Situation assessment of rehabilitation in

February 2020

Situation assessment of rehabilitation in Georgia

February 2020 Abstract This publication summarizes the current gaps, needs and opportunities for intervention in the field of rehabilitation in Georgia. The situational analysis was conducted under the leadership of Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs and with technical support from the WHO Regional Office for Europe and WHO Country Office, Georgia. It was undertaken in collaboration with different Government ministries and State agencies, development partners, United Nations agencies, nongovernmental organizations, disabled people’s organizations and rehabilitation users. It adopted a realist synthesis approach, responsive to the unique social, cultural, economic and political circumstances in the country. The content of this document serves to provide a snapshot in time – not an in-depth analysis of the entire rehabilitation sector. The assessment focuses on rehabilitation policy and governance, service provision and human resource with the aim of improving access to high-quality rehabilitation services in Georgia. Keywords REHABILITATION IN GEORGIA: SITUATIONAL ANALYSIS. 1. Rehabilitation. 2. Rehabilitation policy. 3. Rehabilitation services. 4. Rehabilitation – human resources. 5. Rehabilitation 2030. 6. Person with disabilities – rehabilitation and assistive products. 7. Universal health coverage. I. World Health Organization.

Document number: WHO/EURO:2021-2393-42148-58068.

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Acknowledgements...... v Abbreviations...... vi Executive summary...... viii

1. Background and methodology...... 1 1.1 International, regional and national developments in rehabilitation...... 2 1.2 Methodology...... 2 1.2.1 Stage 1 (completion and consolidation of a standard questionnaire)...... 2 1.2.2 Stage 2 (in-country data collection and preliminary read-out)...... 3 1.2.3 Limitations...... 3

2. Introduction to rehabilitation...... 5

3. Health trends and rehabilitation needs in Georgia...... 7 3.1 Georgia country context...... 8 3.2 Health context, trends and rehabilitation needs in Georgia...... 8 3.2.1 The rise of noncommunicable diseases in Georgia...... 8 3.2.2 Georgia’s ageing population...... 9 3.2.3 Persons with disability in Georgia...... 9 3.2.4 Persons with difficulties in functioning...... 10

4. Overview of Georgia’s health and rehabilitation system...... 11 4.1 Other stakeholders in rehabilitation...... 14

5. Governance of rehabilitation...... 15 5.1 Rehabilitation governance and regulatory documents...... 16 5.2 Rehabilitation leadership, planning and coordination...... 17 5.3 Rehabilitation accountability, reporting and transparency...... 17 5.4 Governance, procurement and regulation of assistive products...... 17

6. Rehabilitation financing...... 19 6.1 Mechanisms for health (and rehabilitation) financing...... 20 6.1.1 Autonomous Republic of ...... 22 6.1.2 Payment processes for rehabilitation treatments...... 22 6.2 Rehabilitation expenditure...... 22 6.3 Assistive product expenditure...... 23 6.4 Out-of-pocket costs of rehabilitation...... 23

7. Human resources, infrastructure and equipment for rehabilitation...... 25 7.1 Context of the rehabilitation workforce in Georgia...... 26 7.2 Rehabilitation workforce training...... 26 7.2.1 Medical doctors...... 27 7.2.2 Physical medicine and rehabilitation (physical therapy)...... 28 7.2.3 Occupational therapy...... 29 7.2.4 Speech and language therapy...... 30 7.2.5 Prosthetics and orthotics...... 31 7.2.6 Psychologists...... 31 7.2.7 Wheelchair provision...... 32 7.2.8 Nursing...... 32 7.3 Pre-service education – clinical practice...... 33 iv

7.4 Licensing, regulation and continuing medical education...... 33 7.5 Rehabilitation workforce numbers and locations...... 33 7.6 Professional associations...... 34 7.7 Remuneration...... 35 7.8 Rehabilitation infrastructure/equipment...... 36

8. Rehabilitation information...... 37 8.1 Data on disability, rehabilitation needs and population functioning...... 38 8.2 Data, digitalization and the Georgian health information system...... 40 8.3 Data on availability /utilization of rehabilitation...... 41 8.4 Data on outcomes, quality and efficiency of rehabilitation...... 41

9. Rehabilitation service accessibility and quality...... 43 9.1 Rehabilitation service accessibility: overview...... 44 9.1.1 Rehabilitation in health facilities...... 44 9.1.2 Rehabilitation for children...... 45 9.1.3 Rehabilitation in the community...... 45 9.1.4 Specialized rehabilitation facilities...... 45 9.1.5 Vision and hearing...... 47 9.1.6 Assistive products...... 47 9.1.7 Rehabilitation in emergency or disaster...... 48 9.2 Quality of rehabilitation: overview...... 49 9.2.1 Rehabilitation interventions...... 49 9.2.2 Treatment plans and dosage...... 49 9.2.3 Multidisciplinary team and person-centred care...... 50 9.2.4 Continuum of care...... 50

10. Rehabilitation outcomes and system attributes...... 51 10.1 Outcomes...... 52 10.2 Attributes...... 52 10.2.1 Equity...... 52 10.2.2 Efficiency...... 52 10.2.3 Accountability...... 52 10.2.4 Sustainability...... 52

11. Georgia – WHO Rehabilitation Maturity Model scores and details...... 53

12. Conclusions and recommendations...... 57 12.1 Conclusions...... 58 12.2 Recommendations...... 58 12.2.1 Governance...... 58 12.2.2 Financing...... 59 12.2.3 Human resources...... 60 12.2.4 Information...... 60 12.2.5 Rehabilitation service...... 60 References...... 62 Further reading...... 64 Annex 1. Overview of rehabilitation...... 65 Annex 2. Rehabilitation in health systems – a guide for action...... 67 Annex 3. Map of Georgia...... 69 Annex 4. In-country schedule...... 70 Annex 5. Preliminary findings – debriefing document...... 72 Annex 6. Key contacts from in-country assessment...... 75 Annex 7. Information on functioning from 2014 census...... 83 v 

Acknowledgements

This report was made possible through the combined efforts of the Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs (MoIDPLHSA), the World Health Organization Regional Office for Europe and the extensive network of stakeholders involved in rehabilitation in Georgia.

This assessment would have been inconceivable without the leadership, vision and technical concept development provided by the First Deputy Minister of MoIDPLHSA, Dr Tamar Gabunia, and the commitment of the MoIDPLHSA Policy Department, specifically the representatives of the Social Unit and Health Unit.

Many thanks to the United States Agency for International Development (USAID), Georgia and Washington (DC), for its continued commitment to rehabilitation and the resources needed to accomplish this task. This situational assessment has been made possible by the generous support of the American people through USAID. The contents do not necessarily reflect the views of USAID or the United States Government.

Contributors

Authors Satish Mishra, WHO Regional Office for Europe; Sue Eitel, WHO Regional Office for Europe; Mzia Jokhidze, MoIDPLHSA; Nino Jinjolava, MoIDPLHSA; Giorgi Kurtsikashvili, WHO Country Office in Georgia

Editors Satish Mishra, WHO Regional Office for Europe; Silviu Domente, WHO Representative and Head of WHO Country Office; Tamar Gabunia, First Deputy Minister of MoIDPLHSA

Peer contributors (individuals and organizations) Health, social, financial, human resources and emergency units and departments at MoIDPLHSA; L. Sakvarelidze National Centre for Disease Control and Public Health; Adjara Ministry of Health and Social Affairs; Social Rehabilitation Centre for Persons Having Limited Ability; Georgian Association of Physiotherapists; USAID project management team; Physical Rehabilitation Programme Georgia, Emory University/Partners for International Development; MAC Georgia; GCECI; Ilia State University; Ivane Javakhishvili State University (TSU); State Medical University; Foundation Aures; Ken Walker Clinic, Tbilisi State Medical University Rehabilitation Department; Social Rehabilitation Centre for Persons with Disabilities; First Step in Georgia; Studio ADC; Neurodevelopment Centre; Coalition for Independent Living; D. Tatishvili National Centre CIU NPO Georgia; Georgian Occupational Therapists’ Association; Georgian Deaf Union; Wolfram Syndrome Georgia; Woman, Child and Society; Georgia Care Platform; Chairman of the Blind Union; Aversi Rehabilitation Centre; Polyclinic #14 - Disability Determination Commission; Neuro-Developmental Centre; Georgian Foundation for Prosthetic and Orthopaedic Rehabilitation; Neurorehabilitation Centre; State University; 1 Polyclinic Batumi; Caritas Tbilisi; Pulmonary Hospital; The National Hero Of Georgia Mariam (Maro) Makashvili Military Rehabilitation Centre; United Nations Children's Fund (UNICEF); Maya Mateshvili, local consultant.

Our gratitude goes to all individuals and rehabilitation users who generously shared their knowledge and experiences related to rehabilitation in Georgia. These contributions are essential to this report.

Peer reviewers Kirsten (Kiki) Lentz, USAID; Manfred Huber, WHO Regional Office for Europe vi

Abbreviations

ACTOR Action on Rehabilitation

AP assistive products

AT assistive technology

CBR community-based rehabilitation

CIL Coalition for Independent Living

ECI early childhood intervention

ESC&UAC Emergency Situations Coordination and Urgent Assistance Centre

FRAME Framework for Rehabilitation Monitoring and Evaluation

GAPTAR Georgian Association of Physical Therapy and Rehabilitation

GEFPOR Georgian Foundation for Prosthetic Orthopaedic Rehabilitation

GEL Georgian lari (currency)

Geostat National Statistics Office of Georgia

GE-OTA Georgian Occupational Therapy Association

GPTA Georgian Physical Therapy Association

GRASP Guidance for Rehabilitation Strategic Planning

GSLA Georgian Speech and Language Association

HMIS Health Management Information System

ICF International Classification on Functioning

ICRC International Committee of the Red Cross

IDP internally displaced person(s)

ISPO International Society for Prosthetics and Orthotics

ISU Ilia State University

LDSC Latter-day Saint Charities

LEPL legal entity of public law

MAC Georgia McLain Association for Children Georgia

MICS Multiple Indicator Cluster Survey

MoD Ministry of Defence

MoES Ministry of Education, Science, Culture and Sport

MoIDPLHSA Ministry of Labour, Health and Social Affairs (shortened version of MoIDPOTLHSA)

MoIDPOTLHSA Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs (also: MoIDPLHSA)

NCDC National Centres for Disease Control and Public Health

NCEQE National Centre for Educational Quality Enhancement

NDC Neurodevelopment Centre

NGO nongovernmental organization

NQF National Qualifications Framework vii 

OOP out-of-pocket

OT occupational therapy/therapist

P&O prosthetics and orthotics

PT physical therapy/therapist

RMM Rehabilitation Maturity Model

SDG Sustainable Development Goals

SFTV Agency for State Care and Assistance for the (Statutory) Victims of Human Trafficking

SLT speech and language therapy/therapist

SRAMA State Regulation Agency for Medical Activities

SSA Social Services Agency

STARS Systematic Assessment of Rehabilitation Situation

SWOT strengths, weaknesses, opportunities and threats

TRIC Template for Rehabilitation Information Collection

TSMU Tbilisi State Medical University

TSU (Ivane Javakhishvili)

UHCP Universal Health Care Programme

UNCRPD United Nations Convention on the Rights of Persons with Disabilities

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WCPT World Confederation for Physical Therapy

WHO World Health Organization viii

Executive summary

The rehabilitation sector in Georgia is evolving, and many examples of good practice are emerging.

That said, rehabilitation in Georgia is firmly rooted in child-focused social programmes and disability, and post-Soviet era treatment techniques and terminology continue to be used.

WHO states that rehabilitation is “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment” (1). In Georgia, the 2014 census shows that 2.69% of the population have a disability and that fully 35% have functional limitations (2).

The leadership of the Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs (MoIDPLHSA) recognizes that rehabilitation is part of health care and a health strategy for the entire population, including people with disability.

The Ministry’s request to the World Health Organization (WHO) for technical assistance to assess the rehabilitation situation and work with it to develop a national strategic plan for rehabilitation is evidence of its commitment to developing the rehabilitation sector within the health system.

This assessment utilizes standard tools developed by WHO and is structured around the WHO building blocks for health system strengthening (leadership and governance, financing, health workforce, service delivery, medicines and technology, and health information systems).

MoIDPLHSA representatives, with technical support from WHO, led the in-country data collection for the rehabilitation situation assessment in Georgia from 10 to 28 February 2020. The assessment comprised over 40 semistructured interviews, focus group discussions and site visits to five locations: Tbilisi, Batumi, , Abastumani and Tserovani ( municipality). Over 100 stakeholders contributed to the process. Preliminary findings from the assessment were discussed on 28 February in Tbilisi.

Although rehabilitation includes psychology and mental health, this assessment does not provide detailed information on mental health, as there is a separate State Programme for Mental Health (1995), managed by MoIDPLHSA, and a mental health strategy is being developed with support from the French Government.1

Key findings

Rehabilitation is not new to Georgia, and there are many positive elements to be acknowledged.

Rehabilitation governance: MoIDPLHSA provides guidance on some assistive products and policy leadership for children with disability. There are focal points for rehabilitation within MoIDPLHSA and a commitment to strengthening rehabilitation in the country.

Rehabilitation financing:MoIDPLHSA, through the Social Services Agency (SSA), provides over US$ 4 million annually for rehabilitation and assistive products. The Autonomous Republic of Adjara (Adjara) provides over US$ 1 million annually for medical and social rehabilitation; in addition, it provides over US$ 200 000 annually for adult rehabilitation services.

1 Source: discussion with MoIDPLHSA First Deputy Minister, 10 February 2020. ix 

Rehabilitation human resources and infrastructure: specialization in rehabilitation is available for medical doctors in Georgia (through residency/postgraduate training); the profession is regulated and a licence to practise is required (the Certificate of Independent Medical Practice). In addition, there are accredited training programmes (at bachelor level and some at master’s level) for physical, occupational and speech therapy.

Rehabilitation information: the 2014 census collects information on disability and functioning. Health facilities send data annually to the National Centre for Disease Control and Public Health (NCDC).

Rehabilitation service accessibility and quality: early childhood development programmes are present in Georgia and there is an extensive network of rehabilitation services for children with disability.

One significant hurdle facing rehabilitation in Georgia is that it is inextricably linked with disability.

Some additional challenges and potential implications are outlined below.

Governance

1. Rehabilitation is not integrated into existing health policies: until rehabilitation is recognized as a fundamental part of the health-care continuum, it will continue to be viewed as purely a disability service.

2. There is no national strategy on rehabilitation: rehabilitation activities will be fragmented unless they are guided by one overarching document that includes all relevant departments, ministries and stakeholders.

3. Rehabilitation focal points exist, but collaboration is ad hoc rather than systematic: the lack of systematic coordination may stand in the way of a streamlined approach to developing the rehabilitation sector.

4. There is limited awareness of rehabilitation beyond its application to disability: a lack of clarity about the concepts of disability and rehabilitation may contribute to misunderstanding or limit the effective integration of rehabilitation into health systems.

5. There is only partial governance for, and availability of, assistive technology: underdeveloped programme structures, policy frameworks, procurement processes and guidance on the provision of assistive products may impede the development of this aspect of rehabilitation.

Financing

1. Rehabilitation services are not included in the Universal Health-Care Programme (UHCP): opportunities for effective and timely interventions to maintain or restore functioning will be limited until rehabilitation is recognized as an essential part of health care and incorporated into the UHCP.

2. The current voucher system does not consider treatment outcomes and may not cover individual needs or costs of treatment: the generic nature of vouchers (predetermined time frame, treatment course, funding) and lack of attention to outcomes may result in investment that is inefficient and/or ineffective. x

Human resources

1. There is inadequate regulation of the rehabilitation workforce: the lack of licensing and competencies (except for rehabilitation doctors), continuing education requirements or standards creates an inconsistent work environment (varying capacities and skill levels), which may undermine the integrity of the rehabilitation professions.

2. There is no national education programme, training plan or professional recognition for prosthetists and orthotists, i.e. prosthetics and orthotics (P&O) technicians: the lack of professional recognition and absence of a standard education programme or plan for prosthetists and orthotists creates an imbalance with other rehabilitation professions.

3. The rehabilitation sector has a plethora of professional associations and terminologies: multiple professional associations serving the same function, together with inconsistent application and understanding of rehabilitation terminologies, impedes the cohesive development of the sector.

Information

1. Information on population functioning in Georgia is not well publicized: noting that 28–35% of the population has limitations in functioning makes a stronger case for rehabilitation than quoting the figure of 2.69% people with disability.

2. There is a lack of consistent and consolidated information related to rehabilitation. The lack of uniform and centralized information on rehabilitation workforce, services and utilization creates challenges in identifying and reporting reliable baseline information.

Rehabilitation services

1. Rehabilitation for adults with health conditions is grossly underdeveloped in Georgia: neglecting this segment of the population reduces participation and potential economic contribution to society.

2. Timely rehabilitation interventions and inpatient rehabilitative care are extremely limited: rehabilitation requires immediate and intensive application to restore neural pathways and prevent secondary conditions.

3. Limited number and type of assistive products available in Georgia: appropriate assistive technology (products and provision) are key to creating opportunities for optimal functioning. xi 

Key recommendations

To address some of the challenges that Georgia faces related to rehabilitation, the following recommendations are submitted for consideration.

Governance

1. Consolidate rehabilitation leadership and coordination. • It is recommended that the Government of Georgia: 1.1 establish a rehabilitation working group to develop and implement a national rehabilitation strategy and serve as a channel for ongoing communication in the sector; 1.2 develop a national strategy on rehabilitation that involves and includes all relevant ministries, departments and stakeholders.

2. Include rehabilitation in any newly developed, revised or updated health policy documents • It is recommended that MoIDPLHSA: 2.1. incorporate rehabilitation into the National Health Strategy 2021–2026; 2.2. engage members of the rehabilitation working group to advise on language in health policy documents to ensure that rehabilitation is appropriately represented.

3. Raise awareness of rehabilitation • It is recommended that MoIDPLHSA and relevant stakeholders: 3.1. design informational materials highlighting rehabilitation and functional gains, particularly aimed at health-care and social services staff; 3.2. share guidance on distinctions between, and intersectionality of, rehabilitation and disability.

4. Strengthen frameworks related to procurement and provision of assistive products • It is recommended that MoIDPLHSA: 4.1. solicit support from WHO to assess the assistive technology situation in Georgia and include it in a national rehabilitation strategy.

Financing

5. Improve resource allocation for rehabilitation services across all levels of health care • It is recommended that MoIDPLHSA: 5.1. introduce rehabilitation procedures into UHCP; 5.2. amend existing voucher system to link payments with evidence on treatment outcomes; 5.3. determine/update the optimal cost of the service package defined by the voucher.

Human resources

6. Resolve identified challenges related to the rehabilitation workforce • It is recommended that MoIDPLHSA, together with the Ministry of Education, Science, Culture and Sport and other relevant stakeholders: 6.1. address the lack of training and professional recognition for prosthetists and orthotists; xii

6.2. develop competencies, regulations and licensing requirements for staff working in physical (PT), occupational (OT) and speech and language (SLT) therapy and prosthetics and orthotics (P&O) staff; 6.3. upgrade clinical pre-service training ensure greater consistency between programmes and sites; 6.4. revise the continuing education requirements for all health staff; 6.5. consolidate professional associations and terminologies related to rehabilitation.

