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Health systems in transition Latvia Doctorates A “doctorate” was formerly the practice of a local internist (for adults) who was usually an unspecialized doctor, usually located in rural areas. Currently, the distinction between “doctorates” and single-GP practices (privately owned) is becoming increasingly blurred as the two are becoming largely indistinguishable. Feldsher-midwife points Some of these still exist as municipal/district health care institutions that provide services such as preventive care and care for the chronically ill, which is closely connected with the work of GPs who provide PHC services to patients living in rural areas. To summarize, PHC providers may be either independent, self-employed practitioners, or may be directly employed by local governments or by health centres. In all cases, statutory care is provided through contracts with the SCHIA, which are carried out either directly (in the case of self-employed doctors) or through the health care institution at which the doctor is employed. Table 6.2 provides two examples of the distribution of key primary care provider settings in two areas of Latvia, Vidzeme and Riga City. It can be seen that the overwhelming majority take the form of the “GP practice”, where the doctor is self-employed. GPs who are employed at health centres or hospitals choose this form as a matter of necessity, as a result of the expense of setting up an independent practice. GP practices that are limited companies are expected to increase in relative importance. While in a number of instances GPs work in the same premises, these are not considered to be group practices according to Latvian legislation, which considers each individual doctor to be working independently. A similar distribution of legal forms of institution, with some variations, prevails in other regions and cities of Latvia. The larger towns (for example Latgale, Kurzeme and Zemgale) tend to have relatively more district/municipal health centres than other areas. Primary health care providers PHC is provided primarily by GPs in the role of family doctors. The specialty of GPs was only established in 1991. The number of certified GPs has increased sharply in recent years due to retraining courses for GPs that have become available since 1992. The overwhelming majority of GPs had been trained as specialists (i.e. not GPs) under the previous system and have retrained in recent 173
Health systems in transition Latvia Table 6.2a Primary health care settings and legal forms, Vidzeme region Vidzeme regional PHC setting Area: 20 319 km 2 (Latvia 64 600 km 2 ) Population: 310 660 (Latvia 2.4 million) Registered patients on GP lists: 297 042 Number of GPs: 192 Density: 15.3 people/km 2 Legal forms GPs in towns Rural Total of institution (6000–29 000 GP inhabitants) GP practice 83 doctors 86 doctors 169 Premises for GP practices in towns are (self- rented from health centres, polyclinics or employed) hospitals, and in rural areas from the local government; in some cases the premises are private. All practices are individual. The largest number of GPs practising at one address is 8 (in health centres) and 3 (in rural districts/municipalities) (note that these are not group practices, since according to legislation each GP is considered to be an independent self-employed individual). Limited 3 doctors 8 doctors 11 There is a growing interest in establishing company limited companies, and it is expected that (one person) this legal form will grow. Economic 2 doctors 5 doctors 7 operator (one person) Limited 1 doctor 1 All doctors are employees; this is not company popular among GPs. (municipal health centre) Limited 4 doctors 4 All doctors are employees; this is not company popular among GPs. (municipal hospital) Total 192 Source: Authors’ own compilation. Notes: PHC: Primary health care; GP: General practitioner. years. Certification for the relatively new specialty of GP is provided by the Latvian Physicians Association. There are three categories of physicians who can qualify as PHC physicians or family doctors: GPs, internists and paediatricians. By 2004, 80% of primary care physicians were trained as GPs, 14% as internists and 6% as paediatricians. Other health care personnel involved with PHC provision are feldshers, or doctors’ assistants, who have mid-level medical education and more responsibilities than nurses; nurses, who may specialize as primary care nurses 174
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Keywords: DELIVERY OF HEALTH CARE E
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9. Conclusions In the early years o
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