Development of Public Health in Independent Georgia

Tengiz  Verulava  Avtandil Jorbenadze

Journal number 1 ∘ Tengiz Verulava ∘ Avtandil Jorbenadze ∘
Development of Public Health in Independent Georgia

https://doi.org/10.56079/20221/8

Reorganization of healthcare system in Georgia was based on the development of public health, aiming to activate of preventive medicine and operate efficient tools of epidemiological surveillance. This paper seeks to explore the attitudes and values which underlie public health reform in Georgia, and to investigate the goals of reform and the strategies designed to achieve them. The article is based on a documentary analysis, which included official documents and non-official journal publications. Georgia was the only country (except the Baltic states) to abandon the soviet system of Sanitary-Epidemiological Service, completely reorganizing it and establishing a new public health infrastructure, built on European principles. The reorganization of the Sanitary-Epidemiological Service implied the separation of supervisory (sanitary control) and executive functions, typical of the Soviet system. As a result, the Public Health Department and the Department for Sanitary Supervision and Hygienic Regulation were established. In terms of decentralization, the funds out of four elements of healthcare system (financing, Policy Development, Standard definition, Management and Administration) were distributed at central, regional and municipal levels. The role of public health is especially increasing in the modern globalized world, when the epidemics of infectious diseases have become topical. In globalized world, the public health challenges go beyond national borders and interests, having huge global political and economic consequences. Therefore, modern public healthcare is reviewed in a global context and requires international regulations, transnational actions and solutions based on coordinated cooperation among different countries of the world.

Keywords: Public health, health care reforms, prevention, healthy lifestyle.

JEL Codes: H51, H75, I18

Introduction

Public health is the key function of the state, ensuring disease prevention and health promotion, achieved through organized public efforts, environmental enhancement, fight against infections, public awareness raising on hygienic issues, early identification of diseases. Furthermore, the study of disease epidemiology allows rational and efficient use of resources to address priority issues, that is of primary importance for a low-income country, like Georgia.

In early years of its existence, the Soviet Union paid great attention to disease prevention. A broad network of sanitary-epidemiological stations was set up for fighting the epidemics of infectious diseases such as typhoid, cholera, chickenpox, dysentery, malaria. Mass vaccination, epidemiological surveillance of malaria, water supply sanitary control, hygienic waste disposal, wastewater improvement and milk pasteurization were included in the list of main activities. In the 1950s and 1960s, the scope of Sanitary-Epidemiological Service was expanded to include occupational hygiene and environmental protection.

Initially, the Sanitary-Epidemiological Service played a major role in fighting against infectious diseases. There have been developed comprehensive vaccination programs for children, helping to reduce many communicable diseases. However, it was much less effective in combatting non-communicable diseases, and health promotion and inter-sectoral actions were completely neglected (Maier CB, Martin-Moreno JM. 2011). Later, in the Soviet Union, the focus was directed to medical-diagnostic measures, which were less concerned with disease prevention. Such a model was expensive, as resources were mainly spent on elimination of outcomes, the reason of which could have been prevented (Ensor T. 1993, 169-87).

The situation worsened especially after the collapse of the Soviet Union in the first years of independence (Papava V. 2012), Balabanova D., Roberts B., Richardson E., Haerpfer C., McKee M. 2012, 840-864). Tough political situation, deteriorated social-economic condition of the country, increased number of refugees, disruption of healthcare system, aggravation of sanitary epidemiological conditions, lack of preventive measures contributed to a significant increase of socially dangerous infectious diseases (UNDF, 1997, WHO, 1998).

The situation was further complicated by violating the vaccination deadlines and nearly terminating the vaccination for children and adolescents in early 1990s (Chanturidze T., Ugulava T., Durán A., Ensor T. and Richardson E. 2009,116.) Between 1990 and 1995, the level of immunization dropped sharply from 95% to 30-50% with vaccinations for major preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, polio, measles), leading to an outbreak of socially dangerous infections.

The failure of the planned vaccination due to the lack of vaccine material led to an epidemic of diphtheria in 1991-1992. There were 23 cases of diphtheria in 1993, 312 cases in 1994, and 425 cases in 1995. Out of those cases, 42 turned out to be fatal. Cases of measles, rubella, and whooping cough were increased. Acute respiratory infections accounted for 43% of mortality in children under 1 year of age. Intestinal infections, botulism, rabies and tetanus became more common. The growth of drug dependence in adults led to an increase in the incidence of hepatitis B in a 15-35-year-old age group.

