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Journal number 2 ∘ Tengiz Verulava Avtandil Jorbenadze

DOI:  10.36172/EKONOMISTI.2022.XVIII.02.T.Verulava.A.Jorbenadze

Expanded Summary

Primary health care can be considered as health care system’s cost-effective mechanism, which is mainly focused on the prevention of diseases and improvement of health. An important part of the reform, which began in 1995, was the reorientation of hospital-oriented medicine to prevention and primary healthcare. The purpose of the research is to evaluate structural and financial changes of primary health care system in Georgia. The article is based on a documentary analysis, which included official documents and non-official journal publications. Georgia became one of the first post-Soviet countries where primary health care policies were introduced. The concept of family medicine was formed. The department of Primary Healthcare was established in the ministry of healthcare. The society of family medicine was formed.

Family medicine has been admitted as an academic discipline, medical training programs have been launched. In 1999 license examinations for primary care specialists were conducted. Significant progress has been made in introducing guidelines and recertification procedures. Since 1996, several pilot projects have been implemented to strengthen the primary health care system. Programs were developed, the main purpose of which was to train physicians as family physicians. In 1997, the United Kingdom Department of International Development (DFID) launched a family doctor training program that trained sixteen family medicine trainers and 48 family medicine specialists. Within the second project of the UK Department of International Development following group of family medicine trainers, primary healthcare nurses, and managers started training. This department also initiated the formation of five demonstration centers for family medicine, including the National Family Medicine Training Center. The British non-government organization OXFAM implemented a primary healthcare pilot project.

During the Soviet period, primary health care was organized within the precinct-territorial concept, where patients had no right to choose a family doctor. After the reorientation, patients were granted the right to choose a family doctor, which increased the competition among doctors. In the centralized Soviet health care system, physicians were civil servants because the Ministry of Health was both a purchaser and a supplier of medical services. As a result of the reform, the function of purchasing medical services was transferred to the medical insurance company, while the function of delivery was transferred to the medical organizations with the status of independent action.

Serious investments have been made to upgrade the material base of primary health care facilities. Infrastructure development projects have been launched with the support of international organizations. World Bank, the United States Agency for International Development, and the governments of the European Union, the United Kingdom, and Japan planned and started the rehabilitation of primary health care facilities and the provision of technical equipment. These projects have made it possible to rehabilitate up to 200 ambulatories and supply them with modern equipment.

Primary health care organizations have become independent legal entities. Contractual relationships have been formed between the medical organization and the healthcare staff. Primary health care organizations were mainly funded by public purchasers (State Medical Insurance Company) based on the capitation remuneration method through federal and municipal health programs, increasing the competition among doctors and motivating them to provide high quality medical care.

25 years passed since the start of healthcare reforms in Georgia, but effective primary health care has not been brought into being. This can be evidenced by the low level of referral of patients to the family doctors and their lack of trust in them.

First of all, primary health care reform should contemplate the development of the family doctor institute, which includes promoting continuing medical education for family physicians, optimizing the geographical distribution and accessibility of the primary health care system, and increasing remuneration for primary healthcare personnel.

Primary health care reform cannot be implemented without the proper education of a family doctor/nurse. This requires raising the level of professional training of staff. The state, with the support of donor organizations, should ensure the development of the required capacity of appropriate primary health care human resources across the country. Continuing medical education for family physicians should also be promoted by the state. In mountainous regions, and especially in rural areas where there is a deficit of primary care medical staff, there is a need to reduce regional disparities in the distribution of medical staff. To do this, it is necessary to encourage the employment of staff in certain regions with much higher financial benefits. This will facilitate a more equitable distribution of human resources across the country.

The reform should be aimed at improving the material and technical equipment of primary health care. In this regard, it is necessary to define the minimum requirements for the infrastructure and equipment of primary health care service providers. The location of primary health care facilities is determined by the principle of optimal geographical access to medical services, which implies the ability to receive services within a 15-minute access zone. For people living in the mountains, or villages with small populations, it is expedient to set up mobile primary health care teams that periodically provide on-site primary health care services from the nearest family medicine center. In this regard, a single-team primary health care provider will be established in rural areas, and a single and multi-team primary health care provider in district centers and large cities. Considering the ratio of primary health care providers to the target population (1 doctor per 2000 population), Georgia needs 2000-2200 family doctors, and 2300-2500 general practitioners. At a later stage of the reform, it is advisable to increase the doctor-nurse ratio. 1 nurse per 250-1000 inhabitants in sparsely populated highland areas. One family medicine team per 1000-2000 inhabitants (1 doctor, one nurse).

To ensure the efficient functioning of the primary health care system, it is necessary to support the development of information system infrastructure and computer software. The information system must provide patients’ clinical information (patient history) confidentially. The basis for data collection is the accounting and reporting forms established by the Ministry of Health.

To facilitate the development of the family doctor institute, it is necessary to ensure the normal remuneration of primary health care medical staff. At present, according to the state program of universal health care, the family doctor is refunded according to the number of beneficiaries registered with her. The program allocates GEL 1.93 per month to each beneficiary, which is accrued to the primary health care facility. The medical institution finances the family doctor with 10-12% of this amount. Consequently, she receives an average of 19-20 tetri on her hand, while the nurse receives half of that. If we take into account that about 2000 beneficiaries are registered with one family doctor, his / her monthly salary is 400 GEL, while that of a nurse is 200 GEL. The institution of a family doctor cannot be developed with such remuneration.

It is advisable to introduce combined methods of primary health care reimbursement (targeted services, targeted reimbursement, etc.). The methods of incentive remuneration of physicians for conducting preventive measures on beneficiaries are particularly noteworthy. The doctor funding method is one of the main levers for the effective implementation of health services.

Primary health care is the foundation of a system. The quality of the population health, access to services, and efficient spending of scarce resources on health care significantly depend on a well-functioning primary health care system.

Keywords: Primary healthcare, family medicine, healthcare system.