Tamar Khomasuridze,1Lela Bakradze,1Tea Jaliashvili.1
1United Nations Populations Fund, Georgia.
Executive summary
The initial period of independence for Georgia resulted in difficult transition years that were exacerbated by civil war, displacement of people from two conflict zones, lack of financial resources and an economic crisis.
The health status of the population, particularly in relation to reproductive health, gave cause for concern due to increases in the numbers of maternal deaths, unsafe abortions and pregnancies among adolescents.
Limited access to reproductive health services and information, particularly for young people, was partly responsible for creating this situation.
The country’s health services, which had been inherited from the Soviet health system, were generally of poor quality and were mainly focused on the needs of women. Lack of male involvement with reproductive health services gave rise to concern, while concepts such as youth-oriented services and issues of
confidentiality and the right of choice had to be introduced throughout the country.
The Georgian Government embarked on an ambitious and complex reform processes that has been
accelerated during the last five years. The United Nations Populations Fund (UNFPA) supports the Georgian Government in its efforts to achieve the International Conference on Population and Development (ICPD) programme of action and the Millennium Development Goals (MDGs), with a special focus on MDG 5:
improving maternal health and achieving universal access to reproductive health services.
One of the important aspects of the UNFPA programme is sexual and reproductive health services for young people. By promoting the reproductive rights of young people and increasing their access to high-quality, gender-sensitive sexual and reproductive health information and youth-friendly services, the organization has made an important investment in improving sexual and reproductive health among the country’s young people.
UNFPA has established youth-friendly medical information centres in all regions of the country under a joint European Union (EU)/UNFPA project called “Reproductive health initiative for youth in the South Caucasus” (RHIYC). Facing the challenges posed by current health reforms and privatization of health care facilities in Georgia, UNFPA utilized a new partnership strategy in establishing youth-friendly services. The strategy aimed to find the most-reliable partners at primary health care level from both the public and private sectors who were committed to collaborate in the development of sustainable and cost-effective youth-friendly services.
The case study focuses on the sexual and reproductive health needs of young people and describes obstacles in accessing sexual and reproductive health information and services, the changing health care environment, the importance of partnership strategies, the operation of a youth-friendly services model and issues around sustainability.
Background
The initial period of independence for Georgia resulted in difficult transition years that were exacerbated by civil war, displacement of people from two conflict zones, lack of financial resources and an economic crisis.
The health status of the population, particularly reproductive health, gave cause for concern due to increases in the numbers of maternal deaths, unsafe abortions and pregnancies among adolescents. This was partly due to limited access to reproductive health services and information, particularly for young people. Health services in general, which had been inherited from the Soviet health system, were of poor quality and were
mainly focused on the needs of women. Lack of male involvement with reproductive health services gave rise to concern, and youth-oriented services and issues of confidentiality and the right of choice were new concepts that had to be introduced throughout the country.
Although the education level of men and women in Georgia was high, general knowledge of family planning, understanding of sexual and reproductive health issues and awareness of reproductive rights were limited due to cultural stigmas and to a lack of supportive policies and education on healthy lifestyles.
Misconceptions and the population’s negative attitude towards modern methods of family planning were the main causes of high rates of abortions; in fact, abortion was considered the only method of birth control.
The two most serious sexual and reproductive health problems facing young people in Georgia then were sexually transmitted infections (STIs) and pregnancy; they remain so today. Sexual activity generally begins at an earlier age than in the past, but young people have inadequate access to information about safe sex and contraception.
HIV/AIDS is another grave concern in the country. HIV/AIDS prevalence rates remain at low levels currently, but the high-risk environment, including widespread injecting drug use and intensive population movements across neighbouring high-prevalence countries, cause Georgia to be at risk of a wide-scale epidemic.
Despite ongoing reforms in the health care sector, a state funding focus on maternal and child health, the development of insurance mechanisms and improvements in specific health indicators, there is still a number of problem areas associated with a reduction in public financing of health care that affect reproductive health services. Resolution of these problems is essential, particularly when the current demographic situation and ageing population problem in Georgia is taken into account. The problem is further complicated by socioeconomic conditions that prevent women from being able to access and afford an adequate level of health care.
