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Georgia: profile on health and well-being

31 декабря 2017 г. Всемирная организация здравоохранения

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Georgia Profile of Health and Well-being The World Health Organization was established in 1948 as the specialized agency of the United Nations serving as the directing and coordinating authority for international health matters and public health. One of WHO’s constitutional functions is to provide objective and reliable information and advice in the field of human health. It fulfils this responsibility in part through its publications programmes, seeking to help countries make policies that benefit public health and address their most pressing public health concerns. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health problems of the countries it serves. The European Region embraces nearly 900 million people living in an area stretching from the Arctic Ocean in the north and the Mediterranean Sea in the south and from the Atlantic Ocean in the west to the Pacific Ocean in the east. The European programme of WHO supports all countries in the Region in developing and sustaining their own health policies, systems and programmes; preventing and overcoming threats to health; preparing for future health challenges; and advocating and implementing public health activities. To ensure the widest possible availability of authoritative information and guidance on health matters, WHO secures broad international distribution of its publications and encourages their translation and adaptation. By helping to promote and protect health and prevent and control disease, WHO’s books contribute to achieving the Organization’s principal objective – the attainment by all people of the highest possible level of health. Georgia Profile of Health and Well-being © World Health Organization 2017 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Keywords GEORGIA, HEALTH POLICY, HEALTH STATUS, HEALTHY PEOPLE PROGRAMMES – STATISTICS AND NUMERICAL DATA, COMPARATIVE STUDY, HEALTH 2020 ABSTRACT Profiles of health and well-being give an overview of a country’s health status, describing data on mortality, morbidity and exposure to key risk factors together with trends over time. They are developed in collaboration with WHO European Member States. When possible, each report also compares a country to a reference group, which in this report is the whole WHO European Region and the Commonwealth of Independent States. To make the comparisons as valid as possible, data are as a rule taken from one source to ensure that they have been harmonized in a reasonably consistent way. Unless stated otherwise, data in this report are mainly drawn from the European Health for All database of the WHO Regional Office for Europe. These data are collected from Member States on an annual basis and include metadata that specify the original source of data for specific indicators. Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). ISBN 978 92 890 5272 6 iii Contents Acknowledgements �� iv Abbreviations and acronyms �� v Summary of situation and trends in health and well-being in Georgia �� vi Introduction �� 1 Selected demographic and economic information �� 2 Health status and burden of disease �� 5 Life expectancy ............................................................................................................ 5 Healthy life expectancy and disability-adjusted life years ................. 6 Morbidity .......................................................................................................................... 6 Infant and maternal mortality .......................................................................... 10 Leading causes of death .......................................................................................... 11 Other major causes of death ............................................................................... 13 Premature mortality ............................................................................................... 15 Risk factors and determinants of health �� 19 Alcohol consumption .............................................................................................. 19 Tobacco smoking ...................................................................................................... 20 Overweight .................................................................................................................. 20 Comparative risk assessment ............................................................................. 21 Health system �� 22 Health 2020 �� 24 Target 1. Reduce premature mortality by 2020 ........................................ 24 Target 2. Increase life expectancy .................................................................. 26 Target 3. Reduce inequalities in health (social determinants target) .............................................................................................................................. 26 Target 4. Enhance the well-being of the population ............................ 26 Target 5. Ensure universal coverage and the “right to health” ......... 27 Target 6. Set national goals and targets related to health ................ 28 Conclusions �� 29 References �� 32 Annex 1� ICD-10 codes for causes of death �� 36 Annex 2� Selected mortality data �� 37 iv Acknowledgements The profiles of health and well-being and accompanying highlights on health and well-being are produced under the overall direction of Claudia Stein, Director, Division of Information, Evidence, Research and Innovation, WHO Regional Office for Europe. The principal authors of this publication were: • Amiran Gamkrelidze, Director General, National Center for Disease Control and Public Health, Georgia; • Maia Kereselidze, Head of Department, Medical Statistics, National Center for Disease Control and Public Health, Georgia; • Ketevan Gambashidze, Head of Division, Data Analysis and Reporting Division, National Center for Disease Control and Public Health, Georgia; • Marina Shakhnazarova, Chief Specialist, Data Analysis and Reporting Division, National Center for Disease Control and Public Health, Georgia; • Nermin Ghith, Consultant, WHO Regional Office for Europe; and • Tina Dannemann Purnat, Unit Leader, Health Informatics and Information Systems, and acting Unit Leader and Programme Manager, Health Information, Monitoring and Analysis, WHO Regional Office for Europe. Other contributors and reviewers were: Nino Berdzuli, Ekaterine Pestvenidze and Ketevan Goginashvili (Ministry of Labour, Health and Social Affairs of Georgia); and Andrei Dadu, Lali Khotenashvili and Annemarie Stengaard (WHO Regional Office for Europe). vANACoD Analysing mortality levels and causes of death ART antiretroviral therapy CIS Commonwealth of Independent States DALY disability-adjusted life year GDP gross domestic product HCV hepatitis C virus HFA-DB Health for All database ICD-10 International Classification of Diseases, 10th Revision MDR-TB multidrug-resistant tuberculosis NCDs noncommunicable diseases NCDC National Center for Disease Control and Public Health PPP purchasing power parity STEPS STEPwise approach to surveillance TB tuberculosis Abbreviations and acronyms vi Summary of situation and trends in health and well-being in Georgia The health status of Georgia’s population has over the past three decades generally followed the trends observed in the rest of the WHO European Region. However, despite noticeable improvements since 2000, the country still faces multiple health challenges. Georgia has made progress on a number of indicators, such as maternal and infant mortality rates, incidence of tuberculosis (TB), and treatment of new and relapse TB cases. Yet the most recent rates for some indicators remain below the averages for both the Region and the Commonwealth of Independent States (CIS). Several factors contextualize Georgia’s health indicator trends: (a) the country’s reform of health care service delivery; (b) the change in population size recorded in its 2014 census (1); and (c) improvements in the coverage of case and death registrations and quality of data in the health information system (2). Over the last 20 years, Georgia’s health care system has undergone several reforms that have improved population health status and narrowed the gap between Georgian and regional averages for many indicators (3). The main goals for these reforms were to ensure universal access to high-quality medical services, to improve the primary health care system and to decrease the financial risks to the population posed by high out-of-pocket expenditures on health (2,4). In 2017, the Georgian Government developed a comprehensive long-term Maternal and Newborn Health Strategy (2017–2030) and a closely related short-term Action Plan (2017–2019) with the aim to give direction and provide guidance for the improvement of maternal and newborn health in the country. Georgia also introduced a national initiative to regionalize the delivery of perinatal care services and ensure the provision of quality care for mothers and newborns (2). This project is an important step towards achieving Sustainable Development Goal 3.2 to reduce maternal and infant mortality. Furthermore, the Georgian Government expanded the universal health care programme with a goal to cover up to 90% of the population by 2014 (2). Key messages • Universal health care reform in Georgia has improved access to health services and reduced financial barriers and out-of- pocket costs for the population. • The maternal mortality rate is high, although infant (including neonatal) mortality also remains a challenge. • The largest burden of disease in Georgia is related to noncommunicable diseases (NCDs), including circulatory diseases, cancer, diabetes and respiratory diseases. • Georgia faces ongoing challenges in the form of high levels of communicable diseases, with an increasing incidence of HIV and a high incidence of TB, including multidrug-resistant TB. • Georgia has used new technologies for electronic data capture and exchange to improve case registration and coverage and quality of information on the existing burden of disease in the country. • Georgia should address: − the need for sustainable financing of the government health programmes and reduction of out-of-pocket costs for the population; − the rising rates of communicable and NCDs in the population; − the high maternal mortality rate, as well as the infant (including neonatal), mortality rate; − the large proportion of ill-defined causes of death in the civil registration and vital statistics system; and − the high level of tobacco smoking among Georgian males. vii The country’s infant mortality rate has been decreasing, but is still higher than the average rates for the CIS and the Region. The maternal mortality rate remains high, yet this may indicate an improvement in the registration of maternal deaths rather than an increase in the maternal mortality rate (5). Georgia also developed its long-term strategy on hepatitis C for 2016–2020. The strategy includes actions in the areas of awareness- raising, surveillance, prevention, screening, diagnostics and treatment (2). The country remains committed to providing free access to the newest antiviral therapy to all people infected with hepatitis C. The incidence of TB has decreased over the past decade, but remains higher than the average for the Region. At the same time, incidences of HIV and AIDS have increased since 2000. Birth and death registration have both significantly improved since 2011 (2), when Georgia introduced an electronic system for vital events registration as well as an increase in fines for late registration or nonregistration of deaths. According to the National Center for Disease Control and Public Health, these actions led to an increase in the number of registered deaths and to a decrease in reported population size (2). The most recent population census, conducted in 2014, showed a significant reduction in the country’s population. As population size is the denominator for many health and demographic