicator: Proportion of inhabitants using 36.8 2010 45 50 of mother’s milk to Society has been child seats in cars (%) ensure child’s health informed about the most frequent causes Performance indicator: Propotion of children using and preventive 19.4 2010 25 30 protective helmets (when cycling or roller-skating) (%) measures of traumas Action result D2: Society informed Performance indicator: The water profile for all official about the impact 30 2011 46 46 swimming sites have been elaborated and published of environmental factors upon health 42 43 Defined policy objective: To decrease morbidity with infectious diseases. Defined policy objective: To ensure effective management of healthcare system and use of resources, to Performance indicator: Morbidity with TB per 100,000 ensure optimisation of resources and long-term sustainability of the healthcare system, as well as equal of the population 37.0 2010 36.6 36.0 access for all Latvia’s inhabitants to those healthcare services, which are paid for from the state budget. (source: CSB) Policy outcome Performance indicator: Morbidity with HIV per 100,000 Performance indicator: Public funding for health sector Policy outcome F1: 3.87 2010 4.5 5.0 E1: Morbidity with of the population 12.2 2010 11.5 11.0 (% of GDP)* Balanced proportion infectious diseases (source: ICL) of public and private Performance indicator: Proportion of household direct has decreased Performance indicator: The number of cases of funding for the payments for healthcare services (%) 39.3 2010 30 30 measles, rubella, poliomyelitis, tuberculous meningitis health sector (source: Eurostat) 1 2010 0 0 and military tuberculosis in infants of local origin Performance indicator: Number of out-patient visits to (source: ICL) Policy outcome F2: a primary healthcare doctor per one patient annually, 2.9 2009 3.1 3.2 Action result E1: Treatment of patients services paid by the state in out-patient sector Updated information Performance indicator: Average number of be days per increases 8.54 2010 6.5 6.5 on preventive 1 patient (all in-patient facilities, all profiles) Performance indicator: the number of prepared measures against 2010 12 12 informative materials Action result F1: The Performance indicator: Number of doctors per 10 000 of and treatment of 31.0 2010 30.0 30.0 Development Plan the population (excluding dentists, interns and residents) infectious diseases prepared for Human Resources Performance indicator: Number of general practitioners 5.9 2010 6.0 6.0 in Healthcare has per 10 000 of the population been elaborated and Performance indicator: Number of nurses per 10 000 of implemented 45.0 2010 50 60 the population Action result F2: Quality criteria Performance indicator: Quality criteria for in-patient - 2010 x x defined for in-patient healthcare facilities defined in legal acts healthcare facilities *The indicator may be changed depending upon the allocated state budget funding. 44 45 6. Further actions The policy aim defined in the Strategy: To prolong the healthy life years of Latvian population and to prevent untimely death, maintaining, improving and restoring health. Objective defined in the Strategy To eliminate injustice in the field of health, Objective defined in the Strategy To eliminate injustice in the field of health, by implementing measures to ensure equal health possibilities to all Latvian inhabitants. by implementing measures to ensure equal health possibilities to all Latvian inhabitants. In 2011-2013 the measure will be implemented in Point of progress: Ensuring partnership and intersectoral cooperation, 1. the framework of funding allocated in the law on facilitating equal health opportunities to all inhabitants the state budget for the current year. In 2014 the Centre of Health Economy will need Tasks/ main Respon- additional funding to ensure one job in the measures fir sible in- Involved amount of 11 260 lats. Term Envisaged funding and its sources reaching the defined stitu- institutions objective tion Therefore the total funding needed in 2014 will be 35 785 lats, including : To cooperate with Throughout the whole period the measure will be public opinion ensured within the framework of funding allocated Remuneration (1000) - 34 785 lats; HI, LPS, Latvian shapers, including for the current year: in 2011 in accordance with Diabetes journalists and editors the approved budget, 2012-2014 - in accordance Salary (1100) - 28 032 lats; Federation, To conduct public 1.1. of mass media, constantly MH with the approved base budget, 2015-2017 in the professional health monitoring, MH, local to provide more same amount. State mandatory social insurance contributions associations, inter alia, maintaining government extensive information (1200) - 6 753 lats; “Mums’ Club” media 1.6. a public health constantly CHE authorities, higher to society about The budget includes funding for implementing public health issues the measure in the amount of 32 912 lats. monitoring and educational reporting system institutions Capital expenditure (5000) - 1 000 lats. To identify (PHMR) mechanisms for In 2015-2017 the total necessary funding will be ensuring effective 34 785 lats (including for providing 1 additional provision of MH, Strategic job - 11 260 lats), including: In 2014 additional funding from the subsidy from information to society Council of Health general revenue will be needed to outsource rese- 1.2. and to submit to 01.07.2014. CHE Sector, Institution Remuneration (1000) - 34 