PUBLIC HEALTH, HEALTH PROMOTION, PUBLIC RELATIONS. Volume 3

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PUBLIC HEALTH, HEALTH PROMOTION, PUBLIC RELATIONS

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Acknowledgements

Oxford Policy Management would like to thank all the individuals, too numerous to name, associated with the programme, Georgian and international. The documents contained in these volumes are the result of several years of collaboration between government officials, development partners, and other contractors. It is our hope that they have already contributed to the development of better health outcomes in Georgia. We also hope that these volumes can contribute in the future to further improvements in health outcomes in Georgia and other countries. It should be emphasised that the views expressed in these volumes cannot be attributed to the Government of Georgia, or the UK Department for International Development.

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Public Health, Health Promotion, Public Relations – Volume 3

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List of volumes

1. Introduction to Primary Health Care in Georgia 2. Primary Health Care – Service Delivery

3. Public Health, Health Promotion, Public Relations 4. Health Policy Systems

5. Health Financing and Purchasing 6. Management Systems

7. Ministry of Labour, Health, and Social Affairs (MoLHSA) Systems – Organisational Development

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List of tables and figures

Table 6.1 Service roles and responsibilities ... 40

Table 6.2 Steps for developing and implementing a national health promotion programme... 44

Table 6.3 Greatest chance of success through Health Promotion... 53

Table 7.1 Examples of HP/BCC interventions... 67

Figure 6.1 The “P” process ... 37

Figure 6.2 Organisational Relationships for Health Promotion ... 42

Figure 6.3 Preventive health action process ... 47

Figure 6.4 Combined and coordinated health promotion activities ... 48

Figure 6.5 The individual in the environment ... 49

Figure 7.1 People’s behaviour ... 60

Figure 7.2 Healthy behaviour... 64

Figure 7.3 The components of HP/BCC... 65

Figure 7.4 Stages of behaviour change model... 66

Figure 7.5 Stages of change related to HIV and STIs ... 67

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Glossary

Ambulatory care – medical care given on an outpatient basis. ‘Ambulatory’ in this case literally

refers to people who are able to walk out of hospital.

Basic Benefits Package – The package of health services financed through the State Budget,

including emergency, primary and some secondary care services.

Continuing Medical Education (CME) – an ethical and moral obligation to maintain and upgrade

knowledge and skill after postgraduate training and during one’s entire career. In some European countries (such as Belgium and Italy) it has become a legal obligation.

Disability Adjusted Life Years (DALY) – is a measure for the overall "burden of disease." It is

designed to quantify the impact of premature death and disability on a population by combining them into a single, comparable measure. In so doing, mortality and morbidity are combined into a single, common metric.

Effectiveness – The extent to which a specific intervention, procedure, regimen of service…does

what it is intended to do for a defined population. The extent to which objectives are achieved (WHO, 2000d).

Efficiency – refers to obtaining the best possible value for the resources used (Alban &

Christiansen, 1995). Technical efficiency means producing the maximum possible sustained output from a given set of inputs. Allocative efficiency is when resources are allocated in such a way that any change to the amounts or types of outputs currently being produced (which might make someone better off) would make someone worse off (World Bank, 2000). Allocative efficiency requires that an economy provides its members with the amounts and types of goods and services that they most prefer. Allocative efficiency is sometimes called “Pareto efficiency.”

Equity – Principle of being fair to all, with reference to a defined and recognised set of values.

There are two kinds of equity: Horizontal equity is the principle that says that those who are in identical or similar circumstances should pay similar amounts in taxes (or contributions) and should receive similar amounts in benefits; vertical equity is the principle that says that those who are in different circumstances with respect to a characteristic of concern for equity should, correspondingly, be treated differently, e.g., those with greater economic capacity to pay more; those with greater need should receive more.

Family Medicine – the medical specialty which provides continuing, comprehensive health care

for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioural sciences. The scope of family medicine encompasses all ages, sexes, each organ system and every disease entity. (1986) (2005)

Feldsher – senior nurse in Soviet “Semashko” health care system (see ‘Semashko’).

General Profile Hospitals – provisional name given to moderately sized hospitals providing a

range of general clinical specialties within fairly ready access of the population.

Health benefit – In health economics, a health benefit is one which is recognised as providing a

gain in terms of reduced costs or increased health.

Health care systems – A formal structure for a defined population, whose finance, management,

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people to contribute to their health, and delivered in defined settings such as homes, educational institutions, workplaces, public places, communities, hospitals and clinics.

Health Management Information System – systems for planning, organizing, analysing and

controlling the data and information, including both computer–based and manual systems.

Health Needs Assessment – a formal, systematic attempt to determine and close important gaps

between current outcomes and desired health outcomes, and the placing of those gaps in priority order for closure. Needs assessments should be used to guide health policy and programme development. It provides information on which to base health funding allocations.

Health Insurance – term generally used to describe a form of insurance that pays for medical

expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. Insurance may be provided through a government-sponsored social insurance programme, or from private insurance companies. It may be purchased on a group basis (e.g. by a firm to cover its employees) or purchased by individual consumers. In each case, the covered groups or individuals pay premiums or taxes to help protect themselves from high or unexpected healthcare expenses. Similar benefits paying for medical expenses may also be provided through social welfare programs funded by the government.

Health policy – A formal statement or procedure within institutions (notably the government) which

defines priorities and the parameters for action in response to health needs, available resources and other political pressures.

