3. Strengthening Latvia’s secondary and tertiary prevention policies

Abstract

Secondary prevention aims to reduce the morbidity of a disease or injury that has already occurred through early detection, and putting in place actions to halt or slow the progress of the disease, while tertiary prevention manages the disease once it has occurred to prevent complications. In Latvia, there are some clear shortcomings when it comes to secondary and tertiary prevention, with low rates of cancer screening coverage, and high rates of complications from chronic diseases such as diabetes. Some improvements should be made to vertical prevention programmes, for example strengthening the cancer screening invitations system(s). Much of the potential to improve secondary and tertiary prevention lies in health system strengthening – investing in the health workforce, strengthening GP responsibilities and capacities, creating chronic disease management pathways for care delivery – and eliminating inefficiencies, in particular better aligning payment schedules with best practice patient pathways and chronic disease care.

3.1. Introduction

Secondary prevention aims to reduce the morbidity of a disease or injury that has already occurred through early detection, and putting in place actions to halt, slow or treat the progress of the disease, while tertiary prevention manages the disease once it has occurred to prevent complications or disease progression. In Latvia, there are some clear shortcomings when it comes to secondary and tertiary prevention, with low rates of cancer screening coverage, and high rates of complications from chronic diseases such as diabetes, high cholesterol or hypertension. Some improvements should be made to vertical prevention programmes, for example strengthening the cancer screening invitations system(s). Much of the potential to improve secondary and tertiary prevention lies in health system strengthening – investing in the health workforce, strengthening primary care responsibilities and capacities, creating chronic disease management pathways for care delivery – and eliminating inefficiencies, in particular better aligning payment schedules with best practice patient pathways and chronic disease care.

This chapter begins by examining the total burden of disease in Latvia, focusing in particular on high burden diseases that are known to be amenable to secondary prevention strategies such as screening and health check-ups (notably cancer, heart disease, and diabetes). Secondly, the chapter describes the existing secondary and tertiary prevention systems in place in Latvia, including both vertical screening programmes such as for breast and cancer care, and screening, health check-ups and disease management delivered through primary care settings. Finally, the chapter highlights key areas for strengthening Latvia’s secondary and tertiary prevention approach, giving recommendations for policies that represent good value-for-money, and will have a positive impact on the health outcomes of the Latvian population.

Box 3.1. What are secondary and tertiary prevention?

There are a range of different ways that secondary and tertiary prevention can be defined and distinguished, and this chapter follows the definitions set out here. Secondary prevention is considered as covering all forms of early detection and screening, while tertiary prevention includes disease management and early treatment to prevent poorer health outcomes.

Secondary prevention aims to reduce the morbidity of a disease or injury that has already occurred (Baumann and Ylinen, 2017[1]). This is done through an early detection, when its detrimental effects are still limited, to be followed up with treatment to halt or slow its progress. Secondary prevention includes activities such as screening programmes for specific diseases (e.g. mammograms to detect breast cancer or colonoscopies to detect colorectal cancers) and health checks covering a range of risk factors and morbidities. Robust secondary prevention, when well joined-up with other health system processes, can help funnel patients towards effective disease management approaches. Interventions to control risk factors for chronic diseases, for example daily, low-dose aspirins and/or diet and exercise programs to reduce risk of heart attack or stroke for patients with hypertension, are sometimes included as part of secondary prevention strategies.

Tertiary prevention aims to lessen the impact of illness on a person’s life and functioning, prevent worsening of symptoms or development of secondary complications. Tertiary prevention is usually focused on helping people to manage long-term, often complex health problems or injuries, such as chronic diseases or permanent impairments, to maximise daily functioning, quality of life, and life expectancy. Tertiary prevention covers interventions put in place to treat, halt or slow down progress of a disease, including programmes such as cardiac or stroke rehabilitation programmes, chronic disease management programmes, or support groups to support quality of life.

For lifestyle diseases such as diabetes and heart disease effective tertiary prevention or ‘disease management’, following detection, can slow the progression of the disease (Baumann and Ylinen, 2017[1]). Interventions to prevent the onset of disease once warning signs are observed, for example weight loss support for pre-diabetic patients or pharmaceutical management of risk factors such as high blood pressure, can also be considered to be part of tertiary prevention efforts. Disease management is also included as part of effective tertiary prevention, such as diabetes disease management which can avoid complications of the disease, for example vascular complications of diabetes. Slowing disease progression is an advantage to the patient, but also to the health system; effective disease management in primary care or dedicated programmes can avoid costly admissions to hospital (Van Loenen et al., 2016[2]; OECD, 2017[3]; OECD, 2019[4]). Ambulatory Care Sensitive Conditions (ACSCs) are conditions for which effective and accessible primary care can generally prevent the need for hospitalisation, and include diabetes and COPD.

3.2. Burden of chronic disease in Latvia

Non-communicable diseases are the leading cause of death in Latvia, in particular ischemic heart diseases, cancer, and cerebrovascular diseases. Additionally, the rate of treatable mortality in Latvia is twice the EU average. This burden of disease points to a need to improve primary prevention efforts, as detailed in Chapters 1 and 2, but also scope to scale-up chronic disease management and early intervention.

3.2.1. Non-communicable diseases are the leading cause of death in Latvia

Non-communicable diseases are the leading cause of death in Latvia, with circulatory diseases (56%) and cancers (21%) accounting for the greatest number of deaths in 2015 (OECD, 2020[5]) (Figure 3.1). In Latvia mortality from ischemic heart diseases, cancer, and cerebrovascular diseases was significantly higher than the OECD average (Figure 3.1); mortality from ischemic heart diseases and cerebrovascular diseases in particular was more than twice the OECD average (OECD, 2020[5]).

Figure 3.1. Main Causes of Mortality in Latvia, 2015

Figure 3.2. Main Causes of Mortality, Latvia and OECD Average, 2017 or latest year¹

Despite the decreasing trends mortality rates due to cardiovascular diseases (mostly ischaemic heart disease and stroke) in Latvia are amongst the highest in the EU, and well above the OECD average (OECD, 2019[7]; OECD, 2020[5]). Mortality from cancer has increased slightly in Latvia, but remain below the OECD average (Figure 3.3).

