Shengelia et al. BMC Health Services Research (2017) 17:544
DOI 10.1186/s12913-017-2485-8
RESEARCH ARTICLE
Open Access
Stakeholders’ views on the strengths and
weaknesses of maternal care financing and
its reform in Georgia
Lela Shengelia1,2,3,5*, Milena Pavlova1 and Wim Groot1,4
Abstract
Background: The improvement of maternal health has been one of the aims of the health financing reforms in
Georgia. Public-private relationships are the most notable part of the reform. This study aimed to assess the
strengths and weakness of the maternal care financing in Georgia in terms of adequacy and effects.
Methods: A qualitative design was used to explore the opinions of key stakeholders about the adequacy of maternal
care financing and financial protection of pregnant women in Georgia. Women who had used maternal care during
the past 4 years along with health care providers, policy makers, and representatives of international partner
organizations and national professional body were the respondents in this study. Six focus group discussions to collect
data from women and 15 face-to-face in-depth interviews to collect data from the other stakeholders were conducted.
Each focus group discussion consisted of 7–8 women. Two focus group discussions were carried out at each of the
target settings (i.e. Tbilisi, Imereti and Adjara). Women were selected in each location through the hospital registry and
snowballing method.
Results: The evidence shows that there is a consensus among maternal care stakeholder groups on the influence of
the healthcare financing reforms on maternal health. Specifically, the privatization of the maternal care services has had
positive effects because it significantly improved the environment and technical capacity of the maternity houses. Also,
in contrast to other former-soviet republics, there are no informal payments anymore for maternal care in Georgia.
However the privatization, which was done without strict regulation, negatively influenced the reform process and
provided the possibility to private providers to manipulate the formal user fees in maternal care. Stakeholders also
indicated that the UHC programs implemented at the last stage of the healthcare financing reform as well as other
state maternal health programs protect women from catastrophic health care expenditure.
Conclusion: The results suggest a consensus among stakeholders on the influence of the healthcare financing
reform on maternal healthcare. The total privatization of the maternal care services has had positive effects
because it significantly improved the environment and the technical capacity of the maternity house. However,
the aim to improve maternal health and to reduce maternal mortality was not fully achieved. Financial protection
of mothers should be further studied to identify vulnerable groups who should be targeted in future programs.
Keywords: Maternal health, Health system, Reform, Financing, Out -of –pocket payment, Georgia
* Correspondence: maillela69@gmail.com
1
Department of Health Services Research, CAPHRI, Maastricht University
Medical Center Faculty of Health, Medicine and Life Sciences, Maastricht
University, Maastricht, The Netherlands
2
The National Center for Disease Control and Public Health of Georgia, Tbilisi,
Georgia
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Shengelia et al. BMC Health Services Research (2017) 17:544
Background
Many countries could not reach the Millennium Development Goal (MDG) for Maternal Mortality Ratio (MMR)
although remarkable improvements have been observed
[1]. Financial accessibility to appropriate maternal care
has been identified as one of the important determinants
of the state of maternal morbidity and mortality [2]. Like
in the MDGs, the equitable access to maternal care has
also been given ample importance in the new Sustainable
Development Goals (SDGs) because of its social, health
and economic development impacts on households as
well as countries’ health system [3].
The target for MMR (i.e. 12 /100,000 live births) has not
been achieved and it amounted to 36/ 100,000 live births in
2015 [3]. Since the independence in 1991, like other former
Soviet countries, Georgia has gone through several phases
of health financing reform to improve access to health care,
including maternal care. These reforms have influenced the
utilization of health care services due to an increase in the
burden of formal fees for services applied in the context of
informal patient payments [4, 5]. Total privatization of the
health system, including purchaser-provider split, is the
most noticeable outcome of the reforms [6].
Privatization of the health system resulted in the transformation of the traditional centralized Semashko model.
However, it was implemented in a weak state capacity to
regulate the private market. Private providers’ interest in
making profits ‘potentially compromise patients’ health
and economic safety. Therefore, the government is investing a considerable amount of money to purchase health
care including maternal care from private providers. This
is also in line with the current reform for the implementation of the Universal Health Care (UHC) program [7].
