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Tengiz Verulava Health Care System in Georgia.Pdf Tengiz Verulava Temur Kalandadze Health Care System in Georgia First edition State Medical Insurance Company of Georgia Tbilisi 2001 1 ISBN 99928-0-219-7 Edited by Akaki Zoidze & Otar Gerzmava Technical editor Vaja Tsotskolauri Health care reform in all countries has been a seach for the Holy Grail, Often poorly informed by evidence and driven by Sustained advocacy. Alan Maynard and John Hulton 2 Contents Foreword Acknowledgements 1. The Country ……..………………………………………………..……………………… 16 1.1. Geographical Location………………………………………………………………………………..16 1.2. Administrative Division……………………………………………………………………………….18 1.3. State system of Georgia…………………………………………………………………............19 1.4. Religion……………………....................................................................................20 1.5. Climate……………………………………………………………………………………………………….20 1.6. Natural Resources……………………………………………………………………………………..21 1.7. History……………………………………………………………………………………………………….22 1.8. Economy……………………………………………………………………………………………………26 1.9. Education………………………………………………………………………………………………..…34 2. Employment, Incomes and the Social Safety Net …. ..……………….37 2.1. Labor Market………………………………………………………………………………………....37 2.2. Salaries and Wages……………………………………………………………………………….....41 2.3. Minimum Subsistence Level……………………………………………………………………..42 2.4. Social Safety Net……………………………………………………………………………………….43 2.4.1. State Social Allowance……………………………….…………………………………..45 2.4.2. Unemployment Benefit …………………………..……………………………………..45 2.4.3. Pension System……………………………………..……………………………………….45 2.5. Social Policy………………………………………………………………………………………….….47 3. Population Dynamics………………….……………………………………………52 3.1. Population and its Distribution………………………………………………………..........52 3.2. Population by Ethnic Origin……………………………………………………………………...53 3.3. Urbanization ………………………………………………………………………………………..….55 3.4. Refugees and Displaced Persons……………………………………………………………..56 3.5. Population Growth………………………………………………………………………………....57 3.6. Structure of the Population by Age Groups………………………………………………61 3.7. Structure of the Population by Sex Groups……………………………………………..65 3.8. Fertility and Family Panning …………………………………………………………………….66 3 4. Environmental and Behavioral Determinants of Health ……….72 4.1. Environment……………………………………………………………………………………….72 4.1.1. Air pollution……………………………………………………………………………….72 4.1.2. Soil……………………………………………………………………………………………..74 4.1.3. Water Supply……………………………………………………………………………..75 4.2. Social-economical Determinants………………………………………………………….79 4.3. Determinants Related to Personal Behavior………………………………………..81 4.3.1. Life Style……………………………………………………………………………………..81 4.3.2. Nutrition……………………………………………………………………………………..82 4.3.3. Tobacco Consumption………………………………………………………………..85 4.3.4. Alcohol Consumption………………………………………………………………….88 4.3.5. Drug abuse………………………………………………………………………………….90 5. Health status …………………………………………………….…………..……. 95 5.1. Life expectancy at Birth……………………………………………………………………….95 5.2. Birth Rate…………………………………………………………………………………………….98 5.3. General Mortality……..………………………………………………………………………101 5.4. Infant Mortality………………………………………………………………………………..107 5.5. Maternal Mortality……………………………………………………………………………114 6. Specific epidemiological background …………………………………. 119 6.1. Communicable Diseases…………………………………………………………………..120 6.1.1. Tuberculosis……………………………………………………………………………124 6.1.2. Malaria……………………………………………………………………………………130 6.1.3. Diarrheal Diseases…………………………………………………………………..132 6.1.4. Food Poisoning, Botulism’s …………………………………..…………………133 6.1.5. Anthrax ………………………………………………………………..………………. 133 6.1.6. Hepatitis ………………………………………………………….……………………..134 6.1.7. Typhoid, Brucellosis, Rabies…………………………………………………….135 6.1.8. Diphtheria ……………………………………………………………………………….136 6.1.9. Acute Flaccid Paralysis……………………………………………………………..138 6.1.10. Sexually Transmitted Diseases……………………………………………….139 6.1.11. HIV/AIDS………………………………………………………………………………..142 6.2. Non-communicable Diseases ……………………………………….. 144 6.2.1. Cardiovascular Diseases……………………………………………………………144 6.2.2. Cancer………………………………………………………………………………………148 6.2.3. Accidents and Poisoning…………………………………………………………..153 6.2.4. Diabetes Mellitus………………………………………………………………………………154 4 6.2.5. Iodine Deficiency Disorders……………………………………………..……………….155 6.2.6. Psychosocial and Mental Health……………………………………….………………156 6.2.7. Digestive System Diseases……………………………………………….……………….158 6.2.8. Respiratory System Diseases…………………………………………….………………159 6.2.9. Nervous System and Sense Organs Diseases…………………….………………161 6.2.10. Genitourinary System Diseases…………………………………….………………..161 6.2.11. Blood and Blood Forming Organ Diseases……………………………………..161 7. History of Georgian Medicine…………………………………………..……….162 7.1. The Pre-Christian Period……………………………………………………..………….……….162 7.2. The Christian Period……………………………………………………………………….