Figure 3.3. Main causes of mortality over time in Latvia and the OECD average, 2000-15

3.2.2. Treatable mortality in Latvia is amongst the highest in the EU

‘Preventable mortality’ are deaths that could mostly be avoided if effective public health and primary prevention interventions are in place; ‘treatable mortality’ refers to deaths that could be avoided if effective health care interventions, including screening and treatment, were in place. Latvia has high rates of both preventable mortality (second highest in the EU) and treatable mortality (third highest in EU) (OECD, 2019[7]). Compared to OECD peers in 2015, Latvia has the second highest rate of treatable mortality (157.0 deaths per 100 000 in Latvia, compared to the OECD average of 77.2) and the second highest rate of preventable mortality (157.0 deaths per 100 000 in Latvia compared to the OECD average of 77.2) (OECD, 2020[5]).

The rate of treatable mortality in Latvia was 203 per 100 000 population, more than twice the EU average of 93 per 100 000 population in 2016 (Figure 3.4). The rate of treatable mortality in Latvia was particularly high for ischaemic heart diseases and stroke; despite falling stroke and ischaemic heart disease mortality rates there is clear room for improvement if Latvia is to catch up with EU and OECD peers.

Figure 3.4. Rates of treatable mortality in the EU, 2016

3.3. Screening, health checks, and disease management approaches in Latvia

This chapter focuses on secondary prevention interventions – screening, health checks – and tertiary prevention – disease management – for chronic conditions that are both amenable to secondary and tertiary prevention, and represent a high burden of disease in Latvia. In particular, this chapter focuses on preventive care and early intervention for cancer, preventive care, early intervention and disease management for cardiovascular disease, and disease management for some chronic conditions that are well amenable to management in primary care, notably diabetes.

This section describes the screening, health checks, and disease management approaches that are already in place in Latvia, focusing on cancer, cardiovascular disease, and diabetes.

3.3.1. Cancer screening and detection in Latvia

In Latvia, a national cancer screening programme is carried out by the National Health Service, in line with Cabinet Regulation No. 555 of 28 August 2018, Procedures for the Organization and Payment of Health Care Services. Women between 25 and 70 years of age should receive an examination of cytological smears from the cervix and posterior vault (Leishman – Nohta combined microscopy of stained preparation). Further, depending on screening results women receive HPV test or biopsy for cervical cancer once every three years, women aged between 50 and 69 should receive mammography screening every second year, and the entire population between age 50 and age 74 should receive faecal immunochemical test once a year (Latvian Government/OECD, 2019[8]). Screening frequencies are well aligned with those of other European countries (Altobelli and Lattanzi, 2014[9]). For breast and cervical screening, invitation letters are sent out to eligible females by the National Health Service, while colorectal screening is left to General Practitioners (GPs) to encourage or deliver opportunistically. Cervical cancer, breast cancer are fully funded, with no co-payment; for colorectal cancer screening tests there is a co-payment for the GP visit unless the screening is undertaken during the specified annual preventive visit.

According to Latvian data, in 2018 43.8% of women in the target group participated in cervical cancer screening, 42.1% of women in the target group participated in breast cancer screening and 16% of target population participated in colorectal cancer screening (Latvian Government/OECD, 2019[8]) (data available from survey “Health Behaviour Among the Latvian Adult Population”, (Latvian Government, 2018[10]).

Compared to OECD peers, Latvia does not perform well when it comes to rates of cancer screening. Screening rates for cervical (Figure 3.5) and breast screening (Figure 3.6) were in the bottom third of OECD countries. Latvia’s colon cancer screening rates, based on rates of lifetime faecal occult blood test, were above the OECD average based on the latest available 2014 data (Figure 3.7).

Figure 3.5. Cervical cancer screening coverage, 2018 or nearest year

Figure 3.6. Breast cancer screening coverage, 2018 or nearest year

Figure 3.7. Rates of lifetime screening for colon cancer, 2014

Though rates of cancer screening in Latvia are low compared to OECD peers, they have been increasing. In Latvia rates of breast cancer screening nearly doubled from 21.1% coverage in 2009, to 42.1% in 2018. Cervical cancer screening rates increased even more significantly from 14.9% to 42.8% across the same period (data age-sex standardised to the OECD population) (OECD, 2020[5]).

This increase is likely in part due to national efforts to increase screening across the last decade. For cervical cancer, organised screening was first implemented in 2009, before which point screening was opportunistic though encouraged (Vīberga and Poljak, 2013[11]). Since 2011, the National Health Service has sent invitation letters to all women aged 25 to 69 years, identifying the target population through a central screening database to which General Practitioners also have access (ibid). Since 2010 the HPV vaccination has been available to girls aged 12-14 in Latvia (Patel et al., 2017[12]).

In theory, General Practitioners (GPs) and nurses in GP practices and practice assistants should have access to the screening database, be able to see which of their patients have received screening invitations but not followed up. However, it is not clear how often this occurs, with GPs reporting that their existing patient lists and appointment demands are too intense to make time for proactive screening follow-up (Vīberga and Poljak, 2013[11]). GPs can undertake cervical screening, but few do; an estimated 1% of GP`s take the cytological material by themselves and send it to laboratory). Latvia has been experimenting with ways to increase engagement of GPs with cancer screening activities, including cervical screening.

A population-based mammography screening programme was also launched in 2009 in Latvia, offering biennial mammography to women aged between 50 and 69, through around 25 radiology units across the country (Hegmane and Eglitis, 2011[13]). Again, invitations to screening are sent through the National Health Service, and GPs can access information on whether their patients have had a mammography. It is unclear how many GPs are actively following up with eligible patients or even opportunistically encouraging patients to get a mammography; the only available data on GP engagement comes from those GPs who participated in a pilot project which awarded a fee for increasing the rate of cancer screening amongst their registered patients. This pilot, intended to improve the responsiveness of the population to cancer screening invitations and thus early diagnosis of cancer, was launched in 2018. GPs were given an additional fee for increasing the response to cancer screening among their registered patients. In 2018, 424 (approximately one-third of all Latvian GPs) applied for the pilot project, of whom 50% met the set criteria for the implementation of cervical cancer preventive examinations. In 2019 483 GPs applied, of whom 37% met the set criteria for the implementation of cervical cancer preventive examinations.

For at least a decade, since the introduction of three national cancer screening programmes (breast, cervical, colorectal) in 2009, the Latvian Government has been seeking to improve participation in screening programmes (see Box 3.2). Despite increases in participation rate, the rate of screening for breast and cervical cancer still remains well below the OECD average, and well below the target rate set by Latvia.

Box 3.2. Efforts to improve cancer screening rates in Latvia

Latvia has taken some steps to increase cancer screening coverage, notably introducing information campaigns, educational seminars, and a pilot programme incentivising GPs to follow-up their patient’s involvement of their patient in screening programs. While the increase in screening rate between 2009 and 2018 for breast and cervical cancer has been impressive, these programmes have not been evaluated for their direct impact on screening.