Nearly 7.4% of GDP in 2014 is allocated to health care [8].
The Ministry of Labour, Health and Social affiars
(MoLHSA) is the state agency, which receives the general government health budget to purchase health care
for the population, including maternal care, from the
private providers. Maternal care in Georgia is provided
by a countrywide network of women consultation centers (WCC) and maternity houses. WCCs are primary
level facilities that provide only antenatal care. The maternity houses are secondary level facilities providing antenatal care, physiological childbirths, Caesarian sections
(C-section) and emergency obstetric care.
The MoLHSA allocates a certain part of total Government Health budget to implement maternal care through
multiple agencies which are responsible for different vertical and horizontal maternal care programs. For example,
the National Center for Disease Control and Public Health
of Georgia (NCDC) purchases the logistics for antenatal
screening tests and distributes money to private providers.
Along with the services, as mentioned above, the following other free-of-charge maternal care services are also
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included: antenatal screening for HIV, Hepatitis B and C,
and syphilis, folic acid and iron supplementations,
physiological childbirths and C-sections [9]. The social
agency is responsible for the provision of antenatal
care, early detection and management of high risk pregnancy and congenital anomalies. The same agency is responsible for payments for both physiological childbirths
and C-sections as part of the UHC program. Practically,
the provision as well as financing of maternal health programs is fragmented because of the involvement of several
agencies controlling vertical and horizontal maternal care
programs.
Despite publicly provided four free-of-charge antenatal
visits as well as childbirth services, out-of-pocket payments
(OPPs) remained a considerable burden for households
because of additional antenatal care visits and fees for
“personal doctors”. For example, the average OPPs for a
C-section and a physiological childbirth were 667.2
GEL and 385.3 GEL respectively [10]. Women in the
highest income quartile paid higher OPPs for childbirth
of any type than the lowest quartile [10, 11]. Moreover,
the cost of medicines is nearly three times higher than
the average cost in other European countries which is
also directly linked to high OPPs [12]. According to
Curatio International Foundation, the high OPPs are related to delays in medications and the utilization health
care services such as outpatient care, hospital and additional maternal care services, which are not included in
the UHC program [11].
The goal of the health financial reform is equitable access to health care; thereby, health and economic protection for the population. In Georgia, nearly 20.1% of the
total population lives below poverty level [13]. The present
OPPs in maternal care in the private market present a
risk, which may hinder the health and socio-economic
protection of households and may also be an obstacle
for achieving the goals of the state UHC program. An
in-depth investigation is essential to assess the key
stakeholders’ opinions about strengths and weakness of
the current maternal care financing. Thus, this study
aimed to assess the strengths and weakness of the maternal care financing reforms in Georgia in terms of adequacy and effects.
Methods
We used a qualitative design to explore the opinion of
key stakeholders about the adequacy of maternal care financing and financial protection of pregnant women in
Georgia. The study was conducted in May and June
2015 in the capital Tbilisi and in two regions of Georgia,
namely Imereti and Adjara. Women who had used maternal care during the past 4 years along with health care
providers, policy makers, and representatives of international
partner organizations and national professional body were
Shengelia et al. BMC Health Services Research (2017) 17:544
the respondents in this study. An ethical approval of the
study was obtained from the National Center for Disease
and Public Health of Georgia.
We conducted six focus group discussions (FGDs) to
collect data from the target women, and 15 face-to-face
in-depth interviews to collect data from the other stakeholders. Each FGD consisted of 7–8 women. Two FGDs
were carried out at each of the target settings (i.e. Tbilisi,
Imereti and Adjara). The target women at each location
were divided into two groups; one group with women
had one child, and another group with women had more
than one child. This was done for a better understanding
of the differences in the women’s experience of childbirth/s based on parity (i.e. primipara or multipara).
