vouchers for obstretic care in georgia

Evaluation of State Obstetric Care Programme for the Population Living Below the Poverty Line in Georgia

Simon Gabritchidze MD, MCHHM, Tamar Trapaidze MD, MPH

19 February, 2008

04/12/23 2

Acknowledgment

The authors acknowledge with gratitude David Gogolishvili’s data analysis and Jonathan Kulick’s support with reviewing and editing.

Financial support from the Caucasus Resource Research Centers – Georgia, the Eurasia Foundation and Carnegie Corporation.

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Why Obstetric Care Programme?

Two of the eight Millennium Development Goals (MDGs) adopted at the Millennium Summit are related to maternal and child health (MDG4 and MDG5);

Georgia’s poor demographic indicators

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Infant deaths per 1000 live births

Source: WHO/Europe, European HFA Database, November 2007

Georgia             

European Region

EU             

CIS

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Maternal deaths per 100000 live birthsMaternal deaths per 100000 live births

Source: WHO/Europe, European HFA Database, November 2007

Georgia             

European Region

EU             

CIS

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Number of live births in Georgia, 1991-2006 years

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

1991 1993 1995 1997 1999 2001 2003 2005

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The General Purpose of the Research

The general purpose of the research was to identify the importance of establishment Data Base of People Living Under Poverty Line in increasing accessibility and availability of quality maternal health services for poor and other vulnerable population groups.

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Study Specific Parameters

General socio-economic characteristics of the study population (income, education, perceived economic status etc)

Level of awareness on the state obstetric programs;

Patient satisfaction with medical services; Quality of medical services, as assessed

through patient and expert opinion survey;

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Study Specific Parameters cont

Financial accessibility of the program services, as perceived by the study population, as well as assessed based on reported household income and the extent of out-of-pocket payments for medical services;

Geographical accessibility of the program services;

Service providers’ opinion on the relevance of State funding and implementation strategies of Obstetric Care Program.

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Study Design and Methodology

Quantitative survey - for beneficiary survey a structured questionnaire was applied;

Qualitative survey – FGDs / working meetings with key informants / stakeholders.

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Study Population

The survey targeted the mothers having deliveries in Zugdidi and Batumi clinics during the last several months;

This included those beneficiaries that are registered as living under poverty line and score less than 70 000 points in the database

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Target groups

1st group – Women, who were identified as SOP beneficiaries, received “card for free medical service”All pregnancy and delivery related medical and non medical expenses were covered by the public funds

2nd group – Women who applied for and received maternity cards, which is suppose to cover delivery medical expenses only;

3rd group – Women, who did not apply/received any benefits from the State programs and paid for all services privately.

Survey Results/Main Findings

Socio-economic characteristics

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Age distributions of respondents

10.1

40.6

28.4

16.2

4.7

6.6

37.7

33.1

16.9

5.7

0 10 20 30 40 50 60 70 80 90 100

<20 yy

20-24 yy

25-30 yy

31-35 yy

>35 yy

Zugdidi

Batumi

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Employment status of respondents

Batumi

77%

9%

13%

unemloyed

selfemployed

private sector

public sector

Zugdidi

90%

5%

unemployed

selfemployed

private sector

public sector

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Employment status of respondents’ spouse

Batumi

39%

17%

27%

17%

unemployed

selfemployed

private sector

public sector

Zugdidi

48%

24%

16%

11%

unemlpoyed

selfemployed

private sector

public sector

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Household income

According to self-reported household income, mean monthly income of the patient’s households in Batumi was

400 Georgian Lari (GEL) (median 525; SD-454, minimal – 50, maximum - 2000)

in Zugdidi the same number was 217 (median 200; SD-170, minimal -30, maximum - 1000).

Such variations between self reported household incomecould be explained by differences of the regions.

Awareness

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Level of awareness on SOP was designed as a composite variable (assessed on the basis of different parameters - knowledge of who is eligible, services covered, payment system etc).

Study showed - beneficiaries of SOP generally are aware of health benefits envisaged by the State program.

although level of awareness on SOP among the beneficiaries is not so high.

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Example

57% of patients in Batumi and 60% in Zugdidi knew that the card for free medical service fully covers all medical and not medical expenses of delivery.

38% in Batumi and 20% in Zugdidi thought that this card covers all those expenses only partially.

While SAP is supposed to fully cover all expenses of delivery and \

prenatal period.

Affordability

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Group I

In spite of the state assistance, in the group I 29% of respondents in Batumi and 17% in Zugdidi consider the financial ill affordability as the main barrier to maternal health services.

17% in Zugdidi and 10% in Batumi reported long distance (geographic accessibility) to the hospital as a main barrier.

In this group trust in health professionals and qualities of services were not perceived as a barrier at all.

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Main barriers associated with deliveries – group II

II group Batumi

8%

66%

17%

other

poor quality

geographical

f inancial

none

II group Zugdidi

18%

6%

29%

47%

other

lack of trust

geographical

f inancial

Out-of-pocket payments

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Delivery related costs group II

On average patients spent out-of pocket 2 times as much as they were supposed to pay officially,

316 GEL on average in Batumi and 198 GEL in Zugdidi;

The main costs were as “honorarium” of doctors: mean 115 GEL in Batumi and mean 107 in Zugdidi.

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Affordability group II

~75% of patients in this group reported, that the amount they had to pay out of pocket was hardly affordable for them;

Only half of patients could afford covering delivery related costs from their existing resources, while the rest had to take loan (35% in Batumi, 33% in Zugdidi) or sell property.