indicators, this change likely influenced the main health and demographic indicators for that year (2). The total fertility rate in Georgia sharply increased to 2.2 in 2014, which suggests under-reporting of the fertility rate in previous years. The total fertility rate in Georgia exceeds the average rates for the CIS and the Region. Since 2014, Georgia has gradually introduced new technologies for data reporting in several areas of the health information system (2), including: • in 2014–2016, electronic case-based reporting systems for in- and outpatients in health care institutions; • in 2015, a population-based cancer registry; and • in 2016, a new electronic registration module for antenatal and obstetric services and the surveillance of maternal and child health (6). viii In 2015, Georgia began developing national policies in alignment with the European policy framework Health 2020, which will form the basis for the future development of a corresponding implementation plan. It initiated the process of setting targets and indicators for the health sector, with a focus on aligning its national health services with Health 2020 targets. It subsequently developed an implementation plan and accountability mechanism in accordance with the recommendations of Health 2020; however, this document has not yet been formally adopted. In 2016, Georgia became the first WHO European Member State to implement the second round of the WHO STEPwise approach to surveillance (STEPS) survey (7) to ascertain the prevalence of risk factors for NCDs in the country. Overall, Georgia has made progress in a number of the 19 core Health 2020 indicators (see table below). Some additional challenges remain in the areas of well-being (Gini coefficient and unemployment rates). Note on data and interpretation Presenting population rate-based trends in Georgia is currently challenging. As a result of the 2014 census and the major change to the population levels used for calculation, time series are not consistent. The National Statistics Office of Georgia is planning to address this challenge by retrospectively recalculating all health-related indicators, taking into account information from 2014 (1). Furthermore, the large share of ill-defined causes of death and the incomplete coverage of death registrations in the past make it difficult to analyse the trends and distributions of main causes of death in the country. Increased efforts are needed to improve the quality of Georgia’s essential population health data. While improved registration and reporting systems can give more accurate information on Georgia’s population health, they can lead to short-term analytical problems when attempting to compare the trends against historic patterns. This challenge is noted throughout this publication. ix Core indicators for monitoring Health 2020 policy targets, Georgia, most recent years available Target Indicator Value Year Male Female Total 1. Reduce premature mortalitya Premature mortality rate from cardiovascular diseases, cancer, diabetes mellitus and chronic respiratory diseases among people aged 30 to under 70 years (age-standardized) 618.9 262.9 422.3 2014 Prevalence of tobacco use among adults aged 15 years and over (age-standardized)b 58.5 5.8 30.0 2013 Pure alcohol consumption per capita among adults aged 15 years and over (recorded data) – – 6.1 2014 Prevalence of overweight and obese (body mass index ≥25) adults aged 18 years and over (age-standardized estimate) 54.0 56.0 55.0 2014 Mortality rate from external causes of injury and poisoning, all ages (age-standardized) 76.0 21.0 46.0 2014 2. Increase life expectancy Life expectancy at birth, in years 68.8 77.3 73.1 2014 3. Reduce inequitiesc Infant deaths per 1000 live births 10.1 8.9 9.5 2014 Proportion of children of official primary school age not enrolled (net enrollment rate) 3.8 2.7 3.3 2013 Unemployment rate (percentage) – – 12.4 2014 National policy addressing reduction of health inequities established and documented NA NA Yes, but only partially 2016 Gini coefficient NA NA 40.0 2013 4. Enhance well-beingd Overall life satisfaction among adults aged 15 years and over (8) NA NA 4.3 2014 Availability of social support among adults aged 50 years and over (9) – – 43.0 2013 Percentage of population with improved sanitation facilities – – 86.3 2015 5. Ensure universal coverage and “right to health” Private household out-of-pocket expenditure as proportion of total health expenditure NA NA 58.6 2014 Percentage of children vaccinated against measles (1 dose) – – 96.0 2015 Percentage of children vaccinated against poliomyelitis (3 doses) – – 89.0 2015 Percentage of children vaccinated against rubella (1 dose) – – 96.0 2015 Total health expenditure as a percentage of gross domestic product NA NA 7.4 2014 6. Set national targets Establishment of process for target-setting documented NA NA Yes 2016 Evidence documenting: (a) national health strategy aligned with Health 2020 (b) implementation plan (c) accountability mechanism NA NA NA NA NA NA Yes No Yes, but only partially 2016 2016 2016 NA: not applicable. a Health 2020 target 1 includes percentage of children vaccinated against measles (1 dose), poliomyelitis (3 doses) and rubella (1 dose). b Prevalence includes both daily and occasional (less than daily) use among adults aged 15 years and over. c Target 3 includes life expectancy at birth. d Target 4 includes Gini coefficient, unemployment rate and proportion of children not enrolled in primary school. Source: WHO European Health for All database (3) unless otherwise specified. xReferences 1. Population for the beginning of the year by age, year and sex. [website]. Tbilisi: National Statistics Office of Georgia; 2017 (http://91.208.144.188/Selection.aspx?rxid=b59820da-3b78- 4465-b8a1-da84f16b0c9b&px_db=Database&px_type=PX&px_ language=en&px_tableid=Database%5cDemography%5cPopulati on%5cPopulation_by_age_and_sex_for_the_beginning_of_the_ year-02.px, accessed 11 August 2017). 2. Health care statistical yearbook 2015: Georgia [e-book]. Tbilisi: National Centre for Disease Control and Public Health of the Ministry of Labour, Health and Social Affairs of Georgia; 2017 (http://www.ncdc.ge/AttachedFiles/yearbook%20 2016_53210b52-12da-4279-9f27-f7a361c84c96.pdf, accessed 11 August 2017). 3. European Health for All database (HFA-DB) [online database]. Copenhagen: WHO Regional Office for Europe; 2016 (https:// gateway.euro.who.int/en/hfa-explorer/, accessed 11 August 2017). 4. Chanturidze T, Ugulava T, Durán A, Ensor T, Richardson E. Georgia: health system review. Health Systems in Transition 2009;11(8):1–116 (http://www.euro.who.int/__data/assets/pdf_file/0003/85530/ E93714.pdf?ua=1, accessed 11 August 2017). 5. Georgia reproductive age mortality study 2014. Executive summary. Tbilisi: National Centre for Disease Control and Public Health of the Ministry of Labour, Health and Social Affairs of Georgia; 2017 (http://www.ncdc.ge/AttachedFiles/RAMOS%20 2014%20Ex%20Summary_ENG_a502747e-2c09-4f23-9e3f- 3fb6ea56d444.pdf, accessed 11 August 2017). 6. UNICEF Georgia. A new electronic system for the maternal and newborn health surveillance is being introduced in Georgia. Tbilisi: UNICEF Georgia; 2015 (http://unicef.ge/44/osrulta_da_ akhalshobilta_ janmrtelobis_metvalkureobis_akhali_sistema/352/ lngeng, accessed 11 August 2017). 7. Georgia STEPS Survey 2016: Fact Sheet. Geneva: World Health Organization; 2017 (http://www.who.int/chp/steps/Georgia_2016_ STEPS_FS.pdf?ua=1, accessed 11 August 2017). 8. Human Development Reports. Human Development Index (HDI) [website]. New York: United Nations Development Programme; 2016 (http://hdr.undp.org/en/content/human-development-index-hdi, accessed 11 August 2017). 9. Global AgeWatch Index 2015. AgeWatch report card: Georgia [online database]. London: HelpAge International; 2016 (http://www. helpage.org/global-agewatch/population-ageing-data/country- ageing-data/?country=Georgia, accessed 11 August 2017). Profile of health and well-being 1 Introduction In 2012, WHO European Member States adopted Health 2020 (1,2), a policy framework supporting action across government and society for health and well-being. With the accelerated implementation of Health 2020, the WHO Regional Office for Europe introduced two new publication series: the country profiles of health and well-being and the highlights on health and well-being. These follow on from the highlights on health series, which ran from the early 1990s to the mid-2000s with the aim of addressing the need for analyses of the health situations and trends in newly emerging states in order to assist European countries with evidence-informed policy-making. The profiles provide comparative analyses of the situations and trends in health and well-being in countries, presenting recent data on mortality, morbidity and exposure to key risk factors and giving special emphasis to all Health 2020 indicators (3), including well- being. They are developed in collaboration with Member States and do not constitute a formal statistical publication. The highlights form a separate, complementary series with policy-makers as the target audience, presenting the main findings from the longer profiles. To make the comparisons as valid as possible, data are taken from a single source to ensure that they are harmonized consistently. Unless otherwise noted, data in the reports are drawn from the European Health for All database (HFA-DB) of the Regional Office (4). These data are collected from Member States and other international sources on an annual basis and include metadata that specify the original source of data for specific indicators. Other data and information used in the report are referenced accordingly. Annex 1 presents the International Classification of Diseases, 10th Revision (ICD-10) codes for causes of death. When possible, each report also compares a country to one or more reference groups of countries, which in this report are all WHO European Member States and the countries of the Commonwealth of Independent States (CIS). Georgia2 Selected demographic and economic information The WHO European Region as a whole is facing a number of demographic and health challenges, including an ageing population and a declining birth rate. The population structure of Georgia reflects in the most part those for the European Region and the CIS (Table 1). However, Georgia’s population trends are of particular interest (5). As reported to the HFA-DB by the National Statistics Office, Georgia had a total population of approximately 3.7 million in 2015. The midyear population in Georgia between the censuses of 2002 (6) and 2014 (7) decreased by 14.7% (5). This decrease is also reflected in changes to the population structure by sex and age (Fig. 1). Table 1. Selected demographic indicators, Georgia, latest available year Demographic indicator Georgiaa WHO European Region CIS Population (in 1000s)b 3727 908 556 281 762 Percentage aged 0–14 yearsc 17.4 17.5 18.9 Percentage aged 15–64 yearsc 68.7 67.4 70.1 Percentage aged 65 years and overc 13.9 15.1 11.0 Crude birth rate (live births per 1000)c 16.3 12.4 15.5 Crude death rate per 1000c 13.2 9.9d 11.4 Natural population growth per 1000e 3.1 2.4 4.0 a Data from Georgia’s National Statistics Office may be slightly different. Data from the HFA-DB are used here for comparability purposes. b 2015 data. c 2014 data. d 2013 data. e Birth rate minus death rate. Fig. 1. Population structure by age and sex, Georgia, 2002 and 2014 250 200 150 100 50 0 50 100 150 200 250 >1 5–9 15–19 25–29 35–39 45–49 55–59 65–69 75–79 85+ Population in 1000s 2014 Females 2014 Males 2002 Females 2002 Males Profile of health and well-being 3 In 2014, the country’s net migration (difference between the number of emigrants and immigrants) was negative (-6543 individuals) (8). The 2014 census determined a marked reduction in the size of the population, which caused a sharp increase in a number of population health indicators. During the past three decades, the share of the population aged 65 years and over increased while the share aged under 15 years decreased. This pattern of population ageing is similar to that seen within the