In Georgia, young people constitute 25% of the total population. The latest study (1) showed that more than half of women (58.9%) cannot afford medical care because of economic constraints. The survey demonstrated that the highest birth rate was found among females between the ages of 20 and 24 years.
More than half of live births were reported among females in the 15−24 years age range. The mean age for marriage (21.6 years) and the average age of commencing sexual activity (21.3 years) among females were almost the same, while the mean age for marriage among males (25.1 years) is significantly higher than the mean age for first sexual intercourse (17.5 years).
These findings demonstrate that there is still a high risk of unintended pregnancy and STIs that is largely attributable to sexual intercourse among unmarried youth without proper use of contraceptive precautions, or without the use of precautions at all.
Surveys conducted in 1999 (2) and 2005 (1) showed that the abortion rate among adolescent females had significantly reduced (by half) by 2005 as a result of intensive efforts targeted at behaviour change and peer education. The surveys also show that the contraceptive prevalence rate has increased in recent years (40.5%
in 1999 and 47.3% in 2005), reflecting rises in availability of modern birth control methods. To make sustainable improvements in youth reproductive behaviour, however, it is critical to strengthen the quality of, access to and affordability of reproductive health services.
The main challenge here is the lack of youth-friendly reproductive health services. According to a report published in 2002 (3), most young people felt they needed more information about services available to them and an adequate level of knowledge about different family planning methods. Young females and teenagers believed the best source of information about reproductive and sexual health services was the medical profession, but only 1.7% of 15−19-year-old and 5.4% of 20−24-year-old females had received such information from health care workers. The most common source of information was close friends and peers
who may have had some experience with the system. Young people were generally distrustful about the providers of medical services and visited them only in emergencies.
Studies of reproductive and sexual health services carried out in Georgia (1−4) have revealed:
a low level of knowledge among young people (despite their good awareness of various
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reproductive and sexual health issues);
poor utilization of reproductive and sexual health services; and
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an inadequate level of medical treatment and consultations in reproductive and sexual health
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services.
Difficulties encountered in accessing and affording reproductive and sexual health services among young people remain an obstacle to health improvement. Improvement in the reproductive health status of young people is a priority in Georgia, not only for medical reasons, but also from social and developmental perspectives. UNFPA is working in partnership with governmental and nongovernmental organizations (NGOs), national institutions and private sector organizations to improve youth access to services.
To achieve this, comprehensive state policies, regulations and a legislative framework need to be in place.
Health care legislation in Georgia creates the basis for protection of human rights, which corresponds to international standards, treaties and conventions ratified by Georgia. At present, several legislative acts in the field of health care address reproductive rights:
Law on Health Care
One of the most important aspects is the policy environment and legislative framework in which youth-friendly services operate. The Law on the Rights of Patients aims to protect citizens’ rights to health care and to ensure the inviolability of their dignity and privacy. It regulates rights to information (Article 16), informed consent (Article 22), age of informed consent, confidentiality, privacy (Article 27), parental consent (which affects young people’s access to services) and special provisions on the rights of minors (articles 40−43).
The Georgia national reproductive health policy document (5) and the strategic plan for reproductive health in Georgia are also significant. These serve as a foundation for detailed annual planning for provision of reproductive health information and services. A comprehensive policy on young people is under
development.
Health system context and health services available to young people
Demand on reproductive and sexual health services from the population, particularly young people, is influenced by a number of medical and non-medical factors. Quality, accessibility and affordability and culture-, gender- and age-sensitive approaches are the issues traditionally considered in all strategies. In the process of health care reform and privatization of health facilities in Georgia, however, developing the role of, and creating partnerships with, the private sector has become an absolutely critical priority for ensuring the sustainability of services.
