Health Services Delivery Amiran Gamkrelidze, MD, PhD, Professor WHO Country Office, Georgia 1

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

There are numerous sources to study health systems There are numerous sources to study health systems. I would recommend three main documents: the first is the World Health Report 2000 on health systems, second Observatory publication – health systems in transition and the last is Tallinn conference 2008 proceedings. The latter represents European Ministerial (Ministers of health and finance) conference that was specially devoted to health systems development in Europe for population’s health and wellfare.

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

WHO Global Health Agenda for 2006-2015 Investing in health to reduce poverty Building individual and global health security Promoting universal coverage, gender equality, and health related human rights Tackling the determinants of health Strengthening health systems and equitable access Harnessing knowledge, science and technology Strengthening governance, leadership and accountability In the Global health agenda WHO has putted 7 major issues: Investing in health to reduce poverty, Building individual and global health security; Promoting universal coverage, gender equality, and health related human rights; Tackling the determinants of health; Strengthening health systems and equitable access; Harnessing knowledge, science and technology; Strengthening governance, leadership and accountability

To achieve their goals, all health systems have to carry out some basic functions, regardless of how they are organized: they have to provide services; develop health workers and other key resources; mobilize and allocate finances, and ensure health system leadership and governance (also known as stewardship, which is about oversight and guidance of the whole system). For the purpose of clearly articulating what WHO will do to help strengthen health systems, the functions identified in the World health report 2000 have been broken down into a set of six essential ‘building blocks’. All are needed to improve outcomes. This is WHO’s health system framework. WHO: Everybody business : strengthening health systems to improve health outcomes : WHO’s framework for action.

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. In any health system, good health services are those which deliver effective, safe, good quality personal and non-personal4 care to those that need it, when needed, with minimum waste. Services – be they prevention, treatment or rehabilitation – may be delivered in the home, the community, the workplace or in health facilities. Service delivery is divided into two broad categories that reflect interventions delivered to individuals (personal health care services) and interventions delivered to groups of people or the entire population (population-based services). “Health care” is closely related to personal health care services, whereas health services that are not “health care”, like public health inspections, health warnings on cigarette advertisements, etc., are population-based health services. It is important to note that personal health care includes both curative and preventive services. The key defining point is whether a service is delivered to an individual patient or to a group. Hence, within the broad category of health promotion, there are both personal services (messages given by an FGP to a patient on the need to stop smoking or change dietary habits) and population-based services (e.g. warning messages on cigarette billboards). Population-based services includes many things traditionally called “public health”. However, it is important to note that some services with “public health benefits”, such as immunizations and TB treatment, are really personal health care services. The distinguishing characteristic, in this case, is how the service is delivered, not the extent to which the benefits extend beyond the individual receiving the intervention (the latter is important for developing policies on the extent to which certain services should be subsidized by the government). Population-based services also include many things not implemented by an MOH. It might even be a government policy to have a tax on the purchase of alcohol and tobacco (though it is debatable whether the primary purpose of these taxes is to improve health or raise revenue).

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

Service delivery during Soviet period Polyclinics Hospitals Population/ Patients General taxes Services OOP Budget Government Regional Authorities Visits 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 Semashko model was primitive, simple and good in this respect. It’s simplicity meant that the population was paying taxes from their salaries, the raised funds were accumulated in the state budget and the hospitals and other medical facilities were funded through the budget, while the population did not know who what paying what for health. In parallel to the “free” healthcare, there was a high rate of informal out-of-pocket payment.

Service delivery during 1994-2004 PHC Hospital Population/ Patients Mandatory Contributions (3%+1%)/ General taxes Services Insurance contributions Contract Government Regional Authorities Budget Visits Private insurance OOP OOP As for Beveridge model, it is almost similar to Semashko, but has several principal differences. These models do not envisage task-specific, purposeful inputs or health taxes. There are general taxes i.e. everyone who works pays 20,30 or 40% to budget. These taxes are used for health, education, defense and all the rest, i.e. certain sums are paid, accumulated in budget and then the budget is distributed for and funds hospitals, policlinics, GPs, etc. Semashko and Beveridge models demonstrate similarity in inputs – general taxes. People do not know how the sum is spent, how much is for health, pension, etc. The difference is that in Semashko model health care is centrally managed and based only on public ownership. Centralized model of Beverage, as in countries with market economy, private sector is allowed, as well as private or voluntary insurance, contracting and other relations typical for market economy. American model is a mixed one. USA was exception and in Europe this is Switzerland who started with voluntary insurance or introduced voluntary insurance as a basic form of health system organization and afterwards gradually added state obligations for special population groups. That is why at present American model is considered as mixed. 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 10

Service Delivery during 2005-2011 PHC Hospitals Population/ Patients General taxes Services Contract Government Budget Visits Insurance companies Insurance contributions Regional Authorities OOP 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 American and Swiss models are typical private health insurance based models. There is no legally set obligatory health insurance in the US. Health services completely rely on private market and own initiative. That is why you are forced to get enrolled yourself or employer has to provide insurance if he/she is very interested in you. The USA, this economically strong country could not develop completely private market based health services and in 60ies was forced to introduce two big programs – Medicare and Medicaid that are budget funded and meant for poor population, disabled and pensioners. The budget funds health services for these people in special hospitals. Today private expenditure on health or the sums paid to private insurance companies in the US amounts to 55% of total and Medicare and Medicaid spends 45%. At present 40 million people in US have no insurance. 11

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 public- private 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

Samegrelo-Zemo Svaneti Rational regionalization of hospital service delivery (four hospital care regions) Tbilisi Digomi Saburtalo Avlabari Abkhazeti Samegrelo-Zemo Svaneti Racha Lechkhumi Mtskheta-Mtianeti Zugdidi Imereti Kutaisi Guria Shida Kartli Adjara Tbilisi Kakheti Batumi Samthkhe-Javakheti Kvemo Kartli

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!

Currently ongoing building/reconstruction of 102 hospitals: The Hospital Sector development general plan considers establishment of modernized hospital network with 7800 beds (GoG decree N11, 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 MoLHSA

Physicians and Nurses per 100000, 2008 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 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 per 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 MoLHSA