1. Ieviņa Alka Latvian Medical Association VILNIUS 26 – 27 SEPTEMBER 2005 New Doctors and Residentship Education in Latvia Data of Rīga Stradina University and Project by the Latvian Association of New Doctors Presented to Latvian Medical Association

2. Excerpts from Medical Treatment Law Medical education – the aggregate of knowledge and skills conforming to the medical education programme recognized under procedure prescribed by law, which is certified by a diploma issued by an educational institution (Medical Treatment Law, as amended on 8 April 2004) Postgraduate education – continuous education of medical practitioners in the form of specialisation or raising of qualification after obtaining a diploma from the medical educational institution (Medical Treatment Law, 1 October 1997) Specialisation – part of continuous education that takes place in accordance to the accredited education programme following a standard of profession and rules of speciality (Medical Treatment Law, as amended on 27 May 2004) Improvement of a professional qualification - part of continuous education in a relevant speciality that takes places in accordance to the freely chosen education programme whose content and time for completion is not subject to regulation (Medical Treatment Law, as amended on 27 May 2004)

3. - Continuous Education - Postgraduate Education - Specialisation - Qualification raising Residentship Education

4. Goal Provision of education, incl. training of practical skills for obtaining the qualification of a specialist

5. History - specialization courses - internship - residentship since - 1990.

6. Residentship Post-graduate training of a doctor in an official language, in a contractual employment relationship with a health care provider institution implementing educational programme, for the acquisition of a speciality in accordance with a accredited professional residentship educational programme in medicine. (Medical Treatment Law, as amended on 27 May 2004)

7. State Funded Residentship Education  Demand from sick-funds for family doctors  Demand from health care provider institutions for specialist doctors  Data from doctors` labour market - number of doctors working outside profession - expected number of retired persons - number of unemployed doctors - vacant position for doctors  Epidemiological data from all regions Ministry of Health Number of planned resident doctors and their structure Proposals from the Agency for Health Statistics and Medical Technologies

8. Normative Enactments 1.Medical Treatment Law, 1 July 1997 2. Law on Higher Education 17 November 1995 amendments: law of 27 December 1996, (LV, 10 Jan. No. 9/10/11) 23 November 2000, law (LV,12 Dec. No. 448/449) 20 May 2003, Ruling of the Constitutional court (LV, 21 May No. 75) 6 January 2004, Regulation of the Cabinet of Ministers No.1 (LV, 9 Jan. No. 4) 3 June 2004., law (LV, 10 June No. 93)

9. Normative Enactments 3. Regulation of the Cabinet of Ministers of 13 March 2001., No.120 “Regulation on funding of residentship education and posting of resident doctors” (LV,16 March, No.43) amendments: Regulation of the Cabinet of Ministers of 3 June 2003, No. 292 (LV, 6. June., No.85)

10. 4. Regulation of Cabinet of Ministers of 23 July 2003, No. 315 “Regulation On the Minimum Requirements for Education Programmes for obtaining professional qualification of a doctor.” (LV, 26. January., No. 109) 5. Rules on doctor`s specialities as approved by the Ministry of Health or Ministry of Welfare of the Republic of Latvia

11. Normative Enactments 6. Regulation of the Cabinet of Ministers of 28 September 2004 No.804 “Regulation on employment remuneration system for medical practitioners of state financed institutions and social workers”

12. State funded residentship education Centre for Professional Medical Education TENDERS Health Care Institutions with teaching rights Institutions of Higher Education Pretenders for Residentship GP Specialists

13. State Funded Residentship Education Ministry of Health Tender procedure for award of contract from state to conduct residentship education programme of specialist doctors Tender procedure for award of contract from state to conduct residentship education programme of family doctors Health Care institutions with teaching rights Institution of Higher Education Tender results Competition for applicants to residentship programmes Doctor admitted to residentship programme