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Necessity of informal payments as perceived by the respondents

III group Batumi

109876543

Pe

rce

nt

40

30

20

10

0

32

8

25

9911

42

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Necessity of informal payments as perceived by the respondents

III group Zugdidi

10876543

Pe

rce

nt

40

30

20

10

0

4

13

3535

444

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Group III

96% of patients in Batumi and 65% in Zugdidi did not apply for the ”voucher”.

However, only 21% of patients in Zugdidi and 36 % in Batumi reported that they were financially well off and didn’t need assistance for delivery.

The main reason for them of not using the State assistance is the regulations, which are incorporated in this program.

Study showed that trust in health care professionals was the lowest in this target group. So that people, even being in need of the social assistance program, prefer to pay money for it, rather then to go to doctors and health care service providers, which are unknown to them.

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Why did not you request medical card?

III group Batumi

20%

44%

36%

3

2

1

III group Zugdidi

62%21%

17%

2

1

3

1=no financial need2=financial need, but not satisfied with conditions3=other

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0

200

400

600

800

1000

GEL

Out-of-pocket payments

Zugdidi 40 200 400

Batumi 0 250 890

I group II group III group

Medical Service Satisfaction

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The patient satisfaction

with the following three aspects of hospital care wasappraised:

(i) Quality of medical services/Qualification of medical personnel;

(ii) Attitude of medical personnel towards patients; (iii) Living conditions at the maternity department.

The patients were asked to assess each of these dimensionsaspects on a 5-score scale, where 1 = extremely poor - 5=excellent.

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Patients mainly assessed the quality of received medical services in maternity houses as medium (50%) and good (27%).

The remaining gave extreme answers excellent or very poor.

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Study revealed that most satisfied with medical services were group I respondents;

Group II patients were more dissatisfied with out of pocket payment and financially ill affordability of program.

However, scored up results of these questions demonstrated moderate satisfaction

Stakeholders opinion survey

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Stakeholders opinion survey

Working meetings / FGDs were conducted in Zugdidi and Batumi;

The representatives of the regional Health Department and the MoLHSA of Ajara, regional branches of the Health and Social Programs Agency, health providers/field practitioners (clinical and administrative staff of Zugdidi and Batumi maternity hospital), local NGOs attended these meetings.

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Stakeholders opinion survey

During these meetings the participants paid particular attention to 200 GEL

“voucher”!

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Deliveries in Batumi and Zugdidi clinics (1 year)

9%14%

57%

44%

34%

42%

0%

10%

20%

30%

40%

50%

60%

FreeMedical

Card

200 GELvoucher

Allexpences

covered bypatients

BatumiZugdidi

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Problems with the ”voucher”

In case of cesarean section or complicated delivery these patients may become financially unprofitable for hospitals;

This is particularly problematic in Zugdidi where the numbers of cesarean sections or complicated cases are quite high and the hospital already has private owner.

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Problems with the ”voucher”

According to the governmental plan absolute majority of hospitals will be private entities within the next few years;

Currently, the private owner of Zugdidi hospital is investing in the building and equipment and is making fewer accents on profit;

However, in future the private hospital may refuse to pregnant women to accept 200 GEL vouchers.

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Problems with the ”voucher”

According to doctors and social agents, very often comparatively rich pregnant women request voucher from the State;

Medical personnel have little income serving this group of patients;

They have little motivation and seek compensation from their patients. This promotes under-table payments.

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Problems with the ”voucher”

FGD in Zugdidi revealed a fact (related to the 200 GEL voucher), which goes beyond health system and has also political importance;

Georgian population of Gali district (Abkhazian conflict zone) have problems to get the “voucher”

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Problem with the reimbursement

The State pays for each pregnant woman from database 400 GEL in Tbilisi and 300 GEL in regions;

Many experts consider that 300 GEL is not enough for quality maternal care and it should be increased.

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Health care reforms

These include questions concerning privatization of hospitals and increasing the role of private insurance companies;

It was difficult for the participants to discuss the pros and cons of the reforms;

However, in case of Zugdidi the participants considered privatization as a positive factor contributing improvements in service quality.

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Conclusion and Challenges for Future

In spite of some positive changes in assuring access to quality of maternal

health services, the State Obstetric Care Program still has several areas that need

improvements.

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Conclusion and Challenges for Future

The State fully covers pregnancy and delivery expenses if the family of a pregnant woman has below 70000 points in this database (14.5% of population);

However, officially recognized number of people living in poverty is much higher and composes about 35% of Georgian population;

The State should take care of this population group as well.

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Conclusion and Challenges for Future

There are number of problems associated with 200 GEL voucher;

The government should introduce more strict criteria for identifiyng beneficiaries of this group (or completely abolish it) and direct funds to the people that really need such assistance.

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Conclusion and Challenges for Future

The difference is in reimbursement of delivery cost by the State between the capital (400 GEL) and regions (300 GEL) does not have logical base;

It will be advisable if the government increases financial assistance for the regions.

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Conclusion and Challenges for Future

The study showed that financial or geographical accessibility to quality maternal care services still remains as a problem (particularly, in Zugdidi);

In line with privatization the government should develop strong regulations in order to assure equity for the whole population.

Thank you for attention

simongabrichidze@welfarefoundation.org.ge

tamari@welfarefoundation.org.ge