“Health care has become accessible for everyone.”
On 30 December 2013, Irakli Gharibashvili held a meeting for the civil sector and media representatives and summarised the achievements of the last year. He stated that: “Health care has become accessible for everyone.”
FactChecktried to investigate whether or not health care is indeed accessible for all Georgian citizens and, if so, just how effective it is.
The Universal Health Care Programme was enacted on 28 February 2013. Under this Programme, universal health care covered all Georgian citizens not having any other type of health insurance. Within the framework of the Programme, beneficiaries in need of in-patient or out-patient services can register at any medical facility participating in the Universal Health Care Programme.
The Head of the Department of Health Care Programme Management, Rusudan Gogolashvili, explained that: “If an individual is not registered at any policlinic but satisfies the requirements for being engaged in the Universal Health Care Programme (that is, the person is a Georgian citizen and has no other form of insurance), in the case of urgent medical treatment he or she will be automatically involved in the Programme.”
The first stage of the Universal Health Care Programme comprised funding for 453 various types of nosology, the service of a general practitioner and basic laboratory tests. Resolution No. 36 of the Georgian Government dated 21 February 2013 provides a detailed list of the in-patient and out-patient services envisaged by the Universal Health Care Programme. In a number of cases, the universal insurance package includes co-funding by the beneficiary. Resolution No. 36 provides the beneficiary with specific information about the services encompassed by his/her insurance policy. Nevertheless, in order to find out whether or not the insurance package covers the particular disease of the beneficiary, oftentimes the actual treatment or tests are a necessary first step.
There are no clinical guidelines or protocols for the majority of the diseases enlisted in Resolution No. 36. At this stage, the guidelines and protocols exist only for 129 diseases. The guidelines describe the treatments for the certain clinical condition of the group of diseases at length. The protocols are created based upon the guidelines and define the steps for treatment, necessary medicines, service fees, etc. The guidelines and protocols are important for the effective performance of the health insurance programmes. In addition, they help to resolve any disputes between the insurance companies and clinics in respect to reimbursement of the service or provided treatment.
Mikheil Kukava, analyst at Transparency International – Georgia, also underlines the importance of the guidelines and protocols: “The treatment of the diseases is regulated through the guidelines and protocols. They support the reduction of the doctors’ discretionary decisions to a maximum extent. In addition, the service control is also conducted by them, as it is far easier to verify whether or not the doctor follows the guidelines/protocols.”
The second stage of the Universal Health Care Programme was initiated on 1 July 2013. The spectrum of the medical services ensured by the Programme has been enlarged; that is, the planned surgeries and the treatment of oncological diseases were added to the list of urgent in-patient and out-patient services. The second stage also encompasses the funding of childbirth expenses with the limit of GEL 500 for a natural birth and GEL 800 for Caesarean sections. Additionally, the spectrum of the services for primary health care and urgent in-patient services was also expanded.
The Health System Performance Assessment Report published in January 2013 indicates that the expenses for medicines comprise almost half of the overall health care expenses. Therefore, the accessibility to medicines may be regarded as one of the important factors of the health sphere. The abovementioned report presents the following recommendation in order to increase the accessibility to medicines: “Enlarging the insurance package for providing better accessibility to the necessary pharmaceutical products.” However, this recommendation is not envisaged in the state Universal Health Care Programme which does not include funding for medicines.
In 2013, the budget for health insurance (the Universal Health Care Programme and other state health care programmes) comprised GEL 505.760 million. According to the preliminary data of the Economic Department of the Ministry of Labour, Health and Social Affairs of Georgia, of this amount GEL 197.76 million remained unspent. The 2014 budget encompasses GEL 278.146 million for health insurance.
According to the 2013 report of the Ministry of Labour, Health and Social Affairs of Georgia, based upon the final data of 2012, within the framework of Resolutions No. 218 and No. 165 of the Georgian Government, a total of 1,618,460 people benefited from state insurance while 362,663 people benefited from private and corporate insurance. Consequently, the Universal Health Care Programme aimed to insure the abovementioned segment of the population. By 1 July 2013, a total of 1,347,658 citizens were provided with medical care within the Universal Health Care Programme.
Within the framework of Resolution No. 218 of 2009 of the Georgian Government, state insurance covered the population below the poverty line, internally displaced persons residing in compact settlements, homeless children and national artists. Based upon Resolution No. 165 of 2012 of the Georgian Government, the state insured children of the age group of 0-5 years, pensioners, students and children with disabilities and severe disabilities.
The state insurance programmes covered under Resolutions No. 218 and No. 165 were and are still implemented by private insurance companies while the Universal Health Care Programme is a prerogative of the Social Service Agency. When state insurance programmes are realised by private companies, the state transfers the amount of the beneficiary to the insurance companies and so the financial risks (additional expenses) are taken by the insurance companies and not the state. Furthermore, the biggest share of the insurance market is occupied by state insurance and in order to develop and sustain the insurance market, the involvement of the private sector in the state insurance programmes is essential.
The Head of the Department of Health Care Programme Management, Rusudan Gogolashvili, confirmed that the beneficiaries of Resolution No. 2018 will join the Universal Health Care Programme from 1 April of the current year. By the end of the year, Resolution No. 165 will be repealed and its beneficiaries will also be transferred to the Universal Health Care Programme. Gogolashvili also stated: “Within the framework of Resolutions No. 218 and No. 165, the insurance companies Alpha and Cartu left the state insurance programme. The licence of Archimedes Global Georgia was revoked. Therefore, the individuals insured by the abovementioned companies were transferred to us. Additionally, starting from 1 January no one is insured or insurance updated within the framework of Resolutions No. 218 and No. 165. Thus, everyone supposed to renew or get insurance within these Resolutions will be engaged in the Universal Health Care Programme.”
