Public Health System Reform: Public Health System Reform: can it affect Human Rightscan it affect Human Rights

- Case of Georgia- Case of Georgia

Mamuka DjibutiMamuka Djibuti

Tbilisi State Medical UniversityTbilisi State Medical University

Reform Reform

In 1995, Georgia embarked on health care reform which In 1995, Georgia embarked on health care reform which entailed public health system reform tooentailed public health system reform too

The Soviet-style sanitary-epidemiological system was The Soviet-style sanitary-epidemiological system was divided into two separate entities – sanitary control and divided into two separate entities – sanitary control and epidemiological serviceepidemiological service

Ambitious decentralization of public health services – Ambitious decentralization of public health services – creation of district-level Centers for Public Healthcreation of district-level Centers for Public Health

Many core functions of public health were delegated to the Many core functions of public health were delegated to the city and district government level city and district government level (e.g. surveillance and control (e.g. surveillance and control functions, including many that pertain to surveillance data collection, functions, including many that pertain to surveillance data collection, analysis, and response)analysis, and response)

Ten years later after the initiation of Ten years later after the initiation of reformsreforms

System-building innovations have not returned in System-building innovations have not returned in sustainable health gain:sustainable health gain:

Substantial increase in the incidence of Substantial increase in the incidence of Vaccine preventable diseases (outbreaks) sexually transmitted disease drug abuse cardiovascular diseases cancer injuries prevalence of smoking etc

Law on Health Care (communicable Law on Health Care (communicable disease)disease)

Central and local government is Central and local government is responsible for communicable disease responsible for communicable disease prevention and controlprevention and control

State is responsible for providing free State is responsible for providing free vaccination to population according to the vaccination to population according to the national calendarnational calendar

State is responsible for providing free State is responsible for providing free antirabies vaccination to populationantirabies vaccination to population

ImmunizationImmunization

Coverage (nationwide) 2005

DPT-3, Polio-3 78%

Hepatitis B-3 64%

Measles-1 85%

Measles-2 62%

Vaccine preventable diseasesVaccine preventable diseases

In 2004, the country experienced a large outbreak of In 2004, the country experienced a large outbreak of measles (reported incidence 158 per 100,000 measles (reported incidence 158 per 100,000 population); population);

In 1998-2004, the country’s official statistics featured In 1998-2004, the country’s official statistics featured 67 fatal cases for rabies 25 fatal cases for diphtheria 25 fatal cases for tetanus

Is it violation of the Law? Human rights?Is it violation of the Law? Human rights?

What is wrong?What is wrong?

There is a law, but problems still existThere is a law, but problems still exist It seems that even good law alone is not enoughIt seems that even good law alone is not enough What are the other factors ???What are the other factors ???

Other FactorsOther Factors

Low budget allocations to public health (may Low budget allocations to public health (may undermine any reform!)undermine any reform!)

No formal link between public health centers and No formal link between public health centers and health care facilities (it was lost under reforms!)health care facilities (it was lost under reforms!)

Inadequate public health workforce in terms of Inadequate public health workforce in terms of knowledge and skills (was not addressed by the knowledge and skills (was not addressed by the reform at all !!!)reform at all !!!)

Poor legislationPoor legislation

Poor legislation – an examplePoor legislation – an example

Organic law on self governance does not make Organic law on self governance does not make local governments responsible for ensuring local governments responsible for ensuring public health public health

As a result - ignorance of public health by the As a result - ignorance of public health by the local governments, which results in serious local governments, which results in serious under funding of local public health servicesunder funding of local public health services

Now, Law on Public Health (pending) is trying to Now, Law on Public Health (pending) is trying to address this problemaddress this problem

Other problemsOther problems

In similar manner, human rights are In similar manner, human rights are violated amongviolated among People exposed to second hand smoke People living in polluted areas People with mental illness who could be

deinstitutionalized but are not etc

Potential solutionsPotential solutions

Alongside with Alongside with ““Health and LawHealth and Law”,”, special emphases must be placed on special emphases must be placed on

““Public Health and Law”Public Health and Law”,, wwhich can help hich can help to properly address the aforementioned problemsto properly address the aforementioned problems

What needs to be doneWhat needs to be done

Proper education and training of future leaders Proper education and training of future leaders and professionals may help to advocate for and professionals may help to advocate for addressing all factors includingaddressing all factors including Resource allocation Workforce development Improving infrastructure Improving public health services etc

Thank you !Thank you !