Health Policy Analysis – the process of assessing and choosing between spending and resource

alternatives that affect the health care system, public health system, or the health of the general public. Health policy analysis involves several steps: identifying or framing a problem; identifying who is affected (stakeholders); identifying and comparing the potential impact of different options for dealing with the problem; choosing among the options; implementing the chosen option(s); and evaluating the impact. The stakeholders can include government, private healthcare providers (e.g. hospitals, health plans, and office-based clinicians), industry groups (e.g., pharmaceutical, biotechnology, and medical device manufacturers), professional associations, industry and trade associations, advocacy groups, and consumers.

Health Promotion – The planned and managed process of encouraging and assisting

improvement in the health of a population as distinct from the provision of health care services. Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behaviour and create environments that support good health practices.

Health systems – The people, institutions and resources, arranged together in accordance with

established policies, to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health.

Health technology assessment – Comprehensive evaluation and assessment of existing and

emerging medical technologies including pharmaceuticals, procedures, services, devices and equipment in regard to their medical, economic, social and ethical effects.

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Joint Stock Company – A private company which has some features of a corporation and some

features of a partnership. The company sells fully transferable stock, but all shareholders have unlimited liability.

Management Systems – the framework of processes and procedures used to ensure that an

organisation can fulfil all tasks required to achieve its objectives.

MoLHSA – Ministry of Labour, Health, and Social Affairs of Georgia, created following the merger

of two ministries – the Ministry of Health and the Ministry of Labour and Social Welfare in 1999. Currently the MoLHSA has the following responsibilities: planning and determining health priorities; developing and implementing national health care policy; drafting healthcare laws and enacting regulations subsequent to primary legislation; ensuring supervision of health-related law enforcement; developing and overseeing the implementation of public health programs; advocating for adequate resource allocation for the healthcare programs from the state budget; and regulating healthcare professions, health facilities and pharmaceutical market.

Multi-Profile Hospital – provisional name given to hospital providing Sub-specialty clinical

services.

Out of pocket Payment – describes ways of paying for services (in this case health). Forms of out

of pocket payment include:

- Direct payment: payment for the goods or services that are not covered by the insurance

or state finding;

- Cost sharing: a prevision of health insurance or third party payment that requires the

individual who is covered to pay part of the cost of health care received. Often referred as formal cost sharing or user charge. Cost-sharing could be direct or indirect.

- Informal payments: unofficial payments for goods or services that should be fully funded

from pooled revenue.

Primary Health Care – health care that is provided by a health care professional in the first

contact of a patient with the health care system. In Georgia, since 2006, Primary Health Care (PHC) is defined as a non-hospital health care. It means that all services provided by general practitioners and specialists in out-patient clinics are considered as a PHC.

Private Health Insurance – Private health insurance schemes are provided by private companies

and are based on voluntary contribution by individuals or by individuals and their employers jointly. There is usually a wide range of private insurance schemes varying in the type of conditions or services covered.

Payroll tax – A tax paid by the employer on the basis of its payroll.

Polyclinic – A type of health provider that provides ambulatory health care for more than one

specialty of services.

Premium – A flat-rate payment for voluntary insurance.

Private health care sector – Involves the transfer of ownership and government functions from

public to private bodies, which may consist of voluntary organisations and for-profit and not-for-profit private organisations. The degree of government regulation is variable.

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Public Health – The science and art of promoting health, preventing disease, and prolonging life

through the organised efforts of society. The field of medicine and hygiene dealing with the prevention of disease and the promotion of health by government agencies.

Purchaser – A health care body which assesses the needs of a defined population and buys

services to meet those needs from providers.

Purchasing Power Parity – the rates of currency conversion that equalise purchasing power

across the full range of goods and services contained in total expenditure and Gross Domestic Product of a country.

Quality of medical care – The degree to which health services for individuals and populations

increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Quality assessment – Planned and systematic collection and analysis of data about a service,

usually focused on service content and delivery specifications and client outcomes.

Quality improvement – Ongoing response to quality assessment data about a service in ways

that improve the process by which services are provided to clients.

Rayon – territorial unit, or district. There are 68 rayons in Georgia.

Rayon Health Corporation – The Health Care Services Act, elaborated by the MoLHSA in 2006,

proposed that that the corporations be established in Georgia to provide public health services in hospitals (Hospital Corporations or HC) and primary health care/ local health services (Rayon Health Corporations or RHC). These corporations had to be independent, non-for profit organizations owned by the State and governed by Supervisory Boards.

Regulation – setting forth mandatory rules that are enforced by a state agency. According to the

broader definition, it incorporates all efforts by the state agencies to steer the economy.

Semashko model – Health care model, functional in the Soviet system, based on complete State

financing of all types of health care services for the entire population of the country.

SUSIF – State United Social Insurance Fund. SUSIF was set up in 2003 following the merger of

the State Medical Insurance Company and the state pension fund, as an independent agency acting under the control of MoLHSA. SUSIF became a key social insurance institution in charge of financing pensions, social security benefits, unemployment and state health programmes.

State Ambulatory Programme – The state programme for the entire population of Georgia,

providing PHC (ambulatory and policlinic) services, paid through the State budget. The service includes consultations with PHC providers, defined specialists at out-patient level, and defined sets of laboratory and diagnostic services.

Tbilisi State Medical University – Tbilisi State Medical University is the largest Medical University

in Caucasus region [Georgia, Armenia and Azerbaijan]. Running for more than 80 years, this university currently educates 5000 students using 1200 Professors.

Under-the-table payments – Informal, unofficial payments which are usually prohibited in order to

have one’s wishes/demands/needs fulfilled in a timely manner or to a larger extent than by following the official rules and regulations.

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Universal Health Insurance – A national plan providing health insurance or services to all

citizens, or to all residents.