In each region, two research assistants identified the
target women. We selected the target women in each location through the hospital registry and snowballing
method. Two-thirds women were sampled from the selected hospital registries consecutively provided they fulfilled the inclusion criteria. Random sampling was not
possible since there were no separate registries only for
the target mothers, thus no usable sampling frames were
available. Information from those mothers was used to
identify the target mothers in the community which
allowed sampling the rest one-third mothers through
snowballing. We did this to enhance the possibility of
selecting women who gave childbirth at different facilities
rather than a single facility; thereby, to get data from
women with diverse experience of maternal care. There
were no age or economic status stratification criteria applied to allow exploring the opinion of women in reproductive age representing diverse socio-economic groups.
For in-depth interviews with the other stakeholders, we
selected three policy makers, three private health facility
representatives, two representatives of international organizations partnering in the development of maternal care,
one representative of national professional organization
and six maternal care providers (physicians). We used
convenience sampling method to select target mothers
and purposive sampling method respondents of in-depth
interview.
The objective was to investigate the adequacy of maternal
care financing and economic protection of pregnant women
from the perspective of different stakeholders. Focus group
and in-depth interview discussion topics were formulated
using primary literature review. The guides were developed
in English (please see Additional files 1 and 2) and then
translated into local Georgian language by the principal
investigator. The data collection instruments (i.e. the
guides) were pre-tested. FGD and in-depth interview
guides were pre-tested and adapted as needed.
Informed written consents were given by all respondents prior to each FGD and interview. All FGD sessions were conducted by a Facilitator with longstanding
Page 3 of 8
experience of conducting FGDs. The Principal Investigator acted as moderator for the FGDs and, conducted
all in-depth interviews. Confidentiality of the collected
data was maintained. Each session was audio-tapped.
The need of audio taping of each FGD session and indepth interview was explained to all respondents and
permission for recording was obtained. All FGDs and
in-depth interviews were conducted in Georgian language.
Which were translated into English by an English language expert. The Principal Investigator compared and
validated the Georgian and English versions of the transcripts. Data was collected during May and June, 2015.
We investigated stakeholders’ opinion about strengths
and weakness of the current maternal care financing reform in terms of its adequacy and effects. We applied
the method of directed qualitative content analysis as
defined by Hsieh and Shannon [14]. Specifically, the
focus was on identifying data in the transcripts related
to two main themes: [1] arguments in support of the
current maternal care financing, and [2] arguments against
the current maternal care financing. We extracted and analyzed the data manually. An abstract coding approach was
applied to develop a set of codes [15] related to the two
themes. Two researchers independently coded the data
based on the key attributes of financing of maternal care as
outlined above and consensus on any discrepancies were
built through discussions. The results were synthesized in a
narrative manner.
Results
A total of 41 women (primipara n = 19; multipara n = 22)
participated in six FGDs and 15 other stakeholders (i.e.
policymakers; n = 3; health insurers, n = 2,;providers,n = 4;
and representatives of national professional, n = 1; and
international organizations, n = 2; and physicians, n = 3)
participated in in-depth interviews. Below, we present the
key stakeholders’ opinions about strengths and weaknesses
in terms of adequacy and effects of the current maternal
care financing reform.
Arguments in support of the current maternal care
financing
Adequacy in terms of financial allocation and
maternal care service package:
Policy makers, providers and physicians mentioned
that the implementation of the UHC program as part of
the current health financing reform, results in an improved financial allocation in health care. Also majority of
the study participants stated that the financial protection
of the population in health care including maternal care
has been improved. According to policy makers, through
the UHC program and several vertical programs, the state
Shengelia et al. BMC Health Services Research (2017) 17:544
has improved coverage for maternal care as well as financial protection of households. The target mothers
also supported this statement; additionally, some mothers
stated that the current UHC program met most of their
needs related to childbirth. Relevant quotes are presented
in Table 1.
Policy makers mentioned that geographical and financial access to maternal care has improved. They stated
that basic antenatal care (i.e. four visits), high risk pregnancies and transportation in case of pregnancy complications are covered under the State vertical maternal care
program and UHC covers childbirths (i.e., physiological
childbirth and C-section). Respondents of in-depth interviews also indicated that any additional services which are
not included in the vertical and UHC programs: for example, antenatal care more than four visits, preeclampsia
and near miss services need to be paid by OPPs. All respondents mentioned that pregnant women have the freedom of choosing facilities and providers, which are not
included in the State programs for example: personal doctors, and medical investigations. However, they have to
pay additional amounts beyond state allocation.