In 1991-1995, a specific type of outbreak of tuberculosis developed in Georgia, resulting in a national problem. Against the backdrop of deteriorated socio-economic conditions of the population, tuberculosis penetrated into the social strata of the country's population, where its prevalence has been traditionally low in previous years. The rate of mortality from tuberculosis was 90% higher than compared to Western Europe. Particular problem was the emergence of drug-resistant forms of tuberculosis. It should be noted that about 85% of new cases of tuberculosis were pulmonary. Prisons, with 5-10 % of prisoners found infected by TB, were named as the key source of TB spread. Case detection was also a problem as the level of microscopic, laboratory and instrumental examination of smear was low.

The cases of diseases, being considered as eliminated, increased, including diphtheria, malaria, visceral leishmaniasis, and rabies. The incidence of sexually transmitted diseases grew. For example, from 1993 to 1994, the incidence of syphilis increased by 100%. Since the 1990s, there has been a sharp increase in the number of people living with HIV and AIDS. However, statistics on sexually transmitted diseases did not reflect the real situation, as the majority of patients preferred to use anonymous medical services. According to some experts, the number of HIV-infected people in Georgia was much higher, due to certain shortage of disposable syringes and medical instruments, lack of public awareness about HIV, ignored condom use, increasing migration and the growth of the rate of sexually transmitted diseases.

The number of patients with ischemic heart disease and hypertension increased significantly from 1990 to 1995. Mortality due to cardiovascular diseases accounted for 72% of total mortality. Between 1990 and 1995, cardiovascular disease mortality increased by 35%, while overall mortality grew by 18%, as evidenced by a decrease in life expectancy.

In the given period, according to the experts, the growth of mortality due to cardiovascular diseases are liked with the emergence of relatively new risk factors (socio-economic crisis, unemployment, poverty and constant stress), added by deteriorating quality of medical care, less affordability of medicines and unregulated death registration practices (Jorbenadze A., Zoidze A., Gzirirshvili D., Gotsadze G. 1999, 221-236). Moreover, high rates of tobacco and alcohol consumption, unhealthy diet and reduced physical activity became significant contributing factors to illness and mortality.

This paper seeks to explore the attitudes and values which underlie public health reform in Georgia, and to investigate the goals of reform and the strategies designed to achieve them. In particular, it explores the extent to which Georgian approaches to public health are consistent with the concepts of modern public health.

Methods

The article is based on a documentary analysis, which included both official and non-official documents. The official papers included legislative and other governmental documents. All health policy documents that could be obtained from WHO/EURO, the Georgian Ministry of Health and regional health departments were included in the study. In total, 14 official papers were analyzed.

Non-official documents were journal publications from major health databases (SCOPUS, MEDLINE, PubMed). The following search terms were used: Georgia plus “public health reform”, “public health system”, “sanitary-epidemiological system”, “san-epid”. Articles published from 1990 to 2021 were included. Articles were included if they contained descriptions of one or more of the following aspects: the public health system or public health reforms in Georgia; organizational structure and reforms of the public health system. Articles were restricted if they published in Georgian; they merely focused on reforms of the health care system. When the articles were analyzed, the English translation of the title was compared with the original meaning. In seventeen articles, the English translation of the title contained ‘public health’ or ‘health care’, while there was ‘medical services’ in the original. These papers were excluded from the analysis.

Overall, the literature search resulted in 32 journal articles of potential relevance to the study. After assessing the full text versions in light of to the inclusion/exclusion criteria, 9 articles were finally included in the paper.

Result

The Beginning of Reorganization, Concept of Public Health

Reorganisation of the healthcare system, launched in 1995, was based not only on the development of a medical model, but also focused on the model of preventive healthcare (Kalandadze T., Bregvadze I., Takaishvili R., Archvadze A., Moroshkina N. 1999, 216-220). Human health is defined not only by a robust medical model and high quality medical services, but also by a healthy life style, prevention or early detection and prevention of the causes of disease. For the society, for an individual, it is primarily economically advantageous to fight the disease, its origin and spread. Studies show that the impact of medical care on human health does not exceed 12-18%. The rest comes to the factors related to a surrounding environment and human lifestyle itself. Therefore, the health of the population is achieved mainly through studying the causes of illness and developing and implementing optimal measures for their neutralization, as well as establishing the healthy lifestyle.

