Strategic approach regarding investments in health under OP “Growth and Employment”   22.11.2016.

EU funds financing for health Focus on inhabitants under social and territorial exclusion risk Concentration on four priority health areas Strategic planning Synergy with other sectors

Implementation progress SO number SO Available funding Progress Funding for which the development of implementation conditions has started Funding for which implementation conditions have been approved Funding for which project selection has started Funding for which projects have been approved Funding for which payments to FB have been made EUR % 9.2.3. Health network development guidelines and quality assurance system 4 609 777 100% 616 395 13% 9.2.4. Common health promotion and disease prevention measures 16 692 797 0% Local health promotion and disease prevention measures (1st call) 19 346 199 11 024 710 57% Local health promotion and disease prevention measures (2nd call) 9.2.5. Medical personnel regional accessibility 9 960 103 9.2.6. Medical personnel lifelong learning 22 765 950 ESF European Social Fund (total) 92 721 025 82 760 922 89% 40 648 773 44% 32 327 284 35% 1% 9.3.2. Health care infrastructure (Major hospitals) 83 296 041 Health care infrastructure (Major project) 91 068 677 Health care infrastructure (others health care providers) 20 000 000 ERDF European Regional Development Fund (total) 194 364 718 174 364 718 90% TOTAL 287 085 743 267 085 743 93% 29% 14% 11% Distribution of ERDF between other health care providers will be reviewed by developing national planning documents

State of play and policy developments Specific health guidelines development World bank research CoM decision on major hospital development [20.12.2016] Infrastructure of major hospitals [SO 9.3.2. 1st and 2nd call] Regulation [27.12.2016.] Projects [29.01.2018. and 06.07.2017.] Hospitalization plan [10.10.2016] Infrastructure of rest service providers [SO 9.3.2. 3rd and 4th call] Regulation and projects National policy planning document [Masterplan] [28.03.2017.] Financing model [11.10.2016.] HR lifelong learning [SO 9.2.6.] Project [30.04.2017.] HR lifelong learning [SO 9.2.6.] Regulation [08.11.2016.] HR accessibility in regions [SO 9.2.5.] Project [31.05.2017.] HR availability in regions [SO 9.2.5.] Regulation [03.12.2017.]

State of play and policy developments Specific health guidelines development Document Project 1st draft Final version Date of approval Submitted Comments Inception Paper - 20.03.15. Multiple 27.07.15. 19.08.15. Health Promotion Review 06.03.15.  Multiple 28.07.15. Quality Assurance Review 04.11.15. 13.11.15. 07.12.15.  19.01.16. 08.03.15. 22.03.16. Provider Payment Review 18.01.16. 17.02.16.  18.04.15. 11.05.16. Research (interviews, focus groups` discussions) 03.03.15.  30.03.16. 15.04.15. Review of the Service Delivery Model 27.04.16  16.06.16.  14.07.16. 14.11.16.    Review of the Benefits Package 16.06.16. 14.07.16. Bottlenecks analysis 10.05.16. 12.05.16. 21.11.16.  Hospital Volume and Quality of Care in Latvia review 27.04.16.  15.08.16. 12.09.16.   09.11.16. mapping 11.07.16. 21.07.16.  25.08.16. 30.09.16.   15.11.16. HR planning and analysis Included in mapping Capital investments planning 19.01.16.  15.11.16.   Manitoring system manual (included in bottleneck analysis) Policy proposals  21.11.16.

