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Main Direction in the Health Sector
(2006-2007)
 
 
I. Introduction

1. This document sets out the main direction for the health sector and the immediate steps over the next two years for achieving them. It takes into consideration the health needs of the population and also the fragile economic and fiscal circumstances of the country that mean that for any proposals to work in practice, they must be realistic and sustainable. This has led to the identification of five key directions. Short-term actions are given in the box below each priority, and a fuller set of short- to medium-term activities are provided in later sections. In implementing these actions the MoLHSA will operate under the following basic principals:

1.1 Responsibility division principle: The obligations and responsibilities of the state, public and individual should be clearly separated for the improvement of the population health status. As such, the state is obligated to fully finance the commitments in the health sector.

1.2 Transparency principle. The state will take steps to ensure that its commitments and the decision making process is as transparent as possible and understandable to the population.

II. Summary of main directions

2.1 Direction one: Improving the health of the people of Georgia by guaranteeing universal access to a package of public health and priority basic health services available to the entire population regardless of place of residence or financial circumstances

Short term actions:
  • Improve the system of surveillance and public health monitoring to protect the health of the population from environmental hazards and communicable diseases.
  • Establish PHC centres, based on family doctors initially in three regions, to be extended to the entire country.
  • Undertake and encourage a campaign for personal, family, and community responsibilities for good health, targeting the leading causes of morbidity and mortality in the country, coupled with advocacy for the rights of citizens in health care.
2.2 Direction two: Helping the population to protect themselves from the catastrophic financial effects of ill health by developing, and financing for the poor, an affordable, accessible, and acceptable basic health insurance product (MediProtect).

Short term actions
  • Define a package of services (MediProtect) beyond the universal package;
  • Purchase MediProtect for the poorest from public sources;
  • Offer MediProtect to the entire population through a regulated system of purchasing.
2.3 Direction three: Increasing the quality of public and private health services by developing appropriate regulations, including contracting, for controlling and monitoring the quality of health services and making information widely available on health care provider performance.

Short term actions
  • Develop new clinical protocols (practice guidelines) based on best international practice, in close collaboration with relevant medical associations
  • Update standards for licensing medical practitioners
  • Strengthen contracting arrangements to enforce quality standards, including clinical practice guidelines and licensing standards
  • Promote the establishment of independent information collection and dissemination on provider performance to enable individuals to make more informed choices.
2.4 Direction four: Strengthen the stewardship and governance function of the MoLHSA and affiliated organizations through an improved policy and regulatory framework and more effective management of the health sector

Short term actions:
  • Complete the restructuring of the Ministry and Affiliated Organisations; determine Regional and Rayon structures;
  • Establish systems and enforcement mechanisms for ensuring accountability of affiliated organisations to MOLHSA including monitoring of performance and governance arrangements;
  • Establish the regulations and structures required for the active purchasing of health care services;
  • Invest in the systems and managers required to make these structures effective.
2.5 Direction five: Enable more effective use of health care resources by upgrading, restructuring and better integrating the health service delivery infrastructure, and creating an appropriately sized, trained and distributed health sector labour force.

Short term actions
  • Prioritize investment in PHC while reducing subsidies for the hospital sector to facilitate restructuring of service delivery network.
  • To improve geographic access to services, carry out targeted investment in geographic areas where services either do not exist or are insufficient or inadequate.
  • Develop and determine the appropriate size, profile, and geographic location of the health sector labor force.
  • Strengthen scientific research to support health system reform, policy formulation, and population health improvement.
III. Situation analysis

3. The transition from a socialist system to a market economy caused economic recession throughout Former Soviet Union (FSU), but the decline was deepest in Georgia. During the period 1992-1996 real national income fell by 78 percent compared to the 1990 level while state health expenditure per person fell to less than US$1 a year. This triggered the need for urgent reforms.

4. In 1995, in response to the economic crisis, the Government launched an ambitious health sector reform and introduced a new model for health care financing, combining tax subsidies, out- of-pocket payments and mandatory health insurance.

