Levan Metreveli, MD, PhD, MPH Member of Parliament of Georgia

1. or EU ENLARGEMENT AND HEALTH SYSTEMS:Experiences and practices from new EU member countries and implications for Georgia WHAT GEORGIA SHOULD DO TO ESCAPE STAGNATION IN HEALTH SECTOR!!! Levan Metreveli, MD, PhD, MPH Member of Parliament of Georgia Committee of Health and Social Welfare

2. Statement of purpose • Exploring successes and failures of the EU new member states in reshaping their health policies aimed at: • Meeting EU health/health-related standards. • Creating favorable conditions for building equitable and effective health care/public health services. We will be more thoroughly exploring the benefits and challenges arising from the EU membership for the national health systems.

3. Statement of purpose • Assessing current structural and operational status of health system in Georgia. Strengths and weaknesses present in the environment, with particular emphasis on political and economic feasibility of reforms. • Revealing organizational challenges present in the health policy and politics in Georgia.

4. Statement of purpose • Addressing the existing challenges by: 1. selecting appropriate policy and strategic approaches and 2. drawing a road map expected to assist the Government of Georgia in developing relatively accelerated and effective mechanisms for fostering health sector reforms. • It is also evident that the proposed set of recommendations would not only fit in the niche of pre-EU-accession preparedness measures, but feed in the government policies aimed at improving health system functioning in general.

5. From western to larger Europe • 15 + 10 = 25 • Old members • New members • Candidate countries • Potential candidates

6. Health system aspects of the EU enlargement • Adoption of EU legislation: Acquis Communitaire(Rome, Maastricht and Amsterdam treaties, other regulations and standards) • EU laws induce direct and indirect (through environmental protection, agriculture, migration, human rights, etc.) influences on the health systems of both old and new member states • The EU is primarily the economic union, therefore health/health care issues certainly assume a somewhat peripheral role.

7. Main areas of impact • Health policy • Health reform • Health/health care standards • Human resources (workforce migration) • Access to health care • Biomedical R&D • Environmental health • “Right to health”

8. Geopolitical Context of Georgia http://members.tripod.com/ggdavid/georgia/maps.htm

9. “Rose Revolution”, Square of Freedom, Tbilisi, Georgia, November 2003 “Rose Revolution” & Democracy • In the late nineties the governance deteriorated, corruption became rampant and the institutions of the and state have been debilitated. • In November 2003, the people of Georgia rose up to protest massive electoral fraud and continued economic decline, now known as the Rose Revolution. • Subsequent presidential elections gave a broad mandate to the new President, Mikheil Saakashvili, who received 97 percent of the popular vote.

10. President George W. Bush and President Mikheil Saakashvili. May 10, 2005, Square of Freedom, Tbilisi, Georgia http://203.15.102.140/assetbin/bushgeorgiaspeech55.jpg International Support & Development The new Georgian authorities have inherited from the previous government a marked decline in socio-economic development. Therefore, very first steps were made to stabilize the system and allow maximally possible social goods to be produced. The Government has established a national recovery program to root out corruption and mismanagement, restore stability, reduce poverty, and secure sustained economic growth. The guiding principles are creation of strong democratic institutions, good governance, development of human resources, protection of cultural heritage, and preservation of Georgia’s territorial integrity and national security. Moreover, the new Government has declared its intention to pursue closer integration with the Euro-Atlantic Institutions.

11. Health situation in Georgia • The three main causes of infant mortality are conditions originating in the perinatal period (58.0%), followed by infectious and parasitic diseases (14.1%) and diseases of the respiratory system (10.8%). (Gamkrelidze, Atun et al. 2002) • The immunization characteristics had shown positive dynamics nevertheless is still far from the perfect. (Badurashvili, McKee et al. 2001)

12. Health sector challenges • The recent economic and political developments in the country have clearly underlined the necessity of concerted action Government-wide and across the sectors. • It is important to note, that Government places an enormous importance on sustainability of economic reforms. • Although it is the strong precedent in the law enforcement and partly in economic block, the Ministry of Labor, Health Care and Social Welfare of Georgia (MOH) evidently appears to be behind the scene.

13. Health sector challenges • The MOH is not armed with credible and systemic strategic vision of development i.e. there is a high need in comprehensive strategic paper on health financing (“white paper”). • The MOH has weak technical and human capacity for leading reforms. The health issues are not politically and publicly sound. • Under these circumstances, ineffective and blurrily organized health system will strongly undermine other achievements. Any further preservation of current situation in health sector will ultimately lead to dramatic worsening of access to health care and equity issues, those to be easily transformable into wider public dissatisfaction and loss of electoral support.