European Region and the CIS (Figs. 2, 3). The significant reduction of the population size reflected in the 2014 census likely influenced the calculations of main health and demographic indicators for that year. The total fertility rate in Georgia sharply increased to 2.2 in 2014, which suggests under-reporting of the fertility rate in previous years (Fig. 4). A similar change from 2013 to 2014 is observed for the crude death rate (Fig. 5). In the case that the National Statistics Office recalculates the population in the intercensus period (between 2002 and 2014), the sharp changes in these indicators between 2013 and 2014 will be adjusted (5). Fig. 2. Percentage of population aged 0–14 years, Georgia, WHO European Region and CIS, 1985–2014 WHO European Region Georgia CIS 0 5 10 15 20 25 30 1985 1990 1995 2000 2005 2010 2015 Pe rc en t Fig. 3. Percentage of population aged 65+ years, Georgia, WHO European Region and CIS, 1985–2014 WHO European Region Georgia CIS 0 5 10 15 20 1985 1990 1995 2000 2005 2010 2015 Pe rc en t Fig. 5. Crude death rate, Georgia, WHO European Region and CIS, 1985–2014 0 2 4 6 8 10 12 14 16 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 00 p op ul at io n WHO European Region Georgia CIS Fig. 4. Total fertility rate, Georgia, WHO European Region and CIS, 1985–2014 0 0.4 0.8 1.2 1.6 2.0 2.4 1985 1990 1995 2000 2005 2010 2015 Bi rt hs p er w om an WHO European Region Georgia CIS Georgia4 Georgia’s natural population growth has increased since 2005, reaching 3.1 per 1000 in 2014 (Fig. 6). According to the National Statistics Office, in 2014 57.4% of the population lived in urban areas and 42.6% lived in rural areas (9). Between 2002 and 2014, the proportion of the population living in urban areas increased despite the overall drop in population recorded between 2002 and 2014 (Fig. 7). Unemployment is an indicator for the Health 2020 target to enhance well-being. Georgia’s unemployment rate increased from 10.3% in 2000 to 12.4% in 2014 (4), which was higher than the average rates for both the CIS (5.5%) and the European Region (9.1%). Georgia’s gross domestic product (GDP, expressed in dollar purchasing power parity (PPP) per capita) steadily increased to US$ 9679 in 2015 (10). However, this was much lower than the average GDP for the European Region (US$ 29 698) and the CIS (US$ 17 792). According to WHO estimates (11), the country’s total health expenditures as a percentage of GDP fluctuated during the last decades, reaching 7.4% in 2014. This was similar to average expenditures in the CIS (6.6%) and slightly lower than those in the European Region (8.2%). Fig. 7. Urban and rural population, Georgia, 2002 and 2014 3730 2140 1590 4372 2285 2087 0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 Total Urban Rural 10 00 p er so ns 2014 Census 2002 Census Source: National Statistics Office of Georgia (9). Fig. 6. Natural population growth, Georgia, WHO European Region and CIS, 1985–2014 –5 0 5 10 15 1985 1990 1995 2000 2005 2010 2015 N at ur al in cr ea se p er 1 00 0 WHO European Region Georgia CIS Profile of health and well-being 5 Health status and burden of disease As described above, the trends reported in this section were likely influenced by the recent changes in recorded population size and improvements to Georgia’s data registration systems such as death and birth registries (5). Where possible, absolute values are included to provide additional information for the interpretation of long-term trends. Life expectancy Life expectancy at birth is defined as the average number of years that a newborn infant would live if prevailing patterns of mortality at the time of birth were to continue throughout his or her life. Georgia has had one of the highest rates of life expectancy compared to the countries of the CIS. While life expectancy at birth has been increasing, a sharp drop occurred in 2014 due to the decrease in population as measured by the 2014 census. This means that the life expectancy calculation for prior years, which used the higher population recorded in the 2002 census, consequently produced higher life expectancy. The marked difference between 2014 and preceding years seems to appear in all life expectancy-related indicators (5). In 2014, life expectancy at birth in Georgia was 68.8 years for males and 77.3 years for females (Figs. 8, 9). This was higher than the average for the CIS (66.4 years for males and 76.0 years for females) but lower than that for the European Region (74.2 years for males and 80.8 years for females, in 2013). The difference in life expectancy between females and males was 8.5 years in favour of females, which was larger than the difference in the European Region (6.7 years), but smaller than that in the CIS (9.7 years). Life expectancy at 65 is defined as the average number of years a 65-year-old would expect to live based on prevailing mortality statistics. Georgia’s rate reflects a trend similar to that for life expectancy at birth (Figs. 8, 9). Life expectancy at 65 in the country was 13.4 years for males and 16.9 years for females in 2014; the sharp Fig. 8. Life expectancy at birth for males, Georgia, WHO European Region and CIS, 1985–2014 55 60 65 70 75 80 85 1985 1990 1995 2000 2005 2010 2015 Ye ar s WHO European Region Georgia CIS Fig. 9. Life expectancy at birth for females, Georgia, WHO European Region and CIS, 1985–2014 55 60 65 70 75 80 85 1985 1990 1995 2000 2005 2010 2015 Ye ar s WHO European Region Georgia CIS Georgia6 drop from 2013 rates (15.2 years for males and 18.8 years for females) was likely due to the change in population size determined in the 2014 census. This rate was lower than the average for the European Region (16.3 years for males and 19.9 years for females) (Figs. 10, 11); the most recent data for this indicator show a widening gap between Georgia and the European Region as a whole. Healthy life expectancy and disability-adjusted life years Healthy life expectancy summarizes mortality and nonfatal outcomes in a single measure of average population health. It has been used to compare health between countries and to measure changes over time (12). In Georgia, the estimated healthy life expectancy increased to 66.4 years for both sexes, 63.4 for males and 66.4 for females in 2015 (13). This was lower than the estimated healthy life expectancy for the European Region in the same year (14), which was 68.0 years for both sexes, 64.1 for males and 70.5 for females. Morbidity Comparable information on morbidity is more limited than on mortality. However, data are available in the HFA-DB on certain infectious diseases, cancers and mental disorders based on routine health reporting systems. The coverage, completeness and quality of these data vary between countries and over time, and comparisons should be interpreted with caution. Primary sources of data are diverse and include registries, surveillance systems and hospitals. Infectious diseases and vaccinations Hepatitis C In 2015, within the framework of the hepatitis C elimination programme launched in April of that year, the National Center for Disease Control and Public Health (NCDC) in Georgia, in collaboration with the Centers for Disease Control and Prevention of the United States of America, conducted the first nationwide hepatitis C virus (HCV) serosurvey in the country (5). According to the survey findings, 7.7% of the population was anti-HCV positive and 5.4% had the active infection (RNA positive). Fig. 10. Life expectancy at age 65 years for males, Georgia, WHO European Region and CIS, 1985–2014 WHO European Region Georgia CIS 10 12 14 16 18 20 22 1985 1990 1995 2000 2005 2010 2015 Ye ar s Fig. 11. Life expectancy at age 65 years for females, Georgia, WHO European Region and CIS, 1985–2014 WHO European Region Georgia CIS 10 12 14 16 18 20 22 1985 1990 1995 2000 2005 2010 2015 Ye ar s Profile of health and well-being 7 The major risk factors for hepatitis C were injecting drug use and blood transfusions. Around 38.2% of antibody-positive study participants had mentioned injecting drug use, and 19.7% had mentioned blood transfusions (5). Almost half of the participants (46.7%) had not reported either of these two risk factors (5). Currently, each person infected with hepatitis C has free access to the newest antiviral therapy (ART) (5). However, while diagnostic costs are partially covered by the Government, the share of copayment depends on patients’ socioeconomic status. To achieve the country’s ambitious goals to eliminate hepatitis C and streamline efforts to strengthen the national response, Georgia developed a long-term strategy on hepatitis C for 2016–2020 (15). This strategy covers awareness-raising among the population, surveillance, prevention, screening, diagnostics and treatment (5). Tuberculosis Tuberculosis (TB) remains a public health concern in Georgia. According to the Roadmap to implement the tuberculosis action plan for the WHO European Region 2016–2020 (16) Georgia remains among the 18 high-priority countries for ending TB in the Region. This is despite the marked decreasing trend in notified TB cases over the past 10 years: from 104 cases per 100 000 in 2006 to 86 per 100 000 in 2014 (Fig. 12). The high burden of anti-TB drug resistance is a key challenge for the national TB programme and the main obstacle for effective TB control in the country. In 2015, the prevalence of multidrug-resistant TB (MDR-TB) was 12% and 33% in new and previously treated TB cases, respectively (17). In 2015, pulmonary TB constituted 80% of new and relapse cases (17). The successful treatment of the combined cohort of new and relapse cases is a representative marker of the overall performance of the national TB control programme. In 2005, the treatment success rate reached only 64.1%; in 2015, it reached 83% (2014 treatment enrolment cohort) (17). The treatment success rate among cases of MDR-TB declined in 2011–2015 from 54% to 43% (in 2009 and 2013 treatment enrolment cohorts, respectively). Such poor treatment outcomes are predominantly due to the high proportion of cases lost to follow-up, which was 34.3% in 2015 (2013 treatment enrolment cohort). In 2011–2015, Fig. 12. Incidence of TB, Georgia, WHO European Region and CIS, 1985–2014 0 20 40 60 80 100 120 140 160 180 200 1985 1990 1995 2000 2005 2010 2015 Ca se s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Georgia8 multidrug resistance increased among new and previously treated cases, from 11% to 12% and from 32% to 33%, respectively (17). HIV The overall rate of newly diagnosed HIV infections in Georgia has continued to increase over the last decade (Fig. 13) and is now among the highest in the Region. The HIV epidemic in the country is largely concentrated among men who have sex with men, people who inject drugs and their female sexual partners (5). Heterosexual transmission is the main reported transmission mode, accounting for 50% of newly reported cases in 2015 (Table 2). The rate of new AIDS diagnoses has declined since 2011, but remains among the highest in the European Region and well above the Region’s average (Fig. 14). Georgia provides universal access to ART (5). Since 2015, the country has implemented its “Treat All” strategy by offering ART to all diagnosed people living with HIV despite their immune status (5). As described above, in 2015 Georgia launched its ambitious plan for eliminating hepatitis C by 2021 and initiated a large-scale HCV testing programme. Within the national HIV and hepatitis C elimination programmes, the country decided to integrate HIV and HCV screening and provide tandem testing for both infections (18,19). Tandem screening for HIV and HCV is also offered to all people who inject drugs and who use harm reduction services within the Global Fund to Fight AIDS, Tuberculosis and Malaria’s HIV programme in Georgia (18,19). Fig. 13. Incidence of HIV, Georgia, WHO European Region and CIS, 1990–2014 0 5 10 15 20 25 30 35 1990 1995 2000 2005 2010 Ca se s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Table 2. HIV, percent distribution of new cases by mode of transmission, Georgia, 2015 Mode of transmission Percent Injecting drug use 28.0 Heterosexual contacts 50.2 