According to most of the respondents, the private health
insurance supplements the maternal care program; however the predominant opinion was that all individuals who
are able to pay have to purchase insurance. This will facilitate the State to expand the package for the poor and the
unemployed people (Table 1).
Maternal care financing versus out-pocket-payments:
Table 1 Statements in support of the current maternal care
financing reform
In- depth interviews
The fees should apply for additional services such as food and room or
patient comfort [1]
The state covers everyone pretty much; the high risk pregnancies are
covered by vertical program [1, 2, 6]
I am for co-payment. I think 10-20% of co-payment could be existed.
Co-payment also means some kind of responsibility from the client’s
side. But it should not be burden for the population [3]
Privatization supported to the legalization of incomes [5]. Informal
payments have been eliminated [6].
Some people cannot pay. Therefore, State should provide full coverage
of maternal care [15]
Focus group discussions
Families are trying to be prepared for the childbirth and most of the
families are ready for payment [16, 17]
I had private insurance. It helped me to pay everything, except
pharmaceuticals [16]
We gave to the doctor a gift as a token of gratitude [16, 17].
I had complicated childbirth and was transferred to Tbilisi. The total cost
was covered by the State completely [21].
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Participants of in-depth interviews stated that despite
the UHC program and vertical programs, pregnant women
are commonly paying for additional services by themselves.
OPPs are mostly related to medications and diagnostics,
which are not included in any of the State programs. According to the women, the presence of OPPs was preferable
if the pregnant women were asking for additional services,
such as private room, personal doctor etc. Some providers
think that OPPs prevent overuse of services. Women
mentioned that family and relatives are the main sources
of OPPs. One woman said – “pregnancy is expected and
improves status of women in families. For this, families
and relatives are willing to pay any extra costs relating to
maternal care”.
Informal payment in health care was a major financial
burden for households previously, which is now completely
eliminated due to new laws and the influence of the
privatization in health care. However, sometimes mothers
and families present gifts to doctors/nurses as a part of
gratitude, which is not an informal payment; instead it is
an expression of good patient-doctor/nurse relationship.
Arguments against the current maternal care financing
Financial allocation versus maternal care package:
According to some private providers, the current allocation of 55 Gel (equivalent to 20 Euro) for four antenatal visits is not sufficient to provide good quality of
care. Also often four antenatal visits and the content of
services did not meet the needs of all pregnant women.
Because of this limited allocation and service contents,
early detection of high risk pregnancies are often missed.
In support of this statement, one woman mentioned that
“I needed extra antenatal visits and tests and all costs
were provided by my family”. One of the privet providers
mentioned that the government allocation for specific
services is quite marginal to make profit. This often
compromised private providers’ interest of joining public
health care programs.
Some policy makers and providers expressed concerns
about the quality of maternal care especially antenatal
care, due to the current financing reform. Relevant quotes
from the transcripts are presented in Table 2. Providers
also mentioned that the current financing system has
fragmented the State maternal care programs. For example, one agency is purchasing antenatal screening
tests for HIV, Hepatitis B and C, syphilis, while another
agency is responsible for the implementation of the
antenatal checkup.
Some of the maternal care providers as well as policymakers indicated that the government should finance
only the poor population by providing them with a wider
package and others should pay OPPs for maternal care
Shengelia et al. BMC Health Services Research (2017) 17:544
Table 2 Statements against the current maternal care financing
reform
In-depth interviews
I think all people who work have to purchase insurance package and
plan pregnancy. But if person does not have income the maternal care
should finance by the government [3].
She needs to do screening on bacteriuria but she said “I don’t have
money” and the doctor reported that “she refused screening” [10].