Universal package – A set of services paid through the State budget for all citizens of the country. Utilization – The number of health services used by a population, often expressed per 1000

persons per month or year.

Voluntary health insurance (VHI) – Health insurance which is taken up and paid for at the

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Abbreviations

AIDS Auto Immune Deficiency Syndrome ARV Anti Retroviral

BCC Behaviour Change Communication CDC Centre for Disease Control

CHD Coronary Heart Disease

DFID Department for International Development DOTS Directly Observed Treatment Therapy DP Disease Prevention

FAQ Frequently Asked Questions FGD Focus Group Discussion

GVG Gesellschaft fur Versicherungswissenschaft und Gestaltung HIV Human Immuno-deficiency Virus

HP Health Promotion HPU Health Promotion Unit IDU Injecting Drug Users

IEC Information, Education, and Communication IMCI Integrated Management of Childhood Illnesses IMR Infant Mortality Rate

IPC Inter-Personal Communication IUD Inter Uterine Devices

MMR Maternal Mortality Rate MPH Masters in Public Health NCD Non Communicable Disease

NCDC&MS National Centre for Disease Control and medical statistics NGO Non Government Organisation

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PH Public Health

PHC Primary Health Care PHD Public Health Department PR Public Relations

RHC Rayon Health Centre RTA Road Traffic Accidents

STI Sexually Transmitted Infections SUSIF State United Social Insurance Fund

SW Sex Workers

TB Tuberculosis

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Introduction to reforms and OPM

This brief introduction is present in every volume of the Primary Health Care (PHC) Reform Support Programme. It aims to analyse the health care system reforms undertaken by the Government of Georgia (GoG) in the period of 2003-2007 in parallel with the implementation of Department for International Development (DfID) Georgian PHC reform support programme, executed by the Oxford Policy Management (OPM). The main emphasis is on capturing the health policy changes affecting the nature and volume of OPM’s work.

Georgian health care reforms

September 2003 – Summer 2005

In 2003, without having elaborated a comprehensive health care reform plan, the GoG concentrated on PHC reform, supported by three major donors – DFID, the World Bank and the European Union. Aid support for this five year period amounted USD 40 million. Two big programmes started in 2003 – the World Bank supported a PHC programme implemented by the World Bank Health Policy Unit, and DFID supported a PHC reform support programme, implemented by Oxford Policy Management.

The Ministry of Labour, Health, and Social Affairs (MoLHSA), in which these programmes were housed, had limited technical capabilities. As a result, it was not able to formulate specific objectives for the aid programmes, and instead expected them to work in a proactive manner. Consequently, until the end of 2003, programmes worked on inception phases, assessing local context and re-formulating their goals and objectives to boost possible outcomes.

After coming to power in the Rose Revolution of 2003, the new government pledged to undertake health care reform, aiming at securing the social welfare and good health of entire population of Georgia. However, despite this political declaration, the new government did not speed up the process of decision making on health care reform strategy development and implementation. The MoLHSA was a passive listener to the proposals coming from different aid partners, being partially involved in the discussions of elaborated technical products.

The major challenge of the 2003-2004 period was that a high number of donors and contractors were competing with each other, while supporting the Ministry in the same area of PHC, and operating in a completely uncoordinated environment because of the low capacity of the MoLHSA to lead the process.

OPM programme

The central goal of the DFID supported PHC reform programme was to enhance the MoLHSA’s capacity to develop and manage the PHC sector. Originally the programme was structured in five work streams, including ‘Support to the PHC Coordination Board and Management Committee’, ‘Support to heath care financing and policy’; ‘Support to Human Resource development for PHC’; ‘Support to the development of Health Management Information systems’, and ‘Support to Health Information Education and Communication System (IEC) based activities’.

From the beginning, OPM has been working closely with the PHC Coordination Board and its Management Committee in the MoLHSA to strengthen the Board’s leadership role in designing and implementing PHC reforms. An early objective of the PHC Board was to develop a PHC reform implementation plan, integrating DFID, World Bank and European Commission support to the MoLHSA, and leading to a harmonisation of donor and government efforts. However, this

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harmonisation was not achieved, partly due to wrong arrangements for the PHC coordination, which was situated outside the Ministry and had only de jure, rather than de facto power; and partly due to low capacity in the PHC management committee. Within one year, the MoLHSA dissolved the PHC Coordination Board and its Management Committee. Responsibility for PHC reform coordination was given to the Director of National Institute of Health.

In the first few months, OPM conducted an assessment of the existing context to structure the programme according to the needs of the government. Initial reviews have been transformed into the reports from early 2004, covering the fields of PHC Policy development; harmonisation of partners; an assessment of PHC roles and functions in Georgia; an institutional map of agencies involved in human resources and service delivery in Georgia; notes on the Evolution of Primary Health Care in Western Europe as well as on European Primary Health Care Policy processes, stakeholders and actors; Resource allocation; Budget structure and budget management for Health Care. According to the request of the Ministry, large technical documents prepared by OPM were also transformed into briefing notes for wider dissemination.

Summer 2005 – January 2006

Aside from healthcare, the new government concentrated sharply on social sector reforms from the very beginning, with the aim of allocating the State social subsidies more effectively to those in need. A “Targeted Social Assistance Scheme” was developed and implemented in 2004-2006, identifying and ranking 1/3 of the population of Georgia according to the social status. 1/4 of the population were defined as recipients of different types of social allowances.

In parallel, the government wanted to develop adequate capacity in the MoLHSA to steward the Social and Health sectors. They approached aid partners, including OPM, to support the Ministry in reorganisation, with the purpose of defining the structure and functions of the “contemporary Ministry of Labour, Health and Social Affairs”, emphasising the need for transforming both social and health segments.