Homosexual contacts 19.8 Vertical transmission 0.8 Blood or blood products transfusion 0.6 Unidentified 0.6 Source: NCDC (5). Fig. 14. Incidence of AIDS, Georgia, WHO European Region* and CIS, 1985–2014 0 2 4 6 8 10 1985 1990 1995 2000 2005 2010 2015 Ca se s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS * No AIDS data are available from the Russian Federation. Profile of health and well-being 9 Vaccine-preventable diseases and immunization In Georgia, measles notification and epidemiological surveillance are obligatory. The country reported outbreaks of measles in 2004 and 2013, indicating the need for improved immunization programmes (Fig. 15). According to NCDC data (5), the heaviest burden of morbidity is among those aged under 1 year and those aged 15–30 years. Coverage of immunization against measles has increased in recent years, except for 2009 (Fig. 16). The decrease in 2009 can be explained by a long-time shortage of the vaccine in the country. In 2015, the coverage rate (97%) exceeded the 95% coverage level recommended by WHO to achieve elimination of measles. Georgia introduced vaccinations against rotavirus, gastroenteritis and pneumococcal infection in 2013 and 2014 (5). The country reported its last detection of wild poliovirus (polio) in 2001, and since 2002 has been certified as a polio-free country. In December 2015, within the framework of the Global Polio Eradication Initiative, Georgia introduced the hexavalent vaccine (5). It also developed an action plan for the transition from the trivalent oral polio vaccine to the bivalent vaccine (5). In recent years, coverage of immunization against polio has increased, although it reached only 89% in 2015 (Fig. 17). All vaccinations included in the national vaccination calendar are free of charge for the population. Fig. 16. Percentage of children with measles vaccination, Georgia, WHO European Region and CIS, 1985–2015 0 10 20 30 40 50 60 70 80 90 100 1985 1990 1995 2000 2005 2010 2015 Pe rc en t WHO European Region Georgia CIS Fig. 15. Incidence of measles, Georgia, WHO European Region and CIS, 1990–2015 0 20 40 60 80 100 120 140 160 180 200 1990 1995 2000 2005 2010 2015 Ca se s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 17. Percentage of children with polio vaccination, Georgia, WHO European Region and the CIS, 1985–2015 0 10 20 30 40 50 60 70 80 90 100 1985 1990 1995 2000 2005 2010 2015 Pe rc en t WHO European Region Georgia CIS Georgia10 Other diseases The major causes of death in Georgia are related to noncommunicable diseases (NCDs) including circulatory diseases, cancer, diabetes and respiratory diseases. Due to the collapse of the registration system in the country, which interrupted surveillance of cases of some chronic diseases,1 the availability of consistent data on malignant neoplasms and cancer morbidity in Georgia is limited (20). Reported cancer incidence and mortality rates from malignant neoplasms in Georgia are therefore significantly lower than the average rates for both the CIS and the European Region (Fig. 18). On 1 January 2015, Georgia established a population-based cancer registry in order to improve the epidemiological surveillance of cancer (5). Following this, more than 9500 new cases of malignant neoplasms were registered in 2015, excluding non-melanoma skin cancers and cancers in situ (5). In 2015, the incidence rate was 282.7 per 100 000 (5) (Fig. 19). As in the rest of the European Region and the CIS, rates of diabetes mellitus have increased in Georgia in recent years. The 2014 rate (2.2%) was similar to the average for the CIS (2.3%) but lower than that for the European Region (3.8%, in 2013). Infant and maternal mortality The infant mortality rate in Georgia has declined over the past 10 years (Fig. 20). In 2014, it was 9.5 deaths per 1000 live births, which was higher than the Region’s average (6.6 deaths per 1000 live births) and similar to that of the CIS (9.3 deaths per 1000 live births). 1 Until 2007, a special dispensary surveillance system for patients with some chronic diseases, such as cancer, mental disorders (including alcohol and drug dependence), endocrine diseases and TB, was in place in Georgia. In 2003–2007, the country began replacing these dispensaries with integrated health care centres; introduced incentives for building private health care centres; and established a programme to provide private-practice medical services in rural settings. These reforms redistributed patients across primary health care facilities and, as a result, the monitoring of patients with some chronic diseases ceased. Georgia therefore introduced electronic systems for data capture and exchange, and established several registries. Fig. 18. Incidence of cancer, Georgia, WHO European Region and CIS, 1985–2014 0 50 100 150 200 250 300 350 400 450 1985 1990 1995 2000 2005 2010 2015 Ca se s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 19. Incidence of malignant neoplasms, Georgia, 2005–2015 0 50 100 150 200 250 300 2005 2007 2009 2011 2013 2015 Ca se s pe r 10 0 00 0 po pu la ti on Introduction of the population-based cancer registry Source: NCDC (5). Profile of health and well-being 11 The maternal mortality rate in Georgia has fluctuated widely over the past decades (Fig. 21). In 2014, it was 31 deaths per 100 000 live births, which was higher than the average rates for both the European Region (12 deaths per 100 000 live births) and the CIS (17 deaths per 100 000 live births). Reproductive-age mortality studies revealed significant improvements in the completeness of death registration for women of reproductive age over the past decade. This was determined to be 98% in 2012 (21). In 2016, the country implemented an electronic registration system for monitoring maternal and child health, and antenatal and obstetric services. This Electronic Module of Pregnant Women and Newborn Health Care (the “birth registry”) (22) registers the first antenatal visit for each pregnant woman and each subsequent follow-up until childbirth or the end of pregnancy. The system also records information about the health status of newborns at the moment of delivery. Leading causes of death A comparison of countries’ age-standardized mortality rates2 highlights population differences in the most common causes of death, allowing for easier identification of preventable deaths. Yet the quality of cause- of-death data is of concern in Georgia, as a large proportion of causes of death are unrecorded due to the breakdown of civil registration system in the 1990s (20). In addition, the share of ill-defined causes of death among all deaths in Georgia has been steadily increasing. Experts used the WHO Analysing mortality levels and causes of death (ANACoD) tool (23) to review cause-of-death data and assess the quality of mortality statistics in the Georgian dataset reported to the WHO Mortality Database (24). The results of the review showed that the proportion of ill-defined causes of death in overall reported causes was 37.6% in 2014; most of these are registered in ICD-10 Chapter XVIII: Symptoms, signs and abnormal clinical and laboratory findings. The fact that some deaths may not be captured in the dataset either because of Fig. 20. Infant deaths per 1000 live births, Georgia, WHO European Region and CIS, 1985–2014 WHO European Region Georgia CIS 0 5 10 15 20 25 30 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 00 li ve b ir th s Fig. 21. Maternal deaths per 100 000 live births, Georgia, WHO European Region and CIS, 1985–2014 WHO European Region Georgia CIS 0 20 10 40 30 50 60 70 80 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 liv e bi rt hs 2 Age-standardized death rates are calculated by the direct method: that is, they represent what the crude rates would have been if the population had the same age distribution as the standard European population. Georgia12 ill-defined causes of death or their not having been registered warrants caution in the interpretation of mortality indicators in Georgia. Georgia’s age-standardized mortality rate from all causes in 2014 (984.4 per 100 000) was slightly lower than the average for the CIS (1078.4 per 100 000), yet higher than the average for the European Region (738.2 per 100 000, in 2013). Quite alarmingly, there is a wide gender gap for this indicator: in 2014, the mortality rate for males (1310.7 per 100 000) was almost twice the rate for females (734.8 per 100 000). As in most European countries, the major causes of mortality in Georgia are related to NCDs. According to WHO estimates, NCDs accounted for 93% of total deaths in Georgia for both sexes in 2014 (25). Diseases of the circulatory system and malignant neoplasms were the leading causes of death for both overall and premature mortality (under 65 years) in Georgia in the same year (Fig. 22). Georgia’s mortality rate due to circulatory diseases has been cause for concern for years. Following the improvements in death registration in 2011, however, the rate for this indicator dropped significantly. In 2014, it was 386.1 deaths per 100 000, which was similar to the average for the European Region (332.7 per 100 000, in 2013) and lower than that for the CIS (602.2 per 100 000) (Fig. 23). Fig. 22. Mortality profile from main causes of death, age-standardized death rate per 100 000 population, Georgia (2014), WHO European Region (2013) and CIS (2014) Endocrine, nutritional and metabolic diseases Infectious and parasitic diseases Diseases of digestive system Diseases of respiratory system External causes of injury and poisoning Malignant neoplasms Diseases of circulatory system Endocrine, nutritional and metabolic diseases Infectious and parasitic diseases Diseases of digestive system Diseases of respiratory system External causes of injury and poisoning Malignant neoplasms Diseases of circulatory system Al l a ge s Ag e 0– 64 y ea rs Age-standardized death rate per 100 000 population WHO European Region Georgia CIS 0 100 300200 400 500 600 700 Fig. 23. Age-standardized death rate from diseases of the circulatory system, all ages per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 200 100 300 400 600 500 700 900 800 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Profile of health and well-being 13 Other major causes of death Georgia’s age-standardized mortality rates from external causes of injury and poisoning, as well as diseases of the respiratory and digestive systems for all ages, are below the averages for the CIS and the Region. The age-standardized mortality rate from external causes and poisoning has fluctuated, but remains at the level of the late-1980s (Fig. 24). The number of recorded deaths in motor vehicle accidents changed dramatically between 2012 and 2014; these changes are also attributed to the improvement of death registration in the civil registration system. Mortality rates from motor vehicle accidents among males (22.0 per 100 000) are about 4 times higher than among females (5.8 per 100 000). The overall mortality rate from motor vehicle accidents is higher than the average rate for the European Region (Fig. 25). In 2014, the age-standardized mortality rate from homicides and intentional injuries for all ages (2.1 per 100 000) was far below the average for the CIS (7.4 per 100 000) and closer to that for the European Region (2.9 per 100 000, in 2013) (Fig. 26). In the same year, it was almost three times higher for males (3.2 per 100 000) than for females (1.2 per 100 000). The mortality rate from respiratory system diseases in 2014 (27 per 100 000) was very low compared to the European Region (45 per 100 000, in 2013) and the CIS (48 per 100 000) (Fig. 27). Fig. 24. Age-standardized death rate from external causes of injury and poisoning, all ages per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 50 100 150 200 250 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 25. Age-standardized death rate from motor vehicle traffic accidents, all ages per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 10 5 20 15 30 25 40 35 45 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 26. Age-standardized death rate from homicides and intentional injuries, all ages