Information

7. Emphasize that the purpose of rehabilitation is to optimize functioning • It is recommended that MoIDPLHSA, together with relevant stakeholders: 7.1. Repackage available information on functioning to highlight the demand for rehabilitation.

8. Support health facilities in collecting, consolidating and sharing rehabilitation-related information • It is recommended that MoIDPLHSA: • 8.1. incorporate information on rehabilitation workforce and service availability in the health facility reporting form submitted annually to NCDC; • 8.2. train health staff in existing patient procedure codes regarding rehabilitation and nursing care.

Rehabilitation service

9. Reinforce efforts to ensure that adults with health conditions receive the rehabilitation they need • It is recommended that MoIDPLHSA: 9.1. continue engaging with the working group dedicated to adult rehabilitation in Georgia.

10. Promote timely rehabilitation interventions across the continuum of health care • It is recommended that MoIDPLHSA, together with relevant stakeholders: 10.1. replicate examples of good practice where rehabilitation is applied in acute care settings; 10.2. support inpatient rehabilitation to maintain or improve function; 10.3. encourage expansion of rehabilitation services at community level. 1. Background and methodology 2 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

1.1 International, regional and national developments in rehabilitation

In February 2017, WHO launched the Rehabilitation 2030 initiative with a call for action (3) that identifies 10 areas for united and concerted action to reduce unmet needs for rehabilitation and strengthen the role of rehabilitation in health. (For an overview of rehabilitation strategies and interventions, see Annex 1.) WHO also released the Rehabilitation in health systems guidelines (4), which provide basic recommendations for strengthening rehabilitation in the health sector and integrating it more effectively across health programmes. This body of work further supported the development of the Rehabilitation in health systems guide for action, released in 2019 (5). A central tenet of the WHO guidance is that rehabilitation is a health service for the whole population: it should be made available at all levels of the health system, and ministries of health should provide strong leadership to strengthen the health system to deliver rehabilitation and develop strategic rehabilitation plans. Information on the Guide for action and rehabilitation in relation to the WHO health system building blocks can be found in Annex 2.

The WHO Regional Office for Europe has initiated a four-year programme (2018–2022) to increase access to rehabilitation services and assistive products in the Region, and has identified Eastern Europe, central Asia and the as a geopolitical priority – an area which includes Georgia.

Within Georgia, rehabilitation policies are strongly associated with disability policies. Georgia ratified the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) in 2013. Article 26 of the Convention refers to habilitation and rehabilitation. In 2017, Georgia drew up a draft law on the rights of persons with disability (not yet approved). The annual State Programme for Social Rehabilitation and Childcare is a key guidance document detailing benefits and subprogrammes for persons with disability.

1.2 Methodology

This assessment uses a newly developed method and reporting template, launched in 2018 by WHO, called the Systematic Assessment of Rehabilitation Situation (STARS). STARS is not an academic evaluation of rehabilitation, nor is it intended as a detailed analysis. It is a snapshot in time to review rehabilitation status, identify strengths and gaps and lay the foundations for a national strategic plan for rehabilitation.

The STARS process in Georgia occurred in two stages:

Stage 1: Completion and consolidation of a standard questionnaire (January 2020)

Stage 2: Three-week in-country data collection and preliminary read-out (February 2020).

1.2.1 Stage 1 (completion and consolidation of a standard questionnaire) In January 2020, MoIDPLHSA received the WHO Template for Rehabilitation Information Collection (TRIC). This questionnaire comprises eight sections with over 100 questions (six sections focused on the health systems strengthening building blocks plus additional sections on infrastructure and emergency preparedness). The focal points within the MoIDPLHSA Policy Department completed the questionnaire in Georgian and sent their responses to the WHO Country Office in Georgia. The TRIC responses were translated into English and sent to the consultant at the end of January. Background and methodology 3

1.2.2 Stage 2 (in-country data collection and preliminary read-out) In-country data collection took place from 10 to 28 February 2020. (For an orientation map of Georgia, see Annex 3.) The assessment team comprised Mr Satish Mishra (WHO Regional Office for Europe), Mr Giorgi Kurtsikashvili (WHO Country Office, Georgia), Ms Nino Jinjolava and Dr Mzia Jokhidze (MoIDPLHSA Policy Department) and Ms Susan Eitel (international consultant). For the assessment team’s schedule during the visit, see Annex 4.

In the first week, the team focused on data collection in relation to the health system building blocks and a facilitated discussion on strengths, weaknesses, opportunities and threats (SWOT) related to rehabilitation in Georgia (for the team’s preliminary findings, see Annex 5). Additionally, the team conducted key informant interviews and site visits to health and rehabilitation services in five locations: Tbilisi, Abastumani (near Akhaltsikhe), Akhaltsikhe itself, Batumi and Tserovani (). See Annex 6 for participant information.

The Rehabilitation Maturity Model (RMM) is another standard tool used during the STARS process. It includes 50 components across seven domains. Each component has illustrative descriptors that indicate the level of maturity of rehabilitation in the health system. The RMM provides an overview of the performance of various rehabilitation components. This overview enables comparison across components and domains that can then in the identification of priorities and recommendations for strategic planning. The international consultant took data from the TRIC and in-country data collection, and aligned this information with the 50 components. This was used to help visualize the preliminary assessment findings presented on 28 February – seeAnnex 5 . A detailed breakdown of individual components of the RMM is provided in Section 11 below.

1.2.3 Limitations

The minor limitation identified during the assessment phase is the lack of a formal working group or committee to support the completion of the TRIC questionnaire, the SWOT analysis and feedback on preliminary findings. This limitation was overcome by the extensive investment of time and effort by the rehabilitation focal points within the MoIDPLHSA Policy Department and highly committed stakeholders in the sector.

2. Introduction to rehabilitation 6 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

WHO describes rehabilitation as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment” (3) (Fig. 1).

The term “health condition” refers to a disease (acute or chronic), disorder, injury or trauma. A health condition may also refer to other circumstances, such as pregnancy, ageing, stress, congenital anomaly or genetic predisposition.

Rehabilitation interventions are targeted actions to build muscle strength and improve balance, cognitive ability or communication skills. This skill-building can assist people in performing basic daily activities, such as moving around, self-care, eating and socializing.

Fig. 1. Aims of rehabilitation interventions

Source: Western Pacific Regional framework on rehabilitation. Manila: World Health Organization Regional Office for the Western Pacific; 2019 (https://iris.wpro.who.int/handle/10665.1/14344, accessed 10 May 2021). Licence: CC BY-NC-SA 3.0 IGO.

Rehabilitation also removes or reduces barriers in society through modifications in people’s personal environments, such as home, school or work, so that they can move around safely and efficiently.

In many countries, rehabilitation is closely associated with disability and is sometimes considered a disability service. However, rehabilitation is a health strategy for the entire population, including people with disability.

Rehabilitation is for all people, forming part of the continuum of health care and part of health systems. Rehabilitation is important at all levels of the health system (tertiary, secondary, primary and community). For additional information on rehabilitation, see Annex 1. 3. Health trends and rehabilitation needs in Georgia 8 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

3.1 Georgia country context

The Georgia country context is complex, with different information sources describing the country in slightly different terms. For the purposes of this report, Georgia is deemed to consist of Tbilisi (the capital city), 10 regions (including Adjara) and two occupied territories – the Autonomous Republic of and the / South Ossetia region (see map in Annex 3).

According to the 2014 population census, Georgia’s population is 3 713 804, of whom 100 113 (2.69%) are identified as persons with disability. The census covered 82% (57 000 square kilometres) of the total area of the country. It could not be conducted in the occupied territories: the Autonomous Republic of Abkhazia and South Ossetia (total area 13 000 square kilometres) (6). According to the Statistical Yearbook of Georgia 2019, the population is 3 723 500 (not including the occupied territories) (7).

As at December 2018, Georgia has 293 000 internally displaced persons as a result of conflict and violence 8( ).

There is significant outmigration of the working-age population. An estimated 0.75 million (16.6% of the population) have emigrated; the primary destination country is the Russian Federation, followed by and Greece (9).

A total of 83.4 % of the population of Georgia are Orthodox Christians, 10.7% are Muslims and 2.9% belong to the Armenian Apostolic Church.

Georgia is a developing country and ranks 70th in the Human Development Index.

3.2 Health context, trends and rehabilitation needs in Georgia

The health context or health trends can serve as proxy indicators of the demand for rehabilitation services. In Georgia, health trends or contextual factors include the rise of noncommunicable diseases, an ageing population and the number of persons with disability or difficulties in functioning.

3.2.1 The rise of noncommunicable diseases in Georgia

The main types of noncommunicable disease are cardiovascular diseases (e.g. heart attacks or stroke), cancers, chronic respiratory diseases and diabetes (10). In Georgia, noncommunicable diseases are estimated to account for 93% of all deaths (Fig. 2) (11). Health trends and rehabilitation needs in Georgia 9

Fig. 2. Estimated mortality in Georgia

NCD: noncommunicable disease. Source: (11).

3.2.2 Georgia’s ageing population

According to the 2014 census, 14% of people in Georgia are aged 65 years or older. By 2050, this age group will rise to 25% of the population (12). WHO is working to refine measures of healthy ageing as part of its 10 Priorities for a Decade of Action on Healthy Ageing (13). The focus is now on older people’s functional ability within their environment, not their age or the conditions or diseases they have (14).

3.2.3 Persons with disability in Georgia

Rehabilitation intersects with the disability sector, since persons with disability are a key population group who may benefit from rehabilitation. Georgia ratified the UNCRPD in December 2013 and officially became a State Party on 13 March 2014.

Statistics on persons with disability living in Georgia are gathered by the National Statistics Office of Georgia (Geostat) as part of the general census of the population, and by the MoIDPLHSA Social Services Agency (SSA) on the basis of State allowances granted to persons with disability.

The 2014 census showed that there were 100 113 registered persons with disability in Georgia (2.69% of the population), while the SSA registered 118 651 persons with disability who were receiving social assistance as of 1 March 2015 (a difference of over 18 000). SSA figures increased to 125 104 in 201715 ( ). Table 1 provides details of the Geostat figures from 2014 compared with those for SSA beneficiaries in 2017. 10 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Table 1. Estimates of persons with disability in Georgia

Information source Total Group I Group II Group III Children

2014 census 100 113 26 784 58 255 9902 5172

2017 SSA beneficiaries 125 104 26 568 75 268 5836 10 052

Disability categories: Group I: acute; Group II: considerable; Group III: moderate (16). Source: (15).

The system for the determination of disability status in Georgia is based predominantly on a medical model of disability; the current system focuses on a specific diagnosis, rather than on the overall state of health of the person and its impact on his/her daily functioning. UNICEF Georgia, in close cooperation with MoIDPLHSA, is implementing a pilot of the social model of disability assessment and status determination system in Adjara. More information is provided in Section 8 below.

3.2.4 Persons with difficulties in functioning

In addition to collecting information on disability, the 2014 census also collected information on functioning. The number of people with difficulty functioning is 1 301 675 (35% of the population). AnnexSee 7 and Section 8 below.

In 2018, Georgia carried out a Multiple Indicator Cluster Survey (MICS) that identifies 28% of adults and children (aged 2–49 years) as having difficulty functioning in at least one domain17 ( ). See Section 8 below for details. 4. Overview of Georgia’s health and rehabilitation system 12 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

In 1999, the Ministry of Health merged with the Ministry of Social Affairs. Since then, areas such as labour, employment and issues relating to internally displaced persons (IDPs) from the occupied territories have been brought under a single ministry, MoIDPLHSA.

MoIDPLHSA is accountable for the health of the population, oversight of the health system, quality of health services and equity in access to health care throughout the country. It also provides oversight of social programmes supporting vulnerable populations.

Within the MoIDPLHSA structure, the Policy Department coordinates issues related to rehabilitation (see Fig. 3); at the time of the assessment, Ms Nino Jinjolava was responsible for rehabilitation-related issues within the Social Protection Policy Unit and Dr Mzia Jokhidze occupied a similar function within the Health Policy Unit.

Fig. 3. Structure and organization of MoIDPLHSA in relation to rehabilitation

ESC&UAC: Emergency Situations Coordination and Urgent Assistance Centre; LEPL: legal entity of public law; MoIDPLHSA/MOLHSA: Ministry of Labour, Health and Social Affairs; NCDC; SFTV: Agency for State Care and Assistance for the (Statutory) Victims of Human Trafficking; SRAMA: State Regulation Agency for Medical Activities; SSA: Social Services Agency. Source: Author’s own.

Legal entities of public law (LEPLs) are independent bodies that carry out Government functions. The key LEPLs within MoIDPLHSA with links to rehabilitation within the health system are described in Table 2.

Table 2. Legal entities of public law within MoIDPLHSA related to health and rehabilitation

Name of LEPL Acronym Description of rehabilitation-related function

Emergency Situations ESC&UAC Ensures/coordinates quality emergency medical and referral assistance in disaster Coordination and Urgent and martial law situations. It is also responsible for managing emergency calls Assistance Centre (#112) and ambulance services and for managing primary health care in villages.

National Centre for Disease NCDC The main institution responsible for health statistics. It provides Control and Public Health national leadership in preventing and controlling communicable and noncommunicable diseases. Overview of Georgia’s health and rehabilitation system 13

Table 2. contd.

Name of LEPL Acronym Description of rehabilitation-related function

State Regulation Agency for SRAMA Responsible for issuing licences for medical activities and permits for health-care Medical Activities facilities and pharmacies, and regulating medical professionals, pharmaceuticals and medical devices.

Social Service Agency SSA Responsible for purchasing publicly financed health services; it is the only actor in the health system for Government-funded cover under the UHCP and social assistance programmes.

Agency for State Care and SFTV Protection, assistance and rehabilitation of victims of human trafficking, violence Assistance for the (Statutory) against women/or domestic violence and victims of sexual abuse. Victims of Human Trafficking Creation of decent living conditions for people with disability, elderly people and orphaned children.

Georgia has experienced extensive health reform over the past 15 years.

The health-care system in Georgia is highly decentralized and was extensively privatized between 2007 and 2012. The main principles were to transition towards complete marketization of the health sector: private provision, private purchasing, liberal regulation and minimum supervision. The State retained control over a few medical facilities dealing with mental illness and infectious diseases, while all other hospitals and clinics were privatized (18). Approximately 84% of medical service providers are private (11).

The Government of Georgia introduced the UHCP in 2013. The UHCP extends publicly financed entitlement to health-care coverage to the entire population. The package covers a range of primary and secondary care services and limited essential drugs. More than 90% of the population are covered by the UHCP programme (11). UHCP does not include rehabilitation services or assistive products.

Some standard indicators for health facilities and personnel are the number of health facilities, beds, physicians and nurses. Information for Georgia is provided in Table 3. Notably, there are almost twice as many doctors as nurses; the rural physician programme accounts for 55% of outpatient facilities.

Table 3. Overview of health facilities and human resources in Georgia

Description Number Number per 100 000

Number of inpatient facilities 273 N/A

Number of hospital beds 15 909 426.90

Number of physicians (including dentists) 30 998 831.90

Number of nurses 17 862 479.30

Number of outpatient facilities (includes rural figures) 2283 N/A

Rural physicians-entrepreneurs 1267 N/A

N/A: not applicable. Source: (11). 14 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

4.1 Other stakeholders in rehabilitation

In addition to MoIDPLHSA, the other ministries that play a role in rehabilitation are the Ministry of Defence (MoD) and Ministry of Education, Science, Culture and Sport (MoES). The MoD manages the National Hero of Georgia Mariam (Maro) Makashvili Military Rehabilitation Centre (see Section 9). The MoES houses the National Centre for Educational Quality Enhancement (NCEQE); see Section 7.

Besides private service providers, international organizations and nongovernmental organizations also contribute to the rehabilitation landscape. Some key intervention areas include workforce capacity-building (scholarships, in-country training and treatment protocols), provision of assistive products, facilitating dialogue and other actions.

The donor landscape for rehabilitation in Georgia is varied. Donors identified during the assessment are listed below. – United States Agency for International Development (USAID): since 2005, USAID has invested nearly US$ 10 million in disability and rehabilitation. Current programmes: US$ 1.2 million to the United Nations Children’s Fund (UNICEF) (2015–2020) and US$ 4.5 million to Emory University (Atlanta, Georgia, United States of America) (2017–2021). – Turkish Cooperation and Coordination Agency: provides 300 000 Georgian lari (GEL) (approx. US$ 100 000) to renovate the existing Rehabilitation Centre for Persons Having Limited Ability Ltd. (Tbilisi).2 – Between 2012 and 2015 over US$ 500 000 was donated by Foundation Johanniter, Government of Japan, International Committee of the Red Cross (ICRC) and the Georgian Foundation for Prosthetic Orthopaedic Rehabilitation (GEFPOR) to establish the Prosthetic Orthopaedic Rehabilitation Centre in Tbilisi.3 – Federal Ministry of Economic Cooperation and Development (BMZ), Germany: supports the nurse training module for home care (nine-year programme and funding amount unknown). – Private investor: Ken Walker University Clinic for Medical Rehabilitation LLC (Tbilisi): US$ 6 million.

2 Source: interview with Centre Director, 20 February 2020. 3 Source: email from GEFPOR, 23 June 2020. 5. Governance of rehabilitation 16 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Key components Status

Rehabilitation legislation There is no mention of rehabilitation in the current 2014–2020 health plan. Nearly all legislation and and policies policies on rehabilitation are covered by a disability framework. Georgia ratified the UNCRPD in 2013. The Human Rights Action Plan for 2018–2020 references habilitation and rehabilitation services for persons with disability.

Rehabilitation strategic plan Georgia has not yet developed a rehabilitation strategic plan.

Leadership and coordination Rehabilitation leadership focuses on guidance and financing for social programmes. There is an interagency group focused on early childhood development and three technical working groups (wheelchairs, adult rehabilitation, professional standards) linked to the Emory University project.

Rehabilitation accountability Outside the disability context, there is no reporting on rehabilitation. There is no evidence of and reporting information collected about performance of rehabilitation, either within social programmes or in the health sector.

Regulatory mechanisms There are low levels of regulation that apply to rehabilitation and assistive technology. Licensing is only required for medical doctors. Pricing and guidance exists for some assistive products through social programmes.

Assistive technology Leadership for assistive technology exists, but all processes and management structure are housed (AT) policies, plans and within social protection. There are many gaps or deficiencies that require further attention. A formal procurement AT assessment (with support from WHO) is planned for Georgia in 2020.

5.1 Rehabilitation governance and regulatory documents

Georgia’s current health plan, the 2014–2020 State Concept of Healthcare System of Georgia for Universal Health Care and Quality Control for the Protection of Patients’ Rights (19), identifies 10 priority areas for improvement. There is no mention of rehabilitation in the document. MoIDPLHSA is currently employing a consultant, Lajos Kovacs, to support the development of the National Health Strategy 2021–2026.

