Category Archive for "2016"

Article: Determinants analysis of outpatient service utilization in Georgia: can the approach help inform benefit package design?

Curatio International Foundation conducted secondary data analyses of Health Service Utilization and Expenditure survey (2 waves), conducted by Ministry of Labor Health and Social Affairs of Georgia, supported by WHO and The World Bank.

We studied factors that impact utilization of outpatient health services in Georgia. Several important findings have been revealed, that can be successfully used to update existing outpatient service package and make it more relevant to the needs of Georgian population.

  1. Household income is linked to service consumption – Families with high and middle income are more likely to use outpatient services than those who have low income;
  2. Out of the pocket payment is one of the important barriers for service usage, in particular increase of service costs by one Georgian Lari reduces the use of outpatient services by 2%;
  3. Patients with chronic illness are less likely to use outpatient services, compared to patients with acute health problems – frequency of outpatient service utilization is 2 times less;
  4. Utilization of outpatient services is affected by the age factor – people from 45 to 64 are less likely to use outpatient services and often seek self-treatment.

To respond to the above listed challenges, it is important to fit outpatient service packages to the population needs.

The recent changes in the Universal Health Care Program, initiated by Georgian government and launched in May, 2017 will be a step forward to improve population financial protection. The changes respond to the research findings and recommendations in regard of outpatient services, that are fully represented in the article.

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Barriers and Facilitators to Adherence to Treatment Among Drug Resistant TB Patients in Georgia

Tuberculosis is a global challenge to public health throughout the world. Poor adherence to treatment remains a significant problem that prevents countries from obtaining high treatment success rates that is essential for health systems to control the epidemic and decrease spread of the disease.

In 2016 Curatio International Foundation conducted a qualitative study to investigate factors that enhance or hinder treatment adherence among Drug Resistant TB patients (DR-TB) in Georgia. The study revealed different types of factors affecting treatment adherence among DR-TB patients and grouped them into structural, social, personal and health system factors according to the study conceptual framework. The study made it clear that all factors are closely interlinked and mutually influence each other.

The study provides evidence that may help policy-makers develop effective strategies for improving treatment outcomes among DR-TB patients. The study findings might be helpful for other countries in the region where TB burden is also high.

The study report and policy brief is downloadable below:

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Transition Preparedness Assessment

Sustainability of national HIV and TB programs gains importance in light of recent changes in the global health landscape when external funders are redirecting resources to poorer states while phasing out from middle-income countries.

TPA tool

TPA framework structure

Objectively evaluation of the country transition readiness is a key in transition process. With this aim in 2015 Curatio International Foundation developed a Transition Preparedness Assessment (TPA) Framework with the Global Fund financial support and piloted in four Eastern European countries Belarus, Bulgaria, Georgia, Ukraine.

The country Case Studies present findings in a standardized way that enable country stakeholders to prioritize areas that need most attention during transition planning and implementation. In addition, the assessment findings are useful for the donors to guide the country in the transition process. These countries share important similarities that are presented in the Synthesis Report. The three countries case studies are also downloadable below.

Synthesis report – 4 countries
Ukraine-case study
Georgia-case study
Belarus – case study

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New Study Findings About Tuberculosis

Curatio International Foundation together with the Partnership for Research and Action for Health organized a meeting at the National Center for Disease Control and Public Health on 26th of December, where two different study findings were represented. Studies aimed to reveal Referral Delay from Primary Care facilities to specialized TB centers and Health System Factors Affecting Adherence to Tuberculosis (TB) Treatment in Georgia. The project was implemented by financial support of the TDR,  the Special Programme for Research and Training in Tropical Diseases, hosted at the World Health Organization (WHO).


CIF prezented qualitative research findings about adherence to Drug Resistant TB treatment and led discussion around the findings – what can be done to improve treatment adherence among TB patients, looking through health system lens. The study report will be available by the end of January, 2017.

CIF inventorised all civil society organizations (CSO) working on Tuberculosis issues in Georgia, with the financial support of Stop TB Partnership through the CFCS round 7.  In the frame of this project TB CSO informational directory has been developed which is available here.