Information campaigns

Public awareness campaign around cancer screening have been organised twice, in 2017 and in 2019, organised by The Centre of Disease Prevention and Control, The Ministry of Health and The National Health Service. The purpose of both campaigns was to improve cancer awareness and screening rates in country.

During the information campaigns several activities aimed at people aged 25 to 74 were carried out. These activities included in-person events, such as lectures in workplaces, and distribution of educational materials on ‘frequently asked questions’ to health professionals and in medical institutions. Other activities were focused on different forms of media impact, for example online expert discussions, collaborations with cultural ‘influencers’, celebrities, and cancer survivors, and advertising on TV, cinema, public transport, radio and internet portals, communication in social networks, educational articles in the printed and electronic media.

Educational seminars

From 2017 to 2019 The Centre of Disease Prevention and Control has been organising educational seminars in workplaces. The seminars are designed to raise awareness of cancer screening and to motivate them to attend preventive health check-ups. Since 2017, more than 1 000 people have attended these seminars, which include discussion of common oncological diseases, symptoms, risk factors, screening programmes, and the ‘myths’ about cancer.

Source: Latvian Government/OECD (2019[8]), Latvian Responses to the OECD Public Health Review Questionnaire.

3.3.2. Health check-ups for chronic disease and chronic disease risks

Basic health check-ups for chronic diseases, for example taking blood pressure or cholesterol, or a screening for cardiovascular disease based on age, family history, and risk factors such as body mass index (BMI), can help diagnose persons at-risk of chronic diseases, or diagnose chronic diseases in their earlier stages when they can be managed with fewer complications.

Several OECD countries have health check-ups for chronic conditions, usually targeted at particular populations, undertaken periodically for example every five years, and sometimes provided by health care professionals other than doctors. In Australia, for example, primary health physician can provide health assessment for people who are at risk of developing a chronic disease. This assessment is provided to people aged between 45 and 49 once if they have at least one risk factor (lifestyle habits or a family history) for developing a chronic disease such as type 2 diabetes or heart disease. The assessment is also provided to people aged 75 and over with an interval of 12 months or longer (Australian Government, 2014[14]; Australian Government, 2016[15]). In Estonia, health check ups and guidance are provided by family nurses for people aged between 40 and 60 with hypertension or diabetes (Habicht et al., 2018[16]), and in 2007, Korea introduced the National Screening Program for Transitional Ages, targeting people at age 40 and 66 (Kim et al., 2012[14]). In England, the NHS Health Check was introduced for people aged between 40 and 74 in 2009 and an invitation letter is sent every five years to those who do not already have diabetes, heart disease, or kidney disease or have not had a stroke, in order to screen them for the risk of developing chronic conditions including heart disease, stroke, kidney disease, type 2 diabetes, or dementia (available only for those above 65 and above). This check-up is often undertaken by a nurse or health care assistant ( (Gmeinder, Morgan and Mueller, 2017[18]; NHS, 2019[19]).

While too much screening can be an inefficient use of resources, and does not appear to improve equity of health outcomes, well-targeted screening can be an effective way to identify and manage chronic disease (see Box 3.3).

Box 3.3. Basic health checks for chronic diseases – costs and benefits

General health check-ups targeting the adult population aim to detect risky health behaviours and try to assess whether people are at risk of developing chronic conditions, such as cardiovascular diseases or diabetes. Activities carried out as part of these health check-ups can involve the establishment of the medical history of the patient, clinical examination, laboratory tests of blood (e.g. for cholesterol and glucose levels) and urine (e.g. for protein, erythrocytes, leukocytes, nitrite) and subsequent counselling based on examination and test results. Across the OECD, healthy condition monitoring programmes account for nearly half of all prevention spending (Gmeinder, Morgan and Mueller, 2017[14]).

Health check-ups are intended to identify people at risk of or suffering from disease, and intervene to prevent, manage, or treat disease. Some evaluations of national or regional health check-up programmes have found that they are effective at identifying disease risks: in an evaluation in the North of England two cases of high cardiovascular risk and a further case of hypertension were identified for every ten health checks performed (Lambert, 2016[15]); the introduction of the NHS Health Check in England was associated to significant but modest reductions in cardiovascular risk amongst high-risk individuals who were screened (Artac et al., 2013[16]; Robson et al., 2016[17])

However, there are some questions about the efficacy of health check-ups. A number of studies conducted in other countries suggest that population-based routine general health check-ups were not effective. A systematic review of 16 studies conducted in Denmark, Sweden, the United Kingdom and the United States found that general health check-ups did not reduce morbidity or mortality among adults while they increased the number of newly diagnosed cases. This systematic review also highlighted the problems such as false-positive result, which causes anxiety and leads to unnecessary follow-up tests, over-diagnosis and overtreatment, suggesting that a general health check-up could be harmful (Krogsbøll et al., 2012[18]). Some argued that studies in the review were too old, based on examples between the 1960s and 1990s, and the effectiveness of contemporary health check-ups may be different due to progress in medical technologies (Lauritzen, Sandbaek and Borch-Johnsen, 2014[19]). Nonetheless, based on these findings, Denmark put an implementation of health check-ups on hold (Krogsbøll et al., 2012[18]). A Cochrane Review including 17 trails that covered 251 891 participants found that general health checks were unlikely to be beneficial, and may lead to unnecessary tests and treatments (Krogsbøll, Jørgensen and Gøtzsche, 2019[20]).

Questions have also been raised about the cost-effectiveness of generalised health check-ups, i.e. those that do not target individuals with existing risk factors such as high BMI or family history of particular diseases (Si et al., 2018[21]). England’s NHS Health Check programme for all adults aged 40-74 every five years, for example, has had mixed evaluation. Some analysis finding that the way the checks were implemented was neither equitable nor cost-effective (Kypridemos et al., 2018[22]; Abdalrahman and Soljak, 2015[23]), and that optimal targeted implementation could improve both equity and cost-effectiveness, and adding other structural policies targeting cardiovascular risk could make a more substantial difference. Other analysis has suggested that while the NHS Health Checks were associated with only modest changes, for example a small reduction in BMI, this was sufficient to justify its costs in terms of QALYs gained and reduction in disease-related care costs (Hinde et al., 2017[24]). Economic modelling by the Public Health England suggested that the policy was both clinically and cost-effective (Public Health England, 2013[25]).