per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 5 10 15 20 25 30 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 27. Age-standardized death rate from respiratory system diseases, all ages per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 20 40 60 80 100 120 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Georgia14 In 2014, the age-standardized mortality rate from diseases of the digestive system (29.3 per 100 000) was lower than the Region’s average (35.2 per 100 000) and that of the CIS (56.9 per 100 000) (Fig. 28). The mortality rate due to endocrine diseases increased over the last decade to 24.3 per 100 000 in 2014 (Fig. 29). Diabetes was responsible for the largest share of all deaths attributed to endocrine diseases (Fig. 30). The age-standardized mortality rate from infectious and parasitic diseases in Georgia has been increasing since 2010, and reached 13.9 per 100 000 in 2014. The improved registration of deaths and coding of underlying causes of death could explain this. The 2014 rate was slightly higher than the average for the European Region (12.3 per 100 000, in 2013), yet much lower than that of the CIS (19.3 per 100 000). Mortality from TB in 2014 was 2.8 per 100 000, and has slowly decreased since the 1990s (Fig. 31). Annex 2 presents selected causes of mortality, comparing the percentage of change from 2000 to the latest available year in Georgia (2014) with the averages for the European Region (2013) and the CIS (2014). Fig. 28. Age-standardized death rate from digestive system diseases, all ages per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 10 20 30 40 60 50 70 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 29. Age-standardized death rate from endocrine, nutritional and metabolic diseases, all ages per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 WHO European Region Georgia CIS 0 5 10 15 20 25 30 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on Fig. 30. Age-standardized death rate from diabetes, all ages per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 5 10 15 20 25 30 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS 0 5 10 15 20 25 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 31. Age-standardized death rate from TB, all ages per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 Profile of health and well-being 15 Premature mortality In Georgia, the lowest age-standardized all-causes premature mortality rates for both sexes was registered in 2001 (298.4 per 100 000). Between 2001 and 2014, the mortality rate (380.2 per 100 000) increased by 27%. This change might be explained by the improvements in the vital registration system as well as the changes in recorded population size after the 2014 census. The rate in Georgia was 33.2% higher than the Region’s average (285.4 per 100 000, in 2013), yet lower than the average for the CIS (483.7 per 100 000). Furthermore, there is a large gender gap in all-cause premature mortality: in 2014 the mortality rate for males (580.5 per 100 000) was much higher than for females (207.8 per 100 000) (Fig. 32, 33). A large share of premature deaths from cardiovascular diseases, cancer and accidents are influenced by health-related behaviours and risk factors. These can be addressed with treatments and health promotion and prevention measures, but their impact is more challenging to clearly ascertain in analyses of trends of premature mortality. In 2014, the share of mortality due to major NCDs among those aged 30–69 years made up 43% of all causes of death in all ages. This is a core indicator of both Health 2020 and the Sustainable Development Goals. The large differences between the reported rates for Georgia (618.9 per 100 000 for males and 262.9 per 100 000 for females) and the Fig. 32. Age-standardized death rate from all causes, males aged 0–64 years per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 200 400 600 800 1000 1200 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 33. Age-standardized death rate from all causes, females aged 0–64 years per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 200 400 600 800 1000 1200 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Georgia16 CIS (972.0 per 100 000 for males and 409.9 per 100 000 for females) indicate possible problems in the identification of underlying causes of death in Georgia (Fig. 34, 35). The trends in the disease groups below must therefore be interpreted with caution. Premature mortality (0–64 years) from diseases of the circulatory system has decreased in most European countries in recent decades, including Georgia. In 2014, the rate for males in Georgia was 151.7 per 100 000, which was slightly higher than the average for the European Region (127.9 per 100 000, in 2013) and lower than that for the CIS (268.4 per 100 000). The rate for females (42.3 per 100 000) was similar to the Region’s average (45.8 per 100 000, in 2013) and lower than that for the CIS (92.8 per 100 000). This indicator displays a significant gender gap: in 2014, premature mortality from diseases of the circulatory system for males (151.7 per 100 000) was much higher than for females (42.3 per 100 000) (Fig. 36, 37). Mortality rates for premature deaths from ischaemic heart disease in Georgia have declined for both males and females since 2000. In 2014, they reached 50.7 per 100 000 for males and 9.3 per 100 000 for females. These were lower than the average rates for the European Region (65.5 per 100 000 for males and 18.0 per 100 000 for females, in 2013) and the CIS (143.3 per 100 000 for males and 39.6 per 100 000 for females). Fig. 34. Age-standardized death rate from major NCDs, males aged 30–69 years per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 200 400 600 800 1200 1600 1000 1400 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 35. Age-standardized death rate from major NCDs, females aged 30–69 years per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on 0 200 400 600 800 1000 1200 1400 1600 WHO European Region Georgia CIS Fig. 36. Age-standardized death rate from diseases of the circulatory system, males aged 0–64 years per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on 0 50 100 150 200 250 300 350 400 450 WHO European Region Georgia CIS Fig. 37. Age-standardized death rate from diseases of the circulatory system, females aged 0–64 years per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on 0 50 100 150 200 250 300 350 400 450 WHO European Region Georgia CIS Profile of health and well-being 17 The mortality rate for premature deaths from cerebrovascular diseases has declined by more than half for both males and females since 2000. In 2014, the age-standardized mortality rate for males (31.9 per 100 000) was still higher than the average for the European Region (24.7 per 100 000, in 2013) but lower than that of the CIS (54.6 per 100 000). In the same year, the rate for females (12.7 per 100 000) was closer to the Region’s average (12.5 per 100 000, in 2013) and lower than that of the CIS (25.4 per 100 000). The mortality rate for premature deaths from malignant neoplasms in males has increased since 2000, and in 2014 reached 81.8 per 100 000. This was lower than the average rates for both the CIS (101.9 per 100 000) and the European Region (86.2 per 100 000, in 2013) (Fig. 38). Premature mortality due to malignant neoplasms for females declined to 50.9 per 100 000 in 2014, which was also lower than the averages for the European Region (57.4 per 100 000, in 2013) and the CIS (63.1 per 100 000) (Fig. 39). In 2014, the premature mortality rate due to malignant neoplasms for males from cancers of the trachea, bronchus and lung (23.0 per 100 000) was responsible for about one quarter of males’ cancer deaths in Georgia (Fig. 40). This rate was close to the average for the European Region (25.4 per 100 000, in 2013). The corresponding rate for females decreased over the same period to reach 2.3 per 100 000 in 2014; this might be explained by low smoking rates among females. Fig. 38. Age-standardized death rate from malignant neoplasms, males aged 0–64 years per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 20 40 60 80 100 120 140 160 180 1985 1990 1995 2000 2005 2010 2015 Ca se s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 39. Age-standardized death rate from malignant neoplasms, females aged 0–64 years per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 20 40 60 80 100 120 140 160 180 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 40. Age-standardized death rate from trachea, bronchus and lung cancer, males aged 0–64 years per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 10 20 30 40 60 50 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Georgia18 Premature mortality due to female breast cancer was responsible for 27% of all premature cancer deaths among females in Georgia in 2014. Premature mortality due to female breast and cervix uteri cancers decreased significantly between 2000 and 2006; this was also the period of the sharp decline in death registration by the civil registration and vital statistics system. After 2006, the rates for the two indicators began increasing, although both show volatility in trends. Some of this increase can also be attributed to the introduction of the state screening programme in 2011 (5). Premature mortality due to female breast cancer reached 13.7 per 100 000 in 2014, which was lower than the average for the European Region (12.3 per 100 000) and similar to that of the CIS (13.5 per 100 000) (Fig. 41). The premature mortality due to cervix uteri cancer in the same year was 5.1 per 100 000, which was higher than the average for the European Region (3.4 per 100 000, in 2013) and slightly lower than that for the CIS (5.9 per 100 000) (Fig. 42). Fig. 41. Age-standardized death rate from female breast cancer, 0–64 years per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 5 10 15 20 25 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Fig. 42. Age-standardized death rate from cancer of the cervix uteri, 0–64 years per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 1 2 3 4 5 6 7 8 9 10 1985 1990 1995 2000 2005 2010 2015 D ea th s pe r 10 0 00 0 po pu la ti on WHO European Region Georgia CIS Profile of health and well-being 19 Risk factors and determinants of health Several factors, including genetics, physical and social environments, and health behaviour, affect the health and well-being of individuals and the population. Risk factors such as unhealthy diets, low physical activity, smoking and heavy alcohol consumption are linked to elevated blood pressure, high serum cholesterol and overweight. These risk factors contribute to premature mortality from cardiovascular diseases and cancers in particular, the two main causes of death in Europe. Risk factors also contribute to a wide range of other chronic illnesses and thus affect the quality of life in general (2). In Georgia, there are no regularly conducted population surveys to assess the prevalence of health risk factors such as tobacco, alcohol and illicit drug consumption, obesity, low physical activity and poor nutrition. Developing a good level of understanding of these risk factors and identifying measures to reduce their influence is essential to acting against the leading causes of mortality and morbidity. Georgia implemented the WHO STEPwise approach to surveillance (STEPS) survey (26) in 2010 and 2016 (27,28) to obtain core data on the established risk factors that determine the major disease burden among the population aged 18–69 years. Alcohol consumption The consumption of alcohol is measured as the recorded amount of alcohol consumed per adult aged 15 years or more over a calendar year in a country, in litres of pure (100%) alcohol.3 In 2014, the recorded alcohol consumption per capita for the adult population in Georgia was around 6.1 litres (Fig. 43). This was lower than the averages for both the European Region (8.6 litres) and the CIS (8.0 litres). Although sales figures do not cover the unrecorded consumption of alcohol, the WHO Global Health Observatory estimates that the unrecorded consumption of alcohol in Georgia is moderate: 2.3 litres per capita in 2010 (29). 