Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1698058870362.pdf (Georgia)
Original Article DOI: 10.5455/amaj.2016.03.026 Effects of Universal Health Insurance on Health Care Utilization: Evidence from Georgia Tengiz Verulava, MD, PhD1 Temur Barkalaia, MD 2 Revaz Jorbenadze, MD, PhD3 Ana Nonikashvili, MD2 Tamara Kurtanidze, MD2 1 Professor at Ilia State University.
Head of Quality Management Department at G. Chapidze Emergency Cardiology Center, Tbilisi, Georgia 2 Researcher at Ilia State University, Tbilisi, Georgia 3 Executive Director of Quality Manage- ment Department at G. Chapidze Emer- gency Cardiology Center, Tbilisi, Georgia Correspondence: Ana Nonikashvili, MD, Researcher at Ilia State University, Kakutsa Cholokashvili Ave 3/5, 0162, Tbilisi, Georgia.
email: ana.nonikashvili.1@iliauni.edu.ge Phone: +995 577284849 Introduction: Since 2013, Georgia enacted Universal Health Care Programme (UHP).

Inclusion of uninsured population in the UHP will have a positive impact on their financial accessibility to the health services.
The study aims to analyze the refer- ral rate of the beneficiaries to the health service providers before introduction and after application of the UHP, particularly, how much it increased the recently unin- sured population referral to primary health care units, and also to study the level of satisfaction with the UHP.

Methodology: Research was conducted by qualitative and quantitative methods.
The target groups’ (program beneficiaries, physicians, personnel of the Social Service Agency) opinions were identified by means of face-to-face interviews.

Results: Enactment of the UHPs significantly raised the population’s referral to the family physicians, and the specialists.

Insignificantly, but also increased the frequency of usage of laboratory and diagnostic services.
Conclusion: Despite the serious positive changes caused by UHP implementa- tions the problems in the primary healthcare system still remain.

Also, it is desirable to raise the availability of those medical services that may cause catastrophic costs.

In this respect, such medical services must be involved in the UHP.

For the purpose of effective usage of the limited funds allocated for health care services provision, the private health insurance companies should be involved in UHPs.
This, together with the reduction of health care costs will increase a competition in the medical market, and enhance the quality of health service.

Keywords: Universal healthcare, Georgia.

Background In 2006, the Ministry of Labour, Health and Social Affairs of Georgia has launched implementation of “Health Insurance Pro- gramme for Socially Vulnerable Families”.

Its aim was to ensure medical service for the population below the poverty line.
In 2012, the Health insurance programme was extended to children aged 0-5, pensioner (senior citizens) women above 60 years and men above 65 years, students and people with severe disabilities.

In 2007, the Health Insurance pro- gramme covered only 4.1% of the popu- lation, in 2012, it increased up to 37.9%, together with persons covered under private and corporate Health insurance (12.9%), overall amounting was up to 50.8% insured persons [1].
Despite the extension of the state health care programme coverage, more than a half of the population of the country, about 2 millions of persons had no insurance and in most cases, were unable to cover the med- ical expenses from own pocket [1].

It shall be mentioned that the number of visits to primary healthcare per person is 2.1 and with this indicator Georgia ends up second in comparison to European countries [2].
To settle the problem, Universal Health Care Programme (UHP) has been intro- www.amaj.az health institutions, which were selected only in Tbilisi due to lowering expenses and possibility of conducting questionnaire within short time.

The study was approved by the Committee on the Ethics of the Ilia State University (Permit Number: 89-324).

Participants provided informed consent.

The consent was written.


Results After introduction of UHP, the visits of population for med- ical services have significantly increased [3].

In February-April 2014 Experts of WHO and USAID carried out assessment of one year results of UHP.

Simultaneously, with the technical as- sistance of USAID/HSSP the phone survey of the population on the satisfaction of obtained services and qualitative study of ser- vice providers and beneficiaries (Focus groups) for assessment of UHP were carried out [3].
The survey showed that major- ity (96.4%) of the beneficiaries of UHP are satisfied or highly satisfied with hospital and/or urgent outpatient service, 80.3% of beneficiaries are satisfied or highly satisfied with planned outpatient service [3].
84.1% of respondents on the planned outpatient component and 78.2% of planned hospitalization and urgent outpatient component indicated that the financial support of population is the most positive part of the Universal Health [3]; also, most of the beneficiaries mentioned the rights to free choice is one of the core positive factors of Universal Health.

7.6% of respondent’s dissatisfaction was mainly about the length of the waiting period for obtaining needed service [3].
According to our study, before introduction of UHP, 23% of respondents consulted family doctor, (10% of which did more than 3 times), 67% didn’taddress at all.