In addition, several studies suggest that population-based health check-ups may potentially increase health inequality. A study in Germany found that those with high risk factors and low socio-economic background are less likely to participate in population-based health check-ups than others, and the study suggested a need to develop a targeted health check-up (Hoebel et al., 2014[26]), and a similar trend was found in the Danish ‘Check Your Health Preventive Program’ (Bjerregaard et al., 2017[27]), and England’s NHS Health Check (Kypridemos et al., 2018[22]; Collins et al., 2020[28]). A systematic review of studies conducted in different OECD countries also found that uptake is low among those with clinical need and higher risk factors, suggesting that population-based health check-ups may in fact increase health inequality and a tailored and targeted approach is needed (Dryden et al., 2012[29]).

In Latvia, the main responsibility for health checks lies with GPs. GPs carry out preventive examinations of adults and children, cardiovascular risk assessment, as well as the cancer screening checks detailed in the previous section. Latvia does not have a national programme of health checks, put does have policies to incentives some specific tests; GPs should encourage all patients to perform the same test or screening in the same way, given that tests are not mandatory and are left to patient choice. An exception is preventive examinations for children under the age of 1, where the GP performs the compulsory examinations, and if the child fails to attend the prescribed exam, the GP or practicing nurse or assistant performs a home visit to the child. In 2018 around one-third of Latvia adults undertook preventive examinations, although it is not possible to establish which tests were in fact undertaken (Self-reported free of charge preventive health check-ups, data from survey “Health Behaviour among Latvian Adult Population”). GPs are able to recruit a second practice nurse if they have more than 1 200 adult patients or 600 patients under the age of 18 on their patient list, and these nurses are theoretically intended to focus on prevention tasks such as lifestyle advice and checks. In reality though, while GP practices can organise their own time and team working practices, the time of the additional practice nurse is often spent on activities other than prevention due to the heavy workload that many GP practices experience. Of course, it depends on how general practitioner organise his own and his team members’ work.

An internationally recognised cardiovascular risk assessment tool Systematic Coronary Risk Evaluation (SCORE) was introduced in Latvia in 2018, after development along with the Latvian Cardiologist’s Association. SCORE is administered by GPs for a small fee-for-service (FFS) payment for EUR 6.40 in 2019 (around five times the basic FFS payment for a GP visit, which is EUR 1.42), with the target of screening patients aged 40 to 65 every five years. GPs are able to calculate the risk of cardiovascular diseases using the SCORE method, which includes items on lifestyle, family history, medical history, age, blood pressure, and total cholesterol. Patients with existing cardiovascular conditions are excluded. The patient should then be provided with appropriate information on health management, for instance nutrition, and/or given a referral for further testing or care. 13 000 people were screened in 2019, and around 70-80% of GPs were estimated to have done at least one risk assessment as of 2019. Currently no reliable data on uptake of SCORE or how effective it is at identifying at-risk patients is available (use of SCORE began in mid-2018). However, anecdotal reports suggest that this risk assessment is a very burdensome process for GPs, and the FFS payment may not make the assessment worthwhile.

Diabetes screening should be carried out every three years for ‘at-risk groups’ aged 10 years and older, and every three years for persons aged 40 years and older even without additional risk factors. Again, screening is carried out by General Practitioners, but the fact that the screening is every 3 years means that it is not well-aligned with the SCORE screening for cardiovascular risk. Latvia also has a pay-for-performance scheme for General Practitioners, which includes some items on preventive activities (Box 3.4).

Box 3.4. General Practitioner pay-for-performance quality scheme

Latvia also has a pay-for-performance scheme focused on ‘quality criteria’ for General Practitioners, which includes some items on preventive activities. This compulsory scheme, which was introduced in 2013, includes annual targets in the domains of prevention, care for chronic conditions, and some routine services (OECD, 2016[30]). Originally established with 14 targets, this was since reduced to eight criteria. For example, cancer screening, and taking LDL cholesterol to monitor cardiovascular disease, were included as part of the pay-for-performance incentives for GPs in 2018.

However, there appear to be some limits to the extent that this pay-for-performance scheme is an effective mechanism for incentivising particular activities or performance. In the last two years less than 4% of GPs have achieved all eight of the targets – 52 GPs in 2018, and 46 GPs in 2019. Reports during the OECD research interviews in Latvia in 2019 suggested that the financial reward for achieving the quality criteria was insufficient given the extra effort that it demanded, and especially given that it would require a either additional hours or concerted shift away from other activities for GPs, who already report being under considerable strain (see Figure 3.8).

Overall, basic health checks and risk screening for chronic disease relies on General Practitioners, and predominantly on opportunistic screenings. However, there are clear challenges around this approach, as pressure on GP time is reported as being acute. Latvia has fewer practicing physicians and slightly more General Practitioners than the OECD average (see Figure 3.8), but is not amongst the countries with the fewest physicians. However, it should be pointed out that remuneration for physicians is amongst the lowest in the OECD when compared to the national average wage, in particular for GPs (see Figure 3.9). These low salaries reportedly contribute to some physicians working at least part of the time in the private sector, which reduce overall availability of physician time. Based on most recently available data, in 2014 Latvian GPs earned exactly the average wage, compared to GPs in neighbouring countries such as Estonia, where GPs earned between 1.6 and 2.4 times the average wage, or Lithuania, where GPs earn 20% more than the average wage. These higher wages in neighbouring countries, and in EU countries, have also led to high rates of out-migration of Latvian health professionals (OECD, 2016[30]). Nurses working in Latvian hospitals earned 80% of the average national wage, the second lowest rate in the OECD (Figure 3.9), and nurses in GP practices are reported to earn less.

Figure 3.8. Practicing Physicians and General Practitioners, 2018 or nearest year

Figure 3.9. Remuneration of General Practitioners and Nurses ratio to average wage, 2018 (or nearest year)

Proactive interventions for high-risk patients, for example nutrition advice for pre-diabetic persons, or lifestyle support for persons at risk for cardiovascular disease, do not appear to be widely available in Latvia.

The Latvian Pharmacists’ Association in cooperation with the Latvian Cardiology Association has developed a training programme for pharmacists about cardiovascular risk identification, self-monitoring measurements, documentation and guidelines (OECD, 2018[31]). Training was started in September 2015, and by 2017, 172 certificates had been issued to pharmacists for the successful completion of a training programme, which would suggest about 10% of Latvia’s pharmacists had received training (OECD, 2020[5]). The impact of training on the improvement of patient coverage will be evaluated in due course.

