Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697751422292.pdf (Georgia)
Editor-in-Chief Avtandil Jorbenadze Editors: Otar Vasadze (Georgia) Otar Gerzmava (Georgia) Daniel J.
West, Jr. (USA) Editorial Board: Rifat Atun (UK) Howard W. Baillie (USA) Attorney Michael J. Costello (USA) Bui Dang Ha Doan (France) Amiran Gamkrelidze (Georgia) Toralf Hasvold (Norway) Ramaz Khetsuriani (Georgia) Vladimir Krcmery (Slovakia) Arsen Kubataev (Russia) Maksut Kulzhanov (Kazakhstan) Askar Kutanov (Kirgizstan) Milan Murgas (Slovakia) Migran Nazaretyan (Armenia) Viera Rusnakova (Slovakia) Roman Shakarishvili (Georgia) Oleg Schepin (Russia) Gaioz Vasadze (Georgia) Nino Vepkhvadze (Georgia) William G. Wallick (USA) Akaki Zoidze (Georgia) Publication of the Journal was made possible due to funding through the United States Agency for International Development administered by the American International Health Alliance National Health Management Center of Georgia The University of Scranton, Pennsylvania, USA Journal of HealtH ScienceS ManageMent and Public HealtH Volume 1, Number 1, 2000, 1 - 84 The Journal of Health Sciences Management and Public Health is published quarterly in English with Georgian summaries for each article.
This Journal is published as a joint cooperation between the National Health Management Center of Georgia and The University of Scranton, Pennsylvania, USA, through a Health Management Education Partnership Program.

The funding for this journal is made possible through a grant of American International Health Alliance (AIHA).
AIHA operates under cooperative agreements with the United States Agency for International Development (USAID) that finances the projects and programs that promote broad-based, sustainable economic growth worldwide.

AIHA establishes and manages partnerships between health care institutions in the United States and their counterparts in Central and Eastern Europe (CEE) and The New Independent States (NIS) of the former Soviet Union.
Any questions regarding the contents and publishing of this journal should be directed to the National Health Management Center of Georgia.

Authors alone are responsible for views and opinions expressed in the articles.

The designations employed and the presentations of the material do not imply the expression of any opinion whatsoever on the part of the National Health Management Center and the University of Scranton.
The mention of specific companies or of certain manufacturers’ products do not imply that they are endorsed or recommended by the National Health Management Center and the University of Scranton in preference to others of a similar nature that are not mentioned.

Any or all requests should be directed to: National Health Management Center of Georgia, 51, Iv.
Javakhishvili St., 380002, Tbilisi, Georgia Phone: +995 32 95 66 80 E-mail: nhmc@nilc.org.ge ISSN 1512-0651 Printed in Georgia Journal of Health Sciences Management and Public Health CONTENTS A NEW HEALTH MANAGEMENT JOURNAL LETTER TO EDITORS NATIONAL HEALTH POLICY OF GEORGIA Avtandil Jorbenadze A NEW HEALTH MANAGEMENT EDUCATION PARTNERSHIP: GEORGIA AND SCRANTON Daniel J.
West, Otar Vasadze, Otar Gerzmava PATIENTS’ RIGHTS LEGISLATION IN GEORGIA Guram Kiknadze, Givi Javashvili, Akaki Barkalaia NEW APPROACHES TO HEALTH CARE FINANCING IN A CONTEXT OF THE GENERAL STRATEGY OF HEALTH CARE REFORMS IN KAZAKSTAN Maxut K. Kulzhanov, Aizhan M. Kulzhanova THE PRIORITY SPHERES OF HEALTH CARE FINANCING AND SUBSIDIZATION OF MEDICAL SERVICES Levan Kobaladze, George Gotsadze, David Gzirishvili, Ramaz Bedianashvili, Ketevan Bubuteishvili, Lili Kochlamazashvili, Mamuka Makhatadze COMPARATIVE ANALYSIS OF HOSPITAL CARE PAYMENT FORMS Levan Kobaladze, David Gzirishvili, Akaki Zoidze, Ketevan Bubuteishvili PSYCHO-SOCIAL VARIABLES IN CHANGE MANAGEMENT: TOUGH TIMES NEVER LAST Daniel J.
West THE MAIN TRENDS OF DEMOGRAPHIC AND HEALTH STATUS DEVELOPMENT OF THE GEORGIAN POPULATION Otar Vasadze, Otar Gerzmava THE IMPORTANCE OF PROFESSIONAL IDENTITY IN HEALTH SERVICES MANAGEMENT Robert J. Spinelli, Daniel J.
West MODELING EMOTIONAL INTELLIGENCE IN ACADEMIC INSTITUTIONS: IMPROVING STUDENT GROWTH IN HEALTH ADMINISTRATION EDUCATION Steven J. Szydlowski HUMAN RESOURCE DEVELOPMENT (HRD) PROFESSIONALS ROLE EVOLUTION: SHIFTING THE PARADIGM FROM INTROSPECTIVE TO “EXTROSPECTIVE” William G. Wallick COMPARATIVE ANALYSIS OF THE INDONESIAN AND CHINESE HEALTH CARE SYSTEM Steven J. Szydlowski INSTRUCTIONS FOR AUTHORS 1 2 3 7 17 27 31 37 41 46 56 66 70 79 83 Journal of Health Sciences Management and Public Health A NEW HEALTH MANAGEMENT JOURNAL During periods of high velocity change, communication and the sharing of information is critical for health services administrators and managers.
The transformation of health care in Georgia and the Caucasus Region is an important part of democratization and privatization.

Change in the health sector of the economy is essential to improving the health status of populations.

This process requires strategic intervention and a proper use of precious resources and energy.
Embodied in the process of change are health professionals dedicated to thoughtful restructuring of health policy, improvement of health management , and creating competition based on cost, access and quality.

Equally important is strategy formulation that enables health services organizations to operate in an environment of constant change.

Innovation and adaptation to political, social, economic and technological reform requires trained and knowledgeable health services administrators.
The Journal of Health Services Management and Public Health is intended to address diverse interests in health care management.

The journal publishes original work in health care management and provides a forum for health care professionals to exchange ideas, strategies, and methods which can facilitate and enhance change and improvements to the delivery of health services, health policy, and health status of populations.
Sections of the journal include: original papers, proceedings from symposia, letters to the editors, case studies, commentaries, book reviews, literature reviews, abstracts, and current events.

In general, readers prefer practical articles that are written in a concise, clear style and substantiated by research and scholarly documentation.
The journal covers a variety of health care management issues and topics including (but not limited to): education, theory, law, ethics, policy, marketing, human resources, financing, planning, governance, medical practice, public health, quality, strategy, delivery of care, organization services, and research.

Thoughtful discussions of social trends and political events likely to affect the delivery, organization, and financing of health care in a significant way are encouraged.
The journal is intended to enhance the sharing of knowledge, research, expression of individual choice and community values, quality of care, social justice for people, and the international exchange of ideas and cooperation.
The journal is made possible through support and funding of the United States Agency for International Development (USAID) and the American International Health Alliance (AIHA) via a Health Management Education Partnership in Georgia between the University of Scranton (College of Professional Studies) and the National Health Management Center, Tbilisi, Georgia Editors 1 Journal of Health Sciences Management and Public Health LETTER TO EDITORS I am very pleased to write a few words for this first issue of the Journal of Health Sciences Management and Public Health initiated by the partnership between Tbilisi National Health Management Center and Scranton University.
The beginning of the journal is another successful accomplishment of the partnership program, which is dedicated to enhancing health management education and promoting the development of a cadre of health managers in Georgia.

One of the most important challenges for the country is the revival of the health care sector through a new model of health care organization and management.
This difficult task is to be accomplished by people who manage health care services in a very resource limited and dynamic environment.

The partnership is in an excellent position to help the new managers acquire new skills and knowledge required by the new health care model, cope with increased management responsibilities and help in their transition from health administrators into real managers.
Successful development of health management training programs that are delivered throughout the country, replication of training centers outside Tbilisi, increased pool of local faculty with international experience and professional development in health management are only a few of the accomplishments which marked the first year of the partnership.
Now the Journal will provide a forum for the faculty and the new cadre of health care managers to share theory and practical applications, discuss new ideas and international experience, evaluate accomplishments and test new models for the Georgian health care system.
The first specialized publication for health care managers ever published in the country, the Journal of Health Sciences Management and Public Health will be a great contribution to professional development in health management and in health system reform in Georgia.

It will provide invaluable input in many areas of health services management, education and research for increased effectiveness of the Georgian health care system.
I would like to thank everybody who contributed their talent, intellect, and time in making this happen, and I wish success to the Journal and to all other endeavors of the partnership program.

Arsen Kubataev Director, Regional Office American International Health Alliance 2 Journal of Health Sciences Management and Public Health NATIONAL HEALTH POLICY OF GEORGIA Avtandil Jorbenadze1 Abstract In 1999 the Government of Georgia adopted the National Health Policy and Strategic Health Plan for 2000-2009.
It has become the national health system’s foremost planning re- source for developing its role in planning, funding and purchasing health services.

The Plan sets priorities among the health problems and presents sound solutions that take into account the projected economic situation of the country and the resources of the health system, which are to be allocated equitably and cost-effectively.
This document focuses on specific interre- lated issues: strategic health planning, situation analysis, the health system’s vision for the 21st century and strategy implementation.

It aims to lead policy-makers and programme planners through the process of strategic thinking to improve the chances of successful implementation.

During recent decades major cataclysms have affected almost half of the world’s population and encompassed a third of the Earth’s territory.
On the same scale changes took place in the sector wide and intersectoral structures.

The boundaries of economical integration, which have been formed over the decades, have also changed.

The most complex changes are taking place in all aspects of public mentality.

The situation became even worse due to global financial crisis, danger of ecological catastrophes, demographic and ethnic problems.
The magnitude of possible results of these factors affect not only countries with transition economies but also the whole world and force us to elaborate long-term plans for steady development through seeking unique decisions and approaches.

Historically this period coincided with the restoration of independence in Georgia.
During the initial years of independence along with various political turmoil Georgia faced destruction in state governance, deepening economic crisis, total disruptions in financial system, deterioration of traditional economic links with neighboring republics and lost markets for Georgian products, almost total paralysis of countries economy.

Economic crisis was further deepened due to internal political crisis, externally inspired separatist movements, and civil war.
All of the aforementioned negatively impacted social structures of the country.

In this situation since August 10, 1995 the 1 Minister of Labour, Health and Social Security of Georgia * reorientation of the Health System has started.

In lieu of moving to a market economy the reforms aimed to develop the health system and adopt the management structures that would assure establishment of new economic relations, protect the human health rights, and use civilized and democratic means to manage the process.
At the initial stage of reorientation it was needed to implement the changes that would maintain the health status of the nation and attempt to improve it.

The health reform was definitely part of the recovery from the social-economic crisis and of the macroeconomic stabilization processes during the period.

The whole health reform process was guided by the election program “FOR NEW DEMOCRATIC GEORGIA” of the president of our country, His Excellency Edward Shevardnadze.
The concept of health sector reorientation entailed the following strategic directions: * Development of legal basis for the new health system * Decentralization of health care administration & management * Development of new economic and financing mechanisms, moving toward program financing Introduction principles of Health Insurance * * Prioritizing Primary Health Care * Reform of Sanitary and epidemiological service * Reform in drug policy * Implementation of privatization in health sector Implementation licensing and accreditation in the health care system 3 Journal of Health Sciences Management and Public Health * Reform in medical education * Reform the medical science * Reform medical information service * Social protection of the medical personnel.
Within the framework of legal basis development for the new health system a number of legislative and regulatory documents were adopted.

The major document is the Basic “Law on Health Care”.
Besides these laws, Georgian parliament adopted following laws: Law on Health Insurance, Law on Drug and Pharmaceutical Activity, Law on Health Taxes, Law on Taxes for Production and Marketing harmful for health Products, Law on Donation of Blood and Its Products, Law on Prevention of AIDS, Law on Psychiatric care, Law on Protection and Promotion of Breast-feeding, Controlled Consumption of Artificial Nutrition.
As a result of the reorganization of the state management function in the sector it became possible to separate strategic and tactical objectives among central and regional health authorities.

This actually resulted in accomplishment of institutional and structural establishment of nation’s health system.

Transformation of the National Health Fund into a State Medical Insurance Company has occurred.
After the initiation of reforms more than 1,500 medical facilities were transformed in self- financing legal entities.

Also the licensing of these institutions as well as pharmacies has been conducted.

Program based management should be considered the most effective aspect of new financing system.

It helped the country to concentrate on the main health problems of the population and development of Basic Benefit Package (BBP) for the population, which is financed by the Federal and municipal programs.
As a result of these reforms there was the establishment of the Public Health Department, whose goals are aimed at initiation of unified mechanisms for disease prevention, reestablishment of medical statistics, and implementing effective surveillance system.
According to the ideology of this department we are implementing healthy lifestyle promotion, health education, etc.… Pharmacy networks and pharmaceutical supply bases were privatized and licensed, this 4 supported the elimination of deficit of pharmaceuticals and related negative processes.
Adoption of state regulatory mechanisms due to Georgian Law on “Drugs and drug policy”, establishing price ceilings on most highly used pharmaceuticals is becoming an issue of critical importance for solving the problem of drug affordability.

In the process of reforms the Ministry of Health was obliged to make complicated and unpopular steps.

Currently the health sector is facing the need for quantitative and qualitative optimization of health facilities and medical personnel.
Resolving this issue is impossible without licensing, certification, privatization, and facility consolidation processes.

The success of the personnel certification process is closely linked with medical education, as quality of health services for the population is highly dependent on the qualifications of human resources.
Significant steps were made in this direction: the necessary minimums of higher and secondary medical education are elaborated; the programs of residencies for main medical specialties are prepared; the process of retraining of GP-s and family medicine nurses has begun; nearly 400 young physicians are trained at the best universities of western countries.

Retraining programs of public health physicians, managers, epidemiologists, statisticians, and others are under way.
This is occurring with support and collaboration of foreign specialists.

In the near future training of economists and jurists is planned for our branch.

The grant based financing method was adopted for improving the management and process of medical research.

Though due to the continuous lack of financial resources this method was not fully utilized.
Simultaneously, our scientists initiated successful professional cooperation with foreign partners and the number of grants obtained due to this cooperation is increasing yearly, which may serve as an evidence of the international recognition of our intellectual potential.

The new infrastructure of scientific-research institutions, which are more and more integrating into university science, is forming.

Certain steps were taken to revive the medical industry.
The first line of a pharmaceutical factory was launched with quality output that is comparable to standards of quality in modern international drug manufacturing.

Investment of twelve million dollars is anticipated to complete the construction of a second line of this factory, which will be started in October of this year.

The project design is completed for the disposable syringes factory, construction of which is also planned by foreign investment.
In addition, several interesting projects are currently under review.

As a result of measures conducted, worsening of the populations’ health condition has stopped.

The spread of infectious and socially dangerous diseases has become manageable.

In the entire process of reorientation the Ministry of Health actively cooperated with representatives of developed countries, international organizations, and health experts.
Especially it has to be mentioned the significance of partnership program “Tbilisi- Atlanta” of the American International Health Alliance, which made possible participation of American consultants in the process of elaboration of the concept of the Georgian health system reorientation.

This important partnership program determined interest and later participation of World Bank in the reforms of the health system.
This, in itself, provided support of the Governments of Germany, Japan, UK, Netherlands, Sweden, Denmark, etc.
In the frame of the partnership program “Tbilisi-Atlanta” Training Center of Emergency Medical Care and National Informational Learning Center have been established and equipped by modern technical means, Association of Nurses began functioning, the programs of retraining of nurses have been elaborated, etc.… Special hopes to tie with new partnership programs, which will promote development of primary health care in two regions of Georgia, will help to elaborate programs of training and retraining of health managers and improve methods of combating against intrahospital infections.
The mechanisms for health reforms represent the levers for implementing changes in health policy and population’s general health.

That’s why, we were given a task by the President of Georgia, Eduard Shevardnadze, to elaborate very concretely and clearly formulated national health policy Journal of Health Sciences Management and Public Health that will determine the main priorities, goals, and objectives of population’s health care and will become major driving force for the sector reforms.
By means of this policy we want to realize the appeal of the WHO to member states: “to base their objectives on the reality of today and dream about tomorrow”.

level of The state of health status of the population reflects the the socioeconomic development of the country.
The document prepared last year on “The Health Status of Georgian Population” reaffirmed the fact that our country, like many other post-socialist states, experiences the double pressure in the burden of diseases characteristic for both the developed and developing Namely, cardiovascular and oncological diseases and accidents represent a major public health problem, along with the spread of infectious diseases.

countries.
Therefore, while defining the priorities we have selected the following criteria: • main causes of morbidity and mortality • maximum coverage of population with • • • • priorities economic impacts of priorities The main priorities for maintaining and improving the health of the Georgian population until the year 2010 are as follows: • improvement of maternal and child health reduction of morbidity and mortality caused by cardiovascular diseases improvement of prevention and detection and treatment of oncological diseases reduction of traumatism, reduction of communicable and socially dangerous diseases, mental health, establishment of healthy life style, and provision of an environment safe for humane health Elaboration of the National Health Policy document and adoption of such is a major step towards the protection of the population’s health, but it is only one of the phases after which the main importance is attached to the actual implementation of the policy through means of intersectorial cooperation at different levels.
According to that purpose, the Strategic Health Plan of Georgia has been created.

Implementing it, the Government of Georgia has to increase its role in the planning, financing, and provision of health services.

5 Journal of Health Sciences Management and Public Health for strategies The detailed the implementation of the Georgian National Health Policy, as presented in this plan, cover the period 2000-2009.
The Plan prioritizes the Health Problems and presents sound solutions that take into account the projected economic situation of the country and the resources of the health system to be allocated equitably and cost-effectively.
The focus of the document is on interrelated particular issues: strategic health planning situation analysis health system vision for 21st century strategy implementation The plan discusses the determination of specific health policy goals and the problems of measuring health status and the impact and efficiency of health interventions.

It is the first such comprehensive document in Georgia, which translates health policies and strategies into actions.
of future The Strategic Health Plan of Georgia is designed to be used by policy-makers, health professionals, representatives of other sectors, and consumers of health care in the country.

It also gives indications for international investment community opportunities arising from the reform of the Georgian health system.

Coordinated donor assistance could greatly contribute to better prospects for the future health of the nation.
According to expert evaluation, the total overall budget for the Strategic Plan during the 10 years (2000-2009) exceeds 2.5 billion dollars.

In cooperation with the Ministry of Economics we have carried out long-term prognostic estimations which indicate, that from the state resources we could expect the overall support of 1.78 billion USD only.

Therefore, there is a need to find 763 million dollars that has been insufficiently met with state resources.
The full-blown financing of the expenditures of the Strategic Plan would be possible in case, if, from one side, Georgian economics develops according to preliminary prognosis and there is constant growth of State Health financing as the share of the GDP (4% in 2005 and 6% in 2009), and, from another side, there are sufficiently such means as credits, grants, strong private sector investments, and new tax-fees on the services, yet not considered in the basic package.
The Ministry of Health plans to extend a participation of service providers, consumer established associations and other NGOs (like Diabetes’ patients association, Hemophilia association, Cerebral Paralysis Children Association, etc…) in the implementation of the Strategic Plan.

Such an approach would integrate the transformation of the mentioned organizations from having an observers status to that of active participation.
And finally, once again, I’d like to express our deep appreciation and gratitude to the Government of the United States, to the US Agency for International Development (USAID), to American International Health Alliance (AIHA) for supporting us, and to express hope that our future collaboration will promote health conditions of Georgian population!
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6 Journal of Health Sciences Management and Public Health A NEW HEALTH MANAGEMENT EDUCATION PARTNERSHIP: GEORGIA AND SCRANTON Daniel J. West1, Otar Vasadze2, Otar Gerzmava3 Abstract An innovative Health Management Education Partnership (HMEP) has been initiated between the National Health Management Center in Georgia and the Graduate MHA Program at the University of Scranton.

The BRIDGE model was previously field tested in a similar project between Scranton and the Slovak Republic.
This model supports strategic initiatives to facilitate change using a professional journal, faculty development, professional development, curriculum development, certification and accreditation, faculty-resident exchanges, faculty appointments, and the development of additional educational materials and resources.

Utilizing a well crafted workplan with specific objectives, the HMEP values and encourages mutual cooperation, collaboration and sustainability of efforts.
The model stresses implementation, monitoring and evaluation of all initiatives with a strong community effort, focus on research and scholarship, and deployment of educational resources and applied management practices.

Overall efforts are directed towards improving health status, educating health professionals and enabling the Georgian government to achieve strategic objectives articulated in the Georgian Health Plan and supported by adopted Georgian health policy.
Introduction Georgia achieved independence from the Soviet Union in 1991.

Between 1992 and 1936 Georgia was part of a single transcaucasian republic.

In 1936 Georgia become one of fifteen republics of the Soviet Union.

The Abkhazian War occurred in 1992 and the government in Tbilisi lost control of this region in Georgia.

This political infighting and destruction of the social fabric was equally devastating to Georgians.
The Tbilisi War from December 21, 1991 until January 6, 1992 led to Edward Shevardnadze, the former Minister of 1 Ph.D., FACHE, FACMPE, Associate Professor, Depart- ment of Health Administration and Human Resources, University of Scranton 423 McGurrin Hall, Scranton, PA 18510, Tele: 570-941- 4126, Fax: 570-941-5882, Email: westd1@uofs.edu 2 M.D., Director, National Health Management Center, 51, Iv.
Javakhishvili Street, Tbilisi, Georgia 380002, Tele: 995 (32) 95-66-80, Fax: 995 (32) 96-03-00, Email: NHMC@nilc.org.ge 3 M.D., Director, Center of Continuing Medical Education National Health Management Center and Head Depart- ment of Public Health and Management, Tbilisi State Medical University 51 Javakishvili Street, Tbilisi, Georgia 380002, Tele: 995 (32) 95-66-80, Fax: 995 (32) 95-28-38, Email: otar@nilc.org.ge Foreign Affairs of the USSR, returning to Georgia in March, 1992.
Under his leadership, Georgia has membership in the United Nations, the Council of Europe, the Commonwealth of Independent States and the Organization and Cooperation in Europe.

In March 1994 Georgia joined the Partnership for Peace limited Program, which provided for military cooperation with the North Atlantic Treaty Organization.

for Security President Shevardnadze has tried to reestablish the position of Georgia given the strategic position at the crossroads of Europe and Asia.
Since his election as President of in November 1995, Edward Georgia Shevardnadze has worked diligently to establish a recovery program for Georgia by advancing a process of democratization.

The transformation to a democratic state will be incremental and difficult given macro environmental include changes privatization efforts, internationalization with a focus towards Western Europe, implementation of of marketization, and decentralization of management structures.
The necessity of maintaining a healthy economy has been recognized and is contingent on policies that encourage business creation, investment and principles that 7 Journal of Health Sciences Management and Public Health trade, the promotion of an infrastructure and an educated workforce with a commitment to human rights.

Stabilizing the economy in Georgia during the transformation process requires difficult political changes essential for macro economic stability.
Micro economic changes have focused on harmonization among various professionals and institutions, liberalization of specific policies affecting people in Georgia, a strong attempt at localization of resources especially in the area of health and education, optimization of critical resources, and encouraging of specialization to enhance macro economic stability (See Figure 1).

development the Fig 1.


Georgia Healthcare Transformation: Social, Political, Economic Processes MACRO MICRO DEMOCRATIZATION PRIVATIZATION INTERNATIONALIZATION MARKETIZATION DECENTRALIZATION HARMONIZATION LIBERALIZATION LOCALIZATION OPTIMIZATION SPECIALIZATION of towards The vision for Georgia’s health care in the 21st century is based on principles of justice, accessibility and equity.
The Georgian National Health Policy goals are improving health, directed providing health care and mobilizing social resources in accordance with priorities for health and human development.

Sustainable resources, development improvement of the physical infrastructure and health information support are consistent with micro economic initiatives.
The Strategic Health Plan of Georgia (2000- 2009) articulates approaches requiring significant leadership from the President of existing Georgia governmental structure.

The Minister of Health and the National Health Management Center have the main responsibility for the throughout human the 8 implementation of this health plan.
The Government of Georgia initiated significant health care reform in 1995 by developing and implementing a new model of organization and management of the health system directing transitional changes that will establish new economic relations, protect human rights and utilize democratic in state management and principles regulation.
The Government of Georgia aims to increase private-sector participation in the health system, decentralizing health system management, creating a legal basis for the new health system, giving priority to primary care, converting principles of health insurance, ensuring social security, reforming pharmaceutical policies, reforming medical education, medical science and health information services.
Improving the health status of the population involves activities on behalf of the whole society requiring a coherent national health policy.

Stabilizing the economy is important during strategic political changes.

The important task under a new democracy is to create an environment that induces efficient allocation and use of resources to facilitate improve productivity innovation.
Selected priorities for better health include: improving maternal and child health, reducing morbidity and mortality caused by cardiovascular diseases, preventing cancer, injuries, communal diseases and mental disorders, establishing healthy lifestyles and providing a safe and healthy environment, developing human resources, providing health education and developing a health care workforce.
and Historical Background In September 1998, the United States Agency for International Development (USAID) awarded the NIS Health Partnership program to the American International Health Alliance (AIHA) under a cooperative agreement.

In February 1999 AIHA announced a solicitation for US partners to participate in NIS Health Partnerships.
In responding to the request for proposal (RFP), the University of Scranton submitted a proposal the development of a BRIDGE Model (Building Relationships in Developing and Growing to AIHA suggesting Economies).

This model developed by the University was first implemented and in the Slovak Republic with utilized significantly positive outcomes and sustainable properties.

An official site visit to the National Health Management Center (NHMC) in Tbilisi, Georgia was conducted from August 16-27, 1999.
On October 25, 1999 a Memorandum of Understanding (MOU) was executed in Tbilisi,Georgia and identical MOU was executed in Scranton, Pennsylvania on November 19, 1999.

The awarding of the Health Management Education Partnership (HMEP) subgrant agreement occurred on August 31, 1999 with a final approval of the workplan with modifications and amendments on March 3, 2000.
(See Table 1) The Scranton-Georgian partners conducted an extensive needs assessment and SWOT analysis to develop specific goal, objectives and workplan for the Health Management Education Partnership (See Table 1).

is The transformation of health care in important part of Georgia an decentralization, democratization, privatization, internationalization and marketization.