The Government of Georgia issues an annual State Programme for Social Rehabilitation and Childcare (20). The goal of the programme is to improve the physical and social conditions of persons with disability including children and elderly, homeless and socially vulnerable people, and promote their social integration. The document outlines the approved subprogrammes, source of funding, beneficiaries, programme supervision, penalties and sanctions and programme implementation period. Information on funding is in Section 6, and services provided in 2019 through this programme are in Section 9.

Georgia ratified the UNCRPD in 2013; Article 26 references habilitation and rehabilitation. In 2017, Georgia drafted the Law on the Rights of Persons with Disabilities (not yet approved). Georgia’s Human Rights Action Plan for 2018–2020, approved by Decree #182 (17 April 2018), envisions an increase in accessibility to habilitation/ rehabilitation services for persons with disability and children, with the evaluation indicator of defining the capacity for developing rehabilitation needs and services for adults (Article 19.1.6).4

There are many policy documents pertaining to early childhood development: – Decree #282 by the Parliament of Georgia, on Approving the National Concept on Early Childhood Intervention (ECI) Aimed at Early Childhood Development (dated 9 February 2017); – Decree #01-188/o by the Minister of Labour, Health and Social Affairs on Approving the Minimum Standards on ECI (dated 18 August 2017); – ECI subprogramme of the State Programme for Social Rehabilitation and Childcare;

4 Source: information provided in the TRIC, February 2020. Governance of rehabilitation 17

– Decree #234 on the 2018–2020 National Action Plan for Implementing the National Concept on ECI (dated 15 May 2018); – Decree #01-66/o by the Minister of MoIDPLHSA (20 August 2018) to Establish an Interagency Working Group to Coordinate the Implementation of the 2018–2020 National Action Plan for Implementing the National Concept on ECI.

5.2 Rehabilitation leadership, planning and coordination

Leadership for rehabilitation is historically grounded in the MoIDPLHSA social programmes for persons with disability. Except for guidance on the implementation of the State Programme for Social Rehabilitation and Childcare, there is very little planning or detail related to the rehabilitation workforce or services.

Although MoD, MoES and MoIDPLHSA each have a role in rehabilitation, there is little evidence of coordination across the three ministries. Conversely, coordination around early childhood development appears to be well established, with an interagency group on early childhood development as well as a coalition of early intervention service providers.

Based on the decision of the Project Support Board within MoIDPLHSA, three technical working groups were established in relation to the USAID-funded Physical Rehabilitation Project in Georgia.5 The 13-member Board is a cross-section of Government, professional associations, international organizations and universities. The three technical working groups focus on: wheelchair service provision, policy on adult rehabilitation, and professional standards, licensing and educational programmes within the project.

5.3 Rehabilitation accountability, reporting and transparency

Reporting on rehabilitation service delivery is at a low level, and data on the status and performance of rehabilitation are either not available or unknown.

5.4 Governance, procurement and regulation of assistive products

MoIDPLHSA has not yet created a priority assistive products list. The State Programme for Social Rehabilitation and Childcare provides some guidance on pricing and supplier criteria for assistive products (especially wheelchairs). The existing guidance and current pricing merit review; and the WHO-supported AT assessment is scheduled for mid-2020 are well timed.

5 This US$ 4.5 million project (2017–2021) is implemented by Emory University with Tbilisi State Medical University (TSMU), Coalition for Independent Living (CIL) and McLain Association for Children (MAC) Georgia. 18 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Specifically, in respect of wheelchairs, the system of wheelchair service provision in the country is supervised by MoIDPLHSA (responsible for development of the policy and the relevant subprogramme) and SFTV (responsible for implementation of subprogramme activities). In addition, a wheelchair service provision working group has been set up in Georgia as part of the physical rehabilitation project supported by Emory University. The working group implements the project activities in accordance with the action plan developed as part of the same project and is accountable to the Advisory Board of the project Physical Rehabilitation in Georgia.

Summary of rehabilitation governance situation

• MoIDPLHSA demonstrates a commitment to rehabilitation through support and actions articulated in the annual State Programme for Social Rehabilitation and Childcare.

• Leadership and coordination of rehabilitation is provided through the current MoIDPLHSA Policy Department (Social Protection Policy Unit and Health Policy Unit).

• Georgia has ratified the UNCRPD and drafted a national disability law.

• In Georgia, rehabilitation and disability are closely connected. Concerted efforts are needed to disentangle them in order to emphasize that rehabilitation is part of the health-care continuum and available to anyone who needs it.

• There is little or no evidence of systematic coordination between Government ministries on rehabilitation.

• There is no national plan for rehabilitation.

• There is no reporting on the status or performance of rehabilitation in health systems.

• There is limited evidence of accountability mechanisms between rehabilitation service providers and MoIDPLHSA. The only accountable medical facilities are those where services are provided by rehabilitation doctors (licensed/certified for independent medical practice). Service providers submit monthly reports to the Agency on the work performed.

• Only medical doctors are regulated (professional competencies) and require a licence to practise (Certificate for Independent Medical Practice). This requirement does not yet apply to any other members of the rehabilitation workforce.

• Early childhood development has many policy documents and coordination mechanisms.

• Assistive products are largely unregulated. The Government has few guiding frameworks for the procurement or provision of assistive products.

• No list of priority assistive products has yet been developed. 6. Rehabilitation financing 20 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Key components Status

Mechanisms for rehabilitation Rehabilitation financing within MoIDPLHSA is primarily for children and adults with disability. financing All other rehabilitation is paid by individuals; almost exclusively as out-of-pocket expenditure (OOP).

Rehabilitation expenditure The three key budget lines for rehabilitation within MoIDPLHSA social rehabilitation and child care for rehabilitation include early childhood development, assistive products, and habilitation/ rehabilitation; the total budgeted amount is GEL 12 million (approx. US$ 4.3 million). See Table 4 below.

Rehabilitation expenditure The budget for social rehabilitation and child care represents less than 1% of the total as proportion of total health MoIDPLHSA budget. Of that 1%, approx. 31% is budgeted for rehabilitation (as above). expenditure

Assistive product expenditure According to MoIDPLHSA 2020 budget, just over US$ 2 million is available for assistive products (see Table 4 below).

OOP costs of rehabilitation OOP payments for health care stand at over 50%. For adults without a disability determination, OOP costs for rehabilitation would be nearer 100%, as it is not covered under UHCP and generally not part of insurance.

6.1 Mechanisms for health (and rehabilitation) financing

In 2013, Georgia launched the UHCP, whereby the SSA reimburses providers according to agreed tariffs for specific conditions and procedures. By May 2017, the UHCP covered more than 95% of the population, based on the number of persons registered with a primary care provider (18). Rehabilitation and assistive products are not included in the UHCP package.

In addition to UHCP, the health budget also finances 23 vertical programmes for priority diseases and conditions. The vertical programmes include mental health, diabetes management, child leukaemia services, dialysis and kidney transplantation, palliative care and a range of public health protection programmes, including tuberculosis control, vaccination programmes and the innovative hepatitis C programme (18).

Fig. 4. Health expenditure 2017

1% 6% Public

OOP Public (38%): UHCP or vertical 38% programmes OOP (55%): out-of-pocket VHI VHI (6%): voluntary health insurance 55% Intl donor (1%): International donors Intl donor

Source: CDC Statistical Yearbook 2018. Rehabilitation financing 21

Voluntary health insurance is also available in Georgia; it accounts for 5–7% of the health budget.6 OOP payments constitute the main source of revenue for health care (57%) (18). For a breakdown of health expenditure, see Fig. 4.

An additional source of financing is through municipal budgets. Each has the discretion to determine supplementary amounts for health-care or social programmes (including rehabilitation), and support for individuals is provided on a case-by-case basis. Information from municipalities was not collected during this assessment.

Table 4. MoIDPLHSA budget 2020

Budget line GEL US$ Percentage of total

Total Government budget 13 000 000 000 4 659 563 265 100.00

1. MoIDPLHSA budget 4 363 000 000 1 563 821 117 33.56

1.1. Population health 1 079 000 000 386 743 751 8.30

1.1.1. Universal health care 757 136 000 271 421 517 5.80

1.1.1.2. Mental health 27 500 000 9 877 759 0.20

1.2. Social protection 3 126 000 000 1 120 996 145 24.04

1.2.1. Pensions 2 230 000 000 799 420 425 17.20

Subdivisions within social protection budget

1.2. Social protection 3 126 000 000 1 120 996 145 100.00

1.2.1. Pensions 2 230 000 000 799 420 425 71.30

1.2.2. Social rehabilitation and child care 37 400 000 13 411 790 11.90

Subdivisions within social rehabilitation and child care budget

1.2.2. Social rehabilitation and child care 37 400 000 13 411 790 100.00

1.2.2.1. Early childhood development 3 200 000 1 147 776 8.55

1.2.2.2. Day-care service provision 6 300 000 2 259 684 16.84

1.2.2.3. Assistive products 5 600 000 2 007 402 14.97

1.2.2.4. Habilitation and rehabilitation of children 3 440 000 1 233 859 9.19

1.2.2.5. Subprogramme to promote communication for deaf people 48 000 17 216 0.12

1.2.2.6. Subprogramme to provide home care for children with 252 000 90 387 0.67 severe and profound developmental delays

1.2.2.7. Subprogramme to provide home care for children with 255 500 91 642 0.68 severe and profound disability or health problems

MoIDPLHSA: Ministry of Internally Displaced Persons from the Occupied Territories of Georgia, Labour, Health and Social Affairs.Source : English version of the Georgian Basic Directions and Data (BDD) 2020–2023 Midterm Budget.

6 Information from finance meeting in Tbilisi, 11 February 2020. 22 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

6.1.1 Autonomous Republic of Adjara

The Ministry of Health and Social Affairs of Adjara has its own budget.7 The total budget amount of the Ministry is GEL 21 000 000 (approx. US$ 7.6 million). Within this budget, there is a broad budget category of medical and social rehabilitation, GEL 2 767 280 (approx. US$ 1 million) with subprogrammes that resemble the MoIDPLHSA budget.

One unique characteristic of the Adjaran budget is an allocation for adult medical rehabilitation. This budget line, GEL 600 000 (approx. US$ 216 000) is listed within general medical services (code 06 02) and not within the medical and social rehabilitation code (06 05). The funding is for adults with disability.

6.1.2 Payment processes for rehabilitation treatments

Payment for rehabilitation is based on a preset number of treatments and/or vouchers, with maximum budget amounts clearly stated. In Georgia, rehabilitation is paid for children under the age of 3 years, children with disability (up to 18 years), adults with disability, elderly, war veterans and other vulnerable populations. The criteria for eligibility are clearly stated in multiple guidance documents.

For children (age 18 years and below), payments through SSA for one calendar year cover the following interventions: – eight courses of treatment – GEL 330 (approx. US$ 120) maximum payment per course; – one course is a maximum of 22 sessions; an individual can receive up to eight course per year; – course duration is 10 days (generally administered over a one-month period).

In summary, a child is eligible for a total of 80 days of interventions that include up to 176 treatments, with a maximum contribution by the SSA of GEL 2640 (approx. US$ 950) per calendar year.

In Adjara, rehabilitation payments for adults with disability in one calendar year include: – two courses of treatment – GEL 600 (approx. US$ 215) maximum payment per course; – there must be at least 15 sessions (procedures or treatments) – maximum one procedure per day.

In summary, an adult with disability in Adjara is eligible for 30 days of interventions for a total ceiling of 30 procedures/treatments with a maximum contribution of GEL 1200 (approx. US$ 430) per calendar year.

For assistive products, SSA mails a voucher for the amount it will reimburse. The individual takes this voucher to an approved service provider to receive the product.

6.2 Rehabilitation expenditure

The projected 2020 rehabilitation budget within social protection is over US$ 6 million (see Table 4).

7 Source: 2020 budget in Georgian, shared during the meeting on 24 February 2020. Rehabilitation financing 23

6.3 Assistive product expenditure

Budgeting and expenditure for assistive products come under the social protection budget, a subdivision of the social rehabilitation and childcare budget. The annual budget for assistive products is about US$ 2 million (see Table 5). Of this amount, nearly half is used for prosthetics and orthotics, one third for cochlear implants and just over 15% for wheelchairs (of which over 60% is allocated to electric wheelchairs).

Table 5. MoIDPLHSA 2020 budget for assistive products

Description GEL* US$ % of total

Assistive products (as taken from Table 4) 5 600 000 2 007 402 N/A

Assistive products (summary of budget lines below) 5 848 500 2 445 534 100

Total budget for wheelchairs (120 electric/500 manual) 934 200 336 830 16

Electric wheelchairs (GEL 4785 / US$1725 per unit) 574 200 205 588 61.5

Manual wheelchairs (720 GEL/ US$259 per unit) 360 000 131 242 38.5

Prosthetics/orthopaedics (extensive price list provided) 2 682 000 967 008 46

Hearing aids (1400 digital hearing aids) 378 000 136 289 6

Cochlear implants – 30 (per unit GEL 39 500 + rehabilitation costs) 1 854 300 668 577 32

Crutches, canes, walking frames (no budget provided) 0 0 0

Smartphones (for deaf and hard of hearing individuals) 6000 2152 0

*: Total budget amount for assistive products is taken from the 2020–2023 Midterm Budget, while specific funding ceiling is taken from the 2020 State Programme for Social Rehabilitation and Childcare. The total amounts may vary and thus the figures and percentages are purely illustrative. Source: (20).

6.4 Out-of-pocket costs of rehabilitation

There are no detailed data available on the OOP costs of rehabilitation. As UHCP does not cover this, it is likely that OOP costs of rehabilitation go far beyond the 55% of OOP costs of health-care services.

Summary of rehabilitation financing situation

• UHCP benefits approx. 95% of the population, but does not include rehabilitation.

• Approximately 84% of Georgia’s health service providers are private.

• The Government of Georgia allocates over US$ 4 million annually (through SSA) for rehabilitation services and products, but resources are primarily for children with disabilities within social programmes.

• The Autonomous Republic of Adjara funds adult rehabilitation; this programme is for adults with disability. 24 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

• MoIDPLHSA (through SSA) provides approx. US$ 2 million annually for a limited type and number of assistive products.

• The voucher system (payment for rehabilitation services and assistive products) specifies dosage, timeline and funding amounts for goods and services. This is irrespective of an individual diagnosis, specific need or treatment outcomes from previous investments.

• Adults (without a disability) who need rehabilitation must pay for services out of their own pocket. 7. Human resources, infrastructure and equipment for rehabilitation 26 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Key components Status

Total number of rehabilitation personnel There are an estimated 300 medical doctors licensed with specialization in rehabilitation or certified for independent medical practice; other rehabilitation personnel include approx. 500 physical therapists, 25 occupational therapists, approx. 1000 speech and language therapists and logopeds and approx. 10–15 P&O technicians (including bench workers).

Number of rehabilitation personnel per Data not centralized, consolidated or available. Some information is available for 10 000 population medical doctors.

Distribution of rehabilitation personnel Information available for rehabilitation doctors (see Table 12 below); no other across geographical areas information is collected at central level.

Licensure and regulations for rehabilitation Only medical doctors require a licence/certificate and are regulated. No other personnel rehabilitation personnel have this requirement.

Rehabilitation infrastructure and There are no minimum standards for rehabilitation equipment. equipment

7.1 Context of the rehabilitation workforce in Georgia

Historically, rehabilitation in Georgia is linked to health resort therapy and massage. Rehabilitation workforce terminology8 includes some post-Soviet-era terms, including balneology (resort therapy) and rehabilitologist (which may refer to a doctor specialized in rehabilitation or a physical therapist). Training programmes focus on massage and therapeutic exercise. The large majority of logopeds speech therapists focus on speech development, phoniatrics and correcting pronunciation.

Training for the rehabilitation workforce in Georgia is evolving. Medical doctors obtain their specialization in rehabilitation through residency. In addition, there are accredited programmes (at bachelor and master’s levels) in PT, OT and SLT. These programmes help to bring existing standards closer to international norms.

Some key challenges in the health workforce are the lack of regulatory structures and competency frameworks to guide the professions (exceptions include medical doctors specialized in physical medicine, rehabilitation and resort therapy). Continuing education is not a requirement in Georgia.

7.2 Rehabilitation workforce training

The MoES and MoIDPLHSA are the two ministries involved in health workforce training. The MoES oversees university education and training programmes for bachelor, master’s and doctoral degrees, and houses the National Centre for Educational Quality Enhancement (NCEQE).9

NCEQE is the only educational quality assurance body in Georgia, established by the Law on Educational Quality Enhancement in 2010. NCEQE is a LEPL under MoES. Its functions include:

8 Though no specific definition is provided, WHO notes: “There are a broad range of health professionals who provide rehabilitation interventions, including physiotherapists, occupational therapists, speech and language therapists, orthotic and prosthetic technicians, and physical medicine and rehabilitation physicians” (Rehabilitation. In: World Health Organization [website]. Geneva: World Health Organization; 2021 (https://www.who.int/ news-room/fact-sheets/detail/rehabilitation, accessed 20 August 2020). 9 Unfortunately, the assessment team did not meet any officials from NCEQE. The information in this report is from the NCEQE website (About us. In: National Center for Educational Quality Enhancement [website]. Tbilisi: National Center for Educational Quality Enhancement; 2020 (https://eqe.ge/en/ page/static/5/chven-shesakheb, accessed 20 August 2020). Human resources, infrastructure and equipment for rehabilitation 27

– implementation of external quality assurance mechanisms of all educational institutions (higher education, vocational education and general education) operating in the country; – development and governance of the National Qualifications Framework (NQF); and – recognition of foreign education (21). NCEQE oversees the NQF. This document unites all the qualifications existing in Georgia, reflects the learning outcomes of different levels of general, vocational and higher education – including the knowledge, skills and responsibilities a person should have (21).

NCEQE also oversees the classification of fields of study in Georgia22 ( ).10

Some fields of study are described inTable 6 . PT is represented by the formal classification of physical medicine and rehabilitation.

Table 6. Classification of fields of study in Georgia

Classification no. Field of study

09 Health and welfare

091 Health

0915 Therapy and rehabilitation (i.e. the study of restoring normal physical condition to those incapacitated by temporary or permanent disability)

0915.1.1 Physical medicine and rehabilitation

0915.1.2. Occupational therapy

0915.2.1. Speech and language therapy

Source: (23).

7.2.1 Medical doctors

MoIDPLHSA regulates postgraduate specialized training for doctors. There are 27 main specializations for doctors. Physical medicine, rehabilitation and resort therapy, as well as sports medicine, are included in internal medicine (24).

MoIDPLHSA Order No. 01-8/n (30 March 2015) gives details of the professional competencies for 31 medical specialties; these include physical medicine, rehabilitation and resort therapy, but not sports medicine.

Medical doctors can attain specialization in rehabilitation through a 3.5-year residency programme after six years of general medical education; an individual with a related medical specialty (e.g. internal medicine) can retrain in physical medicine, rehabilitation and resort therapy by attending a course lasting several months (length is decided by the programme director). These training opportunities are available only at the Tbilisi State Medical University (TSMU). Both pathways require an individual to pass the State exam to obtain a licence (Certificate of Independent Medical Practice).

