EU ENLARGEMENT AND HEALTH SYSTEMS: Experiences and practices from new EU member countries and implic

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EU ENLARGEMENT AND HEALTH SYSTEMS Experiences
and practices from new EU member countries and
implications for Georgia
or
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

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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.

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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.

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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.

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From western to larger Europe

• 15 10 25
• Old members
• New members
• Candidate countries
• Potential candidates

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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.

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Main areas of impact

• Health policy
• Health reform
• Health/health care standards
• Human resources (workforce migration)
• Access to health care
• Biomedical RD
• Environmental health
• Right to health

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

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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.

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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 Georgias territorial
  integrity and national security. Moreover, the
  new Government has declared its intention to
  pursue closer integration with the Euro-Atlantic
  Institutions.

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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)

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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.

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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.

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Available policy window
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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

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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 Generals Office, HIAs
• Developing effective media strategy for health
  reforms.

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Conceptual framework of the proposed policy
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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.

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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.

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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

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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.

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Acknowledgments

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

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THANK YOU!