Change in the health sector of the economy is essential to improving the health status of populations.
A critical element in facilitating strategic changes is proper utilization of health care resources in a process involving health care professionals and academics who are dedicated to thoughtful restructuring of health policy, improvement of health management education, and creating a strong atmosphere and entrepreneurship.
privatization for Hme Model The BRIDGE Partnership Model (Building Relationships in Developing and Growing Economies) requires a well formulated, designed, executed and strategic partnership.
The partnership model is the foundation (organizational vehicle) for designing and implementing a program focused on health management education for health care professionals through curriculum design faculty development, program organization and exposure and access to a wide range of development, and Journal of Health Sciences Management and Public Health Table 1.
Historical Overview of Key Events September 30, 1998 February 19, 1999 March 30, 1999 June 21, 1999 August 20, 1999 August 31, 1999 October 16-27, 1999 October 25, 1999 November 19, 1999 December 17, 1999 January 18, 2000 January 21-30, 2000 February 9-10, 2000 March 3, 2000 USAID awarded the NIS Health Partnership Program to AIHA.

Solicitation for US partners to participate in NIS health partnerships UofS proposal submitted to AIHA.

UofS proposal addendum submitted to AIHA.


UofS officially notified by AIHA of selection to participate with Tbilisi, Georgia, National Health Management Center.

UofS receives partnership program subagreement award (U-CC-GEO-99-P-PTR-SCTB-00) for August 1, 1999 to September 30, 2000.

UofS/USA partner site visit to NHMC Tbilisi, Georgia – Study Tour.

Memorandum of Understanding executed in Tbilisi, Georgia.

Memorandum of Understanding executed in Scranton, Pennsylvania.
Georgia-Scranton HMEP workplan version #1 submitted to AIHA and Georgian HME partners for review and approval.
AIHA comments received on workplan UofS partner site visit to NHMC Tbilisi, Georgia – Workplan revisions and implementation Minister of Health, Dr. Autandil Jorbenadze and colleagues visit UoS – Father McShane, President, students, faculty, steering committee and Mayors office; presented key to the City of Scranton AIHA approval of workplan modifications and amendments: Modification #1 (U-CC- GEO-99-P-PTR-SCTB-01) community health care delivery services and system components (See Figure 2).
The University of Scranton (UoS), Graduate MHA Program, serves as the US partner in the alliance working directly with the National Health Management Center in Tbilisi, Georgia.

The National Health Management Center works closely with the Ministry of Health to implement the Georgian National Health policy and the strategic health plan of Georgia (2000-20009).

The Health Management Education Partnership (HMEP) receives funding via a subgrant agreement with AIHA.
The BRIDGE model utilizes over 40 health care providers in 14 Northeast Pennsylvania counties that represents the full spectrum and continuum of health care services and Involvement of community systems.

organizations and local government as well as professional associations supports the establishment of interpartnership activities 9 Journal of Health Sciences Management and Public Health Fig.

2.
The BRIDGE Partnership Organizational Structure University of Georgia –Scranton Health Management Education Partnership (Collaboration) USAID Funding AIHA Funding Community Partners (Georgia/USA) University of Scranton (Point of Coordination) National Health Management Center Ministry of Health •Steering Committee •Faculty Appointments •Center for Continuous Medical Education • Faculty Appointments AUPHA JCAHCO ACTIVITIES Journal of Health Scineces Management & Public Health Televideo Conferencing Faculty & Resident Exchanges Teaching Modules Curriculum Development Faculty Development Professional Development Code of Ethics Professional Organizations Annual International Health Care Conference Workshops and Symposia Scientific Conferences Accreditation Licensure and Credential Faculty Appointments Scholarship and Research ACHE ACEHSA for the model allowing for the acquisition of applied experiences and additional knowledge with the intent of generating ideas and thinking relevant to health care transformation in Georgia.
Logistical support is forthcoming from AIHA, USAID, and a working relationship with the Association of Health Programs University Administration (AUPHA), and the various professional organizations that exist in the United States including the American College of Healthcare Executives (ACHE) and the Accrediting Commission for Education in Health Services Administration (ACEHSA).
BRIDGE HMEP model encourages the exchange of knowledge and ideas in the area of health management education and allows for a critical analysis The in and assessment of health care education needs in Georgia.

Furthermore, the partnership model stresses a strong exchange of activities among academic faculties as well as students and residents.

The model reinforces the concept that future changes will occur as educators, academics and practitioners interact with the existing health care system in Georgia.
Cultivation and implementation of sustainable ideas are important in a transformation process occurring in Georgia.
The HME model encourages and facilitates changes to existing curriculum focusing on different levels with the intent of training health care managers who have a core body of health care knowledge, theory, skills and values, as well as educating existing professionals and practitioners in current 1 0 Journal of Health Sciences Management and Public Health health care theory, concepts and applications.
HMEP WORKPLAN INITIATIVES implementation of the Successful Georgia-Scranton requires collaboration and open communication among health care professionals and academicians who thoughtfully and critically examine an existing health care system in The mutual exchange of Georgia.
information, the sharing of ideas, and the cultivation of positive working relationships necessitates that the partners develop strong existing relationships with working universities, educational institutions and health care facilities.
Development of a strategic workplan for the partnership requires professionals who are working in an environment of mutual respect, create a atmosphere whereby trust prevails and developing interpersonal relationships that enable the truthful exchange and examination of information and ideas.
As indicated previously, the initial step in development of the HMEP requires a critical assessment of existing needs and then strategically designing goals and objectives to impact through requires health management education which will in turn influence the health status and health care delivery system in Georgia.

Curriculum design, faculty development, professional development and program organization require access to a wide range of health care delivery system components.
The workplan was designed to emphasize creativity and the honest entrepreneurship exchange of information and ideas.

The action plan implementation, monitoring and evaluation after completing specific learning activities related to strategic objectives.

Table 2 identifies the specific goal and objectives of the Georgia-Scranton Health Management Education Partnership.
Specific objectives focus on health management education and accreditation, faculty professional development, management certification, credentialing and licensure, creation of a resident health management exchanges, care conferences and workshops, development of a Center for Consultancy, utilization of existing services and systems and resource international health development, journal, TABLE 2.
HME Goal and Objectives GOAL Enhance health management education, improving health status, and promoting the development of a cadre of health managers by designing, developing and implementing a collaborative, sustainable health management education partnership, program and workplan in Georgia; that has an interdisciplinary-multinational focus on health care continuing medical education, executive management education and university-based health management education; to be realized over a period of three to four years.
OBJECTIVES A.
B. C. D. E. Health Management Education and Accreditation • 2 year post graduate curriculum • Short term and long term courses • Executive education Faculty Development • Teaching methods • Study tours and training • Co-teaching Professional Development • Health professions • Professional organizations • Study tours and training Management Certification, Credentialing and Licensure • Uniform criteria • National standards • Core competencies (KSAs) Health Management Journal • Administration and management • HME education and teaching • Research and scholarship F. G. H. I. J. Resident Exchanges and Initiatives • Future leaders • Projects and community service • Educators and academia International Health Care Conference • Collaboration • Sustainable contacts • Research and scholarship Center for Consultancy • Experts • Existing service and system change • New product development Existing Services, Systems and Entities • NGO cooperation • Partnerships and collaboration • CEE/NIS cooperation Resource Development • 4 satellite centers • Learning Resource Center • TVC, library and technology • New efforts 1 1 Journal of Health Sciences Management and Public Health TABLE 3.
HME Efforts: Levels, Areas and Tarket Audiences LEVELS: 1.

2.

Executive Management Education University Education • • Graduate Undergraduate Short Courses with Concentrations Continuing Education Curriculum Development Course Development Faculty Development Program Development 3.

4.

AREAS: 1.

2.

3.

4.

TARKET AUDIENCES: 1.

2.

3.

4.

5.

6.

Existing and Future Health Care Managers Physicians Nurses University Educators Government Managers Public Health Officials development and expansion.
As depicted in Table 3, the Health Management Education Partnership has designated levels of health management education, areas for change and target audiences.

As such, health management education efforts will focus on university education, executive management education, continuing education and development of short courses with specific concentrations.

The workplan suggests detailed activities in course curriculum development, faculty development and program development.
The target audiences for health management education include; but are not limited to, existing and future health care managers, physicians, nurses, university educators, government managers and public health officials.

development, Educational Process and Focus The HMEP and BRIDGE model between Georgia and Scranton is concerned with the content and process of management education that develops people and expands knowledge.
Creating a learning environment that is proactive and dynamic is essential to the educational process at all levels, of all areas Utilizing an and andragogical model results in an approach with a specific design and implementation of educational programs.

The focus is on adult target audiences.

A.

B. C. 1 2 formulating learning and process design.

Attention is given to the learning environment, the physical environment and psychological climate.
Andragogical process design consists of setting, mutual planning, diagnosis of learning needs, specific objectives, designing learning plans, facilitation of learning, and evaluation of learning experiences.

Participants are encouraged to manage and share in the learning process through approaches that utilize training strategies incorporating experiences.

learning experiential Consequently, the process focuses on application, experience and generalization.
Figure 3 suggests that learning will involve intrapersonal processes, interpersonal processes, and extrapersonal processes.

Therefore, the learner must understand his/ her individual needs, wants and values.

As a precursor to participating in educational activities that have an interpersonal focus, the individual learner must draw upon insights and conclusions related to early stages of development focusing on experience, process, application and generalization as part of the experiential learning cycle.
Figure 4 suggests that the cycle of personal development and education requires a learning process that utilizes andragogical concepts and theory in the acquisition and application of new knowledge, skills and abilities.

Individual learners utilize a model of awareness leading to exploration which generates a different level of understanding enabling the person to take a specific course of action as a result of the educational experience.
Ultimately, application of knowledge, skills and abilities will have a Fig.

3.

Transformation Impact and Educational Training INTRAPERSONAL INTERPERSONAL EXTRA PERSONAL ↑ ↑ ↑ ENVIRONMENTAL CONDITIONS AND CLIMATE Journal of Health Sciences Management and Public Health the learners’ experiences as having important and significant consequences for the type of educational experience.
The model assumes that adults are activated to learn when they experience a need to know or do something in order to perform an activity that has relevance to their life.

The process of health management education necessitates that attention be given to the physical, educational and psychological climate with an orientation to learning resulting in different approaches to the design, operation and implementation of educational programs.
The pedagogical model focuses predominately on content while the andragogical model considers content along with process in the design of educational experiences.

The psychological climate is very important and includes respect, characteristics collaboration, mutual trust, supportiveness, openness and authenticity as well as recognizing the importance that education and learning has of mutual 1 3 impact on the health status of populations as well as changes that will occur to health services and systems.
Application is realized in the form of specific inputs, process and outputs that the individual learner utilizes, individually and collectively, in changing health care services and systems.

Comprehensive Framework and Evaluation discussed As previously the andragogical model is an approach to learning that is very different from the traditional, pedagogical model.
The andragogical model reinforces the idea that the learner is self-directing and that psychological capacity and climate are extremely important to the educational process.

The andragogical model recognizes Journal of Health Sciences Management and Public Health management professionals who respond appropriately to a societal mandate to practice a specific profession.

Table 5 identifies specific values that are, and will be, important to the Georgia-Scranton HMEP.
relationships The needs assessment and SWOT analysis led to the development of specific workplan initiatives which have been identified as goals and objectives.

These goals and objectives have a specific target audience, areas and levels of health management education.
In that application is an important part of the andragogical process and focus, the workplan initiatives are developed with certain properties in mind including: sustainability, replicability, project focused and activities that impact health status.

Consequently, the BRIDGE model utilizes and recognizes evaluation and assessment as important.

Table 5 identifies the types of assessment and evaluation that will be conducted as part of the HMEP.
Cultivating among professional people is essential for the BRIDGE model work.

Developing mutual respect and trust takes time but can be accomplished when working on specific objectives within a workplan.

Implementation of ideas requires projects and a willingness on the part of professional educators and faculty to devote time and resources in creating efforts that will enhance market-oriented solutions to health care delivery problems and privatization in a democratic society.
Creating a learning environment that is holistic, comprehensive and community focused requires synergy and enthusiasm among key participants.

Finally, an essential training framework has been developed for the HMEP (See Figure 6).

The BRIDGE Partnership Model has 3 levels of focus in the areas of continuing medical education, executive management education and university-based management education.
Each area of focus requires faculty development, curriculum development, course development and professional study tours.
The needs assessment, SWOT analysis and Georgia Health Plan identified target audiences requiring health management education and include: physicians, middle management personnel in regional departments in hospitals, head nurses, economists, managers in polyclinics, managers in public health and insurance funds, health care leaders, future health care leaders, managers on human activity and development.
The overall framework and design to health management education recognizes important elements of the health management profession (See Figure 5).

Health care services and systems are heterogeneous utilizing interdisciplinary and multidisciplinary health care teams.

Consequently, each of the professions involved in the provision of health care have a unique body of knowledge with collegial relationships among the professions.
There is usually a strong service orientation for health 1 4 Journal of Health Sciences Management and Public Health employed in government health care agencies, new professions that will emerge in Georgia, managers in rural health care areas, managers in the military health care sector, managers in the industrial sector and NGOs and private clinics.

As depicted in Figure 6, the andragogical model focuses heavily on process in addition to content.
The model draws upon andragogical principles focusing on learning conditions, it requires educators who are sensitive to climate and environment of learning in the area of psychology, physical and educational parameters.

Assuming the necessary learning conditions exist, the initial thrust will be in terms of developing basic competencies for supervisors, managers and executives.

The model further illustrates that there are different levels of competencies required in addition to basic competencies.
For purposes of the BRIDGE model in the health management education partnership between Georgia and Scranton, the National Health Management Center and the University of Scranton will development courses, curriculum, short courses, workshops and symposia that develops basic competencies, first level competencies, second level competencies and third level competencies.
These different levels of competencies will be important for the development of the health management professions in the area of knowledge, skills and abilities.

Finally, with the development of knowledge, skills and abilities there will be the ability in Georgia, via the National Health Management Center, to implement health policy in the area of licensure, certification and accreditation.
Conclusion The BRIDGE model utilizes several innovative educational initiatives, approaches and strategies in an effort to accomplish a specific workplan goal and objectives.

The educational process and focus as well as the comprehensive framework requires dedicated professionals who are willing to openly and 1 5 Journal of Health Sciences Management and Public Health willingly share and examine new information and ideas.
Mutual respect and trust in addition to other key values are important to the HMEP to ensure sustainable outcomes and initiatives.

Continual assessment and evaluation is critical to the BRIDGE model and HMEP activities.

Utilization of pedigogical and andragogical models are necessary and critical to the educational process and learning environment.

The Government of Georgia initiated a thorough reform of the health care system in 1995 as articulated in the state health plan and health policy documents.
Developing and implementing a model of organization and transformation of the health management system will require the development of health management professionals who are competent to implement and achieve a new paradigm of health for Georgia.

The Georgia-Scranton Health Management Education Partnership, utilizing the BRIDGE model, has a vision for health management education in Georgia.
There’s a quote by Albert Einstein and an inscription from Machiavelli’s Tomb that illustrate nicely the spirit underlying the efforts between Georgia and Scranton partners.

THE WORLD THAT WE HAVE MADE AS A RESULT OF THE LEVEL OF THINKING WE HAVE DONE THUS FAR CREATES PROBLEMS THAT WE CANNOT SOLVE AT THE SAME LEVEL AT WHICH WE CREATED THEM.
Albert Einstein THERE IS NOTHING MORE DIFFICULT TO TAKE IN HAND, MORE PERILOUS TO CONDUCT, OR MORE UNCERTAIN IN ITS SUCCESS, THAN TO TAKE THE LEAD IN THE INTRODUCTION OF A NEW ORDER OF THINGS.
Inscription from Machiavelli’s Tomb axali partnioruli programa jandacvis menejmentis swavlebaSi daniel vesti, oTar vasaZe, oTar gerzmava saqarTvelos jandacvis marTvis nacionalur centrsa da skrentonis universitetis (aSS, pensilvania) TanamSromlobis mizania jandacvis menejmentis swavlebasTan dakavSirebuli strategiuli iniciativebis mxardaWera, pedagogebis momzadeba, saswavlo programebis Seqmna.
partniorobis es modeli orientirebulia yvela im iniciativebis danergvaze, monitoringze da Sefasebaze, romlebSic aqtiuradaa Cabmuli sazogadoebrioba.

partniorulma programam xeli unda Seuwyos jandacvis menejmentis sferoSi momuSave profesionalTa codnisa da kvalifikaciis amaRlebas, raTa maT SesZlon saqarTvelos janmrTelobis dacvis erovnuli politikiT gaTvaliswinebuli strategiuli miznebis ganxorcieleba.
1 6 Journal of Health Sciences Management and Public Health PATIENTS’ RIGHTS LEGISLATION IN GEORGIA Guram Kiknadze1, Givi Javashvili2, Akaki Barkalaia3 Abstract The article provides review of legal foundations for patients’ rights in Georgia.

Brief historical analysis of the Georgian State and law is given.

The structure of the patients’ rights legislation is specified.
The article describes the common difficulties of Post-Soviet countries in promotion of the rights of on the example of Georgian experience.

International documents are briefly referred as the conceptual foundations for the Georgian legislation on patients’ rights.

Patients’ social and individual rights are reviewed in details.

Also, some considerations about the implementation of the above-mentioned rights are provided.

Georgian State and Law Georgia has little experience in building a civil society.
At the same time, it has definitively integrated with the western world and harmonized with western law.

Apparently, the legislative basis is one of the most important points in the process of establishing common anthropocentric values and view-points of the civil, open society.

The history of the Georgian state and law dates back to ancient times.

Due to its historical misfortunes, Georgia never the process of great in participated codification.
In the this connection, legislative activity of King Vakhtang VI (XVII-XVIII cc), deserves significant attention.

Chronologically, this period of time coincides with the epoch of creation of the basis for modern law and state in Western Europe.

The drafting of King Vakhtang’s Law Book can be considered an attempt to become closer to the cultural world, which Georgia had aspired to during its whole 1 Professor - M.D., Doctor of Medical Sciences.
Chair- man-Health Legislation Department of National Health Management Center/Ministry of Health and Social Affairs of Georgia, Co-chairman - Georgian Health Law and Bio- ethics Society, Professor of Clinical Medicine-Tbilisi State Medical University; 2 M.D., Ph.D., Chairman - Georgian Health Law and Bio- ethics Society, Expert-Consultant - Health Legislation De- partment of National Health Management Center/Minis- try of Health and Social Affairs of Georgia, Deputy Direc- tor-Curatio Medical Group; 3 M.D.
Consultant-Georgian Health Law and Bioethics Society, Expert-Consultant -Health Legislation Depart- ment of National Health Management Center/Ministry of Health and Social Affairs of Georgia, Specialist- Clinical Department, Pharmacological Committee, Drug and Phar- macy Department/Ministry of Health of Georgia.

history.

In some regions of Georgia, the code of Vakhtang’s Laws was in force up until the second half of the 19th century.
After this, the Russian Empire Laws were spread in Georgia, though some norms of Georgian Law were still in force.

It seems interesting enough to mention, that Russia didn’t have its own civil code in the 19th century, nor even at the beginning of the 20th century.

An attempt to build a modern independent state in 1918-1921 was not successful due to the expansion of Russia.

As a result, Georgia became part of communistic space for the next 70 years.
Thus, formation of the civil society in Georgia started within the borders of another country, making Georgia unable to develop its own legislation independently.

The creation of national legislation is an essential condition for building a national and democratic state as well as a civil society.

Adoption of the Georgian Constitution on August 24, 1995, along with the Georgian Civil Code on June 26, 1997, were significant steps toward the establishment of a national state.
Legislative regulation of any type, including the Health Care System, is essential for its functioning and development, although the perfection of the system is not ensured only by the legislation.
The Universal Problems of Post-Communistic Space Related to the Health Legislation During the 70 year history of existence of the Soviet Union, the legislative activity in Georgia was restricted to slight alteration 1 7 Journal of Health Sciences Management and Public Health or, at best, adaptation of the frame laws, provided by the central authorities of Moscow.

Like other republics of the Soviet Union, there was no traditional training of legal professionals regarding the health care system.
Thus, it was impossible to prepare health care related legislative documents on a highly professional level.

Before the reestablishment of Georgia’s sovereignty, the Law on Health Care, adopted in 1972 by Soviet Government, was in force.

This document showed significant negligence of the individual rights of patients.

Almost none of the basic principles of ensuring patients’ autonomy and self- determination (except the right to keep personal data confidentially) were declared.
Apart from the above-mentioned, the most significant problems of Georgia, like other post-communistic countries, are large bureaucratic care systems, professionals having paternalistic attitudes toward their patients, and the tradition of isolation of citizens from the process of governing the country.

In a totalitarian state, it was absolutely unrealistic for society to participate in policy making or management for any aspect of life, including health care.
With this background, the inertness of society became everyday reality and the pseudo activity of citizens supporting the existing government and ideology was initiated by the government itself.
health In conclusion, at the moment of restoring its independence, Georgia received a burdensome inheritance : • No tradition of independent legislative activity in health care; • Unavailability of professionals (health care lawyers) who can establish the above-mentioned tradition; • Non-orientation of the system toward the patient (different from the patient- centered model of health care system); Paternalistic attitude toward the patient on the part of health care professionals and the entire health care system; Inertness of society and absolute isolation from the process of policy-making and legislative activity.
• • 1 8 Health Legislation of Independent (Brief Chronological Georgia Overview, Main Stages) the In the early 1990s, Georgia lived in severe political, economic, and social conditions.

With this background, the process of political and socio-economic reorganization of the country started.

Health care reform was one of the main components of the process.
After its independence, the health care system regulating acts were presented by the orders, which are the edicts of the President (or Head of the State until 1995), and the decisions of the Cabinet of Ministers.

The only exception was the Law on Blood Donation, adopted by the Parliament in 1994.

This law was prepared before reform initiation and did not adequately reflect the real situation.

declaration of economic components of The history of the new health care system was formed on December 23, 1994.
It was started by the Presidents Order and entitled: No400 “On the Measures of the First Stage of Georgian Health Care System Reorganization”.

On 8 February 1995, the Parliament of Georgia issued a statement “On the Concept of Georgian Health Care System Reorganization”.

In this document, necessity of reform was declared, and political, legal and the Government’s policies were defined.

The creation of an adequate legislative basis was declared to be the main condition of health care reform.
It should be pointed out that this was the first time when the concepts for the right to choose medical personnel and medical institutions and equal access to adequate health care within the obligations taken by the government through medical programs was announced in Georgia.

This document stressed the importance of outlining the rights and obligations of persons, health care personnel and government within the health care system.
Accordingly, the creation of the legislative basis was declared to be the most important tool for the implementation of this concept.

In 1995, the working group for the basic health care law of Georgia was set up at the National Health Management Center (NHMC) of the Ministry of Health and Social Welfare of Georgia.

Later in 1997 at the same institution, this group developed Journal of Health Sciences Management and Public Health into the Health Legislation Department.
The main task of the department is to prepare draft laws regulating different aspects of health care.

The Health Legislation Department of NHMC works in close collaboration with the non-governmental organizations of Georgian Health Law and the Bioethics Society.
The above-mentioned collaboration resulted in the creation of the following draft-laws: “On Health Care”, “Human Organ Transplantation”, “Citizens’ Rights in Health Care”, ‘Protection and Promotion of Breast-feeding and Controlled Use of Artificial Feeding Products” (in cooperation with NGO “Claritas”), “Biomedical Research Involving Human Subjects”, “On Medical Activity”, and “Artificial Termination of Pregnancy” and How countries Patients’ Rights Legislation is Composed in Georgia During the process of creating the basis for patients’ rights legislation in Georgia, taken into account was the experience of other international organizations.
Thus, the patients’ rights legislation was planned in a complex manner.

The different aspects of patients’ rights - social and individual rights, responsibilities of health care professionals, the right to of compensation investigators performing biomedical research involving human subjects, rights of human subjects etc., were presented to different legislative acts.

In the near future, the patients’ rights legislation in Georgia will be responsibilities , Table 1.
Laws on the different stages of preparation/adoption 1 9 Journal of Health Sciences Management and Public Health introduced by the following laws: • The Law on Health Care; • The Law on Medical Insurance; • The Law on Citizens’ Rights in Health Care; • The Law on Medical Activity; • The Law on Biomedical Research Involving Human Subjects; • The Law on Psychiatric Care; • The Law on HIV/AIDS Prevention; • The Law on Drug and Pharmaceutical Activity; • The Law on Human Organ Transplantation; • The Law on Protection and Promotion of Infant Natural Feeding and Controlled Use of Artificial Feeding Products; • The Law on Artificial Termination of Pregnancy.
The Georgian Health Care Law has been considered to be the framework for other documents determining the priorities of legislative regulations for the Health Care System of Georgia.

The following laws are at different stages of preparation/adoption.

Table 1 shows the current status of these documents.
The Conceptual Foundations for the Health Legislation of Georgia One of the main objectives in the process of creating the legislation for the Health Care System was the reflection of internationally accepted principles and norms and elaboration of the mechanisms of their implementation.

Accordingly, the process of the development of patients’ rights legislation in Georgia was greatly exposed to the influence of extensive movement for health care reform in Europe.
Research, educational and legislative activities related to the rights of citizens in health care on national and international levels throughout important Europe.

Eventually, very intergovernmental instruments were developed by authoritative international organizations such as the World Health Organization, the Council of Europe, and the World Medical Association.

Also, specific acts on patients’ rights were introduced in 2 0 some European countries.

The first one was introduced in Finland in 1992.


Patients’ rights legislation of Georgia has been significantly influenced by the strategies and principles presented in the documents prepared by the above-mentioned international organizations.

The data and conclusions of international research/surveys and experience of various countries has also been taken into account.
The most important document playing the main role in pushing and promoting the process of drafting the patients’ rights legislation in Georgia was a “Declaration on the Promotion of Patients’ Rights in Europe” (WHO; 1994).

On the other hand, the above-mentioned movement in Georgia coincided with the adoption of the “Convention on Human Rights and Biomedicine” by the Council of Europe and its opening for signature in Oviedo, (1997).

