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Wednesday, October 10, 2012

Back, but still a bit jet lagged: Health care in the Republic of Georgia

The Republic of Georgia is beautiful, welcoming, has great food, ancient and rich culture, is quite inexpensive, and I am now back. The language is fascinatingly complex, with an alphabet that does not resemble ours in any way, and the capital, Tbilisi, has the feeling of a thriving European city, but there is almost no crime and you can see snow capped mountains and farmed fields if you look up or out. I did no doctoring, but did sit down with a now unemployed pediatrician who told me a bit about their health system. I also talked to other Georgians about how they felt about their health care. Georgians are proud of their wine, their music, their architecture, their food and their loyalty, but they are not particularly proud of the quality of their medical care.

In the Soviet era, before independence, health care was entirely state funded and mainly based in hospitals. After the fall of communism, Georgia was torn apart by the sudden dissolution of their economic system and loss of their major trade partner. Health care rapidly deteriorated and most people had no money to cover it.

Government sponsored insurance covers some of the health needs of kids up to age 6 and adults over the age of 60. Families and patients are still responsible for paying for treatment of serious diseases in kids, and I'm not sure about the elderly, but it sounds like they also have to pay out of pocket for serious illnesses. Doctors are not particularly highly respected or highly paid, though they now have about as many years of education as we do in the US. I'm not sure how good that education is, however. A primary care pediatrician may see 15 or 16 patients on a busy day (a light load by US standards) and make a little over $100 a month.  A highly paid surgeon might make as much as $800 a month. Doctors do not make more than the average worker, and some make less. The cost of living is lower than in the US but not correspondingly lower. Some medical care is inexpensive by our standards: an office call for an uninsured patient costs about $15, but that is actually very expensive for a Georgian. The full cost of a surgery, per my pediatrician friend, might be as much as $15,000, which almost nobody can afford. People do die because they can't afford medical care, though hospitals will not refuse to treat the very ill on the basis of inability to pay. Like in the US, there is a safety net for the very sick and the very poor. My pediatrician friend does not know where the money that people pay for medical care goes, but it is not to the doctors.

Dental care, on the other hand, is a good deal. A British friend said he had gone to Georgia for a root canal which cost around $100. The work was excellent, he said. I don't believe there is dental insurance.

Wikipedia tells me that life expectancy is a little over 74 years, which is low by the standards of the more wealthy European countries and their maternal and infant mortality rates are somewhat higher than those countries, though not as bad as the rest of post-soviet Russia. Smoking (over half of the male population smokes) and automobile deaths are public health issues that contribute powerfully to death rates, but there is still a significant amount of preventable and treatable infectious diseases that kill people.

There is no shortage of physicians in Georgia, with about 1 per 200-250 people. But for whatever reason, quality, cost, accessibility, they are not used.

What wisdom can be gleaned from all of this? There are many recipes for not-good health care systems. In Georgia's case, a soviet model of health care delivery, followed by economic collapse and a war plus many doctors without access to basic technology and without high standards of competence predictably has not been successful. Clean water, adequate nutrition and strong communities go a long way towards keeping the health of the country good despite lack of what I would consider to be adequate medical resources.

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