EU ENLARGEMENT AND HEALTH SYSTEMS:EU ENLARGEMENT AND HEALTH SYSTEMS:

Experiences and practices from new EU member countries and implications for Experiences and practices from new EU member countries and implications for GeorgiaGeorgia

Levan Metreveli, MD, PhD, MPHLevan Metreveli, MD, PhD, MPHMember of Parliament of GeorgiaMember of Parliament of Georgia

Committee of Health and Social WelfareCommittee of Health and Social Welfare

WHAT GEORGIA SHOULD DO TO ESCAPE WHAT GEORGIA SHOULD DO TO ESCAPE STAGNATION IN HEALTH SECTOR!!!STAGNATION IN HEALTH SECTOR!!!

oror

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Statement of purposeStatement of purpose

Exploring successes and failures of the Exploring successes and failures of the EU new member states in reshaping EU new member states in reshaping their health policies aimed at: their health policies aimed at:

1.1. Meeting EU health/health-related standards.Meeting EU health/health-related standards.

2.2. Creating favorable conditions for building Creating favorable conditions for building equitable and effective health care/public health equitable and effective health care/public health services. We will be more thoroughly exploring services. We will be more thoroughly exploring the benefits and challenges arising from the EU the benefits and challenges arising from the EU membership for the national health systems.membership for the national health systems.

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Statement of purposeStatement of purpose

Assessing current structural and Assessing current structural and operational status of health system in operational status of health system in Georgia. Strengths and weaknesses Georgia. Strengths and weaknesses present in the environment, with particular present in the environment, with particular emphasis on political and economic emphasis on political and economic feasibility of reforms.feasibility of reforms.

Revealing organizational challenges Revealing organizational challenges present in the health policy and politics in present in the health policy and politics in Georgia. Georgia.

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Statement of purposeStatement of purpose

Addressing the existing challenges by: 1. Addressing the existing challenges by: 1. selecting appropriate policy and strategic selecting appropriate policy and strategic approaches and 2. drawing a road map approaches and 2. drawing a road map expected to assist the Government of Georgia in expected to assist the Government of Georgia in developing relatively accelerated and effective developing relatively accelerated and effective mechanisms for fostering health sector reforms.mechanisms for fostering health sector reforms.

It is also evident that the proposed set of It is also evident that the proposed set of recommendations would not only fit in the niche recommendations would not only fit in the niche of pre-EU-accession preparedness measures, of pre-EU-accession preparedness measures, but feed in the government policies aimed at but feed in the government policies aimed at improving health system functioning in general.improving health system functioning in general.

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From western to larger From western to larger EuropeEurope

15 + 10 = 2515 + 10 = 25 Old membersOld members New membersNew members Candidate Candidate

countriescountries Potential Potential

candidatescandidates

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Health system aspects of the Health system aspects of the EU enlargementEU enlargement

Adoption of EU legislation: Adoption of EU legislation: Acquis CommunitaireAcquis Communitaire (Rome, (Rome, Maastricht and Amsterdam treaties, other regulations and Maastricht and Amsterdam treaties, other regulations and standards)standards)

EU laws induce direct and indirect (through EU laws induce direct and indirect (through environmental protection, agriculture, environmental protection, agriculture, migration, human rights, etc.) influences on the migration, human rights, etc.) influences on the health systems of both old and new member health systems of both old and new member statesstates

The EU is primarily the economic union, The EU is primarily the economic union, therefore health/health care issues certainly therefore health/health care issues certainly assume a somewhat peripheral role.assume a somewhat peripheral role.

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Main areas of impactMain areas of impact

Health policyHealth policy Health reformHealth reform Health/health care standardsHealth/health care standards Human resources (workforce migration)Human resources (workforce migration) Access to health careAccess to health care Biomedical R&DBiomedical R&D Environmental healthEnvironmental health ““Right to health”Right to health”

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Geopolitical Context of Geopolitical Context of GeorgiaGeorgia

http://members.tripod.com/ggdavid/georgia/maps.htm

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““Rose Revolution” & Rose Revolution” & DemocracyDemocracy

In the late nineties the In the late nineties the governance deteriorated, governance deteriorated, corruption became rampant corruption became rampant and the institutions of the and and the institutions of the and state have been debilitated.state have been debilitated.