In the early 2000s, the primary health care system in Georgia consisted of various outpatient facilities at local level (adult, child and women’s polyclinics and specialized dispensaries), along with village-level ambulatory clinics staffed by one paediatrician or general practitioner and one nurse per 2000 population.
There were virtually no reproductive health services offered at these village facilities – physicians were
6The newly prepared draft law on AIDS is currently under discussion.
ambulatory clinics staffed by one paediatrician or general practitioner and one nurse per 2000 population.
There were virtually no reproductive health services offered at these village facilities – physicians were
traditionally neither trained nor authorized to provide basic reproductive health care at village level, and the ambulatory clinics were neither equipped nor resourced to enable them to do so.
Women receive essential reproductive health services – mainly pregnancy and delivery care, family planning services and abortion, clinical diagnosis and treatment of STIs and reproductive tract infections – through the women’s outpatient clinics (“women’s consultations”) and maternity hospitals located at local and regional centres. The distance of these facilities from many villages, particularly in the mountainous regions, constitutes both a geographic and financial barrier to access for many women.
The only reproductive health services offered to (and utilized by) men are diagnosis and treatment of STIs through dermatovenereological clinics. Men may also consult urologists through adult olyclinics.
Table 1 presents the facilities that offered some sort of reproductive health services at village and regional level in 2005. It includes lists of those reproductive health-related services that, according to the state health programmes and regulations governing the licensing of medical activities, should have been made available.
Table 1. Reproductive health services in the primary health care system, 2005
Rural
Sexual and reproductive health services, including family planning services, are provided largely in special
“reproductive health cabinets” (sexual and reproductive health service units) by gynaecologists who have trained and qualified as reproductologists. There are approximately 75 reproductive health cabinets in the country, the majority of which are located within women’s consultation centres or maternity hospitals.
These reproductive health cabinets and the services offered by the reproductologists staffing them have been largely supported by donor funds and out-of-pocket payments.
The integration of sexual and reproductive health services at primary health care level is the objective of the health care reform that is currently being implemented despite serious obstacles such as military conflicts, displacement of populations and related budgetary constraints. The sexual and reproductive health programmes are coordinated by the Reproductive Health National Council, chaired by the First Lady of Georgia.
UNFPA has been an important source of support to Georgia since 1996. It has aimed to improve the quality of, and access to, sexual and reproductive health services and to increase the demand of the population, particularly young people, for services. Youth sexual and reproductive health is the strategic priority and is integrated in all programme aspects and components in Georgia.
UNFPA has been providing technical and financial support to Georgia, supplying equipment, developing services protocols and guidelines, training service providers, conducting surveys and analytical studies and educating the public on sexual and reproductive health and reproductive rights. The UNFPA programme has also attempted to bridge the gap in geographic accessibility through deployment of mobile teams of reproductive health service providers. More recently, the United States Agency for International
Development (USAID)-supported “Healthy women in Georgia” initiative has provided training and a supply of contraceptives to providers in over 200 village ambulatories, newly renovated primary health care centres and outpatient facilities in Tbilisi and selected regions of the country.
The government does not have a separate youth-oriented sexual and reproductive health programme, but state support is channelled through the following state health programmes:
antenatal care (the recommended four visits are funded by the state; additional visits, tests or
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recommended treatments must be covered by the client);
delivery care (fully, at 400 lari, for families registered with the social assistance system as
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living below the poverty line, and partially, at 200 lari, for others who request state assistance;
these services are provided at select maternity hospitals, contracted for this purpose by the state through the State United Social Insurance Fund);
counselling, testing and treatment for HIV (through resources provided to the Georgian
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Government by the Global Fund for Combating HIV/AIDs, Tuberculosis and Malaria); and contraceptives (provided free of charge through the reproductive health cabinets supplied by
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UNFPA; payment for counselling is made by the clients).
Recent initiatives on youth-friendly health services
UNFPA supports the Georgian Government in implementing the programme of action from the International Conference on Population and Development (ICPD) held in Cairo, Egypt in September 1994 and the
Millennium Development Goals (MDGs) (6), which lay the foundations for improved reproductive health, poverty reduction and economic empowerment of the population.