………..162 7.3. The Russian Conquest Period……………………………………………………….………….164 7.4. The Period of Independence of Georgia (1918-1920)………………..……………..165 7.5. The Soviet Period…………………………………………………………………..………………….167 8. Health Care Reform…………………………………………………………..……….181 8.1. Determinants and Objectives …………………………………………………………….……….181 8.2. Legislation………………………………………………………………………………………..…………186 8.3. Decentralization of Health Care System Management……………….……………….195 8.4. Privatization………………………………………………………………………………….……………..199 8.5. Contracting…………………………………………………………………………………..……………….200 8.6. The impact of changes in health care system………………………………………….……….202 8.6.1. Quality of health care…………………………………………………………………………..202 8.6.2. Solidarity and competition ………………………………………………………..……….. 202 8.6.3. Efficiency………………………………………………………………………….……..………….. 203 8.6.4. Cost containment………………………………………………………………………….…….. 204 9. Organizational Structure and Management…………………………………..…206 9.1. Introduction …………………………………………………………………………………………..………... 206 9.2. Ministry of Labor, Social Affairs and Health………………………………………….………..…. 206 9.3. Regional Health Authorities………………………………………………………………….…………. 209 9.4. District Health Authorities……………………………………………………………………………….. 211 9.5. Department of Public Health…………………………………………………………………………... 212 9.6. Department of Sanitary Surveillance and Hygienic Rationing (DSSHR) ……………… 214 9.7. State Medical Insurance Company………………………………………………………………………215 9.7.1. Internal organization of SMIC……………………………………..…………………………….216 9.7.2. Insured Population………………………………………………………………..218 9.7.3. Benefits Package……………………………………………………………………220 5 9.7.4. Contracts……………………………………………………………………………….225 9.7.5. Public Relations Framework………………………………………………….227 9.7.6. Future Challenges………………………………………………………………….230 9.8. Regional Municipal Fund……………………………………………………………....231 10. Health Care Delivery System…………….………………………….232 10.1. Introduction……………………………………………………………………………….232 10.2. Structure of the Soviet Health Care System………………………………….233 10.3. Organization of Services after Reforms……………………………………..235 10.4. Primary health care service…………………………………………………………..236 10.4.1. Feldsher-Midwife Posts……………………………………………………..238 10.4.2. Rural ambulatory and health centers………………………………….239 10.4.3. Urban and district polyclinics……………………………………………….240 10.4.4. Regional Outpatient Services……………………………………………….241 10.4.5. Republican Facilities……………………………………………………………..241 10.4.6. Special Focus polyclinics……………………………………………………….241 10.4.7. Enterprise Polyclinics…………………………………………………………….241 10.4.8. Patient lists and Referral restrictions…………………………………….248 10.5. Hospital services…………………………………………………………………………..249 10.6.1. Rural hospitals………………………………………………………………………251 10.6.2. District hospitals…………………………………………………………………..251 10.6.3. Regional hospitals………………………………………………………………..252 10.6.4. Special focus hospitals………………………………………………………….252 10.6.5. Republican hospitals…………………………………………………………….253 10.6.6. Physical Infrastructure………………………………………………………...254 10.6.7. Hospital Beds……………………………………………………………………….255 10.6.8. Bed occupancy in hospitals……………………………………………………262 10.6.9. Length of stay……………………………………………………………………….263 10.6.10. Bed rotation rate………………………………………………………………..265 10.6.11. Admissions ……………………………………………………………………….266 10.7. Maternal and Child Health……………………………………………………………267 10.7.1. Health of Children………………………………………………………………….267 10.7.2. Immunization Coverage……………………………………………………….270 10.7.3. Adolescence…………………………………………………………………………271 10.7.4. Physical Developments of Children and adolescents…………..272 10.7.5. Women’s Health………………………………………………………………….272 10.8. Community Care………………………………………………………………….278 10.9. Mental Health Services………………………..………………….………….279 10.10. Anti-tuberculosis Care……………………………………………………….281 10.11. Endocrinology Care……………………………………………………………281 6 10.12. Other Special Care…………………………………………………………….281 10.13. Pharmaceuticals ………………………………………………………………282 10.14. Health Technology…………………………………………………………….284 11. Human resources for health………………………………………...285 11.1. Introduction…………………………………………………………………………………285 11.2. Physicians…………………………………………………………………………………..288 11.3. Nurses………………………………………………………………………………………..291 11.4. Medical education……………………………………………………………………..294 11.5. Health Research…………………………………………………………………………298 11.6. Professional Groups…………………………………………………………………..300 12. Health Care Finance…………………………………………………..301 12.1. Introduction…………………………………………………………………………………301 12.2. Health Care Benefits………………………………………………………………….303 12.3. Health Care Expenditure……………………………………………………………308 12.4. Levels for Financing……………………………………………………………………315 12.5. Sources of Financing………………………..……………………………….……….317 12.6. Transfers from the State Budget…………………………………………......320 12.7. Insurance Compulsory Premiums……………………………………………..321
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