14. Contracts Contract PartnersObject of Contract Ministry of Health Health Compulsory Insurance State Agency /Centre for Professional Medical Education Health care provider institution /Institution of Higher Education Funding of Residentship Programme Health Compulsory Insurance State Agency /Centre for Professional Medical Education !!! Resident  Posting after completion of residentship programme  Refund of invested resources in cases of ill founded failure to complete programme or failure to work for at least 3 years in accordance with posting Institution of Higher Education Health care provider institution  accredited education programmes- - managaement, - supervision, - evaluation of education quality, - document certifying education  Payment for teaching staff

15. Presently resident doctors in Latvia are: Full time employed doctors for the time period required to complete full training in the relevant specialty (Gailezers Hospital, P.Stradina UniversityHospital) Employment Contract with Hospital (Paying resident doctors may or may not conclude it) Remuneration for work (Salary? Scholarship?) Regulation of the Cabinet of Ministers No.120 Funds received pursuant to the Article 4.1. health care provider institutions and institutions of higher education use for : Remuneration of resident doctors` work. Employment contracts stipulate entitlement to remuneration level of the 15th category LVL 94 (after taxes appox. LVL 64) RSU: Resident doctor is a full time employed who spends part of his study time in health care institutions: hospitals, outpatient clinics, family doctors` clinics etc. or the purposes of undergoing practical training LU: residentship training is a postgraduate training of a resident doctor (doctor) in contractual employment relationship with a health care provider institutionin a health care provider institution with teaching rights or in an institution of higher education in medicine. At the same time a resident doctor is a student at Latvia University. Study contract Funds earmarked for education Contract with Health Compulsory Insurance State Agency /Ministry of Health that contains the person`s undertaking to engage in studies at residentship programme and provides for conclusion of employment contract and stipulates the persons` submission to the government posting System for 3 years after completion of Residentship programme Law on Education, Art.55 (4) Educatees have the rights to receive scholarships, credits, benefits and other type of material assistance following the procedure determined by the Cabinet of Ministers. Scholarship? (LVL 58,- from the scholarship fund of an Institution of Higher Education) Government procurement for education in residentship programmes is financed from state budget according to the annual law on state budget Approx. LVL 265,- (including resident octor’s salary/salary for work?/” substitution”) Funds earmarked for education

16. Resident doctor is a doctor (rights and obligations are determined in cooperation with Latvian Medical Association by adopting rules of profession for the regulated profession of a doctor) Full time employed Doctors for the time period required to complete full training in the relevant specialty Employment contract with hospital Doctor’s salary (in Latvia there are some 500 resident doctors) (every year starts ~176) Institution of Higher Education: resident doctor shall be deemed to be a part time student in a contractual employment relationship with a health care provider institution with teaching rights who is at the same time engaged in a postgraduate training in a health care provider institution with teaching rights or the institution of a higher education. The institution of a higher education organizes Evaluation of knowledge and only exercises control over the practical training (through the head of the residentship programme by way o f weekly visits,counselling, control etc.) Study Contract Money earmarked for education Contract with Professional Education CenterHealthCompulsory Insurance State Agency / Ministry of Health and undertaking to submit oneself to the posting by the Ministry of Health that has to be given prior to the commencing of a residentship programme Scholarship? (from state budget funds that are assigned for education in residentship programmes) Government procurement for resident doctors` education is financed from state budget according to the annual law on state budget LVL 265 (excluding resident doctor’s “salary” altogetheor providing for certain scholarship) Paying resident doctors also conclude employment contracts and are salaried, but paying only for their theoretical part of education

17. Contracts Contract PartnersObject of Contract Resident doctor Health care provider institution / Institution of Higher Education Employment contract (funded by state) Resident doctor Institution of Higher Education Fulfilment of obligations on the part of persons admitted to the residentship programme Health Compulsory Insurance State Agency Resident doctor Conditions for remuneration of funds invested in education (in 5 years)

18. Article 26 (1) of the Medical Treatment Law Medical practitioners who have been certified and registered in the register of medical practitioners may independently engage in medical treatment within their competence (as amended on 8April 2004) + (amendments of 27 May 2004) (2) The persons that have completed accredited continuous education programme (specialization? postgraduate training?) that is a continuation of a previous secondary professional or higher medical education in the form of specialization or raising qualification may qualify for a certificate of a medical practitioner in a relevant specialty.