Near miss services should not have any OPPs because this is something
you cannot predict or plan [4]
Focus group discussions
I was asked for additional lab tests. Lastly I found that was not
necessary. I complained to MoLHSA and the facility was penalized [17]
Private providers are increasing fees frequently and suggesting more
consultations than needed [20].
Only emergency services are financed but not preventive measures
even for high risk pregnancies [17]
services. In the current situation, the equal financing of
poor and rich people lead to the problem of regressive
financing. Representatives of national and international
organizations questioned the regulation of financing of
C-section. “The number of C-section has significantly
increased in the country” according to one of the key
stakeholders. Many C-sections are conducted because of
either demand of women or providers’ income interests
rather than real indication. Use of state resources for
such unjustified C-sections causes waste of resources.
The government should strictly regulate this issue for
the proper use of resources.
Opinions about OPPs:
Two women mentioned that specialized laboratory
tests are not included in the current government programs and some are not even available in the country.
One of them mentioned-“I was suggested for a genetic
test which was expensive and not available in Georgia.
The doctor asked me to send sample to Germany. It was
costly and I could not manage to do that.” Some providers mentioned that the burden of OPPs is significant
for maternal care in case of complications. The State
program for the management of pregnancy complications
exists but the program has very strict inclusion criteria.
According to the opinion of one of the providers, management of near-miss cases is often difficult with the available
facilities in the country. However, most of the cases might
be prevented if necessary measures are taken on-time.
Moreover, there is no rehabilitation program for
women who undergo near miss cases. During the FGDs
in Kutaisi and Batumi, women actively raised the issue
of pregnancy-related complications. Women from rural
areas mentioned that some of them faced various types
of complications such as bleeding and preeclampsia,
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and they were transferred to tertiary level facilities in
region or in Tbilisi. According to them, due to severe
complications, they did not pay and the government
covered all expenses.
Regulation:
A few women expressed their dissatisfaction because
of the strict rule of registering before 12 weeks of pregnancy. One of the mothers said that women may not be
registered with the system because of different reasons
and for this they should not be deprived from state
provision of financial support. She mentioned- “I was
not given a voucher because of attending the clinic at
13 weeks of pregnancy. I did not do it intentionally but I
could not manage to go before 12 weeks because of family problems”.
Strengthening the regulation in the healthcare sector
and particularly maternal care is essential according to
the participants. One of the private providers mentioned
that because of the cost-of transportation, pregnant
women delay referrals and this negatively affects the outcome of maternal care as well. The transportation system
is not included in the UHC program.
Discussion
This paper describes stakeholders’ opinions about the
strengths and weakness in terms of adequacy and effects
of maternal care financing reforms in Georgia. The study
gives us an opportunity to examine the influence of the
privatization on maternal health in Georgia. All stakeholders indicated that the recent financial reform in the
health care sector has decreased the financial hardship
for mothers. But also, there is consensus among the
groups that in case of pregnancy complications, and personal choice of facility and provider out of state programs, the burden of the OPPs is significant.
Privatization plays a crucial role in service provision in
the health care sector. In Georgia, it influences the development of the health care system. As in other European
countries, the privatization is a response to public sector
failure [16]. The decision of the government to privatize
the entire health sector is an outcome of a policy-driven
process, but it is not followed by strong regulation mechanisms and this gives room to private ownership of health
facilities, particularly owners of the maternity houses, to
manipulate the user fees. Specifically, our study shows that
there is consensus among stakeholders that the latest
decision of the government to implement UHC program protects mothers from financial burden. However,
the weaknesses in regulation are also observed.
Specifically, the privatization of the healthcare service,
particularly in the maternal care field, has improved the
infrastructure. Some authors argue that privatization in
Shengelia et al. BMC Health Services Research (2017) 17:544
the healthcare sector simulates competition, which leads
to the improvement of quality of care and the service
package [16]. In Georgia, competition between the private maternity houses is mainly associated with improvements in technical efficiency and the infrastructural
capacity of the facilities. Opposite to Georgia, Armenia
and Ukraine maintained a public health system similar
to that established during the Soviet era with a focus on
curative care. In spite of the fact that post-soviet countries
chose their own path of developing their own health system, all countries experience the same problems and challenges in maternity care.
