The state should participate in regional hospitals, which would allow thinking on the national scale, at the same time, cooperation of local hospitals with large clinical university hospitals should be strengthened, Agnese Valuliene, Health Ministry’s State Secretary, said in an interview with LETA.

What do you think about this year's health budget, given the tight conditions under which it was drawn up and the priority given to security?

It is no secret that healthcare is one area where you can never have too much funding. On the other hand, despite the fact that this is a tight budget, additional funding has been allocated to the healthcare sector, including for medicines, oncology. Additional funding was found because health is a priority.

There are various reasons why there can never be too much funding for healthcare, and it is our circumstances that must be taken into account. We have an ageing society - as people age, they get sicker. This is one of the conditions that leads to a greater need for healthcare services and, consequently, to a greater consumption of funding. Additional funding is also needed because science is advancing, facilities and technologies are developing, new and innovative medicines are launched, which always cost more in the initial phase, and it is clear that everyone in the society wants to receive the best healthcare possible. That is why, with so much funding available, there will never be too much funding. We were also given funding in these circumstances, of course, not nearly to the levels that we asked for. We will continue to insist on our priorities and needs in future budgets and we will work to increase the healthcare funding.

Can you name the priorities that were not enough this year and where you would focus more in the future?

We also asked for funding to strengthen security in the sector, but hopefully we will find funding in other solutions in this area. We also asked for funding to expand access to services. Once again, the fact that additional funding was provided for oncology drugs and other medicines is already very good.

Speaking of priorities, Prime Minister Evika Silina (New Unity) recently announced that ensuring access to critical medicines is an important priority. How will the issue of access to critical medicines be addressed in the future, as the views of the pharmaceutical companies and the ministry differ?

There is no difference of opinion. Both the pharmaceutical companies and the state wish to ensure and supply medicines to the population. Opinions probably differ on the speed and the process by which we move towards the goal. As far as critical medicines are concerned, the country already has secured and purchased the range of medicines it needs in a crisis situation.

It should be stressed that we have several levels of crisis medicines. First, what we are always tirelessly saying is that there is the individual level, where we are each responsible as members of the society for having the medicines that we specifically need, for example, if we or our family members have a chronic illness and we need medicines for that, these should always be in the medicine cabinet at home.

What the state already provides is the material reserves. The national material reserve for medicines is maintained by the Emergency Medical Service (NMPD). Last year, the State already allocated EUR 1.5 million for this purpose, and this year, as well as for the next three years, funding has been earmarked to increase stocks.

There is also another level, where funding was already allocated during the Covid-19 for hospitals to purchase three months' supplies of medicines for their own use. So, we already have two levels of national coverage, let alone the individual level. Critical medicines are the additional layer that we are now working on.

A survey conducted by the research agency Norstat in early February discovered that the majority of people have not yet experienced the effect of the medicine price reform - a reduction in the price of medicines. Do you think the objective of the medicine price reform has been achieved?

We believe that the reform has definitely succeeded, we are on track and there is still a transition period. The data available to us shows that prices are coming down. The health minister has also said publicly that he has received information from his patients that they feel that the prices of medicines are falling. We will be able to provide more detailed information and data a little later, but already now, monitoring the 50 most purchased medicines in the country, the data show that the prices of a large majority of these medicines have decreased.

However, residents report the opposite effect, saying the cheapest medicines are becoming more expensive after the reform.

We did not hide at the start of the reform that the cheapest medicines were likely to see a slight increase in costs. In general, it was expected that there would be an increase in costs for medicines priced up to EUR 5, and a decrease in prices for other medicines. At the moment, we see that the price increases are minimal, but the price reductions are significant. I would not like to speculate on the figures, as they are only estimates at the moment, but we will certainly publish detailed data and an explanation later.

Availability of medicines specifically for patients with rare diseases also comes up in discussions. Has the reform also affected access to medicines?

I would say that this is speculation on the subject. There have been situations in the past where medicines have periodically been unavailable. There have also been situations in the past where certain medicines have been unavailable both in Latvia and in other markets, which are completely unrelated to the reform. Even before the reform, there were medicines that were not available on the market because of production interruptions or problems with the supply of active substances. The supply of medicines has definitely also been affected by the war and, before that, by the Covid pandemic. There have always been circumstances and reasons why certain medicines have not been available at certain times.

We always explain to the population and to professionals what the state's response is if a particular medicine is not available. The actions are very varied, starting with the simplest ones, such as looking for alternatives or other doses of the same medicine and adapting the therapy. There are also other options, for example, if a medicine is not registered in Latvia, then we work to get it registered, up to individual supply of the medicine. The country has solutions and algorithms, and they work, and for each case, especially if it is critical, it is known immediately what the action is, and there is cooperation with the associations, with doctors and with pharmacies.