OPM programme

In summer 2005 the top management of the OPM programme changed. The new leader restructured the programme according to the government’s new requirements in key three areas of work:

1. Effective implementation of the new PHC system;

2. Building capacity in key Ministries and associated structures; 3. Support to policy development.

Programme resources began to concentrate on supporting the MoLHSA in Organisational development. Together with Co-reform, the USAID contractor, OPM started work on the overall Ministry Charter, proposing its functions and structure. At the same time, at the request of the MoLHSA and with the approval of DFID, OPM put huge emphasis on the organisational development of the Labour and Social affairs segment. Documents were prepared in the period of autumn 2005-January 2006 on the following areas: assessment reports on current regulatory function at the MoLHSA, and assessments of the Social Policy functions and the organisational structure of the MoLHSA; an organisational assessment of Labour and Employment Policy Department; an Organisational Assessment for Labour Inspection; Charters and sub-charters of the Department of Labour and Social Security, Social Integration and Care Division, Pensions and Social Assistance Division, and Labour Divisions of the MoLHSA; an assessment report on the organisation of Targeted Social Assistance (TSA); organisational requirements for a New Flat Rate

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xvii Pension System; and an assessment of the agencies responsible for the TSA and pensions administration.

At the same time, OPM was intensively working with the Ministry on PHC policy, PHC financing, HR development and organisational design issues, trying to convince the government of the necessity of elaborating the PHC Road Map and overall strategy for health care system development. The documents produced in this period cover wide spectrum of the areas, including the “Stewardship and regulation of health services”; “The Road Map for Primary Health Care Reform”; “Ambulatory Services in Villages”; “Drug Benefit Scheme for Primary Health Care in Georgia”; “Review of the Road Map for Primary Health Care Reform in Georgia from the perspective of pharmaceuticals and Drug Benefit Scheme for Primary Health Care in Georgia”; First draft on the HMIS strategy; Technical Notes on “Delivering better public health services in Georgia”; State Health Budget structure, and “Planning human resources for health in Georgia”; “PR strategy for MOLHSA”. Most importantly, at OPM’s initiative, and with the participation of Co-reform, the MoLHSA prepared a first strategic paper “Main directions in Health”, outlining the goal and main objectives for health system development. Finally, the MoLHSA approved the Road Map for PHC prepared by OPM.

January 2006 – October 2006

In January 2006, the Prime Minister requested the MoLHSA to initiate the transparent and coordinated process for the elaboration of the health sector development strategy with the involvement of all key stakeholders within a four month period.

The first deputy minister was put in charge of the assignment. The National Institute of Health team was leading technical work for the development of the strategy, which would consist of three parts: service delivery, health system organisational design and health care financing sections.

The strategy paper was worked out through the painful but useful process of controversial discussions and debates. The document proposed the development of the health care system based on public ownership, improved public administration and a separation of functions between the different health actors. It envisioned the MoLHSA in the role of a steward with enhanced regulatory and supervision functions. It called for an accelerated role for strategic purchasing through the establishment of strong public health purchaser. The paper also described the service provision in the public sector run through Rayon Health Corporations (RHC) in Primary Health Care and Hospital Corporations (HC) in Secondary and Tertiary Care, as publicly owned non-profit organisations subject to private law; and the strategy gave multiple roles to the private sector in service provision, under proper regulation. It proposed the production of human resources by reforming undergraduate and post-graduate training of both doctors and nurses; and called for the development of health service management capacity through intensive training to run the newly created Corporations through modern managerial criteria.

The paper was submitted to the Prime Minister on June 6, 2006. However, the top government did not approve the paper. The new instruction to the MoLHSA was to elaborate in more detail the separate segments of the strategic document, concentrating on the development of the PHC master plan, the Hospital development master plan, the Health Human Resource development strategy; and the Health care financing strategy. At that time, the government did not make clear that the reason for the objection to the proposed health care development strategy was rejection of the idea of publicly owned, purchased and provided health care services. As a result, all the following assignments were conducted based on an (incorrect) understanding that the government was looking for better proposals for public health care system development.

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In parallel, the MoLHSA, with extensive support from all three donors, was working on finalisation of PHC Master Plan. The goal of PHC development should have been to guarantee universal accessibility to, and efficient utilisation of, basic health services. The plan included upgrading the competences of primary care staff and the rehabilitation of PHC infrastructure countrywide. The plan also involved discussing the development of adequate management and supervision structures for PHC management, together with development of health information systems.

In parallel to the Policy work, the government requested aid partners to concentrate on PHC human resource development. OPM was asked to revisit the budget to allocate funds for the re-training of PHC doctors and nurses, as well as PHC and Health System managers.

OPM programme

OPM was extensively involved in the elaboration of the Health Care Strategy Document. OPM supported the Ministry in setting up the process and gave significant input into the content of the paper. Numerous discussion notes and back up documents worked out in January-May 2006 are testament to this.

Although several stakeholders were involved in the strategy elaboration process, the main weight of technical expertise came from OPM and Co-reform. These two organisations brought different perspectives of the heath system development. OPM supported the continental model of Health systems, favouring social values as equity, fairness to financing, accessibility and affordability. Co-reform, on the other hand, promoted a more US health care model, with Health Maintenance Organisations, primary and hospital service delivery by the same institution, and a private-public mix for health care financing. This partner controversy was reflected in the final strategic paper, which incorporated several options in each section for the health system development.

After June 2006, OPM received new assignments from the Ministry, which asked OPM to elaborate more on the PHC Master plan modification, namely to define the structure and functions of PHC Rayon Health corporations and MoLHSA regional branches; to prepare background materials for Hospital Master plan development, work on Human resource development and health care financing strategies.