785 lats; arch of situation and drafting of recommendations HM information on of Chief Specialists, Salary (1100) - 28 032 lats; for the total sum of 20 000 lats. methods for informing LPS State mandatory social insurance contributions society and the (1200) - 6 753 lats. calculations of the necessary funding. To ensure 1 additional job in 2014 - in the To establish a working amount of 11 260 and in 2015 -201 - 10 260 lats group for identifying The measure will be implemented in the additional subsidy from general revenue will be 1.3. and coordinating 31.12.2011. MH RSU, MES framework of funding allocated in the law on the needed. research in the field of state budget for 2011. In 2014 the measure will be implemented within public health. To implement the limits of the budget allocated by the law on To develop and activities to inform state budget. annual public health The measure will be implemented in the target groups Latvian Diabetes Every year by MES, MA, ME, MT, about health Federation, Latvian In 2015 additional funding from the subsidy 1.4. communications plan MH framework of funding allocated in the law on the

1 April MEPRD issues, i.e., taking Association of from general budget revenue will be needed in cooperation with state budget for the current year. other sectors into consideration From 2014 Osteoporosis in the budget program 01.00.00 “Management 1.7. MH gender differenced constantly and Diseases of of the sector” sub-program 01.01.00 “Central To develop guidelines and developing Bone Metabolism, management of healthcare” - in the amount of on health promotion The measure will be implemented in the informative materials Latvian Public 2 250 lats, including: Local government 1.5. measures in local 31.12.2011. MH framework of funding allocated in the law on the aimed at male Health Foundation authorities, LPS government state budget for 2011. and female target Goods and services (2000) - 2 250 lats. authorities audiences. Developing materials 80 expert hours - 250 lats. Printing the materials (10 000 copies) - 2 000 lats. 46 47 Objective defined in the strategy: To decrease morbidity and mortality from non-infectious diseases, Objective defined in the strategy: To decrease morbidity and mortality from non-infectious diseases, decrease the negative impact of risk factors upon health. decrease the negative impact of risk factors upon health. 2. Point of progress: Reducing the risk factors of non-infectious diseases To elaborate legal Latvian regulation on food CHE, MA, ME, MF, Association of In the framework of resources envisaged in the state 2.8. rations at catering 31.12.2011. MH LFFC, Association Diet and Nutrition budget for the current year. facilities in closed To develop an action “Latvian National In 2011 the measure will be implemented within the Specialists, LANS institutions 2.1. plan for restricting 31.12.2012. MH Coalition for Toba- limits of the funding envisaged by the law on the alcohol consumption cco and Alcohol state budget for the current year. Continue implemen- Control” and other ting “School Milk” NGOs program, envisaging To implement the measure in 2014-2017 funding in the possibility to To implement the amount of 24 942 lats will be needed, including pre-schoolers and In the framework of resources envisaged in the law educational activities Local government additional resources from the subsidy from general 2.9. students of compre- constantly MA RSS, MES, MH on the state budget for the current year and the EU for the population in authorities, RSSNS, budget revenue for the budget program 01.00.00 hensive institutions of budget. all age groups, taking Latvian Association “Management of the sector” sub-program 01.01.00 education to receive into consideration of Endocrinologists, “Central management of healthcare” - in the amount dairy products in the gender differences, LFFC, Latvian of - in the amount of 11 350 lats. framework of the EU on the role of Association of support programs From 2014 2.2. physical activities and MH Osteoporosis In 2014-2017 additional 11 350 lats in the break- constantly healthy nutrition in and Diseases of down of expenditure codes according to economic To continue imple- maintaining health, Bone Metabolism, categories: menting the program on the role of hygiene Latvian Foundation for supplying fruit and and the impact of for Fighting Drug Remuneration (1000) - 9 098 lats; vegetables to school, addiction-inducing Addiction and Salary (1100) - 7 332 lats; envisaging the possibi- substances upon Dipsomania Stare compulsory social insurance contributions In the framework of resources envisaged in the law lity to the students of health. (1200) - 1 766 lats. 2.10. constantly MA RSS, MES, MH on the state budget for the current year and the EU comprehensive insti- Goods and services (2000) - 2 252 lats. budget. tutions of education to To provide advice to receive integrated fruit local government and vegetables in the authorities on the framework of the EU implementation MH, local support programs From In the framework of resources envisaged in the state 2.3. of the guidelines LSMSA government 01.03.2012 budget for the current year. To develop legal for promoting authorities In the framework of resources envisaged in the law physical activities in 2.11. regulation for defining 01.06.2012. MA MH, LFFC local government on state budget for the current year. energy drinks authorities To ensure the To support the transposition of the EU implementation of legal acts to regulate the programme “5 a the distribution of In 2012-2013 the measure will be implemented day” (or 5 helpings of The measure will be implemented the framework e-cigarettes and within the framework of resources envisaged in 2.4. fruit and vegetables constantly MH LALRG, LFFC of resources envisaged in the state budget for the 2.12. 