Funding for Healthcare in the South Caucasus

Government expenditure on healthcare can be an indicator of a government's commitment to the health of its citizens. It is also important for the sustainability of health programmes. Nevertheless, the total health expenditure in all three countries of the South Caucasus is dominated by private spending, including prepaid plans and “out-of-pocket” (on the spot) payments. This blog provides a brief overview of the patterns of government spending on healthcare in the South Caucasus during recent years. The blog also links these patterns to data from the 2012 Caucasus Barometer (CB) about assessments of health, satisfaction with health, and trust in the health system.

Total expenditure on health as a percentage of GDP provides information on the level of resources invested in health relative to a country's overall wealth. In developed countries, government spending on healthcare accounts for approximately 10% of gross domestic product (GDP) or more. This percentage of resources pooled by the government is comparatively lower in the South Caucasus. It accounted for as much as 9.9% of the total GDP in Georgia, 4.3% in Armenia and 5.2% in Azerbaijan, according World Health Organization data from 2011.

Total expenditure on health is distributed between private and government expenditures, which are also unequal across the globe. In more than half of low income countries, government expenditure on health is less than 50% of total health expenditure. Where health spending is comparatively lower in general, the shortfall is made up by private spending. This can also be observed in the South Caucasus where the private amount paid for health services dominates the expenditure (reaching around 78% in Georgia and Azerbaijan, and more than 64% in Armenia). Most of the private expenditure on health in all three countries is so-called “out-of-pocket” – made by patients to both public and private providers at the time of receiving health services. Despite the fact that this method of payment can result in financial catastrophe for individuals or households, in each country in the South Caucasus “out-of-pocket” expenses amounted to 89% of total private expenditure on health.

Despite more substantial budgetary allocations to citizens’ healthcare by the government in Georgia, compared to  Armenia, the CB shows that trust in the healthcare system in these two countries is almost the same (39% and 38%, respectively-“Fully trust” and “Somewhat trust” combined). Azerbaijanis’ trust in the healthcare system is the highest among the three countries, amounting to 51%. Considering the self-evaluation of one’s health, around half of the adult Azerbaijani population rates their health as good or very good. Again, this rate is lower in Georgia and Armenia, where only about one-third of these societies think they have good health. Interestingly, these numbers are again similar despite the fact that the Armenian government has larger health expenditure than the Georgian government.

Private expenditure still dominates the healthcare expenditure in the South Caucasus. Given that large parts of these populations are poor and cannot afford to spend much on healthcare, low levels of government spending on health might have an impact on the health of citizens. Nevertheless, a higher share of government health expenditure does not necessary directly influence the quality of a healthcare system, or an individual’s level of trust or self-assessment of health. Thus, other factors ought to be taken in consideration such as evolving purchasing power parity, the general price of healthcare, or remittances.

For more information on this topic, you are welcome to visit our Caucasus Barometer database.

High Abortion Rates vs. Conservative Views against Abortion in the South Caucasus

There is a tension in the South Caucasus between high rates of abortion (and sex-selective abortion) and overwhelmingly conservative attitudes against it. Abortion rates in Georgia and Armenia are higher than the EU average and the rate in Azerbaijan is below. A 2010 article by the Economist placed Armenia, Azerbaijan and Georgia 2^nd, 3^rd and 4^th, respectively, on a list of countries worldwide where the numbers of girls are off balance at birth - China ranks first. This blog aims to explore attitudes towards abortion and gender in the South Caucasus, and shows that while there are widespread conservative attitudes against abortion, it remains frequently carried out.

Data from 2010 World Health Organization (WHO) report on abortion rates show that there are more abortions among women of reproductive age (15-44 years) in Georgia and Armenia relative to the average in the European Union (See chart below). The abortion rates in the South Caucasus region also vary considerably; the number of abortions per 1,000 live births is lower than the EU average (222) in Azerbaijan (162), whereas it stands at 274 in Armenia, and 408 in Georgia.

The high rate of abortion in the South Caucasus is also linked to sex-selective abortion, whereby pregnancies are terminated if the fetus is female. Male newborns outnumber females by more than 10% in the South Caucasus. For every 100 girls, there are 112 boys in Armenia, 114 boys in Azerbaijan, and 111 in Georgia according to the 2011 CIA World Factbook. Additionally, in 2011 the European Commission declared that “Prenatal sex selection is to be condemned as a phenomenon which finds its roots in a culture of gender inequality”. Thus, the sex-selective abortion problem in the South Caucasus may be a consequence of a greater cultural issue. Another considerable factor is the lower number of children that families in the South Caucasus have over time. For example, in the mid-sixties each family had 3 children on average in Georgia, 4 in Armenia and 5 in Azerbaijan, whereas, according to the 2012 World Factbook, the average number of children per family is now 1.46 in Georgia, 1.38 in Armenia, and 1.92 in Azerbaijan. With a choice of 1 to 2 children, many families in the South Caucasus prefer to have a boy instead.