10 Based on two United Nations Educational, Scientific and Cultural Organization documents: International standard classification of education (ISCED-F-2013) (reference 22) and Education and training fields 2013 – description of detailed fields (ISCED-Foet-2013). 28 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

7.2.2 Physical medicine and rehabilitation (physical therapy)

As noted previously, the formal classification for physical therapy in Georgia is “physical medicine and rehabilitation”. According to NCEQE information on accredited universities and graduates,11 nine universities are accredited to offer a bachelor-level degree in physical medicine and rehabilitation; four of them also provide master’s degree programmes; see Table 7 for details. The number of graduates from each establishment is listed below: – NCEQE figures (non-shaded cells): BA – 507 and MA – 75 – University figures (shaded cells): BA – 670 and MA – 187.

Annual estimates for future years is approx. 100 at bachelor level and approx. 25 at master’s level (conservative figures).

Table 7. Training programmes in physical medicine and rehabilitation in Georgia

Name of university/ Duration Year Accreditation dates Graduates Total Ongoing programme started per year graduates Start End

1. Tbilisi State Medical University

BA (Georgian) 4 years 2008 - - 50–65 337 Yes

BA (English) 4 years 2008 - - ~35 149 Yes

BA 4 years - 11/28/2019 11/28/2026 ? 400 Yes

BA 4 years - 09/06/2012 07/01/2020 ? ? No

MA Paediatric 2 years 2011 12/06/2019 12/07/2026 ~4 23 Yes Rehabilitation

MA Sports Rehabilitation 2 years 2014 12/06/2019 12/07/2026 ~8 22 Yes

MA Rehabilitation 2 years 2011 10/21/2011 07/01/2020 ~3 12 Yes Counsellor

2. Georgian State Teaching University of Physical Education and Sport

BA 4 years 2014 - - 50–70 240 Yes

BA 4 years 2014 07/22/2015 07/22/2020 ? 44 Yes

MA 2 years 2014 05/19/2014 05/19/2020 ? 6 Yes

MA () 2 years 2014 - - 10 120 Yes

3. Teaching University “Geomedi”

BA 4 years - 12/19/2019 12/21/2026 - 15 Yes

MA 2 years - 12/19/2019 12/21/2026 - 12 Yes

4. Saint King Tamar University of Georgian Patriarchate

BA 4 years 2008 12/14/2015 12/14/2021 ~6 21 Yes

5. Batumi Shota Rustaveli State University (BSU)

BA 4 years 2013 08/27/2018 08/27/2024 ~6 1 Yes

11 Source: information from MoES Higher Education Office – by email on 13 March 2020. Human resources, infrastructure and equipment for rehabilitation 29

Table 7. contd.

Name of university/ Duration Year Accreditation dates Graduates Total Ongoing programme started per year graduates Start End

6. Batumi Teaching University

BA 4 years - 03/19/2019 03/19/2025 - - Yes

7. Akaki Tsereteli State University

BA 4 years 2018 06/28/2016 06/28/2023 - -

8. New Vision University

BA Medical Rehabilitation 4 years - 08/16/2016 08/16/2023 - - Yes and Nursing (English)

MA Medical Rehabilitation 2 years - 08/16/2016 08/16/2016 - - Yes & Public Health Management (English)

9. Caucasus International University

BA (English) 4 years - 11/14/2018 11/14/2024 - 26 Yes

BA 4 years - 06/10/2014 06/10/2019 - - No

Dates expressed in figures for brevity, e.g. 10/21/2011 = 21 October 2011. BA: Bachelor of Arts; MA: Master of Arts;?: information not available; -: not applicable; ~: approximately. Source: MoES Higher Education Office, received by email on 13 March 2020.

7.2.3 Occupational therapy

In Georgia, OT training is offered only at Ivane Javakhishvili Tbilisi State University. Key dates are below. – 2001: Two individuals graduate from a 3.5-year OT programme. – 2001–2005: (Tempus Project), 13 graduates12 (eight in the first cohort and five in the second cohort). – 2006: Tbilisi State University launches the four-year BA programme. – 2011: World Federation of Occupational Therapists approves curriculum. – 2006–2020: 26 individuals graduate (approximately 2–3 students per cohort).

There are approximately 25–26 people with a BA in OT in Georgia and currently there are 15 students training for their BA in OT.13 Summary information on training in OT is in Table 8.

The Georgian State Teaching University of Physical Education and Sport – a history

The Georgian Institute of Physical Education and Sport opened in 1939. Among other faculties, the Faculty of Medicine and Rehabilitation admitted 200–300 students per year. In 1998, it became the Georgian Academy of Physical Education and Sport, offering a curriculum of physical therapy and rehabilitation, with 500 students (including those from ). In 2008, the entire facility closed and the students and faculty members were transferred to other universities. In 2014, the university reopened as the Georgian State Teaching University of Physical Education and Sport. Graduates that precede the 2014 opening are not verified and are not included in this report.

12 Of this number, only four remain in the country – the rest have moved to other countries. 13 Source: information from workforce meeting on 12 February 2020. 30 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Table 8. Occupational therapy training programme in Georgia

Name of Duration Year started Accreditation dates Graduates Total Ongoing university/ per year graduates programme Start End

Ivane Javakhishvili Tbilisi State University

BA 4 years – 09/16/2011 07/01/2020 – 16 Yes

BA 4 years 2006 – – 2-3 26 Yes

Source: Information in the first row of the table is derived from NCDC data received from the MoES Higher Education Office by email on 13 March 2020; information in the second row comes from interviews with OT programme faculty. -: not applicable.

7.2.4 Speech and language therapy

Ilia State University (ISU) is the only accredited training institution to provide speech and language therapy training in Georgia.14 It began offering a two-year MA degree in 2017. There were eight graduates in 2019, with a predicted 14 graduates in 2020 and nine in 2021. Every year, ISU can accept up to 15 students.15 At present there is no BA programme, but ISU is hoping to introduce one in the coming years. Summary information on training in SLT is shown in Table 9.

In addition to the ISU master’s-level SLT programme, there are other pathways for Georgians to receive speech therapy training. The information below is illustrative. – Through professional development institutes (in the Russian Federation) in the 1960s; unknown number of graduates. – The Pedagogical University provided a “defectology correction” programme with subprogrammes related to speech. The programme ended in 2002 with an estimated 70–90 graduates.16 – Private training facility (EMTA) (co-founder Nino Gabashvili) provides ~60 hours of training and has trained over 100 people. – Logomedi, founded by Mzia Putkaradze. In 1967, one-year courses were available, currently there is a six-month course with 20–25 graduates per year.17

Table 9. Speech and language therapy training programme in Georgia

Name of Duration Year started Accreditation dates Graduates Total Ongoing university/ per year graduates programme Start End

Ilia State University

MA 2 years – 08/19/2016 08/19/2023 – – Yes

MA 2 years 2017 08/19/2016 08/19/2023 8-10 8 Yes

Source: Information in the first row of cells is derived from NCDC data received from the MoES Higher Education Office by email on 13 March 2020; information in the second row comes from interviews with SLT programme faculty. -: not applicable.

14 Speech and language therapy is the term used in the classification of fields of study in Georgia. The term used by Ilia State University is Master’s Programme in Communication, Speech and Language. 15 Source: information from interview with ISU SLT Programme faculty, 19 February 2020. 16 Source: information from interview with ISU SLT Programme faculty, 19 February 2020. 17 Source: discussion with Mzia Pulkaradze on 25 February 2020 and website http://logomedi.ge/?lang=en. Human resources, infrastructure and equipment for rehabilitation 31

7.2.5 Prosthetics and orthotics

Currently, there is no recognized training programme in P&O in Georgia. Relevant professions (prosthetists and orthotists) are not listed in the national roster of professions.

At the end of the 1990s, with support from ICRC and the International Society for Prosthetics and Orthotics (ISPO), an ISPO-accredited three-year training course for Category II P&O technicians was developed (see below for P&O category description). The training was held at GEFPOR. After the coursework was complete, ISPO representatives came to Georgia to conduct exams; five graduates received certification and four have emigrated to other countries.18 Currently at GEFPOR, there are one Category II P&O specialist and two technologists with 20 years of working experience and retraining from the German P&O company, Ottobock.

ISPO-recognized categories in prosthetics and orthotics

Category I P&O: four-year training in prosthetics and orthotics (offered in multiple countries)

Category II P&O: three-year training in prosthetics and orthotics

Category II Prosthetics (single discipline): 18-month training in prosthetics

Category II Orthotics (single discipline): 18-month training in orthotics

Bench worker: Mixed levels of training and experience; most is on-the-job

The Rehabilitation Centre for Persons Having Limited Ability (MoD Georgia) has 10 P&O staff: – three staff have had three years of training in (1995–1998) – possibly qualified to Category II level; – four staff have been certified by Ottobock (unknown level).

Other training in recent years has been ad hoc and supported by Ottobock or by the United States Government.

In summary, there is only one ISPO-recognized Category II P&O technician in Georgia. There are multiple other levels of training, but the level of qualification is difficult to determine with the information provided.

7.2.6 Psychologists

There are at least 14 universities that offer general psychology courses with over 2000 graduates.19 There is only one programme (at TSU) that offers a master’s-level degree in clinical neuropsychology. During discussion on SLT, it appears that neuropsychologists are involved in adult SLT (addressing aphasia after stroke).20 The TSU programme began in 1998.21 There are 14 graduates from the TSU master’s programme.

18 Source: information from meetings with GEFPOR on 18 February 2020. 19 Source: data sent by MoES Higher Education Office by email on 13 March 2020. 20 Source: discussion with MAC Georgia on 19 February 2020 and interview with ISU SLT programme faculty on 19 February 2020. 21 Source: email communication from MAC Georgia on 19 March 2020. 32 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

7.2.7 Wheelchair provision

Since 2010, at least 10 training courses22 have been held in Georgia using the WHO wheelchair service training packages. The Latter-day Saint Charities (LDSC) have trained nearly 70 people using a shortened version of the WHO training package. A summary training dates, levels and participants is in Table 10.

Table 10. Number of people trained in wheelchair provision (using WHO training packages)

Dates Basic Basic/ Intermed. Advanced Training of trainers intermediate Basic Intermed. Advanced

8–12 March 2010 4 – – – – – –

21 June–2 July 2010 – 5 – – – – –

1–10 February 2011 – – – 5 – – –

19–23 September 2011 – – – – 4 3 3

26–30 September 2011 7 – – – – – –

3–14 October 2011 – – 4 – – – –

2–12 April 2012 – – – 2 – – –

22–26 October 2012 5 – – – – – –

21 June–3 July 2013 6 – – – – – –

17 Oct–6 Nov 2013 – – 4 – – – –

Subtotal 22 5 8 7 4 3 3

LDSC 2010-2019 ~70 No data on the number of individuals currently providing wheelchairs

Total trained 92 5 8 7 4 3 3

Source: Information consolidated from email communication with MAC Georgia, CIL and other stakeholders.

7.2.8 Nursing

Nurses in Georgia are trained in two-year or three-year courses at vocational schools across the country. Since 2011, nursing education has also been provided as a bachelor-level programme in universities. There is no specialization in areas such as rehabilitation nursing.

Caritas Georgia provides a training module (approx. 100 hours) on home care for nursing students.23 Caritas has a memorandum of understanding with 28 colleges, of which eight send students to Caritas for training. There are 10–20 students per course and approximately 400 students per year. To date, Caritas has trained about 2800 nursing students in home care.

22 Wheelchair training has been supported by CIL, MAC Georgia, Neurodevelopment Centre and others. 23 Source: interview on 25 February 2020, Tbilisi. Human resources, infrastructure and equipment for rehabilitation 33

Caritas provides (or plans to provide) other training programmes relevant to rehabilitation: – rehabilitation module (42 hours) – about 100 people trained; – educational programme for caregivers – not yet implemented; to start at the end of 2020.

7.3 Pre-service education – clinical practice

The assessment does not examine details on workforce pre-service training (curriculum content, theory vs. practice and clinical supervision and guidance). Many facilities have agreements with universities to serve as clinical sites for pre-service training. The educational institution sets requirements on performance evaluation forms and selects clinical mentors for students’ clinical practice.

Evidence of good practice and promising future developments supporting clinical practice include: – the TSMU clinical practice assessment form (extremely thorough); – the Caritas mentorship course to help medical professionals become better clinical mentors (2021); – discussion on the use of the Objective Structured Clinical Examination24 in Georgia and including rehabilitation as one of the professional fields to be included.

7.4 Licensing, regulation and continuing medical education

Within MoIDPLHSA, SRAMA is responsible for regulating medical facilities and professionals. Only medical practitioners (physicians) are required to have a licence (Certificate of Medical Practice) in order to practise – no other health professionals have a licensing requirement. A licence is issued after passing a national examination, and is valid for life.

MoIDPLHSA regulates only medical activities and has professional competencies to regulate medical specializations. Within MoES, NCEQE has classified fields of study for PT, OT and SLT, but has not yet completed the NQF for these professions. A working group on professional standards and licensing has been established within the Emory University physical rehabilitation project in Georgia.

There is no continuing medical education (CME) requirement for health professionals working in the field of rehabilitation in Georgia.

7.5 Rehabilitation workforce numbers and locations

In Georgia, about 300 physicians are authorized to engage in independent medical work in the specialty of physical medicine, rehabilitation and resort therapy.25 Data on their employment are provided in Table 11.

24 This examination is a form of performance-based testing used to measure candidates’ clinical competence. 25 Source: Information from the TRIC, completed February 2020. 34 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Table 11. Number of rehabilitation doctors by location in Georgia.26

Location Rehabilitation doctors

Adjara 15

Guria –

Imereti 5

Kakheti 3

Kvemo –

Mtskheta-Mtianeti –

Racha- and Kvemo –

Samegrelo 6

Samtskhe- –

Shida Kartli 1

Tbilisi 84

Total (in Georgia) 114

-: no information available.

Although there are no consolidated data about numbers and locations of PTs, OTs and SLTs working in Georgia, the following estimates are provided from discussions during the in-country assessment: – physical medicine and rehabilitation (PTs): over 500 working in the country – OTs: Approximately 25 in the country – SLTs (and logopeds) – over 1000, with a wide variety of qualifications27 – P&O technicians: approx. 10–15 (including bench workers) – audiologists: approx. 10–12 in the country.28

7.6 Professional associations

There are multiple rehabilitation-related professional associations in Georgia. For some professions, there is more than one association. In addition, the name of an association may not accurately represent the membership. Details are provided in Table 12.

26 Source: annual reporting Form IV- 01 2018 Year; information provided by email by NCDC on 20 February 2020. 27 Source: discussion with Mzia Pulkaradze on 25 February 2020. 28 Source: estimate from discussion with Aversi audiologist on 17 February 2020. Human resources, infrastructure and equipment for rehabilitation 35

Table 12. Rehabilitation-related professional associations in Georgia

Name of association Acronym Date Members Member International affiliation created description

Georgian Association of GAPMR 2019 Focal point: Avtandi Khmiadashvili Physical Medicine and Rehabilitation

Georgian Association GAPTAR 2017 ~200 Physical therapists World Confederation for of Physical Therapy and and physical therapy Physical Therapy Rehabilitation students (WCPT) – 2019

Georgian Occupational GE-OTA 2004 ~40 Occupational World Federation of Therapy Association therapists Occupational Therapists – 2016

Georgian P&O International - 2011 Focal point: Guta Vashadze Association

Georgian Physical GPTA 2017 ~150 Active and non-active Not yet – planning to join Therapists’ Association physical therapists WCPT

Georgian Physical Therapy GPTA 2003 ~120 Doctors with European Society of Physical Association specialization in and Rehabilitation Medicine rehabilitation (ESPRM)

Georgian Speech and GSLTA 2017 ~20 Graduates of ISU’s Plans to be affiliated with Language Therapy master’s programme international speech and Association language associations

Focal point: Tinatin Antidze

National Association of - 2012 Focal point: Dimitri Tsverava Medical Rehabilitation and Sport Medicine

Speech and Language EMTA 2018 30~ Khatuna Kobakhidze Intends (?) to join European Therapists’ Association International Association of Language and Speech

Speech Therapist - 2010 Focal point: Nino Maghlakelidze Association of Georgia

~ approx. Source: shaded cells – individual associations; non-shaded cells – Partners for International Development (PFID) Georgian representation, by email on 21 February 2020.

7.7 Remuneration

In general, salaries for health-care personnel are determined by their employers – the managers of the health- care facilities where they work. Payment is negotiated on an individual basis between health-care personnel and facility managers and can be based on workload or an agreed salary, or have elements of both (18). Primary care doctors working under the Rural Doctors’ Programme are contracted by MoIDPLHSA and paid a monthly salary (25). 36 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

7.8 Rehabilitation infrastructure/equipment

There is no list of essential rehabilitation equipment or materials required at different levels of care. The purchase of medical equipment is the responsibility of hospital managers and the decision is linked to the availability of finances as most hospitals are private enterprises. Current regulations do not set a national ceiling of units per population for high-technology equipment (18).

From site visits conducted during the assessment (see Annex 4), all rehabilitation centres, units or departments had at least one ultrasound, thermal or electrotherapeutic machine. Treatment plinths or mats to facilitate functional movements and activities were less evident. Therapeutic swimming pools were identified in one third of the sites visited.

Summary of rehabilitation human resources and infrastructure/equipment situation

• The nomenclature of the rehabilitation workforce is linked with the classification of fields of study in Georgia. Some existing vocabulary may be poorly aligned with terms commonly applied at international level (example: in Georgia, physical therapy is called physical medicine and rehabilitation).

• PT and SLT training programmes have a long history in Georgia. Graduates of different programmes have variable skills and competencies.

• Licensing is not required for PT, OT or SLT. Competencies and regulatory standards for these professions have not yet been developed in Georgia.

• A working group on professional standards and licensing has been established through the Emory University physical rehabilitation project in Georgia.

• There is no P&O training in Georgia and no recognized P&O Cat I technician in the country.

• There are many professional associations representing the rehabilitation workforce. Some professions have more than one association (PT and SLT have 2–3 associations each) which leads to potential confusion between, or duplication of, organizational mandates.

• There is a lack of comprehensive, consolidated and up-to-date information on numbers and locations of the rehabilitation workforce working in Georgia.

• There are no standard salaries for the rehabilitation workforce. Salaries are negotiated with individual employers and largely based on income from treatments provided.

• Continuing medical education is not required for any health staff in Georgia.

• Medical doctors are regulated and require a licence to practise (Certificate of Independent Medical Practice). Once granted, a licence is valid for life.

• Lack of uniformity and standards in rehabilitation-related pre-service clinical training. There are wide variations in the expectations and guidance between and among training institutions and clinical placement sites.

• Georgia has a well-documented workforce of wheelchair providers.

• The rehabilitation infrastructure (equipment and treatment space) varies; there is no guidance on minimum standards for rehabilitation equipment. 8. Rehabilitation information 38 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Key component Status

Data on disability, rehabilitation needs and population The 2014 census and the 2018 MICS collect data on disability functioning and functioning. A Model Disability Survey is planned for 2020.

