In Georgia, three decades of transition and multiple waves of reforms resulted in a highly fragmented health system with multiple disease specific vertical programs and a complicated matrix of health financing mechanisms. Misaligned incentives and low confidence in primary care led to an overreliance on costly inpatient care.[1] In addition, nearly 95% of health services are privately delivered and in the absence of strong regulation, escalating costs are often borne by households, especially for outpatient medicines.[2]

In 2013, Georgia introduced the Universal Health Care Programme (UHCP), substantially expanding the share of the population with publicly financed health coverage and reducing financial barriers to health services for many. This was made possible due to growing political commitment to UHC and a significant increase in public spending on health. Yet compared to the European Region average (4.9% in 2018), public spending on health in Georgia as a share of GDP remains low (2.8% in 2018).[3] Nevertheless, it represented a notable shift in policy from publicly funded benefits targeted at a narrow segment of the population (e.g., vulnerable, children, elderly) to broader coverage of the population, albeit with the addition of a highly complex system of user charges (copayments). While this signalled progress, financial protection has remained weak and in 2018, out-of-pocket (OOP) payments for health as a share of total spending on health (47.7% in 2018) remained well above the European Region average (29.8% in 2018).[4]  

In early 2020, WHO assembled a team to work with the Ministry on revising and costing the PHC benefits package. When the COVID-19 pandemic was declared, public health attention shifted to the emergency at hand, delaying government reform agendas and straining budgets and health systems. Despite pandemic-related disruptions, WHO added a health policy advisor under the UHC Partnerships to the WHO Country Office (WCO) in Georgia and

In 2019, the Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs invited WHO to review plans to reform the primary health care system. A WHO mission under the UHC Partnership recommended revising the scope of primary health care (PHC) services to become more preventive and people-centred, expanding the scope of practice of nurses, and redefining the role of specialists in the PHC setting.[5] Moreover, the WHO advised implementing performance monitoring and improved payment structures within PHC and provided technical support to guide the establishment of a new National Health Agency.

In early 2020, WHO assembled a team to work with the Ministry on revising and costing the PHC benefits package. When the COVID-19 pandemic was declared, public health attention shifted to the emergency at hand, delaying government reform agendas and straining budgets and health systems. Despite pandemic-related disruptions, WHO added a health policy advisor under the UHC Partnerships to the WHO Country Office (WCO) in Georgia and

moved ahead with a virtual multidisciplinary team of local PHC and policy experts, international consultants, and staff from the WCO, the Almaty geographically dispersed office (GDO) and the Barcelona GDO. Working in close communication with the Ministry, this team revised and costed the refined PHC benefit package and proposed a phased implementation plan. The new payment model proposes a mixed system of capitated payments, rent allowance, and add-on payments for priority services. The phased plan will begin with strengthening the priority services packages (well child care, early child development, type 2 diabetes, hypertension, CVD, and mental health). It also envisages increased utilization of digital health services (which has accelerated in response to the pandemic) and leverages support provided by UNICEF to increase internet access for rural PHC providers and introduce remote visits. Overall, this builds on WHO’s experience in working with PHC leaders to deliver training and scale digital health services to address the need for remote management of COVID-19 cases at the PHC level.

Key Takeaways:

• Covid-19 has highlighted the need for sustained investment in health system strengthening and the critical role of PHC in health emergencies; it is crucial that we capitalize on this window of opportunity.
• Georgia’s response to COVID-19 (including the development of remote treatment protocols and training of PHC providers in telehealth) demonstrates the capability, demand, and need to invest in and build capacity in the delivery of digital health services in PHC.
• In times of crisis, when key government personnel are overstretched, engaging additional local experts is crucial to ensuring progress, coordination, and timely follow-up on the provided assistance.

In parallel with work on PHC, WHO experts also provided comprehensive guidance and inputs for the development of a new Law of Georgia on Medicinal Products. Their input is also informing the reorganization of the National Drug Agency. Notably, this has also triggered interest in further collaboration with WHO in the area of pharmaceuticals resulting in a request for additional assistance in improving access to quality pharmaceuticals.

Throughout 2020, the coordination of interventions to strengthen PHC in Georgia advanced, despite challenges related to the COVID-19 pandemic. This was possible through continued direct support to the Ministry by WHO and the intensive engagement of local partners (through virtual meetings and close follow-up on agreements and new initiatives).