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GEORGIAN MODEL OF HEALTH CARE: RETROSPECTIVE AND INNOVATIVE MODEL PERSPECTIVE
Doctor of Economics Natelauri Iza
Georgia, Tbilisi, Chief of dep.ofP. Gugushvili Institute of Economics TSU
ARTICLE INFO
ABSTRACT
Received 1 July 2017 Accepted 21 July 2017 Published 7 August 2017
The article considers analyze the process of health care reform in Georgia, which began with dismantling of the administrative-command system, continued in the transition period and ending with the formation and functioning of a modern market structures. The basic indicators of health care are investigated in the past and the current period: number of beds, number of doctors and nurses, the number of pharmacies etc. Evaluated created in the period of transition conditions and actions: the privatization of medical institutions, accreditation of medical personnel. Identify priority areas in health care based on the analysis of present state of healthcare economics in the context of a budget crisis. Describes the state of health care financing and the need for grant funding. Based on the analysis of the current state of health care in Georgia and international experience appreciated its innovative model.
KEYWORDS
health care in Georgia,
reforms,
privatization,
priorities,
financing,
government programs, innovative model
© 2017 The Author.
Georgia belongs to the countries that have undergone the transformation of the socioeconomic system and the period of comprehensive reforms of the socio-economic system, beginning with the dismantling of the administrative and commanding economy, continued with the transition period and terminated with the formation of modern institutions and market structures.
The inevitability of the deconstruction of the administrative and commanding economy has led to an economic crisis in the country - inflationary processes, rising prices, massive joblessness, reducing revenues, negative trend of economic growth, deficit of consumer goods, the hardest social background, the ease of integration into the world economic system and others. Practical realism required the objective necessity to change the form of ownership, privatization, creation of market structures, labor motivation, economic liberalization and macroeconomic stabilization, which in turn was a complete and difficult process. The transition period was needed - the time when with active support and participation of international organizations (International Monetary Fund and the World Bank) ended the dismantling of existing socio-political and social-economic system, privatization of the main state ownership and privatization of non-efficient enterprises, formation of institutions and modern market structures started.
The process of reform has affected all sectors of economy, including health care, where the prestarting conditions of the transition period, transitional period and contemporary problems look like:
Starting conditions
The health system of Georgia was integrated into the united Soviet system of health for several decades [17, p. 421-424; 15, p.555-558]. This period was enough to:
- create a material-technical base of health care systems equipped with appropriate devices, devices and tools. The health care system of that time united the hospitals and maternity hospitals,out-patients clinics and clinics, sanitary and preventive institutes(clinics), drugstores,sanatoria, leisure houses, tourist bases, boarding houses and boarding schools (mainly for elder and disabled persons), pioneer youth and alpine camps, sports bases;
- prepare and employ various doctors, nurses, administrative and technical personnel. The motivation of the staff of that time was determined by the fact that the care of the health of the population in the country was recognized as a public affair and declared free medical service.
The main characteristics of the development of healthcare sector during the Soviet period were 1) Number of beds in hospitals- per 10 thousand inhabitants, 110-130 beds in urban and 90-110 beds in rural areas; 2) Number of places in sanatoriums, leisure homes, tourist bases, pioneer youth and alpine camps and sports bases. The places were counted on this segment of their maximum loading
period - August 15th; 3) the number of doctors and nurses taking into consideration the profile. The number of beds in hospitals was considered to be a universal approval indicator, while the rest were identified by the unifing republics independently. The required number of physicians was determined by the number of beds. Number of nurses taking into account the number of doctors; 4) Quantity of pharmacies in the city and in the village. The quantity of the pharmacies in the village is one pharmacy for 6 thousand inhabitants, in the city- in case of 100 thousand inhabitants, one pharmacy for each 10 thousand inhabitants, in case of 100 thousand inhabitants up to 500 thousand, one pharmacy for each 12 thousand inhabitants, in case of more than 500 thousand inhabitants one pharmacy on each 15 thousand inhabitants; 5) environmental (air, water and soil) protection measures with the aim of protection of sanitary hygienic norms; 6) development of physical culture and sports.
