Health Services Delivery Amiran Gamkrelidze MD Ph D

Health Services Delivery Amiran Gamkrelidze, MD, Ph. D, Professor WHO Country Office, Georgia

Starting Points • Health is one of the fundamental Human Rights and equal access to fair, high quality, and cost-effective health care/ medical services should be the main responsibility of the State Policy • For the past 10 -15 years, health has acquired more and more importance on the agenda of international politics and relationships (Health Diplomacy) • Health is a substantial segment of economics (approximately 10% of GDP) – much bigger than education, defense, security, and is one of the major driving forces for general development. The greatest dilemma of the last 20 -30 years is that health expenditure is at least 2 times bigger than economic growth in the countries. Therefore, health care is becoming more and more expensive • Nowadays, poverty is the biggest enemy of health and vise versa: with inefficient healthcare system, any serious disease becomes the main reason of impoverishment

Three dimensions to consider when moving towards universal coverage Health systems should be built on equity principles: 1. Public health services should not be driven by profit, and patients should never be exploited for profit 2. Services should be provided according to need, not ability to pay. Margaret Whitehed, Goran Dahlgren

WHO Global Health Agenda for 2006 -2015 1. Investing in health to reduce poverty 2. Building individual and global health security 3. Promoting universal coverage, gender equality, and health related human rights 4. Tackling the determinants of health 5. Strengthening health systems and equitable access 6. Harnessing knowledge, science and technology 7. Strengthening governance, leadership and accountability

WHO: Everybody business : strengthening health systems to improve health outcomes : WHO’s framework for action.

Health services Personal health care services Population-based health services • Health services include all services dealing with the diagnosis and treatment of disease, or the promotion, maintenance and restoration of health • Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those who need them, when and where needed, with minimum waste of resources.

Historical Evaluation of Health Service delivery in Georgia Liberalization 2005 -2011 Decentralization 1994 -2004 Centralization (soviet period) 1921 -1991

Service delivery during Soviet period General taxes OOP Population/ Patients Government Polyclinics Services OOP Visits Hospitals Budget Budg et Regional Authorities Budget • Hospital 390; Hospital Beds 53 000; Physician 27 000; Nurses 54 000 • Facilities - public ownership, with financing from general government revenues • Planning, organization, control and allocation all resources - in Moscow • Free access for all; Population was attached to polyclinics according to residence • Quality of health services less in comparison with international standards

Service delivery during 1994 -2004 Budget Mandatory Contributions (3%+1%)/ Government General taxes OOP Population/ Patients PHC Services Co nt ra ct Visits Hospital t Bu e dg Regional Authorities OOP Insurance contributions Private insurance Contract • Hospital 275; Hospital Beds 18 000; Physician 21 600; Nurses 21 300 • Decentralization and partially privatization health care provision ; • Health care facilities registered as autonomous State Ltd or joint stock companies • Government regulation by licensing, sertification • Development of family medicine

Service Delivery during 2005 -2011 General taxes ce n a r u Ins ions t u b i contr OOP Population/ Patients Services OOP Budget Government Insurance companies PHC Visits Contract Co ntr ac t Regional Authorities Hospitals • Hospital 266; Hospital Beds 12 000; Physician 20 600; Nurses 18 600 • Market mechanisms to regulate relations between users, purchasers, providers and public authorities and little emphasis on the State regulatory tools and arrangements • Private investment in infrastructure, private ownership and management of the hospitals • Development of private PHC and rural doctor institute

For the past 15 years, after Georgia became independent, there have been more or less successful attempts of the healthcare reform, which obviously has led to certain results: • Increased physical access to medications and certain types of medical services which did not exist before • Prevention of outbreaks • Formation and Development of the new public health system • Modernization and development of the first aid service logistics • Modernization and development of Health Infrastructure • Rapid development of voluntary (private) insurance and targeted health care for most vulnerable populations • New health legislation created • New regulation mechanisms introduced – accreditation/Licensing, certification of physicians, new approaches to continuous medical education and residency training programmes etc.

However, main problems still could not be solved: • Universal coverage of population with medical service; • Affordability of the medical service; • Quality of medical service.

General Challenges in Service Delivery (including Georgia) • Achieving maximum coverage of population with health interventions (only 1/3 of the population) • Reaching the poor and socially vulnerable (well developed, needs additional activities, particularly component of drugs reimbursement for chronic care) • Understanding how different service delivery strategies, such as the publicprivate mix, affect the entire health system (no clear vision on harmonized public-private mix) • Improving and monitoring the quality, safety, and responsiveness of services (HSPA is developed, further implementation is needed) • Promoting patient safety (appropriate strategy is required) • Promoting proper management of client-oriented services (appropriate strategy is required) • Strengthening service delivery infrastructure and information technology systems (is in the process of developing, needs further development and strengthen)

The Recommendations to Improve the Efficiency and Effectiveness of Health Services • Improve access to primary health care services for the population (key role prevention/promotion) • Scaling up Integrated health services (integrating health into all sectors - public policy reforms) • Restructuring hospitals (improving hospital performance, restructuring should go beyond bed closures etc) • More appropriate cost effective alternatives, cost effective delivery of services • Further reduction in length of stay, without matching enhancements in technologies, in an attempt to decrease cost per case • Optimize the numbers and improve the skill mix of medical personnel countrywide • Increased role of public and private sectors and their contribution too public health goals • Organizational development & strengthening - Decentralization / autonomy of providers, increasing stakeholder participation