Thus, the influence of this document is also significant.
comprising The documents the conceptual foundations of the patients’ rights legislation of Georgia in 1995-1998 are listed below: • The Universal Declaration of Human Rights (1948); • The European Convention on Human Rights and Fundamental Freedoms (1950); • The European Social Charter (1961) • The International Covenant on Civil and Political Rights (1966); • The • Of International Covenant on Economic, Social and Cultural Rights (1966); • Declaration Helsinki: Recommendations Guiding Physicians In Biomedical Research Involving Human Subjects; World Medical Association (1964-1996); International Code of Medical Ethics; World Medical Association (1949-1983) Principles of Medical Ethics; United Nations (1982); International Ethical Guidelines for Biomedical Research Involving Human Subjects (1982-1992) and International Guidelines for Ethical Review of Epidemiological Studies; CIOMS (1991); • A Declaration on the Promotion of • • Patients’ Rights in Europe” (WHO; 1994).
• Convention on Human Rights and Biomedicine; Council of Europe (1996); • Universal Declaration on the Human Genome and Human Rights; UNESCO (1997); • Draft Protocol On Biomedical Research; Steering Committee On Bioethics; Council Of Europe (1997).

Social and Individual Rights of Patients in Georgian Legislation Under the term “Patients’ Rights”, almost every citizen of Georgia has the problem of accessibility to health care services.
The allocation of scarce healthcare resources remain to be the most critical problem in this country.

Therefore, one may argue that nowadays social rights of patients shall absorb all available resources and the attention of policy makers in the healthcare system.

On the other hand, the promotion and protection of individual rights of patients seems to be at least of equal importance.
Most health care professionals know little or nothing about the doctrine of informed consent regarding patient’s autonomy and privacy.

by promoting their individual rights might help in achieving their metamorphosis from patients to consumers.

Consumers might play a significant role in shaping the Georgian health care system.

Strengthening patients are further detailed Below is the Georgian legislation for the Law on Health Care which gives a brief review of the social and individual rights of patients.
It should be pointed out that these principles and strengthened in the draft-laws entitled, “On Citizens Rights in Health Care”, “On Biomedical Research Involving Human Subjects”, “On Medical Activity”, and “On Artificial Termination of Pregnancy” etc.
Prohibition of discrimination The new constitution of Georgia declares: “Everyone is born free and is equal before the law regardless of race, skin color, language, sex, religion, political and other beliefs, national, ethnic and social origin, and property and title status of place of residence (Article 14)”.
The Law of Georgia on Health Journal of Health Sciences Management and Public Health Care encompasses the above-mentioned list and stresses inadmissibility of discrimination on the grounds of disease, sexual orientation or negative personal attitude.

Item 2 of the same article prohibits the discrimination of a patient imprisoned during medical care.

Persons imprisoned are to enjoy all the rights declared in the above-mentioned law.
The physician is obliged to establish an order of priority in providing medical care to patients in accordance with medical indications without the consideration of any other privileges.

According to the Law on Psychiatric Care, persons suffering from mental disorders in addition to all other citizens of Georgia (recognized as capable) enjoy all the rights and freedoms ensured by the Constitution.
Partial of Constitutional rights and freedoms is admissible only if a patient is recognized incapable in accordance to the Georgian legislation.

The restriction solely on the basis of psychiatric diagnosis is inadmissible.

The basis for any restriction must be the patient’s actual psychiatric condition and not the general definition of the disease .
restriction The Law on HIV/AIDS Prevention states that HIV/AIDS infected persons have the right to be employed except in occupations when there is danger of the transmission of the disease by blood exposure to non-intact skin and mucus membranes.

The list of these occupations should be determined and approved by the AIDS National Governmental Commission (NGC) in collaboration with the appropriate services.
It is forbidden to discharge HIV/ AIDS infected persons from their jobs or to refuse them employment because of the mentioned disease (except the above- mentioned occupations).

The employer is responsible to act in accordance with this legislation.

HIV/AIDS infected persons have the right to participate in sports training and competitions except in sports when there is danger of transmitting the disease by blood exposure to non-intact skin and mucus membranes.
The list of sports, training, and competition is determined and approved by the through participation of appropriate services.

The law forbids to refuse reception of HIV/AIDS above-mentioned NGC 2 1 Journal of Health Sciences Management and Public Health infected persons in medical, educational and pre-school-age establishments because of the mentioned disease.
institution) without Right to treatment and care Article 37.1 of the Constitution of Georgia declares that “ free medical services are guaranteed in cases determined by law”.

According to the Law of Georgia on Health Care, one of the principles of state policy is to provide the population with universal and equal access to medical care within the frames of state-funded medical programs.
This principle is strengthened by Article 22, which states the main form of state financing for health care is funded through state programs.

Georgian citizens have the right to enjoy medical care envisioned by the state programs on health care.

The medical care is accomplished by the appropriate legal entity taking (medical ownership (whether private or public) and organizational-legal form into consideration.
The state is responsible for the extent and quality of medical service determined by the program of compulsory medical insurance.

law unconditionally obliges physicians to provide a patient with medical care and to ensure his/her continuity if there is grave danger for life which includes suicide attempts, or if a patient needs urgent medical care at a physician’s working place.
While out of work, the physician as well as any citizen, is obliged to provide urgent medical care or first aid within the limits of his/her abilities.

When a physician initiates medical care (whether it be at his/her working place or not), he/she automatically becomes responsible to ensure reasonable care as well as continuity of care.

The The principles of medical insurance are formulated in the Law on medical insurance.
In Georgia, medical insurance is being implemented in two forms: compulsory and voluntary.

The state compulsory medical insurance applies to all citizens of Georgia as well as stateless persons residing in Georgia on a permanent basis, and is implemented via the State Compulsory Medical Insurance Programs.

These programs shall ensure that all insurance is indemnified against medical expenses within the limits of the State Medical Insurance Programs.
Foreign citizens residing and working in Georgia are also 2 2 covered by the State Medical Insurance Program unless otherwise provided by an intergovernmental treaty.

the right Any person has to voluntary medical insurance.

The voluntary medical insurance shall ensure that the insured are indemnified against the costs of any medical service provided to them within duly registered and examined insurance programs.
Right to Information In current Georgian Health Legislation, much attention is paid to the necessity of providing and ensuring information.

The Health Care Law states that the population should be provided with extensive and accurate information on all existing forms of medical care, and regarding the possible ways to get appropriate medical care.
information on According to the same law, all citizens of Georgia have the right to receive in understandable form, comprehensive and accurate their health condition.

On the other hand, physicians are obliged to provide a patient with full and accurate information about his/her health condition, except for cases when the physician is sure this information will significantly harm the patient.

Thus, if appropriate reasons exist, the physician may withhold the information.
The conditions and necessary procedures for the withholding information from the patient are defined more precisely in the draft-law on “the Rights of Citizens in Health Care”.

This issue is of great importance in Georgia.

Despite the existing legislation described above, in the vast majority of cases, patients with fatal diseases are kept unaware, and the true information about their health condition is provided to their relatives.
The necessity of providing the patient with information is also acknowledged in other laws currently in-force, i.e., the Law on Drug and Pharmaceutical Activity.

This law describes the necessity to inform the subject of research or his/her legal representative during the drug trial.

The Law on Psychiatric Care gives the patient the right to receive information concerning the disease and methods of treatment.
Informed consent There is no tradition of obtaining informed before medical intervention in Georgia.

In Soviet Georgian Health Care Law, the necessity of consent consent has been limited to the following cases: • When new, scientifically approved, but not generally used methods and medicines were applied; • When surgical operations were required or; • When complex diagnostic methods were used.
It should be emphasized, that nothing was said about the necessity of providing information before receiving consent.

Therefore, the mentioned document had nothing to do with the principle of informed consent.

During the formation of Georgian legislation on patients’ rights, informed consent is considered to be extremely important and is the main instrument for ensuring patient’s autonomy.
The doctrine of informed consent is reflected in current legislation that is in force, as well as in drafted laws at various stages of discussion.

for requisite According to the Health Care Law, informed consent is considered to be a any medical necessary intervention.

The principle of informed consent is formulated as follows: “the verbal or written informed consent is a necessary precondition for the participation of the patient in treatment, diagnostic, rehabilitation or preventive medical procedures”.
The only exception from the principle of informed consent, may be the cases when there is a need to examine citizens in order to confirm the existence of a principally dangerous contagious disease.

In these cases, citizens are obliged by legislation to undergo all necessary examinations (Health Care Law).

A patient has the right to refuse any kind of medical intervention, except in the cases just mentioned above.

The law envisages expression of the patient’s will in advance (so called “living will”).
Thus, according to Article 10, “all capable persons have the right to express in advance their will in a written form regarding the resuscitation, lifesaving or palliative treatment in the terminal stage of an incurable disease”.

Special issues concerning the treatment of incompetent patients or patients not having decision- making capacity.

Also, special articles regulate issues related to the participation of patients in biomedical research, and regarding the provision of emergency care to them.
regulate articles Journal of Health Sciences Management and Public Health Other laws.
The laws on “Drug and Pharmacological Activity”, “Psychiatric Care” and “Human Organ Transplantation” include articles that stress the doctrine of informed consent for various procedures such as: receiving an informed consent from the subject of research or his/her legal representative; receiving an informed consent from the subject of research or his/her legal representative; and informed consent of patient suffering from mental disease or of his/her legal representative)1 .
Choice of institution or medical personnel Protection of human rights naturally implies a freedom of choice in any sphere including health care.

Like other rights, this right was ignored in Soviet Georgia.

According to the Health Care Law of Georgian Soviet Socialistic Republic, citizens could only apply to physicians or medical institutions (policlinic) that correspond to his/her place of residence or work.
If the patient needed urgent or other forms of hospital care, he/she had the right to undergo treatment in any medical institution, but he/ she had no right to choose a physician.

Citizens’ freedom of choice is currently declared in a series of legislative acts.

Hence the Law of Georgia on Health Care Law says, that “patient has the right to choose the medical personnel and/or institution in accordance with conditions of the insurance agreement.
The agreement should ensure an opportunity to make the choice.

The Law on Medical Insurance determines the realized limits of realization of the right to freedom of choice.

For example, any person residing in Georgia shall have the right to choose a physician or medical institution within the limits of an insurance contract and, accordingly, to receive all medical services provided by the insurance program, irrespective of the amount actually paid by him/her.
Respect confidentiality of private life and Any human right is based on the recognition of autonomy.

The latter is directly related to the inviolability of private life and confidentiality.

Georgian Constitution declares that “information existing in official 1 See the chapter “Specific Groups”, divisions “Subjects of the Biomedical Research” and “Patients with Mental Disorders”.
2 3 Journal of Health Sciences Management and Public Health papers related to the health of an individual is not available for other individuals without the prior consent of the affected individual.

The exception is in cases determined by law, when it is necessary for the State and public security, protection of health, rights and freedom of others (Article 41.2).
According to the current Law on Health Care, medical employees and all other employees of a medical institution are obliged to keep medical secrecy.

On the other hand, the disclosure of information is allowed if it is demanded by a relative or legal representative of the dead person, judicial or investigator bodies, and/or if this is necessary for ensuring public safety, protection of rights, and freedoms of other persons.
The law on HIV/AIDS Prevention grants all citizens of Georgia and all permanent and temporary residents of Georgia, including foreigners, the right to undergo anonymous medical examination on HIV/AIDS.

indicated documentation.

The issue of confidentiality is also regulated by the Law on Human Organ Transplantation.

This law sets up rules, which shall safeguard the confidentiality of donors.

According to the law, only the Information Center of Transplantology should be able to identify donors.
After taking an organ, only the identification in any number should be The accompanying Information Center of Transplantology has the right to disclose a donor’s personality only if: a) use of the organ intended for transplantation/ treatment is dangerous for the recipient’s or other persons health; b) it is required by judicial bodies - on the basis of court decision; c) it is required by the Minister of Health and Social Affairs in accordance with the rules determined by existing legislation).
Dying patient The Health Care Law of Georgia prohibits the accomplishment of euthanasia in Georgia.

This same law regulates issues of terminal care.

This law grants the dying refuse patient resuscitation, life-saving or palliative treatment.

The patient has the right to make decisions related to terminal care in advance.

This is referred to as an advance directive.


Therefore, ill unconscious patients shall receive relevant treatment, if the patient would have had decision-making to his/her terminally right to 2 4 capacity (provided that patient sometime was competent) and had not refused resuscitation, life-saving or palliative treatment.
two almost document regulating Subjects of the biomedical research During recent years issues of the protection of human subjects’ rights and safeguarding their physical and mental integrity in the process of biomedical research gained great importance.

The first statutory the experimentation with human beings was the Law on Drug and Pharmaceutical Activity.

Later in the Law on Health Care, a separate chapter was devoted to this issue.
Though in these all documents internationally accepted principles of human subject protection are declared, the specific law on biomedical research involving human subjects had been drafted.

Currently this law is in draft form and is in the process of the Government.
The discussion at conceptual framework of the above- mentioned laws was composed on the basis of the following international documents: the World Medical Association Declaration Of International Ethical Helsinki, Guidelines for Biomedical Research Involving Human Subjects (1982-1992), the International Guidelines for Ethical Review of Epidemiological Studies (CIOMS; 1991), the Convention on Human Rights and Biomedicine (Council of Europe; 1996), the Universal Declaration on the Human Genome and Human Rights; (UNESCO; 1997), and the Draft Protocol On Biomedical Research (Steering Committee On Bioethics; Council Of Europe; 1997).
the on and animals According to the Health Care Law, any biological research should correspond to the norms of scientific research accepted in Georgia.

The norms of scientific research are based on the grounds of the thorough and accurate conduct of laboratory tests and experiments the comprehensive knowledge of respective literature.

The goals, objectives, methods and expected risks and benefits for humans and animals, are to be pointed out in a scientific research plan.
Any research is to be performed within the boundaries of this plan.

Below are the main principles/rules set forth by the Health Care Law related to involving human biomedical research subjects: • The research plan should be reviewed by a special commission independent of the Journal of Health Sciences Management and Public Health researcher and sponsor and by a research ethics committee; • Before research is initiated, the risks and expected positive results of the research are to be evaluated.
During the biomedical research the interests and well-being of the research subject shall prevail over the interests of science and society.

The risk of the research should be minimized.

It should not exceed the expected benefit of the subject of research and/or the importance of the goals of research .

• Research subject should be fully informed in advance about the goals, methods, expected results of the research, the risks of research, and the possible inconvenience connected with the research.
Biomedical research should not be performed without a written informed consent of the person participating in it.

It is mandatory to inform the person being the subject of the biomedical research on his/her right to refuse participation in the research at any stage, despite his/her preliminary declared consent.

• An incapable person may become the subject of biomedical research if he/she does not express any resistance, and if the informed consent of his/her relative or legal representative is obtained.
If the incapable person has the ability of understanding, his/ her consent is also required.

• During the research the rights of incapable persons, pregnant and child-nursing women are to be protected.
The representative(s) of this contingent of persons may be the subject of a biomedical research only if the expected results of the research are significantly beneficial to this person, or if the expected results of the research are not directly beneficial to this person’s health, but may bring benefit to other persons of the same category and when getting the scientific results is impossible by research of the other category of persons.

• Persons imprisoned enjoy all the rights mentioned above.
The participation of these persons in biomedical researches is permitted only when the expected results of research are directly and significantly beneficial to the health of these persons.

the • • the under existing Problems of Implementation The solid legislative basis for the protection and promotion of patients’ rights is being built in Georgia, to conform with international standards and developments.
Moreover, there is a keen awareness in this country about the significance of alternative ways for the protection and promotion of patients’ rights.

Some initial steps are already performed toward this direction.

At the same time, severe socioeconomic conditions, it would be unrealistic to imagine the situation related to the patients’ rights to be ideal.
There is a conglomerate of negative factors having detrimental effects on the opportunities for the implementation of a patient’s rights declared in the laws.
These factors are: • • scarcity of resources; difficulties related to the reorganization of the entire health care system in Georgia; unawareness of the health care personnel’s principles of modern medical ethics and current health legislation; unawareness of the general population of their rights related to the health/ medical care and thus, their absolute inactivity in this sphere; inactivity of the non-governmental organizations such as professional/ medical associations and patients/health consumers organizations.
Taking into consideration the above- mentioned problems, the implementation of social as well as individual rights of patients provided by the legislation, will require a extensive efforts and time.

In certain regions of the country, the delivery of basic medical service packages to the population remains to be problematic.

Also, other problems related to the realization of citizens’ rights in health care are not solved.
Some of the following remain difficult or impossible to ensure, such as choice of institutions and health care medical personnel, providing medical care to patients only in accordance with medical indications, providing citizens with adequate information on existing resources about charges for medical service and methods of payment etc.

Still, it is an everyday reality when family members have no opportunity to support their relatives being treated at Intensive Care Units (ICU).
The entrance to these ICU facilities as well as several maternity houses for family members is restricted.

rights • 2 5 Journal of Health Sciences Management and Public Health An additional problem is how to compensate the patient for injuries that have occurred in relation to care or treatment.

There currently is no system for complaint procedures and compensation in Georgia.

This issue is also related to the problem of professional responsibility, which needs a solid legislative basis to be prepared.
Currently, the human biomedical research continues to expend.

Though formally all the requirements are followed by researchers, the ethical review procedures of research proposals need significant improvement.

This is due to the lack of specialists in this sphere such as ethicists/ bioethicists and health lawyers, etc.

Thus, it is still a long way from the point when the patients’ rights are declared by laws, regulations, charters, professional codes, etc.
Up to this point, these rights are not truly implemented.

Obviously, the time needed to cover this distance is greatly depended upon how the entire process of reforms will progress in this country and how the status of citizens will evolve from passive patients to active users/consumers of health care services.
saqarTvelos kanonmdebloba pacientis uflebebis Sesaxeb guram kiknaZe, givi javaSvili, akaki barkalaia statiaSi mimoxilulia saqarTveloSi pacientis uflebebis samarTlebrivi safuZvlebi; mocemulia qarTuli saxelmwifos da samarTlis mokle istoriuli mimoxilva; asaxulia pacientis uflebebis Sesaxeb amJamad moqmedi kanonmdeblobis struqtura; aRwerilia saqarTvelos, rogorc postkomunisturi qveynis siZneleebi janmrTelobis dacvis sferos samarTlebrivi uzrunvelyofis sferoSi; mocemulia saerTaSoriso dokumentebi, rac safuZvlad daedo janmrTelobis dacvis sistemis kanonmdeblobis koncefcias; detalurad aris ganxiluli saqarTvelos kanonmdeblobaSi asaxuli moqalaqeTa socialuri da individualuri uflebebi, maTi implementaciis SesaZlo gzebi da sirTuleebi.
2 6 NEW APPROACHES TO HEALTH CARE FINANCING IN A CONTEXT OF THE GENERAL STRATEGY OF HEALTH CARE REFORMS IN KAZAKSTAN Journal of Health Sciences Management and Public Health Maxut K. Kulzhanov1, Aizhan M. Kulzhanova1 Abstract In Kazakhstan, as well as in all Former Soviet Republics, take place unprecedented politi- cal, economic and demographic changes.

These changes conditioned necessity of elaboration of evidenced State Health Policy.
For provision of stable functioning of the system started re- forms of health system financing, particularly, introduction of health insurance, which should promote increase of the responsibility of the citizens and the Government on health.

The article analyses the results of the reforms in health system of the country.
Unprecedented political and economical changes as well as demographic shifts of the population, such as significant birth rate decline, increase of infant mortality rates and deterioration of the level of health happened in Kazakhstan and other countries of former Soviet Union.

Conditions the environment, existence of the regions of ecological catastrophe, sanitary condition of inhabited areas, water reservoirs, water lines, unbalanced nutrition are the issues of great concern.
of These social and economic changes predetermine necessity of scientifically based governmental policy in health care.
Inspite the opinion of experts, that health care system has only 8 – 10% influence on health of the population we consider that qualitative changes in health care system may significantly influence on health of the population, as well as development of the economy and social sphere due to following reasons: Health care is one of the biggest sectors in the economy of the country ( in Kazakstan it is about 10% of total work force) Development of health care has direct influence on production sector.
It can increase or decrease productiveness and quantity of sick-leaves.

 Investment to healthcare infrastructure is as important as to the other sectors of economy.

 Improvement of material and technical resources of healthcare may have political importance.
In general reforms should meet following most important needs of healthcare: 1 Kazakstan School of Public Health Improvement of health status of population; Improvement of medical care quality; Access of the population to basic medical care; Rational utilization of existing resources.

Thus the main objective of healthcare reforms in Kazakstan is improvement of quality, access to medical care provided for population, and its effectiveness.
improvement of Achievement of this objective will be possible on the assumption of taking a complex measures such as legislative, economic, structural, technological, and others, that formulate basic directions of healthcare changes within the framework of general development strategy and establishment of the Republic as a sovereign country.
These are the basic directions of health care reforms in Kazakstan: Improvement of organization and and of healthcare management workforce policy Development and improvement of preventive and curative care technologies, including Primary Medical Care; Changes in a system of financing and economic relations in healthcare; Implementation of medical insurance system.
The main objective of healthcare financing reforms is provision of stable functioning and constant development of the sector.

Implementation of the medical insurance system as an additional financial source assumes transition of healthcare to compound financing.
Active preparation to recurring implementation of medical insurance system in Kazakstan should solve other problem – introduction of real 2 7 Journal of Health Sciences Management and Public Health responsibility of employers, state authorities and citizens for the status of public health and taking measures for its improvement.
Introduction of the medical insurance system in Kazakstan has started by experiments in several regions of the country: Zhezkazgan, West Kazakstan, Kokshetau, and South Kazakstan regions.

These regions have worked out option to implement a national system of Compulsory Medical Insurance.
Following strategic objectives and problems have been identified and solved during a period of the experiment: reorganization of management system taking into consideration new structures of medical organizations, implemented purposeful method of management financing system of medical facilities has been changed, economic methods of Management has been implemented; payments for a volume of provided services considering quality of those services legislative documents on Compulsory Medical insurance, licensing of medical organizations, and medical care quality assessment have been adopted scheme of financial interrelations between medical organizations and structures of medical insurance have been worked out retraining of staff for medical organizations and Compulsory Medical Insurance system has been organized wide explanatory campaign has been introduced for population State (i.e.
budget) healthcare financing is addressed to the diseases of social importance, expensive medical services, and payments for medical services for socially vulnerable population (disabled, with chronic diseases), and others.

Healthcare financing reform is linked with implementation of economic methods of management on every level of medical services provision.

Formation of market relations in healthcare assumes changes in financing of the sector in the regions of the Republic.
The main key-factor of the reforms is a principle based on per capita financing.

Per capita financing of healthcare is an amount of budget sources allocated to primary level of healthcare for: provision of medical care within guaranteed volume of medical services and program of CMI to unemployed and disabled population; execution of purposeful and other healthcare programs.
2 8 In order to calculate a normative of healthcare per capita financing it is suggested to use amount of population of the given area and national (basic) rate of per capita financing.

National per capita financing rate (R) is determined according to the formula: R = B/P Where B – is a budget of healthcare of Kazakstan, and P – is an amount of population of Kazakstan.

Introduction of National per capita rate contributes to leveling of conditions for all regions of the Republic of Kazakstan.
for Level of budget allocations healthcare (V) in a region is determined according to a formula: V = R x Pr R – is a national per capita rate; Pr – is a population of a region.

Volume of budget financing for healthcare of the regions calculated on the basis of national per capita rate will be a basic level of financial for every region.
Purposeful allocations of local budgets, inputs of enterprises, fee for services, and some others can be a source of additional financing of healthcare in economically stable regions.

Introduction of healthcare financing system based on national per capita rate is a first step towards healthcare reforms.

Changing of payment methods of medical facilities financing (per capita financing of primary level with full or partial fund holding, payment per treated patient in in-patient facilities, etc.
), changing of report and accountability, remuneration of labor systems are to be a next step in healthcare reforms.

Interpayments between medical organizations, facilities and healthcare authorities for provision of medical services to population are done on the basis of prices (tariffs) adopted in every region.

Tariffs for medical services worked out by every healthcare facility are to be approved and changed by executive authorities of every region.
Prices for medical services are determined according to unified price- making method that is worked out and adopted by Ministry of Health.

Resources Resources attracted by execution of medical insurance programs are the second source of financing for healthcare facilities.

extra normative services according to contracts with state, cooperative, public enterprises and organizations can be additional sources of healthcare facilities financing.
received from Labor remuneration and material stimulation of healthcare facilities workers, within new conditions depends on amount and quality of their performance, personal input to achievement of final organizational goals.

Those are why healthcare facilities can themselves approve list of staff and determine salaries in accordance with functioning scheme.
Healthcare facilities are provided with broad rights to determine forms and systems of their staff salaries, to choose ways of utilization of resources for salaries and distribution of wage-fund in accordance with total and personal input of staff.

Amount of wages for healthcare workers is not limited within approved wage-fund.

Financial incentive for healthcare facilities leaders is done only by approval of local authority for healthcare organization.
Main Priorities of the Economic in Strategy Relations Development Healthcare.

1.

Stepwise transition to per capita financing of the sector; scientific grounding and elaboration of indicators for realization of the main principles of the strategy.

2.

Approval of social normative of population needs in the volumes of outpatient, inpatient, and diagnostic services.

3.

Grounding and elaboration of optimal correlation of all costs in a structure of healthcare.
Restructuring of healthcare with moving not less than 40% of resources to development of PMC.

4.

Elaboration and approval of long-term normatives of the needs in volumes of financing by every source.

5.

Formation and development of health services market and competition on the basis of multi-structural forms of property.

6.

Classification of medical organizations as a non-profit organizations.

7.

Elaboration and approval of a price restraint policy for medical services.

8.
8.

Monitoring of medical, social, and economic effectiveness in a process of reforms.

Journal of Health Sciences Management and Public Health 9.

Grounding and approval of main priorities programs of medical considering their profitability, and social factors.

10.

Reforming of wage-system for medical workers according to a volume and quality of provided medical services under the conditions of multichannel financing.

Mechanisms of realization of Economic Relations Development Strategy in Health Care.
Real mechanisms of stepwise realization of given strategy are to be scientifically based and approved by Government in accordance with priorities and following goals Adequacy of the financing volumes to the volumes and quality of medical services.