Data from the 2010 CB also shows that people of both genders are more likely to say they prefer a son. Men in Georgia and Armenia indicate the greatest preference to have a male child (approximately 60%), whereas one third (33%) of Azerbaijani men agree. CB data also indicates that the gender of a child matters least in Azerbaijan and most in Armenia, whereas in all three countries men are more likely than women to say that they want a boy.

Yet, despite the high rate of abortions, and specifically sex-selective abortions, the CB 2011 shows that attitudes towards abortion in these countries remain very conservative. Well over half of the Georgian (76%) and Armenian (61%) populations believe that abortion can “never be justified” (This question was measured on a 1-5 scale where 1 =”never justified”, 5=”always justified”. The question was not asked in Azerbaijan). 

Moreover, the high rates of abortion are puzzling in these countries where the majority of the population says religion is important in daily life (92% in Georgia, 92% in Armenia and 80% in Azerbaijan according to the CB 2012), and where trusted religious authoritative bodies (i.e. Georgian Orthodox Church in Georgia, Armenian Apostolic Church in Armenia, and both Shia and Sunni Islamic Organizations in Azerbaijan) consistently advocate against abortion.

How can we explain these conservative attitudes against abortion along with the high rate of abortion in the South Caucasus? Is it a familiarity with abortion as a method of contraception from the Soviet Union, the availability of sex-selective technology, cultural attitudes, or something else? What do you think?

Roads and Safety in the South Caucasus

According to the World Health Organization (WHO), every year about 1.3 million people die as a result of road accidents worldwide. In 2011, the UN launched the Decade of Action for Road Safety 2011-2020. A year later, the UN General Assembly adopted Resolution A/66/L.43 to improve road safety conditions worldwide. This blog addresses satisfaction with road conditions and road safety in the former Soviet Union, specifically in the South Caucasus region.

GALLUP surveys conducted in 2011 show that only 36% of the adult population in the former Soviet Union is satisfied with the roads and highways in areas where they live.  In part, the surveys focused on the South Caucasus, Central Asia, Russia, Moldova, the Ukraine, and Belarus. Satisfaction with roads is highest in Georgia (69%) and lowest in Moldova (17%). In the South Caucasus, Georgia is followed by Azerbaijan (51%) and Armenia (37%). 

In general, unsafe vehicles, poor road infrastructure, careless driving habits, drunk-driving, and speeding are major causes of traffic accidents in the region.  Based on the WHO European Status Report on Road Safety, mortality rates from traffic injuries in the Commonwealth of Independent States (CIS) have increased since the late 1980s compared to the EU. However, it is also important to note that there are differences within the EU region as well.
  

From the late 2000s, Azerbaijan, Armenia, and Georgia have adopted road safety legislature and promoted safety campaigns, such as the 2010 Road Safety Program Project in Azerbaijan, the 2009 National Road Safety Strategy for Armenia and Yerevan and Five Year Action Plan, and road safety enforcement measures and traffic policing in Georgia. These campaigns can have a positive impact on society. Improving roads and highways in the region might contribute to the fact that, according to the WHO European Health for All Database (HFA-DB), death rates for road traffic accidents have been generally decreasing since the late 90s in Armenia, Azerbaijan, and Georgia.

Compared to the 1990s, the standard of roads has improved in the South Caucasus. However, careless driving practices are still common, and it takes much longer to change driving culture. Overall, traffic injuries can continue to be prevented by improving road infrastructure, enforcing speed limits, preventing driving while intoxicated, and promoting more road safety campaigns in the region.

Blood Donation in Georgia: Obstacles and Opportunities

According to a report by the World Health Organization, blood donations in Georgia fall below the estimated need for patients. Approximately 60,000 donations are necessary per year to cover Georgian patients’ needs, while the number of actual blood donation does not exceed 37,000. Moreover, 95% of blood donations come from paid donors. The main obstacle in advocating volunteer blood donation is due in part to the fact that being paid to donate blood is deeply rooted in public perceptions and volunteer blood donors get little support from Georgian society. This blog looks at the obstacles and opportunities for fostering volunteer blood donation and shows that over half of the Georgian population disagrees with the statement that “people donating blood should be paid”, and that lack of awareness remains a deterrent.