3.3.3. Chronic disease management in Latvia

The bulk of chronic disease management is the responsibility of General Practitioners in Latvia, and some of the challenges previously outline around workforce capacity likely also impact upon disease management capabilities. For routine care patients are expected to visit their named GP. However, it is not always clear whether GPs or specialists should be caring for patients with chronic diseases. For example, for diabetes the main burden of care for diabetes should lie with the GP, while for chronic obstructive pulmonary disorder (COPD) a patient can visit a GP, or a specialist, can be cared for in a specialist clinic. A cardiovascular disease pathway was introduced in 2019, and a diabetes pathway was introduced in 2020 which is a positive step forwards (National Health Service, 2020[32]).

OECD data suggests that there is room for improvement in chronic disease management in Latvia; avoidable hospital admissions for Asthma and COPD were well above the OECD average in 2017 (Figure 3.10). There is room for improvement still, too, when it comes to management of diabetes (wand reducing both admissions to hospital and amputation from complications).

Figure 3.10. Asthma and COPD hospital admission in adults, 2017 (or nearest year)

Figure 3.11. Quality of diabetes care, 2017 or nearest year

For diabetes management, the majority of activities – patient education, nutrition advice, some medication prescribing, foot scan – should take place at the GP level. There are 17 diabetes management cabinets in Latvia and 31 diabetes foot care cabinets, run by nurses, which give lifestyle advice, education, insulin support, and advice on disease management.

There are no caps on the reimbursement of visits to endocrinologists for patients with a diabetes diagnosis, and patients can self-refer to endocrinologists and have this visits reimbursed if they have a diabetes diagnosis. While data tracking the extent to which stabilised diabetic patients are making repeat specialist visits is not available, this is theoretically possible and arguably a potential source of inefficient use of specialists’ time, and representing poor value-for-money. There are limits on GP prescribing, although some of these for instance for on-patent drugs are not necessarily unusual as compared to other OECD countries. GPs can only prescribe metforminum and sulfonylurea group medicines, other medicines for Type 2 diabetes have to be prescribed or approved by endocrinologists in order to be reimbursed. Other limits on GP prescribing, for example on medication for cardiovascular disease were also reported.

It is notable that in 2017, Latvian consumption of anti-diabetics, anti-hypertensive, and cholesterol lowering drugs are the lowest, third lowest, and fifth lowest rates (DDD per 1 000 population) in the OECD (OECD, 2020[5]). There appear to be some gaps in reimbursement coverage for basic pharmaceuticals and medical devices for persons with chronic disease. For example, anti-coagulants are reimbursed only if a patient has previously experienced a stroke. Some pharmaceuticals for heart failure are subject to a 25% co-payment rate. Pre-diabetic drug treatment is not reimbursed.

Reports to the OECD during their research interviews in Latvia in 2019 suggested that patient compliance with pharmaceutical regimens was also a major challenge. For example, doctors report hearing fears of side effects from common medications such as statins, with a lot of information coming from a widely read magazine falsely warning of risks from medical treatments and pharmaceuticals.

3.4. Strengthening secondary and tertiary prevention

3.4.1. Improving health literacy for the population and health professionals should be a priority

Low levels of health literacy, misinformation around common medical care and pharmaceuticals, and possibly distrust of the medical system, appear to be relatively widespread in Latvia, and affect delivery of effective public health interventions across the board (see Chapter 1, 2, 4) (OECD, 2016[30]). Low levels of health literacy appear to be affecting chronic disease management capacities too, for example reported reluctance of patients to take ‘preventive’ pharmaceuticals such as statins. In general, people with low overall health literacy who also have a chronic disease also appear to know less about their disease, likely complicating chronic disease management (Gazmararian et al., 2003[33]; Dunn and Conard, 2018[34]; van der Heide et al., 2018[35]; Moreira, 2018[36]). Health literacy amongst health professionals may also need to be improved, for example underscoring the efficacy of generic pharmaceuticals and insuring that inaccurate information is not being shared with patients.

In Latvia increasing health literacy through patient education, education for health care professionals (see also Chapter 4), and making easy-to-understand health information broadly available should be a priority, and does not necessarily entail significant resource investments (see Box 3.5). Indeed, health literacy programmes in schools have been found to represent good value for money (Mcdaid, 2016[37]). Improving general population health literacy can also have positive impacts for patients with chronic diseases can help individuals better manage their condition, including necessary treatment or control protocols and behaviour modification, and improve shared decision making with health care professionals (Dunn and Conard, 2018[34]; Poureslami et al., 2016[38]; van der Heide et al., 2018[35]).

Box 3.5. Promoting population health literacy

Three approaches can be taken to improving health literacy, all of which are complementary: improving individuals’ health literacy; improving health professionals’ health literacy and communication skills; and making generally available health information easier to access and understand.

There is a strong relationship between good general literacy and numeracy, and good health literacy, so strong education systems and health education for children are a key starting point for good health literacy in later life. Many OECD countries, including Latvia, include health education as part of the school curricula, and evidence suggests that targeting younger population helps build healthy habits and skills. Health literacy training can also be targeted as part of disease self-management skill building. For example, the Evivo international programme “Devenir acteur de sa santé” (i.e. To become an actor of its own health), is based on Stanfords’s Chronic Disease Self-Management Programme. It consists on a standardised course programme that teaches basic skills to manage the challenges related to disease and health. This programme has been successful in supporting individuals’ autonomy in managing their own health and has been adapted and used in countries including Austria, Switzerland, France, Ireland, and Finland.

Improving health professionals’ health literacy and communication skills can include training health professionals to avoid medical jargon in oral and written communications with patients, eliciting questions from patients, asking after patient’s concerns, prioritising ‘need-to-know’ information and insuring that the patient has understood these key points, and recommending the use of medical interpreter services in the case of linguistic barriers. Some countries have introduced communication toolkits to help health professionals adapt their communication to patients’ health literacy level. In Canada, the “Easy Does It! Plain Language and Clear Verbal Communication”, is a training manual developed for health providers carrying advice and stories on how to communicate with patients to improve the quality of care.