State of play and policy developments HR policies Decrease of specialists by 21% to 6 919 Increase of GP and ambulatory nurses by 13% to 3 726 Increase of hospital nurses by 51% to 4 973 Decrease of GPs by 29% to 1 177 WB key findings regarding HR National policy document regarding HR will be incorporated in the common policy planning document for health sector development (by 28.03.2016.) Project applications and projects implementation plans in the frames of SO 9.2.5 and SO 9.2.6. will be prepared taking into account national policy planning document

Health infrastructure mapping WB research - key findings Decrease of population to 1,84 m Decrease of number of beds in acute hospitals by 28% to 5 195 Decrease of number of long-term hospital beds by 8% to 3 729 Concentration of complicated services and availability of basic services Health care Four stationary health care levels Five emergency levels Availability of ambulatory health care Equipment planning Infrastructure Quality assurance system development Health care financing management reform Integrated health management and IS development Gradual investments in health care infrastructure and HR WB recommendations for the reforms  

Health infrastructure mapping Present situation Health care Primary health care 1320 general practitioners 105 doctors assistants Doctors on duty and phone consultations 204 home care institutions 14 emergency medical assistance units Secondary ambulatory health care 11 types of primary specialists 11,6 million ambulatory visits 0,2 million operations in day hospitals Stationary health care 3 university hospitals 7 regional hospitals 11 local hospitals 7 care hospitals 8 psihiatric hospitals 4 other monoprofile hospitals 322 thousands of hospitalisations Emergancy medical service 190 EMS teams in 102 places 443 thousands calls Arriving time: in cities 15 min (89%) in countryside 25 min (83%)

Health infrastructure mapping Optimization of health care network Widening accessibility for specialized health care Increase of scope and amount of ambulatory services Provision of appropriate care for chronic patients Centralization of high level specialized health care services Geographical accessibility Optimal resource provision according to services

Health infrastructure mapping Primary care Strengthen GP capacity and resources, to ensure that patients solve their health issues at primary level To improve team work and to promote involvement in health promotion and disease prevention To provide an opportunity for GPs to consult with relevant specialists It is necessary to increase state paid Primary care share in the total amount of ambulatory visits It is necessary to develop GP network by developing multi-GP offices Solutions for cooperation between GP and social services Development of network of doctors on duty and revision of functions (placement, working hours etc.) It is necessary to increase home care service provision in rural areas and to evaluate the scope of services Optimisation of Urgent Medical Aid Stations operation

Health infrastructure mapping Secondary ambulatory health care It is planned to increase the number of ambulatory services up to 12,5 m in 2025 To revise the role and functions of ambulatory health care institutions in provision of care by defining criteria for contracting To define the set of secondary ambulatory health care services that would allow to measure result for the patient It is necessary to evaluate the number of direct accessibility specialists and scope of services To improve secondary ambulatory care (incl. day hospital services) in territories which are far from stationary care providers It is necessary to clearly define services which should be provided in day hospitals, separating them from 24 hours stationary services To improve ambulatory units in hospitals, thus improving accessibility and quality of ambulatory services in the cities

Health infrastructure mapping Emergency medical services Providing the changes in stationary care institutions network, at the same time the revision of pre-hospital emergency service providers network and the evaluation of location and number of emergancy care teams will take place It is necessary to improve arrival time for the calls to provide compliance with the control time in the regulations – in 90% of cases 15 minutes in cities and 25 minutes in rural areas

Health infrastructure mapping Stationary health care Planned patients and chronic patients Second level Urgent medical Aid Station I level hospital 24 hour emergency help services (5 specialists) Available diagnostics and treatment for planned and acute patients Stabilization of health condition for transportation to higher level hospital Distance / accessibility – up to 60 minutes II level hospital 24 hour emergency help services (8-10 specialists ) Operates an insult unit Distance / accessibility – up to 90 minutes Hospital with additional specialization in oncology and cardiology III level hospital 24 hour emergency services (10 specialists) Secondary and tertiary care services Distance / accessibility up to 180 minutes for tertiary care. Hospital with specialization in traumatology / in maternal care / in rehabilitation profile IV level hospital