Is there confidence that the introduction of single e-health appointment will reduce queues and make services more accessible, eliminating double appointments with doctors?

The single queue is being set up precisely to prevent double and triple appointments, so it will certainly have an impact. I would avoid answering such a strong statement that the single appointment will reduce queues, because queues are not longer simply because patients make several appointments. That is only one of the reasons, because, again, there is a lack of funding and also a lack of doctors. The introduction of the single appointment will certainly eliminate double and triple appointments, but will it eliminate queues completely? No, it requires more resources.

What opportunities do you see for improvement in the future of the Oncology Disease Reduction Plan? Will there be a separate section and proposals for patients with rare tumors?

As far as we know, colleagues are currently in discussions on how to finalize the plan. Whatever the plan, the main objective is to provide the patient with the necessary treatment so that the disease is diagnosed as soon as possible, especially in oncology, because then the chances of recovery are greater. Medicines must also be available, including innovative medicines, not only for rare tumors but also for all other patients. Treatment, accessibility and quality of services and rapid diagnosis are the things that we are basically focusing on. Colleagues are finalizing the plan and we will see the results of the discussions soon.

What is the progress on the regulation on medicines procurement? What opportunities are planned for hospitals in this area? Is it possible to allow hospitals to purchase medicines directly from the manufacturer?

We have developed a framework and discussions with industry are ongoing. The proposed amendments to the regulation provide for exactly that, so that medical institutions, hospitals, would be able to purchase medicines directly from the manufacturer. The amendments are not being proposed with the idea of excluding any player from the logistics, by no means, because everyone has a role to play in this system, but this should enable hospitals to obtain medicines more quickly in specific cases and for specific needs. You also raised the issue of unavailability of medicines earlier, so in such cases, it should be possible for those working in the system to go directly to the manufacturer to ensure that the medicines are available more quickly. Such amendments to the regulatory framework are currently being drafted and we intend to move them forward for approval.

You are also scheduled to discuss changes to the pharmacy operating rules. What changes are planned for the regulation of pharmacists?

We are still discussing this with the industry. I have to say that negotiations in the healthcare system and with the players in the healthcare system are always very exciting because each player knows how to do things better and we agree that everyone has their own reasoned proposals. But when we sit down around the table, opinions often clash and we have to find a common ground.

In this case, we are talking about what other services pharmacists could be allowed to provide in pharmacies. I will not speculate at the moment on what those services will be. We have to wait for the outcome of the negotiations. There have been more than one discussion and we are now in a mature position to take the planned changes forward for approval.

No one is in any doubt that we need to extend the competences of the professionals working in the healthcare system or the right to perform other services. In this respect, we are already talking about expanded competences for nurses in general care, about pharmacists providing additional services in pharmacies. It is also definitely a change of habits, a change of mindset.

How will the ministry continue to support Ukraine? Recently, there was a draft decision to send EUR 67,000 worth of medical supplies to Ukraine.

We have been in close contact with our Ukrainian counterparts from day one and we are continuing to do so. This particular shipment is also the result of direct contact between our Emergency Medical Service and our Ukrainian colleagues. We have a list of what we need from Ukraine and then we see what we have and what we can deliver. On the healthcare side, the rehabilitation services that we are providing to Ukrainian soldiers are continuing. There has not even been a discussion that anything might change in the way we are providing support to Ukraine to the best of our ability.

You recently took over the Daugavpils Regional Hospital. How do you assess the current situation there, both in terms of financial and staffing support?

I have to say that the current board had already done its work to stabilize the financial situation of the hospital. Of course, the injection of public capital has also helped, including to cover debts which would otherwise have been more difficult to do. I am now convinced that both the board and the ministerial colleagues who are responsible for the company have a very clear vision of what needs to be improved and put in order in the hospital, so that we do not slip back into the hole, but move in the direction of financial development. Stabilization measures have therefore already been taken. Processes are under way, and I would remind you that the Cabinet of Ministers, when deciding on the aid, also recognized that it was necessary to assess the responsibility of both the previous managers and the other parties involved as to why the hospital was in this situation.

For my part, the task is to draw up a clear action plan on what has been found, and then to take the next steps with specific deadlines in the foreseeable future on how we will put the financial situation, supervision and the transparency of remuneration in order.

Does the ministry have confidence that other regional hospitals are being managed carefully and will not require a quick intervention and takeover as in the case of Daugavpils?

We would like to believe so. In all hospitals, the majority of funding comes from the state for the provision of public health services.