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Article: Privilege and inclusivity in shaping Global Health agendas

Health Policy and Planning published an article Privilege and inclusivity in shaping Global Health agendas.  CIF director George Gotsadze co-authors the paper together with Kabir Sheikh, Sara Bennett and Fadi el Jardali.

The article discusses lack of inclusivity in Global Health and possible actions to promote inclusivity and diversity in the field.

“Northern voices dominate Global Health discussions. Of recent Lancet Commissions, excluding representatives from international organizations, 70% of commissioners on the Women and Health commission came from the global North, and likewise, 71% of the Health and Climate Change commission, 72% of the Global Surgery commission and 73% of the Global Health commission (Lancet 2016). Only two out of the 16-member Board of Directors of the Consortium of Universities of Global Health come from the global South (CUGH 2016). No current or past president and only one current member of the World Health Summit’s scientific committee is from the global South (WHS 2016). Only one of the 17 advisory board members of the journal Global Health Governance is based in a low/middle income country (LMIC) institution (GHG 2016).

Only 15% of the world’s population lives in high-income countries. Yet Global Health conferences continue to be dominated by invited Northern speakers and important committees on Global Health composed mainly of Northerners. The words of a few from the global North wield a disproportionate power that carries …”

The full text is downloadable here.

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Evaluation of UNICEF’s Contribution in Central and Eastern European Five Countries

Curatio International Foundation conducted evaluation of UNICEF’s contribution to reduction of under 5 mortality in five countries: Kazakhstan, Kyrgyzstan, Moldova, Serbia and Uzbekistan. The evaluation covered 12 years from 2000 – 2012 and was performed in 2014-2015.

UNICEF’s Regional Office foEvaluation of UNICEF’s Contribution (1)r the CEE/CIS commissioned this Multi-Country Evaluation, as one of a series of such exercises, to a) document progress in reducing under-5 and infant mortality and morbidity and to generate lessons on how this was accomplished; b) inform programs aimed at scaling-up evidence based and equity focused interventions; and c) enable better partnering with national governments to advance the child health and rights agenda.

The evaluation was based on a Theory of Change to reduce and close the equity gap in under-5 and infant mortality and morbidity in the CEE/CIS and applied both UNICEF MoRES framework and the WHO essential health system functions approach.

Evaluation findings are assembled across the following key areas: Impact on health status of children; Equity; Relevance; System level changes; UNICEF’s contribution; Sustainability

The study found reduction of infant and under-5 mortality and morbidity over the evaluation period, although equity gaps exist in different geographical, gender and socio-economic groups. The evaluation concluded that UNICEF-supported programmers addressed the most important causes of infant and under-5 morbidity and mortality and were mostly successful in identifying and applying the right interventions to address the health system bottlenecks.

Key Recommendations

The evaluation recommended to sharpen equity-focus of programming, consider not sufficiently addressed underlying causes of child mortality and morbidity and addressing persisting bottlenecks at health system and community levels.

To learn more, download full evaluation report.

Download Report



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CIF Pharmaceutical Price and Availability Study (Fifth Wave Results)

The Curatio International Foundation has released the results of the fifth wave of the Pharmaceutical Price and Availability (PPA) study in Georgia. The study set out to generate further evidence regarding pharmaceutical prices and availability in the country through the continuous monitoring of the prices of medicine. One of the chief aims of the study is to inform and strengthen health policy and contribute to evidence-based discussions around current trends and processes in pharmaceutical market in Georgia.

The study analyzes the current, as well as the previous four waves of the PPA studies that have been conducted by CIF since 2009. The main findings of the research responds to two important questions:

  1. What is the trend of physical and financial availability for Generic (LPG) and Originator rand (OB) drugs in Georgia, and how is the treatment cost linked to the availability?
  2. How is Georgia’s pharmaceutical sector being developed after the introduction of the new prescription policy?

