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Georgia: Controversial Plan Emerges To Reform Health Care

Georgia has taken the initiative among former Soviet states to reform its health-care system. Tbilisi last year launched a 10-year consolidation program to downsize and upgrade its hospital network. But the initiative faces fierce resistance from trade unions and opposition parties.

Tbilisi, 31 October 2002 (RFE/RL) -- Recent statistics released by the United Nations World Health Organization, or WHO, show Georgia among countries with the highest concentrations of medical doctors.

With 436 physicians per 100,000 inhabitants in the late 1990s, Georgia was outmatched by only four countries, including Monaco and Italy. Among communist or former communist countries, only Cuba and Belarus had ratios superior to Georgia's.

Some in Tbilisi explain that circumstance by the attraction exerted by the medical professions, which they say were extremely popular in Soviet Georgia.

Yet, many argue that such a number of physicians is too heavy a burden for today's cash-starved Georgia. They have advocated staff cutbacks in a bid to optimize a state-owned health system driven to decay by more than a decade of political turmoil and economic hardship.

Tengiz Tsertsvadze is the chairman of Tbilisi's Infectious Diseases, AIDS, and Clinical Immunology Research Center and Georgia's national AIDS coordinator. He told RFE/RL that, in his view, a country that can allocate only 1 percent of its gross domestic product to public health has no other option than to downsize its medical system. "Even a developed country could not afford such a large number of doctors and medical establishments. How then could Georgia, where health spending is so low, sustain such a system? Officially, Georgia spends 7.6 percent of its annual consolidated budget to support the medical sector. This percentage is much lower than in Eastern European countries. Given that our national budget is small, public health expenditure is ridiculously low. It currently stands at somewhere around $9 a year per inhabitant," Tsertsvadze said.

Tsertsvadze supports a World Bank-sponsored plan drafted by the Health and Social Care Ministry to optimize the state-owned medical network throughout the country.

The plan, approved last year by President Eduard Shevardnadze, is part of an overall reform of Georgia's health sector. It envisages merging some of the country's 287 hospitals, closing down the less-profitable ones, and using the proceeds to modernize dilapidated health facilities.

Health Ministry officials say the number of hospital beds would be reduced to 10,000 by 2010 from a current 19,000. Consequently, Georgia should retain about 90 consolidated hospitals. The government believes that should suffice to cover the country's needs.

Giorgi Nikolaishvili is the managing director of Georgia's Health and Social Projects Implementation Center, which oversees the realization of the hospital-consolidation program. He told our correspondent that it would be a mistake to believe the number of hospitals will simply be cut down. "I often hear people say that we're planning to close down nearly half [of our hospitals]. No, we are not closing them down, we are merging them. Maybe from a purely mathematical viewpoint it looks as if we were closing down hospitals, or planning to, roughly speaking, reduce their number to some 100 from a current 200. But our plans have a different meaning. What we're doing is merging, say, two or three legal entities into one. What is going on is a restructuring process. So, to say simply that we'll keep only 100 hospitals out of 200 is, I believe, erroneous," Nikolaishvili said.

The consolidation program has many opponents who argue that it will lay off thousands of skilled hospital staff without providing adequate redundancy payments.

Opponents of the program say the newly laid-off physicians will be offered a bonus of just 2,000 laris (less than $1,000) and that doctors will have great difficulty finding new jobs. They also point to the fact that, with compensation worth about 300 laris, nurses and other junior staff face an even bleaker future.

The Solidarity medical trade union is spearheading the campaign against the consolidation plan, with the backing of former Justice Minister Mikhail Saakashvili's National Movement opposition party. Solidarity Chairman Levan Metreveli said that, in Tbilisi alone, up to 6,000 hospital doctors may lose their jobs in the coming years. "What shall we do with all these people? To throw all these doctors, nurses, technical staff, and stretcher bearers out into the street will probably lead to a social explosion. Physicians are a highly qualified part of our intelligentsia, and if they are thrown out into the street, they will have no further prospects. A doctor cannot find a job in a factory, can he?" Metreveli said.

Yet, many hospital managers support the optimization program.