After introduction of the programme, 49% of respondents have addresses 1 to 3 times, 27% more than 3 times, 21% of respondents didn’t address at all (diagram 1).

Prior to introduction of UHP, 34% of respondents addressed specialized doctor 1-3 times, 18% - more than 3 times, 48% didn’t address at all.
After introduction of the programme, 52% of respondents consulted with specialized doctor 1-3 times, 18% - more than 3 times, 30% didn’taddress at all.

67% of beneficia- ries mentioned that they addressed specialized doctor via referral of a family doctor.

14% mentioned that they directly addressed Diagram 1.

Percentage comparison of visits of beneficiaries prior and after introduction of Universal Health Programme.

86 duced since February 28, 2013.


2 300 000 uninsured persons became the beneficiaries of the UHP.

The programme aims at providing financial support for accessibility to healthcare to Georgian citizens who are not insured.

First tıme in the history of the country the state programme extends to citizens of the country, as well as holders of neutral identification cards/neutral travel documents and individuals without citizenship status.
The state money allocated for healthcare almost doubled from 2012 to 2013 and increased from 365 million to 634 million GEL [1].

UHP cover ambulatory consultations of a family physician, planned and urgent out-patient service, urgent in-patient treat- ment, planned surgical operation (including daycare inpatient) and related examinations in specified limit.

UHP provides the beneficiary with the opportunity of free choice of a medical institution.
The programme beneficiary has a right to select a healthcare provider throughout Georgia and register with any family physician.

Further, in case of dissatisfac- tion with the service provided, a person can change the provider once in two months.

There is no any limit for selection of a provider when obtaining emergency in-patient or out-patient service.

As for the planned in-patient service the beneficiary has to address the Agency of Social protection and obtain a voucher or a letter of guarantee.
Any medical institution, which meets the requirements established by the law, is eligible to participate in UHP.

The aim of the study is to analyze the address of beneficiaries prior to and after Universal health i.e.

the extent to which the visits of previously uninsured population to primary healthcare institutions has increase and also, the study of their satisfaction with above mentioned programme.
Methodology Methodological basis for the study is the literature about UHP including scientific works and internal data.

The study covers qualitative and quantitative components.

Qualitative study implies identification of viewpoints of primary health personnel and healthcare experts with regard to UHP.

In terms of Qualitative component in-depth interviews were conducted with participation of the experts of the social protection Agency, primary health medical personnel and healthcare experts.
Strat- ification random sampling was used for selection of primary health institutions.

The types of medical institutions (outpa- tient, family medicine centers), as well as participation in the UHP were used for stratification variables.

6 primary health institutions were selected.

Stratification random selection meth- od was used for selecting beneficiaries.

Due to inaccessibility to sampling database, the respondents were selected at the primary health institutions randomly.
In terms of the study, 500 benefi- ciaries were questioned.

The study applied face-to-face interviewing method.

The in- terviewing was done through special structured questionnaire.

The questions were separately developed for each target group.

In terms of the project, two different types of questionnaires were used – for family doctors and primary health beneficiaries.

Obtained data were analyzed by descriptive statistics.
Study limitations include random selection of primary Verulava et al.Universal health insurance: Evidence from GeorgiaAMAJ2016; 3: 85-88www.amaj.az Diagram 2.

Study of satisfaction of beneficiaries with Universal Health Programme.

Diagram 3.

Positive sides of Universal Health Programme by assess- ment of beneficiaries.

87 In assessment of positive sides of UHP the majority of an- swers were “Better than nothing” (80%) and “free of charge” (62%).
Other positive sides mentioned by beneficiaries were the possibility to obtain specialist consultations (46%), free choices of outpatient service and the doctor (43%) (diagram 3).

As for negative side of the project the beneficiaries basically mentioned dissatisfaction with co-payment (71%), as well as limited list of services (68%) and medicines (63%) covered by the programme and absence of reimbursement for stomatologic services (45%) (diagram 4).
In 6 outpatient clinics (three mixed types, two for juvenile and 1 for children) selected for study, 40 family doctors and 30 specialized doctors (pediatricians, neuropathologists ophthal- mologists) were interviewed.

70% of family doctors mentioned that after introduction of UHP 15-20 patients visit them per day, and in 30% this number is 25.

Half of the interviewed doctors stated that prior to intro- duction of UHP the visit number was 8-10, in 40% - 10-12, in 10% - 15 patients per day (Table 1).
In case of specialized doc- tors, 60% have 10 patients per day , and 40% have10-15 patients per day after introduction of UHP; prior to UHPe maximum 10 patients consulted with specialized doctors per day (Table 1).

