Dr Irina Karosanidze, a primary health care (PHC) doctor in Georgia has long worked to shape the direction of PHC reform in the country to make health services more accessible and responsive to the needs of the population. Recently, she has been on the frontlines of a dramatic transformation in PHC delivery in Georgia; one that will hopefully have a lasting and positive impact on the lives of everyone, everywhere in the country.

”It is a question of people being able to access health services and receive health care advice when and where they need it. With the rapid acceleration of digital health services due to the pandemic, that can even be at home,” said Irina who is working closely with the Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs to adapt PHC services to meet the demands of a global pandemic.

Thanks to leaders like Irina, new protocols were rapidly developed and revised, and PHC providers across the country were trained in managing mild COVID-19 infections remotely. They also learned to remotely manage patients who had been discharged from the hospital after acute infection of COVID-19.

Why is PHC important in Georgia?

Before COVID-19 struck, the Ministry was already committed to increasing the efficiency of health service delivery in Georgia and advancing universal health coverage (UHC) through strengthening the PHC system and integrating priority services. The population’s health needs were becoming increasingly complex due to the growing burden of noncommunicable diseases (NCDs) such as diabetes, cancer, heart and lung diseases. NCDs are estimated to account for a staggering 94% of all deaths in Georgia; equivalent to more than 50,000 deaths annually. It has become clear that reforms are needed at the PHC level to enable transition from a fragmented disease-centred approach to one that is more holistic, integrated and people-centred.

In November 2019, a WHO mission conducted through the UHC Partnership reviewed the Ministry’s PHC reform plans. It recommended revising the scope of services to include more preventive, people-centred services, expanding the scope of practice of nurses, and redefining the role of specialists in the PHC setting. The review found that lack of performance monitoring and misaligned payment incentives undermined the system’s overall potential. In addition, high out-of-pocket payments for medicines disproportionately affected the poorest people in the population leading to increased poverty and sometimes catastrophic spending on health. 

In early 2020, the Ministry asked WHO to provide technical support to revise the PHC benefits package and payment model. This would help increase access to evidence-based prevention and treatment services and support the integration of health programmes to strengthen the PHC system. Then, COVID-19 struck.

While Georgia initially experienced low rates of COVID-19 infection, cases rose dramatically throughout the last quarter of 2020. In early 2021 the country is facing a severe epidemic, with PHC called upon to serve a core role.

“Primary Health Care is a top priority for the government,” said First Deputy Minister Dr Tamar Gabunia, “COVID-19 has presented many challenges, but it has also offered opportunities to invest in rural infrastructure and telemedicine equipment and to build well-established systems for improved communication.”

A PHC approach is also an essential foundation for health emergency and risk management, and for building community and resilience. Georgia has repeatedly demonstrated its commitment to strengthening pandemic preparedness and to detecting, and responding to public health risks.

While Georgia initially experienced low rates of COVID-19 infection, cases rose dramatically throughout the last quarter of 2020. In early 2021 the country is facing a severe epidemic, with PHC called upon to serve a core role.

“Primary Health Care is a top priority for the government,” said First Deputy Minister Dr Tamar Gabunia, “COVID-19 has presented many challenges, but it has also offered opportunities to invest in rural infrastructure and telemedicine equipment and to build well-established systems for improved communication.”

A PHC approach is also an essential foundation for health emergency and risk management, and for building community and resilience. Georgia has repeatedly demonstrated its commitment to strengthening pandemic preparedness and to detecting, and responding to public health risks.

Capacity building to influence policy and practice

WHO, through the UHC Partnership, has supported the capacity building of organizations and individuals in Georgia to play a key role in shaping the strategic direction and implementation of PHC reforms and UHC.

“It is essential to ensure that WHO technical support is tailored to the needs of the country and appropriately adapts evidence-informed practices to the realities of the environment and the needs of the population. In Georgia, this is achieved through active engagement with partners on the ground,” explains WHO Representative in Georgia Dr Silviu Domente.