In this regard, the role of public healthcare system is especially critical, as it serves for disease prevention, health promotion, management and analysis of epidemiological situation, establishment of healthy life style. The main criterion of public health priority lies primarily in cost efficiency of preventive measures. Based on timely and adequate information, it allows to identify the most relevant problems for the country and regions, that in its way will be a prerequisite for targeted decision-making under rational and limited resources.

After gaining the independence, some Post Soviet countries, (including Armenia, Belorussia, Russian federation and the Ukraine) have maintained the organizational structure and philosophy of sanitary-epidemiological service inherited from the Soviet times. Some countries (including Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan) have set up additional structures.

It should be noted that Georgia was the only country (except the Baltic states) to abandon the soviet system of Sanitary-Epidemiological Service, completely reorganizing it and establishing a new public health infrastructure, built on European principles (Rechel B. 2014). Examples of functions and structure were taken from Western European and US models. USA Centre for Disease Control, the World Bank, WHO, and the Israeli Minister of Public Health and especially, Mrs. Donna Edna Shaleila have significantly contributed to the shaping of a modern public health system in Georgia. It is noteworthy, that in the next years, public health services with similar functions and names were formed in many other countries, including the countries of eastern Europe (DA., Field MG. 1996, 307–312).

The reorganization of the Sanitary-Epidemiological Service implied the separation of supervisory (sanitary control) and executive (epidemiological supervision) functions, typical of the Soviet system (Gzirishvili D., Mataradze G. 1999, 4–26). As a result of healthcare sector reorganization in the country in 1995, the Public Health Department and the Department for Sanitary Supervision and Hygienic Regulation were established. The Public Health Department was entrusted with the following functions.

immunization, promotion of medical record-keeping,
infectous and noninfectious disease monitoring,
analysis and forecast of epidemiological situation, promotion of healthy lifestyle.

The Department of Sanitary Supervision and Hygienic Regulation is responsible for preventing the negative impact caused by environmental factors on the health of the population, developing the sanitary-hygienic norms for work, living, food, radiation and chemical safety and for controlling the compliance with them. There have been formed the local/regional/urban services of the Department of Sanitary Supervision and Hygienic Regulation.

Public health and sanitation inspection services complemented each other in some way in shaping and maintaining the public health environment. They represented the executive institutions for public health measures.

In 1997, the fundamental “Law on Healthcare” was adopted, regulating the field of healthcare, with defining the framework for public health measures. According to this law, public health protection is "a system of state obligations, aimed at protecting, maintaining and restoring human physical and mental health by preventing diseases, studying and controlling their dissemination, establishing a healthy lifestyle, promoting a safe environment for human health."

Organization of Public Health

On 1996, the Public Health Department was established by Order of the Minister of Health. The objective of the Department was to improve the health of the population through medical and preventive measures. The Public Health Department was entrusted with the following functions: monitor the epidemiological surveillance and set the priority directions, prevent socially dangerous diseases, manage and finance the state programs, keep biostatistics, promote the healthcare, organize the measures for the establishment of a healthy lifestyle.

One of the key objectives of the reorganization included the decentralization of public health system. For this purpose, a system of two-level public health services was established: at the central level - Public Health Department and at the local / municipal level - Public Health Centers. Public Health Centers (including 10 regional coordination functions) were municipal and regional organizations, responsible for public health provision among the population living within administrative framework, in particular, they were accountable for analyzing and managing the epidemiological situation, organizing and implementing appropriate measures for disease prevention. The fundamental mission of Public Health Centers included the evaluation of public health, coordination and monitoring of the activities, and implemention of public health programs. The responsibilities of the Public Health Service were as follows: Epidemiological peacefulness in the country, early identification and prevention of diseases, provision of information, prevention of public health threats and timely response to them, prevention of environmental impacts and behavioral risk factors, fundamental and applied biomedical science development

Target-program funding was defined as the form of financing based on the established share ratio of central and local state budgets. At the same time, international programs, promoting the global health, were launched with the support of donor organizations. The system of health promotion, preventive examination of population and management of the activities for establishing the healthy life style was put into operation.

