REPRODUCTIVE HEALTH CARE ISSUES IN GEORGIA
by Tengiz Asatiani

In Georgia, the collapse of the Soviet regime in 1991 was followed by disruption of inter-republic and foreign trade, decline of production, hyper-inflation, unemployment and civil war. The economic crisis has led to rapid deterioration of medical services that had never been fully satisfactory.

Public health care services are now operating well below capacity in terms of beds and medical staff. In rural areas hospitals are mostly empty and many are closed altogether. When they are open, doctors and other medical staff attend only spasmodically, intent as they must be on making a living in private practice, or as best they can in any other way available to them. Patients must buy medicines, which were formerly dispensed at hospitals, from the commercial markets.

The public services now rely for medical supplies and equipment mainly on humanitarian assistance, offered by a large number and variety of international organisations. In these circumstances (a change from a single, centrally controlled source to a multiplicity of largely uncoordinated donors and recipients) there is scope for improved management.

Reproductive health services are highly medicalised and insensitive to the social, emotional, and interpersonal needs of women and their families. The country has not invested in family planning education nor in medical, nursing, and midwifery training to improve consumer oriented practice and basic public health services. The collection of maternal mortality statistics and the necessary audit of data are ineffective. Prevention and treatment programs are poorly developed, if they exist at all. Health professionals lack training in family planning, prenatal and neonatal care and emergency obstetrics.

In maternity hospitals and women's clinics shortages of drugs, equipment and supplies are common. Excessive emphasis is placed on high technology, expensive tests and procedures and relatively little on education and health promotion. Doctors, midwives and nurses working in primary care have a very low social status and little in the way of monetary or other incentives. They are the last to receive a share of available resources and in-service training. On paper, the system looks highly developed, but women in rural areas still travel long distances to health centres that are not necessarily equipped to offer even basic services, and to be looked after by staff who may not know how to provide a minimally acceptable standard of care.

In the nineties fertility has dramatically decreased in Georgia, while infant and maternal mortality have been rapidly increasing. There was a fall in the total number of births from 89,000 in 1989 to approximately 54,000 in 1995. The crude birth rate dropped from 19.2 in 1970 to 17.0 in 1990 and 11.8 in 1995. This drop occurred despite a stable abortion ratio (0.6-0.7) and a low (7%-10%) contraceptive usage rate.

The infant mortality rate had risen in 1995 by 13%, reaching 21.4 per 1000 live births. The decline of infant mortality between 1990 and 1992, as well as the sharp rise in 1995 may be more apparent than real, according to the Ministry of Health, which believes that about half the districts submit incomplete or otherwise defective data.

The most frequent causes of infant mortality in Georgia used to be respiratory illness and perinatal conditions. Respiratory conditions have since declined as a cause, in favour of other and less well defined causes, but this could be a statistical aberration. Respiratory conditions continue to be the principal cause of child illness in the country. The incidence of infant deaths from perinatal conditions, which are often indicative of the quality of antenatal and postnatal care, has remained about the same in absolute terms, but with the decline of infant mortality and of the portion due to respiratory infections, it has increased in relative importance.

The maternal mortality rate for the period 1984-1995 was approximately 35 deaths per 100,000 live births, estimated to be more than four times higher than in Western countries. The major causes were haemorrhage (44.7%), pulmonary and amniotic embolism (17.5%), sepsis (12.7%), gestosis (11%). Both the age of the mother and her parity were associated with higher relative risk for maternal death. Women over 30 years of age accounted for 48% of the deaths. Seventy-five percent of maternal deaths occurred among multiparous women, with 34% occurring in women with greater than five pregnancies.

So far there has been no legislation or regulation governing health delivery and medical education systems. A general law on health is being prepared and should be presented to the Parliament of Georgia in September. Regulations creating residency programs in obstetrics and gynaecology have been issued; rules on licensing of health professionals have been approved and enacted and rules on the accreditation of medical and nursing training institutions also approved and enacted.