Real statistics show that in 1985 28,000 doctors and 60 300 nurses were employed in Georgia. 14 241 doctors and 17 910 nurses in Tbilisi; The number of hospitals was 435, 61 in Tbilisi; Number of beds in Georgia was 55 400, in Tbilisi 16 400; In addition to hospitals 1362 outpatient clinics and polyclinics, 646 women consultation, total number of beds 4 482; 53.7 doctors, 115,7 nurses and 106,8 beds in Tbilisi, 122.7 doctors, 154,3 nurses and 141,3 beds in Georgia; The large share of the total number of physicians was represented by women -65%; In hospitals every year 906 000 people were treated, 17,4 [16, p.252-256] from every 100 person.
In the 90s of the last century, as a result of the dismantling of ecomonium, the long-term effects of impact remain, on the one hand, the state with its enormous wealth, and on the other hand, surrenders their mentality (by way of thinking) and labor motivation. Financed buildings and constructions of the World Bank and International Monetary Fund experts have been assessed as amortized, inventory and equipment as obsolete and incompatible with modern standards. The main reform of the healthcare sector was planned. [2, p. 14].
Transition period
The transition period started with state property privatization, accreditation and certification of medical personnel [2, p. 83-84,173-175]. Privatization program was defined for two years and 4 stages. With the recommendation of the Monetary Fund, the amounts withdrawn from the privatization process should be reduced to the volume of federal and municipal programs, excluding privatization expenditures.
In 1996-2000, "the social-economic development indicator plan developed by the Ministry of Economy of Georgia" evaluated the health condition in the field of health care as a "very serious and especially alarming" - a significant increase in socially dangerous diseases (tuberculosis, mental illness, venereal diseases, etc.). The political and economic crisis, the sharp increase in the number of refugees and internally displaced persons violated deadlines for vaccination of children and adolescents, which led to the explosion of diphtheria and other dangerous infections. More intestinal infections, botulism, typhus and tetanus cases "[2, p. 84].
Thirteen (13) Regional Management Centers for Health Care were created to ensure the decentralization of the health system. Their task was to define the main directions of the medical care of the population and coordinate activities of the medical institutions of the regions; The form of state funding has also been changed. The rule of traditional budget (subject) financing has changed the program and targeted program funding; A new financial service was established for the accumulation and distribution of funds - "State Fund for Health" [2, p. 173-175]. An Indicative Plan of 1996-2000 was followed by an indicative plan of 2000-2005 [3, p. 30, 196-197]. This plan has been defined as 1) policy in health care and 2) measures to improve health care system.
State policy has been declared as priorities for health care: improving maternal and child conditions, reduction of mortality caused by cardiovascular diseases, prevention of oncological diseases, improvement of exposure and treatment, reduction of trauma, reduction of transient and socially dangerous diseases, phsychological health, establishing a healthy route of ife and solving the problems of effective environmental factors.
As for the improvement of the health care system, they are considered: elaboration and perfection of legislative and subordinate normative acts; Optimization of the network of medical institutions, completion of privatization process; Improvement of the quality of medical services, strengthening the mechanism for the protection of medical standards; Continuation of licensing of medical institutions and certification of medical and pharmaceutical personnel.
The health situation in the health sector has further aggravated the budgetary crisis in the country. It is vital to attract resources from abroad. The solution was found in grant funding.
Health care financing in Georgia
According to the World Health Organization [9] the main source of health care in the world is state funding - 33% and compulsory social insurance - 26% .Payment payments and private insurance contributions. Paid payments and private insurance contributions together constitute 37%, 18% and 19% respectively. Similar statistics in Georgia are as follows (see Table 1)
Table 1.
Years The share of public expenditure on health care in total outlook on healthcare (%) The share of private expenditures on health care in total outlook on healthcare (%)
2002 13,5 74,3
2003 15 77,6
2004 15,5 78,4
2005 19,6 77,7
2006 21.9 73
2007 18.4 72,4
2008 20,6 68,9
2009 23 71,2
2010 23,1 74
2011 18,4 78,8
2012 15,1
2013 19,8,
2014 26,7
2015 29,8
Source: National Health Accounts. Ministry of Finance of Georgia [9]
As the table shows, private expenditures in Georgia are represented by large share values. On average, the share of private expenditures in total cost of healthcare is 74.63%, and the share of public expenditures is 20.41%. The share of state expenditure is characterized by a tendency of growth. In 2012 it was 15,1%, in 2013 -19.85%, in 2014 -26,7%, in 2015 - 29.8%. We have interesting statistics regarding GDP. In Share1, the share of public spending on healthcare was 1.73% of GDP, and the share of health expenditure totaled 9,76%.