Source: World Health Organization

According to the Caucasus Barometer 2011, about 80% of Georgians have never donated blood and 61% have not seen or heard anything about donating blood during the last two years. 57% do not personally know anyone who has donated blood in the last 10 years. Yet according to the same data, 61% of Georgians disagree with the statement that “people donating blood should be paid” (only 22% agree). If, as the data shows, over half of the Georgian population is against paid blood donations, what obstacles prevent the establishment a good practice of blood donation in Georgia? To explore the potential reasons behind this finding, CRRC asked Georgians why they have never donated blood.

Source: Caucasus Barometer, 2011

The data shows that 20% of Georgians cannot state an exact reason for not donating blood. A promising 9% say they do not know where to go and only 4% say that they do not like the idea of donating blood. 20% think that not being in good health or doctors’ advice against blood donation is the main reason why they have never donated blood, while 8% are afraid of possible infection, and 7% of Georgians indicate a fear of needles.

In another survey on Volunteerism and Civic Participation in 2011, CRRC asked Georgians what they thought were the main reasons why people do not donate blood. The answer options are different here, but still reflect the difference between what people mention as their own reason for not donating blood and their perceptions of others’ reasons for the same behaviour. Namely, 17% say people are preoccupied with their own problems. While talking about themselves only, 6% say they do not have time to donate blood. Similarly, 10% of Georgians think that being indifferent towards the problems of others is the main reason for people not donating blood – an answer which is less likely to be mentioned when people talk about themselves.

Source: Survey on Volunteerism and Civic Participation, 2011

As the chart shows, 30% of Georgians are unsure about the reasons why people do not donate blood in Georgia. 15% mention being afraid of infections as a reason for not donating blood, reflecting a concern related to blood safety standards that exists in Georgian society and prevents some people from donating blood.

Lack of awareness seems to be another factor explaining the low level of volunteer blood donors in Georgia. 6% of Georgians think people find donating blood as unnecessary. 5% say people do not know where to go in order to donate blood and 4% think people do not know that they can donate blood at all. In total 15% of Georgians think having no information is the main reason why people do not donate blood. These results indicate that there is room for awareness-raising campaigns. Filling the information gap can be an important step to promoting volunteer blood donation in the country.

Finally, Georgians were asked how possible it is that they donate blood in the next 12 months. 38% of Georgians are unsure, 21% think it will never happen and a promising 11% say it is highly expected. CRRC data indicates that this 11% can be increased by improving blood safety standards and raising public awareness about the importance of blood donation, as well as about blood banks already operating in Georgia.

Road Safety and the South Caucasus | WHO Global Status Report on Road Safety

A recent report published by the World Health Organization (WHO) claims that over 90% of the world’s fatalities on the roads occur in low-income and middle income countries, which constitute only 48% of the world’s vehicles. The study assesses the status of road safety in 178 countries, identifies gaps in road safety and proposes recommendations for intervention.

A principal finding reveals that very few countries have comprehensive road safety laws that are effectively enforced. Hence, only 29% of the countries meet basic criteria for reducing speed in urban areas, and less than 10% of countries rate the enforcement of their speed limits as effective. Moreover, only 20% of low-income countries have a law requiring young children in cars to be in car restraints in contrast to 90% of high income countries , which have similar regulations. Additionally, only 57% of countries require seatbelts to be used by passengers in both front and rear seats.

The report provides data on the three South Caucasus countries as well: the separate country profiles include data on the availability and enforcement of road safety laws, statistics on the vehicles and road traffic fatalities. According to the study Georgia has the highest number of fatal and non-fatal traffic accidents in the Caucasus. The data from the Ministry of Internal Affairs shows that 737 road traffic fatalities and 7,349 non-fatal road traffic injuries were reported in 2007. Officially in 2007 the number of the reported road causalities was lower in Armenia: 371 reported fatalities and 2,720 non fatal road traffic injuries, with a significant majority of incidents involving pedestrians. However, the actual numbers in both countries could possibly be higher, considering the fact that in some cases the non-fatal injuries go unreported and post-accident results are rarely recorded.

Yet, Georgia scores surpisingly high on the enforcement of the road safety laws. -- perhaps given its quite successful police reform and recent emphasis on breathalyzer tests. Drunk-driving law enforcement is rated nine out of ten (ten being the most effective), though the State Road Police 2007 data reveals that 37% of the road traffic deaths in the country involved alcohol. Road safety law enforcement scores are striking in Azerbaijan as well, where all the road traffic law enforcements, including drunk-driving, motorcycle helmet, seat-belts and child restraints are rated nine out of ten.

When drawing conclusions, however, we need to take into consideration that the ratings are based on the results of a self-administered survey, and represent the populations’ perceptions of the law enforcement, rather than the facts. While the report provides information on the methodology, it is still unclear, for example, how many people were surveyed and how the respondents were selected.

The full report can be found here.