As our study shows, one of the advantages of the
privatization in Georgia is the abolishment of the informal payments. In the country, informal payments existed
during the soviet era and became more common in the
early 1990’s. Even at the beginning of the 21 century, informal payments were directly paid to the provider, were
demanded by providers as well as influenced by a soviet
culture of gratitude [17]. Informal payments provided a
way to obtain medical care immediately [18]. This is also
confirmed by our findings. Thus, the elimination of informal patient payments is not the result of a more efficient resource allocation or more adequate regulation by
the State, but an outcome of private owners’ efficient
managerial capability in this regard. At the same time,
there is evidence that in other post-soviet countries such
as Ukraine, informal payments for maternal care are still
widely spread [19].
Nevertheless, our findings indicate that formal OPPs
are a significant burden for pregnant women in Georgia.
During the focus group discussions, some mothers
mentioned that beside the initial payments, they were
requested to pay some additional amounts for additional
services in case of complications, which they paid officially. Moreover, respondents of the in-depth interviews
also stated that during the antenatal period, most women
required additional visits and because of this, they paid
extra out of pocket. The OPPs are also increasing due to
phenomenon of “personal doctor”. The phenomenon is
not unique for Georgia.
Women have autonomy of choosing facility, provider
and diagnostics, and even mode of delivery location,
then they are also kept responsible for the payment,
when they have the ability to pay. Thus, the current financial reform is regressive since both the poor and the
rich are getting equal state facility. Whenever needed,
the richer segment has access to specialized services
through OPPs but the poor segment is not supported by
state program for the specialized services. A progressive
financing system could protect both the poor and the
rich pregnant women.
Women in Ukraine and Armenia also use this type of
service but in these countries, they mostly pay for it
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informally [19, 20]. We identify in our study that the
main push factors to search and pay extra for a personal
obstetrician are: safety, responsiveness and personal
comfort. It is clear from our study that pregnant women
and their families prefer to pay more for the service of a
personal obstetrician and ensure “high quality of care”.
However, they choose a personal obstetrician according
to their ability to pay as well as taking into account direct and indirect costs. This situation leads to inequities
and disparities among mothers as not everybody can afford a personal physician and might receive substandard
care. For example, one of the participants of the focus
group discussion mentioned that her mother had to pay
all expenses for the last pregnancy. Moreover, epidemiological surveillance of maternal mortality done by the
NCDC of Georgia showed that maternal mortality is
higher among lower middle and low income groups because lower income groups utilize fewer maternal care
services due to direct and indirect cost [21]. This is
found in our study as well.
The implementation of the UHC program in Georgia
is influenced by an increased burden of OPPs and decreased utilization of health services [6, 22]. UHC, including the coverage of maternal care, remains a
priority in the post-2015 agenda [23]. The goal of the
UHC implementation in Georgia is to protect the health
of the entire population and to promote a sustainable economic and social development, as it is targeted by WHO
in 2010 [24].
Our study shows that after the implementation of the
UHC program, the utilization of healthcare services became easier and catastrophic health care expenditure
reduced as the UHC program finances childbirth and
C-section services. In Georgia, the share of C-sections
is high (41.5% in 2015) compared with European countries [25]. According to participants in the focus group
discussions and in-depth interviews, the State finances
C-section on demand. The UHC program pays 500 GEL
for a C-section performed on demand of the patient and
800 GEL in case of a medical indication. However, the
price for a C-section on demand is the same as for a normal vaginal delivery. However, the potential short-term
maternal outcome of a vaginal delivery compared with
elective C-section includes a shorter length of hospital
stay, lower infection rates, fewer anesthetic complications,
and higher breastfeeding initiation rates [26]. Beside this,
our study shows that the fees for services of childbirth and
C-section varied from 900 to 3500 GEL among healthcare
providers. The variation in the fee-for-service rates depends on how famed the maternity house is and what
additional comfort they provide to the users. However, the
UHC financing of any type of childbirth protects the
mothers and their families from catastrophic health expenditure. Compared to Georgia, C-sections are lower in
Shengelia et al. BMC Health Services Research (2017) 17:544
Ukraine and Armenia; two former-soviet states. In 2013,
the number of C-sections per 1000 live birth was quite
high and reached 371.09 in Georgia while it was 238.07
and 168.88 in Armenia and Ukraine respectively [27].