Finally, making easy-to-understand information available in written forms, for example brochures, websites or even phone text-message services, is one of the most common ways to increase knowledge around health issues. Web-based interventions provide vast amounts of information, which can be easily updated, and easy for the information consumer to tailor their search for information. Ensuring that accurate information is the most easily available is also key, for example that government-created information is easily found when conducting a search online and that populations are not led towards false or misleading information. One study in 18 Latin American and Caribbean countries – including Mexico, Chile, Colombia, Costa Rica, Mexico and Peru – found the probability of finding information of national health authorities among the top ten results on Google was less than 7%. Additionally, for more than half of the countries, information was not a top result in Google. Several countries also have developed guidelines and distribute written information including infographics and posters (e.g. Australia) or comics (e.g. France, i.e. SanteBD) that provide easily readable health related information to different stakeholders, including disabled individuals.

Source: Moreira (2018[39]), “Health Literacy for People-Centred Care: Where do OECD countries stand?”, OECD Health Working Papers, No. 107, OECD Publishing, Paris, https://doi.org/10.1787/d8494d3a-en

3.4.2. Latvia should strengthen cancer screening with pre-filled appointment times

Cancer screening stands out as an area where significant improvements shuold still be made in Latvia, specifically for breast and cervical screening, for which rates are amongst the lowest in the OECD despite improvement over the past decades.

It is clear that considerable efforts have been made to increase both breast and cervical screening, from public campaigns to encouraging GPs to reach out to patients directly, centralising the screening invitation information system, and making mobile mammography an option in rural or under-served areas. Sending a personalised letter and following up with an individual phone call are consistent with evidence of best practice (Segura et al., 2001[40]; European Commission, 2018[41]), and Latvia has been encouraging GPs to follow up with women in the target group who have not attended screening. However, capacity of GPs and GP practice nurses is already clearly stretched. Latvia may wish to consider whether other health professionals, for example pharmacists, could be involved in personal follow-up calls to screening invitations. At the same time Latvia should consider including a pre-arranged screening appointment time and location in invitation letters, an approach some other OECD countries have found successful (Box 3.2), either in the first screening invitation or in a follow up to persons who have not responded to the first invitation.

Additionally, including additional information in languages other than Latvian, alongside the invitation letter which is legally required to be sent in Latvian, would help accessibility for the large population who are not native speakers of Latvian.

Box 3.6. Increasing response rates to breast cancer screening invitations using pre-arranged appointments

In countries including Denmark, Finland, Germany, Ireland, Italy, the Netherlands, Spain, Sweden and the United Kingdom, mammography screening invitation letters include a fixed appointment date (OECD, 2019[42]). In these countries women in the breast cancer screening target group received a letter, or a follow up letter after a first missed appointment, with a pre-arranged date, time and location for screening already filled out. This approach is also consistent with European Commission Initiative on Breast Cancer Guidelines, which recommend that women are invited to breast cancer screening with a letter including a fixed appointment, followed by a phone or written reminder (European Commission Initiative on Breast Cancer, 2019[43]).

A randomised control trial in England found that women who did not attend their first offered appointment and were invited again for breast cancer screening with a letter with a pre-arranged time were nearly twice as likely to attend screening than women in a control group who received an invitation letter with a telephone number to call to book their new screening appointment (Allgood et al., 2017[44]).

3.4.3. Promote chronic disease management through organisational and payment incentives

To improve outcomes for people with chronic diseases in Latvia, who represent a significant proportion of the overall disease burden, it will be critical to strengthen chronic disease management. This should include coordinated and proactive interventions for people identified as at-risk of chronic diseases, for example pre-diabetic patients, comprehensive support for disease management and self-management for controlled chronic diseases, and high responsiveness in the event of disease complications. Improving chronic disease management should also be seen as a way of improving efficiency. Timely interventions in the pre-disease period can stop the progress of a condition and reduce a patient’s need for care. Effective chronic condition management can reduce complications which can be very costly, both in terms of more intensive specialist support including hospital stays, and increased disability which can take people out of the workforce earlier in their life course.

Latvia can look to strengthen chronic disease management in a three-step process, that could be pursued simultaneously or incrementally depending on capacity, and whether it is possible to undertake some pilot projects in the country:

Development of clinical guidelines or disease management pathways;
Development of chronic care management programmes led by dedicated multi-disciplinary teams;
Development of bundled payments for chronic conditions.

Development of clinical guidelines or disease management pathways

Chronic disease management pathways, or clinical guidelines, should be available for all high prevalence chronic diseases, to give guidance to health care providers and patients over expectations of the care that should be delivered and received. Latvia introduced a disease pathway for cardiovascular disease in 2019, and a diabetes pathway in 2020 (National Health Service, 2020[32]). This represents a very positive step towards developing best practice guidelines for chronic disease care. For the moment these pathways are focused on information for General Practitioners, but could be expanded to integrate other care providers (for example specialists, or patient-support groups), and be produced in a patient-facing format.

Chronic disease pathways, which could be produced in both patient-facing and clinician-facing formats, should clearly establish the professional responsibilities of health professionals at different stages of disease. These pathways can be used to set quality expectations for chronic diseases such as diabetes and cardiovascular disease, and standardise quality of care across Latvia. The pathways can also be used to clarify expected roles for different care providers. For example, it does not seem necessary that stable diabetes patients regularly see specialist endocrinologists, but rather they could be managed by GPs.

A simple care pathway for diabetes, from the Czech Republic, can be found in Figure 3.12. Other countries, for example England (Figure 3.13) have developed more complex pathways which include expectations at different stages of the disease, the roles for different care providers, key interventions and target outcomes. England’s ‘NHS RightCare Pathway: Diabetes’ includes, for example, an expectation that care planning and an annual review take place for patients with both Type 1 and Type 2 diabetes, and the Pathway includes links to supportive documentation to help with care planning. In England, the expectation is that a lot of diabetes care is provided by multidisciplinary teams in community care settings, and the Pathway includes details of the services that the team would usually provide (patient education, pregnancy advice, foot protection team).

Figure 3.12. The Czech Republic – care pathway for patient with type 2 diabetes

Figure 3.13. Diabetes pathway in England – NHS RightCare Pathway: Diabetes, summary table

Having established clear chronic disease management pathways, there is a need to ensure that other levers within the system are effectively aligned with the pathway. This includes aligning payment and reimbursement incentives, as well as ensuring that health professionals have the tools and capacities they need to undertake the responsibilities expected of them. For example, when it comes to diabetes, more limits on frequency of specialist visits, or limits to reimbursement for visits without a referral, could be introduced. At the same time, GPs would need to have the capacity to take on the main responsibility for diabetes management especially for stabilised patients, including ensuring the capacity to do blood sugar testing in all practices, and prescribing a full range of therapeutic pharmaceuticals.

