Problem: Ageing population with a rising burden of chronicity; lack of coverage for basic health services and high out-of-pocket costs for patients; low productivity resulting from an overabundance of physicians; weak gatekeeping ability of primary care.
Solution highlights: Government reforms aiming to establish universal health care, increase state involvement in the health system and strengthen regulation have been introduced; articulating a clear government vision ensured a strong foundation on which to build reforms; learning from previous experiences and seeking expertise from international partners helped the initiative avoid potential difficulties; inclusion of stakeholders in the design process helped build local consensus for change; following the strategy development process, detailed plans were drawn up to guide proposed reforms.
Description of practice
Increasing life expectancy and declining birth rates have contributed to population ageing in Georgia and have increased the burden of chronic disease. In 2007, the majority (77%) of all-cause mortality was attributed to circulatory diseases and cancers. Despite efforts to strengthen primary care to address changing population health needs, gatekeeping by primary care providers remained weak. Furthermore, an overabundance of salaried physicians (462 per 100 000 population compared to an EU average of 327 per 100 000 population) reduced productivity; general practitioners saw just a few patients per day on average. A lack of monitoring and government oversight within the largely privatized health system weakened accountability and hindered performance improvements. The private health insurance system also left a large proportion of the population without coverage for basic health services and out-of-pocket health expenditures were high.
Running counter to health system reforms emphasizing decentralization and privatization that occurred throughout the 1990s and 2000s, a new wave of reforms aiming to establish universal health care, increase state involvement in the health system, and strengthen regulation and oversight was introduced following the election of the new government in 2012. Universal health coverage offering a basic package of services including primary care and emergency medical services was introduced in 2013, with this later expanded to include elective surgery, oncology and obstetric care. Emphasis has been placed on expanding disease prevention services, including screenings for cardiovascular disease and cancer, and on developing health promotion services to increase awareness of behavioural factors such as diet, physical activity and tobacco use. Strengthening primary care services has also been weighted as highly important and the Ministry of Labour, Health and Social Affairs is leading an effort to better define, standardize and monitor primary care, with support from partners including the World Bank and the United States Agency for International Development (USAID). While the initiative is still in the early planning stages and the impact of proposed reforms remains to be seen, strong government support for improving primary care is evident. Currently, the Ministry of Labour, Health and Social Affairs continues to develop the initiative and lead health system reforms. While the specific actions to be taken moving forward currently remain unclear, leaders are focused on “creating a system with a clear vision, a clear mandate and simplified standardization procedures that are well monitored and supervised.” Once this foundation has been achieved, leaders hope to strategize ways to further improve health system quality.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
Several actors have contributed to the design and planning of the initiative. The Ministry of Labour, Health and Social Affairs is leading the effort and is currently working with stakeholders – including national and local governments, international development partners and health providers – to build an initiative that is informed by experts, locally relevant and practical. However, as the initiative is still in the early stages of development, leaders do not yet “have a clear list for who will be involved or who will be in charge of what”. Relationships between stakeholders have been described as strong, which has facilitated the change process so far.
The initiative is still in the early planning stages and the impact of proposed reforms remains to be seen.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Nino Beridze
- Ministry of Health, Labour and Social Affairs