In response, within five months OPM produced a number of significant technical documents, including the “Governance of the health system in Georgia; Role, organisation and operations of the Regional MoLHSA”; “Governance and Management of Medical Facilities;” “Managing Health Systems in the Public sector;” “Georgian PHC Reform: Management Evaluation Systems;” “Health Management Information Systems Technical Strategy”; “Planning Human Resources for Health in Georgia”; “Prototype Hospitals Planning Philosophy;” “An Outline Service Delivery Model for Hospital Services in the Reformed Health System” “Report on staffing norm development for hospital services in Georgia, Final Draft”; and “ OPM NIHSA Hospital Cost Model”.

In summer 2007, OPM was requested to work on the development of the Public Health System for the MoLHSA. In response to MoLHSA’s request, OPM elaborated four memos on Public Health Systems development, covering the proposals for the needed Public Health structure and capacity in the MoLHSA and subordinated agencies; and revision of State public health programs.

“Health promotion and Disease prevention strategy” was also finalised in cooperation with the Public Health Department and National Centre for Disease Control staff. Health promotion Guidelines were prepared and provided to the Ministry.

In parallel, at the government’s request, OPM revisited the programme budget to allocate funds for the development and prevision of Health Care Management Programme and for the re-training of PHC doctors and nurses.

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xix Re-training of the PHC personnel was undertaken using the curricula and the programme prepared by the first DFID supported health project in 2001-2002. OPM produced following documents for the Management training programme: “Health Service Management Training programme Introduction”; and “Health Service Management Training programme Curricula”; followed by a number of quality materials for all three modules of the training. According to Georgian regulation requirements, the Management training programme was accredited by the MoLHSA. OPM made plans for accreditation of the programme by international accreditation agency “the Institute of Leadership and Management.”

November 2006 – end of 2007

In autumn 2006, the State Minister in charge of Public reforms was requested by the Prime Minister to lead the elaboration of new Health Reform Strategy. The Prime Minister was assigned as the head of Governmental committee for health and social reforms, in charge of decisions about the health policy. The governmental team was requested to prepare an alternative version of the reform, based on the following principles:

- Almost full privatisation of health service provision;

- Radical changes in State Health resource allocation to the benefit of socially vulnerable; - Involvement of private insurance in health service purchasing;

- Significant simplification of governmental regulations.

The new arrangements for health policy elaboration and decision-making virtually excluded active participation by donors and contractors. Most of the work fell to the MoLHSA staff to work on daily assignments coming from the State Minister.

International and local experts were requested to revise the elaborated technical work to fit with the government’s new vision of a private sector based health care system. Most of the aid agencies, including OPM, preferred therefore to select a single niche in the PHC reform process, more or less independent of the government’s decisions on health system design, and concentrate on it. With the agreement of the government and DFID, OPM identified ‘Health Care Management training’ as a desirable output that could be produced before the end of the programme.

The Ministry also requested that some of the OPM programme resources should be allocated to modular trainings for PHC personnel. In addition, OPM found it necessary to build a PHC networking capacity in Georgia in the context of global privatisation of primary and secondary care facilities.

In summer 2007, the Ministry asked OPM to conduct a Health Needs Assessment. This would be used as a basis for the revision of benefit package covered by the State health programmes, and the development of health insurance packages to be purchased through the State funding.

OPM programme

OPM has concentrated on Health Management Training programme development and provision. In fact, almost all local and senior international staff were involved in the processes of preparing and delivering training. In 18 months, seven groups of twenty-five people have been re-trained, composed of PHC, Hospital and Health Systems Managers. By mid 2007, OPM Management Training programme became a brand, famous among health care managers all over Georgia. In recognition of the OPM programme’s success, MoLHSA allocated funds from the 2007 budget to finance the health management training for 200 managers in addition to those trained by OPM, using OPM developed curricula and materials. The fact that MoLHSA took over the training

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provided a guarantee for the sustainability of OPM’s product, as several local academic and training institutions got involved in the delivery of the Management programme.

In parallel, OPM has been working intensively on modular trainings for the re-trained GPs and nurses in three regions – Ajara, Kakheti and Imereti. These efforts were highly appreciated by the PHC providers, who requested an extension of the trainings to other regions. In total, about 250 individuals will be re-trained through the modular trainings by summer, 2008.

From December 2007, OPM initiated activities for building the capacity of PHC medical personnel to network in regions. As mentioned above, this initiative was particularly important as the government declared a plan to privatise PHC facilities countrywide in 2008. This privatisation would mean that instead of existing Rayon policlinic/ambulatory unions in most of the regions in Georgia, there will be individual PHC providers in villages, rayon centres and cities. PHC personnel will therefore need some form of networking capability in order to derive sufficient power and the ability to speak with a joint voice to the MoLHSA and private health purchasers. OPM intends to prolong these activities until the end of the programme.

By the end 2007, OPM finalised the work on health human resource strategy, producing the papers on “Planning of the Medical Workforce in Georgia;” “Workforce estimation model for Kakheti region”; “Workforce Model Presentation”.

Finally, in agreement with the Ministry, OPM intends to conduct the Health Needs Assessment from March, 2008. Field work will be completed within one month. OPM will provide the Report of the assessment to the MoLHSA by June 2008. In the current context, this assignment also gains particular importance, because the government intends to revisit the insurance package purchased by private health insurance companies through the State health service programme for the population below the poverty line. In parallel, the MoLHSA intends to modify the health care services covered by other State Health programmes for the entire population of Georgia and some specific groups of target beneficiaries. Health Needs Assessments results would provide a sound background for evidence-based decision making by the MoLHSA.

