A forgotten crisis: improving IDP access to health services in Georgia
Published on 19/10/2017
Georgia is not the first country that comes to mind when you think of current humanitarian crises. The multitude of recent natural disasters in Mexico and the Caribbean, the cholera outbreak in Yemen and the displacement of Rohingya in Myanmar are all more prominent and acute emergencies. The continuing conflict in Syria dominates when we consider complex prolonged situations. Yet R2HC research can take place in any location where public health is affected by humanitarian emergencies. This includes longer-term protracted crises, such as the displacement of people following conflicts almost a decade ago.
A recent visit to Georgia highlighted how R2HC-funded research is improving health systems for vulnerable populations many years after they were forced from their homes. Conflicts with neighbouring Russia have led to around 300,000 people displaced within Georgia. The most recent was in 2008, and yet the Internally Displaced People (IDP) population continues to reside in accommodation built as temporary housing in the immediate aftermath. Recognising their health needs, the Georgian Government has established health insurance schemes targeted at IDP populations. The situation is complex, however. There is shared responsibility for delivery of health services across national and regional governments, whilst various IDP groups have been offered different entitlements.
In response, Health Research Union (HRU) set out to establish if targeted insurance schemes are positively impacting on IDP health. HRU is a respected NGO founded by Georgian physicians who are supporting the health needs of vulnerable people. They provide daily clinical services, whilst also running a research programme that has secured prestigious international funding.
HRU has used R2HC funding, awarded in 2015, to shine a light on the challenges faced by IDPs in accessing and paying for local health services. Working in collaboration with local partners they have undertaken one of the most extensive surveys of the IDP population in Georgia. Adapting a standard Health Utilisation and Expenditure Survey (HUES), they undertook interviews with over 1,500 households, randomised in clusters to achieve a representative sample across several IDP populations.
The National Centre for Disease Control in Georgia led on conducting the survey, using a wealth of experience in conducting similar household surveys on health-related matters. Local NGO Abkhazeti was crucial to ensure buy-in from the IDP households. Their 20-year experience of working with IDP communities helped overcome the scepticism felt by people who have participated in previous studies without seeing the results. Abkhazeti’s on-going relationships with local IDP community leaders will enable them to feed back survey findings and help raise the voice of IDPs in response.
HRU’s findings show that despite Government attempts to target health insurance schemes to IDPs, the complexity has left IDPs substantially in the dark about their entitlements. At a meeting with community leaders in Berbuki compact settlement in Gori we heard how this had resulted in significant out-of-pocket expenditure on health services. One community leader commented on the rising and unaffordable costs of medicine, as these are not included in the insurance coverage. Another pointed out that even the doctors themselves do not know what their IDP patients are entitled to. The research also highlights that self-medication levels are notably higher than amongst non-IDP populations, whilst levels of alcohol use are concerning.
The study provides valuable evidence for Government Ministries to use to further develop health systems and services that work for IDPs. Despite the Government’s good intentions, the failure to properly communicate the availability of targeted health insurance has meant health outcomes are not improving as hoped. HRU is well-positioned to use this evidence to encourage Government departments and other stakeholders to act. Through their impressive work on Hepatitis C treatment, HRU has existing close working relationships with key Government health figures. Their local knowledge enables them to target findings at the right people, and the scientific rigour of their studies means it can’t just be dismissed as criticism for political purpose. Early signs from both the Georgia Ministry of Health and the Government of Abkhazia are positive, although it remains to be seen if words are turned into the action needed.
The survey data will also have longer term impact if it can be used as a baseline, enabling follow-up surveys to determine trends in healthcare provision and accessibility. There is potential too for findings to help inform the regional situation where other countries, most notably Ukraine, are dealing with the consequences of more recent conflicts.
Georgia’s displaced populations are no longer facing the acute crisis that characterises humanitarian emergencies. Yet as we approach almost a decade from the 2008 conflict, HRU’s research provides an opportunity to achieve long term health system change for a population that continues to suffer.
Author: Simon Pickard, R2HC Portfolio Manager, October 2017