Despite the increase in healthcare spending in recent years and the introduction of the universal healthcare program, access to healthcare remains a challenge. Primary, essential healthcare plays a crucial role in the availability of medical services and public health management, yet its scope remains limited in Georgia.
Why is this important?
In regions populated by ethnic minorities, access to primary healthcare services, including those provided by village doctors, is a significant challenge. In areas like Akhalkalaki and Kvemo Kartli, where the majority of the population resides in rural areas, the need for the development of primary healthcare in these regions is particularly pressing.
Our comment:
In regions inhabited by ethnic minorities, the effective functioning of the rural doctor program faces obstacles such as expensive and complicated travel between villages and cities, irregular working schedules at health centers, inadequate remuneration and side jobs in doctors, deficient infrastructure, and shortages of medicines and equipment.
How is the healthcare system administered?
State primary healthcare programs are centralized, - a system that has often faced criticism for its perceived inefficiency.
At the central level, policies are formulated and executed by the Ministry of IDPs from the Occupied Territories, Labour, Health and Social Protection of Georgia (referred to as the Ministry). At the local level, municipalities also share responsibility for public health protection, primarily focusing on preventive vaccinations, disease prevention, and control. In coordination with the Ministry, they may also organize other health-related events.
The rural doctor program, which serves as a vital component of primary healthcare, is entirely centralized. The Ministry is responsible for its implementation and oversight through the Medical Holding of Georgia, - a Non-entrepreneurial (Non-commercial) Legal Entity.
What do we know about the role of local governments?
The role of municipalities is somewhat limited, as is the information they possess regarding healthcare needs. Komentari attempted to gather data about the number of healthcare professionals, including doctors and nurses, outpatient clinics, and their functionality from municipalities inhabited by ethnic minorities as part of the rural doctor program. However, four out of five municipalities (Marneuli, Gardabani, Ninotsminda, Akhalkalaki) redirected our inquiry to the Ministry and the holding, leaving our request for public information unanswered. Only Tetritskaro municipality responded to our inquiries. According to the City Hall, 21 outpatient clinics are operational in 89 villages of the municipality, with a total of 23 doctors and 19 nurses serving. This ratio likely fails to meet the geographic availability criteria, which stipulates service within a 15-minute reach area. The doctor-nurse ratio is also concerning, as best practice suggests a ratio of 1 doctor to 3 nurses. The imbalanced ratio of doctors to nurses is also highlighted in the healthcare system development vision for 2030 proposed in the Parliament, citing a shortage of nurses both in rural and urban areas. The same document identifies the uneven geographical distribution of medical personnel as a broader challenge.
What would decentralization change?
In an interview with us, Dr. Tengiz Verulava, a Healthcare Economist, emphasized that enhancing the involvement of local authorities in managing and monitoring primary healthcare programs significantly influences their effectiveness. This is because decentralization:
- reduces the administrative burden on the central authority in managing doctors and nurses across all villages nationwide;
- decreases the costs associated with rural doctors and encourages them to remain in rural areas, as local governments can cover insufficiently allocated resources for transportation, infrastructure maintenance of medical centers, or other needs;
- fosters a stronger connection between the population and local government, which is better equipped to address their needs.
What additional steps should be taken?
Despite the increasing demand and funding for health services in Georgia, expenditure on primary healthcare services remains low, making it the weakest part in the system. Both the quantity and geographical distribution of rural doctors, as well as their compensation, are inadequate, leading to their involvement in multiple roles and consequently reducing the operating hours of medical centers in villages.
It is crucial to thoroughly assess the needs of rural communities and regions and enhance the territorial and demographic distribution of medical personnel and services. Access to primary healthcare is further hindered by poorly equipped dispensaries/medical posts and inadequate transportation systems in rural areas.
Rural residents face significant challenges in accessing medical services or obtaining medication due to expensive, infrequent, or irregular transportation routes between villages and cities. This underscores that enhancing access to primary healthcare services and eliminating existing barriers necessitate systematic and comprehensive changes, including the equitable distribution of responsibilities and resources between central and local governments.
However, at the heart of these reforms lies a proper understanding of the state's role in providing healthcare as a public good. This issue extends beyond the challenges in primary care and is fundamentally linked to the excessive commercialization of the healthcare system in Georgia and the proliferation of for-profit clinics.
This article is produced under project “Increasing Public Resilience in Ethnic Minority Regions through Access to Information and Analysis,” funded by a grant from the Institute of War and Peace Reporting (IWPR) with the support of the UK Government. The opinions, findings and conclusions stated herein are those of the authors and do not necessarily reflect those of IWPR or the UK Government.”