The opponents of the positive influence of maternal
care financing on maternal health are quite open about
the negative effect of the fragmentation of the vertical
and horizontal maternal health programs due to high
administrative costs. This raises the issue of efficiency
[28]. In this situation, the organization of antenatal care
through several agencies without a monitoring and evaluation mechanism needs attention from the policy makers.
Since 1997, Georgia offers 4 free antenatal services in accordance with WHO recommendations [28, 29]. Many
maternity houses do not participate in the program because of two reasons: first, because of insufficient compensation per package and second, the service content of the
antenatal care package does not cover all antenatal care
needs. Mothers as well as providers and representatives of
national and international organizations, strongly advocate
an increase of the antenatal care package financing. Since
years, the antenatal package has remained the same and
the government pays the same amount (55 GEL) [7] in
spite of the inflation and changes in user fees. Almost all
women-participants mentioned that they visited antenatal
care clinics at the request of the physician nearly 10 or
more times, and paid OPPs. This finding indicates that
the interest of the maternity houses that participate in the
State antenatal care programs is to recruit pregnant
women and then encourage them to utilize more services than necessary. All these findings indicate that
there is supply-induced demand in Georgian maternal
care and a providers’ interest to increase their income.
This raises the question of efficiency and effectiveness
of the maternal healthcare programs. The fragmentation of maternal healthcare programs and high pharmaceutical costs are common in Ukraine and Armenia as
well. Both countries are facing challenges in the equity
of healthcare financing [14, 30].
Universal coverage of maternal care reflects the individual rights of pregnant women and social solidarity
[31]. However, it should focus on equity and should take
into account the social determinant and needs of subgroups and those who are vulnerable [3]. Georgia is a
lower middle income country. In 2014, GNI per capita
was 4490.00 [31]. In this situation, the burden of UHC
without the regulation and monitoring mechanism is
significant for the country.
Strengths and weakness of the study
We triangulated the stakeholders’ opinions to strengthen
the validity and reliability of the results. A wide range of
stakeholders were included in the study that gives a real
picture of maternal care in Georgia. However, a small
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number of settings were included in this study. Thus, the
results cannot be extrapolated to the entire country. However, as in any qualitative study, the primary research objective is to collect in-depth information on the views of
the stakeholders rather than achieving representatives for
the country. Accordingly, the results are important because they provide an in-depth understanding of the problem. Further, experienced facilitators managed the FGDs
and also explored the in-depth opinions of the target
women. Thus, we mitigate the facilitator-related bias by
choosing an experienced moderator and interviewers, and
by applying a guide to assist them during the data collection process. Also, we pre-tested the guide before the field
works. By involving experts in the translation process, we
diminish such bias to a certain extent.
Conclusion
This qualitative study was done in two regions and in
Tbilisi and aimed to elicit stakeholders’ opinions about
maternal health financing in Georgia. The results of our
study suggest a consensus among stakeholder groups on
the influence of the healthcare financing reform on maternal healthcare. The total privatization of the maternal
care services has had positive effects because it significantly
improved the environment and the technical capacity of
the maternity house. But the privatization was done
without strict regulation, which negatively influenced the
reform process and provided the possibility to private
providers to manipulate user fees in maternal care.
Stakeholders also indicate that the UHC program implemented at the last stage of the healthcare financing
reform protects the mothers from catastrophic health
expenditure. Besides UHC, the State implemented several
vertical maternal health programs and maintained financial access to basic maternal healthcare services.