State spending on healthcare in 2012-2015 (see Table 2)
Table 2.
Years State health expenditures (Million GEL) GDP (%) The share of healthcare expenditures in total state surveys (%)
2012 332,8 1,3 15,1
2013 435,5 1,6 19,8
1014 588,3 2 26,7
2015 656,2 2,24 29,8
Source: National Health Accounts. Ministry of Finance of Georgia [9].
According to the 2016 budget of Georgia, health care financing amounted to 3 070 000 000 GEL, 309% of total state spending [8].
Health care and social sphere grant funding
According to our information, the grant funding for healthcare and social sphere of Georgia has been carried out in two periods: 1994-2002 and 2003-2012 [7]. In 1994-2002, 34 projects were planned. 19 of them were completed, 15 projects were completed in 2005-2007. Most of the projects -26 projects included technical assistance, 8 projects (worth 15 798 000 USD), and financial assistance. Financial Support Georgia has received the World Bank, the United States and the Netherlands:
1) Three projects belong to the World Bank with a total value of 49 300 000 USD. One of these projects is planned for 14 000 000 USD, 2 planned;
2) Two projects belong to the UNDP at a total cost of 457 500 USD. One of them is worth $ 130,000, one is ongoing;
3) Six projects belong to the World Health Organization with a total value of 455 000 U.S. dollars .The six projects are in progress;
4) Four projects belong to the UN Children's Fund. All four projects are in progress;
5) One project, worth $ 301 400, belongs to the UN Population Fund. The project is ongoing;
6) Seven projects belong to the European Union, with a total cost of 2 359804 EUR. All seven projects are completed;
7) Four projects with a total value of 46 330 000 USD belong to the US. All four projects have been completed. It should be noted here that the US assistance to Georgia in 1992-2002 exceeded 1 billion US dollars. It included refugees supporting food, water, medicines, immunization programs, etc.
8) Two projects were funded by Germany, with a total value of 6,400,000 German marks. One of them, with a cost of 1 400 000 German mark is completed, one is planned;
9) Two projects were funded by the Swedish Development and Cooperation Agency at a total value of 7 786 000 SEK. Of them, at a cost of 5 786 000 SEK is ongoing, one is completed; The two projects belong to the Netherlands, with a total value of 298 000 Dutch hearts. Both projects are completed;
10) One project cost $ 4 100,000 to Japan. The project is ongoing.
The value of international organizations and foreign countries grants for 1992-2002 107 902 700 USD, 2 359 804 EUR,
6 400 000 German mark,
7 786 000 SEK, 2 130 000 HG
In 2004-2012 the grant funding was implemented in the amount of 120 495 700 GEL by the State Budget of Georgia:
The funding for primary healthcare was spent by the World Bank on 935 000 GEL (2004), the European Union by 4 212 300 GEL (2008, 2011 and 2012), totaling 5 147 300 GEL,
The Tuberculosis and Leukemia Emergency Program and Regional Program for Combating Tuberculosis was financed by 16 931 300 GEL. GFW 6 166 500 GEL (2005-2011) and Global Fund GF 10 764 800 GEL (2008, 2009 and 2010)
The Global Fund has spent 16 253 700 GEL (2006-2011) on strengthening national response to effective implementation of malaria prevention and control,
World Bank paid 4 996 800 lari (2006-2011) to the pandemic preparedness and responses to bird flu and human trafficking.
Strengthening of national response to effective implementation of HIV AIDS prevention and control was financed by Global Fund in Georgia by 77 166 600 GEL (2005-2011). Current period
In Georgia, the universal health care program is recognized in the current healthcare system. Within the framework of this program every citizen has a basic package of medical services since 2013. The program promotes the improvement of health care conditions in the country - access to medical services and medicines, the cost of service and the low income of the population.
20 Government Programs of 2017: Organized Screening of Cervical Cancer, Prevention of Mental Development of Mild and Medium Quality of Children from 1 to 6 Years, Diagnosis and Supervision of Epilepsy, Pilot Retinopathy Screening, Surveillance Survey , Safe blood Lee, occupational disease prevention, management of infectious diseases, HIV infections / AIDS management, maternal and child health, drug-addicted patients treatment, health promotion, mental health, children's cancer services, palliative care patients inkulabelur, rare diseases and permanent replacement treatment dakvem Ebarebul treatment, immediate emergency medical care and transportation, the village doctor, regional services. Health Care Listed Programs are funded by 799 500 000 GEL this year [4].
