Having reviewed the current resource allocation decision-making process, this section considers the actual distribution of SUSIF and municipal health care expenditure between geographic areas, and compares this to various indicators of need for such expenditure.
The indicators most frequently used internationally (see Annex 3.1) to measure the relative need for health services between different geographic areas such as regions or districts, are:
• population size;
• demographic composition, as young children, the elderly and women of childbearing age tend to have a greater need for health services;
• levels of ill-health, with mortality rates usually being used as a proxy for morbidity; and
• socio-economic status, given that there is a strong correlation between ill-health and low socio-economic status and that the poor are most reliant on publicly funded services.
Figure 3.4 shows that two regions in particular (Tbilisi and Adjara) are relatively ‘over-resourced’
when total publicly funded health care expenditure is compared to their need for health services based on two indicators, namely their population size and poverty levels. While over 55% of total health care expenditure (57% of SUSIF and 49% of municipal health care expenditure) occurs in Tbilisi, this region only accounts for a quarter of the population in Georgia and about 20% of the households who have incomes that are less than 50% of the poverty level are found in this region.
The comparable figures for Adjara are 13% share of total health care expenditure (7% of SUSIF and almost 30% of municipal expenditure), 9% of population and 3% share of the poorest households. In contrast, regions such as Kvemo Kartli and Imereti are relatively ‘under-resourced’
in relation to indicators of need. For example, less than 4% of health care expenditure occurs in Kvemo Kartli yet this region accounts for 11% of the population and 13% of very poor households.
In the case of Imereti, the share of health expenditure is 9%, of population is 16% and of very poor households is 21%. Figure 3.4 shows that differential capacity of municipalities to fund health services is of particular importance in contributing to disparities between expenditure and health care need patterns. While it should be noted that health facilities in Tbilisi do provide specialist services for residents from other regions, and thus an unadjusted comparison of expenditure with the population resident in the region is too simplistic, the magnitude of the differential between health care expenditure and relative need for health services strongly suggests an inequitable distribution of resources in Georgia.
Figure 3.4 2003 health care expenditure (SUSIF and municipal health departments) compared with distribution of population and poverty (% share of total)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% share
SUSIF health expenditure
Municipal health expenditure
Total health expenditure
Population Poverty
Racha-Lechkhumi Mtskheta-Mtianeti Samtskhe-Javakheti Guria
Kvemo Kartli Shida Kartli
Samegrelo-Zemo Svaneti Imereti
Kakheti Tbilisi Adjara
Sources: World Bank 2004 (for municipal health expenditure); SUSIF (for SUSIF expenditure) State Department of Statistics of Georgia website (for population); Dershem and Sakandelidze 2002 (for poverty)
Similar disparities in the distribution of health care personnel are evident, with the greatest number of doctors relative to population being found in Tbilisi and the highest number of nurses in Tbilisi and Adjara (see Figure 3.5). Regions like Kvemo Kartli and Guria are particularly under-resourced in terms of health personnel. This pattern is also reflected in the distribution of health facilities, with the number of hospital beds relative to the resident population being significantly greater in the largest urban areas, particularly Tbilisi (Tsekvava 2004).
Figure 3.5 Regional distribution of doctors and nurses (per 100,000 population) premature death, have the least access to health personnel and most importantly to public funding for health services. As demonstrated in the 2001 Georgia Household Survey, this translates into households seldom seeking care when ill and the poorest households incurring the highest burden of out-of-pocket payments. For example, almost 73% of household members who reported a non-chronic illness or injury did not seek immediate health care, with 82% indicating that they did not seek care due to a lack of financial resources. Individuals belonging to poor households spend 12.6% of their incomes on chronic illnesses, compared to 6% by those in the richest quintile. The disparities were even larger in the case of outpatient care for acute illness when poor households again spend 12.6% of their incomes but the richest households spend only 2.7% of their income.
The burden of health care expenditures on households is substantial. About 33% of households report health care expenditure greater than 20% of their total income in the case of chronic illness, 9% report comparable expenditure levels on acute outpatient care and of considerable concern is that 55% report such spending when a household member has required hospitalisation. This can have catastrophic effects on households and result in some households falling into poverty. For example, for those who required inpatient care, 10% more individuals fell below the poverty line after paying for these health services compared with before they incurred this expenditure (World Bank 2004).
This evidence provides a very strong basis for arguing that limited public sector resources for health care should be directed to preferentially benefit poor households in order to contribute to achieving the poverty reduction goals of the EDPRP. The EDPRP (Government of Georgia 2003) provides some, albeit relatively limited, guidance on health sector priorities which it identifies as:
• Actions which provide for maintenance of healthy and safe environment
• Actions in the area of public healthcare
• Actions in the area of primary and urgent healthcare treatment”. (EDPRP para. 404)
The EDPRP also explicitly indicates that there should be “increased accessibility to basic medical services, including marginal groups” (para 405) and that “financial and geographic accessibility of
the minimum required medical service for the population and healthy and safe environment” should be ensured (para 409). The EDPRP suggests that an essential package of health services should be provided and that government should “ensure their financing in full” (para. 406). The main criterion for determining this package would be that of cost-effectiveness (para. 408) which implies that certain services currently included in the BBP, such as organ transplants, are unlikely to be in an EDPRP priority package. There is clearly a strong emphasis on primary level health services.
The Strategic Health Plan for Georgia: 2000-2009 provides additional insights into priorities for the health sector (MoLHSA 1999). It indicates that the key responsibility of government is “to provide disease prevention and health promotion programmes, a safe environment and care for vulnerable population groups”. This policy document also notes that “government expenditure on health care will primarily be allocated to preventive services and primary health care” and that “this will be achieved by shifting considerable resources to primary health care from hospital services”. The Strategic Health Plan also explicitly supports the concept of equity in the use of health care resources and states that the “national health policy gives top priority to those who are worst off and will also address unequal distribution among all social groups of health status and provision of health and social services. Information should be collected to indicate whether the principle of equity is being maintained”.
Thus, various policy documents support the notion of promoting equity in the allocation of health care resources between geographic areas and socio-economic groups, as well as giving priority to primary care services. As indicated in section 3.2.3, the World Bank (2004) estimated that 18% of public sector expenditure was devoted to primary care (which they defined as outpatient care) and 9% on preventive care with the remainder being spent on inpatient care. The information presented in Annex 3.2 suggests that expenditure on these categories may be even lower at 3%
on preventive and promotive services (via spending by the PHD) and 12% on outpatient care (via SUSIF). However, aspects of certain other SUSIF programs, such as medical care for children, prenatal care and treatment of TB and other infectious diseases, would also fall into the primary health care category, but the exact primary care share of these programs could not be determined.
In addition, the major component of spending by municipal health departments, accounting for 22% of overall health care expenditure, could be considered to be primary care services as this relates largely to local public health and sanitary surveillance. Although it is not possible to determine the precise expenditure on primary care services, it does appear that achieving the health policy goal of devoting the majority of government health care resources to primary care is still some way off.