 Stepwise leveling of costs of Government and CMI between regions, urban and rural areas.

 Calculation of population needs in volumes and quality of medical services and stepwise its satisfaction.
improvement of Optimization of the healthcare facilities network depending on population needs in out- and in-patient services.

 Elaboration and approval of social normative in the sector of healthcare.
Analysis of healthcare reforms in Kazakstan shows following factors that hamper the progress of reforms: General economic crisis in the country and its negative reflection on social sphere; Healthcare system is not a priority to our Government; Insufficient development of the optimized reform conceptions, modern methods of management; Lack of specialists for elaboration and effective realization of big changes in financial and economic sector of healthcare and medical insurance, as well as improvement of medical care level and improvement of organizational structures.
2 9 Journal of Health Sciences Management and Public Health axali midgoma jandacvis sistemis dafinansebis sakiTxebisadmiYyazaxeTSi maqsut kulJanovi, aiJan kulJanova yazaxeTSi, iseve rogorc sxva yofil sabWoTa respublikebSi aRiniSneba uprecedento politikuri, ekonomikuri da demografiuli cvlilebebi.

am cvlilebebma ganapiroba mecnierulad dasabuTebuli jandacvis saxelmwifo politikis SemuSavebis aucilebloba.
dargis stabiluri funqcionirebis uzrunvelyofis mizniT daiwyo jandacvis sistemis dafinansebis meqanizmebis reformireba, kerZod, samedicino dazRvevis princi pebis SemoReba, ramac xeli unda Seuwyos rogorc mTavrobis, ise TiToeuli moqalaqis pasuxismgeblobis amaRlebas janmrTelobaze.

gaanalizebulia qveyanaSi dawyebuli reformebis Sedegad Seqmnili mdgomareoba.
3 0 Journal of Health Sciences Management and Public Health THE PRIORITY SPHERES OF HEALTH CARE FINANCING AND SUBSIDIZATION OF MEDICAL SERVICES Levan Kobaladze1, George Gotsadze2, David Gzirishvili3, Ramaz Bedianashvili4, Ketevan Bubuteishvili5, Lili Kochlamazashvili4, Mamuka Makhatadze6 Abstract On the basis of analysis of different models of health care and experience of several countries, the priority spheres of health care financing and subsidizing of medical services have been studied and recommended for usage in Georgian Health System, taking into account the present realities of the country.
As is well known, the point of departure for prior financing by government is that effect achieved for each monetary unit (for example dollar) spent in health care should be maximal and at the same time government should ensure accessibility and equality in health services.

Achievement of this is difficult for most countries.

That is why the World Bank has suggested developing countries define a basic packet.
It means that service having utmost influence on population’s health should be basically financed by public resources and it will give opportunity to obtain maximal effect by means of existing limited financial resources.

Health care financing should not be perceived only from this pragmatic approach, because social, economic, political and cultural realities of the country should be taken into consideration.
Taking into account these realities government can determine four basic targets for health care financing.

They are: 1. Financing of services mostly required by poor section of the population and distinguished by the most elastic prices, i.e.

at decrease of such service prices demand from poor sections of population rises much faster.
Selection of such a target is based on the principle of social insecurity, 1 M.D., Ph.D., MPA, Head of Coordination Department of International Programs of NHMC 2 M.D., Ph.D., Director of “Curatio International Founda- tion” 3 M.D., Medical Director of “Curatio Medical Group” 4 Scientific Worker of NHMC 5 Economist of NHMC 6 M.D., Ph.D., Deputy Director of Georgian Social Invest- ment Fund or it gives government the ability to help socially insecure sections and give them opportunity to receive medical service in good time.
2. Financing of those health care facilities and services that have maximal effect first on public health and then on personal health are: environmental safety provision, struggle against infection carriers, clean drinking water, education of the population on sanitation, etc… Immunization of the population may also be considered here, but it’s more quasi-public health because common health is achieved by vaccination of the individual (or by personal health at first) and not vice-versa.
This target of health care financing is based on the principle of common health priority over personal one, i. e. the state takes care of those things that are of benefit more for community then for a person.

3. Financing of treatment of those diseases that prevail in the population of the country, i.e.

determination of diseases that do most harm to the economic of the country.
This target of financing is founded on the epidemiological status of the population and finances are directed to those pathologic conditions that disturb populations most of all.

This goal is very pragmatic; its points of departure are only epidemiological situation and economic effectiveness.

4. Financing of regions with the lowest economic potential in a country.

It is usual that in regions with a low economic potential the economic state of population is also poor.
The latter conditions directly impact the low level of health care utilization by the population.

In the end results in a 3 1 Journal of Health Sciences Management and Public Health negative influence on that population’s health.

The government has the ability to choose target regions based on geographic principle and purposefully devote health care resources to such regions.
Probably it would be correct to say that health care financing systems of different countries use these targets for financing, more or less, and accordingly implement state policy by means of different forms of financing.

For demonstration purposes example of several countries will be examined.

United States government finances basicly two programs – Medicaid and Medicare.
The first is for pensioners and disabled and the second is for socially and financially insecure section, basicly unemployed, i. e. in the first case government used epidemiological principle and combined it with age groupings and in second case – socioeconomic principles.

Besides, there is public financing for provision of clean drinking water, combating infectious diseases and their carriers, and others.
This is built on the principle of a geographic target such as Indian reservations and purposefully directs resources to such geographic areas identified.

Notwithstanding, that government uses all 4 targets mentioned, it should be said that geographic target is minimally represented in USA health care financing and financing by social and epidemiological principles have a lead position.
that are In Germany where Bismarck’s system of social insurance arose, targets selected by social and common health principles have a leading role.

Here we should also mention that it is difficult to name a country, which does not have a healthcare financing target determined on the principle of common health measures.

Having described basic characteristics (of course not complete) of health care systems we’ll try to make conclusion and divide world systems into several basic groups typologically.
At present almost all countries have health care systems that are quite different and at the same time have much in common.

There are four basic health care models today: 1) social insurance system (so called “Bismarck’s” or German model); 2) centralized systems of communist (post communist) countries (so called “Semashko’s” model); 3) national health care system (so called “Beverage’s” or Great Britain model); 4) so called “American” model.
Although there is one of four basic models in almost all countries of the world, actually none of them is an exact copy of basic one.

The oldest model is Bismarck’s system, the basis of European social insurance systems.

Social health care system started up in Germany in 1883.

It was financed partly (1/3) by employer and partly (2/3) by employee.

The role of government in Bismarck’s social insurance system is minimal as compared with other systems.
Government defines conditions for management of hospital funds, provider and patient relationships, but it does not intervene directly in health care funding and provision.

Hospital funds were responsible for fulfillment of this plan; interaction between health care providers and hospital funds was based on contracts.

Insurance was obligatory only for workers having income lower than a certain level.
Bismarck’s concept of social insurance became a model for many countries (for example Belgium, Netherlands and others).

The second group of health care systems 3 2 Journal of Health Sciences Management and Public Health (so called Soviet or Semashko’s model) developed after the Russian Revolution and with expansion of Soviet influence spread in different countries.

In Semashko’s model health care provision is extremely centralized and financed from the state budget.
Its purpose is guaranteeing of accessibility to free health care to everybody.

For equal accessibility emphasis is made on geographic distribution of health services in the whole country.

Facilities are in public ownership and are managed by local government agencies, under direct control from the central government.

Professionals (basically therapeutists, pediatricians, etc…) provide primary care in polyclinics.

Population is attached to polyclinics according to residence.
Hospitals and polyclinics are on a budget and the staff receives salary.

Besides, it should be mentioned that the Soviet health care system is characterized by a powerful net of departmental primary and secondary health care facilities, basicly for industrial workers.

It causes existence of parallel systems for different groups of the population, often beyond the sphere of influence of the ministry responsible for health care (for example railway departmental facilities).
After World War II “Semashko’s model” was introduced in the countries of socialist camp (Czechoslovakia, Hungary, Poland, GDR), although non-of them had an exact copy of the original Soviet model.

Common in Semashko’s system model was a focus on quantitative growth of medical staff and bed funds in order to compensate for the low quality of health care facilities and lack of equipment.
Besides, as remuneration of medical staff was made by means of salary, demand for overproduction was avoided, but in order to add to their low-income doctors often requested additional payments or gifts from patients (except GDR).

The third group of health care systems so called “Beverage’s” model developed in the United Kingdom (Great Britain and North Ireland) after World War II as the National Health Service (NHS).
The NHS has a lot in common with Semashko’s model: both of them are centralized and financed by the government.

Facilities basically are in public ownership and the staff receives a salary.

Although Beverage’s system is less regulated by government there is more room for private insurance and services.

Other significant differences lie in the way a patient’s admission into the health care system occurs.
In Beverage’s model this is the family doctor and public service, in Semashko’s model, the polyclinic.

Besides, Beverage’s model differs with Semashko’s system in that it does not enclose the departmental sector in health care.

In addition to the United Kingdom, Beverage’s model is widespread in the countries with socialist orientation (Sweden, Finland, Norway and etc).

The fourth model is the American health care system.
It began assuming its present type in the sixties under President Kennedy, although its transformation and amendments never stop.

Because of its dynamic character different elements of the three systems mentioned could be found in it, for example there are state and federal programs for old-age and low-income sections of the population (Medicare and Medicaid) financed from state budget as in Beverage’s and Semashko’s models.
Like the soviet model the government also finances departmental medical services (veterans, navy, national minorities on reservations, etc…).

There is an insurance system as in Bismarck’s model.
The basic difference from it is that the states share of financing in American health care system is the least (40%), as compared with other systems (in Beverage’s system 80-90%, in Semashko’s model 95-100%, also in Bismarck’s model resources are transferred to providers from state budget through hospital (insurance) funds).

Insurance fees are based on employer.


Besides, it should be mentioned that in consequence of precedent nature of American law, financial-legal relationships in the health care system are very polymorphous, dynamic and the principle “do what is not prohibited” is maximally accomplished.
The American system is characterized by the largest expenditures for health care on a world scale; at one glance it seems that a large financial support must be guarantee for improvement of the population’s health, but as reality shows it is not so.

Most of the funding for healthcare services is spent for expensive manipulations that are often excessive and carried out only in order to increase service price and accordingly remuneration.
Existence of different sources of payment for some patients also increases expenses.

All of the aforementioned raise healthcare expenditures 3 3 Journal of Health Sciences Management and Public Health but measurable improvement of human health status, as indicated by the data, does not occur.

Despite existing variety, health care systems of all countries try to meet following requirements: 1.

Improvement of population’s health state and social well-being 2.
Guaranteed and equal accessibility to healthcare service 3.

Guaranteed macro- and micro-economic effectiveness of expended health care resources 4.

Improvement of clinical effectiveness 5.

Rise in medical service level and consumer’s satisfaction 6.

Ensuring systems long-term financial stability Having described basic characteristics of health care financing systems we’ll briefly discuss forms of provision of health care policy chosen by government.
When improvement of the population’s health state is the main task of health care and one of the mechanisms for its accomplishment is subsidization of health care, there are 4 basic principles for valuation of services.

The state has the ability to achieve an effect adequate to expenses only in the case of balanced usage of these 4 principles.
• Subsidization should be high on activities, services that have much better influence on public health, than personal – this is service distinguished by higher quality among alternatives that population has.
Here it should be mentioned that if the alternative is the efficient private sector (for example Indonesia private sector is represented by those doctors working in public sector, who in order to gain additional income work during evening hours after public service), in such cases it should have priority.

Subsidies should be high for service (public and private) demand for which is mostly elastic in relation to price.

The government can not oblige consumers to use health care services.
It should only create an environment when the consumer’s demand for a service rises.

Subsidies cause growth of utilization on account of reduction of prices.

The more elastic the demand in relation to prices the more increased utilization of subsidized services by the population.

But there is a hazard that demand may be much more elastic on a service that is unprofitable.

That is why • 3 4 • • subsidies should be directed only to services that have a much more positive effect on public health.
Financing of such services has the highest effect because it has a great influence on population’s health and at the same time causes volumetric growth of specific health care provision.

Subsidization should be available for population groups that are characterized by more elasticity in relation with price.

As it was mentioned in the previous example, subsidization has effect only when it causes growth of health care utilization by a population.
Consequently, subsidization should be high for poor sections of the population, whose requirements are much more elastic in relation to service prices.

Subsidies should be high for those services and in those geographic areas, where abilities of private sector and/or other alternatives (competition) are scarce.

In a highly competitive environment subsidies may have no effect, but promoting transition of a solvent population from private sector providers to public ones.
In this case the entire volume of service utilization will remain invariable and will cause protection and distortion of market relations.

The best type of subsidization is when government subsidy promotes for growth of medical service utilization, or when a population who would not receive treatment without subsidization receives services.

That is why financing of certain preventive and treatment measures in a geographic area where availability of alternative providers is scarce gain utmost importance.
Governmental subsidies also have considerable influence on prices established by private health care providers.

Always with subsidization a question arises before the private sector: “is it profitable to deliver services with price established by government?” This question forces the private sector to provide services with the same competitive price or to look for a markets sphere, where government does not intervene by subsidies.
The fact that in some areas there are no private providers and public providers hold all the market does not mean automatically that in case of public provider’s absence the private provider would not occupy it.

It only shows that in existing situation private providers do not regard this area as profitable.

Journal of Health Sciences Management and Public Health Schematically subsidization may be 2. accomplished in three ways: 1.
Reduction of service prices - so called “subsidization of services (product)”.

Service price is invariable, but at the time of purchasing (utilization) the cost is covered (partially or entirely) – so called “subsidization of purchase (utilization)”.

3.

The price is invariable, but while getting a member of insurance program premium price (or its part) is covered and insurance program covers service expenses – so called “insurance subsidization”.
From a macro-economic point of view forms two and three are much more expedient, because in the case of form one it is difficult to avoid “side effects” of protectionism.

“Insurance subsidization” is more adjusted to Bismarck’s model, “subsidization of utilization” – Beverage’s and American models.
In case of subsidization of insurance or utilization government does not intervene directly in valuation of services that may be based on pure market principles or administrative mechanisms (for example, what’s going on at present in Georgia).

Health care providers (leaving out of account forms of their estate) follow pure economic principles at valuation and achieve satisfaction of entire financial requirements of organization by means of competition in the medical market.
As a result of such competition both the state and consumers stand to gain, because in terms of equal price-formation the provider is forced to attract patients, in essence, on account of better (prior) quality.

The imperfection of subsidization of uti- lization is in the difficulty of its accomplishment.

It requires existence of an insurance system of some form (a “third-payer”).
Subsidization of utilization is attractive for being on stage of tran- sition or developing countries, where appro- priate infrastructure is absent.

Diminution of negative factor of service subsidization – protectionism is possible by sev- eral ways.
In particular, subsidization according to category of disease so called profile subsidi- zation; or by subsidization of those area of health provision where monopoly of state is obvious and will remain for years; in Georgian reality it may be mother and child care with ap- propriate prenatal services.

Insurance subsidization form requires well- developed insurance infrastructure.

The insurer may be government, companies with mixed estate, or private.
Their summary capacity should be enough for complete coverage of a population.

In this case subsidy-giver – federal or local government helps citizen to acquire needed premium, which citizen could not pay.
In the end the whole population despite their social or economic situation will be insured – or guaranteed a basic health service package; rational expenditure of accumulated sums is carried out by insurance companies that secures effective usage of resources; the government is released from the economic and financial func- tions.
It creates the opportunity to balance in- 3 5 Journal of Health Sciences Management and Public Health terests of citizens, insurance companies and health care providers by means of political mechanisms.

At the creation of such a scheme, either decentralized or centralized, the govern- ment may define how accumulation of sums should occur (or how many insurance compa- nies should share national premium of obliga- tory insurance).
The best example of this sys- tem is Holland and if we take the constitution into consideration this scheme may be most at- tractive for Georgia in future.

Summary On the basis of analysis of different mod- els of health care and experience of several coun- tries, the priority spheres of health care financ- ing and subsidizing of medical services have been studied and recommended for usage in Georgian Health Care System, taking into ac- count the present realities of the country.

References 1.
References 1.

European Health Care Reforms.

Analysis of Current Strategies.

WHO ROE , Copenhagen, 1996, 157p.

2.

Schieber, G. & Maeda, A.

A Curmudgeon’s Guide to Financing Health Care in Developing Countries.

World Bank Discussion Paper No.

365, 1997.

Innovations in Health Care Financing 1/40 3.

Montague Brown.

Health Care Financial Management.

1992, 209p.

4.

Cleverley W.O.. Essentiales of Health Care Finance.

1997, 442p.

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<tcrt- A=- B=U= <ht[n- F=V tcrt- A=- B=U= <ht[n- F=V= tcrt- A=- B=U= <ht[n- F=V Hfqyrtvfqth=^Plhfdjj[hfytybt Uthvfybb= Vjcrdf- 1994- 224 c= 6.

Marree, J., Groenewegen, P.P.

Back to Bismark: Eastern European Health Care Systems in Transition.

1997, 126p.

7.

E. Van Doorslaer & A. Wagstaff.

Equity in the Finance of Health Care.

Equity in the Finance and Delivery of Health Care: An International Perspective.

Oxford: Oxford University Press.

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Schwartz, F.W., Glennerster, H., Saltman, R.B.


Fixing Health Budgets.

1996, 235p.

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Chollet, D.J.

& Lewis, M. Private Insurance: Principles and Practice.

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Innovations in Health Care Financing 77/ 114 janmrTelobis dacvis dafinansebis prioritetuli sferoebis subsidirebis Tanamedrove problemebi levan kobalaZe, giorgi gocaZe, daviT gziriSvili, ramaz bedianaSvili, qeTevan bubuteiSvili, lili koWlamazaSvili, mamuka maxaTaZe Catarebuli gamokvleva Seexeba janmrTelobis dacvis sistemis dafinansebis sxvadasxva modelebis Sedarebas.
Seswavlil iqna janmrTelobis dacvis dafinansebis prioritetuli sferoebi qveynis realuri mdgomareobidan gamomdinare.

kvlevis safuZvelze mowodebulia rekomendaciebi mimarTuli saqarTvelos janmrTelobis dacvis sistemis dafinansebis saqmeSi axali midgomebis danergvis Sesaxeb.
3 6 Journal of Health Sciences Management and Public Health COMPARATIVE ANALYSIS OF HOSPITAL CARE PAYMENT FORMS Levan Kobaladze1, David Gzirishvili2, Akaki Zoidze3, Ketevan Bubuteishvili4 Abstract The aim of the study was to elaborate the conclusions and recommendations, that will be used by governmental bodies during making decision on choosing of forms of financing in the sphere of health care.
On the basis of expertise of domestic and foreign experience of health care financing, the universal matrix has been elaborated, where all the alternatives, their evalu- ation by criteria and priorities of criteria (for decision-makers) are reflected.

Goal and Methodology Goal The goal was to elaborate conclusions and recommendations which should be considered by the State in decision making regarding the selection of financing schemes.
Particularly, it refers to the reimbursement forms of health care expenses within the Basic Health Package: Table 1.

Brief Description of Alternatives • Program Payment (reimbursement of claims based on fixed rates - State standards) • Conditional Standards (modified version of the previous one) • Per diem • Global Budgeting The list of alternatives were determined by the terms of references.
Alternative # 1 Alternative # 2 Alternative # 3 Alternative # 4 Definition Typology Program Paym ent (Initial Version) Conditional Standards Per Diem Global Budget Volum e based Paym ent Volum e Based Paym ent Volum e Based Paym ent Fixed Subsidy Paym ent Unit Diagnosis (Standard) Diagnosis (Standard) adjusted to de facto intervention (allowed sum of interventions <=standards) Patient bed-days adjusted to profile Profile and Capacity (num ber of beds, adm issions, patient bed-days, capital assets, etc.)
Paym ent Type Retrospective Retrospective Retrospective Prospective Paym ent Rule Paym ent directly to provider after subm ission of claim s indicating on diagnosis Paym ent directly to provider after subm ission of claim s indicating on diagnosis and list of interventions Paym ent directly to provider after subm ission of claim s indicating on profile and num ber of bed-days Paym ent in advance of the certain amount (at once or periodically) Rating (Pricing) Principle Standards of the Payer (fixed) Standards of the Payer (sem i-fixed) Foreign Analogs DRG (Medicare, USA) Medicaid and Blue Cross 1 M.D., Ph.D., MPA, Head of Coordination Department of International Programs of NHMC 2 M.D., Medical Director of “Curatio Medical Group” 3 M.D., MPA, Deputy Minister of Labour, Health and Social Affairs 4 Economist of NHMC Historic or functional Standards of the Methodology Payer (by profile) The expertise was carried out using a) Holland worldwide experience in development, usage and evaluation of different payment schemes, b) general statistics and economical indicators.
The expertise aimed to develop weighted Form er SU, VA in USA, UK, Canada score for each alternative.

It strafed: • to develop major criteria; 3 7 Journal of Health Sciences Management and Public Health • to evaluate the alternatives according with 3.
Conceptual Adequacy criteria • to weight criteria according with priority As a result, the matrix was developed reflecting both the score assigned by experts and the weights assigned by decision makers making the final results flexible for usage in sense of continuous effectiveness along with changes in priorities for decision makers.

List of Criteria Executability 1.

1.1.

1.2.

1.3.

2.

1.4.

2.1.

Fitting the current infrastructure Doesn’t needs restructuring Management Capacity 1.3.1.
Human and Technical Resources Simplicity of technology 1.3.2.

1.3.3.

Controllability Installation Easiness Economical Effectiveness 2.1.1.

2.1.2.

Cost per unit purchased Ratio of Administrative/ Operational Costs 2.2.

2.3.

2.4.

Payment Delay Payment (Pricing) Adequacy Promotion of micro-economic efficiency 3.1.

3.2.

3.3.

3.4.
Concordance with the main philosophy of the reorientation Provision of resource saving task (on a state level) Population’s (customers’) satisfaction Providers’ satisfaction Conclusion General Conclusions The expertise revealed, that • There is no ideal form of reimbursement of hospital costs • The choice depends on the priority of criteria weighted by decision-maker • If Executability is a priority, then the Global Budgeting and Per Diem payment get highest values, if economical effectiveness/ efficiency - Per Diem and etc.
• Special matrix developed due expertise allows a decision-maker to make a choice dynamically considering priorities.

Interpretation of the results needs caution.

Payment forms can’t be discussed/evaluated pulled out from common context, i.e.

ignoring other components of health care financing and without the consideration of certain basic health care indicators.

Table 2.
Evaluation of Alternatives by Criteria Criteria Alternatives Program Financing Conditional Standards Per Diem Global Budgeting Executability Macrostructure (Feasibility) Microstructure (No need in restructuring) Human Resources Technical Capacity Installation Easiness Economical Cost per unit purchased Ratio of Administrative/Operational Costs Payment Delay Payment (Pricing) Adequacy Promotion of micro-economic efficiency Conceptual Adequacy Concordance with the main philosophy of the reorientation Provision of resource saving task (on a state level) Population’s (customers’) satisfaction Providers’ satisfaction Promotion of quality care assurance General Criteria Equity Accessibility/Affordability Quality Journal of Health Sciences Management and Public Health Table 3.
Weighting Matrix for Final Evaluation of Alternatives by Criteria in accordance with Decision-makers’ Priorities Criteria Alternatives Priority of Criteria Program Financing Conditiona l Standards Per Diem Global Budgeting (W eighting is carried out by decision-maker according to Weighted Ranking 41 29 48 44 Executability Macrostructure (Feasibility) Microstructure (No need in restructuring) Human Resources Technical Capacity Installation Easiness Economical Cost per unit purchased Ratio of Administrative/Operational Costs Payment Delay Payment (Pricing) Adequacy Promotion of micro-economic efficiency Conceptual Adequacy Concordance with the main philosophy of the reorientation Provision of resource saving task (on a state level) Population’s (customers’) satisfaction Providers’ satisfaction Promotion of quality care assurance priorities using 3 mark scale) Conclusion 1 The present expertise had a task to evaluate four payment alternatives.
However the number of reimbursement schemes is much more and diversified over the world.

Some differ insignificantly, but some distinct groups of reimbursement models were left beyond the expertise: e.g.

payment directly to consumer rather to provider, or well-known method of prepayment - per capita and etc.

It’s noteworthy that the present expertise mainly covered only one case of payment process when the state is a third-party payer and health care provider is a paid side.
However, in a free market, even along with compulsory state health programs/insurance, it is possible for somebody else to be a third-party payer, like employer, which is legally asked to take responsibility for employees’ health care costs.

In other words, let us assume that there are only to type of employers in the country: the state and private sector.
On the other hand, the population or employed can be divided in three major groups: state employed, private sector employed and vulnerable (single pensioners, disabled.

etc.).

The private business can be obliged to provide coverage for basic health care to their employees, correspondingly the public sector - to public employees, and vulnerable or eligible for social protection can be covered due to join efforts.
In such a case, within the basic compulsory health programs (common for everybody) payment is delivered directly to provider, thus it reduces dependency on the state as a single compulsory third-party payer in the country.

Self-employed group of population is not reflected in the figure.
According with State Budget Employer Private Sector Employer Public Sector Employee Private Sector Eligable to Social Security System Employee Public Sector 3 9 Journal of Health Sciences Management and Public Health worldwide practice they either can be asked to get coverage either through state compulsory insurance or both sectors can share responsibility on their health care costs like in regard with vulnerable.
Regarding payment forms, unified schemes can be imposed, or each sector can have free choice just to ensure coverage of basic health packages.

The major advantage of proposed scenario compared to the current situation is that the State will be much more clear about its liabilities: e.g.

who and how many people are under its responsibility, how much can the State spend and etc.
The most important issue is that each payer: State or Private Employer purchase health care himself and pays directly to provider (or moderator like HMO/PPO) making the process of allocation of health care resources more apparent and tangible (in opposite from current situation, when all resources are collected in one join basket, but distribution and payment is provided by other bodies...).
The proposed scenario more fits the health care system operating in free market conditions, because: • Implicates the diversification of fund collection and distribution/payment forms; • Brings closer consumer/payer and provider, which, on the one hand, promotes competition on the supplier side, and, on the other hand, implementation of more efficient schemes of payment on the demand side; • The State, as a third-party payer, is released from expenses on the health care of the certain part of population, which allows to use more rationally the available resources, like to increase the basic package volume or make it more effective.
Conclusion 2 Solution to one of the most important problems the health care system is confronting - rationalization of utilization of health care resources only by improving/modifying payment models is a mere waste of a time.