Shota Gogichaishvili is the executive director of the Infectious Diseases, AIDS, and Clinical Immunology Research Center, a reorganized hospital that emerged a year ago from the amalgamation of Tbilisi's AIDS Center and the Infectious Diseases Hospital. He said all 156 employees, out of an original 465-member staff, that fell victim to the optimization process were paid large bonuses, at least by Georgian standards. "Including wage arrears and compensation, some of our employees received up to 5,000 and 6,000 laris, that is, about $3,000. Of course, if one compares this to Europe, it is ridiculously low. But in a country where the average monthly salary stands at 30 to 40 laris, I think it is not that bad," Gogichaishvili said.

Gogichaishvili said that some of his former employees have already found new jobs and that those who were still unemployed two months after being laid off were granted another two-month salary bonus. Like other advocates of the hospital reform, he argues that this is the first time redundant workers are being paid compensation in Georgia's recent history.

Tsertsvadze agrees with trade unionists that social care for laid-off staff should be a constant priority. Yet, he believes there is no other way to bring Georgia's health-care system closer to international standards than to sacrifice a large number of its medical personnel. "True, part of the medical staff will remain jobless. We agree with our opponents who say this is a very serious and painful issue. But our positions differ when it comes to deciding what is most important. Do we, or do we not, need to make those painful, yet indispensable, decisions? There are two possible options. Either we leave everything as it is and continue to pretend that our 21,000 physicians really work, that we do have a health-care system and that patients are looked after or we optimize everything and set up a quality health care that will further develop but make a certain number of people redundant. Opinions can differ on this and which is the most objective and correct is hard to say. But, personally, I am a convinced supporter of the reforms," Tsertsvadze said.

Meanwhile, opponents have started resisting consolidation plans.

Earlier this year, some 60 doctors deemed not eligible for new jobs appealed to a regional court to protest the upcoming restructuring of the capital's Children's Hospital No. 1. Optimization plans have been suspended pending the court's decision.

Protests movements have also been reported at Tbilisi's Ophthalmology Center.

Although he agrees that Georgia's health sector should be reformed, Solidarity Chairman Metreveli questions the rationale behind the present consolidation program, saying it might leave the country's 4 million to 4.5 million citizens without proper medical care. "When we ask [Health] Ministry officials why they are planning to close down hospitals, they answer that they are not working at full capacity, that we do not need such a large number of beds, which costs superfluous spending and that, therefore, we need to cut down the number of hospitals. But why do hospitals not work at full capacity? It is because people cannot afford medical care. In a country where minimal pension wages are worth something like $6 a month, patients simply cannot pay. This is why hospitals are not full. Not because people don't get sick. On the contrary, people are getting even sicker than 10 years ago because new infectious and parasitic diseases, such as lechmaniose [dog-borne parasitic disease], malaria, tuberculosis, and amoebiasis, have appeared. Therefore, health spending should rise, and there is a demand for those hospitals that the government is planning to close down," Metreveli said.

Metreveli argues that it will be much more costly to build new hospitals when they are needed than to sustain the existing infrastructure.

Solidarity and Saakashvili's National Movement, which in last June's local elections campaigned to eradicate corruption in all municipal structures, also claim the consolidation plan lacks financial transparency. In their view, there is no guarantee that proceeds from selling hospital property will be used to upgrade decaying health infrastructures.

Yet, Tsertsvadze and Gogichaishvili say that, after optimization, their hospital was able to purchase new, vitally needed equipment and to pay its electricity and water bills -- things that were inconceivable before.

More important, they say patients can now enjoy better health care and no longer need to bring their own drugs or pay for medical treatment legally covered by the state. The staff is now getting an average 120 laris per month compared to 40 laris a year ago.

Prior to consolidation, the hospital treated an average of 20 people a day. Now, Gogichaishvili said, its daily occupancy stands at around 130 patients for 220 beds.

As for claims that the optimization program might profit corrupt civil servants, Tsertsvadze said: "Even though a few people might divert part of the privatization proceeds, we have to move forward because, if we bring the optimization process to a halt, the situation will worsen. What we need to do is take action and make sure that everything is transparent."