5. Broader structural changes were also initiated, but these reforms were often incompletely implemented. Decentralisation over key functions and responsibilities was not accompanied by adequate fiscal decentralization. Dismantling rayon level administrations undermined local ability respond to health problems such as infectious disease outbreaks and environmental threats. Making health facilities autonomous without appropriate alternative governance structures weakened accountability of providers to both the government and the public. Separating outpatient from inpatient facilities, without new systems for referral, impaired the links between different levels of care.

6. Bold reforms in the health sector within the context of economic hardships and a transforming government’s role in an emerging market, have not, as a consequence, led to desired results. A number of problems became apparent.

6.1. Introduction of out of pocket payments created financial barriers to accessing services. Private formal and informal payments now cover 80% of total health spending in Georgia. Costs of a single episode of illness can be enough to impoverish a household.

6.2. Limited public financing for essential public health services and broken functional links between central and local levels of government, has limited their ability to control and respond to infectious disease outbreaks.

6.3. Limited access to quality services caused deterioration in the health of the nation that is exacerbated by an ageing population. Georgia is now faced by a double burden of chronic non-communicable diseases, mainly of middle age and the elderly, accompanied by the re-emergence of infectious diseases such as tuberculosis and diphtheria.

6.4. The breakdown of the links between different levels of the health system means that it is now far more difficult to offer a continuum of care for patients. Pregnant women and newborns, for example, experience much more difficulty in accessing services that link their conditions from primary to secondary care levels. Mortality caused by conditions emerging during peri-natal period increased from 17.4 to 19.3.


IV. The role of the state in the health care sector

7. The government, in line with the constitution and international resolutions, has an obligation to improve and develop the following functions in the health care sector:

7.1. Stewardship and overall governance and regulation of the sector, including setting strategic objectives that assess and respond to the needs of the population.

7.2. Protect the public and individual from dangerous environmental factors and socially hazardous diseases.

7.3. Develop health financing appropriate to the needs identified and the economic capacity and fiscal policy of the country. Health financing policy includes funds channelled through both the public and the private sectors. An important component of this function is purchasing, which can be done by a range of purchasers including public and private insurance as well as individuals purchasing out-of-pocket.

7.4. Resource generation by ensuring a supply of appropriate inputs for the production of high quality health services including, a well qualified and appropriately sized health care workforce, ensuring the availability of technologies and safe and efficacious pharmaceuticals, and establishing standards for health care facilities. Government is best placed to shape the provider response through its influence over the production of the health care workforce - hence the importance of training in family medicine.

7.5. Supporting the development of high quality medical and public health services. This is to be achieved in some cases by directly providing services and in other cases establishing effective contracts for the purchase of services supported by a strong regulatory framework to ensure at least minimum standards of service quality throughout the health care system.

8. The response by the Georgian government to the current situation is limited by the financial resources at its disposable that account for at most 25% of total health spending. It is necessary, therefore, to 1) combine actions that directly finance and provide services with 2) measures to develop an enabling environment that encourages both public and private providers to deliver effective medical care and enables individuals to access the services most appropriate to their health and social circumstances.


Main Directions

V. Direction one: Improving the health of the people of Georgia by guaranteeing universal access to a package of Public Health and priority basic health services available to the entire population regardless of place of residence or financial circumstances

9. The government will finance and guarantee the provision of a Universal package of priority services to the entire population. This package will cover:

9.1. Public health activities including protection of the population from dangerous environment factors (such as water and food safety, accident prevention, health and safety at work, un-healthy lifestyles, etc.) and prevention and treatment for socially hazardous diseases (such as tuberculosis, HIV/AIDS, mental health)

9.2. Primary health care (PHC) (medical and nursing consultation, emergency services to stabilize acute conditions, basic laboratory diagnostic services & selected pharmaceuticals) based on the model of family medicine

10. The universal package will be funded from state resources and every citizen of Georgia will have a right to obtain these services in their area of residence.