80% of interviewed family doctors think that visits have considerably increased after introduction of UHP; 20% of fam- ily doctors consider this increase to be - insignificant.

60% of interviewed specialized doctors thinks that after introduction Diagram 4.
Negative sides of Universal Health Programme by assess- ment of beneficiaries.

specialized doctor without referral of family doctor; according to 19% of respondents they addressed specialized-doctor some- times directly and sometimes through a referral (see diagram 1).

Prior to introduction of programme 31% of respondents took laboratory analysis during one year 1-3 times , 12% - more than 3 times, 57% didn’tusethis service.
During the last one year, in terms of UHP, 38% of beneficiaries took laboratory examina- tion 1-3 times, 22% - more than 3 times, 40% - didn’t take at all (diagram 1).

As for instrumental examination, prior to introduction of the programme, during the year, 26% of respondents used it 1-3 times, 12% - 3 times, 62% didn’t use it.

After introduction of UHP during one year 37% of respondents took instrumental examination 1-3 times, 10% - more than 3 times, 53% - didn’t use it all (diagram 1).
Satisfaction level of beneficiaries with UHP is following: 35% of respondents are satisfied with the programme, 36% - are less satisfied, 2% express dissatisfaction, 27% hasn’t utilized the pro- gramme yet but positively assess its existence; 53% of respon- dents state that prior they used private/corporate insurance; out of them 37% give priority to private/corporate insurance, 16% - give priority to UHP (diagram 2).

Table 1.
Table 1.

Percentage distribution of consultations of beneficiaries with family doctors and specialized doctors, a year prior to introduction of Universal Health Programme (UHP) and after introduction.
Percentage (number) of visits of beneficiaries per day Family Doctor Specialised Doctor Prior to UHP 50% (8-10) 40% (10-12) 10% (12-15) After introducing UHP Prior to UHP After introducing UHP 70% (12-20) 30% (20-25) 100% (5-10) 60% (8-10) 40% (10-15) 100% (8-15) 100% (12-25) 100% (5-10) 100% (8-15) Verulava et al.Universal health insurance: Evidence from GeorgiaAMAJ2016; 3: 85-88www.amaj.az 88 Diagram 5.
The dynamics of visits to family doctors and specialized doctors, after introduction of Universal Health programme.

of UHP the visits of patients has increased insignificantly, 30% considers the number of visits to be slightly increased and 10% of doctors thinks that the number has increased significantly.

Among specialized doctors, the pediatricians think that the number of patients has dramatically increased after introduc- tion of the programme for children of the age of 0-5 (diagram 5).
The Majority of Experts positively assessed UHP.

According to them, the programme has many positive sides: financial ac- cessibility to healthcare services, free choice of medical providers and doctors, treatment of many diseases, number of financed analysis and instrumental examinations.

According to expert’s opinion, it is reasonable to extend outpatient service package and add some services, including coverage of some medicines to UHP.
Some experts thinks that the negative side of UHP is the long waiting time for planned surgical operations.

Also, because of private insurance companies will lose clients hinder devel- opment of insurance market.

Besides, the state fund will have monopoly on the insurance market and try to dictate fees to medical institutions; for short period it will result in decreasing medical service fees but in the long term perspective it will affect the quality of services.
Further, it will negatively affect medical institutions, which will try to reduce work places and salaries.

Conclusions and recommendations According to the study results, despite the serious advance- ments, there are still problems associated with the primary health care.

The UHP together with many positive factors, has many flaws that need corrections.

It is necessary to increase the financial accessibility of services linked with high expenses.
In this regard, the volume of these services shall be increased.

It is reasonable to engage private insurance companies in implementation of state health care programmes for effective use of available scarce resources.

This will increase competitiveness and the quality on the healthcare market together with decreasing of healthcare expenses.

Declaration of competing interests The authors declare that they have no competing interests.

Authors’ contributions T.V.


contributed to the study design, acquisition of data, anal- ysis and interpretation of data, and prepared the manuscript.

R.J. contributed to the study design, acquisition of data, analysis and interpretation of data, and commented on manuscript drafts.

References 1.

Verulava, Tengiz.

Health Policy.

Ilia State University.

Tbilisi.

2016.

2.

Health system performance assessment report, Tbilisi, MoLHSA.

2013.

3.

The Government of Georgia.


Universal Health Pro- gramme: Annual assessment report.

2015.

For information on submitting a manuscript or for subscription information, please visit our website, www.amaj.az Verulava et al.Universal health insurance: Evidence from GeorgiaAMAJ2016; 3: 85-88www.amaj.az