3 Measurements are based on sales figures among people aged 15 years and over. Fig. 43. Pure alcohol consumption, recorded litres per capita among those aged 15 years and over, Georgia, WHO European Region and CIS, 1990–2014 0 1 2 3 4 5 6 7 8 9 10 1985 1990 1995 2000 2005 2010 2015 Li tr es p er c ap it a WHO European Region Georgia CIS Georgia20 Tobacco smoking The percentage of regular daily smokers is measured among adults aged 15 years and over. Data on prevalence of smoking are obtained through surveys, so comparability of the data may be limited due to the different methods used. To increase the comparability of data, WHO has produced estimates of age-standardized tobacco use. In 2013, the estimated age-standardized prevalence of tobacco use in Georgia was 58.5% for males, which is one of the highest values in the European Region (where the average rate is 38.5%) and higher than the average for the CIS (51.8%). In contrast, only 5.8% of Georgian females are estimated to use tobacco – this is lower than the averages for both the European Region (20.7%) and the CIS (16.1%). In 2015, Georgia conducted the European School Survey Project on Alcohol and Drugs to study alcohol, tobacco and other drug use among students (30). It showed that 21% of students had tried smoking at the age of 13 years or younger (28% of boys and 13% of girls), and that 4% were daily smokers (6% of boys and 2% of girls). Georgia has in recent years introduced several tobacco control measures. The Government developed a tobacco control strategy, an action plan for 2013–2018 and a state tobacco control programme, as well as a draft of legislative changes to bring tobacco control measures similar to international and national legislation mandates and to initiate a large-scale anti-tobacco campaign (31). It also developed a national health promotion strategy for 2014–2019 and a health promotion programme with a tobacco control component (31). Overweight In 2014, 56% of females and 54% of males in Georgia were overweight (body mass index of 25 or more), representing a slight increase since 2010 for both sexes. The prevalence of obesity (body mass index of 30 or more) also increased between 2010 and 2014. More females (24%) were obese than males (18%) in 2014. Georgia’s prevalence of overweight and obesity are similar to the Region’s averages for females (55% are overweight and 25% are obese), but lower than its average for males (63% are overweight and 21% are obese). Profile of health and well-being 21 Comparative risk assessment WHO estimates for the number of disability-adjusted life years (DALYs) attributable to selected risk factors only apply at the regional level. For this reason, estimates produced by the Institute for Health Metrics and Evaluation, which are available at the country level, are used here (32,33). The Institute estimates that the highest burden of disease in Georgia is caused by dietary risks, followed by high systolic blood pressure. Estimates of the top 10 risk factors and the associated burden of disease measured in DALYs for Georgia are given in Table 3, disaggregated by sex. Table 3. Top 10 risk factors and the associated age-standardized burden of disease, Georgia, by sex, 2015 Risk factors DALYs (average rate per 100 000 population) Estimated value Uncertainty interval (lower and upper) Females Dietary risks 6109 (5205–7091) High systolic blood pressure 5698 (4975–6428) High body mass index 3260 (2224–4312) High fasting plasma glucose 2625 (2177–3204) High total cholesterol 1977 (1468–2609) Air pollution 1831 (1340–2474) Impaired kidney function 1181 (977–1409) Tobacco smoke 1036 (855–1237) Child and maternal malnutrition 714 (502–990) Low physical activity 614 (441–790) Males Dietary risks 11 412 (9860–13 006) High systolic blood pressure 10 253 (9105–11 353) Tobacco smoke 8433 (7377–9499) High body mass index 4840 (2971–6627) High fasting plasma glucose 3742 (3150–4456) High total cholesterol 3712 (2928–4642) Air pollution 3684 (2799–4833) Alcohol and drug use 3503 (3001–3994) Impaired kidney function 1432 (1184–1692) Low physical activity 1124 (765-1489) Source: Institute for Health Metrics and Evaluation (32). Georgia22 Health system The key indicators for the health system in 2014 are shown in Table 4. The number of hospital beds in Georgia fell between 2000 and 2014; in 2014, the rate was much lower than the averages for both the European Region and the CIS. The number of physicians has been increasing since 2006 and is notably higher than the averages for the European Region and CIS (Fig. 44). In contrast, the number of nurses has been decreasing since 1998 and is much lower than the averages for the European Region and the CIS (Fig. 45). WHO’s estimate for total health expenditure in Georgia as a percentage of GDP has increased. It reached 7.4% in 2014, which was higher than the averages for both the European Region and the CIS. WHO’s estimate of the country’s public sector health expenditure as a percentage of total health expenditure was 21% in 2014, which was much lower than the averages for the European Region and the CIS. Table 4. Key indicators for health resources, use of health services and health expenditure, Georgia, WHO European Region and CIS, 2014 a WHO estimates. Source: WHO HFA-DB (4). Indicator Georgia, 2014 Percent change since 2000 WHO European Region CIS Hospital beds per 100 000 313.3 –34.8% 553.9 715.7 Physicians per 100 000 517.0 +36.5% 322.3 309.98 Dentists per 100 000 57.7 +69.6% 53.4 33.2 Nurses per 100 000 413.6 –10.9% 740.4 622.3 Midwives per 100 000 16.3 –61.3% 39.9 45.2 Inpatient care discharges per 100 10.5 +125.8% 17.9 19.9 Average length of stay, all hospitals (days) 5.2 –48.6% 8.7 11.0 Outpatient contacts per person per year 3.5 +150.0% 7.6 8.9 Total health expenditure as percentage of GDPa 7.4 +6.9% 8.2 6.6 Total health expenditure, PPP (US$) per capitaa 627.7 +274.9% 2574.7 1233.1 Public-sector health expenditure as percentage of total health expenditurea 20.9 +23.1% 67.9 51.1 Private household out-of-pocket payments as percentage of total health expenditure 58.6 –29.0% 26.6 46.2 Profile of health and well-being 23 Fig. 44. Physicians per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 100 200 300 400 500 600 1985 1990 1995 2000 2005 2010 2015 Ph ys ic ia ns p er 1 00 0 00 WHO European Region Georgia CIS Fig. 45. Nurses per 100 000 population, Georgia, WHO European Region and CIS, 1985–2014 0 100 200 300 400 500 600 700 800 1985 1990 1995 2000 2005 2010 2015 N ur se s pe r 10 0 00 0 WHO European Region Georgia CIS WHO’s estimate of Georgia’s total health expenditure in PPP (US$) per capita in 2014 was below the averages for the European Region and the CIS. Georgia’s rate of private household out-of-pocket expenditure is one of the highest in the Region: in 2014, it represented 58.5% of total health expenditure. A detailed description of the country’s health system is available in Georgia: health system review (20). Georgia24 Health 2020 Health 2020, the health policy of the Region, aims to support action across government and society to improve the health and well- being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems that are universal, equitable, sustainable and of high quality (2). Member States of the European Region have agreed on a set of core indicators to monitor progress towards the Health 2020 policy targets (3). The newly revised country profiles of health and well-being and accompanying highlights on health and well-being constitute a country-by-country means of reporting progress towards achieving the overarching targets of Health 2020. For Georgia, the Health 2020 indicators are given in Table 5. Target 1. Reduce premature mortality by 2020 The age-standardized premature mortality rate from the four major NCDs (cardiovascular diseases, cancer, diabetes mellitus and chronic respiratory diseases) among people aged 30 to under 70 years in Georgia decreased to 422.3 per 100 000 in 2014. This was lower than the average for the CIS (652.0 per 100 000) and the European Region (395.5 per 100 000, in 2013). Moreover, premature mortality from the four major NCDs in 2014 was much higher for males (618.9 per 100 000) than for females (262.9 per 100 000). Age-standardized mortality from external causes of injury and poisoning is below the averages for both the European Region and the CIS. However, the death rate among males is 3.7-fold higher than among females. In Georgia, the recorded alcohol consumption in 2014 was lower than the averages for the European Region and the CIS. The prevalence of tobacco smoking among males was higher than that of the Region. As in the rest of the Region, the prevalence of overweight and obesity has been increasing in Georgia, reaching 55% in 2014; this was similar to averages for both the European Region and the CIS. Profile of health and well-being 25 Table 5. Core indicators for monitoring Health 2020 policy targets, Georgia, most recent years available Target Indicator Value Year Male Female Total 1. Reduce premature mortalitya Premature mortality rate from cardiovascular diseases, cancer, diabetes mellitus and chronic respiratory diseases among people aged 30 to under 70 years (age-standardized) 618.9 262.9 422.3 2014 Prevalence of tobacco use among adults aged 15 years and over (age standardized)b 58.5 5.8 30.0 2013 Pure alcohol consumption per capita among adults aged 15 years and over (recorded data) – – 6.1 2014 Prevalence of overweight and obese (body mass index ≥25) adults aged 18 years and over (age-standardized estimate) 54.0 56.0 55.0 2014 Mortality rate from external causes of injury and poisoning, all ages (age-standardized estimate) 76.0 21.0 46.0 2014 2. Increase life expectancy Life expectancy at birth, in years 68.8 77.3 73.1 2014 3. Reduce inequitiesc Infant deaths per 1000 live births 10.1 8.9 9.5 2014 Proportion of children of official primary school age not enrolled (net enrollment rate) 3.8 2.7 3.3 2013 Unemployment rate (percentage) – – 12.4 2014 National policy addressing reduction of health inequities established and documented NA NA Yes, but only partially 2016 Gini coefficient NA NA 40.0 2013 4. Enhance well-beingd Overall life satisfaction among adults aged 15 years and over (33) NA NA 4.3 2014 Availability of social support among adults aged 50 years and over (34) – – 43.0 2013 Percentage of population with improved sanitation facilities – – 86.3 2015 5. Ensure universal coverage and “right to health” Private household out-of-pocket expenditure as proportion of total health expenditure NA NA 58.6 2014 Percentage of children vaccinated against measles (1 dose) – – 96.0 2015 Percentage of children vaccinated against polio (3 doses) – – 89.0 2015 Percentage of children vaccinated against rubella (1 dose) – – 96.0 2015 Total health expenditure as a percentage of GDP NA NA 7.4 2014 6. Set national targets Establishment of process for target-setting documented NA NA Yes 2016 Evidence documenting: (a) national health strategy aligned with Health 2020 (b) implementation plan (c) accountability mechanism NA NA NA NA NA NA Yes No Yes, but only partially 2016 2016 2016 NA: not applicable. a Target 1 includes percentage of children vaccinated against measles (1 dose), polio (3 doses) and rubella (1 dose). b Prevalence includes both daily and occasional (less than daily) use among adults aged 15 years and over. c Target 3 includes life expectancy at birth. d Target 4 includes Gini coefficient, the unemployment rate and the proportion of children not enrolled in primary school. Source: WHO HFA-DB (4) unless otherwise specified. Over the last decade, the child immunization coverage for measles, polio and rubella has increased, and yet the coverage for polio in 2015 was still lower than the averages for the European Region and the CIS. Georgia26 Target 2. Increase life expectancy Life expectancy at birth in Georgia in 2014 was 68.8 years for males and 77.3 years for females – lower than in previous years. However, this lower value is likely due to the drop in population size determined by the 2014 population census. As discussed above, this change in population size in 2014 resulted in lower