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Georgia’s Health Policies in Public Health, Health Promotion and Health Communications

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1 Documentation for Georgia’s Health Policies in Public

Health, Health Promotion and Health Communications

J Patrick Vaughan

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1.1 Introduction and background

The health policies adopted by the Government of Georgia, acting through its Ministry of Labour, Health, and Social Assistance (MoLHSA), need to show how the Government is responding to the current and future health needs of its population. In the last decades Georgia has undergone both demographic and epidemiological transitions, which has major implications for the future national health policies it adopts. (See the separate Literature Review entitled: Georgia: Morbidity and Mortality – Patterns, Trends and Health Services Utilisation). General mortality in Georgia is now similar to the average patterns in Eur-A1 and Eur-B+C2 groups of countries. The infant mortality rate (IMR) was officially 23.8/1000 live births in 2004, fertility has fallen below replacement level, and there is an aging population profile. About 70% of overall mortality is now due to cardiovascular diseases (CVD) and these diseases and neuropsychiatric conditions (mental, neurological and substance use disorders) now account for the highest burden of disease. The main risk factors for male mortality are high blood pressure and tobacco consumption, and for females, high blood pressure and excessive weight.

Over half of all people reporting a chronic illness seek care while only 25% of those reporting a more acute illness seek care from a medical provider. In 2005 there were 2.1 primary health care encounters per person/year for medical care but occupancy of primary health care facilities was only 38%. Household health expenditures are particularly high for inpatient care, with over 55% of those seeking inpatient care reporting health expenditures above 20% of income.

The Georgian Primary Health Care (PHC) Reform Programme was formally established as a separate unit within the Ministry of Labour, Health and Social Assistance (MoLHSA). However, it soon became clear that the PHC Reform Programme needed to respond to the Government’s new political reforms for more liberalisation, decentralisation and privatisation and how these would impact in the health sector. Three major health policy issues clearly emerged as requiring much greater attention.

Three fundamental policy issues emerged. First, what is the role for the Government of Georgia, acting through its MoLHSA, in safeguarding its essential state public health programmes and services, including its concerns for equitable and fair health policies for its poor and disadvantaged citizens? The implications for essential public health functions are tackled next in Part One.

Second, how are the Government’s new public health policies responding to very high current levels of morbidity and mortality due to cardiovascular diseases and their associated risk factors? Clearly priority now has to be given to strategies for health promotion and disease prevention, both at the individual and population levels. The implications for adopting stronger policies for health promotion are tackled in Part Two.

Third, how can the Government strengthen its role in public health communications and health education, including for public education in promoting healthier lifestyles? The implications for this are outlined in Part Three.

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Eur-A comprises Andorra, Austria, Belgium, Croatia, Cyprus, the Czech republic, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Malta, Monaco, the Netherlands, Norway, Portugal, San Marino, Slovenia, Spain, Sweden, Switzerland and the United Kingdom. These are countries with very low child mortality and very low adult mortality.

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Eur-B+C comprises Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Estonia, Georgia, Hungary, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Poland, Republic of Moldova, Romania, Russian Federation, Serbia and Montenegro, Slovakia, Tajikistan, Turkey, Turkmenistan, Ukraine and Uzbekistan. These are countries with low child mortality and low or high adult mortality.

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1.2 Part one: essential public health functions

1.2.1 Memo 1: Essential public health functions requiring funding by government

This memo focuses on the essential functions for public health and its concern with the health status of all age/sex groups in the population, including the poor and vulnerable groups. Public health programmes are explained and reasons are given why governments should invest in them. Priorities for 2008 include: communicable diseases; strengthening health policies and planning for health promotion; supporting reproductive and child health programmes. Capacity development priorities include evaluations of PH programmes for effectiveness and costs; improving the health information system; strengthening MoLHSA’s professional capacity in PH; and supporting new research efforts into changing patterns of disease burden due to non-communicable diseases (NCDs) and associated lifestyle risk factors.

1.2.2 Memo 2: Review of Georgian draft law on public health

The draft Law is clear on its general aim and the competencies of national and local Government in public health are well covered, but the focus is mainly on infectious diseases, sanitation and hygiene. However, the draft says little about promotion of health and healthy life styles, programmes for family and reproductive health, and combating non-communicable diseases. In addition, the draft Law is vague on which organisations and administrative levels should have responsibility for implementing public health programmes. Responsibility for regulating and monitoring the provision of national public health services through non-government and private organizations is not mentioned. There is no mention of mechanisms for consulting the public or for public health communications.

1.2.3 Memo 3: Reorganisation of the public health department and centre for disease control

This memo comments on the functions of the Public Health Department (DPH) and the Centre for Disease Control (CDC) following their merger into one new organisation, including responsibility for surveillance, medical statistics, and investigation of epidemics. However, high level responsibility for public health policy formulation in the central Ministry remains unclear. Responsibility for surveillance of diseases and monitoring use of public health programmes remains unclear, and for health promotion and nutrition, water quality, sanitation, food hygiene, air quality and housing are also not indicated. There is a need to clarify national, regional and local responsibilities. Concern is raised for professional capacity for policy formulation in public health within the MoLHSA itself.

1.2.4 Memo 4: Essential public health programmes requiring funding by government

Essential programmes are included the MoLHSA annual budget, with Ministry priorities identified by level and allocation. The annual budget is the main planning mechanism. However, these health programmes are neither clearly identified nor grouped in the Budget, for instance, by level of intervention, disease category, population at risk or health facility. Essential programmes should also include health promotion, disease prevention and control, reproductive and child health, and health information and surveillance. The Ministry retains responsibility for establishing health priorities and policies, but programme implementation will be delegated to designated government organizations or contracted to agreed agencies. Important next steps are outlined.