31.12.2013. MH CHE any other products the law on state budget for the current year. (see per day) in Latvia, current year. envisaged as Annexe 2). increasing the consumption of fruit substitutes for tobacco and vegetables (except medical devices) To develop informative educational materials WHO, local The measure will be implemented in the framework government on preparing cheap To carry out research 2.5. 31.12.2013. MH NGO of funding allocated in the law on the state budget authorities, higher and nutritional food on the risk factors In the framework of resources envisaged in the law for the current year. 2.13. constantly CHE educational to persons with low of non-infectious on state budget for the current year. institutions, Latvian income diseases Public Health To inform healthcare Foundation Association personnel (general To carry the survey of General practitioners, neuro- of WHO International School Practitioners, In the framework of resources envisaged in the law logists) on factors From MH, In the framework of resources envisaged in the state 2.14. study on smoking year 2014 CHE WHO 2.6. Latvian Association on state budget for the current year. causing occupational 01.07.2012. MW budget for the current year. among adolescents /2015 of Rural General diseases and timely (GYTS) in Latvia Practitioners, RSU diagnosis of occupa- ILSEH Latvian Association tional diseases To identify factors of Gynaecologists hindering the To develop a draft and Obstetricians, The measure will be implemented in the framework organisation of legal act to restrict the Latvian Association In the framework of resources envisaged in the law 2.7. 30.06.2013. MH MA, LFFC of resources envisaged in the state budget for the 2.15. cancer screening and 31.12.2012. HPC amount of trans-acids of General on state budget for the current year. current year. improve screening in food products Practitioners, for early diagnosis of LU, Riga Eastern oncological diseases University Hospital 48 49 Objective defined in the Strategy: To improve the health of mother and child, decrease infant mortality. Objective defined in the Strategy: To improve the health of mother and child, decrease infant mortality. 3. Point of progress: Improving the health of pregnant women and children In 2011-2013 the measure will be implemented within the framework of the funding envisaged by In 2012-2017 funding in the amount of 11 479 lats is the law on the state budget for the current year. MES, NGO, mass envisaged for implementing the measure. In 2011-2017 funding in the amount of 16 021 lats To implement media, “Mums’ To ensure educational Club” media, is envisaged for the implementation of the measure. In 2014-2017 additional resources will be necessary education on activities for Association “Latvian sexual and from the subsidy from general budget revenue for Latvia’s Association In 2014-2017 additional funding will be necessary parents on the National Coalition reproductive the budget program 01.00.00 “Management of the for Family Planning from the subsidy from general budget revenue for harmful impact for Tobacco and 3.3. health issues to constantly MH sector” sub-program 01.01.00 “Central management and Sexual Health the budget program 01.00.00 “Management of the of addiction- Alcohol Control” teenagers, taking of healthcare” in the amount of 2 000 lats, the „Papardes zieds” sector” sub-program 01.01.00 “Central management inducing and other NGOs, into consideration breakdown according to the codes of economic of healthcare” in the amount of 2 000 lats, including: substances upon Latvian Association gender 3.1. constantly MH categories : Goods and services (code 2000) - 2 000 lats. the health of a of General differences Goods and services (2000) - 2 000 lats. pregnant woman Practitioners, and the foetus, on Latvian Association Organising 8 seminars and discussion groups for Organising informative educational events on adolescents (the average costs of organising one healthy nutrition of Rural General topics related to family health, including: lectures, seminar - 250 lats). for children, Practitioners, discussion groups, health weeks, and round table inuring children, Latvian Association To prepare an discussions. physical activities of Gynaecologists informative report 6 to 10 event (the average costs of 1 event from 200 and safety and Obstetricians, of infertility lats to 300 lats). LFFC problems 8 events * 250 lats = 2 000 lats. in Latvia, to In the framework of resources envisaged in the law To inform medical 3.4. 30.12.2012 MH HPC identify the on state budget for the current year. staff, parents and current situation opinion shapers and provide in mass media recommendations In the framework of resources envisaged in the law 3.2. on the role of constantly MH NGO for improving it on state budget for the current year. mother’s milk in ensuring and maintaining a child’s health 50 51 Objective defined in the Strategy: To promote healthy and safe living and working environment, to decrease Objective defined in the Strategy: To promote healthy and safe living and working environment, to decrease traumatism and mortality from external causes. traumatism and mortality from external causes. 