11. In line with government social obligations, the Ministry will determine and approve the list of services in the universal package.

12. The Ministry will approve tariffs for reimbursing providers for services in the universal package in agreement with provider groups.

13. Action will be taken to enable the public health system to become more responsive to emerging needs in each area of the country. The organization and financing of the public health care service will be improved so that the system at national and local level is able to:

a. identify emerging problems at an early stage and plan the necessary activities for the protection of the population

b. carry out continuous surveillance of the health status of the population using up to date and reliable epidemiological information

c. implement public health activities including public information and education, health promotion activities.

14. Much of health service provision can and should be managed at strengthened primary care centres where the state will ensure the provision of quality community and personal health services to all. Improved primary care will help individuals to minimise the financial costs of ill-health by obtaining treatment at an early stage of disease and help protect the public from communicable disease through disease prevention, early diagnosis, and treatment.

15. Such services will be provided throughout the country under the current structures but will receive specific attention in a number of pilot sites in Kakheti, Imereti and Adjara that are being refurbished with support from the international community. Staffing norms for doctors, nurses and managers will be established for these pilots. The pilots will provide the opportunity to learn from experience before extending the PHC reform to the entire country

16. In order to enable the provision of similar services across the country, steps will be taken to reduce regional inequalities in the availability of public funding by developing a system for resource allocation that more accurately reflects the needs of the population. This will be done in collaboration with local government.

17. Steps will be taken to assist the population to reduce disease and improve their own health and welfare by providing information on healthy lifestyles – nutrition, reproductive health and family planning, consumption of potentially harmful substances. The MOLHSA will, where necessary, work with other ministries to encourage these improvements.


VI. Direction two: Helping the population to protect themselves from the catastrophic financial effects of ill health by developing, and financing for the poor, an affordable, accessible, and acceptable basic health insurance product (MediProtect).

18. In order to protect the population from poverty caused by the unavoidable costs of worsening health status the state will introduce and regulate basic health insurance coverage across the country. A basic health insurance package (MediProtect) will insure the population from the financial risks that arise from getting the necessary specialist and inpatient medical services, which deal with the majority of illness encountered by the population. This approach will make it possible to unite state and private financial resources in insurance and so help individuals manage risk in a more effective way than is possible with systems of official or unofficial user charges.

19. The state will purchase MediProtect for poor households, who will be identified based on the means-tested social assistance targeting system.

20. MediProtect coverage for the the non-poor will be purchased on an individual or group basis. The state will encourage employers to join the scheme on behalf of their employees.

21. The price (maximum and minimum premium) and services covered by MediProtect, as well as the quality of services provided, will be strictly regulated by the state. A system for regulating MediProtect, and other health insurance products will be developed that combines financial obligations and health-specific controls.

22. MediProtect will be widely publicised through state information channels, the media and at health facilities.

23. Any services individuals require that go beyond the entitlement of MediProtect will be purchased by individuals on a voluntary basis through direct payment or by obtaining supplementary health insurance coverage in the private insurance market.

VII. Direction three: Increasing the quality of public and private health services by developing appropriate regulations, including contracting, for controlling and monitoring the quality of health services and making information widely available on health care provider performance.

24. The objective of state regulation in the health sector is to assist individuals in accessing services that best meet their health needs. Regulation will be implemented through direct intervention to control standards, through contracts established by the health purchaser, and by the provision of better information so that individuals are able to make more informed choices.

25. Action will be focused on ensuring that all providers meet a minimum standard of practice while also encouraging them to develop services that begin to achieve international standards of quality. A variety of measures will be used to improve the quality of services:

a. The standards of licensing for medical and nursing staff will be updated, and will include a requirement for regular updating of qualifications through continuing education

b. New procedures for ensuring that pharmaceuticals are both safe and efficacious will be developed to prevent the distribution of sub-standard and ineffective products. Measures to ensure that medicines purchased by the state are cost-effective will be introduced including a focus on the purchase of generics as part of an essential drugs list.

c. A system of accreditation of health service providers based on independent standards will be developed that encourages providers to achieve higher standards of treatment outcome and patient satisfaction.

d. New clinical protocols (treatment guidelines) will be developed, in close collaboration with relevant medical associations, which reflect international best practice and will be used in the contracts with providers.