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1.3 Part two: Strategies for health promotion

1.3.1 Strategy for health promotion and disease prevention within PHC

There are now a range of scientifically accepted health interventions that, when implemented, can improve public health by modifying social determinants and lifestyle behaviours. This paper outlines a short-term strategy (over two years) for national health promotion in Georgia that takes into account the experiences in other countries where such programmes are well established. It covers the aim and theoretical approach involved and the Georgian policy context for its further development, followed by the principles adopted and how the strategy could be operationalised. It also recommends the strengthening of a specialised capacity to organise the strategy within the MoLHSA and decentralised PHC services. It also draws attention to various enabling conditions and describes consultation with key stakeholders.

1.3.2 Health promotion and behaviour change: guidelines for health care providers and schoolteachers

Behaviour Change Communications (BCC) focuses on modifying individual behaviours and their context and, in particular, the importance of families in promoting health. The paper first suggests the need for political will and an understanding of the scientific basis for targeting interventions. It lays out the principles involved and emphasises the need to use social marketing and influential community groups and individuals. It also outlines the need to orientate PHC workers and which facilities and services need to be in place. Additional guidelines focus on the importance of professionally developed communication materials and the need to monitor and evaluate implementation. There is a summary chart for priority health issues in PHC and their targeted interventions.

1.3.3 Interview guidelines for information collection on health promotion capacity

This structured questionnaire is for a rapid assessment of the training required prior to implementing the health promotion strategy. It is for the use of managers in government services, private sector organisations and non-governmental agencies. It aims to identify priority health issues, types of programmes, priority target groups and donor support. It also covers production, testing, distribution and evaluation of materials and equipment.

1.3.4 Rapid study of local understanding of selected health issues in Adjara and Imereti (volume one)

This rapid research (carried out in late 2005 and early 2006), which focuses on understanding local beliefs and behaviours, is an example of the studies needed for the adaptation of international health promotion strategies to local conditions in Georgia. Representatives of national agencies participated in the development of the research instruments, mainly focus group discussions, and relevant health promotion materials for use in PHC facilities. Prior to the fieldwork each researcher was issued a toolkit and guidelines. The study found that the concept of a healthy lifestyle had reached even remote villages, although many felt it was incompatible with their poverty, heavy physical activities and harsh living conditions. Findings are presented for cardiovascular diseases, goitre, women’s health, family planning, childhood illnesses, infectious diseases, drug use and nervous diseases. The causes of diseases were frequently correctly identified, as was the importance of good nutrition.

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1.4 Part three: Communication strategies

1.4.1 Public relations strategy of the MoLHSA

The objective was to assist the MoLHSA to build a supportive environment for the reforms amongst its own staff, health professionals, the public and donors, based on a flow of information which was well planned, carefully targeted and used appropriate language. The activities described covered the period July-December 2005. The communications were to be informed by public opinion research using mainly focus group discussions and small baseline surveys to be conducted in Imereti and Adjara. The document then summarises the reform messages and the tools and techniques to be used. Finally, the implantation is described based on three groups for media relations, public relations, and monitoring and analysis.

1.4.2 Communications strategy for the primary health care reforms

This document aimed to achieve a joint consensus between stakeholders for the main strategy for communications supporting the Government’s PHC reforms. The objectives were: to create demand for the reforms by the public and health professionals, to prepare for the national roll-out, to build public trust, and to ensure leaders understood the reforms within the overall national reforms. The guiding principles are outlined, followed by proposals for a three-stage campaign of preparing the ground, launching the reforms (from May 2006), and sustaining the momentum from early 2007. The operational framework is also described on the roles of primary and secondary stakeholders, including the private sector. The strategy’s detailed activities are described, together with the cost implications for the three stages, starting in January 2006.

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Advise on Essential Public Health Functions Requiring Funding by Government

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2 Advise on Essential Public Health Functions Requiring

Funding by Government

Dr J Patrick Vaughan

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Executive summary

This memorandum focuses on what is public health (PH) and its essential functions. PH aims to raise the health status of all age/sex groups in the population, including the poor and all other vulnerable groups. It is very concerned, therefore, with health inequalities. PH programs are explained and the main reasons why governments should invest in them.

There is no widely accepted definition PH but broadly it is concerned with planning all PH programs and clinical services, and affects of other sectors like education, agricultural and industry. It also includes the environmental affects. Essential PH functions are: collection of health information for health status, priorities and services utilisation; programs in health promotion; and implementation of communicable and non-communicable diseases prevention and control.

Important characteristics of PH programs are outlined and the economic arguments for investing in them. Issues for the PH Department/Centre for Disease Control are discussed. Options are presented for budgeting and contracting of PH programs and how they might be organised at national, regional and rayon levels.

Important priorities for investment in 2008 include: communicable diseases - immunisation, tuberculosis and HIV/AIDS; strengthening health policies and planning for health promotion; supporting reproductive and child health programs. Capacity development priorities include evaluations of PH programs for effectiveness and costs; improving the health information system; strengthening Ministry’s professional capacity in PH; and supporting new research efforts into changing patterns of disease burden due to non-communicable diseases (NCDs) and associated lifestyle risk behaviours and risk factors.

Important ‘Next Steps’ include a full review of the new draft of the Public Health Law; deciding on the structures and functions necessary for essential PH in the reformed Ministry; strengthening the Ministry’s professional capacity in PH; and rationalising PH in the 2008 budget.