As for the number of beds in medical personnel and hospitals, statistics are as follows:
Table 3.
2010 2011 2012 2013 2014 2015
Number of beds in hospitals-thousand 12,1 12,8 11,3 11,6 11,7 12,8
Number of physicians - thousand 21,2 21,8 19,4 22,4 24,3 22,9
The average medical personnel - a thousand 19,3 17,9 14,1 15,5 15,6 16,4
Number of addresses to doctors - thousand 7623,3 7705,9 9494,7 10974,3 11886,1 13243,9
The number of population in Georgia = thousand 4436,4 4469,2 4497,6 4483,8 4490,5 3713,7
Source: [http://geostat.ge - "Health and Social Security", "Population"].
Number of beds per 100,000 people in 2015 was 345, number of doctors 691, average medical personnel 442. Similar figures for EU countries are equal to 177, 327 and 679 [13]. Compared to 2012, the number of beds increased by 1,37 times (ie 37%), the number of physicians 1,6 times (60%), the average number of medical personnel 1,4 times (40% I). The number of requests to doctors is constantly growing. This indicator has increased by 11% compared to the previous year, by 37% compared to 2012, by 8% in 2014 and 15% in 2013 compared to the previous year.
The statistics show that the healthcare sector reforms are inaccurate and unsatisfactory:
1) Considering that in 65% of hospitals, the number of beds is up to 50, and 34% varies between 11-20 inches [12], and the number of hospitals over 12,000 is 320; If a patient is in a hospital with an average of one week (7 days) a bed can handle 4 patients per month and 48 per year. 12800 beds, in these conditions, will serve 614 400 patients. It turns out that 3 713 700 residents will be able to get full beds of all six people in the hospital. This is unrealistic, which teaches the inevitability of the closure of the hospitals;
2) There is no justification for the number of physicians and medical personnel. Doctors are much more than needed, and nurses are much less than needed. We have more than 2 doctor and 1,5 times less nurses compared to the optimal number. Annually, 1200 physicians and 100 nurses [13] are prepared each year as well as their remuneration rate. According to experts, the surplus of doctors in the near future will create problems for their employment. We need to approach European standards to reach the number of 12 149 doctors and 25 216 nurses, instead of 22 900 doctors and 16,400 nurses (see Table 3), calculating 3 713 700 inhabitants (327 doctors and 679 nurses for 100,000 inhabitants)
3) As for the pharmaceutical market, this segment is the main 3 monopolist company: AVERSI, GPS and PSP. Their lack of high prices on pharmaceutical products (much lower rates on similar products in Europe) and prevents patients from avoiding the low revenue of the latter. It is also a fact that pharmaceutical companies are negotiating with the doctors to provide their patients with the medications they have at least [14];
4) Emergency medical assistance is a subject of separate judgment. In 2010-2014 ambulance services were provided: 1 074 000 people in 2010, 882,000 in 2011, 1035 000 in 2012, 1 200 000 in 2013, 1 231 000 in 2014 and 1 453 000- In 2015 [9]. Training program is being implemented in the field of emergency medical care, it is planned to upgrade the auto park and improve the dispatch services [12].
In the health care field, it is considered as indicators that are indicators, indexes in the system of ratings developed by various authoritative organizations. Considering the indexes in which the current state of healthcare in the calculation of the calculation of statistics and expert evaluations
Prospective Health Care Innovative Model
Statistics and analysis in retrospect and modern trends in the development of medicine on the one hand, on the other hand, indicate the need for health care innovative model in Georgia. Innovative-economic model of healthcare industry mainly involves three types of innovations: technology, organizational and professional. With limited material, financial and professional resources, the field should be able to provide solutions to the population, international standards, providing medical services, quality prevention, diagnosis and treatment of diseases.
Problems within the innovation model of health care are multifaceted, requiring joint coordination work of different profile specialists and structures, conducting research, calculation and analysis methods, bringing the legislative basis to innovations, separation of functions of the participants in the process.