The old system of pharmaceutical distribution has collapsed. Currently 75% of pharmaceuticals are supplied through an unregulated private market. The instructions for the storage of drugs are often neglected, making them ineffective or even dangerous. Neither public nor private sector personnel have experience in pharmaceutical procurement and management. In addition, an adequate infrastructure for distribution and retail does not exist. Another important source of medicines and supplies is aid from humanitarian agencies. Although these donations have been of great benefit, in some instances they have not been used or used incorrectly, as they are products unfamiliar to medical staff and the instructions are often written in a foreign language.

When Georgia was part of the Soviet Union, the health sector was under-funded. The situation has grown worse since the collapse of the economy. The fall in real expenditure was accompanied by a shift in the line item composition of expenditures. The rising costs of heating oil and other hard currency supplies took precedence over spending on wages and maintenance in a failing budget. Over the last three years revenue sources for the health sector have changed dramatically. The private sector has become the major source of revenues and the provision of services by the state has been dramatically reduced.

According to unreliable data two thirds of the population live below the poverty line with approximately 800,000 in the most vulnerable groups, including more than 270,000 refugees. There is no effective mechanism for identifying this especially vulnerable sector of the population, in an economy where the institutions are inexperienced and poverty is a widespread, yet new, social phenomenon.

Georgia has more than 120,000 persons working in the health sector. The number of physicians and other health professionals engaged in mother and child care is one of the highest per capita in the world. Undertrained, under-utilised and inadequately managed doctors and nurses greatly inhibit the efficiency and effectiveness of the mother and child health care system. There are 36 private medical schools granted authorisation from the Ministry of Education of Georgia. So far there are no accreditation procedures for these schools, no quality standard for teaching and no licensing and certification procedures for graduates in obstetrics and gynaecology and paediatrics. It is estimated that more than 2000 newly qualified graduates will join the vast cohort of medical personnel every year. The educational process does not provide the knowledge and skills necessary to carry out competency-based and evidence-based care comparable to international standards. There is a lack of management skills for the medical institutions. Training in health system planning and management, health administration, and health system financing was not available, or if available was of a very low quality in Georgian educational institutions. High quantity and poor quality of human resources contribute a lot to our poor health outcomes.

To revitalise the health care system, the government of Georgia has embarked on the difficult process of reformation of this complex public sector. The reforms were initiated by the Ministry of Health of Georgia in 1994 and supported by the Government. Legislation passed in June 1995 introduced important changes:

1. preventive public health services to be improved, State financing of clinical services to be reduced, strategic planning, monitoring and policy adjustment by the Ministry of Health to be a priority;
2. provision to be separated from financing, effected by setting up a State Health Fund, and regional agencies to be financed by government and municipal contributions and wage-based social security tax;
3. hospitals to be self managed, with all staff paid by income generated solely by the institutions;
4. allocation to the supply of health services; and
5. the legitimisation of previously illegal direct payments from users to providers, enabling the privatisation of hospitals, polyclinics and dental clinics, as well as the import and distribution of pharmaceuticals, under effective and efficient government regulation.

In order to support the reforms in the health sector, the Ministry of Health has started implementing a health project supported by the World Bank. The project and its components have been designed by the Georgian specialists and World Bank experts. The project preparation period has finished and the package approved by the Parliament of Georgia. As soon as the conditions for the credit stability are met the project becomes effective.

The Healthy Children and Safe Motherhood sub-component specifically aims at decreasing infant mortality by 30% in the whole country, and at decreasing infant perinatal and maternal mortality by 50% in Tbilisi during the four years of the Project. These specific objectives will be reached by:

1. supporting a sustainable Basic Package of Health Benefits that will include the most cost-effective women's and children's health interventions;
2. developing modern protocols of care, and guidelines for women's and children's health services that will be implemented on a national level;
3. training of health professionals;
4. reorganising women's and children's services in small, and revitalised facilities in selected areas, to demonstrate how to improve delivery of care; and
5. developing pilot referral systems that will contribute to the integration of all levels of women's and children's health care.

Activities geared toward the health of women and infants will also be carried out in other project components, notably health system reorientation, rehabilitation and maintenance of health facilities and development of health human resources. There is much to do.

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