2.1 Introduction

This memorandum examines the main general and theoretical issues concerning essential public health but does not enter into discussions on the merits of either individual public health programmes or priorities for specific interventions.

This memorandum first focuses on understanding what is meant by public health and what are the essential public health functions. Next some important characteristics of public health programmes are explained and the main reasons for governments to invest in them.

Next this memorandum provides brief advice in order to answer the following questions: 1. What essential public health functions need to be organised by government?

2. What are the options for undertaking these functions, either directly or through contracting? 3. What are the most appropriate structure and budget for these functions?

4. What is the most effective balance between national services and those decentralised to regions and rayons?

5. What should be the priorities for spending on public health functions in 2008? Finally, this memorandum outlines some important next steps.

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2.2 What is public health?

Public Health (PH) aims to raise the overall health status of all age/sex groups in the whole population, including for all vulnerable subgroups, such as the economically poor (urban and rural) and workers, mothers, children, elderly, disabled etc. PH is very concerned, therefore, with health inequalities. It has the potential to make substantial improvements in the health status of the whole population. Clinical services focus on diagnosis, cure, care and rehabilitation services for sick individuals which, although also very important, only make a smaller and more limited contribution to improving health. Clinical services treat sick individuals and rely on them presenting themselves and demanding services.

Unfortunately the term Public Health does not have a definition that is widely accepted but it does have two main uses. As a broad conceptual framework the term Public Health is concerned with how to improve the health status of whole populations, including how to plan for all public health and clinical programmes, and the affects on health of other development sectors, including education, agricultural and industry. The role of the environment would be included in this framework.

A narrower use of the term Public Health focuses on three essential functions necessary for improving health: collection of health information to understand trends in health status and health priorities; the use of public health programmes in health promotion; and the implementation of communicable and non-communicable programmes for disease prevention and control.

Public health interventions aim to be effective early in health/disease processes, often while people are still apparently well, while hospital and clinic services are organised to intervene later when sick people present with disease(s) that are already well established.

2.3 What are the characteristics of public health programmes?

There are six important characteristics of public health programmes that define their differences from clinical interventions. These need to be taken fully into consideration when making plans for government investments in health:

2.3.1 PH focuses primarily on intervening much earlier than curative services

Public health aims to improve health status by first maintaining and promoting good health, often called Health Promotion, and second to prevent the onset of diseases, usually called Disease Prevention and Control. Health promotion includes such interventions as better nutrition (e.g. iodine fortification, lower sugar and salt intake), reduction in environmental exposures (e.g. air pollution, occupational dusts) and reducing unhealthy risk behaviours(e.g. cholesterol blood levels, unsafe sex, obesity, drug use). Disease prevention usually focuses on primary interventions (e.g. childhood immunisation, post-exposure rabies vaccine) and/or early detection by screening for the early stages in new cases of both communicable (e.g. hepatitis, meningococcal carriers) and non-communicable diseases (e.g. breast cancer, diabetes and raised blood pressure).

2.3.2 PH programmes are strongly evidence based and rely on tested health interventions

Most PH interventions have been scientifically tested, usually involving controlled trials and/or evaluations of many programmes operating in different countries. There is good evidence and experience, therefore, that these programmes are both effective in achieving good health outcomes and impacts, as well as being cost-effective as a national investment. In addition, the

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interventions have low levels of known side-effects and unwanted consequences. This evidence is frequently stronger than that for the many procedures and interventions used in clinical services for diagnosis, cure and care.

2.3.3 PH programmes need to cover a high proportion of all at risk and vulnerable people

To be fully effective PH programmes need to reach all people in the whole population who need the service (called population coverage, e.g. more than 90% young children need measles immunisation to prevent outbreaks). Although new population-based programmes will have low programme coverage in the early stages, the aim must be to raise coverage over time to higher levels by improving programme reach, implementation and quality. Effectiveness crucially depends on achieving high levels of population coverage and high programme quality.

2.3.4 PH programmes rely on the cooperation of ‘healthy’ individuals

Sick people are usually aware of their need to attend hospital and clinic health services but ‘healthy’ people may be largely unaware of their need to use any PH services being offered (e.g. antenatal care, Tb clinics). Full public cooperation is needed, therefore, if the programme is to be effective. This requires that the population, and particularly those at high risk, must be well informed about the benefits of cooperating with the programme (e.g. health beliefs and communications), for the delivery points to be easily accessible (e.g. in terms of distance and cost) and for the interventions to be acceptable and affordable to the at risk people (e.g. HIV/AIDS screening and counselling, blood pressure measurement, cervical cellular tests).

2.3.5 PH programmes are a ‘public good’ that rely on positive incentives

Achieving high levels of public cooperation for high coverage means that all incentives must encourage utilisation and disincentives need to be removed. As a minimum such programmes must deliver their interventions locally (i.e. be accessible) and should be offered free of charges and costs to the users who are those most at risk. This applies equally to poorer and richer families.

2.3.6 PH planning and programmes depends on valid and reliable health information

Improvements in health status will be revealed by trends in health indices and by data collected by a strong and reliable health information system, based on routine reporting and surveillance systems. This information is crucial for programme planning, implementation, monitoring and the evaluation of programme health outcomes and impact.

2.4 Why invest in public health programmes?

There are good economic arguments for investing in public health. Reductions in public health investment now will only lead to higher future costs. This is the classic false economy.

While there may be short-term economic savings to be achieved by reducing public health programmes, the long term cost will increase substantially as new cases of disease occur which will lead to an increased utilisation of expensive hospital and clinical services.

PUBLIC HEALTH, HEALTH PROMOTION, PUBLIC RELATIONS. Volume 3