4. Point of progress: Decreasing the impact of traumatism and environmental risks upon public health To inform society about the To prepare negative health updated impacts of air, information drinking water In the framework of resources envisaged in the on actions to 4.6. constantly HI MH, MEPRD Every year In the framework of resources envisaged in the and swimming law on state budget for the current year. 4.1. be taken in an EMAS MH water pollution till 1 March law on state budget for the current year. emergency and and individual providing first possibilities of help in trauma prevention cases To prepare To educate proposals for parents and decreasing the medical staff on level of excessive NGO, local State Inspectorate HI, MH, In the framework of resources envisaged in the the most frequent 4.7. noise in places, 01.01.2014 government for the Protection In the framework of resources envisaged in the MEPRD law on state budget for the current year. 4.2. causes of trauma constantly MH where it disturbs authorities, MT of the Rights of the law on state budget for the current year. among children people in their Child, NGO and safety work, life and measures to leisure prevent traumas Research carried To organise out on the impact seasonal of environmental educational factors (chemical campaigns and substances, road traffic safety dust, including Road Traf- campaigns, nanoparticles, In the framework of resources envisaged in the fic Safety focusing upon In the framework of resources envisaged in the noise, law on state budget for the current year, to the 4.3. constantly Directo- MI, EMAS, LSMSA 4.8. 31.12.2017 RSU, MH MES, MEPRD the vulnerable law on state budget for the current year. electromagnetic, extent possible attracting the funding of the EU rate, State road traffic ionization funds or other project resources. Police participants, and other taking into radiation, urban consideration environment, gender global warming) differences upon human To facilitate health knowledge and To inform medical skills among facilities about pre-schoolers In the framework of resources envisaged in the 4.9. handling medical constantly MH HPC and students of law on state budget for the current year. In the framework of resources envisaged in the waste and correct 4.4. comprehensive constantly MES SCCD management of it law on state budget for the current year. educational institutions on personal safety and healthy lifestyle To conduct effective surveillance of the products and In the framework of resources envisaged in the 4.5. services market, constantly CRPC, HI ME, MH law on state budget for the current year. to ensure the accessibility of only safe products and services 52 53 Point of progress: Prevention of infectious diseases Objective defined in the Strategy: To ensure an effective management of healthcare system and use of 5. Rīcības virziens: infekcijas slimību profilakse resources, to ensure the optimisation of costs and sustainability of the healthcare system, as well as equal To improve access to all Latvian inhabitants to those healthcare services, which are paid for from the resources of the informing state budget. society about the significance Point of progress: Developing a high quality system of healthcare services, ensuring the accessibility of The measure will be implemented in the 6. of measures From services to all Latvian inhabitants 5.1. ICL MH framework of funding allocated in the law on for preventing 01.01.2012 the state budget for the current year. infectious 6.1. Provision of healthcare services and development of resources diseases, including the role Elaborate a of vaccination plan on the To improve the development of 30.06.2012 MH In 2011 and 2012 the measure will be CHE, HPC collection of human resources implemented in the framework of funding 6.1.1. statistical data, in healthcare and allocated in the law on the state budget for the 31.12.2012 MH CHE, HPC by educating a development current year. The measure will be implemented in the plan for medical staff on 5.2. constantly ICL MH framework of funding allocated in the law on healthcare system filling out forms the state budget for the current year. and reporting Involving a about concrete second nurse in infectious the GP practice, The measure will be implemented in the diseases 6.1.2. ensuring that 31.12.2013 MH HPC framework of funding allocated in the law on In cooperation the nurse the state budget for the current year. with WHO WHO, Latvian sees patients implement Association independently training of of General The measure will be implemented in the Provision of in- 5.3. medical staff 31.12.2012 ICL Practitioners, framework of funding allocated in the law on patient healthcare on prevention Latvian Association the state budget for the current year. services in and diagnosis of Rural General hospitals, of infectious Practitioners which ensure diseases the amount of HPC, CHE, local The measure will be implemented in the To assess the 6.1.3. human resources 31.12.2014 MH government framework of funding allocated in the law on effectiveness and meet the authorities the state budget for the current year. and structure of quantitative The measure will be implemented in the criteria set in legal the system for 5.4. 