While speaking to FactCheck,Mikheil Kukava underlined the risks connected with universal health care: “If the state insures every citizen, a new risk emerges that the employers will transfer this obligation to the state and, thus, increase the fiscal burdens of the budget. In addition, if the insurance companies will no longer be involved in the state health insurance programmes, the medical insurance market will disappear. The fact that the Social Service Agency does not implement quality monitoring is also important. This is one of our recommendations that was not considered by either the previous or the current government.”
Rusudan Gogolashvili also commented on the abovementioned issue: “The Social Service Agency has an electronic database providing the patient’s history, test results, stages of treatment and doctor’s prescriptions. We monitor certain cases; the monitoring process comprises the identification of the patient and the disease, whether or not the patient received the treatment given in the patient card, whether or not the treatment provided in the card was appropriate to the disease, etc. Additionally, the Ministry also monitors the Universal Health Care Programme.”
According to the Head of the Internal Audit of the Ministry of Labour, Health and Social Affairs of Georgia, Kakhaber Dzimistarishvili: “The Ministry conducts the financial monitoring of the Universal Health Care Programme. The financial monitoring of the Programme started in January and will be finalised in March.”
In December 2013, the International Foundation Curatio published research on the health care system. The research was based upon the opinions and expectations of relevant experts. A total of 98 experts were interviewed. The report comprises the period of May-October 2013 and is the second phase of the aforementioned research. We took interest in how the experts evaluate the quality of medical services. The research findings indicated that: “According to the evaluations of the experts, the problem still remains in the quality of the medical services and the system of medical education as was evident in the first phase of the research.”
To the question: “How has the quality of medical service changed in last six months?,” 41.7% of the experts responded that it has not changed. This indicator comprised 42% in the first phase of the same research (April 1013). In the second phase of the research, 21.9% of the experts indicate that the quality of medical service has “slightly or significantly worsened” while in the first phase this indicator comprised 14.1%.
The Minister of Labour, Health and Social Affairs of Georgia, Davit Sergeenko, also commented upon the abovementioned issue. According to his statement: “The quality of health care has not gotten worse; however, it still remains a problem.”
Conclusion
The Universal Health Care Programme was enacted on 28 February 2013. The universal insurance covered all citizens not having any other insurance package. On 1 July 2013, the second stage of the Universal Health Care Programme was initiated and the Programme enlarged. The first stage of the Programme encompassed the funding of 453 various types of nosology, the service of a general practitioner and basic laboratory tests. At the second stage, the list was enriched by planned surgeries, the treatment of oncological diseases and childbirth expenses (GEL 500 for a natural birth and GEL 800 for Caesarean sections).
Before the enactment of the Universal Health Care Programme, within the framework of Resolution No. 218, the state insured the following segment of the population: persons below the poverty line, internally displaced persons residing in compact settlements, homeless children and national artists. Based upon Resolution No. 165, state insurance was expanded for children of the age group of 0-5 years, pensioners, students and children with disabilities and severe disabilities. Within the framework of the abovementioned Resolution, the insurance of the population is secured by private insurance companies.
The Universal Health Care Programme is implemented by the Social Service Agency; private insurance companies are also deployed. Based upon the information of the Ministry of Labour, Health and Social Affairs of Georgia, Resolution No. 218 will be repealed on 1 April while Resolution No. 165 will be repealed by the end of the year. The beneficiaries of the abovementioned Resolutions will be transferred to the Universal Health Care Programme.
As the Ministry stated, according to the latest data of 2012, a total of 1,618,460 people benefited from Resolutions No. 218 and No. 165 while 362,663 people were insured by private and corporate insurance. By 1 July 2013, a total of 1,347,658 citizens were registered in the policlinics as the beneficiaries of the Universal Health Care Programme.
As evident, the majority share of health insurance belongs to state health care programmes. Private insurance companies will not be able to participate in them which, according to various experts, will negatively affect the development/existence of the health care market.
According to the field specialists, the guidelines and protocols are the important factors of high quality and effective health care. The guidelines/protocols support the simple implementation of the quality monitoring procedures. Currently, they exist for only 129 diseases.
At this stage, the Social Service Agency monitors only certain cases encompassing the identification of patients and diseases. The financial monitoring of the Universal Health Care Programme is implemented by the Audit Department of the Ministry of Labour, Health and Social Affairs of Georgia. As for the quality of health care, it is not being monitored at this stage.
According to the research of the International Foundation Curatio conducted in 2013, a certain part of the experts consulted is of the opinion that health care quality has deteriorated while the majority of the experts, as well as the Minister of Labour, Health and Social Affairs of Georgia, Davit Sergeenko, believes that the quality of medical service remains a problematic issue.
According to the Health System Performance Assessment Report published in January 2013, the expenses for medicines comprise almost half of the total health care expenses. The Universal Health Care Programme does not include expenses for medicines.
Based upon the assumption that the Prime Minister speaks about the accessibility of health care, and taking into consideration the following factors:
- The Universal Health Care Programme covers all Georgian citizens not having any other type of insurance,
- Before the introduction of the Universal Health Care Programme, the state insured the segment of the population having the least access to health care and
- The Universal Health Care Programme does not encompass expenses for medicines that comprise half of the total expenses of health care,