Dr Irina Karosanidze is one of the experts contributing to PHC reform efforts in the country. With a massive increase in demand for services, she and the family health training centre she established in 2001 are key in helping to define how PHC can address COVID-19 while maintaining the delivery of essential health services. They are also contributing lessons learned which can be used to inform the long-term transformation in health care delivery for Georgia. Indeed, COVID-19 has focused attention on the importance of primary care and created an opportunity to advance care and increase access through accelerating the use of digital health services.

Georgia is among the 115 countries to which the UHC Partnership helps deliver WHO support and technical expertise in advancing UHC. The Partnership is funded by the European Union (EU), the Grand Duchy of Luxembourg, Irish Aid, the Government of Japan, the French Ministry for Europe and Foreign Affairs, the United Kingdom – Foreign, Commonwealth & Development Office and Belgium.

Why does primary health care matter during COVID-19?

The health care system of Georgia currently faces a dual challenge of responding to the immediate needs during the COVID-19 crisis while also safeguarding and strengthening essential lifesaving health services. Adhering to the principles of UHC means ensuring equity for all, and protection for the most vulnerable. PHC is the cornerstone of a sustainable health system for UHC.

“Georgia has launched a strong response to COVID-19 but the pandemic has highlighted the need to accelerate progress to ensure that no one is left behind. Strong robust health systems, primary health care and accessible public health services are the best way we can deliver universal health coverage across the country. These strategies will build resilience against future health emergencies and help get essential services to people in need,” said Dr Hans Henri P. Kluge, WHO Regional Director for Europe during a visit to Georgia in December 2020.

Effective PHC is the most inclusive, effective and efficient approach to delivering health and enhancing people’s physical and mental health. But there is an urgent need to further develop and increase use of PHC services Georgia, at a time when many people fear using health services in person due to the perceived risks of COVID-19 infection.

So PHC practitioners are working hard to train health workers to address this challenge, and to reach people remotely with essential health services.

WATCH

Press conference – WHO Country Office in Georgia

Interview in Georgia with Dr Hans Kluge, WHO Regional Director for Europe

“To ensure that people with chronic diseases continue to receive treatment, a telephone triage and consultation system has become an effective mechanism. Improving remote counselling skills resulted in significant reduction of unnecessary face-to-face visits and increased patient satisfaction,” said Irina.

The revised design of the PHC services envisions increased delivery of remote and digital services to improve access for rural populations, to ensure no one is left behind.

COVID-19 highlights that PHC-led approaches, including community-based strategies, contribute to more successful health responses.  Strong trust in governments help generate more support for their strategies. Establishing and maintaining this trust requires transparency, use of evidence, and stakeholder engagement, especially with health service users and patient organizations.

WHO is promoting a two-phased strategy focused on supporting Georgia to first, maintain essential lifesaving health services, and second—with strong support from the UHC Partnership—to advance health systems recovery, preparedness and strengthening, with a focus on PHC and UHC.

“Access to quality health care is a concern the world over, and the European Union is proud to be working closely with WHO to develop this in 115 countries globally, including in Georgia. During the pandemic, our joint efforts here have focused on training and the roll-out of updated COVID-19 procedures, together with substantial material support, as part of the EU’s wider support to the country during these challenging times,” said Carl Hartzell, EU Ambassador to Georgia.

Strengthening PHC with a long-term vision for UHC

COVID-19 has disrupted health systems, devastated communities and economies and continues to push countries to invest in health for all. Georgia is taking advantage of the opportunity to expand the benefit package of PHC services, strengthen capacities of the PHC teams, improve coordination of care and optimal use of diagnostic and specialized services. The country is aiming for every citizen to get the health services they need, with no one left behind.  Greater investment in rural infrastructure, telemedicine equipment and better communication systems is needed to reach populations currently not using PHC services. Strong community-based strategies, and engaging patients and organizations, will increase trust and use of the services available. For Georgia, these are crucial steps in tackling the pandemic and ultimately achieving UHC.