## Live and Learn Recently, Prime Minister Andris Kulbergs was astonished to learn how the Latvian system of inpatient medical care is organized. The head of government was not just surprised, but shocked! Of course, some pedant will immediately recall that Kulbergs did not come to the position of prime minister from the street - he was a member of the Saeima for 3.5 years, and his political force, the United List, was even part of the second Karins government. Moreover, it was the candidate delegated by the United List, Liga Mengelsone, who headed the Ministry of Health for almost a year in the second Karins government! ## Doctors to Themselves In any case, Kulbergs has every reason to tear apart the healthcare organization system, which is indeed ineffective and structured in such a way that neither the prime minister nor the Ministry of Health can "directly intervene" in the activities of hospitals. The fact is (and the prime minister pointed this out) that hospitals are legally state limited liability companies. This means they must engage in commercial activities and operate for profit. Kulbergs is right that de facto hospitals cannot operate at a profit, as they primarily rely on government subsidies. Yes, hospitals do provide paid services - for example, specialists within the outpatient clinics of university hospitals offer paid consultations. However, this provides hospitals with minimal income compared to government subsidies and mainly allows the medical professionals to receive a bonus to their salaries. It is obvious that the structure of state limited liability companies was created to easily fend off those who allocate the main funds to hospitals, namely the Ministry of Health. Operational management is carried out by the hospital boards, which are supposedly overseen by a council - neither the Minister of Health nor the State Secretary can directly influence the management of the hospital. This system allows for the financing of a large management staff. ## Without Boards and Councils? In fact, the prime minister, unknowingly, indirectly called for a return to the old system of our terrible past, when hospitals were managed without intermediaries - the Ministry of Health. And there was much more order. Most importantly, if the state allocated money, for example, for increasing the salaries of medical staff, then this money was spent exclusively on medical staff, not on other needs. And the Ministry of Health could directly control all of this. The prime minister also lamented about the payment system for hospitals for treatment and diagnostics. Hospitals receive funding from the state treasury not for cured patients, but for each procedure performed. "But in this case, anything can be written! How can this be verified?!" the head of government exclaimed. ## No Money, But You Get Treated Of course, in many ways, hospital representatives are right: today the healthcare system is funded, to put it mildly, not fully. Meanwhile, politicians act according to a well-established scheme: first, they allocate funds to healthcare below the critical level, fully knowing that in the summer or early autumn, they will have to allocate additional funds to hospitals - mainly from the contingency fund. This is precisely the case where both the prime minister and the Society of Hospitals are right: on the one hand, insufficient funds are allocated, and on the other hand, the allocated funds could be used much more effectively. Most importantly, it is time to change the hospital management system! It is time to return to the old centralized system - at least concerning university (state) clinics. However, such a reform requires a completely different Minister of Health - one who understands healthcare organization well, not just someone who smiles beautifully. Not a reform, but still... To be fair, the recently approved reform of the hospital network in Latvia, although not a reform in the full sense of the word, allows for the organization of the inpatient medical care system - now at least family doctors and emergency teams will understand in which hospitals patients will receive specific medical assistance - depending on the disease profile. And then, as the prime minister expressed, a patient with a cut finger will not be taken directly to the university hospital. ## Did You Call a Doctor? Meanwhile, this reform does not address the issue of effective outpatient (primary) care - especially during evening hours, as well as on weekends and holidays. Outpatient medical centers (clinics) should have the ability to provide medical consultations on weekends, and a day hospital should operate. However, this again comes down to state funding. As for the long-standing dream of the Minister of Health Abu Meri to revive the Riga 1st Hospital as a 24-hour emergency inpatient facility, significant funds are needed here as well - tens of millions of euros! But it is clear that all of this will be decided (if it happens) by the next Saeima and government. ## Offended by the 'Black Hole' Meanwhile, the Society of Hospitals, concerned about the prime minister's rhetoric, invited him to a meeting: "The Latvian Society of Hospitals (OB) invites Prime Minister Andris Kulbergs for a constructive conversation with representatives of hospitals about their work and the problems of the healthcare system. The OB calls on the prime minister to jointly seek solutions to improve the accessibility and quality of healthcare. This call was made after the prime minister's statements at a press conference regarding emergency departments and hospital admission departments, which were referred to as a 'black hole,' as well as accusations of systemic manipulation and fraud. According to the OB, such statements create an unjustifiably negative perception of the work of medical institutions and their staff. The Society notes that the public healthcare system in Latvia has been one of the most poorly funded in the European Union for many years, and the responsibility for the funding of the sector, accessibility, and development of services lies primarily with the creators of state policy. Therefore, solving the problems of the sector is the responsibility of the government and the Saeima... The Society emphasizes that in 2025, assistance was provided to 596,415 residents in the emergency and admission departments of Latvian hospitals. This work was carried out by doctors, nurses, physician assistants, and other healthcare specialists who often work at the edge of their physical and emotional capacities. The OB agrees that reforms are necessary in the healthcare system, more effective use of resources, and better organization of patient flow. However, changes cannot be based on discrediting the sector or reducing public trust in medical institutions. The Society also notes that hospitals daily fulfill the functions delegated by the state and often operate under conditions where the available funding does not cover actual costs.