These program protect pregnant women from catastrophic
health care spending for maternity care. In addition, stakeholders reported that the healthcare reforms eliminated
the informal payments. However, vulnerable groups are facing difficulties in paying the formal fees for some lab tests
that are not in the basic package and also because of transportation cost for antenatal care. As study participants indicated, an increase in the basic antenatal care package and
its financing, as well as strengthening the regulation in the
healthcare sector, especially regarding the unjustified use of
C-sections, are essential for Georgian maternal healthcare
services.
In spite of the significant steps taken by the government
to improve maternal health and to reduce maternal mortality, the target was not achieved. Therefore, the financial
protection of mother should be further studied to identify
the needs of the vulnerable groups who should be targeted
in future programs.
Shengelia et al. BMC Health Services Research (2017) 17:544
Additional files
Additional file 1: Guide for In-depth Interview. The Guide for In-depth
Interviews was used to study stakeholders’ views on the strengths and
weaknesses of maternal care financing and its reforms in Georgia.
(DOC 88 kb)
Additional file 2: Guide for Focus group discussions. The Guide for
Focus group discussions was used to study stakeholders’ views on the
strengths and weaknesses of maternal care financing and its reform in
Georgia. (DOC 100 kb)
Abbreviations
C-section: Caesarian sections; GDP: Gross domestic product; HIV: Human
immunodeficiency virus; MDG: Millennium Development Goal;
MMR: Maternal Mortality Ratio; MoLHSA: Ministry of Labor, Health and Social
Affairs; NCDC: National Center for Disease and Public Health of Georgia;
OPP: Out-of-pocket payments; SDGs: Sustainable Development Goals;
UHC: Universal health coverage; WCC: Women Consultation Centers
Acknowledgements
Authors of this paper thank the Netherlands Fellowship Programme (NFP) for
funding this research (Budget number: 30957427 N).
Availability of data and materials
The authors confirm that the data will be made available from the corresponding
author on reasonable request.
Authors’ contributions
LS: research concept, developing discussion guides, organizing discussion
groups, cross checking of all translated transcripts with audio records to
ensure validity, codifying the text, data processing, analyzing and interpreting,
and writing the manuscript. MP: research concept, developing discussion
guides, critical reviewing and revising the final manuscript. WG: research
concept, developing discussion guides, critically reviewing the manuscript, and
revising the final version. All authors read and approved the final manuscript.
Competing interest
All authors declare that they have no competing interests.
Dr. Milena Pavlova, co-author of this paper, is a Section Editor for BMC Health
Services Research.
Authors’ information
LS: MD, MPH, PhD candidate of the Department of Health Services Research,
Faculty of Health, Medicine and Life Sciences, Maastricht University, the
Netherlands, and Head of the Maternal and Child Health Section, the National
Center for Disease Control and Public Health of Georgia. MP: PhD, Associate
Professor, Department of Health Services Research, Faculty of Health, Medicine
and Life Sciences, Maastricht University, the Netherlands. WG: PhD, Professor,
Department of Health Services Research, Faculty of Health, Medicine and Life
Sciences, Maastricht University, the Netherlands, and Top Institute Evidence-Based
Education Research (TIER), Maastricht University, the Netherlands.
Ethics approval and consent to participate
Ethical clearance was obtained from the National Center for Diseases Control
and Public.
Health of Georgia (Reference No.: IRB-2015-023). Informed written consent
was obtained from all participants for audio recording of the sessions.
Confidentiality and anonymity were assured and confirmed. All audio
records, transcripts and processed data have been secured with selective
access to the authors only.
Consent for publication
Not applicable.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Health Services Research, CAPHRI, Maastricht University
Medical Center Faculty of Health, Medicine and Life Sciences, Maastricht
Page 8 of 8
University, Maastricht, The Netherlands. 2The National Center for Disease
Control and Public Health of Georgia, Tbilisi, Georgia. 3Georgian Association
of Gynecologists and Obstetrics, Tbilisi, Georgia. 4Top Institute
Evidence-Based Education Research (TIER), Maastricht University, Maastricht,
The Netherlands. 5Varketili 3, IV 401 aprt.75, Tbilisi, Georgia.
Received: 21 February 2017 Accepted: 31 July 2017
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