The answers to these questions are available in the main findings of the study:

Main Findings


  • Currently, OB availability is almost two-times higher compared to LPG
  • The observed trend in decreased LPG availability can be attributed to several factors:
    • Insufficient knowledge and/or trust in the quality of LPGs among consumers and providers
    • Low demand for LPGs among the population caused by physician reluctance to prescribe generic medicines
    • The revenue-maximizing strategy of pharmaceutical suppliers
  •  It is likely that increased competition caused by legal changes in the country’s drug laws in late 2009 determined the downward trend in the OB prices observed during 2009-2012 waves, albeit OB prices rebounded and significantly increased in 2016
  • OBs are largely imported from western countries. Therefore, it is possible that the price increase documented in 2016 can be partially attributed to the significant devaluation of the country’s national currency against the USD and Euro that began in late 2014, and continued throughout 2015. Consequently, OB prices increased in both pharmacy networks and in independent pharmacies
  • In 2015, MoLHSA initiated a new prescription policy with the aim of reducing the level of irrational drug use in the Country. The importance and/or need for prescription system introduction is unquestionable, like in many other countries; however, the insufficiency and/or lack of the necessary instruments for the effective operation of the system most likely allowed pharmaceutical companies to use this initiative to further increase their profits. This assumption is supported by the fact that while in 2012 markups were largely comparable for prescription and non-prescription drugs, in 2016, we observed significant changes in behavior. Namely, markups for prescription OBs are now 89% higher compared to non-prescription OBs, and markups on prescription LPGs are currently 210% higher compared to non-prescription LPGs
  • Surprisingly, locally-manufactured LPGs are sold at a higher price compared to their imported equivalents, most likely affording greater profit potential to local manufacturers. Along with the marketing strategies used by the largest retail networks (also linked to local manufacturing), the promotion of locally-produced drugs over imported drugs helps local producers effectively use their market power in a poorly-regulated marketplace

A single policy intervention in a complex pharmaceutical market like Georgia’s will most likely fail to meet its objective i.e. a reduction in costs to the public, and improved access to pharmaceuticals. Therefore, the government needs to immediately implement a multi-pronged policy to better address the issue.

This policy should include the following:

  1. The introduction of reference pricing on the market – the government can achieve this by learning from other countries’ (high/low/middle-income) experiences and best practices. Through observing others’ experiences, the most appropriate reference pricing methodology can be utilized to further facilitate the regulation of drug prices in the country.
  2. Encourage the use of generic prescription drugs and enforce the generic substitution in the prescription of medicines.
  3. Introduce strict rules and controls for drug promotion, marketing, education, and sponsorship gifts to doctors.
  4. Enhance pharmaceutical market monitoring to adequately adjust for weaknesses in the policy or its implementation.

The full report is available here.

 About the Study

The study was conducted using World Health Organization (WHO) standard methodology. The survey looked at the prices and mark-ups of 52 medicines (brand-name medicines and their generic equivalents) in six regions of Georgia.

CIF has been conducting the PPA study since 2009. The results of the study’s previous waves were released in 2010, 2011, 2012 and 2014.


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HIV risk and prevention behaviours among Prison Inmates in Georgia, 2015

HIV risk and prevention behaviours among Prison Inmates in Georgia, 2015Curatio International Foundation continues implementation of Bio-Behavioral Surveillance Surveys (BBS) among Key Affected Populations (KAP’s) with the aim to measure HIV prevalence among KAP’s, monitor risk behaviors among these groups and generate evidence for advocacy and policy-making.

The current study describes the most recent wave of BBS surveys among prisoner population in Georgia (Bio-BBS surveys among prisoner population have been implemented since 2008).  Study also was looking at STI (Syphilis) prevalence. CIF implemented this study together with partner organisations – Center for Information and Counseling on Reproductive Health – Tanadgoma and the Infectious Diseases, AIDS and Clinical Immunology Research Center.

The study used a Simple Random Sampling (SRS) Method. A sample of 300 prisoners were recruited in the survey from 3 penitentiary establishment located in Tbilisi, Rustavi and Kutaisi.

The study was financially supported by the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM).

Major findings:

Socio-demographic characteristics

  • The median age of prisoners was 34, with the age ranging from 18 to 78 years, majority (74.1%) were with the secondary education. Less than half (46.8%) of the inmates were married.
  • Median duration of imprisonment is 1.5 years years, ranging from 0.08 to 19 years.