Of course its possible to improve some indicators in case of the right choice of the payment scheme, but the space for these improvements is quite limited.
So, without revising other components of the health care financing any discussion on and expectation of the cardinal improvement of the situation is fruitless.

Conclusion 3 While selecting the appropriate health care financing the State needs to distinguish its two functions (roles): the function of payer and function of owner, because very often these two roles get in conflict.
Thus, if the State really wants to elaborate efficient financing model, it should determine at first, which function is a priority: the role of a payer or the role of an owner, and only afterwards the State should start policy development and implementation.

Instead of Epilogue The situation can be viewed like the following: A track was designated to carry a large heavy freight and, because of that, was equipped with powerful engine and used correspondingly too much resources (fuel).
Due to the lack of recourses carrying the same freight became impossible.

As a result, the size and weight of the freight was reduced by ten.

However, on the way it turned out that resources (fuel) are still not enough.

Upgrade of carburetor was decided in order to cope with the problem.

So the task was imposed to make fuel supply more efficient and rational to the old powerful engine.
So the question arises: What will be more right to do in order to cope with the problem: to replace the old powerful engine (if not the entire vehicle) with more economic engine, or to restrict the exploration only by modification/ modernization of the carburetor or the fuel?
stacionaruli momsaxurebis anazRaurebis formebis SedarebiTi analizi levan kobalaZe, daviT gziriSili, akaki zoiZe, qeTevan bubuteiSvili stacionaruli momsaxurebis anazRaurebis samamulo da ucxouri gamocdilebis analizis safuZvelze SemuSavebulia algoriTmi, romlis meSveobiT SesaZlebelia alternativis Sefaseba, anazRaurebis saTanado kriteriumebis Camoyalibeba da maTi prioritetulobis dadgena.
SemuSavebulia rekomendaciebi, romlebic SeiZleba gamoyenebul iqnes saxelmwifo struqturebis mier janmrTelobis dacvis sferos dafinansebis formebis SerCevis procesSi.
4 0 PSYCHO-SOCIAL VARIABLES IN CHANGE MANAGEMENT: TOUGH TIMES NEVER LAST Journal of Health Sciences Management and Public Health Daniel J. West1 Abstract Consideration of teaching psycho-social aspects in health management education must promote formation of new thinking of managers, because deep knowledge of psycho-social problems is necessary for carrying out the changes according to modern requirements, which is complicated in case if only traditional methods of management are used.
Rationale This is a short paper which will hopefully be invigorating for the reader.

I have had an opportunity to travel to the Republic of Georgia four times since October of 1999.

Based on what I have seen, and the people I have talked to, I became motivated to develop a different type of article for the first issue of the new journal.

I wanted to write an article that has more of an affective direction and content rather than behavioral or cognitive focus.
completing Recently I was traveling to visit with a student who was an administrative residency in another city.

I had taken an audiotape series to listen to in the car as a way of occupying time during the long car ride.

On this particular occasion I was listening to an audiocassette series entitled “Tough Times Never Last but Tough People Do” by Robert H. Schuller.

As I was driving and listening I immediately thought of my friends and colleagues in Georgia.
Dr. Schuller’s comments seemed so applicable to the people I know in Georgia, and the difficulties related to reform efforts.

I hope that this article produces some form of kinetic energy and will service as a motivational article for those who read the manuscript.
The article is intended to stimulate thinking about several psycho- social variables that can facilitate change in a democracy that is undergoing major changes; 1 Ph.D., FACHE, FACMPE, Associate Professor, Department of Health Administration and Human Resources, University of Scranton 423 McGurrin Hall, Scranton, PA 18510, Tele: 570-941- 4126, Fax: 570-941-5882, Email: westd1@uofs.edu an article that causes people to encounter one another with different velocities and thinking for generating new directions and creating synergy in actions.
Introduction Since the election of President Edward in 1995, Georgia has Shevardnadze established a recovery program that is extremely far reaching, highly energetic, and yet difficult to achieve.

In particular, the transformation of health care in Georgia is predicated upon several macro changes which involves democratization, decentralization, internationalization and privatization, marketization.
The strategic direction also has specific micro environmental changes which touch upon more of the psycho-social dimensions of change management.

Some of these principles involve harmonization, liberalization, localization, optimization and specialization.

The National Health Management Center and the University of Scranton have been working on a Health Management (HMEP) since Education Partnership August, 1999.
Change in the health sector of the economy is essential to improving the economic conditions in general and the health status of people in Georgia in particular.

The partnership model is designed for the implementation of a multi-faceted health management education program aimed at health care professionals in various sectors.

The HMEP is designed to address certain strategic health care plans developed by the Ministry of Health to implement the Georgian National Health Policy.
The partnership model between the National the Health Management Center and 4 1 Journal of Health Sciences Management and Public Health University of Scranton will implement educational models that address behavior, content and affective domains.

The specifics of this model have been discussed in another article in this first issue of the journal.
implementation Globalization The accelerated changes occurring in Georgia require managers to have a working knowledge of international relationships, foreign affairs, as well as an understanding of global economies.

Implementing strategic plans in Georgia requires a balance and understanding of how to capitalize on internal resources within the country as well as being able to think in more global terms that impact on the total economy of Georgia.
Interestingly, of globalization efforts, which are very complex, will require managers who have fundamental skill sets and competencies: team building , organizational skills, communication skills and very specific management skills.

Working with culturally diverse groups is important in generating ideas and concepts that can be applied or modified for use in Georgia.

Solutions to economic and social conditions in Georgia will require a “Georgia specific response” to special conditions.
However, in the context of globalization, it will be even more critical for leaders and managers to be aware of their own stereotypes and limitations in working with surrounding countries and in global regions of the world.

Leaders will need to have a tolerance for higher levels of change and ambiguity, and at the same time have sufficient creativity and inventiveness to facilitate and implement change management strategies.
In the global environment managers need high levels of cross-cultural awareness and sensitivity to work in global business environments and settings involving different nationalities, ethnic backgrounds and languages.

Minimizing cross-cultural misunderstanding and misperceptions requires the development of communication skills that improve awareness and enhance cross-cultural communication.
Finally, the transformation and reform processes in Georgia require an emphasis on the increased transfer of knowledge.

New practices, 4 2 approaches, techniques and technology can effectively be transferred from one country or several countries to Georgia.

However, transferring of knowledge from one culture to another requires the ability to understand values, attitudes, norms and beliefs that are part of a cultural specific social system.
Social structures and cultural sensitivity/awareness helps people transfer knowledge.

The ability to resource interdependencies when designing new organizational structures serves as the basic platform for all other events and activities, especially in the fields of education and health care.

understand human Individual variables Changing conditions within a country and implementing new strategies and structural changes requires higher levels of adaptation and awareness.
Leaders will implement changes but people will need time to assimilate new values, technology, information and international relationships within this framework.

It is often easier to understand difficulty with adaptation by understanding organizational cultures.

Furthermore, organizations adapt and change based on values and perceptions of employees within organizations.

Finally, an impact on organizational change requires some understanding of the interactive nature of work, family and the community.
Creating social and organizational change means that managers need to be sensitive to organizational cultures and people within organizations.

Leaders must understand and respect other peoples’ expectations, perceptions, values and attitudes.

The level of understanding and appreciation for commonalties and differences can have an effect on overall outcomes of the change process.

Leaders and managers need to articulate core values and create cultures that are supportive of change processes.
In order for change to evolve over a period of time, leaders need to be effective in communicating the history of the organization, developing communication norms and values, insuring a process of socialization, and facilitating participative decision making and problem solving.

Empowerment encourages decisions that gives ownership to outcomes of a transformation process.

Personal investment in outcomes and future directions draws heavily upon the human psyche.
in and emerging is essential an organizational It is the intent of this article to underscore the importance of psycho-social variables change management.

Understanding organizational behavior and to individual differences accommodation and adaptation strategies related to globalization efforts within and between countries, and the ability of organizations to function differently in a developing economy.
Managers must understand how individuals fit into organizations as well as understanding how environment accommodates individual differences.

Therefore, leaders of change must appreciate and understand that psycho-social variables such as abilities, skills, values, personality, perceptions and experiences provide a basis for understanding human behavior, performance and adaptation capacity.

In Georgia, managers are attempting to implement massive democratic changes in the economy.
of various Understanding how human behavior is influenced and affected by rapid change provides a foundation for understanding motivation, group behavior and leadership.

Management strategies requires leaders who know how to manage cultural change and organizational behavior, and understand individual differences and capacities to assimulate change.

New organizations, change in leadership, as well as environmental variables, effect not only behavior but effect adaptation and performance.
Performance related behaviors are important in the process of planning, organizing and controlling processes within change important organizations and the larger society.

sectors the The organization-individual fit can be understood by examining psychological variables such as personalities, perception and attitudes.

The whole discipline of industrial psychology provides a basis for affording leaders and managers an opportunity to understand these significant variables.
Individuals and organizations need to have meaning with respect to the external Journal of Health Sciences Management and Public Health and to organize environment, and develop communication systems interpret experiences.

Perception is an important cognitive process that enables individuals and organizations to collect, organize and store appropriate information and knowledge.

The perceptional process is important to understanding input, throughputs and outcomes in organizational change processes.
Therefore, it is essential that managers understand perception and behaviors (individual psychology) in trying to facilitate appropriate and positive change processes (organizational psychology).

Attitudes have important implications for leaders and managers since attitudes influence learning, the transfer of knowledge, predispositions towards the external environment, and form a basis for all interpersonal relationships.
Attitudes are tied to personality and influence the human capacity to assimulate change.

Attitudes effect cognition and behavior.

These particular components must be understood by managers in order for change to occur within a country, between countries and within organizations.
Finally, integrating vision and values within a strategic framework requires an understanding of personality, how a personality is organized as well as how personalities are influenced by social- economic-political-cultural environments.

There are many theories of personality used to understand human behavior, a discussion of which goes far beyond the purpose of this paper.

Suffice it to say that organizational behavior has major for individual performance, group behavior and team achievement.
Individual behavior must be understood in order for effective communication to exist and for mutual contributions to be made by individuals to an organization and vice versa.

These processes ultimately influence social- economic-political adaptation to transformation for an entire nation.

implications Change management The only real constant in this world is change.

Change is random and discontinuous and effects everyone.
Effective managers and leaders must manage change, and facilitate 4 3 Journal of Health Sciences Management and Public Health education.

the successful implementation of appropriate changes, at macro and micro levels.

Managing change is possible within organizations by developing strategies that facilitate organizational development and allow for the implementation of new knowledge and interventions.
Change can be managed through the use of power, reason Organizational and/or development refers to a process that has very specific rules, interventions and techniques that are used to help people and organizations become more effective and efficient.

Organizational development is a process that changes social systems and creates change agents in organizations who are able to work with significant others to facilitate large scale behavioral changes among and between groups of people.
Creating an effective and knowledge management innovative knowledge environment is difficult during periods of transformation and reform.

Things are changing quickly and uncertainty prevails.

Leaders and managers serve as both internal and external change agents, and need to develop approaches that utilize resources and knowledge to help individuals, groups within organizations and organizations to interact in various sectors of the economy.
Therefore, it is incumbent on leaders and managers to understand external change processes, internal change management and developing interventions to enable external-internal change to occur in an orderly fashion.

Incremental changes may be more effective in facilitating assimilation of new knowledge and ideas.

system Comprehending Georgia is undergoing major economic, technological and social-political change processes.
the implementations of these external factors and forces requires an organizational learning process that is proactive.

It also assumes that leaders and managers understand how to diagnosis a problem and provide an appropriate intervention.

Problem solving and decision making are critical variables to organizational and organizational change.

However, education and knowledge management are the keys to success.
development 4 4 Future directions In addition to education, there is a human quality called hope.

It is my personal belief that the leadership in Georgia at all levels must keep hope alive.

In order to do this, effective leaders will need to reduce fear of change, eliminate prejudice and indifference, and perhaps most importantly, irradicate negative thinking.

Problems can be solved no matter what the level of difficulty.
Problems can be solved by reinforcing in people a sense of faith and courage based on the acquisition of knowledge and ideas.

Knowledge is power.

Knowledge generates kinetic energy.

Knowledgeable people create synergism.

Choices exist and every problem has positive and negative variances, which means that there are possibilities to solve most problems.
Given the psychology of human behavior, it is essential that leaders recognize that individuals control responses to problems and how problems will be examined and perceived.

How people react to difficult situations makes the entire difference in whether or not problems are solved.

How we see a problem is the problem and this is related to perception.

Everyone has problems.

Countries have problems, organizations have problems and so do individuals.
Problems are solved by generating ideas, stimulating creativity and controlling our own reactions to problems.

In the psychological literature, this effort requires a process of introspection and reflection; a process whereby people are given the time to closely examine the parameters of a problem and select courses of action based on individual analysis.

Effective leaders can facilitate and reinforce optimization and visualization of appropriate solutions.
Leaders must understand the importance of hope for the future.

Solving problems in Georgia will require a more holistic and community based approach.

Change will occur incrementally through positive decisions at all levels of government and society.

Change will occur because people believe that there is a future and have hope that tomorrow will be different from today.

Dedicated leaders and competent managers do exist in Georgia.
Journal of Health Sciences Management and Public Health These leaders will move forward with positive change processes.

Leaders and managers will need to exhibit and model pride in the Georgian culture, offer chooses for people, and develop social structures to accommodate and facilitate change.

Leaders will need to collect actual data to develop information that facilitates new knowledge and generation of creative solutions.
By implementing embracing change, and incremental change, leaders will effectively manage macro and micro changes in Georgia for the future.

“THE GREATEST GOOD WE COULD DO FOR OTHERS IS NOT TO SHARE OUR RICHES WITH THEM, BUT TO REVEAL THEIRS.
George W. Cranes cvlilebebis marTvis fsiqo-socialuri aspeqtebi daniel vesti jandacvis menejmentis saswavlo programebSi fsiqo-socialuri aspeqtebis swavlebis gaTvaliswinebam xeli unda Seuwyos menejerTa axleburi azrovnebis Camoyalibebas, vinaidan socialuri fsiqologiis problemebis Rrma codna aucilebelia Tanamedrove moTxovnaTa Sesabamisi cvlilebebis gatarebisTvis, rac menejmentis mxolod tradiciuli meTodebis gamoyenebisas zedmiwevniT gaZnelebulia.
4 5 Journal of Health Sciences Management and Public Health THE MAIN TRENDS OF DEMOGRAPHIC AND HEALTH STA- TUS DEVELOPMENT OF THE GEORGIAN POPULATION Otar Vasadze1, Otar Gerzmava2 Abstract During the last years the demographic situation in Georgia has been changed dramatically, which sharply changed the prognostic parameters of population reproductive process.

The structure of the population has been changed accordingly– increase of the aging population and decrease of the childbirth.
The authors have some reccomendations to improve the current situation The social-economic situation, existing in recent years in Georgia, greatly effected the health status of the population and the main trends of its demographic development.

The rapid increase in population slowed in the 1990s.

Instead of a 17% increase, the total population in 1997 was parallel with 1989 (table 1).

The number of the Georgian population is caused by many reasons.
These reasons were influenced by a variation natural of natural indicators and mechanic movement (migration) of the population.

This has resulted in the difficult situation in Racha-Lechkhumi, where the number of population is reduced to 2-4% since 1995; depopulation tendencies of population is marked out in Kakheti, Imereti and other regions.

The sharp changes in recent Georgian demographic processes took place though the high inertivity which is recognize to this day.
It is worth mentioning that different tendencies Table 1.
The number of permanent population of Georgia in 1989-1997 (thousand) years 1989 1990 1991 1992 1993 1994 1995 1996 1997 average annual 5 405,9 5 417,6 5 420,9 5 412,4 5 397,7 5 383,0 5 374,3 5 377,2 5 388,5 year start-up 5 400,8 5 413,5 5 421,6 5 420,3 5 404,6 5 390,9 5 375,1 5 373,4 5 381,0 1 The Director of National Health Management Centre 2 The Director of Continuous Medical Education Centre of NHMC, the Head of Chair of Public Health and Manage- ment of TSMU 4 6 arose in different periods.
Taking them into consideration, time may alleviate the existing demographic crisis.

In 1990-1997 we can distinguish periods having special effect on the demographic development of the population.

Due to known events in 1990-1992, immigration of non-Georgian population (mainly Russians, Greeks, Ukrainians and other nationalities) sharply increased.

This was caused by an absolute decrease in population.

However, the increase of children and youth was noticeable in age-sexual structure of population.
It was conditioned by: • The main part of immigrants was presented by overaged people.

• Due to the fact that representatives of Russian and other nationalities since 70s had few children, their migration did not greatly effect the birth rate.

• The most important factor is national ideas effected the short-term, but high increase of the birth rate in Georgian population.
Due to war activities in Abkhazia and Samachablo, a new wave of internal and external migration effected almost 20% of the country’s population.

The major part of emigrants this time was represented by people of Georgian nationality.

Since 1993 this process caused sharp reduce of birth rate of population which was supported by the previously mentioned problems and the deterioration of economic situation of the country’s population (fig.

1).

High intensity of urbanization since 1996 is evident.
The major part of IDPs from Abkhazia are migrated young people from other rural regions concentrated in cities.

This process, due to unemployment and social disarrangement, negatively effects the Fig.

1.

Dynamics of number, birth rate and migration activity of the Georgian population in 1989-1997 Fig.

2.
2.

Sequence o Journal of Health Sciences Management and Public Health Number of population Delivery External Migration 1989 1990 1991 1992 1993 1994 1995 1996 1997 data of 1980 the number of second, third and fourth children made up 60% of the total number of children born during the year.

In 1990 their share decreased to 45%, while according to the data 1997 it reduced by 38%.

It means that in case of maintaining the existing tendency, the family is unable to provide enlarged reproduction.
According to the data of the general census of population carried out in 1979 150 women per thousand had one child, 240 - 2 children, demographic behaviour of this quite a big group of population and its health state.

Prevalence of different social diseases TB, drug abuse and toxicomany, psychical deviation, etc.

is high in this contingent.


Insignificant increase of population started in recent years (1995-97) which denotes improvement of social-ecomonic situation of the country (for example, according to the data of 1997 in comparison with the previous years increase of population of Georgia made up 1,03%).
The birth rate reduced almost twice in comparison with 1989 (table 2): In the same period it is more and more common to have one or two children in the family planning process of the Georgian population (whilst according to the special studies the desirable number of children in 1986-1990 was three).

This is more prevalent after the first child.


Taking into consideration the reasons causing the increase of the number of families with one child, it becomes clear that; in conditions when enlarged reproduction of the country’s population needs each family to have 2.5 child, i.e.

there should be 3 children in each second family (table 3).
It should be stressed also that the tendency of multichildren families is maintained in several regions of the country (Zemo Adjara, Kvemo Kartli), but it has no significant influence on the general indicators (fig.

2).

As the figure represents according to the 4 7 Journal of Health Sciences Management and Public Health Fig.

2.

Sequence of newborns in Georgia in 1980, 1990 and 1997 Table 4.
Indicators of marriages and divorces of the Georgian population in 1992-1997 years 1990 1992 1993 1994 1995 1996 1997 marriages 9.1 5.5 4.9 4.5 4.4 4.0 3.5 divorces 3.3 1.0 0.7 0.6 0.6 0.5 0.5 329 - three and more children.

The census of the population carried out in 1989 revealed the trend of reducing of the number of women with three or more children (300 per 1000 married women), but at present the number of families with three children twice reduced.
This is a real danger in regards to depopulation of the country’s population.

The decrease of birth rate is closely bound with the decrease of the number of marriages (table 4).

It should be mentioned that increased average age of married people conditions the trend of increasing the portion of hereditary diseases among the infants.

Unlike other countries (Russia, countries of Baltic Sea, Scandinavian countries, etc.)
where the number of natural children makes up 25-60% of the total number of newborns due to the Georgian traditions the share of natural children in our country is 6-10% (by different regions nationalities).

Thus taking into consideration existing specificity while calculating the prognostic indicators of the population and planning the demography policy, it is necessary to strengthen the institute of family.
Although recently the indicator of registered divorces reduced, different studies confirm that the number of unregistered divorces is high enough.

Increase of the share of incomplete families denotes the same fact.

The above mentioned demographic trends effected the age-sexual structure of population and stimulated the process of “aging” of the population which, from our viewpoint, will have negative influence on the economy of the country (fig.

3).
3).

The number of population over 60 is 900 000 in Georgia.

The indicator of burden of able-bodied people in this regard reached about 30%.

New and rapidly changing demographic trends, such as destroy of traditional multigenerational structure of Georgian families and increase of the portion of so called nuclear families, is twice as harmful for the society.
On one hand, the state is compelled to deliver old people this sort of social care, which was mainly provided by the member of multigenerational families (care, feeding, primary 4 8 Journal of Health Sciences Management and Public Health medical care, etc.).

On the other hand, the young generation of nuclear families left without care and control of older members sets additional problems for the society and state.

Untimely mortality of able-bodied people causes serious problems for Georgia.
This indicator is almost 25% higher than the analogic data of 1989.

It is very important, that in comparison with females, mortality among males is higher and is characterized with higher speed of increase (fig.

4).

It should be mentioned, that mortality rate in males of 40-55 is much higher.

Especially complicated situation is among IDPs from Abkhazia and Samachablo where this data is significantly higher.

As the figure shows, indicators of male and female mortality varies in other age groups.
Only in elderly population, over 75, mortality curve in both sexes, is characterized by similar dynamics.

Mortality dynamics of the population is significantly different in urban and rural regions.

Mortality dynamics in rural population is characterized by more positive trends.

For example, in the contingent mortality level of children under one year and especially able- bodied people is much lower.

The peak is shifted to elderly population.


Despite the fact that mortality rate in Georgia is equal to the analogic data of the neighboring countries, it does not show the real situation (table 5).

Since 1992 the facts of insufficient functioning of death’s system is more frequent, especially in rural regions (its share is 15-20%).

Registration of population reproduction is deteriorated in recent years.

For example, in 4 9 Journal of Health Sciences Management and Public Health Table 5.
Mortality rates in Georgia and neighbouring countries Armenia Azerbaijan Georgia Russia Turkey 1980 7,4 9,2 15,7 1990 6,6 6,9 9,6 15,0 1997 7,5 13,8 1995 6,6 6,4 7,5 14,2 7,0 80s average number of cases of death was 44- 46 thousand, this year it reduced to 37 679.

It denotes insufficient functioning of mortality registration.

The analogic situation exists in registration of mortality of children under one year, especially in rural regions.
Sanitary-epidemiological situation existing in the country is densed, which is caused by deterioration of sanitary conditions of settled regions (due to financial difficulties water, air, soil protection measures are not carried out); due to frequency of social diseases TB, food poisonings, child infections, etc.

connected with poverty.

The serious problem is implementation of appropriate preventive programs among ill people.
Mortality rate caused by these reasons, which in recent years less effected the total indicators, sharply increased (table 6).

The structure of mortality of population reflects the changes taking place in recent years: mortality indicators caused by infectious diseases, especially among children are quickly increasing.

Increases in the number of patients with TB, STD and AIDS.

Stabilization of the indicators of blood circulation system and oncologic diseases is noticeable.
Existing trends of the population morbidity and mortality denotes to the fact that in some cases their structure will gradually approach the similar indicators of developed countries; though indicators characterizing for the developing countries will be preserved.

This is supported by the fact that reference of patients with some chronic diseases to health facilities significantly reduced.
The registered reason of their death is not the disease which really caused the death, but some diagnosis of previous years or a disease adjusted to the age.

This is why frequency of some pathologies in the reason for death and requires clarification by comparison of rates of registered disease.
The existing situation requires the immediate intervention and appropriate measures as trends of demographic development of the country’s population is less known for public and caused indifference concerning the problems arisen in healthcare system.
Influence of the population life conditions on the medico- demo-graphic indicators 5 0 According to the data obtained by the State Department of Statistics from the study carried out 1997 the average number of able-bodied population over 15 was 713, 9 per 1000.

631 of them worked (226,3 were employed, 368,4 self-employed) and unemployed 51,8.

In spite of existing high level of unemployment only a part of unemployed people was registered.
The average monthly income of employed population according to the economic sectors is as follows: • • Budget organizations and institutes - 48,6 State enterprises - 38,7 Lari Lari • Nonstate enterprises - 36,8 Lari • Foreign or joint ventures - 69,3 Lari The study revealed that males had 20-50% more income than females.

This difference was not so obvious in the past.

It is noticeable that monthly income of one household was much lower than established cost of consumers basket.
For example, the average monthly incomes were as follows: • employed work - 32,9 Lari • self-employed - 26,5 Lari • selling agricultural products - 18,1 Lari • pensions, scholarships, other premiums - 8,3 Lari In addition, incomes from farming in rural regions were 30-40% less than in urban regions.

According to the structure of monthly expenses calculated by the State Department of Statistics, expenses on food of the country’s population made up 40,8%, on transport - 6%, heating - 6,7%.
Expenses on education, cultural activities and rest sharply reduced.

This situation has negative effect on the health of population.

It must be stressed that population spends only 2,5% of the total expenses on health (including purchasing of medications, covering ambulatory and hospital expenses through co-payment, etc.).

It is interesting that expenses on health are nearly equal to the expenses on purchasing tobacco and alcohol.

It denotes that people are not practicing health behavior.
The situation becomes more complicated.

According to the existing evaluation the level of the population poverty became higher and in 1998 it made up 50,2%.

This figure is 6,0% higher in comparison with the one of the previous year.

The indicator increased by 11,6% in urban areas and made up 67,5%, and by 3,0% in rural regions and made up 48,3%.
Journal of Health Sciences Management and Public Health The level of poverty represents the general trend of poorness, but it does not reflect the condition of poor people.

A more realistic and delicate indicator is the depth of poverty, expressing the grade of poorness against the limit of poverty.

In 1997 the depth of poverty was 16,1%, in 1998 - 19,5%.

This means that the poor population became poorer and moved far away from the minimal living standard.