values for all population-based health indicators for that year. If the National Statistics Office retrospectively corrects population size for preceding years based on the 2014 census, the indicator trends will be corrected to a uniform population denominator. Target 3. Reduce inequalities in health (social determinants target) Georgia has made gains in closing the gaps in children’s health status. In 2014, infant mortality rates were 10.1 per 1000 live births for boys and 8.9 per 1000 live births for girls; both have steadily decreased since 2003. However, infant mortality rates in 2014 remained higher than the rates for the CIS and the Region. Since 2000, the country has also made some improvements in the proportion of children of official primary school age not enrolled; this indicator decreased to 3.8% for boys and 2.7% for girls in 2013. Unemployment is an indicator measuring the target of reducing inequities (1). Georgia’s unemployment rate increased to 12.4% in 2014, which was higher than the averages for both the European Region (9.1%) and the CIS (5.5%). The measure of income inequality (Gini coefficient) has remained steady since 2000, and was 40.0 in 2013. This was higher than the averages for the European Region (33.4) and the CIS (35.1, in 2012). Georgia’s unemployment and Gini coefficient rates highlight the need for a national policy to effectively tackle inequalities in the country. Target 4. Enhance the well-being of the population Well-being, as monitored by a set of indicators, is a relatively new construct, and further country data is required for adequate trend analysis. Data from the Gallup World Poll for 2014, obtained through Profile of health and well-being 27 the United Nations Development Programme’s Human Development Report (33), give Georgia an overall life satisfaction index of 4.3 on a scale from zero (least satisfied) to 10 (most satisfied). This is lower than the average for the European Region (5.9) (33). Among people aged 50 years and above, 43% of Georgians reported in 2013 that they had relatives or friends on whom they could count when in trouble. This was much lower than the average for the European Region (86%). As of 2015, 86.3% of both urban and rural populations in Georgia had access to a sewage system, septic tank or other hygienic means of sewage disposal. This has decreased since 2000 primarily due to the decline of improved sanitation facilities in rural areas, which was 75.9% in 2015. By contrast, the availability of improved sanitation facilities in urban areas was 95.2% in 2015. Target 5. Ensure universal coverage and the “right to health” Since 2013, Georgia has laid the foundation for health policy that is oriented towards public health and welfare (5). In February 2013, it implemented a universal health care insurance programme to provide universal state-funded medical care (35). More than 90% of the population takes part in the programme; the remaining 10% of the population has private medical insurance (5). The programme covers planned outpatient, emergency in- and outpatient services, elective surgeries, cancer treatments, obstetrical care and funding for essential drugs. This has improved access to health services and reduced financial barriers and out-of-pocket costs for the population (5). The proportion of private household out-of-pocket expenditure has decreased since 2000, and was 58.6% in 2014. However, the 2014 expenditure was almost twice the average for the Region. This likely results in inequitable access to health care and financial hardship for many households – especially poorer households – which may in turn exacerbate poverty and have a negative impact on health. WHO estimated that Georgia’s total expenditure on health (as a percentage of GDP) slightly increased between 2000 and 2014 to 7.4%. This level of expenditure was close to the average for the CIS (6.6%) and slightly below the average for the European Region (8.2%). Georgia28 According to a recent survey of the United States Agency for International Development (36), 96.4% of beneficiaries of the universal health care programme in Georgia are satisfied or very satisfied with the emergency medical services at hospital level. Target 6. Set national goals and targets related to health In 2015, Georgia began establishing a process for target-setting in the health sector. The NCDC organized a multisectoral meeting to discuss national perspectives on Health 2020 targets and indicators (5). It focused on the alignment of national health services with Health 2020 targets, and the subsequent development of an implementation plan and an accountability mechanism in accordance with the recommendations of the Health 2020 policy framework. Policy-makers defined a national set of indicators to monitor progress towards the Health 2020 targets. The document has, however, not yet been formally adopted. Profile of health and well-being 29 Although the health status of the Georgian population has steadily improved for a number of health indicators over the past two decades, some improvements have been relatively slow. The main population health indicators show significant changes from the trends observed up to 2013 and in 2014, when a new population census was conducted. This 2014 census measured a large decrease in the size of population, which in turn caused a break in the trends of the main population health indicators whose calculation depends on the population denominator. Therefore, trends and values for 2014, the last-available year, must be interpreted with caution. Despite improvements, the most recent data show some specific areas of concern in Georgia: a number of health indicators are worse than the averages for both the European Region and the CIS. In terms of key indicators of health, Georgians are living longer lives. Fewer infants are dying, but levels of maternal mortality remain very high compared with other countries across the Region. The majority of deaths in Georgia are due to major NCDs. The main causes of death are diseases of the circulatory system and malignant neoplasms (cancers), other NCDs, and external causes of injury and poisoning (accidents, suicides and homicides). Since 1990, overall premature mortality has been decreasing, although it is still high compared to the regional average. Georgia introduced a population-based cancer registry in 2015 to improve the surveillance of cancer. A review of the latest data obtained from the registry indicates that it records more cancer cases than were known of before it was introduced. The cancer incidence rate derived from this registry is close to the average rates for both the European Region and the CIS. Unlike many countries across the Region, Georgia faces ongoing challenges in the form of high levels of communicable diseases. The incidence of TB is decreasing but remains higher than the average for the Region; a high burden of MDR-TB is the major contributing factor. Data show rapid increases in incidences of HIV and AIDS since 2000. Georgia’s HIV rate approached the average for the Region, but Conclusions Georgia30 due to late diagnoses its rate of new AIDS diagnoses (2006–2015) is considerably higher. Overall, vaccination coverage is high for measles, rubella and polio. In 2009, a drop in measles vaccination coverage was followed by an outbreak. Since 2013, Georgia has implemented additional vaccination campaigns to address the epidemic. Georgia also has a very ambitious programme for eliminating hepatitis C. The NCDC is running programmes to address the burden of communicable disease. The rate of physicians per 100 000 population is one of the highest in the Region. The number of nurses, however, is one of the lowest. Between 2000 and 2010, Georgia’s total health expenditure as a percentage of GDP was higher than the regional average, but has since decreased. At the same time, the total health expenditure in PPP (US$) per capita has stayed low compared to the Region’s average. Georgia’s major challenge in this area is the high share of private household out-of-pocket health expenditure. Out-of-pocket expenditure in the country is among the highest in the Region. Since 2013, as part of its efforts to lay the foundation for health policy that is oriented towards public health and welfare, Georgia has increased public sector expenditures on health. The recorded alcohol consumption per capita among those aged 15 years and over has decreased over recent years. The most recent reported level of alcohol consumption was lower than the average rates for the European Region and the CIS. Georgia is among the European countries with the highest levels of tobacco use among males (estimated at 58.5% in 2013), which points to increased health risks among this group. Georgia has in recent years introduced several tobacco control measures, including a tobacco control strategy, an action plan for 2013–2018, a state tobacco control programme and a draft of legislative changes. These will bring tobacco control measures similar to international and national legislation mandates and contribute to the initiation of a large-scale anti-tobacco campaign in the country. In addition, Georgia has a national health promotion strategy for 2014–2019, which includes a health promotion programme with a tobacco control component. Data on overall life satisfaction among adults aged 15 years and over, collected by the Gallup World Poll, show that Georgia’s life satisfaction index is below the average for the Region. Profile of health and well-being 31 There is cause for concern regarding inequality in Georgia, reflected in the country’s higher-than-average Gini coefficient and proportion of children of official primary school age not enrolled, as well as its limited improvement in the unemployment rate. An effective policy is needed to tackle health inequities in the country. Although the overall health situation has improved in Georgia in the past decades, the gaps between national figures and the averages for the Region, as described above, are still substantial for a large number of indicators. The noticeable improvements in the national registration systems, however, are particularly encouraging. Georgia introduced systems for electronic data collection and exchange in several areas of the health information system, and established both the birth registry and the cancer registry. In addition, Georgia introduced measures to ensure more complete registration of deaths and improve quality of the causes-of-death data. These measures will improve the coverage and quality of essential health information in the country, which will enhance overall understanding of the population’s health challenges. The cancer registry in particular will help to improve the health of the population by supporting actions and informing policies on these illnesses that form one of the major causes of death in the country. Population estimates still need to be adjusted based on the results of the 2014 population census. This will facilitate the analysis of changes within the country over time, as well as comparisons with neighbouring countries and those across the Region. Of particular importance are Georgia’s ongoing efforts to continue aligning national health policies with Health 2020 targets and goals. Sustained implementation of existing and planned health programmes, along with ongoing monitoring of changes in health trends, will allow Georgia to improve its health profile in the coming years. The continued adoption of this approach, supported by evidence-informed system reforms, will assist Georgia in becoming a healthier nation. Georgia32 References 1. Health 2020: a European policy framework supporting action across government and society for health and well-being. Copenhagen: WHO Regional Office for Europe; 2012 (EUR/RC62/9; http://www.euro.who.int/en/about-us/governance/regional- committee-for-europe/past-sessions/sixty-second-session/ documentation/working-documents/eurrc629-health-2020-a- european-policy-framework-supporting-action-across-government- and-society-for-health-and-well-being, accessed 11 August 2017). 