30.06.2012 ICL MH framework of funding allocated in the law on acts epidemiological surveillance and the state budget for the current year. prepare a final report Establishing a To improve mechanism for cooperation funding hospitals with European to ensure that Centre for Disease the amount of Prevention and funding to be The measure will be implemented in the allocated for The measure will be implemented in the Control, obtaining 5.5. constantly ICL MH framework of funding allocated in the law on 6.1.4. hospitals changes 31.12.2013 MH HPC, CHE framework of funding allocated in the law on the most recent information about the state budget for the current year. depending the state budget for the current year. diagnosis and upon meeting prevention of the defined new infectious requirements diseases (quality of work and cost effectiveness) 54 55 Objective defined in the Strategy: To ensure an effective management of healthcare system and use of Objective defined in the Strategy: To ensure an effective management of healthcare system and use of resources, to ensure the optimisation of costs and sustainability of the healthcare system, as well as equal resources, to ensure the optimisation of costs and sustainability of the healthcare system, as well as equal access to all Latvian inhabitants to those healthcare services, which are paid for from the resources of the access to all Latvian inhabitants to those healthcare services, which are paid for from the resources of the state budget. state budget. Development of 6.2. Pharmaceutics a network of care MH, LPS, local The measure will be implemented in the 6.1.5. hospitals (beds) to 31.12.2014 CHE government framework of funding allocated in the law on Development ensure long-term authorities the state budget for the current year. of medicines 01.10.2014 The measure will be implemented in the care to patients reimbursement 6.2.1. CHE SAM framework of funding allocated in the law on system, including To develop out- the state budget for the current year. new diagnoses patient care and and medicines decrease the time patients spend To develop criteria in hospitals, The measure will be implemented in the for assessing 6.1.6. expanding the 31.12.2014 VM HPC, CHE framework of funding allocated in the law on the accessibility 6.2.2. 31.12.2012 LPA CHE, CRPC Within the budget of LPA. functioning of the state budget for the current year. and quality of day clinics and pharmaceutical increasing the care effectiveness of To prepare services provided amendments To develop to legal acts, The measure will be implemented in the and introduce defining 6.2.3. 31.12.2013 MH framework of funding allocated in the law on quality criteria quality criteria The measure will be implemented in the the state budget for the current year. for in-patient for assessing 6.1.7. 01.01.2013 MH CHE framework of funding allocated in the law on pharmaceutists’ medical facilities, the state budget for the current year. work introducing amendments into To inform society The measure will be implemented in the legal acts From 2012 6.2.4. about rational use CHE SAM framework of funding allocated in the law on constantly To prepare of medicines the state budget for the current year. amendments To introduce to legal acts, stricter control of defining the the advertising of Latvian Advertising rights of prison The measure will be implemented in the medical devices Association, Ethics inmates to receive 6.2.5. constantly SAM, CRPC framework of funding allocated in the law on and nutrition Committees of LPA reimbursement The measure will be implemented in the the state budget for the current year. supplements and producers 6.1.8. medicines and 01.10.2011 MJ MH framework of funding allocated in the law on the obligation of the state budget for the current year. the Ministry of Justice to cover the patient’s fee for healthcare provided to prison inmates 7. Reporting and Evaluation Procedure The Ministry of Health shall provide information to the Cabinet of Ministers on the implementation of the Strategy twice in the period of validity of the Strategy: an informative report on mid-term evaluation of the Strategy in 2014 and the final report on the implementation of the Strategy in 2018. In case of necessi- ty the Ministry of Health shall prepare amendments to the Strategy and shall submit them for review to the Cabinet of Ministers. 56 57

Annexe 1 to the Public Health Strategy for 2011-2017 Explanation of the Terms used in the Text Consumption of alcoholic beverages per capita - the consumption of alcoholic beverages in Latvia per capita is calculated by dividing the amount of alcohol consumed in the respective year by the average number of the population in the year. This indicator is calculates both in terms of consumed alcohol in each group of beverages and expressed as absolute alcohol. Consumption of alcoholic beverages expressed in absolute alcohol - an indicator of alcoholic beverages consumed in Latvia, which is calculated for each group of beverages and expressed for all groups of beverages as absolute alcohol. When expressing the data as absolute alcohol, the amount of consumed alcohol in each group of beverages is re-calculated and equalled to 100% alcohol. Day clinic - a medical facility, where the patient, who does not need care and surveillance provided by healthcare personnel, re- ceives assistance in the form of diagnosis and treatment. Diseases and disorders are diagnosed at day clinic; patients receive treat- ment and care there. Quality of life - an indicator of the well-being of a person, family, a group of persons, society, which includes