The severity of poorness increased as well.


It shows inequity among the poor families.

In 1997 it was 8,1% and in 1998 - 10,2%.

Extremely high levels of poverty exist among the lonely people.

This takes into consideration that this category is mainly represented by elderly population the state has to make big contributions in their medical care and social security.
The carried out studies revealed that in the structure of the expenses of the poorest population, expenses on food had the leading position, while the least amount of money was spent on education and cultural activities - 1,6%, and on transport- 2,3%.

Population expenses on transport increased to 7,2%, on rest - 3,9% and purchasing utensils and other goods - 10%.

The country’s population undergoes rapid division into different social layers.
The differences are not only in economic, but also in socio-cultural characteristics of this layer.

In 1998 the number of families with income of 800-1500 Lari increased to 7,4% in comparison with the last year indicator 6,9%.

This can be compared with rich families with income of more than 1500 Lari became 1,2%.

Difference in basic health indicators became very obvious as well, especially between the poorest and comparatively well of layers of population.
The existing situation is proved by the fact that well off population spend 20-30% less on treatment and purchasing of medications.

It is quite understandable as poverty is always accompanied by high level of morbidity and correspondingly with the increase of medical expenses.

This year, by order of the Ministry of Health, a special study, aiming to compare the health state of two groups of Tbilisi population of lower and high income, was held (figure 5).
It was found that health indicators of the poor people was much worse than expected.

This situation should condition high needs for corresponding medical care.

Despite the 5 1 Journal of Health Sciences Management and Public Health includes beans, different cereals, vegetables and fruit.

However, impoverish of the diet conditioned by lack of meat and diary products significantly effects health of population.
This situation partially conditions the process of deceleration (retardation of children’s and adolescent’s physical development).

It has reflected in low indicators of physical development of young population.

Besides, pathologic conditions connected with malnutrition became very frequent.

In this regard the condition of IDPs from Abkhazia is extremely severe (Table 8).
Special study proved that low income, bad living conditions, malnutrition and unemployment cause social isolation of a person and increase of frequency of connected with it somatic and psychic disorders.

Significant statistical increase of indicators of morbidity and mortality is found.

Despite the fact that this layer of population is mainly provided by adequate and free medical care, extremely low reference to physicians exists.
Very rarely a patient refers to a health facility immediately after detection of a disease.

Mainly, reference of this contingent to physicians is extremely low.

At the same time, the representatives of the higher social class are not only healthier, but are characterized with high medical activities.

Their major part refers to a physician not only in the case of illness, but on purpose of prevention as well, and pursue healthy life style.
The poor class are not an invariable part of population, as they are part employed in some instance.

Income is closely connected with socio-economic situation existing in the country.

This group includes public workers, IDPs and pensioner.

Variation of their incomes is connected with timely and full paying of salaries, pensions and premiums from the state budget.

The dynamics of food products consumption significantly changed in recent years and greatly depends on the above mentioned factors.
According to the available data everyday diet of the most part of the population includes mainly bread and bread products (65-85% according to the different social groups), vegetables (including potato) - 8-14%, fruit (by seasons) - 2-12%.

Besides, consumption of milk and diary products (2-8% according to the different groups), meat and meat products (5- 12%), sugar and confectionery (2-6%) significantly reduced.

There is a tendency of caloricity reduction in other countries.
This process is more accelerated in CIS countries and in Georgia.

Besides, caloricity of diet in South-Caucasus countries is lower than established physiologic standard (according to some authors it makes up 3200-2800 calories) (Table 7).
Making up for the deficiency of meat and diary products ingredients amino acids, proteins and vitamins, the traditional Georgian diet 5 2 Journal of Health Sciences Management and Public Health these patients have to refer to a physician, as disability caused by the disease results with unemployment.

Despite the fact that the majority of IDPs had been working in different fields of national economy during the prewar period, 26% of them do not have permanent source of income, 73% - do not work by specialty.
IDPs from Abkhazia being in extraordinary situation their majority is absolutely dependent on external conditions (temporary working place, social premiums, humanitarian aid, etc.).

Thus, its clear why 32% of respondents from IDPs estimate their conditions as the most severe, 44% of respondents consider that their conditions are hard, 21% think that the situation is satisfying and only 1% thinks that their living conditions are good.
Unemployment and having only premiums determine low incomes of IDPs, which moves them beyond the poverty limit.

Hard living conditions for a major part of the country’s population promotes the increase of share of such bad habits as tobacco, alcohol and drug abuse.

According to estimation of UNESCO experts only in Europe almost 500 thousand people die annually due to smoking, more than 630 thousand people die in India due to the same reasons, in South Africa - 10 thousand, etc.
Carrying out the active measures against tobacco abuse conditioned decrease of demand for such products in developed countries (e.g.

in 1990-1995 tobacco consumption decreased by 9% in Sweden, by 6% in Australia and New Zealand, etc.).

Therefore, attention of tobacco producing transnational companies was shifted to markets of developing countries (among them former Soviet Union countries), where neither legislation nor public opinion is ready for carrying out effective antitobacco propagation.
Moreover, marketing of tobacco production in this regions is more profitable (due to cheap working power, possibilities of sell nonstandard products, imperfectness of revenues taxation regulations and other reasons).

To enlarge markets, the main emphasis is shifted to the attraction of new groups of permanent consumes (firstly it concerns young people, minors, women, etc.).

It is achieved by means of advertising campaigns, low prices of the products, etc.
In recent years, through implementation of new policy, transnational companies obtained the greatest profit, instead of expecting loss.

It is important to note in the last decade the comparison with Europe where demand for tobacco products per adult reduced by 7%, in USA and Canada by 6%, in Africa it increased by 42%, in South America by 29% and in Asia by 22% (Table 9 ).

Situation in CIS countries and among them in Georgia became very complicated.
The number of tobacco abusers, especially among the young population rapidly increases.

Some definite studies revealed that average age of stable tobacco consumers decreases.

This indicator significantly increased in women.

So, nowadays the share of tobacco consumers in Georgia is much higher than the same indicator of the most European countries, where demand for tobacco products steadily reduces.
tradition of moderate consumption of wine and other alcohol drinks conditioned low level of alcoholism until 90s.

But, at the same time so called “everyday” Ancient 5 3 Journal of Health Sciences Management and Public Health consumption of alcohol, mainly of wine is very characteristic for Georgian reality.

Certainly, it negatively affects the health of people (cardiovascular, endocrine, digestive and other systems).
In the following years, the situation became more complicated due to hard political and especially economic situation, selling of alcohol drinks in damping prices, and production of low quality wine and other alcohol drinks.

One of the serious problems is the forgiving attitude of the society and high consumption of alcohol by young people.

These factors significantly promoted the increase of alcohol consumption among young population and women.
The study revealed that 90% of females respondents under 18 consider that alcohol consumption is a bad habit, 50% of them consumed alcohol irregularly, 80% from 300 female respondents above 18 consumed alcohol (70% periodically, and 10% systematically), 70% of them also considered that it was a bad habit.

The deterioration of narcologic services functioning till 1991, was a great harm for anti- alcohol and anti-drug abuse activities.
At present, efforts towards restoration of this system are carried out, but due to financial problems achieving desired results is very 5 4 difficult.

In 1998 200 alcohol and 340 drug abusers and 37 toxicomans consuming different substances with narcotic effect are registered by first detected diagnosis.

These figures do not reflect the real situation and their number is much higher.

In 1998 9428 chronic alcohol abusers were registered (table 10).
Due to weakening of the frontier – guards, especially in the beginning of 90s Georgia became one of the transit countries for passing narcotic drugs from Asia to Europe.

The other way for passing narcotic substances is from North Caucasus.

Despite strengthening of administrative measures narcotic and toxic substances easily reach their consumers.
The dynamics of the entrance of narcotic drugs in Georgia is: until 70s cannabis marihuana and some handicraft narcotic substances were in use, in 80s narcotic drugs of opium group were added (such as opium and morphine), in 90s new, extremely drastic drugs (buprenorphin, alphametilphentanil and cocaine) appear in an illegal turnover.

In 90s the types of consumed narcotic means obviously changed.

Opium, morphium and morphine have leading position in this regard.
It denotes that narcotic substances enter from Central Asia and other narcobusiness centres of golden crescent.

Their range (hashish, codeine, etc.)

enlarged due to activation of the North-Caucasus way.

National composition of drug addicts, consumers and toxicomans has been changed.

According to data of recent years the contingent of drug addicts was mainly multinational, the major part of them is represented by Georgians.
The existing situation conditioned that the major part of drug addicts is unemployed.

If in recent years, employing of this contingent was in the focus of attention as from governmental structures, so as from local authorities lately labour rehabilitation of drug addicts is out of public notice.

And as an outcome – 91,4% of this contingent is temporarily or completely unemployed.

According to evaluation of international experts Georgia nowadays is harmed by drug addiction.
Drug addiction is widely prevailed among youth and minors.

It involved women.

Living conditions of population is significantly effected by level of fulfilling of Journal of Health Sciences Management and Public Health obligations by state in healthcare system.

Studies carried out by experts of Ministry of Health and international organizations made obvious, that about 300 mln Lari is spent on healthcare in Georgia (it makes approximately 60 Lari per capita), 87% of this amount is out of pocket payment.
In 1996 healthcare more or less got amounts determined by the budget, so it was possible to legalize 10mln Lari paid by population to health facilities.

During the next two years, reduction of financing of state healthcare programs was followed by reduction of legalization of money paid by the population.

If we consider that healthcare budget in 1998 was fulfilled by 58% existence of so called “shadow market” should not be a great surprise.
The existing situation shows that getting the necessary amounts for maintaining the minimal living standard for the major part of population, is more and more difficult.

Despite the extreme need, this contingent gets round of referring to the health facilities for medical care.

This is the first step to their disability and early death.
saqarTvelos mosaxleobis janmrTelobis mdgomareobisa da demografiuli ganviTarebis ZiriTadi tendenciebi oTar vasaZe, oTar gerzmava ukanaskneli aTwleulis ganmavlobaSi saqarTveloSi arsebiTad Seicvala demografiuli mdgomareoba, ramac mniSvnelovani gavlena moaxdina mosaxleobis aRwarmoebis dinamikaze da mis prognozul maCveneblebze.

Sobadobis gamokveTilad Semcirebis fonze daCqarda mosaxleobis daberebis procesi.
situaciuri analizis Sedegad dasaxulia rigi RonisZiebebi, romlebmac xeli unda Seuwyos arsebuli mdgomareobis gaumjobesebas.

5 5 Journal of Health Sciences Management and Public Health THE IMPORTANCE OF PROFESSIONAL IDENTITY IN HEALTH SERVICES MANAGEMENT Robert J. Spinelli1, Daniel J. West2 Abstract Establishing professional identity in the field of health service administration is essential for the development of the profession in Georgia.
Use of professional organization member- ship is critical to enhancing professional identity and societal recognition of the profession.

Appropriate management training and the use of services provided by professional organiza- tions enables individuals to become leaders in their professional disciplines, and offer signifi- cant contributions to the health care profession and community.
Introduction Professional identity is the cohesiveness created among professionals who share a given discipline that instills common professional beliefs, goals, and objectives.

Within the field of health service administration, one of the most important career objectives for an individual is to establish professional identity and have a code of ethics.

These elements allows the health care professional to contribute to the field and develop appropriate recognition among and between other disciplines.
Effective communication between disciplines reduces barriers and increases interactions with peers to enhance professional outcomes and improve the delivery of health care services and systems in the community at large.
This paper examines the key elements of a profession and addresses the importance of professional organizations in the process of forming a professional identity, a professional code of ethics, benefits of membership within professional organizations, and examples of professional organizations for health service administration.
1MPH, MBA, President & CEO, The Bloomsburg Hospital And Affiliated Faculty Member Department of Health Administration & Human Resources University of Scranton 2 Ph.D., FACHE, FACMPE, Associate Professor, Depart- ment of Health Administration and Human Resources, University of Scranton 423 McGurrin Hall, Scranton, PA 18510, Tele: 570-941- 4126, Fax: 570-941-5882, Email: westd1@uofs.edu 5 6 Central and Eastern Europe and The NIS Countries It is in the direct interests of the United States to build partnerships for health and to exert greater leadership in transnational health problems.
Global health transcends national boundaries and has become a more pronounced issue in the globalization of the world economy.

As U.S. business leaders are responding to rapid globalization, professionals and educators in the health sciences can provide creative and entrepreneurial leadership in the areas of research and development, surveillance, education and training, global partnerships, coordination and leadership (Institute of Medicine, 1997).
A significant reorientation and restructuring of health services and systems is needed in Central and Eastern Europe (CEE) and the NIS to address economic pressures, social-political disequilibrium, and primary health care needs of people.

Planning or strategy development is one of several processes needed to navigate and manage change (Rice, 1994).
New strategies, paradigms and models must address health management education as well as broad-based institutional restructuring to achieve a market- oriented health care sectorial transformation (Cleland, 1994).

Global health advocacy is in the best interest of all nations in a global health village.

simultaneously In Georgia, democratization and a free market economy has resulted in immediate opportunities for change in the health care sector.
However, with a severely depressed economy, the sustainability of health system changes is a major problem (West, Krcmery, Rusnakova, Murgas, 1998).

CEE/NIS countries have focused on cost control measures to respond to economic pressure which has created social - political concerns regarding access, quality and health status.

The reform debate on health policy coupled with incremental changes has precipitated social tension and disequilibrium in organizational structures (Saltman, Figueras, 1997).
Transformation efforts of the health care sector in Georgia employs strategies of privatization, liberalization, decentralization, marketization and transnationalization.

There is little empirical evidence concerning the effectiveness of these approaches to reform policy and responding to macroeconomics pressures.

Given the chaotic nature of economic reform and democratization processes, new approaches/models are needed to address discontinuous changes requiring nonlinear interventions.
Global intersectorial action through transnational cooperation and partnerships requires collaborative strategies to address inequities between and within CEE/ NIS countries (World Health Organization, 1998).
creates discontinuities Movement from a state of socialism to a free market economy requires the preparation of health care managers who will be able to provide leadership on complex issues, respond to change and develop new organizational structures, services and systems of health care (West, Krcmery, Rusnakova, Murgas, 1998).

Change and disequilibrium conditions requiring global teamwork and collaborative interorganizational relationships.
Health sector reform and transformation requires the existence of a variety of social structures to implement strategies of localization, harmonization and optimization of resources between providers, the public and consumer.

This is especially true when attempts are made to shift responsibility from government to the private sector using privatization policy and strategy.

Health care transformation efforts in CEE/NIS requires effective and systematic management.
The development of health care management infrastructure needs to be addressed at several levels: university prepared managers, education for established managers, and a systematic continuing education process to maintain current skills and knowledge.
Establishing a new system of health care Journal of Health Sciences Management and Public Health management capable of responding to current changes and future initiatives (demands) in the CEE/NIS region is a challenging task (Aaronson, West, Heshmat, Ramirez, 1998).
Aaronson and West (1997) in the introduction to a special issue of the Journal of Health Administration Education state: “In any paradigm shift, academia has the opportunity to contribute to the development and understanding of the new paradigm.

At the core of the philosophical shift from state socialism to free market economies is the central role of management in the capitalist enterprise.
Academic institutions that are preparing the next generation of leadership for health care enterprises can have a profound effect on the ability of management to achieve the skill and confidence levels necessary to become change agents.” Professional Organizations One of the most significant ways of identity and establishing professional contributing to development of new paradigms for change is through membership in professional associations.
Professional associations have clearly defined missions, goals, and objectives established to assist members.

Professional organizations give members an opportunity to develop a professional identity with their peers as well as provide recognition for what society refers to as a “professional”.

These organizations focus their efforts on providing the highest quality of professional development services (i.e.
continuing education, support services) to ensure that members provide proper standards of management for organizations in order to facilitate the best possible care to customers and various stakeholders.

Professional organizations focus on creating leaders, not managers.

The work of Bennis and Nanus (1995) as well as Covey (1989) helps to explain and differentiate managers and leaders.
In the book Leaders, Strategies for Taking Charge, leadership is defined as a “morally purposeful and elevating: allowing higher degrees of consciousness, including liberty, freedom, justice, and self- actualization” (Bennis and Nanus, 1985).

5 7 Journal of Health Sciences Management and Public Health Management is defined as “a set of contractual exchanges or agreements that result in association compliance” (Bennis and Nanus, 1985).
Leaders, through development of knowledge, skills and abilities (KSAs), match vision with key organizational values and mission to create social, political and economic support systems.

Managers do not have the ability to create vision and in actuality create an environment in which power is rooted in their position.

Management is more task oriented while leadership involves empowerment of individuals.
“Management means doing things right, while leadership means doing the right things.” (Bennis and Nanus, 1985).

Covey in his 1989 book “The Seven Habits of Highly Effective People” offers the following difference between leadership and management.

“Leadership is primarily a high powered, right brain activity.

It is more art than based on philosophy, while management is more left brain activity which involves analyzing, sequencing and specific application of activities (Covey, 1989).
In sum, leadership involves the ability to impart vision, values, and creativity.

It is decision-making and prioritizing, constantly adjusting the current system, creating opportunity, excitement, and energy in an organization.

Leaders create synergy throughout all parts of the organization.

Professional organizations and associations seek to develop individuals who are leaders in their field.
When the individual succeeds, the professional organization succeeds, as well as the professional health care management team.

Standards of the Profession Drastic changes have taken place in the scientific and technological base of medicine which have significantly altered the delivery of health services and the development of health systems.

These changes affect every health care professional but have particular relevance to health services administrators.
The delivery of health services occurs within the context of some type of organization, and therefore health services administrators must be concerned with the human, technological and physical resources that make the modern practice of medicine possible.

The key elements for the health management profession includes a unique body of knowledge, collegial relationships, services orientation and a societal mandate to practice.
These key elements of the profession occur within the context of management as an art with a strong scientific base.

Managers must learn how to make decisions, establish objectives, structure organizations, motivate people and manage resources.

Health service administrators think in terms of the management process which implies specific actions taken to reach certain endpoints or produce certain outputs.
Longest (1990) defines management “as process, with both interpersonal and technical aspects, through which the objectives of the health services organization are specified and accomplished by utilizing human and physical resources and technology.” In the practice of management, there are specific functions performed or facilitated which include planning, organizing, directing, coordinating and controlling.
Katz (1974) identified three types of skills needed in the practice of management which includes technical skill, human skill, and conceptual skill.

Katz further suggests that not all managers will need to utilize these skills but that every manager must rely on these skills in the performance of their work.

Mitzberg (1975) contends that understanding the manager requires an examination of the different roles played by the manger in fulfilling managerial include responsibilities.
interpersonal roles, informal roles and decisional roles.

These roles In addition to understanding roles and functions of managers, it is also possible to look at health services administrators from the standpoint of standards utilized in the profession.

Some of these standards have values which underlie fundamental behaviors.
In order to implement the elements of the health management profession, it is possible to operationalize professional behaviors through several venues: 1) 2) 3) professionalism, 4) professional identity, a sense of direction, 5) a life style, 6) refined skills, 7) 8) governance, 9) professional autonomy 10) interdisciplinary practice.
a special way of life, continuity of purpose, 5 8 Journal of Health Sciences Management and Public Health Health service organizations operate in a high velocity environment involving continuous change and the health services administrator is subjected to this same dynamic world.

How the manager responds depends in part on professional identification, recognition and KSAs.

Special Way of Life Health service administrators are held to higher personal standards by the profession and society.
There are significant expectations from the community and consumer.

Each professional organization requires that certain professional standards be met via implementing a code of ethics as well as maintaining certain educational standards.

Senior health care executives find every aspect of their life affected by their chosen profession.

Continuity of Purpose Health service administrators must have some type of vision for the future.
Although it is impossible to accurately predict what will occur in the future, administrators engage in a planning process whereby certain decisions lead to achieving specific objectives and/or outcomes.

Health service administrators have as a core purpose the provision of high quality, cost effective care for the patient.
This overall purpose and direction permeates the health service organization and provides a continuity of purpose for the organization as well as developing an important corporate culture.

Finally, the provision of health services normally requires a 24-hour operation by the organization, and as such, health service administrators practice the profession across all areas of their life, 24 hours per day, 365 days a year.
Professionalism The health services profession can be described as heterogeneous as compared to other industry which has a more homogeneous work force.

Professional disciplines in health service organizations have different levels of training and service requirements to the profession and community.

However, the higher standards for health services administration requires the ability to work with multidisciplinary teams in interdisciplinary settings.
The harmonization among and between professions is difficult to achieve in most health service organizations but specific professional behaviors must be present and exhibited by the health service administrator in order to allow professionalism to be part of the culture of the health care organization.

Health service administrators are committed to ongoing education, teaching, service and scholarship within the health organization and profession.
Professional Identity Health management is a unique profession encompassing a specific body of knowledge, skills and abilities.

A sense of identify is derived from this body of knowledge in addition to the professional commitment and responsibilities to the community.

Health service administrators work in organizations with multidisciplinary teams which require professional socialization skills, as well as an ability to differentiate management functions from clinical functions.
Sense of Direction The overall direction that a health service organization takes really comes from the various roles played by the health services administrator and management staff.

As previously indicated, it is essential for the manager to have purpose and vision within and for the organization.

This is translated into a very specific mission statement and a well articulated vision which has goals and objectives to carry out the management process.
Important to this process is that the health service administrators have mature values and beliefs that cultivate and encourage professional socialization and generates a positive culture for the provision of health services.

Following the Hippocratic oath and obligation of doing no harm to any patient, the administrator must always advocate truth and social justice in the pursuit of knowledge and provision of services within health care systems to patients and society.
A Lifestyle Administrators in the profession are motivated by core values and fundamental principles related to the provision of health services.

As the professional interacts in the health care organization, the same person lives in the community and interacts with society.
Service to society is important in meeting 5 9 Journal of Health Sciences Management and Public Health specific obligations of the profession, and it is essential that positive attitudes and character be exhibited at all times by the administrator.

This is often referred to as authenticity and congruency which are important characteristics and qualities for health care leaders to exhibit within an organization, the profession and community.
Refined Skills Health services administrators and leaders must develop specific skills related to the body of knowledge of the profession.

At a more personal level, administrators engage in a continual process of introspection and reflection as they lead an organization into the future.

Articulating the vision for an organization requires the ability to develop refined intrapersonal as well as interpersonal skills.
Coordinating interdisciplinary and multidisciplinary teams in a heterogeneous environment is extremely difficult.

Maintaining confidentiality at all times, offering services in the best interest of the patient, as well as making decisions that are proactive requires the development of refined skills in the practice of management.
Finally, social activism is necessary in order to solve difficult problems that exist within the organization as well as the health care community in which the organization, resides.

Governance Managers affiliate with professional organizations and associations for several reasons.

Each organization, specific to a discipline of health services administration, has a code of ethics and articulated values that provide guidance to the manger and leader.
Each profession requires different levels of licensure and certification so that specific standards are upheld and maintained in the provision competent care to the patient.

Another unique element to the health care profession is the degree of self-governance required in addition to regulations provided by state and federal regulators.

If health service administrators fail to follow a code of ethics and maintain appropriate standards, they may be subjected to specific sanctions in the profession.
Finally, in order to maintain the KSAs required by the health services administrative profession, lifelong learning is a commitment necessary to maintain a mature and positive professional identity.

Professional Autonomy Another unique element to the health care professions is the ability to engage in critical thinking.

Additionally, professionals appreciate the importance of intellectual property within a knowledge organization.
Leaders value and support academic freedom and freedom of inquiry within the organization and attempt to cultivate among the other professionals an atmosphere and culture that generates new ideas and enthusiasm.

At the same time, health care leaders respect and appreciate the KSAs of other professional disciplines and the need for self governance by the various professions.

Interdisciplinary Practice As discussed earlier, health care organizations require the use of interdisciplinary teams.
The heterogeneity of the professions within health organizations means that individuals must appreciate the skills, knowledge and abilities related to other disciplines.

Implementing appropriate strategy and achieving objectives requires contributions from various disciplines empowering others, and encouraging professionals to work in health care teams.
Inter-intra-extra professional actions and activities are extremely important in achieving specific outcomes especially in the area of evidenced-based medicine.

Health care organizations need to reflect a cultural of collaboration and cooperation through interdisciplinary teamwork following a strategy to improve health care in the area of accessibility, cost and quality of care.

Graduate Education Continuing post-graduate education is an excellent way to assist individuals with professional identity.
Achievement of a masters’ degree in the field of health care management helps an individual acquire the KSAs needed to be a leader in a given discipline.

Graduate and post-graduate degrees also assist individuals in advancement within their own professional societies.

For example, the American College of Healthcare Executives (ACHE) acknowledges individuals with graduate education to advance faster within ACHE than those without such education.
Advanced educational training and extensive examinations are necessary to advance within the organization 6 0 Journal of Health Sciences Management and Public Health and obtain the status of a Certified Healthcare Executive (CHE).

Individuals with graduate education have the necessary KSAs to prepare them for the written and oral examinations in the advancement process.

Benefits of Professional Associations Establishing professional identity is important for key health care stakeholders.
Maintaining affiliation and membership in recognized associations has several distinct benefits: 1.

Professional healthcare associations provide up-to-date information regarding the key events in the field of health care management; 2.

A professional code of conduct and ethical guidelines; 3.

A body of knowledge; 4.

Networking and monitorship; 5.

Access to research and scientific literature.


All of these elements bring together the most current and dynamic trends that are occurring in the health care industry, giving the individual member of the organization the most up-to-date information and research to properly lead their organizations.

Members of professional organizations also have an opportunity to submit articles for publication in association journals helping to contribute knowledge to the development of the profession.
Educational Programs Through affiliation in a professional organization, several venues of continuing education are made available to members.

These can be in the form of conferences, or specific topics targeting an individual’s interest within the professional organization.

Educational programming is open to all members of the professional organization and members are usually given discounts to attend these seminars.
It is also a requirement by the organization for executives to attain continuing education units or CEUs to continue membership; that is, in order for an individual to stay current in their field, they must continue to grow, learn and develop.

Obviously self growth and development requires structured educational programs to enhance self-learning.

Networking Networking allows members to develop relationships between individuals who share similar goals and interests.
Professional organizations provide the ideal venue for executives and managers to meet each other and to facilitate the networking process.