Three subunits have been defined under Public Healthcare Department

National Centre for Disease control
The Centre for health Promotion and Disease prevention
Medical Statistics and Information Centre

National Centre for Disease Control (NCDC)was founded in 1996. It coordinates the epidemiological surveillance, fight against communicable diseases and preventive activities, provides methodic and practical assistance to regional and local healthcare centers, medical institutions, conducts trainings for healthcare professionals, carries out field works, is equipped with national reference -laboratories, studies the cases of epidemic outbreak and their cause-effect links. The NCDChas a network of regional branches, producing quarterly epidemiological bulletins. It coordinates the national immunization program and also cooperates with other donors and centers of disease control, for instance, with the USA Centre for Disease Control and Prevention.

Medical Statistics and Information Centre is responsible for collection of health statistical data. The Centre for Health Promotion and Disease Prevention is accountable for health awareness and health promotion. In 1996, the first annual statistical Reference book was released “Health care - Georgia”, which presented the key statistical indicators of public health condition and healthcare resources of the country. For calculation of indicators presented in the reference book, the methodology recommended by World Health Organization is used, allowing to compare the indicators of Georgia with the indicators of other countries.

In terms of decentralization, Georgia again proved to be the only exception among post-soviet countries, where the funds out of four elements of the healthcare system (financing, Policy Development, Standard definition, Management and Administration), were distributed at central municipal level, and management and administration - at central, regional and municipal levels (Gotsadze G., Chikovani I., Goguadze K., Balabanova D., McKee M. 2010, 440).

Thus, according to a logical framework, public healthcare system of Georgia was resembling to the models of public healthcare system of the developed countries. The abovementioned relates to the responsibility and financing levels, provision of key services (immunization, epidemiological surveillance, healthy life style…).

The principle of operation of the existing system of public healthcare was about dividing the volume and responsibilities of key service delivery per level. In 1996-2003, public healthcare priorities included immunization, epidemiological surveillance, oncology disease fighting, safe blood, antidrug and traumatism prevention, establishment of healthy lifestyle, active case finding and other activities.

The programs of infectious disease prevention, chronic disease management and healthy lifestyle, the measures that were necessary for the health of the population living in a particular area, considering the social-economic, cultural and natural characteristics, were financed at local level through municipal programs. But in a number of cases, the local financing was symbolic. At the local level, there was a problem of real responsibility for public health, and lack of awareness of obligations, insufficient knowledge about public health and respectively, adequate budgeting.

Public health network development in Georgia was of great importance, both in terms of epidemiological surveillance and disease control system regulation, which was virtually disrupted at regional level, and in terms of forecasting the epidemic situation and developing and implementing adequate preventive measures.

At the request of the World Health Organization, timely receipt, evaluation and analysis of data on the prevalence and structure of infectious diseases has been provided, enabling timely implementation of appropriate control measures. For addressing these problems, „Epidemiology Management Program", "Healthy Lifestyle Promotion and Disease Prevention Program" and other preventive programs have been launched in the country, which in turn echoed the resolution of the World Health Assembly, declaring that the development of epidemiological surveillance systems and enhancement of infectious disease control at the national level based on laboratory research is the best way to prevent these diseases from spreading internationally.

The reorganization of public health soon yielded its first results. The spread of infectious diseases was significantly reduced by launching a state program of routine immunization, implementing the practice of safe injections and medical manipulations, introducing a safe blood program.

In 1995-1996, the campaign of mass immunization for 3-60-year-old population was carried out with TD vaccine, with the coverage - 83% through the support of the Government of Japan, United Nations Children's Fund, USAID, World Health Organization and other organizations. With their assistance, in 1995, a serological study of immunity to diphtheria after booster dosing was conducted in Kakheti in different-age-population. It was found that the population aged 30-49 years still did not have protective immunity. Based on the study, a second booster dose of TD vaccine was administered to the contingent of this age in 1997, with the coverage - 86%. As a result, the epidemic of diphtheria has been under control since 1998 (Gamkrelidze A., Atun R., Gotsadze G.. MacLehose L. 2002).