We are also planning discussions with other municipalities to allow the state to become involved in regional hospitals. As for other hospitals, the state would not be involved because it is in a critical financial situation, but we believe that with the state involved in the management of important and critical hospitals, a more national view can be taken of the management and delivery of services to the population. It is logical and understandable that regional hospitals and local authorities want to provide the best and most accessible care for their population. However, if we look at quality of service issues, not all the services that are available in a particular municipality are always of the right quality for the population, because there are simply not enough facilities to provide the service. These are very related issues that we also want to discuss with the municipalities and give our perspective on why we think that critical hospitals should have public participation. I am not saying fully state-run, but with state participation.

One of the "sore" topics in the regions is childbirth services. Is there no plan to centralize this area more and more in the larger hospitals in the near future?

This is not a clear-cut question. We also see the example of Finland, where women often travel 200 kilometers to give birth, but there is transport, there is the possibility of staying longer, there is the possibility of waiting for the birth, because when the labor has already started, it not sensible to travel 200 kilometers. In the future, if we are talking about quality criteria and where the service should be, then we must always think about the existence of all the other services in the country, including how to get the patient to the service.

For childbirth, all services must be of the highest quality and, of course, this issue is more sensitive for people who live further away from the regional center. The population then probably does not understand why the service is not available locally, and our task is to explain that this can sometimes even be a danger, because the service may be of poor quality. Childbirth is a high-risk service, sometimes it is necessary to intervene quickly, urgently, because there are all kinds of complicated cases. There has been widespread media coverage of cases where, unfortunately, a mother or a newborn dies in childbirth because there was inadequate emergency care.

Discussions are ongoing and we are very much looking forward to having a set of criteria that will guide us in the future in planning the distribution of services in the country.

Why did I mention the Finnish example? Even when we have a set of criteria, we will have to see how and where we can apply them. We absolutely need criteria, even if someone is opposed to that. We need to work towards a safe and quality service for citizens. At the same time, of course, there is a much greater risk of 'cutting off' a service somewhere, not enabling the citizen to receive the service where we have planned it. It is all very interconnected and needs to be seen in the context. You cannot close a maternity ward without anticipating how a woman will get to the point of service when she needs help during labor.

People in regions also complain about access to dental care for children. How to address this issue?

Funding is one part, but the other, even more painful, is the lack of specialists and often the reluctance to work in pediatric dentistry. We have already raised the tariffs for children's dentistry, precisely because of how specific and necessary it is, and indeed a very sensitive and painful issue. What we are already doing is mobile dental teams, at least to help in this way in providing a service to children as and when they need it. There is no quick answer to this, the tariff has already been raised, and work is being done to motivate specialists to apply to work directly with children and to work in the public service.

I am not getting off the subject, but health literacy is also an important issue. Experts say that children come to the dentist with extremely decayed, bad teeth, and this is a matter of home hygiene. The issue of ignorance and neglect of dental health is extremely important. We are working on this, but we do not have the magic wand to create enough specialists. If funding is a problem, then it can be solved, but we need specialists to provide this service, and that also takes time.

What infrastructure improvements can be expected in municipal hospitals in the coming years with EU support?

We are currently in the selection process and almost EUR 300 million are available in the current funding period. These are large sums and this is the first year that secondary outpatient facilities have also been funded. The funding has been distributed to hospitals at all levels, to general practitioners' practices and also to mono-profile facilities.

If we are talking about the major projects that we are currently working on, I would like to mention the 'Hospital at Home' project. This project has already been granted funding, including from the foundations, to be implemented by the Riga East Clinical University Hospital in close cooperation with local authorities. The concept of the project is that the patient does not stay and receive treatment only in hospital, but can be at home, even in a remote region, and is provided with constant supervision by medical staff.

However, with regard to regional hospitals and cooperation, the sore point is the transfer of patients and which level of hospital the patient is treated. This is an extremely important issue in order to match hospital capacity and resources and really provide the patient with the treatment that he needs at the time. At the moment, there are good individual collaborations between our clinical university hospitals and regional hospitals, including the Daugavpils regional hospital, but this area should certainly be developed further. We want to look at cooperation in even greater depth when we talk in the future about a change in the status of clinical university hospitals and a possible change in governance.

What can you tell about cooperation of regional hospitals with university hospitals? In what areas should it be developed?

Of course, hospitals work together and do not live in their own world. It is true, however, that cooperation, if it is not regulated and defined, depends on specific people in specific institutions. That is just the way it is. If the staff, including the managers, the doctors, are focused on cooperation, then, of course, cooperation is much more successful.

We are working on establishing the hospital network in legislation. I would like to avoid the word 'compulsory', but it is clear that there must be cooperation. As we are a small country, we are in a very good situation because we know each other, we are close enough to have such cooperation. There is cooperation, but such a framework would probably give more authority, including to the methodological centers, to the management of resources.