Breaking the Cycle: Addressing the Drivers of Impoverishing Healthcare Costs in Georgia

BackgroundFinancial protection is a core goal of universal health coverage, ensuring access to necessary healthcare without financial hardship. It is assessed through indicators like catastrophic and impoverishing out-of-pocket (OOP) health spending. Despite Georgias Universal Health Coverage Program (UHCP) introduced in 2013, covering nearly 90% of the population, the incidence of catastrophic and impoverishing health spending remains high and stagnant compared to other European countries. ObjectiveThis study investigates factors associated with impoverishing health expenditures among Georgian households to inform policy decisions and prevent healthcare-related poverty. MethodsData from the Household Income and Expenditure Surveys (HIES) conducted by GeoStat from 2009 to 2023 (N = 198,292 households) were analyzed using survey-weighted logistic regression to account for the complex survey design. Impoverishing health expenditure, based on the relative poverty line suggested by the WHO Regional Office for Europe, was the outcome variable, with explanatory variables guided by Andersens behavioral model for healthcare utilization. ResultsOOP expenditure on drugs emerged as the most significant determinant of impoverishment (OR 43.3, 95% CI 39.3-47.7, P < 0.001). The poorest quintile faced the highest risk (OR 44.5, 95% CI 22.1-89.7, P < 0.001) compared to the richest quintile, with slightly lower odds for the second quintile. Impoverishment probabilities decreased before UHCPs introduction (2009-2013) and slightly increased afterward, averaging 0.34 for 2014-2023 compared to 0.28 in 2013. DiscussionThe decline in impoverishment odds during 2009-2013 highlights the greater financial protection provided by benefits focused on the poor before UHCPs expansion. Addressing impoverishing expenditures, particularly for outpatient drugs benefiting the poorest, requires increased public investment, broader coverage, and gradually extending benefits to other vulnerable groups. Incorporating lessons from the WHO Regional Office for Europes recommendations could further strengthen Georgias financial protection policies. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSAfter the introduction of UHCP in Georgia and many lower-middle-income countries, the progress towards better financial protection has been limited, undermining the success in service coverage index on the path to universal health coverage. What this study addsThis study examines the factors dragging financial protection behind by exploring the drivers of healthcare costs, particularly types of health spending leading to health disparities. How this study might affect research, practice or policyThis study provides policymakers with insights into drivers of impoverishing health expenditure, particularly how to curb OOPs on pharmaceuticals, especially for poor and reduce financial burden leading to impoverishment. The study suggests policy options for reducing impoverishing effects of spending on medicines and advocates for "progressive universalism".