Health infrastructure mapping Stationary health care Source: Ministry of Health

Planned number of patients 2025 Number of patients per bed Health infrastructure mapping Systemically important health care providers Hospital Level of hospital Planned number of patients 2025 Planned number of beds 2025 Number of patients per bed Eastern Clinical University Hospital of Riga IV 80 108 2 068 39 Pauls Stradiņš Clinical University Hospital 46 723 815 57 University Children`s Hospital 17 492 355 49 Traumatology and Orthopedic Hospital 9 138 210 44 Riga Maternity Hospital 9 522 146 65 National Rehabilitation center "Vaivari" 5 181 252 21 Liepāja Regional Hospital III 16 151 291 56 Daugavpils Regional Hospital 26 747 543 Ziemeļkurzeme Regional Hospital 13 136 247 53 Jelgava City Hospital 11 982 229 52 Vidzeme Hospital 12 952 265 Jēkabpils Regional Hospital 9 728 190 51 Rēzekne Hospital 10 277 241 43 IV level hospitals 168 164 3 846 III level hospitals 100 973 2 006 50 Total 269 137 5 852 46

Health infrastructure mapping Investments calculations Available financing – 194 364 718 EUR : ERDF 152 136 253 EUR National 42 228 466 EUR I call - 83 296 041 EUR II call (Stradins Hospital) - 91 068 677 EUR III and IV call – 20 000 000 EUR Rationale for the calculations 88% from all the hospital beds are already concentrated in high intensity stationary health care institutions Lower intensity hospitals demand lower technology provision and smaller area of premises is needed to provide relevant services. Ambulatory service delivery should be developed in order to make basic services more accessible (especially primary health care) Calculations are similar to the approach used in EU funds 2007-2013 period when local and care hospitals and ambulatory health care institutions (incl. primary care centres) received 15% (in comparison to the previous period, presently the support is needed for a considerably smaller number of lower level institutions).

Health infrastructure mapping Major medical devices Nr. Medical equippment Unit costs (may vary), euEUR I Medical equippment, with unit costs above 100 000 EUR 1. USG Up to 110 000 2. Endoscopic Unit Up to 130 000 3. X-Ray Up to 264 000 4. Mammography Unit Up to 290 000 5. Gamma Camera Up to 650 000 6. CT Up to 850 000 7. Angiography Up to 1 450 000 8. MRI - Magnetic Resonance Imaging Up to 1 815 000 9. Linear Accelerator Up to 4 600 000 II Medical equippment, with unit costs from 20 000 EUR to 100 000 EUR 10. Incubator, Infant (intensive care) Up to 25 000 11. Surgical table Up to 33 000 12. Anesthesy Unit Up to 50 000 13. Lithotripter Up to 73 000 14. Laparoscopy Unit Up to 97 000

Health infrastructure mapping Premises development needs Necessary area calculated based on beds planning data Necessary area compared with existing area thus calculating necessity for new area Necessary area (reduced by new area) compared with developed area in last 10 years thus calculating renovation necessity Necessity for development of ambulatory care calculated based on present ambulatory care unit areas Based on identified area and average construction costs, necessary investments are calculated for the development of premises and adding 15% for furniture, IT and small medical devices

Health infrastructure mapping Investments calculations (corrections) Allocation corrected according to the calculated needs IV level university hospitals up to 25 000 000 IV level mono-profile hospitals up to 2 500 000 EUR III level hospitals up to 15 000 000 EUR Allocation corrected according to the maximum project amount according to the relevant hospital level Allocation corrected according to the distance from institution to Riga Allocation is corrected proportionally according to the available financing

State budget activities Improvements in 2017 Sector Additional services Ambulatory care Ambulatory examinations and treatment accessibility +194 422 patients Number of diagnostic examinations in primary health care (GP referrals) +22 000 examinations Ambulatory rehabilitation and physical medicine services +32 686 patients Oncology patient care Number of diagnostic examinations in secondary ambulatory care in oncology (specialist referrals) +14 659 patients Hospital level oncology patient treatment +10% (+3445 patients) Medicine accessibility per unique patients in oncology +20% (+4494 patients) Reimbursed medicine Patient provision with reimbursed medicine for existing diagnosis and medicines +26 073 unique patients Improved service accessibility Specialists +401 000 patients Day hospitals +26 900 patients Endoprosthetics +1 365 patients

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