It is very important for professionals to share knowledge and experiences with other members, thus helping foster career development.

Professional socialization allows individual members to form professional and personal relationships with other members of the organization and allows the professional society to continue to form a strong bond among its members.
Mentorship and networking enables professional colleagues to seek guidance and support when encountering difficult issues in the profession.

Professional Code of Ethics / Value Systems One of the substantial benefits of maintaining membership in a professional organization is that the members need to follow a professional code of ethics and value system within the discipline.
Members of the organization have guidelines and ethical positions on ways in which the practice of medicine and health care management should be practiced on a daily basis.

This value system can be incorporated into daily practice allowing a health care manager to develop a positive corporate culture.

The code provides individuals with an accepted response and course of action to rely on when ethical questions and crises arise within the organization.
More importantly, adherence to the code of ethics of the professional society ensures proper conduct in providing health care services to the community, patient, organization and other key stakeholder groups.

Career Assistance In order for an association to benefit its members, it also must help them with career advancement.

By developing opportunities for members to further their educational and career path, the professional organization becomes a in career development and vital advancement.
Services such as providing a listing of job opportunities in organizational publications, having career advancement link 6 1 Journal of Health Sciences Management and Public Health education information on the internet, and setting up job assistance programs for individuals who are members of an organization assists members.
Additionally, providing relevant and timely career continuing development vis-à-vis attaining certain levels of education within the field of health care management and insuring employers that executive maintain KSAs as a health care leader.

Finally, networking opportunities lead to career advancement opportunities among professional members of the association.

fosters Credentialing ACHE offers a credentialing program for its members.
Credentialing programs allow individuals to attain certain status, and advance within the professional organization.

Credentialing processes also help to prevent skill decay.

ACHE utilizes voluntary credentialing as a professional society whose mission is to increase effectiveness of health care management by providing high professional and ethical standards.

ACHE has historically promoted the achievement and maintenance of administrative competence in the areas of health services administration.
It does this through membership requirements which constitute a certification process involving education, examination, peer review, and adherence to ethical standards.

In addition, there are three different levels of affiliation with the organization; Associate, Diplomate and Fellow status recognizing the advancement of health care executives through the certification process.
The examination itself is periodically revised to reflect current policies and practices in the management of health care institutions, systems and delivery of health care services.

The health care profession is an applied discipline.
Credentialing gives individuals recognition by the professional organization and signifies to others in the field know that individuals have the skills and leadership qualities necessary to lead an institution through the dynamic changes occurring in a high velocity health care environment.
Opportunities for Leadership By being associated with the professional association, members will be given opportunities to participate in leadership situations where they can chair task forces, serve on committees, 6 2 councils, and commissions on health care thus giving individuals valuable leadership experience that contributes to career advancement and leadership development.
Legislative Representation Another important aspect within professional organizations is the ability to develop political interest groups, thus creating lobbying efforts on certain health care issues pertinent to health care leaders and the industry.

The association gives members a voice in what can be a very intimidating political arena.
The national association presents the issues to various legislative bodies allowing members the ability to continue to run their facility knowing that the issues important to their organization’s survival are being addressed by the professional organization.

One voice is typically not heard in the political arena, but the voice of thousands in the profession will be heard, thus assisting in facilitating political changes and public advocacy.
Civic Mindedness Professional organizations help to develop future leaders - leaders who will benefit the community and society-a-large.

This is an essential element in creating a professional identity by being a benefit to the community.
Professional organizations assist in the reshaping of thinking, developing the ability to see the community as a whole, giving members perspective on how their organization can benefit their community, and further assisting providers of care in shaping the future of health in the community.

Professional Organizations in the United States In the United States, professional organizations exist at local, regional, state, and national levels.
Members of these organizations come from a wide spectrum of health care occupations.

Examples of relevant professional organizations in the United States are the American College of Healthcare Executives (ACHE), Medical Group Management Association (MGMA), National Rehabilitation Association (NRA), the Association of University Programs in Health Administration (AUPHA), and the American Public Health Association (APHA), just to name a few.
Journal of Health Sciences Management and Public Health ACHE has a mission to be the professional membership society for health care executives; to meet members’ professional, educational, and leadership needs; to promote high ethical standards of conduct; and to advance health care management excellence.

ACHE is an international society of more than thirty thousand (30.000) health care executives.
The association is known for its prestigious credentialing and educational programs; members have the opportunity to participate actively in functions and activities at local, state, and national levels.

The association is dedicated to helping individuals achieve professional goals in the field of health care management, maintaining standards of excellence, and achieving national certification.

to MGMA is a national organization in the United States.
It has a mission to improve health care administration in medical groups; provide leadership and lay activity directly involving medical groups; collect information concerning present and proposed national, state, and local legislation pertaining to all areas of medical group management; and to promote the education of members through meetings, seminars, and written communications.
It offers members notice of upcoming educational sessions, discounts on the educational sessions, membership directory information enhance networking opportunities, and newsletters to keep people informed.

MGMA is in all 50 states of the United States and has a large and diverse membership.

NRAs mission is providing opportunities through knowledge and diversity for professionals in the field of physical medicine and rehabilitation.
NRA has been active since the 1920s in assisting people with disabilities.

It has continued to do that throughout its existence and has constantly supported legislation that assists individuals with disabilities.

The association is a leading advocate of rehabilitation for disabled individuals and rehabilitation professionals, and has been instrumental in changing rehabilitation services and systems in the United States.
As well as being an advocate for its membership, NRA provides its membership with continuing education, publications, and career development counseling to foster professional growth and development for its members.

The Association of University Programs in Health Administration (AUPHA) is a not- for-profit association of university-based educational programs, faculty, practitioners and provider-organizations.

AUPHA is dedicated to improving the field of health management and practice.
AUPHA’s membership also consists of more than 200 international administration programs and more than 100 affiliated health care organizations.

AUPHA is an advocate for research in management and the organization and delivery of health services, and is involved with promoting graduate and undergraduate curriculum reforms and faculty development.
The American Public Health Association (APHA) has a collective membership in access of 50,000 members representing all disciplines and specialties in the public health spectrum.

There are 24 special sections established along fields of discipline and special interest areas within the APHA organization.

APHA provides a prestigious monthly journal with strong advocacy activities at the federal, state and local levels of government.
Leadership opportunities include the ability to work on committees, holding office, conduct a seminar or workshop, and write papers for the professional journal.
This organization is devoted to the protection and promotion of public health through setting standards to eliminate health problems, initiating projects designed to improve health, conducting research on health problems, launching public awareness campaigns, and publishing numerous materials reflecting the latest findings and developments in public health.
The Association for Health Services Research (AHSR) is the only national membership organization formed exclusively to promote the field of health services research and to strengthen the relationship between users and producers of research.

A membership in AHSR is open to any individual or organization with an interest in health services research.
This national organization attempts to promote and strengthen the field of health services research, increase public and private finding for health services research, influencing the development and implementation of public and private sector policies concerning research, disseminating health services research findings, and educating the public on the need for health services research.
6 3 Journal of Health Sciences Management and Public Health Conclusion Professional health services administrators must embrace the concept of community- oriented primary health care and recognize the need to improve the process of public policy on health issues.

For health services administrators to become leaders, it is essential that appropriate education be attained and that leaders be able to assess their own strengths and weaknesses.

Every country engages in some type of process to improve health.
The progress of medical science has generated expectations regarding the cost, quality and access to health care.

Achieving and maintaining high levels of health in any population depends on solving problems, as well as understanding the importance of personal behavior, economic status, education, housing and other social factors that significantly affect health status.
Leaders in health services administration must help communities utilize limited resources and guide efforts to reshape health care delivery in communities.

Health care has no national boundaries.

The scope and accelerating pace of change in health and medical services provides health services administrators with an opportunity to demonstrate specific skills and abilities in achieving health service delivery system and service changes.
Developing new paradigms and methods for delivering health care requires managerial competence and ongoing training.

Of paramount importance in future of health services administration is acquiring and maintaining managerial competency and dynamic leadership.

The complexity and rapidity of the changes in health care mandate purposeful preparation for a career in health services management.
Formal professional education needs to be augmented with continuing education and strong affiliation with professional organizations who prepare people for a changing and dynamic industry.

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6 4 Journal of Health Sciences Management and Public Health profesiuli kompetenturobis mniSvneloba janmrTelobis dacvis sferoSi momuSave menejerebis saqmianobaSi robert spineli, daniel vesti jandacvis menejerTa profesiuli kompetenturobis zrdaSi erT-erTi prioritetuli mniSvneloba eniWeba aqtiurad momuSave profesiul organizaciebs (asociaciebs, kavSirebs), rogorc calkeul dawesebulebebSi, aseve qveynis an regionis masStabiT, vinaidan isini gansakuTrebul yuradRebas uTmoben uwyvet ganaTlebas da menejerTa kvalifikaciis amaRlebas.
profesiuli kompetenturobis gafarToebis saqmes mniSvnelovnad uwyobs xels sazogadoebis mier am profesiis aRiarebac.

6 5 Journal of Health Sciences Management and Public Health MODELING EMOTIONAL INTELLIGENCE IN ACADEMIC INSTITUTIONS: IMPROVING STUDENT GROWTH IN HEALTH ADMINISTRATION EDUCATION Steven J. Szydlowski1 Abstract Successful managers in business and health sector have specific skills, which are in direct relation with their professional growth.
At the same time the trainers of specific educational institutions are not ready to reveal the potential leaders timely.

Educational system mainly determines those determinants which support the students in development of only professional competence.

In the process of development of training program less attention is paid to those methods of training which fully reveal the potential abilities of the students and the skills necessary for the leader.
Introduction Successful business and health care leaders have many characteristics and traits that are correlated with career advancement.

In the academic setting the teacher is trained and the curriculum is designed to develop these traits in the student.
The academic system is expected to identify the characteristics to establish a core practical competence in the student, develop the knowledge base specific to the profession and humanities field, and use different teaching methods to assist the learner achieve highest potential.
Although new teaching theories for andragogy have been implemented to improve the growth of the student, several academic theorists suggest that the classroom setting ignores the need to develop emotional intelligence (EI) as part of student development.
Emotional intelligence, as opposed to intellectual intelligence, is defined as “the ability to monitor one’s own and others’ feelings and emotions, to discriminate among them, and to use this information to guide one’s thinking and actions” (Salovey and Mayer, 1990).

This includes the ability to control the mood of conversation and regulate the involved parties’ emotions.

The majority of academic curricula are designed and professors are trained to develop the intellectual intelligence of the student.
1University of Scranton, Scranton, PA 18510-4597, (Tel) 570-941-4367, (Fax) 570- 941-5882, Email:sjs14@uofs.edu This includes scholarly research, lectures on theories, models, concepts, etc., specific to the discipline, and continually advancing adult learning techniques.

Recent research suggests that emotional intelligence may be the main factor or trait of successful managers.

Research and Study Drs.

Jack Mayer and Peter Salovey2 are the co-founders of the EI concept.
Their work has launched a number of significant writings and research studies on EI that has supported additional thinking and development in the area of EI.

Daniel Goleman3 is probably the most notable.

Goleman (1998) suggests that the most important factor for senior managers who started at entry-level positions was emotional intelligence, not IQ, advanced education, or practice skills.
Goleman (1998) also reported in a study conducted in the 1950’s of 80 doctorate-level professionals, that EI was four times more important in determining professional success rather than IQ.

The professionals were measured over a 40 year time span from the 1950’s to the 1990’s.

Research in the early 1980’s suggested that 81% of the competencies that distinguished outstanding managers were identified as EI (Boyatzis, 1982).
Boyatzis (1982) studied over 2,000 supervisors, middle managers, and executives from 12 organizations.

Spencer (1993) found that of 21 competencies that distinguished excelled performers from average performers, 18 were related to EI.

Only two 6 6 of the 21 were related to Intellectual Intelligence or IQ.

Other studies have been conducted that support the importance of EI in successful people.
These studies and the advocacy for EI do not ignore the necessity intelligence and practical for average knowledge, to emotional in addition intelligence to perform the job functions and responsibilities.

Discovering Emotional Intelligence The two main competencies of EI, personal and social competence, are analyzed below.
1) Personal Competence: Managing Ourselves • Self-Confidence Self-Awareness (Emotional and Intellectual) - Accurate Self-Assessment - Self-Management - Adaptability Self-Control - Conscientiousness - - Initiative - Achievement - Trustworthiness • 2) Social Competence: Managing Relationships • • Social-Awareness Empathy - Service orientation - - Organizational Awareness Social Skills - - - Developing others Change Agent - Communication - Conflict management - Teamwork and Collaboration - Leadership Influence Personal and social competencies are essential traits for health care students and professionals to acquire and develop in order to become successful.
Effective management in the health industry involves tremendous interaction and management of human resources and networks.

Emotional intelligence provides the tool to achieve anticipated career and organizational outcomes.
Salopek (1998) suggests that improving emotional intelligence requires learning that is different from cognitive or Journal of Health Sciences Management and Public Health technical training; consequently, educators must take an active role in developing methods to facilitate EI development.

Structuring EI in the Classroom The instructor must first understand and develop EI personally to successfully teach or instill this growth experience for the student.
Once the instructor is qualified for and reaches an appropriate level of EI development, the teacher is properly prepared to make assessments for individual students are.

Confusion between the level of EI and personality may make the assessment difficult.

Personality is the instinctual image and behavior of a person.

Emotional intelligence is the ability to monitor and control emotions within self and others.
It is important for the instructor to understand the difference between “learned EI” and “unlearned EI”.

Some students have inate skills and abilities to control emotions and effectiveness of communication, other students have no experience.

Such intelligence is referred to as “unlearned EI”.

Regardless of the level of “unlearned EI”, it is safe to state that all persons can improve individual EI.

This area for improvement where the “learned EI” can be developed should occur in the classroom settings.
Another supporting study of 181 jobs in 121 worldwide companies has suggested that corporations hire MBAs with the desired capabilities of communication skills, interpersonal skills, and initiative (Goleman, 1998).

These are all elements of EI, not IQ or technical know-how.

Emotional intelligence is even more relevant for MHA students who are expected to perform managerial tasks and spend the majority of time interacting with staff, consumers, board members, the community, and other key stakeholders.
“Leaned EI” can be taught in different forms.

Epstein (1999) quotes Mayer when he suggests that “EI is like most other abilities which are partly genetic and partly the environment…[and] individuals can be taught what different feelings might mean and how they relate to yourself and others”(Epstein, 1999).
Goleman (1998) cites “best practices” for teaching EI competencies to include (Bates, 1999): - Assessing the individual and training specific to each person’s skill level, - Delivering assessment with care by 6 7 academic by administration and professors in the academic institution is critical for EI to be used in courses and across the curriculum.

Many and instructors do not understand the importance of EI in the development of successful health administration and business students.
This ignorance is the primary barrier to teaching EI.

administrators If EI has been approved for teaching in the institution’s classroom, the instructor will probably find some students unwilling to cooperate.

The instructor needs to demonstrate, through research and discussion, the importance of EI for student success.

Salopek (1998) suggests that the absence of assessing student readiness to participate is a major flaw of teachers.
Before the concepts and teaching methods for EI are used, the instructor must motivate students to understand and appreciate this new teaching methodology.

Conclusion Studies support the use of modeling and teaching emotional intelligence in the academic settings to develop traits that make students successful in the workforce.

Ignorance of EI by academic institutions and faculty is a disser vice to the student and creates a disadvantage in a competitive global business world.
Faculty and administration must accept the challenge and become trained in the area of EI.

Common guidelines must be developed and approved within the academic setting to meet teaching standards.

The goal of the teacher is to provide the student with the knowledge, skills, and abilities to become successful.
If the professor focuses only on theoretical models of systems and work environments, the student is not receiving the proven characteristics of EI that successful people need to succeed in applied settings past academic training.
Journal of Health Sciences Management and Public Health sensitivity and feedback - Motivating [students] - Focusing on clear, manageable goals - Arranged support though coaching and - guidance Reinforcing change through recognition In the classroom setting it is important to provide individual treatment of developing EI in students as well as class treatment.

This can be done through group projects, one-to-one exercise, or any method the instructor feels appropriate for the student and class demographics.
Barriers to Teaching EI Although research has been conducted in the area of EI and supporting data shows the importance of EI in the success and growth of students, most academic institutions have ignored or are unable to implement and teach EI.

The minority of academic institutions that have attempted and continue to teach EI have faced some barriers.
Harrington-Lueker (1997) states that schools who teach EI often face resistance from people inside and outside of school and are forced to explain their motives.

Resistance is a result of the greater community being unaware of the concept of EI and the correlation to successful people, as well as a belief that teaching emotions is too personal and violates student privacy.
Ratnesar (1997) states that many families with students under the age of 18 expressing personal feelings is a violation of family privacy due to the students talking about problems that may exist within the home.

The most intense barrier for teaching EI is probably the inability of people to accommodate change.

The status quo is comfortable for the academic instructor, the student, and administration.

Commitment 6 8 Journal of Health Sciences Management and Public Health References 1.
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Salopek, J.

Train your brain.

Training and Development, 1998, (52),10, 26-33.

Spencer, L. (1993).

Competence at work : models for superior performance.

New York : Wiley.
New York : Wiley.

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6 9 Journal of Health Sciences Management and Public Health HUMAN RESOURCE DEVELOPMENT (HRD) PROFESSION- ALS ROLE EVOLUTION: SHIFTING THE PARADIGM FROM INTROSPECTIVE TO “EXTROSPECTIVE” William G. Wallick1 Abstract The literature related to the roles that HRD professionals perceive they should play in organizations reflects an evolution from an introspective to an “extrospective” approach to defining the various roles.
This evolution is evident in role studies conducted in the past and is further evident in the more recent studies of HRD roles.

As a new direction toward defining HRD roles unfolds, we must discover and embrace innovative ways to identify the most essential HRD roles that are critical to the success of individual HRD professionals, the HRD profession in general, and the organizations we serve.
Keywords: HRD Roles, Introspective, Extrospective Roles of HRD professionals have been studied by a variety of researchers (HRD professionals, consultants, and scholars) over the past three to four decades.

The research focused primarily on shaping a framework of roles from which HRD professionals could operate.

The framework has been used to benchmark and compare the actual roles with the roles discovered and suggested by the various researchers.
However, the vast majority of the studies conducted were “introspective”.

This means that HRD professionals looked to fellow colleagues within the profession to identify the roles that could ultimately support and enhance the HRD profession.

Others have not substantially verified HRD professionals’ perceptions of their roles outside the HRD arena.

“The question of whether or not trainers have correctly identified the roles they are providing organizations has gone unanswered” (Bengtson, 1994, p. 1).
The accuracy of HRD professional’s perceptions of their roles in organizations is certainly questionable considering that most of the studies were introspective or self-assessing in nature.

It is essential to discover the most appropriate roles for HRD professionals in organizations from the perspective of other key organization members.
The focus from primarily an introspective approach to a 1 ABD, CHE, SPHR, Director Undergraduate Human Resources Studies Program, University of Scranton 403 McGurrin Hall, Scranton, Pennsylvania 18510, Tel.

: (570) 941-4128, e-mail – wgw1@uofs.edu somewhat more “extrospective” approach to defining roles began to evolve over the past two decades.
Wallick (1999) defined the term “extrospective” as a phenomenon whereby HRD professionals look outward to examine how their roles can be enhanced, supported, and shared by others within organizations.

“Extrospective” can be thought of as the antonym of introspective whereby HRD professionals reflect inward to examine how their roles can enhance and support the HRD profession.
Nine major competency studies were conducted between 1970 and 1989 that helped shape the HRD field and served to help increase practitioner’s awareness of HRD (Gilley & Eggland, 1989).

Each of the nine studies included various roles that the researchers found to be important and relevant to the practitioner’s success as HRD professionals.
Bengtson (1994) used the eleven roles identified by McLagan and Suhadolnik (1989) to compare the perceptions of HRD roles with those of CEOs in selected manufacturing firms.

The main purpose of Bengtson’s (1994) study was to determine if a gap existed between what certain CEOs perceived as appropriate HRD roles compared with the HRD professional’s perceptions of their actual roles.
Although there were many limitations to Bengtson’s (1994) study, the results of the research showed that CEOs perceived someone other than the HRD professional to be best suited for seven of the eleven roles identified by McLagan and Suhadolnik (1989).

7 0 Journal of Health Sciences Management and Public Health The McLagan and Suhadolnik study was the most complete and up-to-date study of HRD roles and competencies at the time Bengtson conducted her research.
Since that time other researchers (Rothwell, 1996; Piskurich & Sanders, 1998; Rothwell, Sanders, & Soper, 1999) have further studied perceptions of HRD roles.

However, their research included the perceptions of other organizational members such as line managers, staff employees, and information system staff members to assist in determining the most appropriate and valuable roles for HRD professionals in organizations.
Additionally, the scope of the more recent studies was greatly expanded to include organizations from around the world.

These researchers recognized that the role of the HRD professional could no longer be solely determined by the HRD professionals themselves but required a greater focus on systems thinking, which by its very nature, must include input from a greater representation of organizational members.
Initiated by Rothwell (1996), the concept of shared responsibility for HRD roles appears to have produced a favorable trend for the HRD profession.

Since his 1996 study (this was the first major undertaking to update McLagan and Suhadolnik’s 1989 work), the two most recent major role and competency studies have included the concept of shared responsibility.
The results of this current research demonstrate the value and the potentially positive effect that input from other organizational members can have on the HRD profession.

It is equally important to gain the input from the highest levels in the organization to further add to the value that HRD professionals can provide to an organization.
Foundational Role Studies In 1962 Leonard Nadler completed work on his doctoral dissertation which focused on the needs of selected training directors employed by the Commonwealth of Pennsylvania.

Nadler interviewed training directors, their subordinates, and their administrators to determine what training directors did and the “know-how needed to accomplish these tasks” (Nadler, 1962, p. 1).

He looked at tasks and know-how in terms of expected, actual, and ideal.
He determined that training directors performed the following tasks: obtain and control a budget; choose, purchase, and evaluate training equipment; provide leadership and supervision to training staff; determine needs, plan curriculum, conduct training, and evaluation; obtain and share information concerning training planned and accomplished (Nadler, 1962, p. 1-2).
In order to accomplish these tasks training directors needed to know: general administrative principles curriculum and practices; development, instructional materials, instruction, and general philosophical positions in education; how to use data gathering techniques to determine training effectiveness; how adults behave in work situations; the communication process (speaking, writing, reading, listening); the objectives of the state agency (Nadler, 1962, p. 2).
Nadler’s original research was important for three reasons.

First, it served as the basis for further research.

Lippitt and Nadler (1967) used the original research as the basis for a discussion of the emerging roles of the training director.

Second, the concepts of tasks and know-how were now described as roles.

And third, the work of Nadler and Lippitt (1967) served as the foundational framework for Nadler’s Model that described the three major roles of the human resource development (HRD) specialist.
The three major roles (as cited in Gilley & Eggland, 1989) were Administrator, Consultant, and Learning Specialist.

Nadler’s Model also inspired the research and development of other models, including enhancements and refinements to his own model.

The U.S. Civil Service Commission (USCSC) conducted another foundational study of trainer roles in 1973.

The purpose of the study was to investigate “(barriers) to effective employee development in the federal government” (Chalofsky & Lincoln, 1983, p. 37).
“The roles included career counselor, consultant, learning specialist, program manager, and training administrator” (Gilley & Eggland, 1989, p. 310-311).

Nadler’s Model was used as the basis for the USCSC study.

The USCSC study was important because it “provided a structure for the federal government (roles, competencies, and tasks), and it provided a standard of performance for HRD specialists” (Gilley & Eggland, 1989, p. 311).
7 1 Journal of Health Sciences Management and Public Health In March 1976 a subcommittee of the Ontario Society for Training and Development’s Professional Development Committee was formed to investigate core competencies of trainers.

The investigation resulted in the identification of four roles and eleven competencies that the subcommittee believed necessary to effectively perform the identified roles.

The four roles identified were instructor, designer, manager, and consultant (Kenny, 1976, p. v).
In 1982 Kenny authored an article in which he discussed the notion of trainer certification.

In that article, Kenny described the 1976 study of roles and competencies but stated that “we finally settled on 12 areas of core competency” (Kenny, 1982, p. 145).

The competency apparently missing from the 1976 report was research and development.

There was no explanation given by Kenny (1982) as to why the twelfth competency (i.e., research and development) was not mentioned in the original study.
This may have simply been an oversight on the part of the author.

Although the specific methodology used to identify the roles and competencies was not discussed, Kenny (1976) described a seven member working committee, six other members, and eight corresponding members who communicated about the perceived roles and competencies of trainers.
Additionally, the for Training and American Society Development’s Professional Development Committee as well as people in various community colleges were contacted for input regarding the study.

Lastly, a review of the then current literature was conducted and a partial listing was noted at the conclusion of the article in the bibliography.
The Ontario Society for Training and Development study has been and continues to be quoted as an important study in the field of training and development (Chalofsky & Lincoln, 1983; Gilley and Eggland, 1989; McLagan, 1983; Pinto & Walker, 1978; Rothwell & Cookson, 1996; Rothwell & Sredl, 1992).

Major Role Studies The major studies described below were all commissioned by the American Society for Training and Development (ASTD) and are discussed in chronological order.
The American Society for Training and Development (1978) “In 1976 ASTD charged the Professional Development Committee with the task of developing a role model for HRD specialists” (Chalofsky & Lincoln, 1983, p. 65).

After two years of brainstorming ideas the committee elected to use their work as a foundation for conducting “a national study of what HRD professionals actually do, rather than publish another theoretically based role model” (Chalofsky & Lincoln, 1983, p. 65).
The purpose of the study was to determine the competencies needed for effective performance in training and development and to create a research base for enhancing and refining those competencies as the profession continued to evolve.

Pinto and Walker (1978) defined role “as a set of activities performed by an individual in fulfillment of the expectations imposed by professional standards of behavior or employer position requirements” (p. 59).
They defined competencies as “the specific skills knowledge, abilities and other attributes, such as values and attitudes, necessary for effective role performance” (Pinto & Walker, 1983, p. 65).

The roles Pinto and Walker (1978) identified are listed in Table 1.

This study was significant first because of the large scope of the research.
Pinto and Walker (1978) surveyed over 14,000 ASTD members in the United States and in other countries that ultimately resulted in 2,790 usable surveys or approximately 20% of the surveys mailed.