In November 2003, the people In November 2003, the people of Georgia rose up to protest of Georgia rose up to protest massive electoral fraud and massive electoral fraud and continued economic decline, continued economic decline, now known as the Rose now known as the Rose Revolution.Revolution.

Subsequent presidential Subsequent presidential elections gave a broad elections gave a broad mandate to the new President, mandate to the new President, Mikheil Saakashvili, who Mikheil Saakashvili, who received 97 percent of the received 97 percent of the popular vote. popular vote.

“Rose Revolution”, Square of Freedom, Tbilisi, Georgia, November 2003

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International Support & International Support & DevelopmentDevelopment

The new Georgian authorities have The new Georgian authorities have inherited from the previous government a inherited from the previous government a marked decline in socio-economic marked decline in socio-economic development. Therefore, very first steps development. Therefore, very first steps were made to stabilize the system and were made to stabilize the system and allow maximally possible social goods to be allow maximally possible social goods to be produced. The Government has established produced. The Government has established a national recovery program to root out a national recovery program to root out corruption and mismanagement, restore corruption and mismanagement, restore stability, reduce poverty, and secure stability, reduce poverty, and secure sustained economic growth. The guiding sustained economic growth. The guiding principles are creation of strong democratic principles are creation of strong democratic institutions, good governance, institutions, good governance, development of human resources, development of human resources, protection of cultural heritage, and protection of cultural heritage, and preservation of Georgia’s territorial preservation of Georgia’s territorial integrity and national security. Moreover, integrity and national security. Moreover, the new Government has declared its the new Government has declared its intention to pursue closer integration with intention to pursue closer integration with the Euro-Atlantic Institutions.the Euro-Atlantic Institutions.

President George W. Bush and President Mikheil Saakashvili. May 10, 2005, Square of Freedom, Tbilisi, Georgiahttp://203.15.102.140/assetbin/bushgeorgiaspeech55.jpg

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Health situation in GeorgiaHealth situation in Georgia

The three main causes of infant mortality are The three main causes of infant mortality are conditions originating in the perinatal period conditions originating in the perinatal period (58.0%), followed by infectious and parasitic (58.0%), followed by infectious and parasitic diseases (14.1%) and diseases of the respiratory diseases (14.1%) and diseases of the respiratory system (10.8%). (Gamkrelidze, Atun et al. 2002) system (10.8%). (Gamkrelidze, Atun et al. 2002)

The immunization characteristics had shown The immunization characteristics had shown positive dynamics nevertheless is still far from positive dynamics nevertheless is still far from

the perfect. (Badurashvili, McKee et al. 2001)the perfect. (Badurashvili, McKee et al. 2001)

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Health sector challengesHealth sector challenges

The recent economic and political The recent economic and political developments in the country have clearly developments in the country have clearly underlined the necessity of concerted action underlined the necessity of concerted action Government-wide and across the sectors. Government-wide and across the sectors.

It is important to note, that Government places It is important to note, that Government places an enormous importance on sustainability of an enormous importance on sustainability of economic reforms. economic reforms.

Although it is the strong precedent in the law Although it is the strong precedent in the law enforcement and partly in economic block, the enforcement and partly in economic block, the Ministry of Labor, Health Care and Social Ministry of Labor, Health Care and Social Welfare of Georgia (MOH) evidently appears to Welfare of Georgia (MOH) evidently appears to be behind the scene.be behind the scene.

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Health sector challengesHealth sector challenges The MOH is not armed with credible and systemic The MOH is not armed with credible and systemic

strategic vision of development i.e. there is a high need in strategic vision of development i.e. there is a high need in comprehensive strategic paper on health financing (“white comprehensive strategic paper on health financing (“white paper”). paper”).

The MOH has weak technical and human capacity for The MOH has weak technical and human capacity for leading reforms. The health issues are not politically and leading reforms. The health issues are not politically and publicly sound. publicly sound.