Taking into consideration the economic and social situation in our country, the state of the important place in the innovative development of the healthcare sector. Its obligations include: innovative health management and insurance, development and implementation of innovative management model, care for innovative health care, safety and quality. There is already information that the Ministry of Labor, Health and Social Affairs of Georgia is launching new innovative model of healthcare 11 together with the international consulting group within the Association Agreement with the European Union. The Ministry of Healthcare, Labor and Social Security and the International Consulting Group provides for: control and availability of medicines; Creation of a new healthcare system; Improvement of ambulance system; Providing patients with high quality, safe and effective treatment, ultimately bringing the system in line with the best countries of Europe and then strictly adhering to European standards.
In the conditions of innovative model, it is the subject of separate judgment. Prices do not cause the fact that prices will increase. In the increased prices, if the economic situation does not radically change, the balance between the supply and demand of medical services will be broken.
We have already had a disruption situation, when economic reforms began, a large number of enterprises have stopped functioning, most of the working population remained unemployed, revenues decreased catastrophically, infection and so forth. Diseases, there was no medical insurance [5]. Because of the increased prices on medical services, the population could not afford necessary medical assistance. Later, the problem was resolved by active involvement of the state through the introduction of universal health insurance. What's up to this time? What is the real solution?
The following circumstances should be considered:
1) Disease, Infectious diseases, scale, in the near future and in the medium-term perspective. According to the National Statistics Office of Georgia (8 - "Health Care") Registered Diseases For the first time diagnosis, morbidity of children under the age of 0 to under the main groups of diseases, morbidity of the population through infectious diseases (including wheezing), the number of population morbidity and tumors Sexually transmitted Men, the number of HIV-AIDS cases from year to year. The number of people with tuberculosis in the population is declining. Statistics - The ever-increasing trend of disease, it is possible to assume that in the future the rate of doctoring will increase even further;
2) Demographic aging of population is observed in Georgia. The average duration of life for the period of 2009-2017 is 73 years [8- "population"]; By 2030 this figure will increase to 75.2 years, Women will be 78.2 years old, 71.9 years for men [6, p. 86]. This is another factor in the increase in the number of doctors attending doctors;
3) A significant part of Georgia's active population is abroad. Most of them use medical services (dental, oncological, ophthalmologic, urological, etc.) in their homeland for various reasons (one of the reasons for the price). Receiving medical services at relatively low prices stimulates not only the Georgians but also the foreigners of nationality for treatment in our country; This is especially true for neighboring countries. Innovative model should work in favor of the increase in demand for medical services by foreigners;
4) Individual level of living is the level of living and subsistence minimum. One is the necessity of treatment and the second is the solvency requirement. In Georgia, the situation is inadequate (see Table 4).
Table 4.
years Average monthly income per person (GEL) Average monthly expenses per person (GEL) Median consumption Below 60% share of the population (%)
2012 218,4 785,9 22,4
2013 246,6 890,5 21,4
2014 273,3 973,2 21,4
2015 294,5 1022,0 20,1
2016 294,2 1056,9 20,6
Source: [http://geostat.ge - "life level", "minimum wage"]
As it is shown from the table, Georgia - a significant part of population is extremely poor; Average monthly income of the population is low; The difference between revenue and expenses is big; In the period of 2012-2016 the average revenues increased by 19 GEL and expenses by 67.5 GEL; Despite the fact that income and expenses are rising in absolute indicators, the absolute growth of the absolute growth decreases from year to year, this is an undesirable tendency for prospects and indicates any service to the population. Deterioration of access to medical services; 5) Incomes and expenditures in the country are closely linked to the current state of economic development and the possible changes in the perspective. The condition looks like this (see Table 5).
Table 5.
years GDP real growth % change GDP deflator % change
2010 6,2 8,6
2011 7,2 9,5
2012 6,4 1
2013 3,4 -0,8
2014 6,4 3,8
2015 2,9 5,9
2016 2,7 4,0
Source:[http://geostat.ge -„GDP"]
The information presented in the tables used by us indicates that the population will be insolvent in case of innovations in case of delivery of increased health care services.
Thus, the innovative health care model approaching EU standards requires the state to develop and implement active economic, financial and personnel policies; It refers to a substantial improvement of living standards, and the introduction of innovations in the financial assurance mechanism, corruption in the health sector to minimize, to come up with an innovative management system, with the relevant foreign authorities, in close cooperation, health care through cooperation with international organizations for even more active.
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