deputy minister mariam jashi - directions of healthcare reform

Basic Directions of Healthcare

System in Georgia

Mariam Jashi MD, MPH, MPA Ministry of Labour, Health and Social Affairs of Georgia

23 March 2013

Overarching principles/arguments – selecting strategic directions

1. International guidance and platforms

2. Human Rights based arguments

3. Analysis of local epidemiology (disease burden)

4. Scientific evidence and/or best international practices

5. Results-based planning exercise

9 strategic directions for 2013-2017 (ongoing strategic planning)

1. Health governance

2. Health Care Financing

3. Human resource development

4. Health information system (e-health, EMR)

5. Health service organization

6. Maternal, neonatal and child health

7. Priority non-communicable diseases

8. Priority communicable diseases

9. Enhanced inter-sectoral cooperation (education, penitentiary, agriculture)

Total Health Expenditure Structure

18% 20% 23% 23% 18%

73% 70% 72% 74% 79%

9% 10% 6% 3% 3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2007 2008 2009 2010 2011

International Aid Private Public

• > 70% of total health expenditures still out of pocket payments

• 9% of households faced catastrophic expenditure in 2010 vs. 6% 2006

• 50% of population still not protected from financial risks associated with healthcare

Household health expenditures as a percentage of total household capacity to pay

7.4% 7.6% 9.2% 10.6% 11.9% 12.6% 13.6% 13.3% 14.3% 15.2%

1.6% 2.0% 2.4% 2.6% 3.0% 3.7% 4.4% 3.6% 3.7% 3.5%

6.5% 8.9%

12.4% 13.4%

15.2% 14.2% 15.6% 15.5%

17.8%

23.1%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Curative Care Ancillary services to medical care Medical Goods

• Share of household expenditure on health increasing (~40%)

• Expenditure on pharmaceuticals ~ 57% of private expenditure

Towards Universal Health Care Global Context

United Nations General Assembly resolution on “Universal Health Coverage” (December 2012)

– urging governments to move towards providing all people with access to affordable, quality health-care services

WHO and the World Bank Ministerial on Universal Health Coverage (February 2013)

– Ministers discussing universal health coverage in the context of their respective countries

Universal Health Coverage

Nations with universal health care

Nations with legislated mandate for Universal health coverage, but which have not reached it yet

>60 Countries over the World progressing towards universal health coverage

Universal Health Coverage Georgia

706 336

805 392

1 635 217 4 497 600

2008

2012

2013

2010

People below poverty line

People below poverty line,

Teachers, Orphans....

Children under 5 years, Pensioners, Students,

Disabled Persons

2 200 000 Universal Health care

Program

1 652 351 State Health Insurance

Program

~ 470,000 Individual/corporate insurance schemes

Universal healthcare program 1st Phase from February 2013

1. Program goal

– Increase geographic and financial access to primary health care

– Rationalize expensive and high-tech hospital services by increasing PHC utilization

– Increase financial access to urgent hospital and outpatient services

2. Entails

– Planned outpatient services

– Urgent outpatient services

– Urgent hospital services

– The services are fully financed, do not require co-payment by a patient

– Upper limit for urgent medical care – 15 000 GEL

“Minimum” package to be expanded in July 2013 to “Basic”

(1) Health Governance

• Evidence-based policy- and programming

• Total quality management system for health services

- internal/external audits and control mechanisms

- step-wise introduction of accreditation system – perinatal care, ambulatory, lab, hospitals

• Standards of care

– national guidelines, protocols, revised institutional mechanism

• Drug regulations: prescription policies, quality assurance/control

• Patients rights protection: enhancing mediation services, mal-practice

(2) Health Financing

1. Towards universal health care

- considering coverage of essential drugs

2. Increasing budgetary allocations for health care – increasing fiscal space

- Genera revenues

- innovative funding (tobacco, alcohol)

1. Financial sustainability of global PPP funded projects

- Global Fund (HIV, TB)

- GAVI (new and under-used vaccines)

2. Introduction and operationalization of Diagnosis-Related Groups (DRGs)

(3) Human resources for health

HRH development planning

- overstaffing, underutilization of PHC and hospital services

- Financial or non-financial incentives for improved mix and geographic

distribution of health professionals

Reforming medical education and certification system

- undergraduate, postgraduate/clinical residency, continuous medical education

- qualification and certification instruments/exams

- inter-sectoral commission on ME reform

- distribution of health care professionals

(4) Health service organization

Inventory and regionalization

- recently completed inventory of medical infrastructure (1,553 facilities)

- regionalization/referral

Strengthening primary health care

- conceptualizing the vision (family medicine)

Emergency medical care

- focus on performance-monitoring and quality improvement (~10% hospitalization)

Laboratory networks

- public health – local, zonal and national labs

- clinical labs (QA/QC, accreditation)

(6) Infant mortality, Under-5 mortality, Maternal mortality and MGD

0

10

20

30

40

50

60

70

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 აგმ

სამიზნე

2015

Infant Mortality Under-five Mortality Maternal Mortality

NCDC&PH

(6) Promote maternal and child health

• Improve “active” surveillance

– maternal and child mortality

– epidemiological studies

– anonymous investigation

• Improve perinatal care quality

- promoting effective perinatal care practices

- regionalization/master plan

- accreditation of perinatal care

Main Causes of Mortality

71%

12%

1% 2% 5% 5% 4%

Column1

CVD Cancer

Chronic Respiratory Diseases Diabetes

Other NCD Communicable Diseases

Injuries

(7) Priority non-communicable diseases

• Develop NCD strategy and action plan

- PHC level screening and prevention

- 2013 – Hypertension year

• Focus on health promotion

- strengthening tobacco regulations

• Scaling up/decentralizing screening programs

- early detection and prevention of cancer

(8) Priority communicable diseases

• Improve and promote early detection of TB, HIV/AIDS

• Towards malaria free certification

• Immunization

– achievement/sustaining high national/sub-national coverage for traditional antigens

– Introducing Rota (2013) and Pneumococcal (2014)

– Measles elimination in 2015?

• Focus on international health regulations