Data, digitalization and Georgia’s health information systems Annual reports from health facilities sent electronically to NCDC.

Very limited information from health system data on the Data on availability/utilization of rehabilitation availability or utilization of rehabilitation.

There is no centralized data, and very limited information on Data on outcomes, quality and efficiency of rehabilitation outcomes, quality and efficiency of rehabilitation.

Data-driven decision-making There is no active planning of health personnel.

Outside of education institutions, there is very limited research Government funding for rehabilitation research on rehabilitation in Georgia.

8.1 Data on disability, rehabilitation needs and population functioning

To obtain reliable information showing how well a population is functioning, the Government must integrate a detailed “functioning module” into a health survey or where possible, undertake a dedicated functioning and disability survey.

In the 2014 census, Georgia collected data on population functioning and disability (26) based on questions devised by the Washington Group on Disability. The two questions from the 2014 census are shown in Fig. 5.

Fig. 5. Questions from the 2014 census related to disability29

The number of people in Georgia with disability is 100 113 (2.69% of the population); details are summarized in Table 13.

29 Content from Geostat questionnaire #2 (2014 census), http://census.ge/en/methodology/kitkhvarebi, accessed 30 September 2020. Rehabilitation information 39

Table 13. Number of people identified with disability status (2014 census)

Total Group I Group II Group III Children

100 113 26 784 58 255 9902 5172

The number of people with difficulty functioning is 1 301 675 (35% of the population); see Table 14 for summary information, and Annex 7 for details.

Table 14. Number of people who identified any difficulty in functioning (2014 census)30

Summary of six domains30 Description of limitation Total

Some difficulty A lot of difficulty Cannot do it at all

Number of people 977 633 264 966 59 076 1 301 675

Percentage 26.3 7.13 1.59 35

In 2018, Georgia carried out a MICS that identified 28% of children and adults (aged 2–49 years) as having difficulty functioning in at least one domain17 ( ). See Table 15 for details.

Table 15. Number of people with difficulty functioning, by age group (2018 MICS)

Age group Sex Number surveyed Percentage with difficulty functioning in at least one domain

2–4 years Both 1606 1.8

5–17 years Both 5827 9.5

18–49 years Male 2455 6.8

18–49 years Female 6488 9.9

2–49 years Both 16 376 28.0

Source: (17).

Disability status determination

The disability status determination system in Georgia is based predominantly on a specific diagnosis, the International Classification of Diseases, 10th edition (ICD-10), and is grouped into three categories: Levels I, II and III.31 Since 2008, the Government of Georgia has nominated the facilities that are eligible to determine disability status. There are approximately 70 facilities authorized to determine disability status, 23 of them in Tbilisi.32 Disability status is important for determining eligibility for State allowances – social package and is a requirement for accessing SSA payment vouchers for designated rehabilitation services and assistive products.

30 These are seeing, hearing, walking/climbing steps, remembering/concentrating, communicating, and self-care. 31 Level I is the most severe disability, Level II is moderate, and Level III is mild and not eligible for disability pension. 32 Source: Health Unit, MoIDPLHSA Policy Division, 18 February 2020. 40 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Disability status determination is influenced by age (over 18 years), diagnoses (some must be assessed annually, while others are determined for life) and onset of the problem (waiting period of six months after onset of the condition). Disability status determination is not based on function.

In 2017, UNICEF Georgia, in close cooperation with MoIDPLHSA and the Georgian Association of Social Workers, began developing a social model of disability assessment and status determination system. The pilot project in six medical facilities in Adjara runs from April 2019 to May 2020. To date, over 600 people have joined the pilot (including 250 children). There is a parallel pilot project in three clinics in Akhaltsikhe (November 2019–June 2020).33 The premise of these pilot projects is to compare disability status determination using the current medical model with the piloted social model of disability status determination. Data analysis of the differences between them may serve as a foundation for future decision-making on disability determination.

8.2 Data, digitalization and the Georgian health information system

The foundation for building the unified Health Management Information System (HMIS) in Georgia was laid in the period 2000–2015 within the framework of the USAID Georgia health system strengthening programme. As part of this programme, a document was published, entitled “Georgia Health Management Information System strategy: healthy Georgia, connected to you” (27). The document describes how MoIDPLHSA will implement a new HMIS to interconnect the information needs of the Ministry, insurers, providers and patients.

Various international partners and donor organizations, including UNICEF, the United Nations Population Fund (UNFPA), Caritas in the , the United States Centers for Disease Control and Prevention and many other organizations joined this process in later years.

Since 2012, the State has also been actively involved in these processes and many business processes have been shifted from paper-based to electronic media, and various processes have become fully automated. Currently, a few dozen electronic systems and registries operate in the country, which document and manage health- related issues for the citizens of Georgia.

Since 2012, new technologies of data reporting have been gradually introduced in Georgia. Electronic reporting systems were launched for all inpatient and outpatient health facilities providing services countrywide, including under the UHCP and vertical programmes (18).

Each year, NCDC collects information from all medical facilities.34 The three main forms discussed during the assessment are Form #01 (facility information and statistics on staffing structures), hospital registration Form #066 (provides information on patients – diagnosis and treatments) and Form #025 (information on initially identified outpatient cases). In the Nordic Medico-Statistical Committee (NOMESCO) Classification of Surgical Procedures (NCSP), there is a chapter on rehabilitation and nursing care (Code R). NCDC requests hospitals to provide up to three major surgical procedures and three or more diagnostic or therapeutic procedures. During the years 2018–2019, there was only one report classified as “other rehabilitation procedure” (R4R160).35

33 Source: interview with UNICEF, Tbilisi, 20 February 2020. 34 Source: interview with NCDC on 18 February 2020, Tbilisi. 35 Source: NCDC, 20 February 2020. Rehabilitation information 41

8.3 Data on availability /utilization of rehabilitation

There are no consolidated data on the availability or utilization of rehabilitation in Georgia.

Individual facilities36 collect information on treatments provided, but there is no uniform data set or standardized forms or registry between facilities.

Two initiatives provide information on the availability of rehabilitation. The first is a hard-copy pamphlet called the “Akhaltsikhe municipal social and health services guide”. In 2013, the and five partner organizations (with funding from the European Union) created a pamphlet that outlines available services in the municipality with the following format: – name of service – what kind of support is provided by the service? – for whom is the service intended? – who provides the services? – what steps do I need to take to get a service (what documentation to submit)? – contact information.

The second initiative is the planned electronic mapping of service providers37 being developed by MAC Georgia. It should be noted that this system is not part of the HMIS.

8.4 Data on outcomes, quality and efficiency of rehabilitation

There are no consolidated data on the outcomes, quality and efficiency of rehabilitation in Georgia.

Summary of rehabilitation information situation

• The 2014 Census lists 100 113 people with a disability (2.69% of the population) and identifies 1 301 675 people (35% of the population) have difficulty functioning.

• The 2018 MICS (16 376 people, age 2–49 years) notes that 28% per cent of those surveyed have difficulty functioning.

• Information on work locations of medical doctors is collected and available.

• There is no collated nor centralized information on the work locations of PTs, OTs, SLTs.

• There are no centralized data available on names and locations of health facilities that provide rehabilitation services.

36 These include health facilities (public and private), rehabilitation and day centres. 37 Source: Sheaghe Discovering Services (www.sheaghe.ge, accessed 30 September 2020). 42 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

• Determination of disability status is based primarily on the ICD-10 diagnosis. There are two pilot programmes to determine disability incorporating functioning. Tools have been developed by UNICEF and the initiative is funded by USAID Georgia.

• No data are collected on outcomes, quality or efficiency of rehabilitation services.

• Data-driven decision-making is not a common practice related to workforce planning in the field of rehabilitation.

• There is very little research on rehabilitation in Georgia. 9. Rehabilitation service accessibility and quality 44 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Key components Status

Percentage of tertiary and secondary hospitals with Consolidated and centralized data are not available. rehabilitation services

Percentage of districts/communities covered by rehabilitation Consolidated and centralized data are not available. services

Number of specialist rehabilitation facilities/units One specialist rehabilitation facility (pulmonary), and approx. 10 that focus on rehabilitation (see narrative and Table 16).

Number of rehabilitation beds and rate per 10 000 population Estimated approx. 130 rehabilitation bed capacity in the country (see Table 16).

9.1 Rehabilitation service accessibility: overview

Consolidated and centralized data on the location of rehabilitation services in Georgia are not available. Although NCDC collects annual data from health facilities, information on rehabilitation is not included. Most health service providers in Georgia are privately managed and have their own staffing structures and operating systems. UHCP covers treatment procedures and hospital stays (not rehabilitation).

In Georgia, the availability of rehabilitation is weighted towards children with disability, with services funded through social programme budgets. An adult with disability may be eligible for some rehabilitation services and products, but the vast majority of adults needing rehabilitation must pay OOP for any intervention.

The assessment team visited approx. 15 health service and rehabilitation providers (public and private), but did not visit any balneology (health resort), audiology or ophthalmology facilities. The main findings are in this section. They do not adequately reflect all services, and further investigation is needed.

9.1.1 Rehabilitation in health facilities

In general, rehabilitation treatments are grouped into three main categories: physiotherapy procedures (generally these comprise machines to deliver electrotherapeutic, iontophoresis, light, thermal and ultrasound treatments), medical massage and medical exercises.

Two polyclinics visited during the assessment each have one licensed doctor specialized in rehabilitation who delivers physiotherapy procedures for adults and children. All payments are OOP.

Larger private companies (Aversi, Evex, PSP-New Hospitals, D. Tatishvili Medical Network) each have a specialized unit or rehabilitation centre as part of their network. Aversi notes that five of their 11 clinics nationwide offer rehabilitation (one is a formal rehabilitation centre, while four clinics have one staff PT).

Rehabilitation case study: awareness of and incentives for inpatient wards

Dr Nino Kervalishvili has a PhD in cardiology and a specialization in rehabilitation. She has worked in Aversi Clinic for over 10 years. During this time, she (with two other medical doctors) provides awareness training on rehabilitation to medical doctors in the Aversi inpatient wards. The monthly training courses have evolved to 2–3 times per year as many doctors understand and prescribe rehabilitation – especially for postsurgical cases. Although payments for rehabilitation are still OOP, Aversi offersreduced rates on rehabilitation for inpatients, while the Tatishvili Medical Network offers 20–50% discounts on rehabilitation for all insurance companies. Rehabilitation service accessibility and quality 45

9.1.2 Rehabilitation for children

Within MoIDPLHSA, rehabilitation for children is available through three social subprogrammes:38 early childhood development, rehabilitation/habilitation and day care.

According to MoIDPLHSA,39 29 organizations provide early childhood development services for 1300 beneficiaries in 13 municipalities (Akhaltsikhe, Batumi, , Gori, , , , , , Tbilisi, , and ). The early childhood development programme includes children up to the age of 7 years; children under 3 years do not need to have a disability to be accepted into the programme.

MoIDPLHSA notes that there are 31 organizations that provide services within the children’s rehabilitation/ habilitation subprogramme.40 Services can be offered in the home, within day-care centres, or in rehabilitation centres/clinics. Organizations must be registered as providers; a ministerial order provides guidance on the requirements for being a service provider, but there are no standards. There are 1516 children enrolled nationwide; the majority receive services at rehabilitation centres.

Day-care centres are for vulnerable children (619 children) and children with disability (1059 children), as well as for children with severe and profound developmental delays (58 children).41 There are 37 day-care centres for children with disability (ages 6–18 years old) (28). In addition, there are day-care centres for adults with disability (781 adults).

9.1.3 Rehabilitation in the community

Georgia offers some home-based care programmes for children with severe disabilities. Four service providers in three locations (Tbilisi, Telavi and Zugdidi) provide rehabilitation care for 49 children.42 As for community- based rehabilitation (CBR), some municipalities have a budget for home care.43

Since 1996, Caritas has provided home-care services through trained nurses in six locations in Georgia (Akhaltsikhe, Batumi, Gori, Kutaisi, and Tbilisi). Rehabilitation is one component of home care. Caritas has translated the “Home Care Manual” written by Ingeburg Barden into Georgian (29). This manual provides information on exercise, movement, activities of daily living and products to increase functioning.

9.1.4 Specialized rehabilitation facilities

The assessment team visited nine facilities that have a specific focus on rehabilitation (seeTable 16 ). Information in this section highlights information from four centres that have inpatient beds. Each has its own strengths in providing rehabilitation services. That said, little attention is focused on sharing best practices, tools or experiences across rehabilitation service providers in Georgia.

38 Each of the subprogrammes has its own budget line; see Table 4 of the present report. 39 Source: TRIC, completed February 2020. 40 Source: TRIC, completed February 2020. 41 Source: interview with MAC Georgia, 26 February 2020. 42 Source: MoIDPLHSA interview on 11 February 2020. 43 Source: interview with Caritas, 25 February 2020. 46 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Lung Disease Rehabilitation Centre (Abastumani) – Opened October 2019; it is the only hospital in Georgia operating as a rehabilitation hospital.44 – Guidelines and protocols for pulmonary rehabilitation were approved on 21 February 2020. – Government funds 100% of inpatient care (individuals can stay for up to 20 inpatient days per year). – The National Tuberculosis and Lung Centre in Tbilisi is the main patient referral site. – Target groups: persons with disability with lung disease, IDPs, war veterans, socially vulnerable people and people working in dangerous occupations – following the 2018 Government-approved list. – The rehabilitation centre has a capacity of 100 beds; but has had 60 patients in total since October 2019. – The Government provides GEL 126 000 (approx. US$ 40 000)/month.45 – Rehabilitation staff: two doctors, one PT and four nurses.

The National Hero of Georgia Mariam (Maro) Makashvili Military Rehabilitation Centre – Original centre opened in 2014; new US$ 4.5 million centre officially opened 27 January 2020. United States Government provided US$ 4.5 million, while Georgian MoD provided GEL 1 million for equipment (30). – Target group – wounded military personnel on long-term convalescent leave. – There are 530 beneficiaries (270 from Georgia and 264 from Ukraine); 529 men and one woman. – Currently there is accommodation for 1746 wounded military personnel and their caregivers. – Treatment is provided in two-week rotations; to date, Georgian beneficiaries have had 74 rotations, while Ukraine has had 17 rotations. – MoD funds the centre; all care and transport to and from the centre are provided free of charge. – Clinical rotations are available for students studying psychology. – Staff (all paid by MoD): four case managers, one MD rehabilitation specialist, four PTs, two OTs, three psychologists.

PSP-New Hospitals inpatient rehabilitation department – New Hospital has the only inpatient department in Georgia for neurological rehabilitation. – The department is linked to the neurology unit and opened in mid-2019. – There are five dedicated rooms (with an additional bed for a caregiver), and four additional beds available in the acute neurological unit if needed. – Patients must come with a family member or designated caregiver. – All payments are OOP. – Staff: two neurologists, one nurse, one assistant nurse, six PTs (other departments can use), no OTs or SLTs. – Outpatient rehabilitation is also offered; the unit has 5–6 patients per day (all OOP).

Ken Walker University Clinic for Medical Rehabilitation LLC (Tbilisi) – The nine-floor clinic is due to open in March 2020; six floors are for adults and three are for children. – The clinic is built on land provided by TSMU and is functionally linked to the TSMU First University Clinic. – As of March 2020, there are 12 beds for adults. In due course, there will be 48 beds for adults and children. – Target staffing structure: seven MDs, 35-40 PTs, seven OTs, three psychologists and nursing staff. – All payments for adults are OOP; treatment for children may be covered by social programmes. – The team visit on 20 February took place before the opening, and construction was still ongoing. The clinic is due to open in March 2020, with services and staffing structures phased accordingly.

44 Has an ownership right in inpatient rehabilitation facility, granted by MoIDPLHSA. 45 This payment is based on 60% occupancy of the Lung Disease Rehabilitation Centre. 46 The centre plans to increase bed capacity to 50. Rehabilitation service accessibility and quality 47

Table 16. Specialized rehabilitation facilities and number of beds47

No. Name Location Public/ Beds Rehabilitation staff private MD PT OT ST Psy

1. Lung Diseases Rehabilitation Centre Abastumani Public 100* 2 1 0 0 0 (MoIDPLHSA )

2. The National Hero of Georgia Tserovani Public 17** 1 4 2 0 3 Mariam (Maro) Makashvili Military (MoD) Rehabilitation Centre

3. David Tatishvili Medical Centre Tbilisi Private 0 2 26 0 1 ? (Health Palace) Rehabilitation Department

4. PSP-New Hospitals Tbilisi Private 5*** 1 6 0 0 0 Inpatient Rehabilitation Department

5. Ken Walker University Clinic for Batumi Private 0 3 3 0 1 2 Medical Rehabilitation LLC

6. Ken Walker University Clinic for Tbilisi Private 12**** 8 35 7 7 3 Medical Rehabilitation LLC

7. Aversi Rehabilitation Centre Tbilisi Private 0 2 6 0 0 0

8. Chakvi Neurorehabilitation Centre Batumi Private 0 2 9 0 5 15 (Evex)

9. Neurodevelopment Centre Tbilisi Private 0 4 15 2 8 ?

* 100 bed capacity, but in three months the centre has had a total of 60 patients. ** 17 patient beds, plus equal number for caregivers; plans to expand to 50 beds in the future. *** Five patient beds plus an equal number for caregivers; can increase patient beds to nine if needed. **** 12 beds for adults planned for March 2020, but plans for a total of 48 beds for children and adults in the future.

9.1.5 Vision and hearing

In 2018, MoIDPLHSA mandated hearing screening for all newborn babies, with a target of 95% coverage. A finite number of hearing aids and cochlear implants are funded and available through the MoIDPLHSA social programmes. Spectacles are available in main hospitals and funding is OOP. Additional details are not provided in this report as the team did not visit the National Centre of Audiology or specialized ophthalmology facilities.

9.1.6 Assistive products

Assistive products are available through private pharmacies (OOP payments), providers approved by MoIDPLHSA / SSA, and charitable donations. MoIDPLHSA/SSA funds 11 types of assistive product.48

47 Source: site visits to each of the facilities listed. Clarification on number of beds is provided below the table. The shaded staffing figures for the Ken Walker University Clinic Tbilisi reflect the anticipated staffing structure in the future. 48 Source: information collected from the TRIC, completed February 2020. 48 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

MoIDPLHSA provides variable guidance on service providers and technical specifications of the assistive products.49 For most products, the provider of the service (goods) is the entity registered by MoIDPLHSA.

For the goods, most component activities identify selection, production and fitting of the device.

It is remarkable that wheelchairs have additional and unique requirements for providers and component activities that are very different from other assistive products. Specifically, the provider must have: – wheelchair production in Georgia and with more than 50% of the total number of employees being persons with disability;50 – certified personnel, and submits documents demonstrating qualifications to the SSA.

Component activities for wheelchairs provide detailed product specifications, but vouchers do not cover wheelchair service for manual wheelchairs. Table 17 shows the products provided through the State Programme for Social Rehabilitation and Childcare.