Under these circumstances, ineffective and blurrily Under these circumstances, ineffective and blurrily organized health system will strongly undermine other organized health system will strongly undermine other achievements. Any further preservation of current achievements. Any further preservation of current situation in health sector will ultimately lead to dramatic situation in health sector will ultimately lead to dramatic worsening of access to health care and equity issues, worsening of access to health care and equity issues, those to be easily transformable into wider public those to be easily transformable into wider public dissatisfaction and loss of electoral support.dissatisfaction and loss of electoral support.

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Available “policy window”*Available “policy window”*

EU LAWEU LAW& &

REGULATIONSREGULATIONS

GEORGIA’SGEORGIA’SNEED IN NEED IN BETTER BETTER HEALTH HEALTH SYSTEMSYSTEM

DEMOCRATIZATION DEMOCRATIZATION & &

CIVIL SOCIETYCIVIL SOCIETY

PROPOSEDPROPOSEDPOLICY POLICY

APPROACHESAPPROACHES

* (Kingdon 1995)

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Policy objectivesPolicy objectives

1.1. Improving intra-government cooperation and Improving intra-government cooperation and establishing permanent communication establishing permanent communication mediummedium

““Inter-Ministerial Club on Health” (IMCH)Inter-Ministerial Club on Health” (IMCH)

2.2. Strengthening human and technical capacity Strengthening human and technical capacity of the MOHof the MOH

Redesigning the mission statement of the MOHRedesigning the mission statement of the MOH ““Ministerial Fund of Human Resources Development” Ministerial Fund of Human Resources Development”

(MFHRD)(MFHRD) External “Expert Board on Health Systems” (EBHS)External “Expert Board on Health Systems” (EBHS) Full-time expatriate consultant(s) to the ministerFull-time expatriate consultant(s) to the minister New “Department of Health Policy” (DHP)New “Department of Health Policy” (DHP) Reforming MOH PR DepartmentReforming MOH PR Department Optimizing doctor/nurse ratioOptimizing doctor/nurse ratio

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Policy objectivesPolicy objectives

3.3. Enhancing cooperation with old and new EU Enhancing cooperation with old and new EU member countriesmember countries

MOH Eurointegration OfficeMOH Eurointegration Office Drafting strategy paper on cooperation with EU member Drafting strategy paper on cooperation with EU member

statesstates

4.4. Developing a “white paper” on health sector Developing a “white paper” on health sector financingfinancing

5.5. Creating favorable legal environment for health Creating favorable legal environment for health reforms with the emphasis on EU legislationreforms with the emphasis on EU legislation

6.6. Structural and institutional reformsStructural and institutional reforms Surgeon General’s Office, HIAsSurgeon General’s Office, HIAs

7.7. Developing effective media strategy for health Developing effective media strategy for health reforms.reforms.

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Conceptual framework of the Conceptual framework of the proposed policyproposed policy

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 developmentAbsence of “white paper” on health system

reform NEGATIVE FACTORS

Political commitment to joining EUWide international support

Successful reforms: law enforcement, education, defense

Experiences from new EU member statesHigh public/electoral support of reforms

Presidential program on hospital rehabilitation

POSITIVE FACTORS

POLICY CHANGES

Government-wide

cooperation on health

Strengthening human &

technical capacity of MOH

Enhancing cooperation with old and new EU

member states

Developing “White Paper on health system financing

Harmonizing legislation

Structural & institutional

reforms

New media strategy on

health

Technostructure

Strategic Apex

Macroeconomic and social influences

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Unique Supportive Unique Supportive EnvironmentEnvironment

The Government of Georgia has an excellent package of recent (2003-The Government of Georgia has an excellent package of recent (2003-2005) successful reforms in its portfolio. It is of paramount importance 2005) successful reforms in its portfolio. It is of paramount importance that socially very painful reforms in law enforcement and education that socially very painful reforms in law enforcement and education has been highly tolerated by the general public. There are two certain has been highly tolerated by the general public. There are two certain benefits for the MOH: the radical reformation experience is in place benefits for the MOH: the radical reformation experience is in place and public acceptance of the reforms is relatively high. Therefore, the and public acceptance of the reforms is relatively high. Therefore, the MOH should enjoy this supportive environment (which logically may MOH should enjoy this supportive environment (which logically may not last indefinitely and another chance simply may not be available).not last indefinitely and another chance simply may not be available).