Sexual behavior

  • Sexual practices among prisoners was not high (35.2%). However, mostly heterosexual contacts were being reported (95.3%), only 4 respondents reported having both heterosexual and homosexual contacts and only 1 inmate said it was homosexual contact.
  • As for the condom use during the last anal intercourse, 3 out of 5 respondents said it was used, and other reported not using condom due to the trust towards the partner.

Drug Use Behavior and Additional Risks

  • Slightly more than half of the respondents (52.2%) reported having used drugs in their lives. Out of those, who have ever used drugs, 87.9% reported use of injecting drugs and 68.8% – use of non-injecting drugs.
  • Only 10.3% of the respondents reported using non-injecting drugs during the last 12 months, and only 8 inmates reported having used injecting drugs. It is noteworthy that none of the inmates reported needle/syringe sharing during the last 12 months.
  • Additional risks related to HIV exposure were found to be also small. Almost one third of the prisoners (31.6%) reported having done tattoo while in prison. Only five prisoners reported using shared syringes for treatment purposes and 3% used razors that were used by the others. Alcohol use is extremely low in prisons – 3% reported using it during the last 12 months.

HIV knowledge and HIV testing practice

  • The majority of the respondents (91.4%) report that they have heard about HIV/AIDS.
  • Knowledge about HIV, measured by the Global AIDS Response Progress Report Indicator, was low – 23.3%. In general, level of knowledge on HIV has not changed from 2011 to 2015.
  • HIV testing offer in prisons as well as uptake by the prisoners has increased, which demonstrated successfulness of the HTC cabinets established by the prevention programs within the penitentiary system.

Sexually Transmitted Infections (STI)

  • Awareness on STIs in general is high. Majority (91.0%) of the respondents have heard about STIs, knowledge or health-seeking behavior of the prisoners has not changed since 2012.


  • Prisoners have various sources of getting information on HIV and STIs, the most trustful of them being TV, booklets, NGO representatives as well as healthcare workers.
  • The study revealed statistically significant increase in the percentage of the respondents (25.2% in 2015 vs 18.3% in 2012, p<0.05) who were covered by preventive program.

HIV and Syphilis prevalence

  • The HIV prevalence found by the survey was 2%. In the previous survey the prevalence was 0.3%. However, this increase is statistically not significant.
  • Prevalence of syphilis was low. Comparison of syphilis prevalence with the data of 2012 survey demonstrated statistically significant decrease (p<0.001).

Full study report is available here. 

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Washington DC hosts workshop Immunization Costing: what have we learned, can we do better?

On May 17-18 EPIC Immunization Costing hosts workshop Immunization Costing: what have we learned, can we do better? in Washington DC.  CIF executive director George Gotsadze and Business Develop
ment unit director Ketevan Goguadze are invited to attend the event.

George Gotsadze will be one of the panelist in the panel discussion: Sustainable institutional linkage and improving immunization program implementation, taking place on May 18 in frame of the workshop.Capture

About the event: EPIC supports a community of practice comprised of researchers and practitioners concerned with measuring immunization program cost and financial flow – and utilizing such information to improve program operations and mobilize resources.

A 300 members’ community from more than 50 organizations are involved in immunization programs across the globe, exchanging information and enabling new approaches, collect and use cost information to improve vaccine delivery.

The workshop is sponsored by Bill and Melinda Gates Foundation and organized by Harvard School of Public Health.

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Bio-Behavioral Surveillance Survey among Men who have Sex with Men in two major cities of Georgia, 2015

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Bio-Behavioral Surveillance Survey among Men who have Sex with Men in two major cities of Georgia, 2015

Curatio International Foundation continues implementation of Bio-Behavioral Surveillance Surveys (BBS) among Key Affected Populations (KAP’s) with the aim to measure HIV prevalence among KAP’s, monitor risk behaviors among these groups and generate evidence for advocacy and policy-making.