Table 17. Products provided through the State Programme for Social Rehabilitation and Childcare (2019)

Product Total number provided

Electric wheelchair 150

Manual wheelchair 500

Prosthetics and orthotics 1153

Walkers, crutches, canes, white canes 84

Cochlear implants 35

Hearing aids 1500

Smartphones 100

The Latter-day Saint Charities (LDSC) organization donates adult basic manual wheelchairs to Georgia through the International Association “Women of Georgia for Peace and Life”. From 2004 to 2019, 8710 wheelchairs were delivered, with approx. 700 wheelchairs scheduled for 2020. Basic-level service providers are trained mostly from among Government social workers and a few staff from the local partner.51

9.1.7 Rehabilitation in emergency or disaster

The LEPL Emergency Situations Coordination and Urgent Assistance Centre (ESC&UAC) provides and coordinates high-quality emergency medical and referral assistance during disaster and martial law situations. Although the Government of Georgia has a National Civil Security Plan (31), and MoIDPLHSA is tasked with medical care, neither rehabilitation services nor assistive products are mentioned in the document.

49 Source: information collected from the English translation of the 2018 State Programme for Social Rehabilitation and Childcare; subprogramme on assistive devices. 50 Components of the programme list “providing x”; for wheelchairs, the list also includes promoting employment of persons with disabilities and local wheelchair production. 51 Source: email correspondence with Eric Wunderlich, LDSC, 20 February 2020. Rehabilitation service accessibility and quality 49

According to the ESC&UAC representative, emergency situation response plans were updated in 2019–2020. These plans are available at respective medical facilities and LEPL ESC&UAC. The LEPL ESC&UAC has agreements with pharmacological companies to provide assistive products in emergency situations. These agreements are available at pharmacological companies and LEPL ESC&UAC.

Emergency situation management plans mostly stress rehabilitation (recovery) of medical establishment strengths (infrastructure, equipment, material and technical base and human resources) and elimination of the consequences of the emergency situations.52

9.2 Quality of rehabilitation: overview

9.2.1 Rehabilitation interventions

Very few treatments were observed during the assessment. All rehabilitation units/departments/centres have machines to deliver electrotherapeutic, light, thermal and ultrasound treatments. Half have space to provide manual exercises, and one third of them (five centres visited) have aquatic therapy.53

Assessments for rehabilitation are ordinarily conducted by the physician (in some cases with others in the rehabilitation team) and prescription and planning stems from the physician’s understanding of rehabilitation and its aim of increasing or restoring function.

There are two treatment protocols for rehabilitation in Georgia – one for pulmonary rehabilitation and one for cerebral palsy. Ken Walker Clinic is developing a protocol for stroke rehabilitation. WHO is developing a package of rehabilitation interventions that outlines treatment protocols for 30 health conditions most impacted by rehabilitation interventions; the target release date is the end of 2020.

Note-taking practices vary between settings regarding content and how information is collected and stored (paper or electronic storage). At present, there is little to no information collected on outcomes of treatment or change in functional status.

9.2.2 Treatment plans and dosage

Although there is evidence of individual treatment plans, dosage almost always follows a preset number of treatment sessions, or a budget ceiling, and is not based on treatment outcomes. One exception noted during the assessment is at D. Tatishvili Rehabilitation Centre, as that is a service provider for adults and does not use a voucher system. Therefore, the number of procedures is individual and the treatment plan is tailored to the patient’s condition.

52 Source: email clarification from ESC&UAC, 23 June 2020. 53 Facilities explained that, in 2020, MoIDPLHSA/SSA included aquatic therapy as a reimbursable treatment. 50 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

9.2.3 Multidisciplinary team and person-centred care

Of the rehabilitation centres visited, three sites54 emphasized their structured multidisciplinary team meetings to review individual files and discuss case management. This is not to say that other sites do not engage in this practice; this review merely highlights centres visited that shared this information.

9.2.4 Continuum of care

There is very little evidence of referrals between departments or rehabilitation settings.

Summary of rehabilitation accessibility and quality situation

• There are no national data on availability and location of rehabilitation services.

• Rehabilitation for children with disability is provided through multiple early childhood development programmes, habilitation/rehabilitation subprogrammes and day-care centres. These initiatives are funded through the MoIDPLHSA social programme budgets.

• Adult rehabilitation is available in some health facilities, but payment is largely OOP.

• The three examples of Government-funded adult rehabilitation are in Abastumani, Tserovani in Mtskheta Municipality (MoD) and Adjara – all require adults to have a disability determination to access this support.

• Inpatient rehabilitation is rare in Georgia; only four locations in the country have beds dedicated to rehabilitation.

• MoIDPLHSA offers home-based care for a small number of children with severe disabilities. Some nongovernmental organizations offer basic rehabilitation through their home-care programmes. The majority of the programmes are municipal programmes.

• Physical rehabilitation is not explicitly mentioned in emergency planning documents.

• MoIDPLHSA provides funding and guidance through SSA for 11 types of assistive products.

• Since 2004, over 8500 adult basic wheelchairs have been donated by LDSC to Georgia.

• In general, rehabilitation dosage is driven by predetermined treatment sessions or directed by the formula stated in the voucher system. Dosage is not determined by treatment outcomes.

• There is some evidence of case management and multidisciplinary team meetings.

• There are almost no treatment protocols for rehabilitation in Georgia (exceptions are pulmonary rehabilitation and cerebral palsy).

• There is very little evidence of rehabilitation-related referrals between departments or facilities.

• Rehabilitation across the continuum of care is not yet practised in Georgia, and there are many gaps in service.

54 The National Hero of Georgia Mariam (Maro) Makashvili Military Rehabilitation Centre, D. Tatishvili Medical Centre (Health Palace) Rehabilitation Department and Neurodevelopment Centre. 10. Rehabilitation outcomes and system attributes 52 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

10.1 Outcomes

There is no unified database on rehabilitation at the national level. However, rehabilitation centres / departments provide information on existing rehabilitation services and the number and qualifications of rehabilitation personnel.

Outcomes of rehabilitation (measuring functioning gains or slowing loss of functioning) are rarely measured. Without this measurement, it is impossible to determine the effectiveness of rehabilitation interventions.

10.2 Attributes

10.2.1 Equity

Without data analysis on the details of existing services (staffing numbers and qualifications within each of the different rehabilitation settings), it is difficult to assess or understand equity in rehabilitation coverage. Rehabilitation coverage for adults is extremely limited in Georgia.

10.2.2 Efficiency

As there is little outcome measurement and limited evidence-based models of care, measuring efficient delivery of rehabilitation is a challenge.

10.2.3 Accountability

Accountability is measured at the level of health personnel, service providers and governing agencies. There are very few mechanisms ensuring accountability for rehabilitation, and there is no reporting on rehabilitation.

10.2.4 Sustainability

The value of rehabilitation in health care, to restore or maintain function, has not been well established. Identification and recognition of the economic benefits of rehabilitation needs further attention. 11. Georgia – WHO Rehabilitation Maturity Model scores and details 54 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

The RMM is a standard tool used during the STARS process. There are 50 components across seven domains in the RMM. Each component has illustrative descriptors that indicate the level of maturity of rehabilitation in the health system. The purpose of using the RMM is to provide an overview on the performance of different rehabilitation components. This overview enables comparison across components and domains that can then assist in the identification of priorities and recommendations for strategic planning. The international consultant took data from the RCQ Template for Rehabilitation Information Collection and in-country data collection, and aligned this information with the 50 components.

Table 18 summarizes the seven domains, the components within each domain, scores for each component and the rationale for the score. The rationale is taken directly from the description in the RMM associated with each score.

Table 18. Rehabilitation Maturity Model scores and details, Georgia

KEY TO SCORES: JUSTIFICATION

4 Already present, needs no immediate action The RMM provides standard descriptive content for each maturity level. Overlap exists between levels. Rationale (justification) for the 3 Needs some strengthening score describes the key attributes that led to the selection of the score. 2 Needs a lot of strengthening

1 Very limited; needs establishing

GOVERNANCE SCORE/JUSTIFICATION

1 Rehabilitation legislation, policies and plans 2 Policy frameworks encompass some aspects of rehabilitation

2 Leadership, coordination and coalition-building for 2 Small amount of interagency coordination for rehabilitation rehabilitation

3 The capacity and levers for rehabilitation plan 2 Some management processes and mechanisms are implementation in place

4 Accountability, reporting and transparency for 2 Accountability for rehabilitation is at a low level rehabilitation

5 Regulation of rehabilitation and AT 2 There are low levels of regulation that apply to rehabilitation

6 AT policies, plans and leadership 1 AT plans/vision are not available

7 AT programmes and procurement 2 AT programmes exist

FINANCING SCORE/JUSTIFICATION

8 Rehabilitation financing and coverage of the 2 Limited integration of rehabilitation into financing population for health care

9 Scope of rehabilitation included in financing 2 Small ranges of rehabilitation interventions are financed

10 Financing of rehabilitation and out-of-pocket costs 2 Fees for rehabilitation services do not accommodate all clients

HUMAN RESOURCES AND INFRASTRUCTURE SCORE/JUSTIFICATION

11 Rehabilitation workforce availability 2 Not enough rehabilitation personnel in the health- care system

12 Rehabilitation workforce training and competencies 2 Little effort to identify country-specific rehabilitation needs

13 Rehabilitation workforce planning and management 1 Information on situation of rehabilitation personnel not collected Georgia – WHO Rehabilitation Maturity Model scores and details 55

Table 18. contd.

HUMAN RESOURCES AND INFRASTRUCTURE SCORE/JUSTIFICATION

14 Rehabilitation workforce mobility, motivation and 2 International mobility has an adverse effect on the support workforce

15 Rehabilitation infrastructure and equipment 2 Low level of infrastructure available within health care

HEALTH INFORMATION SYSTEMS SCORE/JUSTIFICATION

16 Information about rehabilitation needs, including 2 Some disability questions included in 2014 census population functioning and disability

17 Information about rehabilitation availability and 1 There is no unified database on availability of utilization rehabilitation services

18 Information on rehabilitation outcomes and quality 1 Health information systems do not generate data on quality of care and rehabilitation outcomes

19 Rehabilitation information used during decision- 1 No reports on the status or performance of making rehabilitation

SERVICE – ACCESSIBILITY SCORE/JUSTIFICATION

20 Availability of specialized, high-intensity 1 Very low availability of longer-stay rehabilitation in rehabilitation Georgia

21 Availability of community-delivered rehabilitation 2 Low level of community-delivered rehabilitation in the country

22 Availability of rehabilitation integrated into tertiary 1 Little or no rehabilitation integrated into medical care specialties

23 Rehabilitation integrated into secondary care 1 Very little or no rehabilitation across secondary care facilities

24 Rehabilitation integrated into primary care 1 Very low to no integration of rehabilitation into primary health care

25 Occurrence of informal, self-directed rehabilitation 2 Few opportunities exist for informal self-directed care

26 Availability of rehabilitation across acute, subacute 1 There are large gaps in all phases of care and long-term phases of care

27 Availability of rehabilitation across mental health, 2 A small number of low vision and auditory care vision and hearing programmes services exist

28 Availability of rehabilitation for target population 2 There has been limited development of rehabilitation groups based on country need for specific target groups (children)

29 Early identification and referral to appropriate health 3 There is a moderate level of monitoring of and rehabilitation programmes for children with developmental milestones and referral practices are developmental difficulties and disabilities moderately well established

30 Availability of rehabilitation in hospital, clinical 2 Early childhood intervention services are established, settings and the community for children with but at low level, there are many gaps in geographical developmental difficulties and disabilities areas at the community level

31 Availability of assistive products, including 2 The range of assistive products available is low those for mobility, environment, vision, hearing, communication and cognition

32 Availability of assistive products and their service 2 Provision of assistive products is sometimes delivery accompanied by assessment

33 Affordability of rehabilitation 2 Low evidence and knowledge about affordability of rehabilitation

34 Acceptability of rehabilitation 2 Many barriers for people with different impairment types

(Continued) 56 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Table 18. contd.

SERVICE – QUALITY SCORE/JUSTIFICATION

35 Extent to which evidence-based rehabilitation 1 Very low level of evidence-based interventions interventions are utilized utilized; very few or no clinical practice guidelines, protocols or standards of care

36 Extent to which rehabilitation interventions are of 1 Specialization among rehabilitation personnel needs sufficient specialization and intensity to meet needs to be improved

37 Extent to which rehabilitation interventions 2 Only a few materials exist across rehabilitation empower, educate and motivate people services that support client education

38 Extent to which rehabilitation interventions are 1 Very low and highly variable level of quality and underpinned by appropriate assessment, treatment consistency in the assessment, treatment planning, planning, outcome measurement and note-taking measurement of outcomes and note-taking practices practices in rehabilitation personnel

39 Extent to which rehabilitation is timely and delivered 1 Low level of timely rehabilitation across all levels of along a continuum, with effective referral practices care

40 Extent to which rehabilitation is person-centred, 2 There is a low level of person-centred care; a small flexible and engages users, family and carers in number of personnel practise it when they can decision-making

41 Extent to which health personnel and community 1 Across health personnel there is a very low level of members are aware, knowledgeable and seek knowledge on rehabilitation; most don’t know when rehabilitation and where to refer

42 Extent to which rehabilitation is safe 1 No established mechanisms to support delivery of safe care

OUTCOME AND ATTRIBUTES OF REHABILITATION SCORE/JUSTIFICATION

43 Coverage of rehabilitation interventions for 2 Rehabilitation is available for some of the population population groups that need rehabilitation that needs it, but many groups miss out on the rehabilitation they need

44 Functioning outcomes of rehabilitation for those who 1 Very low level of effective rehabilitation, where it is receive rehabilitation available

45 Equity of rehabilitation coverage across 1 Very low level of equitable access to rehabilitation disadvantaged population groups

46 Allocative and technical efficiency of rehabilitation 1 Allocative and technical efficiency not well understood or measured

47 Multilevel accountability for rehabilitation 1 Very few or no mechanisms ensuring rehabilitation performance accountability

48 Financial and institutional sustainability of 2 There has been little planning for future needs rehabilitation

49 Resilience of rehabilitation for crisis and disaster 2 Rehabilitation is integrated into emergency plans to a small extent

50 Functioning of the population 1 There is no measurement of population functioning 12. Conclusions and recommendations 58 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

12.1 Conclusions

The rehabilitation situation in Georgia is evolving, but continues to be influenced by the extensive links with disability and historical associations with post-Soviet treatment techniques and terminology.

While strengths of rehabilitation governance are found within social programmes for children with disability there is limited integration of rehabilitation within health policies and no overarching document or national strategy on rehabilitation to bring relevant departments, ministries or stakeholders together.

Although the MoIDPLHSA has contributed several million dollars toward rehabilitation financing; this is primarily through social programmes. Rehabilitation is not included in UHCP, and adults needing rehabilitation have little option but to pay out-of-pocket for the limited services available.

Regulatory structures and licensing are required for doctors but these do not apply to other human resources for rehabilitation (PT, OT, SLT). There are accredited training programmes in PT, OT and SLT, but no continuing education requirements. There are multiple professional associations serving similar purposes, and terminology used in the sector can be conflicting or confusing.

The 2014 census collected information on the population functioning with a disability. The NCDC collects data from health facilities, but there is no consolidated or centralized rehabilitation information (including locations of workforce, availability and utilization of services or any outcome data.)

Rehabilitation services for adults with health conditions are grossly underdeveloped in Georgia. Although there are many promising initiatives, there is very little experience of sharing or exchange among service providers. Outcome-based care is not the norm, and there are many gaps in rehabilitation across the health- care continuum.

12.2 Recommendations

To address some of the challenges that Georgia faces related to rehabilitation, the following recommendations are submitted for consideration.

12.2.1 Governance

1. Consolidate rehabilitation leadership and coordination

It is recommended that the Government of Georgia:

1.1. establish a rehabilitation working group to develop and implement a national rehabilitation strategy and serve as a channel for ongoing communication in the sector;

1.2. develop a national strategy on rehabilitation that involves and includes all relevant ministries, departments and stakeholders. Conclusions and recommendations 59

2. Include rehabilitation in any newly developed, revised or updated health policy documents

It is recommended that MoIDPLHSA:

2.1. incorporate rehabilitation within the content of the National Health Strategy 2021–2026;

2.2. engage members of the rehabilitation working group to advise on language in health policy documents to ensure that rehabilitation is appropriately represented.

3. Raise awareness on rehabilitation

It is recommended that MoIDPLHSA and relevant stakeholders:

3.1. design informational materials highlighting rehabilitation and functional gains, particularly aimed at health-care and social services staff;

3.2. share guidance on distinctions between, and intersectionality of, rehabilitation and disability.

4. Strengthen frameworks related to procurement and provision of assistive products

It is recommended that MoIDPLHSA:

4.1. solicit support from WHO to assess the AT situation in Georgia as a contribution to a national rehabilitation strategy.

12.2.2 Financing

5. Improve resource allocation for rehabilitation services across all levels of health care

It is recommended that MoIDPLHSA:

5.1. introduce rehabilitation procedures into UHCP;

5.2. amend the existing voucher system to link payments with evidence on treatment outcomes;

5.3. determine/update the optimal cost of the service package defined by the voucher. 60 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

12.2.3 Human resources

6. Resolve identified challenges related to the rehabilitation workforce.

It is recommended that MoIDPLHSA, together with MoES and other relevant stakeholders:

6.1. address the lack of training and professional recognition for prosthetists and orthotists;

6.2. develop competencies, regulations and licensing requirements for PT, OT, SLT and P&O staff;

6.3. upgrade clinical pre-service training ensure greater consistency between programmes and sites;

6.4. rejuvenate continuing education requirements for all health staff;

6.5. consolidate professional associations and terminologies related to rehabilitation.

12.2.4 Information

7. Emphasize that the purpose of rehabilitation is to optimize functioning

It is recommended that MoIDPLHSA, together with relevant stakeholders:

7.1. repackage available information on functioning to highlight the demand for rehabilitation.

8. Support health facilities to collect, consolidate and share rehabilitation-related information

It is recommended that MoIDPLHSA:

8.1. incorporate information on rehabilitation workforce and service availability into the health facility reporting form submitted annually to NCDC;

8.2. train health staff in existing patient procedure codes regarding rehabilitation and nursing care.

12.2.5 Rehabilitation service

9. Reinforce efforts to ensure that adults with health conditions receive the rehabilitation they need.

It is recommended that MoIDPLHSA:

9.1. continue engaging with the working group dedicated to adult rehabilitation in Georgia. Conclusions and recommendations 61

10. Promote timely rehabilitation interventions across the continuum of health care

It is recommended that MoIDPLHSA together with relevant stakeholders:

10.1. replicate examples of good practice where rehabilitation is applied in acute care settings;

10.2. support inpatient rehabilitation to maintain or improve function;

10.3. encourage the expansion of rehabilitation services at community level. 62 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

References

1. Rehabilitation 2030: a call for action. Meeting report. Geneva: World Health Organization; 2017 (https:// www.who.int/disabilities/care/Rehab2030MeetingReport2.pdf?ua=1, accessed 30 September 2020).