Effective anti-epidemic measures were taken during various epidemic of waterborne intestinal infections, hepatitis, typhoid fever (Akhaltsikhe, Poti, Batumi, Kobuleti, Khoni, Rustavi…). In this period, thanks to a huge assistance of the government of Japan, USA and other countries, it was made possible to first, launch the planned vaccination, and then, implement a mass vaccination of the population. Due to high coverage of vaccination in June of 2002, WHO Certification Commission for the European region granted Georgia with the status of polio free zone, that has been retained by our country to this date.

The development and implementation of multi-year state program focused on DOTS (Directly Observed therapy, short-curse) strategy, recommended by the World Health Organization, has improved the epidemiological situation in a certain way. The idea of the strategy lies in elaboration of a perfect system to control tuberculosis, that ensures the reduction of mortality, illness, disease spread in the society and prevention of the development of resistance to anti-TB medicines. This is implemented through identification, diagnoses, treatment, prevention of TB cases and by carrying out standard activities of epidemiological surveillance.

Especially noteworthy is the establishment of Lugar Centre, for which the foundation was laid by signing the agreement between the presidents of USA and Georgia on biosafety in 1997. It dealt with non-proliferation of nuclear, chemical and biological weapons in the world and was one of the key components of the country’s biological security. The agreement laid the groundwork for the development of this type of program not only in Georgia, but in Eastern Europe as a whole. Famous Republican Senator Richard Lugar lobbied for the establishment of the center in Georgia. In 1998, Lugar made his first visit to President Eduard Shevardnadze and decided to establish a Lugar laboratory. Considering, that the Lugar Center is one of the main and important tools of the healthcare system, in 2002, at a meeting between Richard Lugar and the Minister of State, it was agreed that the Lugar Center would be subordinated to the healthcare sector and integrated into public healthcare system.

As of today, the Lugari Centre is one the best scientific research bases across the Caucasus region in the fields of biomedicine and biosafety. The Centre is equipped according to the highest standards and has been granted with the third level of biosafety, meaning, that almost all kinds of microbes are studied there. As per modern classification, the third level laboratory can diagnose the corona virus, allowing timely detecting and managing this infection. Its role is especially vital in the era of modern pandemics.

Thus, as a result of healthcare system reorientation in Georgia, a groundwork was laid for a new public health system, set up on modern principles, reflecting the latest global experience. However, the key challenge in public healthcare service reorganizion consisted in incomplete financing of state programs (Verulava T., Dangadze B. 2018, 401-406, Verulava T., Maglakelidze T. 2017, 143-150). Healthcare system was suffering from chronic financial deficiency, as the state frequently failed to fund the promised liabilities (Verulava T. 2019, 57-62).

The changes made by the government in 2007, the Public Health Department was merged with the National Center for Disease Control to form the National Center for Disease Control and Public Health. The abovementioned has virtually diminished the role and importance of public health, as the Center for Disease Control is the only tool in the system of public health. As a result, the attention from central and local government to the public health has been decreased. Moreover, the Sanitary Supervision Service was abolished and its separate functions were redistributed to different ministries and agencies. Due to the Service cancellation, various facilities (e.g medical organizations, dental offices, beauty salons) were left unattended, with no control of service delivery quality and safety norms.

Conclusion

In modern times, when the healthcare system of Georgia is focused more on treatment rather than on prevention, it is important to recognize public health and preventive medicine as the top priority for healthcare system development, for further coordinated development of public health, hospital sector and preventive healthcare services, for public-private partnership in public health sector development. The role of public health is especially increasing in the modern globalized world, when the epidemics of infectious diseases and pandemics have become topical. In globalized world, the public health challenges go beyond national borders and interests, having huge global political and economic consequences. Therefore, modern public health is reviewed in a global context and requires international regulations, transnational actions and solutions based on coordinated cooperation among different countries of the world.

International health regulations constitute a legal framework that determines how countries should respond to the threat of international diseases. Its objective includes prevention, protection and control of international spread of the disease. Based on global regulations, the country's public health system should develop a permanent system that timely identifies and eliminates the public health risks that may lead to a mass spread of the disease.

Considering the fact that the fight against infectious diseases is primarily a public good rather than a private, individual service, the era of infectious disease epidemics requires an increase of the role of public health measures and further enhancement of cooperation between the state and the private sector.

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