Development of chronic care management programmes led by dedicated multi-disciplinary teams

Disease management programmes (DMP) have long been a recognised best practice approach for chronic diseases (Box 3.7). Chronic conditions are frequently complex to manage, at risk of a range of complications, and such programmes can offer comprehensive care to patients tailored to their disease. For example, a disease management programme for diabetes could offer diet and exercise support to help patients control their blood glucose levels and reduce their BMI, group sessions focused on education or peer support, and regular scheduled check-ups (Box 3.7).

Box 3.7. Disease Management Programmes (DMP)

Definitions of disease management (programmes) vary substantially. Common features are: (1) an integrated approach to care/coordination of care among providers, including physicians, hospitals, laboratories and pharmacies; (2) patient education; and (3) monitoring/collecting patient outcomes data for the early detection of potential complications. DM programmes do not normally involve general coordination of care. They also not normally include preventive services such as flu vaccination.

Source: (Knai et al., 2014[47])

Disease management programmes have been found to be effective for a range of chronic conditions, including depression, heart failure and diabetes (Knai et al., 2014[47]). A review of systematic reviews or meta analyses found positive impacts of that disease management programmes: for chronic heart disease DMPs contributed to reducing health care use and mortality; DMP for diabetes improved functional status and clinical outcomes and sometimes reduced health care use; for COPD functional status and clinical outcomes were improved along with some reduced health care use; and DMPs for depression improved functional status and clinical outcome, quality of life, and patient satisfaction (Knai et al., 2014[47]).

In Germany, disease management programmes are a primary way of structuring care for people with common and costly chronic conditions, follow a coordinated approach to treatment, following evidence-based guidelines, introduced as a way of improving quality and efficiency and reducing fragmentation in care (Erler, Fullerton and Nolte, 2015[48]; Busse, 2004[49]). German DMPs exist for breast cancer, type 1 and 2 diabetes, coronary heart disease, asthma and COPD. Patients who could be covered by a DMP choose whether to take part, and select a physician (usually their GP) who then acts as the coordinating physician. These DMPs usually include self-management support through an approved education programme, coordination of care between the GP, specialist, and inpatient care as necessary, and decision support using evidence-based guidelines (ibid.). Physicians involved in the DMPs are obliged to have met certain training standards, and attend specific trainings to be able to participate, and a defined set of indicators are used to track the patients within DMPs which allows providers to compare their patient data with that of other practices (ibid). Although there have not been evaluations of all of the DMPs, and some studies have been unable to find evidence of improved medical outcomes, broadly the DMPs have been found to have improved quality of care for chronic diseases (Erler, Fullerton and Nolte, 2015[48]; Szecsenyi et al., 2008[50]; Fuchs et al., 2014[51]). Since their introduction in 2003 DMPs have been linked to a risk compensation scheme, offering health insurance funds an incentive for participation, and enrolment has grown year-on-year.

Development of bundled payments for chronic conditions

Bundled payments for chronic conditions have been introduced in OECD countries to incentivise coordination of care for chronic conditions between providers, or provide a broader set of care (for example education, regular checks, occasional specific checks) for chronic conditions (OECD, 2020[52]; OECD, 2016[53]). Bundled payments can encourage collaboration within and across care settings, contribute to greater standardisation of care for example by requiring adherence to quality criteria, and can strengthen data availability by requiring the collection of monitoring indicators or integration of data systems across care settings, and control overall costs (OECD, 2016[53]). Canada and France have used bundled payments for chronic conditions with some success (Box 3.8)

Box 3.8. Bundled payments for chronic conditions in Australia, and France

Bundled payments are currently used in six OECD countries, and have been found to be effective in improving care quality for chronic conditions. In Canada and France bundled payments have been introduced focusing on improving care, establishing financial incentives for better coordination between providers, and a more wrap-around package of care.

Bundled payments for Comprehensive Care Management in Canada

In Canada, the province of Manitoba, introduced Comprehensive Care Management (CCM) tariffs to physicians in 2017. This is a bundled payment that supports physicians to provide care to patients with complex needs in order to promote continuity, co-ordination and access to care, whilst also making care more comprehensive and patient-centred. The tariffs encourage the use of interprofessional teams and promote preventive care. The overarching objective is to encourage physicians to treat more patients suffering from diabetes, asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension, and coronary artery disease who typically require longer GP visits and more time to co-ordinate care. Five tariffs became available as of 1 April 2017 to pay eligible physicians for the annual management of primary health care for enrolled patients, and these payments are scaled according to complexity. CCM tariffs also include data requirements that help track the quality of care and registration of patients with complex needs.

Bundled payment for health teams in France

In France, a new five-year pilot programme was launched in 2019 to experiment with bundled payments. The programme, called ‘Payment for Health Professional Teams’ (Paiement en Equipe des Profesionnels de Santé (PEPS), has the objective is to ensure greater care integration, improved patient care pathways, and greater care co-ordination between primary health care and secondary care providers. The bundled payment will substitute the fee-for-service schemes, and will only apply for patients followed by a GP in a multi-professional health care centre (Centres de Santé). The pilot targets diabetes patients and elderly patients (aged 65 years and over), but also includes all patients having a named GP. Bundled payments will eventually be rolled out nationally from 2023 if evaluations show positive results.

Source: OECD (2020[52]), Realising the Potential of Primary Health Care, https://dx.doi.org/10.1787/a92adee4-en

3.4.4. Create more capacity in primary care for patient education, disease management, and disease detection

Primary care providers, and specifically General Practitioners, are at the heart of secondary and tertiary prevention in Latvia. While some interventions are managed vertically, for instance breast and cervical cancer screening, and there are a small number of chronic disease cabinets for instance for diabetes, the bulk of screening, disease risk detection, patient contact, and chronic disease management, lies with General Practitioners. To strengthen secondary and tertiary prevention capacity, and impact, Latvia should look to increase capacity in primary care.

However, as previously discussed in this chapter, given that Latvian GPs are broadly agreed to already be significantly time and resource stretched increasing secondary and tertiary prevention activities in primary care would require some further investment of resources in the sector. Should such resources be available, to improve secondary and tertiary prevention the priorities for increasing capacity should be focused on patient education, comprehensive disease management, and, eventually some systematic or opportunistic screening and check-ups to detect disease. Exploring whether there are ways for other health workers – for instance nurses or pharmacists – to play a role in delivering some of these key prevention activities is a possibility for Latvia to explore (Box 3.9).