2. 2014 general population census. Tbilisi: National Statistics Office of Georgia; 2014 (http://census.ge/en/ results/census1/health, accessed 30 September 2020.

3. Rehabilitation 2030: a call for action. In: World Health Organization [website]. Geneva, World Health Organization; 2020 (https://www.who.int/rehabilitation/rehab-2030-call-for-action/en/, accessed 30 September 2020).

4. Rehabilitation in health systems. In: Rehabilitation [website]. Geneva: World Health Organization; 2020 (https://www.who.int/rehabilitation/rehabilitation_health_systems/en/, accessed 30 September 2020).

5. Rehabilitation in health systems: guide for action. Geneva: World Health Organization; 2019 (https://apps. who.int/iris/handle/10665/325607, accessed 30 September 2020). License: CC BY-NC-SA 3.0 IGO.

6. 2014 general population census. Main results. General information. Tbilisi: National Statistics Office of Georgia; 2016 (http://census.ge/files/results/Census_release_ENG.pdf, accessed 30 September 2020).

7. Statistical yearbook of Georgia: 2019. Tbilisi: National Statistics Office of Georgia; 2019https://www. ( geostat.ge/media/28916/Yearbook_2019.pdf, accessed 30 September 2020).

8. Georgia. In: Internal Displacement Monitoring Centre [website]. Geneva: Internal Displacement Monitoring Centre; 2019 (https://www.internal-displacement.org/countries/georgia, accessed 30 September 2020).

9. Migration and remittances factbook. Washington (DC): World Bank; 2016.

10. Key facts. In: Noncommunicable diseases. Geneva: World Health Organization; 2020 (https://www.who. int/news-room/fact-sheets/detail/noncommunicable-diseases, accessed 30 September 2020).

11. National Centre for Disease Control and Public Health. Healthcare statistical yearbook 2018: Georgia. Tbilisi: National Statistics Office of Georgia; 2019.

12. Ageing. In: United Nations Population Fund Georgia [website]. Tbilisi: United Nations Population Fund Georgia; 2014 (https://georgia.unfpa.org/sites/default/files/pub-pdf/Ageing%20and%20Older%20 persons%20ENG_0.pdf, accessed 30 September 2020).

13. 10 priorities for a decade of action on healthy ageing. In: Ageing and life-course [website]. Geneva: World Health Organization; 2020 (www.who.int/ageing/10-priorities/en/, accessed 30 September 2020).

14. Sadana R. Healthy ageing—what is it, can we measure it and use it [presentation delivered at expert group meeting on Measuring population ageing: bridging research and policy, Bangkok, Thailand, 25–26 February 2019]. Geneva: World Health Organization; 2019.

15. Data analysis on persons with disabilities living in Georgia. Tbilisi: Institute for the Development of Freedom of Information; 2018 (https://idfi.ge/en/data_analysis%20_on_persons_with_disabilities_ living_in_georgia, accessed 15 September 2020).

16. Decree on approval of the regulation on the rule of determining the status of disability permit, 13 January 2003. Tbilisi: Ministry of Labour, Health and Social Protection; 2003. Conclusions and recommendations 63

17. Georgia multiple indicator cluster survey 2018, survey findings report. Tbilisi: National Statistics Office of Georgia; 2019 (https://www.unicef.org/georgia/media/3501/file/Georgia_MICS_2018_en.pdf, accessed 20 August 2020).

18. Richardson E, Berdzuli N. Georgia: health system review. Health Systems in Transition, 2017; 19(4):1–90.

19. On approval of the 2014–2020 State concept of healthcare system of Georgia for universal health care and quality control for the protection of patients' rights (Ordinance No. 724, 26 December 2014). Tbilisi: Government of Georgia; 2014 (https://matsne.gov.ge/en/document/view/2657250, accessed 30 September 2020).

20. Approval of the State Programme of Social Rehabilitation and Childcare 2020 (Resolution No. 670, 31 December 2019). Tbilisi: Government of Georgia; 2019.

21. Self-assessment report for ENQA review. Tbilisi: National Centre for Educational Quality Enhancement of Georgia; 2018 (https://enqa.eu/wp-content/uploads/2018/09/NCEQE-SAR-2018.pdf, accessed 15 September 2020).

22. International Standard Classification of Education (ISCED). In: Eurostat statistics explained [website]. Luxembourg: Eurostat; 2020 (https://ec.europa.eu/eurostat/statistics-explained/index.php/International_ Standard_Classification_of_Education_(ISCED)#ISCE, accessed 24 April 2021).

23. The National Qualifications Framework. In: National Centre for Educational Quality Enhancement [website]. Tbilisi: National Centre for Educational Quality Enhancement; 2014 (https://eqe.ge/eng/ parent/787, accessed 30 September 2020).

24. On the definition of a list of medical specialties, related medical specialties and sub-specialties (Order N136/n, 18 April 2007). Tbilisi: Ministry of Internally Displaced Persons from the Occupied Territories of Georgia, Labour, Health and Social Affairs; 2007.

25. Quality of primary health care in Georgia. Geneva: World Health Organization; 2018 (http://www.euro. who.int/__data/assets/pdf_file/0003/373737/geo-qocphc-eng.pdf?ua=1, accessed 20 August 2020).

26. Disability. In: 2014 general population census [website]. Tbilisi: National Statistics Office of Georgia; 2014 (http://census.ge/en/results/census1/health, accessed 30 September 2020).

27. Georgia Health Management Information System strategy: healthy Georgia, connected to you. Tbilisi: Ministry of Labour, Health and Social Affairs of Georgia; 2011 http://www.georgia-ccm.ge/wp-content/( uploads/ABT_en-US-1.pdf, accessed 20 August 2020).

28. Hayes J. Supporting the development of quality day-care centres for children with disabilities in Georgia. 2017.

29. Dzagnidze B. Caritas Georgia published home care manual. Georgia Today. 4 April 2013 (http://old. georgiatoday.ge/article_details.php?id=11010, accessed 30 September 2020).

30. Unique rehabilitation centre opened for wounded military servicemen in Tserovani. In: News [website]. Tbilisi: Ministry of Defence of Georgia; 2020 (https://mod.gov.ge/en/news/read/7705/unique-rehabilitation- centre-opened-for-wounded-military-servicemen-in-tserovani-, accessed 30 September 2020).

31. Approval of the National Civil Security Plan (Decree #508, 24 September 2015). Tbilisi: Government of Georgia; 2015 (https://matsne.gov.ge/document/view/2993918?publication=0, accessed 30 September 2020). 64 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Further reading

Noncommunicable disease country profile: Georgia. In: World Health Organization [website]. Geneva: World Health Organization; 2014 (https://www.who.int/nmh/publications/ncd-profiles-2014/en/, accessed 30 September 2020).

The situation of human rights and freedoms in Georgia. Annual report of the Public Defender of Georgia. Tbilisi: Office of the Public Defender of Georgia; 2018http://www.ombudsman.ge/eng/saparlamento- ( angarishebi, accessed 30 September 2020).

Universal health coverage. Fact sheet. In: World Health Organization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage- (uhc), accessed 30 September 2020).

Verulava T, Maglakelidze T. Health financing policy in the South Caucasus: Georgia, Armenia, . Bulletin of the Georgian National Academy of Sciences. 2017;11:143–50. Annex 1. Overview of rehabilitation 65

Annex 1. Overview of rehabilitation

Rehabilitation is a health strategy alongside other health strategies, including promotion, prevention and curative and palliative care (1) (see Fig. A1.1). It is a fundamental part of health services and integral to the realization of universal health coverage. Rehabilitation covers multiple areas of health and functioning, including physical and mental health, vision and hearing. Rehabilitation interventions1 primarily focus on improving the functioning of an individual and reducing disability. Rehabilitation is a highly integrated form of health care, with most rehabilitation being delivered in the context of other (i.e. not rehabilitation-specific) health programmes, for example orthopaedic, neurology, cardiac, mental health and paediatric programmes. Rehabilitation improves people’s everyday functioning and increases their inclusion and participation in society and is thus an investment in human capital.

Fig. A1.1. Rehabilitation in health framework

Source: (1).

1 Rehabilitation interventions are a form of health intervention. A health intervention is an act performed for, with or on behalf of a person or population whose purpose is to assess, improve, maintain, promote or modify health, functioning or health conditions. Examples of these acts in the context of rehabilitation include; manual therapy, exercise prescription, provision of assistive products, education and modification of home environment. 66 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Rehabilitation and habilitation2 should be available at all levels of health care, from specialist referral centres through to primary and community settings.3 Rehabilitation interventions are delivered in health facilities as well as in the community, for example in homes, schools and workplaces. Rehabilitation is a highly person- centred form of health care; it is goal-oriented (i.e. very individually tailored), timebound and an active rather than passive process. Rehabilitation is most commonly delivered through a multidisciplinary team, including therapy personnel (physiotherapists, occupational therapists, speech and language therapists), prosthetists, orthotists and psychologists, and through specialist rehabilitation medicine doctors and nurses. It can also be delivered through appropriately trained community-based rehabilitation personnel and other health personnel.

Rehabilitation is for all the population; this includes people with disability, as defined by the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD),4 and many others. People with short-term health conditions also benefit from rehabilitation, and it commonly contributes to the prevention of impairments associated with disability. Rehabilitation regularly optimizes surgical outcomes, decreases the length of hospital stays, prevents complications, decreases readmissions and facilitates a return to optimal functioning. Many people with disability also benefit from rehabilitation; in addition, they often require other programmes, such as those that support their social inclusion, participation in education, access to a livelihood or access to justice. Programmes that include people with disability and whose primary aims are education, training, employment or social inclusion should be delivered through non-health ministries and align with the mandate of the ministry concerned.

Reference

1. Rehabilitation in health systems: guide for action. Geneva: World Health Organization; 2019 (https://apps. who.int/iris/handle/10665/325607, accessed 30 September 2020). License: CC BY-NC-SA 3.0 IGO.

2 In this report, as with other WHO documents, the word rehabilitation also includes habilitation. Habilitation refers to rehabilitation in the context of people who were born with congenital health conditions. Article 26 of the United Nations Convention on the Rights of Persons with Disabilities refers to both rehabilitation and habilitation. 3 The Services Framework for Rehabilitation reflects the distribution of rehabilitation required to meet community needs. 4 As defined by the UNCRPD, “people with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis to others”. However, rehabilitation is for all the population, for example people with short-term functioning difficulties and many people who do not identify as having a disability or are not legally acknowledged as disabled through a Government procedure. Annex 2. Rehabilitation in health systems – a guide for action 67

Annex 2. Rehabilitation in health systems – a guide for action

REHABILITATION IN HEALTH SYSTEMS – A GUIDE FOR ACTION

Overview

Rehabilitation in health systems – a guide for action (the Guide) assists governments in strengthening the health system to provide rehabilitation.

This initiative is an outcome of the meeting Rehabilitation 2030: A Call for Action Geneva, 6–7 February 2017).

The Guide is a four-step process that is estimated to take about one year to complete (each country is different). WHO has developed standard data collection tools; these were first used in 2018.

In general, the process starts when the Ministry of Health expresses interest in the process and/or requests technical support from WHO for this activity.

The assessment is based around the six building blocks for health systems strengthening. The relevance for rehabilitation is outlined for each building . See Table A2.1 below.

Table A2.1. The four-phase process

Objective WHO guidance Tools Activity timeline

1. Assess the situation Systematic Assessment of Template for Rehabilitation TRIC: January 2020 Rehabilitation Situation Information Collection (TRIC): eight (STARS) domains, 97 questions; MoIDPLHSA In-country assessment 10-28 self-assessment February 2020

Rehabilitation Maturity Model Zero-draft report: (RMM): seven domains, 50 questions; 13 March 2020 consultant-supported scoring First draft: 29 April 2020

2. Develop a rehabilitation Guidance for Results from STARS report Anticipated dates: strategic plan. Rehabilitation Strategic contributes to development of 27 April– 8 May 2020 Planning (GRASP) strategic plan

3. Establish monitoring Framework for FRAME guidance assists in To happen simultaneously evaluation and review Rehabilitation Monitoring establishing a monitoring framework, with Strategic Plan process and Evaluation (FRAME) including the selection of indicators

4. Implement the Action on Rehabilitation Planning, action and evaluation cycle After strategic plan and strategic plan (ACTOR) monitoring framework are in place 68 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

The WHO health system building blocks form an important framework that is reflected within the Guide. Across the six building blocks are components that reflect rehabilitation. Table A2.2 below illustrates the health system building blocks and corresponding rehabilitation components. The assessment and measurement of these rehabilitation components is a subject of the tools in the Guide.

Table A2.2. Health system building blocks and rehabilitation

The six building blocks of Components reflecting rehabilitation the health system

1. Leadership and governance • Laws, policies, plans and strategies that address rehabilitation • Governance structures, regulatory mechanisms and accountability processes that address rehabilitation • Planning, collaboration and coordination processes for rehabilitation

2. Financing • Health expenditure for rehabilitation • Health financing and payment structures inclusive of rehabilitation

3. Health workforce • Health workforce that delivers rehabilitation interventions – primarily rehabilitation medicine, rehabilitation allied health / therapy personnel and rehabilitation nursing

4. Service delivery • Health services that deliver rehabilitation interventions, including rehabilitation delivered in rehabilitation wards, units and centres, in hospital settings and rehabilitation delivered in primary care facilities and other community settings; the availability and quality of rehabilitation are considered

5. Medicines and technology • Medicines and technology commonly utilized by people accessing rehabilitation, primarily assistive products

6. Health information systems • Data relevant and inclusive of rehabilitation in the health information systems; for example, population functioning data, rehabilitation availability and utilization data, rehabilitation outcomes data Annex 3. Map of Georgia 69

Annex 3. Map of Georgia Annex 3. 70 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Annex 4. In-country schedule

Systematic assessment of rehabilitation situation in Georgia

Date Activity Location

Saturday Ms Eitel arrival in Georgia Tbilisi 8 February 2020

Mr Mishra arrival in Georgia Tbilisi

In-brief with WHO Tbilisi Monday 1. MoIDPLHSA focal points Tbilisi 10 February 2020 2. MoIDPLHSA First Deputy Minister Tbilisi

3. Topic-specific: governance /emergency Tbilisi

4. Topic-specific: finance Tbilisi Tuesday 5. MoIDPLHSA Consultant for National Strategic Plan Tbilisi 11 February 2020 6. Topic-specific: information systems Tbilisi

Wednesday 7. Topic-specific: human resources (training and workforce) Tbilisi 12 February 2020 8. Topic-specific: service delivery and assistive technology Tbilisi

Thursday 9. Strengths-weaknesses-opportunities-threats (SWOT) Tbilisi 13 February 2020

10. Focus group – service providers (centres) Tbilisi Friday 11. Focus group – service providers (individuals) Tbilisi 14 February 2020 12. Focus group – service users Tbilisi

Saturday Mishra departure from Georgia Tbilisi 15 February 2020

13. Aversi Rehabilitation Centre Tbilisi

Monday 14. Aversi Clinic – otorhinolaryngologist, audiologist Tbilisi 17 February 2020 15. Tbilisi State Medical University (physical therapy training) Tbilisi

16. Tatishvili Centre/Health Palace Tbilisi

17. Polyclinic #14 –Disability Determination Commission Tbilisi

Tuesday 18. Polyclinic #14 – Rehabilitation Service Tbilisi 18 February 2020 19. Neurodevelopment Centre Tbilisi

20. Georgian Foundation for Prosthetic Orthopaedic Rehabilitation Tbilisi

21. MAC Georgia Tbilisi Wednesday 22. Ilia State University (speech therapy training) Tbilisi 19 February 2020 23. Centre for Independent Living Tbilisi

24. UNICEF Tbilisi Thursday 25. Rehabilitation Centre for Persons Having Limited Ability Ltd. Tbilisi 20 February 2020 26. Ken Walker University Clinic for Medical Rehabilitation LLC Tbilisi Annex 4. In-country schedule 71

Date Activity Location

27. Aversi Rehabilitation staff Tbilisi Friday 28. PFID/Emory University Rehabilitation Project Tbilisi 21 February 2020 29. PSP-New Hospitals – Neuro-rehabilitation Department Tbilisi

Sunday Travel to Adjara – overnight Batumi Batumi 23 February 2020

30. Adjara Ministry of Health and Social Affairs Batumi

31. Ken Walker Clinic Batumi Batumi Monday 32. Chakvi Neuro-Rehabilitation Centre (Evex) Batumi 24 February 2020 33. Batumi Shota Rustaveli State University Batumi

34. 1 Polyclinic Batumi – UNICEF pilot project site / rehabilitation service Batumi

Travel to Tbilisi Tbilisi

Tuesday 35. Caritas (office and rehabilitation unit) Tbilisi 25 February 2020 36. USAID Tbilisi

37. Professional Standards Working Group Tbilisi

Wednesday 38. Akhaltsikhe Municipality Akhaltsikhe 26 February 2020 39. Lung Disease Rehabilitation Centre Abastumani

Thursday 40. Ministry of Education and Sport – Higher Education Tbilisi 27 February 2020 41. Tserovani Military Rehabilitation Centre (MoD) Tbilisi

Friday Debriefing Tbilisi 28 February 2020

Saturday Eitel Departure from Georgia Tbilisi 29 February 2020

PFID: Partners for International Development; USAID: United States Agency for International Development. 72 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Annex 5. Preliminary findings – debriefing document

Slide 1. Slide 2.

Slide 3. Slide 4.

Slide 5. Slide 6. Annex 5. Preliminary findings – debriefing document 73

Slide 7. Slide 8.

Slide 9. Slide 10.

Slide 11. Slide 12. 74 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

Slide 13. Slide 14.

Slide 15. Slide 16. Annex 6. Key contacts from in-country assessment 75

Annex 6. Key contacts from in-country assessment

Email and phone details have been removed in the interests of privacy.