What are the main constraints in ensuring accessible, responsive, high quality, and efficient health service delivery system? Lack of : • political will or commitment to the health sector as a major priority • holistic approach to the health systems blocks development • adequate financing of health sector by public and private sources • commitment for moving towards universal coverage • advocacy of public and individual responsibility • development of primary, secondary and tertiary health care services (Infrastructure, human capital development etc) • legislation on central and municipal responsibilities of health services delivery

What gaps exist in quality management both at health care institutions and at the system level? Lack of: • appropriate infrastructure on primary, secondary and tertiary health care levels • appropriate health technologies • health professional trained and skilled according to the international standards • health managers trained according to the international standards • modern health information management system

Which problems will be on the priority list of health sector reforms until 2020? • Elaboration of National Health Policy and implementation plan 2011 -2020 • Balanced (harmonized) development of mandatory and voluntary health insurance and general social insurance • Rationally balanced (harmonized) development of public/private mix of health sector financing as well as service delivery and infrastructure • Long term strategy on Human Resources development including medical, nursing and allaying health specialties

What strategic policy options can government explore as a possible reform course? • Rational regionalization of health service delivery, which would not be in accordance with political and economical regionalization (Four Health Care Regions) • Introduction of corporate management of hospital networks in health care regions • Increased roles and responsibilities of Municipal Governments in primary and secondary health care service delivery

Rational regionalization of hospital service delivery (four hospital care regions) Tbilisi Digomi Saburtalo Abk haz eti Avlabari Samegrelo. Zemo Svaneti Racha Lechkhumi Zugdidi Guria Imereti Kutaisi Shida Kartli Adjara Batumi Mtskheta. Mtianeti Tbilisi Samthkhe. Javakheti Kvemo Kartli Ka kh et i

What should be the role of various stakeholders (internal and external) in implementing reforms in this area? • Support in the elaboration of National Strategy of Georgian Health Care 2020 and implementation plan (GEO Government, WHO, WB, EU, USAID, Georgian Diaspora) • Support in the development of Infrastructure (GEO Government, National and International private and public investment foundations and investors) • Support in the development and training of the Human Capital according International Standards (National and International Academic Society, Professional Associations, Georgian Diasporas in USA, Europe and other countries)

Thank you for your attention!

• The Hospital Sector development general plan considers establishment of modernized hospital network with 7800 beds (Go. G decree N 11, January 26, 2007) • Currently ongoing building/reconstruction of 102 hospitals: - 23 with state budget investment - 76 with private investment - 3 with support of donor organizations Mo. LHSA

Physicians and Nurses per 100000, 2008 Physicians per 100000 Nurses per 100000 1600 1: 3. 49 Ratio of nurses to physicians 1400 4. 00 1: 3. 28 1: 3. 00 1200 1: 2. 24 3. 50 1: 3. 65 3. 00 1: 2. 37 1000 1: 1. 91 800 4. 50 1: 3. 91 1: 2. 39 2. 50 1: 1. 92 1: 2. 40 2. 00 600 1. 50 1: 0. 97 400 323. 7 775. 2 EU 258. 4 944. 0 K U 388. 6 1, 518. 7 0. 00 itz er la nd 238. 0 780. 8 a en i ov Sl Po la nd 216. 2 519. 3 400. 7 1, 400. 2 ay or w N Li th u an ia 369. 6 711. 2 354. 0 1, 062. 6 an y m G er G eo rg i a 462. 0 446. 9 345. 2 819. 3 ce Fr an to n Es 0. 50 Sw C ze ch R ep. 0 ia 354. 0 793. 6 200 334. 9 640. 2 1. 00 WHO-EURO. Health far all data base

Development of Primary Health Care • In 2008, 777 family doctors received 2000 GEL as a social assistance; additionally, appropriate equipment was provided free of charge to rural areas to promote the creation of private family doctor practice in villages. • By 2009, 178 Primary Health Care facilities were built/repaired and equipped, 1200 family doctors and 1037 family nurses were retrained. • In 2009, rural medical facilities were founded as private enterprises and 1360 private family doctors and 1480 family nurses were contracted by the Government. GHSPIC

Hospitals per 100000 population WHO-EURO. Health far all data base

Hospital beds per 100000 population WHO-EURO. Health far all data base

In-patient care admissions per 100 population WHO-EURO. Health far all data base

Average length of stay, all hospitals (Number of days) WHO-EURO. Health far all data base

Bed occupancy rate in %, acute care hospitals only WHO-EURO. Health far all data base

First visits to primary health care facilities vs. hospitals and other facilities as a percent of total first visits Health Utilization and Expenditure Survey 2007, 2010

Outpatient contacts person per year WHO-EURO. Health far all data base

Percentage of medical consultations where medicine was prescribed but not purchased because of affordability, by income quintile Health Utilization and Expenditure Survey 2007, 2010

General Government Expenditure on Health Structure of Total Health Expenditure Mo. LHSA