19. Article 33 of Medical Treatment Law (as amended 1June 2000) Persons studying at medical education institutions (perhaps also resident doctors?) within the framework of the educational programme may engage in medical treatment only under direct supervision of a certified medical practitioner.

20. Article 28 of Medical Treatment Law (as amended 1October 2000) The acquisition of a diploma of medical education shall permit the person, until certification in a specialty, to engage in medical treatment only under the supervision or guidance of such medical practitioner, as has a right to engage in the practice of medical treatment in the relevant field

21. The Status of a Doctor after University Doctor - trainee - without certificate Independent, but …. Works under supervision of a specialist Change of attitude during the years of independence Appealing for hospitals and specialists as a cheap labour force Registration with Latvian Medical Association? Contract with Health Compulsory Insurance State Agency?

22. IS A RESIDENT DOCTOR A MEDICAL PRACTITIONER? Medical practitioners – persons who have a medical education and who are engaged in medical treatment (Medical Treatment Law, 1 October 1997); Certificate of a medical practitioner – a document issued by the Latvian Medical Association, or the certification institution authorized by the Cabinet of Ministers that certifies the professional proficiency of the relevant person and indicates that the medical practitioner as a specialist is competent to independently engage in the practice of medical treatment (specialist practice) in the relevant field. (Medical Treatment Law, 1 October 1997);

23. The most pressing problems: Ambiguous legal status of resident doctors Resident doctor considered student according to Law On Institutions of Higher Education Rules of residentship of Institutions of Higher Education (RSU, LU) Contract with the Ministry of Health on postgraduate programme Medical Treatment Law Resident doctor considered employee according to Labour contract concluded with Health Care institution Law On Regulated Professions and the Recognition of Professional Qualifications Medical Treatment Law

24. Why this Project? Increasing dissatisfaction on the part of resident doctors with postgraduate education system and their low salary Limitations, flaws and contradictions in legislation and other documents defining status, rights and obligations of resident doctors Lack of legislation that would enable a competition on the labour market in other EU countries Government posting system of new doctors

25. The most pressing problems: Government Posting System Psychological factor Doctors degree at the age of 24 Certificate of specialist at the age of 28-30 Posting by the government from 28 till 31/33 Usefulness Most of the `posted` new specialists remunerate their postgraduate education in good faith Legality Provided for only in the Regulation No. 120 of the Cabinet of Ministers and contracts drafted pursuant to this Regulation by the Ministry of Health/ Health Compulsory Insurance State Agency with residentship training institution and labour contracts by some Health Care Provider Institutions

26. Dynamics of state financing of resident doctor`s Education

27. Presently only the rich can afford residentship training, others must be allowed to work

28. Project Needs to be done: Draft a rules for non-specialist doctors with the right of practice (rules for doctor`s profession) Draft a rules for the registration of a non-specialist doctors with the right of practice Summon a working group for the implementation of a project (in co-operation with Latvian Medical Association, Institutions of Higher Education, health care institutions, Ministry of Health/ Health Compulsory Insurance State Agency and with the help of legal experts)

29. Project Gains: Increase of salary according the current rate of increase for specialist doctors and pursuant the Regulation of the Cabinet of Ministers The right of independent practice in the chosen health care institution within the limits as defined in the Rules Become registered doctor in Latvia with the right of independent practice which is one of the necessary prerequisites enabling postgraduate training abroad

30. One cannot reproach the hungry for accepting a piece of bread from a stranger … … but perhaps it could be possible to arrange that one’s own people provide him with food!

31. Thank you for your attention!