26. Contracts between state health purchasing agencies and health care providers, as well as contracts between state health purchasing agencies and private insurers, will be used to ensure compliance with quality standards developed by the MoLHSA.

27. The Government will take steps to ensure that information on the quality of health services is made available to health service purchasers/insurers and individuals. Promote the establishment of independent government and non-government information collection and dissemination on provider performance to enable individuals to make more informed choices.

28. The state will establish a clear and simple procedure for patients to make complaints and seek re-dress for poor quality service that is independent of health service providers and purchasers.


VIII. Direction four: Strengthen the stewardship and governance function of the MoLHSA and affiliated organizations through an improved policy and regulatory framework and more effective management of the health sector

29. Complete the restructuring of the Ministry and affiliated organisations. The new structure and functions of the MoLHSA, affiliated organizations, and regional and rayon health structures will be designed and implemented to support the implementation of the main directions of the health sector.

30. The state will strengthen the coordination and management of providers at the rayon and regional level. The management of providers will be enhanced by providing professional skills development in health care management for key staff within facilities. This will include support to the training of business managers within newly developed primary health care centres.

31. Establish systems and enforcement mechanisms for ensuring accountability of affiliated organisations to MOLHSA including monitoring of performance and governance arrangements.

32. The state will assist in developing an active purchaser function within the health care sector that will better represent the health care needs of the population. The health fund will be given substantial assistance to develop systems for needs assessment, contracting with providers, directly or indirectly, and monitoring of performance. It will be given sufficient autonomy to carry out these functions independently of health care providers and in the interests of patients and consumers.

33. Assistance will be provided to health facilities to help them respond to more active purchasing by public and private insurers. This assistance will include staff development, assistance in contracting and performance monitoring and upgrading selective services to meet the higher standards of modern medical protocols.

34. The further development of the health management information system, which will regularly search, process and transfer the information necessary for the management of the health care to the local and central government and public.


IX. Direction five: Enable more effective use of health care resources by upgrading, restructuring and integrating health service delivery infrastructure and creating appropriately sized, trained and structured health sector labour force.

35. State investments will be directed at health services that provide maximum coverage of population health problems. In the transitional period the state undertakes to gradually increase the state and private finance, attract investments for primary health care, public health and emergency medical care facilities including both capital investments and human resources. There were will be a decreased overall allocation of state investment for hospital facilities although funds will be made available to assist in helping the hospital sector to enhance efficiency through management and structural reforms.

36. Establish a Certificate of Need system for approving building infrastructure and reconstruction and also introduction of new/high technologies in the state and private medical care sector

37. In order to improve geographic accessibility of appropriate services, the state will carry out targeted investments (in infrastructure and human resource development) only in geographic areas where services either do not exist, are insufficient or inadequate, or where investments can help to achieve improvements in productivity and efficiency. The government of Georgia will not make investments where either in the state or non-government sector, or both, there is sufficient capacity. In such places, the state will focus on improving financial accessibility to providers.

38. Through a consensus process determine the desired profile for the Georgian health workforce in 15 years time. Invest in key areas – family medicine doctors and nurses; community nurse-midwives for rural areas; broad based specialists for secondary hospitals; health service managers.

39. Plan the need for medical and nursing staff so that the supply and demand of highly trained staff is better matched in the country as a whole and in individual regions/rayons.

40. The scientific-research activities oriented towards health system reform, policy formation and population health problems will be strengthened. This will place emphasis both on necessary biomedical and epidemiological research, including the appropriate use of international evidence and experience, and also developing capabilities in policy oriented research drawing on social-science, economics and related disciplines.