The current study describes the most recent wave of BBS surveys among Men who have Sex with Men (MSM) in Georgia (Bio-BBS surveys among MSM have been implemented since 2007).  Study also was looking at HCV and STI (Syphilis) prevalence among MSM. CIF implemented this study together with partner organisations – Center for Information and Counseling on Reproductive Health – Tanadgoma and the Infectious Diseases, AIDS and Clinical Immunology Research Center.

The study used a cross-sectional design and respondent‐driven sampling methodology (RDS). A sample of 415 MSM18 years and older were recruited in the survey in two major cities of Georgia: Tbilisi and Batumi.

The study was financially supported by the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM).

Major findings:

Socio-demographic characteristics

  • The median age was 28 years in Tbilisi and 29 – in Batumi, majority had secondary level education, had never been married, big proportion of MSM had permanent work, and majority’s monthly income was less than 500 GEL.
  • The study did not reveal high proportion of heavy alcohol use or injecting drug use, indicating that there is no overlap with key populations such as MSM and PWID.

Sexual behavior

  • MSM had different types of both male and female sex partners (regular, occasional and commercial).  The median number of male partners (anal/oral partners) in the last 12 months 6 in Tbilisi and 5 – in Batumi. Tbilisi number is higher than that of 2010.
  • Out of MSM that reported anal partner during the last year, 63.2% in Tbilisi and 78.8% – in Batumi used a condom during their last anal sexual contact. Condom use at last AI in Tbilisi in 2015 slightly higher compared to 2010 (61.7%).
  • Overall more than 50% of MSM reported having female sex partner  (regular, occasional or paid) during the last 12 months- 55.4% in Tbilisi and 53% in Batumi. More than two thirds (71.2% in Tbilisi and 65.9% in Batumi) said they used a condom at last sexual intercourse with their female partner.Since 2010 there is increase in condom use at last sex with female partners in Tbilisi. As for Batumi, this rate is also high.

Condoms and lubricants

  • There was a slight increase in the proportion of MSM who reported receipt of condoms from preventive programs during the last 12 months in Tbilisi from 40.3% in 2010 to 43.5% in 2015.
  • Awareness about condoms stays high.
  • Awareness about the lubricants as well as their reported use during the last AI has improved vastly in Tbilisi and is also high in Batumi. These are higher indicators compared to the previous surveys, which can be explained by provision of free lubricants by preventive programs, started since 2014.

HIV knowledge and HIV testing practice

  • Knowledge and testing on HIV showed significant improvement in Tbilisi since 2010 – from 19.9% in 2010 to 30.4% in 2015 (p (2-tailed), 0.001). In Batumi this indicator was measured the first time and reached 35.2%.
  • During the recent five years there is statistically significant improvement in MSM awareness where to get HIV test in case of necessity (p < 0.001), as well as in the proportion of MSM who were tested during the last 12 months and received results (p< 0.001). This can be explained by sustainable use of HIV rapid (finger prick) testing in the outreach under preventive programs, which makes HIV testing easily accessible to the target group.
  • Researchers also measured increase in testing uptake from 2012 to 2015, and it was also statistically significant (p (2tailed) – 0.07).


  • Survey participants reported that they have experienced violence because of sexual orientation or homosexual behaviour in the last 12 months (32% in Tbilisi and 4.7% in Batumi). In Tbilisi violence rate has increased significantly compared to 2012.

Program coverage / media

  • Coverage by preventive intervention measured by awareness of where to get a HIV test and receipt of a condom during the last 12 months increased from 20.9% in 2010 to 43.5% in 2015 in Tbilisi. In Batumi coverage is quite high – about 40%.
  • NGOs, internet and friends seem to be the major and best way for conveying messages to MSM.

HIV, HCV and Syphilis prevalence

  • The most alarming finding of this study is increase in HIV prevalence in Tbilisi from 6.4% in 2010 to 25.1% in 2015. During last five years we observe three-fold increase of HIV prevalence. Batumi HIV prevalence is also very high – 22.3%.
  • Syphilis was detected in 35% of the MSM in Tbilisi and 24.6% – in Batumi.As for syphilis, its prevalence is quite high but does not show difference compared to 2010 results.
  • Hepatitis C prevalence was 7% in Tbilisi but much higher in Batumi – 18.9%

Full study report is available here.

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