There is a high degree of certainty in fiscal environment as opposed to There is a high degree of certainty in fiscal environment as opposed to the ambiguous tax regulations under the previous Government. The the ambiguous tax regulations under the previous Government. The new Tax Code (2004) provided well-defined macroeconomic frame for new Tax Code (2004) provided well-defined macroeconomic frame for health financing.health financing.

As a result of wide Western support to democratization, the As a result of wide Western support to democratization, the international donor assistance literally “boosted” after the “Rose international donor assistance literally “boosted” after the “Rose Revolution”. Besides already approved or functioning donor projects, Revolution”. Besides already approved or functioning donor projects, there are numerous realistic opportunities for future donor funding.there are numerous realistic opportunities for future donor funding.

The unity and team-environment are explicit features of the current The unity and team-environment are explicit features of the current Government, as opposed to the previous one. In this sense the MOH Government, as opposed to the previous one. In this sense the MOH may enjoy the benefits of concerted action.may enjoy the benefits of concerted action.

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Unique Supportive Unique Supportive EnvironmentEnvironment

The expectations for radical reforms in health sector are relatively high in The expectations for radical reforms in health sector are relatively high in political establishments (both governmental and opposition), hence a good political establishments (both governmental and opposition), hence a good prerequisite of political support.prerequisite of political support.

Despite poor donor coordination, the majority of donor-funded projects are Despite poor donor coordination, the majority of donor-funded projects are concentrated on primary health care (key component of any health concentrated on primary health care (key component of any health system), so in the short-run the MOH may secure saved money for other system), so in the short-run the MOH may secure saved money for other purposes.purposes.

As a matter of fact, current MOH leadership sustained for over two years As a matter of fact, current MOH leadership sustained for over two years (turnover was very high in other agencies of post-revolution Government) (turnover was very high in other agencies of post-revolution Government) and may be judged as a relative guarantee of sustainability of reforms in and may be judged as a relative guarantee of sustainability of reforms in the future if launched now.the future if launched now.

There is a substantial intellectual, technical and institutional capacity in the There is a substantial intellectual, technical and institutional capacity in the NGO sector, which may be effectively utilized with at least two beneficial NGO sector, which may be effectively utilized with at least two beneficial outcomes: overall performance in the MOH will be improved and outcomes: overall performance in the MOH will be improved and participatory component of consensus on major policy decisions will be participatory component of consensus on major policy decisions will be enhanced.enhanced.

The recently launched Presidential Program on Hospital Sector The recently launched Presidential Program on Hospital Sector Rehabilitation created favorable conditions for conducting radical structural Rehabilitation created favorable conditions for conducting radical structural reforms. reforms.

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Consequences of further delay Consequences of further delay of reformsof reforms

Dramatic worsening of access to health care and Dramatic worsening of access to health care and of equity issues, those of equity issues, those to be easily transformable to be easily transformable into wider public dissatisfaction and loss of into wider public dissatisfaction and loss of electoral support.electoral support.

N.B. The better health care was one of the prominent pre-election N.B. The better health care was one of the prominent pre-election promises of the current political leadershippromises of the current political leadership

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Where are we Where are we now?!now?!

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

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AcknowledgmentsAcknowledgments

Dr. Deborah A. McFarland, MPH, MSc, PhDDr. Deborah A. McFarland, MPH, MSc, PhD Dr. Richard Saltman, PhDDr. Richard Saltman, PhD Mr. Daren Djirikian, MPHMr. Daren Djirikian, MPH Dr. Levan Baramidze, MD, PhD, MPHDr. Levan Baramidze, MD, PhD, MPH

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THANK YOU!THANK YOU!