14. GEORGIA’S NEED IN BETTER HEALTH SYSTEM EU LAW & REGULATIONS PROPOSED POLICY APPROACHES DEMOCRATIZATION & CIVIL SOCIETY * (Kingdon 1995) Available “policy window”*

15. Policy objectives • Improving intra-government cooperation and establishing permanent communication medium • “Inter-Ministerial Club on Health” (IMCH) • Strengthening human and technical capacity of the MOH • Redesigning the mission statement of the MOH • “Ministerial Fund of Human Resources Development” (MFHRD) • External “Expert Board on Health Systems” (EBHS) • Full-time expatriate consultant(s) to the minister • New “Department of Health Policy” (DHP) • Reforming MOH PR Department • Optimizing doctor/nurse ratio

16. Policy objectives • Enhancing cooperation with old and new EU member countries • MOH Eurointegration Office • Drafting strategy paper on cooperation with EU member states • Developing a “white paper” on health sector financing • Creating favorable legal environment for health reforms with the emphasis on EU legislation • Structural and institutional reforms • Surgeon General’s Office, HIAs • Developing effective media strategy for health reforms.

17. POLICY CHANGES Weak professional capacity in the MOH for reforms Lack of political will in the MOH for radical change Lack of Government-wide concerted action in the health sector Insufficient institutional development Absence of “white paper” on health system reform NEGATIVE FACTORS Political commitment to joining EU Wide international support Successful reforms: law enforcement, education, defense Experiences from new EU member states High public/electoral support of reforms Presidential program on hospital rehabilitation POSITIVE FACTORS Strategic Apex Technostructure Macroeconomic and social influences Government-wide cooperation on health Developing “White Paper on health system financing Strengthening human & technical capacity of MOH Harmonizing legislation New media strategy on health Enhancing cooperation with old and new EU member states Structural & institutional reforms Conceptual framework of the proposed policy

18. Unique Supportive Environment • The Government of Georgia has an excellent package of recent (2003-2005) successful reforms in its portfolio. It is of paramount importance that socially very painful reforms in law enforcement and education has been highly tolerated by the general public. There are two certain benefits for the MOH: the radical reformation experience is in place and public acceptance of the reforms is relatively high. Therefore, the MOH should enjoy this supportive environment (which logically may not last indefinitely and another chance simply may not be available). • There is a high degree of certainty in fiscal environment as opposed to the ambiguous tax regulations under the previous Government. The new Tax Code (2004) provided well-defined macroeconomic frame for health financing. • As a result of wide Western support to democratization, the international donor assistance literally “boosted” after the “Rose Revolution”. Besides already approved or functioning donor projects, there are numerous realistic opportunities for future donor funding. • The unity and team-environment are explicit features of the current Government, as opposed to the previous one. In this sense the MOH may enjoy the benefits of concerted action.

19. Unique Supportive Environment • The expectations for radical reforms in health sector are relatively high in political establishments (both governmental and opposition), hence a good prerequisite of political support. • Despite poor donor coordination, the majority of donor-funded projects are concentrated on primary health care (key component of any health system), so in the short-run the MOH may secure saved money for other purposes. • As a matter of fact, current MOH leadership sustained for over two years (turnover was very high in other agencies of post-revolution Government) and may be judged as a relative guarantee of sustainability of reforms in the future if launched now. • There is a substantial intellectual, technical and institutional capacity in the NGO sector, which may be effectively utilized with at least two beneficial outcomes: overall performance in the MOH will be improved and participatory component of consensus on major policy decisions will be enhanced. • The recently launched Presidential Program on Hospital Sector Rehabilitation created favorable conditions for conducting radical structural reforms.

20. Consequences of further delay of reforms Dramatic worsening of access to health care and of equity issues, those to be easily transformable into wider public dissatisfaction and loss of electoral support. N.B. The better health care was one of the prominent pre-election promises of the current political leadership

21. Where are we now?! There is a big challenge related with further possible delay of radical reforms in the Health Sector of Georgia. The unique supportive political and international context of the “Rose Revolution” may most effectively be utilized in the course of health reforms. The next chance of comparable scale will be barely available in the foreseeable future. The rationale of political logic dictates that the immediate action must be undertaken.

22. Acknowledgments • Dr. Deborah A. McFarland, MPH, MSc, PhD • Dr. Richard Saltman, PhD • Mr. Daren Djirikian, MPH • Dr. Levan Baramidze, MD, PhD, MPH

23. THANK YOU!