Box 3.9. Changing workforce skills – a bigger role for nurses and pharmacists in chronic disease management

Nurses and pharmacists are playing a growing role in supporting chronic disease care, for example leading disease management programmes or clinics, undertaking some disease checks and tests, and providing patient education. There is also some good evidence for these changing workforce roles representing good value-for-money. Research confirms that expanding professional roles or delegating tasks to some primary health care professionals improves efficiency;. nurses or community pharmacists can, for example, help meet patients’ clinical needs more effectively and comprehensively, with less use of physician time, and at lower costs (OECD, 2020[52]). In some cases, cost savings are found by shifting tasks to less expensive health workers; some estimations show that up to 77% of preventive care and 47% of chronic care could be effectively delegated to non-physician team members (Shipman and Sinsky, 2013[54]). Extensive evidence suggests that nurses in general practice can help overcome shortages of primary physicians, providing tasks including patient education, co-ordination, prevention advice or drug prescriptions and by working in collaboration with primary health care physicians. A systematic review of more than 60 studies found that advanced nursing roles in primary care contributed to better patient outcomes, greater patient satisfaction and reduced hospitalisation (Matthys, Remmen and Van Bogaert, 2017[55]).

A growing number of OECD countries, including Australia, Belgium, Canada, England, Finland, Italy, Switzerland and the United States, are giving a bigger role to community pharmacists in promotion and prevention activities (OECD, 2020[52]). systematic reviews have also found that community pharmacist-led interventions in chronic disease management can improve clinical outcomes in a wide array of chronic diseases (Newman et al., 2020[56]).

In some OECD countries community pharmacists are engaged in health promotion activities, screening programmes, vaccination and counselling activities. They are allowed to monitor particular clinical parameters and screen for undiagnosed conditions including, for example, cardiovascular risk assessment, colon cancer screening, and some infectious diseases such as HIV and tuberculosis (OECD, 2020[52]). In Switzerland, pharmacists have been taking a leading roll in colorectal screening with the “No to Colorectal Cancer” campaign developed by the Swiss Pharmacy Association. The programme offers a screening service in collaboration with doctors. Pharmacists have to screen patients aged between 50 and 75 who have not had a colonoscopy within ten years. The pharmacist uses a questionnaire to determine a patient’s risk of colon cancer. Then either a stool test is performed by the pharmacist, or the pharmacist will refer the patient to a primary health care physician. The pharmacist discusses the results of the stool test and those patients with negative results are scheduled for follow-up screening in two years. Evidence from the Swiss Pharmacy Association shows that within six weeks, the programme detected an estimated 58 cases of cancer and 368 cases of advanced adenoma. Overall, the programme was found cost-neutral, compared to the cost of preventive treatments.

There are fewer examples of community pharmacists playing a key role in chronic disease management. However, systematic reviews which have also found that community pharmacist-led interventions in chronic disease management can improve clinical outcomes in a wide array of chronic diseases (Newman et al., 2020[56]), and some good evidence that when community pharmacists provide patient education and behavioural counselling this can improve medication adherence and therapeutic outcomes in patients with chronic conditions (Mossialos et al., 2015[57]). Italy and Finland have both introduced diabetes programmes led by community pharmacists (OECD, 2020[52]). In Finland, the “Apteenkkien Diabetesohjelma” programme gives pharmacists a key role in coordinating care and delivering prevention information. Belgium also has a ‘pharmacist co-ordinator’ role for patients with chronic conditions, launched in 2017, under which the pharmacist is expected to have a global view of all of the patient’s medications, to co-ordinate with the primary health care team and assess potential gaps in medication use. The aim is to allow patients with chronic illnesses to better manage their health and to stay autonomous as much as possible, but also to reduce the workload of primary health care physicians. In Italy a national diabetes prevention campaign was launched in 2017, with 5 600 pharmacies and 160 000 patients participating. Among the patients examined, around 3% were found to be diabetic and 9% had a previous diagnosis of diabetes. In addition, 36% of patients were diagnosed with prediabetes, with high risk of developing diabetes within the next ten years.

At Chapter 4 of this report underlines, at present the role of pharmacists as a provider of public health service is sufficiently recognised enough in Latvia. Indeed, the role of the community pharmacist has changed over recent years in most OECD countries. Pharmacists can play a key role in giving advice to patients and supporting them to navigate their health needs, and manage their care. For example, in response to the rising burden of chronic disease and multi-morbidity pharmacists can be called upon to tailor advice to the complex needs of individual patients, while the shift away from hospital care means pharmacists are increasingly providing diverse services, in community pharmacies or as part of integrated health care teams. In Latvia there are clear opportunities for pharmacists to play a different role in the health care system.

3.5. Conclusion

There is clear scope for GPs and primary care nurses to play a more active role in patient education, screening promotion, and disease management, but given the current workforce situation, it seems unlikely that there is sufficient capacity. Secondly, there are some perverse incentives that exist in the system, especially in the area of disease management, which encourage over-use of specialist care. For example, after an initial referral from a GP diabetic patients have free access to endocrinologists, which is reimbursed, even if their condition is stabilised. Given that specialists receive a fee-for-service payment for patient visits, there appears to be a strong incentive to keep seeing patients whose conditions are not particularly complicated, and could be managed by GPs. There are weak clinical guidelines and pathways for the management of diabetes, and other chronic conditions, including over the division of responsibilities between primary and specialist care providers. In addition, there are some unusual restrictions on GP prescribing, notably that GPs are not allowed to initiate prescribing of some key second line diabetes drugs, or anti-retrovirals.

To strengthen Latvia’s secondary and tertiary prevention, firstly, there is a clear need for patient and population education focusing on a range of topics, including screening, disease management, use of generics, and antibiotics. GPs and especially nurses in GP practices should take a more active role in this. Second, there appear to be some ways that cancer screening could be strengthened, for example using text message invites, and/or pre-booked appointments for screening included in the invitation letter. Third, there is a need to establish clearer patient pathways and expectations for chronic conditions, for example through more gatekeeping regarding specialist care visits, and aligning the reimbursement schedule accordingly. Finally, to make meaningful improvements in both early disease detection and disease management, there is a need to create more capacity in primary care. Expanding primary care capacity should include expanded roles for nurses and, in particular, pharmacists. Pharmacists should be seen as key public health actors, who could be far more involved in directing care to patients, patient education, and even as care coordinators. At the same time, further resource investment in primary care – the lynchpin of secondary and tertiary prevention in Latvia – is warranted. If this investment were to be made, it would be appropriate to focus on encouraging more general population health literacy, patient education, and further active disease management for example through chronic disease management programmes.

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