UNFPA fully established its country office in Georgia in 1999. The UNFPA Georgia Country Programme, run in partnership with the Georgian Government, revolves around three core areas:
reproductive health
It takes this programme forward through addressing topical issues such as the quality and accessibility of reproductive health services, gender equality and the availability of quality data for development.
One of the important aspects of the programme is young people’s sexual and reproductive health. The organization provides important investment aimed at preventing sexual and reproductive health problems from an early age by promoting young people’s access to quality sexual and reproductive health information
and gender-sensitive, youth-friendly services.
Youth-friendly, gender-sensitive services proffer solutions to many problems, including dismissing taboos round sexual health and involving men in reproductive health issues by increasing their access to information and services. The strategy on youth-friendly services agreed by UNFPA and the Georgian Government covers topics related to capacity-building of reproductive health service providers, improving the structures and conditions of health facilities, and encouraging youth participation in programme design, implementation and monitoring.
The development of youth-friendly sexual and reproductive health services has had a critical impact on the achievement of recognized reproductive rights for young people and the improvement of youth sexual and reproductive health indicators in Georgia.
As a post-Soviet country, Georgia faced the following challenges:
issues around the affordability of quality reproductive health services
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limited access to reproductive health services for males
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lack of availability of youth-friendly reproductive health services.
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To meet these challenges, youth-friendly medical information centres have begun to be established in all regions of Georgia under the “Contributing to the expansion of youth-friendly sexual and reproductive health services, information and counselling” stream of the RHIYC programme.
It was decided to establish two types of reproductive health services for young people:
youth-friendly reproductive health information centres at universities in Georgia to improve
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access to quality information; and
youth-friendly reproductive health information medical centres, to be established in the capital
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and all 10 regions of Georgia.
The strategic plan developed by UNFPA and its partners consists of several interlinked important steps.
Step 1. Ask young people to determine their needs
The first step in specifying priorities and actions to establish youth-friendly sexual and reproductive health services was to review relevant surveys and analytical studies to determine young people’s needs and identify obstacles to accessing information and services. In addition, a special survey on youth-friendly reproductive health services in Georgia was conducted in 2007 to assess the “youth friendliness” of existing sexual and reproductive health services and to develop recommendations on how to fill existing gaps with new service units, meeting the needs of young people and international (WHO) standards for youth-friendly services.
During the survey, in-depth interviews based on a specially designed questionnaire which focused on issues such as physical and financial accessibility of sexual and reproductive health services and confidentiality and privacy issues were conducted. In addition, five different scenarios were developed to determine the quality and adequacy of medical care and consultations. Specially trained interviewers visited sexual and reproductive health services with these scenarios, which focused on the assessment of quality of medical consultations and services, the attitudes of medical personnel towards patients, and confidentiality and environmental issues.
The survey findings and recommendations provided the basis for development of the strategic plan, with a detailed description of youth-friendly services and the implementation of an appropriately targeted strategy for the development of youth-friendly sexual and reproductive health services, leading to the overall
improvement of youth sexual and reproductive health. Twenty-one youth-friendly sexual and reproductive health services (information and medical information centres) are now in the process of opening and will be fully operational by September 2009 all over Georgia.
Step 2. Changing environment, adequate partnership strategies
The process of privatization of health care facilities in Georgia changed the health care environment and caused an alteration in initial plans to create youth-friendly services.
To help meet these challenges, UNFPA deployed a new partnership strategy which aimed to identify the most-reliable partners at primary health care level (both public and private sector) who were committed to collaborate in the development of sustainable, cost-effective youth-friendly services. UNFPA invited applications and carefully assessed submissions, taking into account a wide range of issues such as
geographic coverage, capacity, service gaps and development opportunities. Interested potential partners had
geographic coverage, capacity, service gaps and development opportunities. Interested potential partners had