2. Health 2020: a European policy framework and strategy for the 21st century [website]. Copenhagen: WHO Regional Office for Europe; 2013 (http://www.euro.who.int/en/publications/policy-documents/ health-2020.-a-european-policy-framework-and-strategy-for-the- 21st-century-2013, accessed 11 August 2017). 3. Targets and indicators for Health 2020: Version 3. Copenhagen: WHO Regional Office for Europe; 2016 (http://www.euro.who. int/en/health-topics/health-policy/health-2020-the-european- policy-for-health-and-well-being/publications/2016/targets-and- indicators-for-health-2020.-version-3-2016, accessed 11 August 2017). 4. European Health for All database (HFA-DB) [online database]. Copenhagen: WHO Regional Office for Europe; 2016 (https:// gateway.euro.who.int/en/hfa-explorer/, accessed 11 August 2017). 5. Health care statistical yearbook 2015: Georgia [e-book]. Tbilisi: National Centre for Disease Control and Public Health of the Ministry of Labour, Health and Social Affairs of Georgia; 2017 (http://www.ncdc.ge/AttachedFiles/yearbook%20 2016_53210b52-12da-4279-9f27-f7a361c84c96.pdf, accessed 11 August 2017). 6. Tsuladze, G. Demographic yearbook of Georgia, 2013. Tbilisi: United Nations Population Fund Georgia; 2014 (http://iliauni.edu.ge/ uploads/other/13/13240.pdf, accessed 11 August 2017). 7. Population by age and sex for the beginning of the year, 2014 [spreadsheet]. Tbilisi: National Statistics Office of Georgia; 2017 (http://geostat.ge/cms/site_images/_files/english/population/02%20 Population%20by%20age%20and%20sex%20for%20the%20 beginning%20of%20the%20year.xls, accessed 11 August 2017). 8. Migration: emigrants and immigrants by sex and age, 2016 [online database]. Tbilisi: National Statistics Office of Georgia; 2017 (http:// geostat.ge/index.php?action=page&p_id=173&lang=eng, accessed 11 August 2017). Profile of health and well-being 33 9. Preliminary results of 2014 general population census of Georgia, 2016. Tbilisi: National Statistics Office of Georgia; 2017 (http://geostat.ge/cms/site_images/_files/english/population/ According%20to%20preliminary%20results%20of%20the%20 2014%20population%20census%20Final.pdf, accessed 11 August 2017). 10. Real gross domestic product, purchasing power parity (USD) per capita. European Health for All database (HFA-DB) [online database]. Copenhagen: WHO Regional Office for Europe; 2016 (https://gateway.euro.who.int/en/visualizations/line-charts/hfa_34- real-gross-domestic-product-ppp-per-capita/?=country:GEO;WHO_ EURO;CIS, accessed 11 August 2017). 11. Total health expenditure as % of GDP, WHO estimates. European Health for All database (HFA-DB) [online database]. Copenhagen: WHO Regional Office for Europe; 2016 (https://gateway.euro. who.int/en/visualizations/line-charts/hfa_565-total-health- expenditure-as-of-gdp-who-estimates/?country=GEO;WHO_ EURO;CIS, accessed 11 August 2017). 12. Global Health Observatory (GHO) data. Healthy life expectancy (HALE) at birth [website]. Geneva: World Health Organization; 2017 (http://www.who.int/gho/mortality_burden_disease/life_tables/ hale/en/, accessed 11 August 2017). 13. Global Health Observatory (GHO) data repository. Healthy life expectancy (HALE). Data by country [website]. Geneva: World Health Organization; 2017 (http://apps.who.int/gho/data/view.main. HALEXv?lang=en, accessed 11 August 2017). 14. Global Health Observatory (GHO) data repository. Healthy life expectancy (HALE). Data by WHO region [website]. Geneva: World Health Organization; 2017 (http://apps.who.int/gho/data/view.main. HALEXREGv?lang=en, accessed 11 August 2017). 15. Strategic plan for the elimination of hepatitis C virus in Georgia, 2016–2020 Tbilisi: Ministry of Labour, Health and Social Affairs of Georgia; 2017 (http://www.moh.gov.ge/uploads/files/2017/akordeoni/ failebi/Georgia_HCV_Elimination_Strategy_2016-2020.pdf, accessed 11 August 2017). 16. Roadmap to implement the tuberculosis action plan for the WHO European Region 2016–2020. Towards ending tuberculosis and multidrug-resistant tuberculosis (2016). Copenhagen: WHO Regional Office for Europe; 2016 (http://www.euro.who. int/en/health-topics/communicable-diseases/tuberculosis/ publications/2016/roadmap-to-implement-the-tuberculosis-action- plan-for-the-who-european-region-20162020.-towards-ending- tuberculosis-and-multidrug-resistant-tuberculosis-2016, accessed 11 August 2017). Georgia34 17. WHO Tuberculosis country profiles: Georgia. Geneva: World Health Organization; 2017 (https://extranet.who.int/sree/ Reports?op=Replet&name=%2FWHO_HQ_Reports%2FG2%2FPR OD%2FEXT%2FTBCountryProfile&ISO2=GE&LAN=EN&outtype= html, accessed 11 August 2017). 18. Georgian national HIV/AIDS strategy for 2016–2018. Tbilisi: Ministry of Labour, Health and Social Affairs of Georgia; 2017 (http://www.georgia-ccm.ge/wp-content/uploads/HIV-NSP-2016- 20181.pdf, accessed 11 August 2017). 19. National Centre for Disease Control and Public Health, 2016. Tbilisi: National Centre for Disease Control and Public Heatlh of the Ministry of Labour, Health and Social Affairs of Georgia, 2017 (http://ncdc.ge/AttachedFiles/Brochure_2016_website_ f8d37697-27e6-42b9-a676-7cfe6d204dc8.pdf, accessed 11 August 2017) 20. Chanturidze T, Ugulava T, Durán A, Ensor T, Richardson E. Georgia: health system review. Health Systems in Transition 2009;11(8):1–116 (http://www.euro.who.int/en/about-us/partners/observatory/ publications/health-system-reviews-hits/full-list-of-country-hits/ georgia-hit-2009, accessed 11 August 2017). 21. Georgia reproductive age mortality study 2014. Executive summary. Tbilisi: National Centre for Disease Control and Public Heatlh of the Ministry of Labour, Health and Social Affairs of Georgia, 2017 (http://www.ncdc.ge/AttachedFiles/RAMOS%20 2014%20Ex%20Summary_ENG_a502747e-2c09-4f23-9e3f- 3fb6ea56d444.pdf, accessed 11 August 2017). 22. A new electronic system for the maternal and newborn health surveillance is being introduced in Georgia [website]. Tbilisi: UNICEF Georgia; 2015 (http://unicef.ge/44/osrulta_da_ akhalshobilta_ janmrtelobis_metvalkureobis_akhali_sistema/352/ lngeng, accessed 11 August 2017). 23. Analysing mortality levels and causes of death (ANACoD) electronic tool. Version 2.0. Geneva: World Health Organization; 2017 (http://www.who.int/healthinfo/anacod/en/, accessed 11 August 2017). 24. WHO Mortality Database [raw data files]. Geneva: World Health Organization; 2017 (http://www.who.int/healthinfo/statistics/ mortality_rawdata/en/, accessed 11 August 2017). 25. Noncommunicable Diseases (NCD) Country Profiles: Georgia, 2014. Geneva: World Health Organization; 2014 (http://www.who.int/ nmh/countries/geo_en.pdf, accessed 11 August 2017). 26. STEPwise approach to surveillance (STEPS). Geneva: World Health Organization; 2017 (http://www.who.int/chp/steps/en/, accessed 11 August 2017). Profile of health and well-being 35 27. Georgia STEPS Survey 2010: Fact Sheet. Geneva: World Health Organization; 2017 (http://www.who.int/chp/steps/Georgia_2010_ Fact_Sheet.pdf?ua=1, accessed 11 August 2017). 28. Georgia STEPS Survey 2016: Fact Sheet. Geneva: World Health Organization; 2017 (http://www.who.int/chp/steps/Georgia_2016_ STEPS_FS.pdf?ua=1, accessed 11 August 2017). 29. Global Health Observatory (GHO) data [online database]. Geneva: World Health Organization; 2015 (http://www.who.int/gho/en/ , accessed 11 August 2017). 30. European School Survey Project on Alcohol and Other Drugs: Georgia Country Report, 2016. Tbilisi: National Centre for Disease Control and Public Health of the Ministry of Labour, Health and Social Affairs of Georgia; 2016 (http://ncdc.ge/AttachedFiles/ ESPAD%202015%20Eng_ff90040a-5688-4d6d-8e66-87f2f4a5a41b. pdf, accessed 11 August 2017). 31. ჯანმრთელობის ხელშეწყობის ეროვნული სტრატეგია [National Health Promotion Strategy]. Tbilisi: Ministry of Labour, Health and Social Affairs of Georgia; 2014 (in Georgian). 32. Global Burden of Disease (GBD) results tool [website]. Seattle: Institute for Health Metrics and Evaluation; 2016 (http://ghdx. healthdata.org/gbd-results-tool, accessed 11 August 2017). 33. Human Development Reports. Human Development Index (HDI) [website]. New York: United Nations Development Programme; 2016 (http://hdr.undp.org/en/content/human-development-index-hdi, accessed 11 August 2017). 34. Global AgeWatch Index 2015. AgeWatch report card: Georgia [online database]. London: HelpAge International; 2016 (http://www. helpage.org/global-agewatch/population-ageing-data/country- ageing-data/?country=Georgia, accessed 11 August 2017). 35. Government of Georgia. 2015 წლის ჯანმრთელობის დაცვის სახელმწიფო პროგრამების დამტკიცების შესახებ [Universal health care programme 2015]. Tbilisi: Legislative Herald of Georgia; 2015 (https://matsne.gov.ge/ka/document/view/2891068, accessed 11 August 2017) (in Georgian). 36. Government of Georgia. On approval of the 2014–2020 state concept of health care system of Georgia for “universal health care and quality control for the protection of patients’ rights”. Tbilisi: Legislative Herald of Georgia; 2014 (https://matsne.gov.ge/en/ document/view/2657250, accessed 11 August 2017). Georgia36 Annex 1. ICD-10 codes for causes of death Cause of death ICD-10 codes Cancer of cervix uteri C53 Cancer of female breast C50 Cancer of trachea, bronchus and lung C33–C34 Cerebrovascular diseases I60–I69 Chronic liver disease and cirrhosis K70, K73, K74, K76 Diseases of the circulatory system I00–I99 Diseases of the digestive system K00–K93 Diseases of the respiratory system J00–J99 External causes of injury and poisoning V00–V99, W00–W99, X00–X99, Y00–Y99 Homicide and intentional injury X85–X99, Y00–Y09 Infectious and parasitic disease A00–A99, B00–B99 Ischaemic heart disease I20–I25 Malignant neoplasms C00–C97 Motor vehicle traffic accidents V02–V04, V09, V12–V14, V20–V79, V82, V87, V89 Suicide and self-inflicted injury X60–X84 Symptoms, signs and ill-defined conditions R00–R53, R55–R99 Tuberculosis A15–A19, B90 Table A1. ICD-10 codes for causes of death Profile of health and well-being 37 Annex 2. Selected mortality data Table A2 presents selected mortality data for total population by sex in Georgia compared to the WHO European Region and the Commonwealth of Independent States (CIS). The age-standardized death rate per 100 000 population and percentage changes from 2000 to the latest available year are outlined. Table A2 Selected mortality for total population by sex in Georgia, 2014 Cause of death Sex Georgia (2014) WHO European Region (2013) CIS (2014) Rate Percent change since 2000 Rate Percent change since 2000 Rate Percent change since 2000 All causes Both 984.4 +3.7% 738.2 −22.2% 1078.4 −22.0% M 1310.7 +6.0% 963.5 −23.3% 1477.0 −22.7% F 734.8 −2.7% 566.6 −21.3% 795.08 −21.1% Infectious and parasitic diseases M 23.5 +54.8% 17.1 −22.3% 29.8 −34.0% F 5.7 +19.1% 8.1 +6.2% 10.0 −5.8% Malignant neoplasms M 166.1 +34.3% 208.2 −14.6% 207.3 −16.2% F 92.5 +18.1% 118.0 −9.7% 111.2 −10.9% Diseases of the circulatory system M 500.0 −42.3% 418.9 −26.9% 789.0 −20.7% F 302.6 −46.4% 269.1 −28.6% 475.7 −24.4% Diseases of the respiratory system M 40.9 +19.0% 66.7 −29.2% 79.3 −39.2% F 17.9 −12.0% 30.8 −22.6% 28.0 −34.0% Diseases of the digestive system M 47.5 +3.9% 46.7 −5.8% 78.1 +18.5% F 15.3 −11.6% 25.7 −1.8% 40.6 +25.1% Symptoms, signs and ill-defined conditions M 363.8 +998.7% 39.3 −4.5% 60.3 −13.6% F 212.7 +1908.4% 25.3 −4.2% 39.0 −20.0% External causes of injury and poisoning M 75.9 +55.7% 83.5 −37.0% 161.6 −43.0% F 20.7 +90.9% 24.7 −33.0% 39.6 −39.6% Motor vehicle road traffic injuries M 22.0 +228.8% 13.3 −27.4% – – F 5.8 +248.5% 4.1 −27.2% – – Suicide and self-inflicted injury M 8.4 +64.3% 18.8 −34.7% 28.0 −48.5% F 1.6 +53.3% 4.4 −28.1% 5.3 −38.9% Homicide and intentional injury M 3.2 −45.4% 4.4 −60.1% 11.83 −61.9% F 1.2 +17.0% 1.4 −60.2% 3.37 −63.9%

The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Member States World Health Organization Regional Office for Europe UN City, Marmorvej 51 Copenhagen Ø, DK-2100, Denmark Tel.: +45 45 33 70 00; Fax: +45 45 33 70 01 Email: eucontact@who.int Website: www.euro.who.int

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Организация Всемирная организация здравоохранения (ВОЗ / WHO)

Тип документа Publications

Дата принятия 31 декабря 2017 г.

Источник Всемирная организация здравоохранения