ChronIC dIsease In euroPe
333
The inadequate mechanisms to make sure the invested resources are used effectively are generic to the Georgian health system as a whole. There are poor linkages between primary and secondary care and ineffective patient follow-up or monitoring of outcomes. The scope of work of primary care practitioners is limited and they rarely diagnose and manage diabetes (similarly to other chronic disease), which instead takes place within the vertical systems. Diagnosis and treatment of diabetes complications involve hospital admission and unaffordable outof-pocket payments. There are no evidence-based guidelines on diabetes management (or many other chronic NOD’s), formal support and quality assurance. Prevention and effective management of complications is limited, increasing adverse outcomes. The main areas where improvement are similar to what is seen to be key in the UK and USA —the key is not the overall level of resources and inputs but the way health systems processes and operation. In Georgia, improving diabetes outcomes will involve simplifying pathways to care and drugs, reassessing staff roles and insulin distribution systems. This would require better co-ordination of the inputs into the system (e.g. primary and secondary care physicians having a mechanism to share information). In summary, what is needed is not more money but development of an integrated and responsive health systems. Our work in Kyrgyzstan showed a similar lack of coordination, with some inputs taking precedence over others, and lack of linkages between actors in the health system (Hopkinson et al., 2004). As in Georgia, the problem was not so much in the availability of insulin and drugs (it was fully financed by donors in the 1990s), but ensuring a reliable supply responding to need. Despite tenders and tight state control, minor glitches disrupted the procurement and distribution systems. This and the fact that on discharge, the hospitals are not allowed to provide supplies of insulin, meant disruption in taking insulin for people in rural areas.