Original article |
Health care-seeking behaviour and out-of-pocket payments in Tbilisi, Georgia
1 Curatio International Foundation, Tbilisi, Republic of Georgia, 2 Abt Associates, Bethesda, MD, USA and 3 Health Policy Unit, London School of Hygiene and Tropical Medicine, London, UK
Correspondence: George Gotsadze, Ph.D., Director, Curatio International Foundation, 37d Chavchavadze ave., Tbilisi, 0162, Republic of Georgia. Tel: +995 99 50 10 75; Fax: +995 32 99 55 40; E-mail: G.Gotsadze{at}curatio.com
Based on a household survey conducted in Tbilisi, Georgia, in 2000, this paper examines current patterns of health care-seeking behaviour and the extent of out-of-pocket payments. Results show that health care services are a financial burden and that private (out-of-pocket) payment creates financial barriers to accessing health services. Members of the poorest households are less likely to seek care than people from more affluent households, and devote a higher share of household monthly expenditure to health care. Households have adopted various strategies to overcome these financial barriers, but the strategies are likely to contribute to both declining economic status and worsening health outcomes. The paper provides an evidence base to help direct future policy reform in Georgia. Government needs to: (1) prioritize public financing of services for the poor, in particular through amending the Basic Benefit Package so that it better reflects the needs of the poor; (2) promote the quality and utilization of primary care services; (3) address the issue of rational drug use; and (4) consider mobilizing out-of-pocket payments on a pre-paid basis through formal or community-based risk pooling schemes.
Key Words: health financing, care-seeking behaviour, transition economies
1The system of revenue collection introduced in Georgia is often referred to as social insurance, although the revenues are not collected by independent funds nor are they kept separate from other legally mandated taxes. Therefore, in this paper we refer to payroll taxes rather than social insurance contributions.
2SUSIF was created at the end of 2002 after merging the State Pension Fund and State Medical Insurance Fund (SMIC).
3Based on the available literature (Fylkesnes 1993; Andersen 1995; Kunst and Mackenbach 1995; Newbold et al. 1995; Noro et al. 1999; Haagenars et al. 2001), household income, educational attainment at the level of household, household size, age and gender were used for the logistic regression.
4Computed household monthly expenditures were adjusted both for differences in the consumption needs of different individuals (the equivalence scale) and for economies of scale according to the State Statistic Department standard methodology.
5The incidence rate was calculated by dividing the total number of disease incidences, 1917, by total population residing in the surveyed households.
6The survey instrument questioned separately those who had only used self-treatment. It did not consider those who had used self-treatment plus other strategies involving care seeking from a health care provider.
7Lari = Georgian national currency. In 2000, the exchange rate was 1.98 Lari to 1 US$.
8This amount includes both formal and informal fees as well as any drug or treatment costs associated with the consultation.
9This analysis does not include 19 cases of hospitalization with subsequent use of eight services, as described in Figure 2. And further, due to the missing 57 cases who were not able to recall the cost of an outpatient care episode, the total number of cases analyzed is less than the 707 cases of service utilization reported earlier in the paper.
10Based on existing regulations in the country, all fees are expected to be paid to the cashier. Thus any direct transaction between the patient and provider was treated as informal. These findings should be treated cautiously as practices vary across facilities.
11The unemployment rate increased from 11.7 to 15.2% during 1997–2000 (Telyukov et al. 2003).
12The average monthly salary was 57.3 Lari (
US$28) (TACIS 2002).
13Internists are district doctors for adults.
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