Pinto and Walker (1978) noted that “since the questionnaire was developed for practitioners, a number of academics, consultants, students, vendors and retired members may not have been able to respond appropriately” (p. 60).
Second, the researchers used commonly accepted research methods to collect and analyze the data.

Lastly, the study has been accepted as foundational and continues to be cited in many references and texts (Chalofsky & Lincoln, 1983; Gilley & Eggland, 1989; McLagan, 1983; Nadler, 1989; Rothwell, 1996; Rothwell & Cookson, 1996; Rothwell & Sredl, 1992; Rothwell & Soper, 1999).
Models for Excellence (1983) In 1981 the Professional Development Committee of ASTD commissioned a Training and Development Competency Study known today as Models for Excellence.

One underlying reason for the study was to examine relevant 7 2 competencies as a basis for a meaningful discussion on the topic of certification for trainers.

Patricia McLagan was named director of the study.


She and her team were charged with developing a model that would provide a detailed and current definition of excellence for training and development professionals that could be used as a standard for performance (Gilley & Eggland, 1989).
McLagan’s (1983) methodology consisted of a series of studies that were specially designed to accomplish seven steps: 1) Determine the domain of the training and development field; 2) Determine the key roles for the [training and development] T & D field; 3) Identify the major environmental forces expected to affect the field in the near future; 4) Identify the critical outputs which the T & D function is expected to produce; 5) Identify the critical competencies for the T & D field; 6) the Develop behavioral anchors competencies; and 7) Cluster the roles to reflect common competency requirements (p. 7).
for Ultimately, McLagan’s 1983 study Models for Excellence defined the training and development field by firmly identifying it as a specialty area within the larger context of the human resources field.

Further, the study focused on assisting professionals to change through learning by providing a future-oriented description of the field that could be used to select, manage, and develop professionals (McLagan, 1989).
Additionally, the results of the study “defined training and development work in terms of results or outcomes rather than tasks and activities, which was the focus of many other studies” (Gilley & Eggland, 1989, p. 318).

The study identified training and development as one of nine specialty areas in the human resources field that consisted of 15 functions or roles that required a body of knowledge to support 32 competencies and 102 outputs (Gilley & Eggland, 1989).
The fifteen key roles are identified in Table 1.

Models for HRD Practice (1989) The third major competency study called the Competencies and Standards Study was commissioned by ASTD in 1987 to build on and expand the results of the 1983 study.

The study is better known today as the Models for HRD Practice.
Assisted by a large task force of human resource development (HRD) experts, McLagan and the task force were charged with Journal of Health Sciences Management and Public Health conducting the study, communicating its results, and developing a plan for applying the results (McLagan & Suhadolnik, 1989).

There were key differences between the 1983 and the 1989 studies.
Specifically, the 1989 study covered the field of HRD rather than just training and development, included standards of quality for the HRD outputs, and identified major ethical issues facing HRD professionals (McLagan & Suhadolnik, 1989, p. 2).

HRD roles were defined as “roles that individuals in HRD will perform in the future and that encompass the range of responsibilities and functions that define HRD work” (McLagan & Suhadolnik, 1989, p. 69).
and Suhadolniks’s Pinto and Walker (1978) surveyed all ASTD members as a part of the methodology used for their study.

In contrast McLagan’s methodology was specified by ASTD to include only a task force of individuals at the forefront of HRD (McLagan & Suhadolnik, 1989).

McLagan (1989) methodology was similar to the methodology used in McLagan’s (1983) study.
“Selected HRD experts reviewed and expanded on the results from the 1983 study to produce a preliminary HRD model consisting of future forces, outputs, quality requirements, competencies, and ethical issues for identified HRD roles” (McLagan & Suhadolnik, 1989, p. 7).

This review produced an initial draft of an HRD model that was subsequently revised to produce a second draft model, and then a final HRD Model.
The results of the study produced a list of future forces likely to have a significant impact on HRD and HRD professionals; 11 functional HRD roles; 74 outputs that HRD professionals must produce or provide to others; 35 competencies necessary to produce HRD outputs; major ethical issues facing individuals in HRD; role profiles for each role that describe the outputs for the role, the quality requirements for each output, the competencies needed to produce the outputs, and the major ethical issues facing individuals in each role; and role clusters that identify roles with similar critical competencies and linkages between them (McLagan & Suhadolnik, 1989, p. 17).
The 11 roles identified in the 1989 study are listed in Table 1.

The ASTD Models for Human Performance Improvement (1996) The fourth major ASTD-sponsored competency study was 7 3 Journal of Health Sciences Management and Public Health Table 1.

Comparison of Trainer Roles Identified in 6 Major Studies ASTD Models for Human Performance Improvement (Rothwell, 1996).

The study builds upon the work of Pinto and Walker (1978), McLagan (1983), and McLagan and Suhadolnik (1989).
The purpose of the study was “to lay the foundation for future work on human performance improvement” (Rothwell, 1996, p. 2).

Rothwell (1996) used commonly accepted research methodologies to conduct the study.

He first prepared an extensive review of literature on relevant competencies.

Next, he gathered a panel of experts to select the competencies that they believed were most relevant to the study of human performance improvement.
Rothwell (1996) identified four roles tied 7 4 Journal of Health Sciences Management and Public Health to human performance improvement work, identified 38 competencies, including 15 core competencies, “needed by those who perform human performance improvement work” (Rothwell, 1996, p. 18).

One major limitation of the research is its lack of empirical rigor.

But Rothwell (1996) clearly explains that the field of human performance improvement is fast and ever changing, requiring almost continual updating.
Empirical research may produce reliable and valid results but often results that are too outdated to be useful.

“Methodological rigor has been sacrificed to a certain extent in order to obtain faster, more current results” (Rothwell, 1996, p. 2).

This study was important to the field of training and development for two major reasons.

First, the study suggested that a broader, systems thinking view of the training profession was on the horizon.
Traditionally the HRD professional tended to bear the sole responsibility for assessing, designing, developing, and implementing programs and processes for improving performance within organizations.

The sole responsibility mindset appears to have been self-imposed.

For the first time the focus began to shift from trainers as the exclusive proprietors of employee development.
The study included suggested ways for both line managers and employees to participate and share in the responsibility for improving human performance through learning and management solutions.

Second, the shared responsibility concept suggested by Rothwell (1996) was used in the subsequent major ASTD competency study conducted by Piskurich and Sanders (1998).
They suggested that line managers as well as information systems staff should consider the roles they play in supporting the work of the HRD professionals.

for Learning Technologies (1998) The fifth major ASTD- sponsored competency study was ASTD Models for Learning Technologies (Piskurich & Sanders, 1998).

The study specifically examined the roles and competencies that training professionals needed to enable them to select, manage, and implement learning technologies in the workplace.
ASTD Models Piskurich and Sanders (1998) modeled their research methodology on McLagan and Suhadolnik’s (1989) ASTD Models for HRD Practice and Rothwell’s (1996) ASTD Models for Human Performance Improvement.

The roles for learning technologies described by Piskurich and Sanders (1998) are listed in Table 1.

The study was important for three reasons.

First, it was the leading study to specifically examine the role, competency, and output requirements for learning technologies.
Second, although the main purpose of study was not to depict the larger field in which training resides (Rothwell, Sanders, & Soper, 1999), it did focus on identifying and describing the competencies required of training professionals to effectively perform their roles in a now technologically advanced field.
Finally, the study examined the organizational forces potentially affecting the use of technology in the future as well as some emerging trends in technological advancements (Piskurich & Sanders, 1998).

ASTD Models for Workplace Learning and Performance (1999) The most recent ASTD-sponsored competency study is ASTD Models for Workplace Learning and Performance (Rothwell, Sanders, & Soper, 1999).
The study describes the competencies, as perceived by practitioners and line managers, needed for successful workplace learning and performance now and five years into the future.

Although formal training still occurs, the focus is now on creating conditions in the workplace where managers and employees alike can be more responsible and accountable for learning and high performance.

Training focuses on changing individuals by equipping them with new knowledge and skills (Rothwell et al., 1999).
Training has traditionally been viewed as an activity rather than a method of producing results in work settings.

The concept of Workplace Learning and Performance (WLP) was designed to stimulate a shift toward bridging the gap between activity and results.
The research questions inherent in this study centered on the current competencies required for success in WLP as perceived by practitioners, senior practitioners, and line managers and the competencies that will be required in five years (Rothwell et al, 1999).

The research methodology used to conduct this study was similar to recent ASTD-sponsored studies, except that part of this study was conducted and data were collected for the first time on the World Wide Web.
Rothwell et al (1999) identified seven workplace learning and 7 5 Journal of Health Sciences Management and Public Health performance roles that are listed in Table 1.
Rothwell et al (1999) noted four limitations of the study: (1) the results could not be generalizable to represent the work of all WLP practitioners; (2) levels of experience and expertise of the respondents could not be easily verified; (3) there were varying levels of computer technology among potential participants, many with outdated software that prevented some potential participants to respond; and (4) there was an uneven distribution of responses among disciplines and levels within organizations.
Nonetheless, this study is important to the field of training and development for the following reasons: (1) it is the first study that primarily examines future competencies - past studies focused on the then current training environment and suggested additional or enhanced roles based upon current thinking; (2) it is the first major study in the field of training to use a web-based data collection effort; and (3) the study further expanded the idea of “extrospective” thinking and the trend of shared responsibility within a systems approach to the training profession.
Rothwell et al (1999) invited both practitioners and line managers to jointly assess the competencies needed for effective workplace learning and performance.

Bengtson (1994) examined for the first time CEO perceptions of trainer roles in selected central Pennsylvania manufacturing companies.
Limitations to the study were 1) it was designed to examine perceptions and not actual skill and knowledge levels of trainers; 2) manufacturing was the only industry type examined; 3) the organizations in the study employed less than 1,000 employees; 4) the sample size was considered small and did not represent all manufacturing organizations; and, 5) since the sample was drawn from central Pennsylvania, the results could not be generalizable to other areas of the United States (Bengtson, 1994, p. 13).
Despite the limitations inherent to Bengtson’s (1994) study, the results are nonetheless significant and subject to further study.

Discussion and Recommendations The foundational and major studies examined here establish the bedrock of the body of literature on HRD roles.

The various role studies have helped to shape the broader HRD field and continue to serve as indispensable structural and operational guides to the most common HRD roles and competencies.
However, if we unconsciously govern our behaviors and the resulting roles by attempting to only fit within the defined boundaries of the studies, we may limit our creativity in defining new and expanding roles.

The role studies conducted over the past two decades produced at least thirty-six role descriptions.

The number of HRD roles has fluctuated from a high of 15 (McLagan, 1983) to a low of four (Pinto & Walker; Rothwell, 1996) since Pinto and Walker’s groundbreaking study.
However, the actual number of roles is far less important to discuss than why the roles continued to evolve and change.

Changing expectations of the organizations served by HRD professionals is a major reason why the roles continue to evolve (Rothwell, et al 1999).

Not only must HRD professionals be multidimensional and innovative in leading performance improvement efforts in organizations, they must be equally creative in defining their roles in a fast-paced, ever-changing organizational environment.
Identifying the most appropriate roles does not mean simply adjusting parts of the traditional HRD professionals’ work.

It calls for a fundamental change in how we view and represent ourselves in organizations.

One approach to fundamentally altering our own views is to seek input from others outside the HRD profession as to how HRD roles might be enhanced, supported, and shared by others within organizations.
Bengtson (1994) attempted to determine Chief Executive Officer (CEO) perceptions of HRD roles in selected Pennsylvania manufacturing companies.

CEOs were selected as subjects for the study because “as the top decision-makers in the organizations, [they] have the authority to restrict or expand a function’s scope of responsibility” (Bengtson, 1994, p. 1).
If an HRD professional’s perceptions of their roles are incongruent with the perceptions of the top leadership, it is perhaps useless for HRD professionals to continue to prepare themselves for roles that CEOs perceive as inappropriate for their organizations.

It would, however, be very advantageous for HRD professionals to prepare themselves for roles that are consistent with HRD profession as well as for their specific 7 6 Journal of Health Sciences Management and Public Health organization.
Although CEO perceptions of HRD roles are indeed critical in determining appropriate and meaningful HRD roles, other key organizational member’s perceptions may be equally important.

The perceptions of other top leaders, e.g., Chief Operating Officers (COO), Chief Financial Officers (CFO), as well as managers and staff employees could also provide valuable input and insights into the most appropriate HRD roles as direct consumers of the efforts of HRD professionals.
determine their opinions about the most appropriate roles that they believe HRD professionals should play and compare the roles that they identify to the actual roles of HRD professionals in an organization.

3.

Choose a specific type of industry (e.g., Pharmaceuticals) and survey the senior leaders to determine their perceptions about the most important HRD roles.

Compare the senior leader perceptions to the actual HRD roles in the selected companies.
The best way to advance an extrospective approach to discovering new HRD roles is through research and further research is indicated in this area.

Suggestions for research include: 1.

Survey organizational members to determine their opinions about the most appropriate roles that they believe HRD professionals should play and compare the roles that they identify to the roles identified in the major studies.

Survey organizational members to 2.

4.


Conduct in-depth interviews with consumers of HRD products (e.g., managers or staff members) to determine the value they receive, as a direct result of the HRD professional’s efforts.

New and unique roles may emerge from this type of research.

References 1.

Bengston, B.L.

(1994).

An analysis of CEO perceptions concerning trainer roles in selected central Pennsylvania manufacturing firms (Doctoral dissertation, Pennsylvania State University, 1994).
Dissertation Abstracts International, 56, 478.

2.

Chalofsky, N.E., & Lincoln, C.I.

(1983).

Up the HRD ladder: A guide for professional growth.

Reading, MA: Addison-Wesley Publishing Company.

3.

Gilley, J.W., & Eggland, S.A. (1989).

Principles of human resource development.

Reading, MA: Addison-Wesley Publishing Company.

4.

Kenny, J.B. (1976).

Core competencies of a trainer.

Canadian Training Methods, Special Issue, i-xvi.

5.

Kenny, J.B. (1982).


Competency analysis for trainers: A model for professionalization.

Training and Development Journal, 36(5), 142-148.

6.

Lippitt, G.L., & Nadler, L. (1967).

Emerging roles of the training director: Is training sufficiently creative and innovative to serve its full purpose?

Training and Development Journal, 21(8), 2-10.

7.

McLagan, P.A.

(1983).

Models for excellence.

Washington, DC: The American Society for Training and Development.

8.
8.

McLagan, P.A., & Suhadolnik, D. (1989).

The models for HRD practice: The research report.

Alexandria, VA: The American Society for Training and Development.

9.

Nadler, L. (1962).

A study of the needs of selected training directors in Pennsylvania which might be met by professional education institutions.

Dissertation Abstracts International, 24(2).

(University Microfilms No.

63-3766) 10.

Pinto, P.R., & Walker, J.W.

(1978).

What do training and development professionals really do?
Training and Development Journal, 32(7), 58-64.

11.

Piskurich, G.M., & Sanders, E.S.

(1998).

ASTD models for learning technologies.

Alexandria, VA: The American Society for Training and Development.

12.

Rothwell, W.J.

(1996).

The ASTD models for human performance improvement: Roles, competencies, outputs.

Alexandria, VA: The American Society for Training and Development.

13.

Rothwell, W.J., & Cookson, P.S.

(1996).

Beyond Instruction: Comprehensive program planning for business and education.
San Francisco, CA: Jossey-Bass Publishers.

14.

Rothwell, W.J., Sanders, E.S., & Soper, J.G.

(1999).

ASTD models for workplace learning and performance.

Alexandria, VA: The American Society for Training and Development.

15.

Rothwell, W.J., & Sredl, H.J.

(1992).

The ASTD guide to professional human resources development roles and competencies (2nd ed., Vol.1).

Amherst, MA: HRD Press.

16.

Wallick, W.G.

(1999).


Review of literature: An analysis of CEO perceptions regarding trainer roles in Fortune 500 companies.

Unpublished manuscript.


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7 8 Journal of Health Sciences Management and Public Health COMPARATIVE ANALYSIS OF THE INDONESIAN AND CHINESE HEALTH CARE SYSTEM Steven J. Szydlowski1 Abstract International trade and investments have great importance in financing and economic development of health system.

In conditions of stable economics and production increases the volume of health system financing.
Comparison of health systems in Indonesia and China shows the great influence of increase of international trade and investments on the perspectives of health system development in these countries.

There is a big competition between these countries to attract investments and increase of export.

On the bases of carried out analyses was made a conclusion that in the future financing of health systems in Indonesia and China will increase.
Introduction International trade and investment have major implications for health care financing and economic development.

Stable economies and balance of trade surplus have historically increased the amount of health care financing by governing entities and improved economic growth.

International trade and investment greatly influenced the Indonesian and Chinese health care systems and continue to play a major role in the future of health care delivery.
Indonesia and China compete to attract foreign investment and increase exports to improve their economies.

Competition between the countries continues to increase and will continue to influence health care financing in each country.

Indonesian Health Care System The Indonesian Health Care system is made of health centers, sub health centers, mobile health centers, health posts which include village medicine posts and hospitals.
Drug prescription control and national movements to maintain healthy populations has been one of the most recent efforts to improve health care and stabilize growing costs of health care in Indonesia.
The Ministry of Health, Republic of Indonesia defines health control as a functional health organization unit serving as a health center which renders conventional health services to the community and also plays an important role in community 1 University of Scranton, Scranton, PA 18510-4597, (Tel)570-941-4367/ (Fax) 570-941-5882, Email:sjs14@uofs.edu in predetermined health participation activities.

These health centers are pre- hospital areas where care is provided.
The sub health centers and mobile health centers provide limited services to the community but are more accessible for people.

The health posts, village medicine posts and village birth attendance posts are maintained to reach villages outside the immediate area of the health centers.

The village medicine post was established to evenly distribute essential medicines to the remote areas.

These posts are used to treat simple ailments.


Village maternity posts are critical for the remote areas that cannot access general medical care.

The maternity posts are designed for a physician to assist with normal and moderate risk deliveries.

The village posts are more cost effective than entry into the hospital.

Hospitals are classified in several different ways.
The main difference is between government hospitals owned by the Ministry of Health, local and civil authorities, armed forces and ministries.

Government hospitals are classified into 4 categories: Class A Advanced facilities, which provide specialist and sub specialist care.

Class B General hospitals that have moderate facilities, which can provide specialist services with limited sub specialty.

Class C Basic facilities with at least four specialist care capabilities.
7 9 Journal of Health Sciences Management and Public Health Class D Lowest level general hospital with basic facilities and care (http://www.depkes.go.id/ ENGLISH/hfa/resour2.htm).

The strategy for improving the health status in Indonesia does not only depend on the support from the central and local governments but also the help of the community leaders and entrepreneurs as the population continues to increase and health problems worsen.
Although the demand for high quality health services and new technology exists, financial resources are not available.

The Indonesian Ministry of Health recommends that the community should assist in financing health care.

The Ministry of Health also recognizes the need to educate local health authorities in the areas of financial management and systems integration to make the best use of the limited resources.
International international development and balance of payments have a major impact on financing the health care and improving Indonesia’s current economic condition.

Health care funding historically comes from the government and private donation.

trade, Increasing costs of health care and limited resources in Indonesia have become major concerns.

Currently the Indonesian government spends approximately 2.0% of the GNP on health care expenditures (http://www.depkes.go.id).
Chinese Health System The Chinese government currently spends about 3.8% of its GNP on healthcare expenditures (World Health Organization, 1998).

The Chinese national government only spends about 1% of its budget on health care while the local and providential government spends the remaining 2.8%.

The majority of health care financing comes from individual out-of-pocket, private insurance, employers, and providential and local government (Hesketh, 1997).
Datamonitor, a health care marketing strategy company based in London, estimates that 23% to 25% of the Chinese population — about 400 million people — receive some sort of health care reimbursement from the government.

The remaining 75% of the population rely on self-financed health care, 8 0 either private insurance or direct payment.
The Chinese government officials say that they pay for 60% of the total costs in the system, which in 1995 totaled about 9.6 billion USD (80 billion RMB) (http:// www.senate.gov/~dpc/crs/report/ascii/98- 74).

The cultural and regional differences in China are apparent in the field of medicine.

In China’s largest cities such as Beijing, Shanghai, Guangzhou and Qingdao, modern state run private medical facilities offer services of similar standards in Europe, Japan or the United States.
Many of the prestigious doctors of China have their practice in this region.

The scenario is different in the Western interiors of China where the economy is dependent on agriculture.

The physicians still rely on state-sanctioned herbal remedies and traditional medicines.

(http:// english.china.com/cdc/en/).


Government statistics indicate there are about 5.02 million health care providers at 205,000 hospitals and clinics to serve China’s population, 1.5 million are physicians with Western-style training, the remaining are nurses, technicians, medical support staff and traditional healers (http://www.senate.gov/~dpc/crs/ report/ascii/98-74).

Health care market analysts suggest that the actual number of medical facilities is much smaller.
The IMF (1998) estimates that there are 51,929 small regional clinics in China, which are rural township hospitals with 20 beds or less each.

Clinics offer a wide range of primary and curative care but very little advanced care.

The other medical units are teaching and clinical training facilities that offer advanced care to patients.

These units are generally located within a province and are designed to meet the varying needs of a large region.
There are about 14,762 hospitals of this type providing 22% of the total care in China (IMF, 1998).

The size ranges from 20 beds to several hundred.

Another type of health care facility in China is the People’s Liberation Army, military hospitals that offer services to the armed forces and to select high-ranking government and Communist Party officials.

There are around 300 of these medical facilities in China.
Outside the realm of the state run system are hospitals administered by industrial companies that provide care to employees and their families.

Comparative Analysis Indonesian export to foreign countries slowed due to the economic crisis in 1997 as well as increased competition from China.
The crisis in Indonesia was caused by 1) an over reliance on short term foreign borrowing by business enterprises and banks; 2) over investment in real estate; 3) inadequate supervision of financial institutions; 4) declining terms of trade.

As a result of the struggles in Indonesia, China has become an attractive target for investors from Japan and other foreign countries.
The low cost labor force, high skilled labor, and extensive investment in China have helped the economy (http://www.dprin.go.id/ data/economy).

This has improved health care delivery and financing in China while Indonesia has been forced to rely on minimal funding and health care services due to poor economic status.

The crisis adversely affected the political stability, widened the social economic gap, and increased unemployment in Indonesia.
Religious and ethnic conflicts took the forefront slowing the development of small business and economic growth.

Health care delivery in Indonesia has suffered as a result of inadequate funds, high dependence on government funding, and decrease in foreign exports and trade.

In China, the economic growth has helped stabilize household income resulting in less dependence on government financing of health care.
Datamonitor forecasts that income levels will rise steadily in China and will cause the private insurance to increase.

Though the amount spent on health is low compared to the west it will increase proportionately with the increase in the disposable income.

China’s economic reforms are responsible for widespread improvements in access to care and quality of care.

The Ministry of Health and the provincial health boards manages China’s state health care system.
The Ministry of Health has begun to offer financial incentives to companies that bring high-tech health intervention products to China.

In recent years, the number of advanced medical Journal of Health Sciences Management and Public Health products in the country has increased.

The Indonesian health care system has taken the opposite direction.

More dependence on self- healing and minimal outpatient village care has become the norm due to poor economic conditions and limited household incomes.
improved economic It is evident that the shift to more private health care financing in China has resulted from conditions.

the International trade and direct foreign investment in China has helped the improved economy and increased household income.

The Indonesian financing of health care has suffered due to economic decline.
The inability of the Indonesian government to finance health care due to high dependence from society and inadequate funds has forced the people into other alternatives to health care such as self- healing and prevention.

Conclusion The health care reform efforts are directly influenced by the economic development of the countries.

The need for more privatization is critical.

Although sometimes difficult to establish, private business development will improve the economy.
There is a need to attract more foreign and domestic investment in the countries.

New and/or improved services and products are essential to become more competitive in the foreign markets.

Continued health promotion and better distribution of health care financial resources will establish a more healthy population in the countries.

This needs to begin through improved quality in public hospitals.
The outreach/village posts need more resources to provide outpatient services to reduce the number of inpatient admissions.

Developing countries are vulnerable in a time of change and reform.

However, many opportunities arise for entrepreneurs and international investment.

Increased economic growth, private business development, and greater foreign investment in each country will help develop more stable economies which will improve financing of health care to create health communities.
8 1 Journal of Health Sciences Management and Public Health References 1. http://indag.dprin.go.id/Ingg/Trade/Exim/ Stindag http://www.dprin.go.id/data/statistic/trade/ defaulth/htm http://www.dprin.go.id/data/economy http://dprin.go.id/data/investm/profilr.htm http://www.depkes.go.id/ENGLISH/hfa/ resour2.htm http://www.senate.gov/~dpc/crs/report/ascii/ 98-74 2.

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Hesketh, T., Zhu, W.X.

(1997).

Health in China: the healthcare market.

British Medical Journal, 314, 1616-1625.


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World Health Organization (1998).

Basic health indicators (country-reported data).

http://www- nt.whosis/statistics/r…, basic, reported, endpoint & language-english.

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Eiteman, D., Stonehill, A., and Moffett, M. Multinational Business Finance, Eight Edition, 1997. indoneziis da CineTis jandacvis sistemebis SedarebiTi analizi stiven Sidlovski saerTaSoriso vaWrobas da investiciebs didi mniSvneloba aqvs jandacvis sistemis dafinansebisa da misi ekonomikuri ganviTarebis saqmeSi.

stabiluri ekonomikisa da Warbi warmoebis pirobebSi matulobs jandacvis dafinansebis moculobac.
indoneziisa da CineTis jandacvis sistemebis Sedareba cxadyofs, Tu raoden didi gavlena moaxdina saerTaSoriso vaWrobis da investiciebis gafarToebam am qveynebis jandacvis sistemebis ganviTarebis perspeqtivebze.

am qveynebs Soris mimdinareobs mwvave konkurencia qveynisSida investiciebis mozidvasa da eqsportis gazrdaze.

Catarebuli analizis safuZvelze keTdeba daskvna, rom perspeqtivaSi jandacvis sferos dafinanseba indoneziasa da CineTSi kidev ufro gaumjobesdeba.
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