NO. NAME ORGANIZATION

1. MoIDPLHSA FOCAL POINT MEETING (FEB 10, 2020)

1 Nino Jinjolava Chief Specialist, Social Protection Policy Unit

2 Mzia Jokhidze Chief Specialist, Health Policy Unit

3 Giorgi Kurtsikashvili WHO Georgia, Rehabilitation Focal Point

4 Satish Mishra WHO Regional Office for Europe, Disability and Rehabilitation Office

5 Sue Eitel Consultant

6 Maya Mateshvili Interpreter

2. MoIDPLHSA DEPUTY FIRST MINISTER (FEB 10, 2020)

1 Dr Tamar Gabunia First Deputy Minister MoIDPLHSA

2 Dr Silviu Domente WHO Representative and Head of WHO Country Office

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Satish Mishra, Sue Eitel/Maya Mateshvili

3. TOPIC-SPECIFIC MEETING: GOVERNANCE AND EMERGENCY (FEB 10, 2020)

1 Amiran Gogitidze LEPL Emergency Situations Coordination & Urgent Assistance Centre Head of Medical and Call Management Department

2 Ketevan Kiladze Chief Specialist, Service Dept of Medical Pharm. Regulation Agency

3 Khatuna Zaldastanishvili Head of Department of Professional Regulation, MoIDPLHSA

4 Medea Kakachia USAID Project Management Specialist

5 Sabina Ciccone Programme Director, Physical Rehabilitation Project in Georgia

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Satish Mishra, Sue Eitel/Maya Mateshvili

4. TOPIC-SPECIFIC MEETING: FINANCE (FEB 11, 2020)

1 Darejan Iakobishvili Chief Specialist of Financial Economic Department MoIDPLHSA

2 Nana Cherkezishvili

3 Irakli Natroshvili Director, Ken Walker University Clinic for Medical Rehabilitation LLC

4 Lela Tsotsoria Chief Specialist Health Care Department

5 Ketevan Goginashvili Chief Specialist Health Care Policy Division

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Satish Mishra, Sue Eitel/Maya Mateshvili

5. MoIDPLHSA CONSULTANT FOR NATIONAL STRATEGIC PLAN (FEB 11, 2020)

1 Dr Lagos Kovacs Senior Expert in Health Policy and Strategic Planning

* Assessment Team: Giorgi Kurtsikashvili, Satish Mishra, Sue Eitel

6. TOPIC-SPECIFIC MEETING: INFORMATION SYSTEMS (FEB 11, 2020)

1 Alexander Turdziladze NCDC, Deputy Director General

2 Lia Charekishvili Geostat, Head of Social Infrastructure Statistics Division

3 Mariana Jalagoinia Geostat, Population Census and Demographic Statistics Dept.

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Satish Mishra, Sue Eitel/Maya Mateshvili

(Continued) 76 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

NO. NAME ORGANIZATION

7. TOPIC-SPECIFIC MEETING: HUMAN RESOURCES – TRAINING AND WORKFORCE (FEB 12, 2020)

1 Tamila (Tea) Eristavi Social Rehabilitation Centre for Persons Having Limited Ability

2 Neli Kakulia Georgian Association of Physiotherapists

3 Medea Kakachia USAID Project management specialist

4 Rusudan Bochorishvili GCECI

5 Nino Tsintsadze Ilia State University

6 Nino Rukhadze Ivane Javakhishvili State University (TSU) occupational therapy

7 Rusudan Lortkipanidze Georgian Occupations Therapists’ Association

8 Mamuka Gogorishvili GEFPOR

9 Marika Kalmakhelidze GEFPOR

10 Eliso Murvanidze G.P.T.A

11 Khatuna Zaldastanishvili MoIDPLHSA, Head of Department of Professional Regulation

12 Ketevan Kiladze MoIDPLHSA, Agency of Medical Regulation, Prof. Reg Department

13 Lela Maskhulia TSMU, Dean of Physical Medicine and Rehabilitation Faculty

14 Archil Undilashvili Emory University Atlanta, GA, USA

15 Sabina Ciccone PFID Project Director

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Satish Mishra, Sue Eitel/Maya Mateshvili

8. TOPIC-SPECIFIC MEETING: SERVICE DELIVERY AND ASSISTIVE TECHNOLOGY (FEB 12, 2020)

1 Lira Topuridze Formerly MoIDPLHSA and MP, Retired

2 Ana Abashidze PHR

3 Neli Kakulia Georgian Association of Physiotherapists

4 Archil Undilashvili Emory University Atlanta, GA, USA

5 Jeremy Gaskill MAC Georgia/MAC USA

6 Ekaterine Tortladze Foundation Aures

7 Irakli Natroshvili Ken Walker Clinic, TSMU Rehabilitation Department

8 Tamila (Tea) Eristavi Social Rehabilitation Centre for Persons with Disabilities

9 Nino Jghartava First Step in Georgia

10 Tamuna Zaalishvili First Step in Georgia

11 Guna Bibileshvili Studio ADC

12 Zaza Kakushadze Neurodevelopment Centre

13 Maia Bagrationi-Gruzinksi MAC Georgia

14 Ana Tsitsagi Coalition for Independent Living

15 Medea Kakachia USAID Project Management Specialist

16 Sabina Ciccone PFIO, Project Director

17 Tea Adamia D. Tatishvili National Centre CIU NPO Georgia

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Satish Mishra, Sue Eitel/Maya Mateshvili Annex 6. Key contacts from in-country assessment 77

NO. NAME ORGANIZATION

9. SWOT (FEB 13, 2020)

1 Tamila (Tea) Eristavi Social Rehabilitation Centre for Persons Having Limited Ability

2 Neli Kakulia Georgian Association of Physiotherapists

3 Marika Kalmakhelidze GEFPOR

4 Eliso Murvanidze G.P.T.A

5 Ekaterine Tortladze Foundation Aures

6 Lela Maskhulia TSMU, Dean of Physical Medicine and Rehabilitation Faculty

7 Ketevan Kiladze MoIDPLHSA, Agency of Medical Regulation, Prof. Reg. Dept.

8 Maia Bagrationi-Gruzinksi MAC Georgia

9 Sabina Ciccone PFIO, Project Director

10 Ana Tsitsagi Coalition for Independent Living

11 Medea Kakachia USAID Project Management Specialist

12 Nino Japaridze MoIDPLHSA

13 Lira Topuridze Formerly MoIDPLHSA and MP

14 Tea Adamia D. Tatishvili National Centre CIU NPO Georgia

15 Nino Rukhadze Ivane Javakhishvili State University (TSU); OT

16 George Dzneladze Coalition for Independent Living

17 Giorgi Dzneladze Disability Mobility Centre

18 Rusudan Lortkipanidze Georgian Occupational Therapists’ Association

19 Zaza Kakushadze Neurodevelopment Centre

20 Guna Bibileshvili Studio ADC

21 Jeremy Gaskill MAC Georgia/MAC USA

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Satish Mishra, Sue Eitel/Maya Mateshvili

10. FOCUS GROUP SERVICE PROVIDERS –CENTRES (FEB 14, 2020)

1 Nino Patatishvili Studio ADC

2 Ekaterine Tortladze Foundation Aures

3 Tea Adamia D. Tatishvili National Centre CIU NPO Georgia

4 George Dzneladze Coalition for Independent Living

5 Zaza Kakushadze Neurodevelopment Centre

* Assessment Team: Sue Eitel/Maya Mateshvili

11. FOCUS GROUP SERVICE PROVIDERS – INDIVIDUALS (FEB 14, 2020)

1 Eliso Murvanidze G.P.T.A

2 Rusudan Lortkipanidze Georgian Occupational Therapists’ Association

3 Nino Rukhadze Ivane Javakhishvili State University (TSU); OT

4 Lira Topuridze Formerly MoIDPLHSA and MP

5 Sabina Ciccone PFID, Project Director

* Assessment Team: Satish Mishra

(Continued) 78 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

NO. NAME ORGANIZATION

12. FOCUS GROUP SERVICE USERS (FEB 14, 2020)

1 Amiran Batatunashvili Georgian Deaf Union

2 Maia Metonidze Georgian Deaf Union, Co-Chair

3 Leila Khachapuridze Wolfram Syndrome Georgia

4 Elene Paichadze Wolfram Syndrome Georgia

5 Nana Sharashidze Woman, Child and Society

6 Ucha Vakhania Georgia Care Platform

7 Rezo Maisuradze Chairman of the Blind Union

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Satish Mishra, Sue Eitel/Maya Mateshvili

13. AVERSI REHABILITATION CENTRE (FEB 17, 2020)

1 Maia Kurtanidze Head of Aversi Rehabilitation Centre

2 Nino Buzariashvili QM Manager, Training Centre Director

* Assessment Team: Mzia Jokhidze, Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili

14. AVERSI CENTRE – OTORINOLARINGOLOGIST /AUDIOLOGIST (FEB 17, 2020)

1 Tamila Shaiashvili Otorhinolaryngologist/Audiologist

2 Nino Buzariashvili QM Manager, Training Centre Director

* Assessment Team: Mzia Jokhidze, Sue Eitel/Maya Mateshvili

15. TBILISI STATE MEDICAL UNIVERSITY (FEB 17, 2020)

1 Lela Maskhulia Professor, Head of Physical Med & Rehabilitation Dept.

2 Valeri Akhalkatsi Director Sports Medicine Clinical Centre

* Assessment Team: Mzia Jokhidze, Sue Eitel/Maya Mateshvili

16. TATISHVILI CENTRE /HEALTH PALACE (FEB 17, 2020)

1 Dr Tea Adamia Head of Rehabilitation

* Assessment Team: Mzia Jokhidze, Sue Eitel/Maya Mateshvili

17. POLYCLINIC #14 – DISABILITY DETERMINATION COMMISSION (FEB 18, 2020)

1 Aleksandre Kezevadze Director

2 Natalia Memarnishvili Deputy Director

3 Mariam Kvernadze Family Doctor, Committee Responsible – Secretary

4 Nana Iluridze Family Doctor, Permanent Member of the Committee

5 Giorgi Bezhanishvili Invited Expert (neurologist)

* Assessment Team: Mzia Jokhidze, Sue Eitel/Maya Mateshvili

18. POLYCLINIC #14 REHABILITATION SERVICE (FEB 18, 2020)

1 Aleksandre Kezevadze Director

2 Marina (?) Doctor, PT Department – sole practitioner

* Assessment Team: Mzia Jokhidze, Sue Eitel/Maya Mateshvili

19. NEURO-DEVELOPMENTAL CENTRE (FEB 18, 2020)

1 Zaza Kakushadze Head of Neurologic Rehabilitation Programme

* Assessment Team: Mzia Jokhidze, Sue Eitel/Maya Mateshvili Annex 6. Key contacts from in-country assessment 79

NO. NAME ORGANIZATION

20. GEORGIAN FOUNDATION FOR PROSTHETIC ORTHOPAEDIC REHABILITATION – GEFPOR (FEB 18, 2020)

1 Marika Kalmakhelidze Public Relation Manager

2 Mamuka Gogorishvili Production Director

* Assessment Team: Mzia Jokhidze, Sue Eitel/Maya Mateshvili

21. MAC GEORGIA (FEB 19, 2020)

1 Maia Bagrationi-Gruzinski Programme Manager

2 Jeremy Gaskill CEO

* Assessment Team: Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili

22. ILIA STATE UNIVERSITY – SPEECH THERAPY TRAINING (FEB 19, 2020)

1 Nino Tsintsadze Associate Professor

* Assessment Team: Mzia Jokhidze, Sue Eitel/Maya Mateshvili

23. CENTRE FOR INDEPENDENT LIVING – CIL (FEB 19, 2020)

1 Giorgi Dzneladze Centre for Independent Living

2 Ana Tsitsagi Project Coordinator

* Assessment Team: Mzia Jokhidze, Sue Eitel/Maya Mateshvili

24. UNICEF (FEB 20, 2020)

1 Ketevan Melikadze Social Welfare Officer

* Assessment Team: Giorgi Kurtsikashvili, Sue Eitel

25. THE REHABILITATION CENTRE FOR PERSONS HAVING LIMITED ABILITY LTD. (FEB 20, 2020)

1 Tea (Tamila) Eristavi Director

* Assessment Team: Mzia Jokhidze, Sue Eitel/Maya Mateshvili

26. KEN WALKER UNIVERSITY CLINIC FOR MEDICAL REHABILITATION LLC – FACILITY TOUR (FEB 20, 2020)

1 Irakli Natroshvili Director, Ken Walker University Clinic for Medical Rehabilitation LLC

2 Nino Rukhadze Ivane Javakhishvili State University (TSU) occupational therapy

3 Rusudan Lortkipanidze Georgian Occupations Therapists’ Association

4 Archil Undilashvili Emory University Atlanta, GA, USA

5 Leila Chantladze Project Coordinator, PFID/Emory University

* Assessment Team: Nino Jinjolava, Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili

27. AVERSI REHABILITATION CENTRE – PT STAFF (FEB 21. 2020)

1 Dr Nino Kervalishvili Head of Rehabilitation Department

2 Three physical therapists working in the gym – all graduates of TSMU

* Assessment Team: Sue Eitel/Maya Mateshvili

28. PFID/EMORY UNIVERSITY PHYSICAL REHABILITATION PROJECT IN GEORGIA (FEB 21, 2020)

1 Leila Chantladze Project Coordinator, PFID/Emory University

2 Sabina Ciccone Programme Director, PFID/Emory University

* Assessment Team: Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili

(Continued) 80 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

NO. NAME ORGANIZATION

29. PSP FIRST HOSPITALS (FEB 21, 2020)

1 Dr Temur Magania Head of Neurology and Neuro-rehabilitation Department

2 Dr Tamar Tskitishvili Neurologist

* Assessment Team: Mzia Jokhidze, Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili

30. ADJARA MINISTRY OF HEALTH AND SOCIAL AFFAIRS, BATUMI (FEB 24, 2020)

1 Zaal Mikeladze Minister

2 Nino Nizharadze First Deputy

3 Zurab Tenieshvili Deputy Minister

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili

31. KEN WALKER CLINIC BATUMI (FEB 24, 2020)

1 Eka Solomonitze Manager

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili and Nino Nizharadze (Adjara Government)

32. CHAKVI NEUROREHABILITATION CENTRE – EVEX CLINIC (FEB 24, 2020)

1 Tamar Mjavanadze Administrative Manager

2 Medea Tskhomelidze Neurologist

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili and Nino Nizharadze (Adjara Government)

33. BATUMI SHOTA RUSTAVELI STATE UNIVERSITY – BSU (FEB 24, 2020)

1 Marina Koridze Professor, Dean of Natural Science and Health Faculty

2 Neriman Tsintsadze MD, PhD Associate Professor, Responsible for Rehabilitation Programme

3 Nato Zosidze Associate Professor

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili and Nino Nizharadze (Adjara Government)

34. 1 POLYCLINIC BATUMI – PT AND UNICEF PILOT PROJECT (FEB 24, 2020)

1 Dr Tengiz Shervashidze Director

2 Manana Zoidze Deputy Director

3 Giuli Khiladze MD – specialist in rehabilitation working as PT in polyclinic

~6 UNICEF Team Team that is supporting the pilot project disability determination

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili

35. CARITAS TBILISI (FEB 25, 2020)

1 Gaioz Kubaneishvili Health Care Programme Manager

2 Neli Vartanova Coordinator of the Rehabilitation Centre / Trainer

7 Mariam Latsabidze Health Care Programme Public Relations Specialist

* Assessment Team: Mzia Jokhidze, Sue Eitel/Maya Mateshvili

36. PROFESSIONAL STANDARDS WORKING GROUP (FEB 25, 2020)

~12 Led by Sabina (Emory) – with participants from professional associations and TSMU

Mzia Putkaradze Speech and Language – historical leader since 1967

* Assessment Team: Sue Eitel Annex 6. Key contacts from in-country assessment 81

NO. NAME ORGANIZATION

37. AKHALTSIKHE MUNICIPALITY (FEB 26, 2020)

1 Gurami Melikidze First Deputy Mayor of Akhaltsikhe Municipality

2 Imze Nadiradze Working in pilot project for Disability Determination – France

* Assessment Team: Nino Jinjolava, Giorgi Kurtsikashvili, Sue Eitel

38. ABASTUMANI PULMONARY HOSPITAL (FEB 26, 2020)

1 Revaz Zhgenti Director

2 Khakhaber Beridze Clinical Manager

3 Maka Mirziashvili PhD, Doctor in Rehabilitation

4 Teona Avaliani (Medical Student in Pulmonology – daughter of Maka)

* Assessment Team: Nino Jinjolava, Giorgi Kurtsikashvili, Sue Eitel

39. MINISTRY OF EDUCATION, SCIENCE, CULTURE AND SPORT (FEB 27, 2020)

1 Natia Gabitashvili Deputy Head Higher Education and Science Development Dept.

2 Nino Svanadza Higher Education Department

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili

40. THE NATIONAL HERO OF GEORGIA MARIAM (MARO) MAKASHVILI MILITARY REHABILITATION CENTRE (FEB 27, 2020)

1 Tata Oniani Psychologist

2 Natia Gamadzen Physical Therapist (Master’s Degree PT – Sports)

3 N. Chabashvili Psychologist

4 Tatia Guramishvili ?

* Assessment Team: Mzia Jokhidze, Giorgi Kurtsikashvili, Sue Eitel/Maya Mateshvili

41. PRELIMINARY FINDINGS PRESENTATION – MoIDPLHSA (FEBRUARY 28, 2020)

1 Tamila (Tea) Eristavi The Rehabilitation Centre for Persons Having Limited Ability

2 Neli Kakulia Georgian Physical Therapy Association (GPTA)

3 Medea Kakachia USAID Project management specialist

4 Maia Bagrationi-Gruzinksi MAC Georgia

5 Jeremy Gaskill MAC Georgia/MAC USA

6 Maguli Shaghashvili UNICEF

7 Gaioz Kubaneishvili Caritas Georgia

8 Nino Rukhadze Ivane Javakhishvili State University (TSU) - OT

9 Rusudan Lortkipanidze Georgian Occupations Therapists’ Association

10 Mamuka Gogorishvili GEFPOR

11 Sabina Ciccone PFIO, Project Director

12 Eliso Murvanidze G.P.T.A

13 Irakli Natroshvili Ken Walker Clinic, TSMU Rehabilitation Department

14 Tea Adamia D. Tatishvili National Centre CIU NPO Georgia

15 Ekaterine Tortlade Aures Foundation

(Continued) 82 SITUATION ASSESSMENT OF REHABILITATION IN GEORGIA

NO. NAME ORGANIZATION

16 Nino Kervalishvili Aversi Clinic

17 Maia Kurtanidze Aversi Clinic

18 Nino Buzariashvili Aversi Clinic

19 Lali Gabashvili Clinic TSMU

20 Sergo Maghradze GEFPOR

21 Keti Gigineishvili Georgian Association of Social Workers

* Assessment Team: Nino Jinjolava, Mzia Jokhidze, Sue Eitel/Maya Mateshvili Annex 7. Information on functioning from 2014 census 83

Annex 7. Information on functioning from 2014 census

Description of Total population Description of limitation Total function (3 713 804) responses No difficulty Some A lot of Can’t do it difficulty difficulty at all

Seeing 3 097 544 468 710 98 480 9158 3 673 892

Percentage of total population 83.00 12.60 2.65 0.25 98.90

Hearing 3 434 688 191 501 41 621 6082 3 673 892

Percentage of total population 93.00 5.20 1.10 0.16 98.90

Walking or climbing steps 3 452 894 144 322 60 681 15 995 3 673 892

Percentage of total population 93.00 3.90 1.60 0.43 98.90

Remembering/concentrating 3 573 168 72 906 21 987 5831 3 673 892

Percentage of total population 96.00 1.96 0.59 0.16 98.90

Communicating 3 607 943 42 919 16 246 6784 3 673 892

Percentage of total population 97.00 1.15 0.44 0.18 98.90

Self-care 3 575 440 57 275 25 951 15 226 3 673 892

Percentage of total population 96.00 1.50 0.698 0.41 98.90

TOTAL N/A 977 633 264 966 59 076 1 301 675

Percentage of total population N/A 26.30 7.13 1.59 35.00

Refusal 7262

Percentage of total population 0.195

Not stated 32 650

Percentage of total population 0.879

N/A: not applicable.

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