physical and men- tal health, leisure time and spending it, work, links with society, the right to take independent decisions and to implement them, as well as material means. Pharmaceutical care - an element of healthcare, which a pharmaceutist provides within his or her competence, providing pharma- cotherapuetical advice, information about medicines and their use. This care contains monitoring the use of medicines by permanent customers of the pharmacy, dissemination of medicines and other healthcare, prevention and health promotion products, preparing medicines, health promotion and advocacy of disease prevention, on the basis of recent scientific findings and considering the cus- tomers’ interests, as well as ensuring customer data protection within the limits of their competence. Integrated fruit and vegetables - products, the cultivation of which is based upon biological methods of plant protection, monito- ring and recording of the spread of pests and diseases, as well as using optimal doses of fertiliser. Average life expectancy of newborns - the number of years that the people born in a given year would live, if during their lifeti- me the mortality rate in every age would remain the same as in the year they were born. Reimbursement medicines - medicines fully or partially paid for by the state, which in cases of certain diagnoses are prescri- bed by general practitioners or specialists mentioned in the list of reimbursement medicines. The state may reimburse the costs of medicines in the amount of 50, 75 or 100%. Quintile - one fifth of the number of surveyed households, grouped in an increasing order according to the monetary revenue at their disposal per one member of the household. First quintile covers the poorest households, but the 5th - the most prosperous. Abortions - cover legal, medicinal abortions and abortions performed outside medical facility. Maternal mortality - the number of deceased women per 100,000 live born infants, who have died during pregnancy or 42 days af- ter termination of pregnancy, irrespectively of the length and localisation of pregnancy, if the causes are linked with pregnancy or whi- ch the pregnancy or its management aggravated, but not an accident or a contingency. Mortality - the rate of death cases, usually expressed per 100000 of the relevant population (population of the relevant age, gender, etc.). Risk of poverty rate - number of inhabitants living beneath the level of relative poverty (the proportion of those persons, whose equivalent total net income is smaller than 60% of the national median income). Cause of death - a disease, a pathological condition or an injury, which has caused or facilitated death, as well as an accident or an act of violence, which has resulted in death., Predictable healthy life years - the years that the person of the given age could live in good health (without functional disorders or restrictions). Perinatal mortality - number of stillborn children and children who die during the first week of life, per 1000 stillborn and live bir- ths. Perinatal death includes the perishing of foetus before birth, during labour 9stillborn) and the death of the newborn during the first week of life (early neonatal death). Potential years of life lost - years that a person would have lived up till a certain age (here the calculations are based upon the age of 65), if he or she had not died because of an accident, disease or some other cause. Primary healthcare - the first and main level of healthcare system, the first stage of interaction between a patient and the provider of healthcare services, in which main health problems of the population are dealt with, using simple and cost effective medical techno- logies. General practitioners together with their teams (doctor’s assistant or a nurse and midwife), as well as dentist, dentist’s assistant, dental nurse and dental hygienist provide primary healthcare to patients registered with them at out-patient medical facilities and out- patient departments of in-patient medical facilities. Public health - research and targeted activities aimed at disease prevention, increasing life expectancy, promoting mental (psychic) and physical health by organising large-scale activities. Sexual and reproductive health - physical, mental and social wellbeing linked with human reproductive system. Secondary healthcare - specialised out-patient and in-patient healthcare, targeted at emergency, acute or scheduled healthca- re (provided at an out-patient medical facility, out-patient department of a hospital, emergency medical assistance facility, day cl- inic, hospital). Screening diagnosis or screening - targeted search for a disease in persons, who have no symptoms linked with the disease that is searched for and who belong to a risk group (most often - specific age group), which has the highest morbidity with the disease. In-patient care - treatment of patients, involving being under constant, round the clock care of healthcare personnel. Services of secondary and tertiary level healthcare are provided as in-patient care. Health - physical, mental (psychic) and social welfare, which is the natural foundation for the existence and survival of the state and the nation. Healthy life years - estimated years of life that will be lived in good health (without functional restrictions or restricted activities) Infant mortality - the number of children, who die during their first year of life, per 1000 live births. 58