Discover the groundbreaking insights from “Financial protection and universal health coverage in Georgia: an analysis of impoverishing healthcare costs using household income and expenditure surveys,” a pivotal study published in BMJ Global Health. Auth Authored by Tsotne Gorgodze, Akaki Zoidze, Jolly Mae Catalan, and George Gotsadze, this research delves into a crucial, yet often overlooked, aspect of universal health coverage (UHC): financial protection against debilitating healthcare costs.
Despite Georgia’s Universal Health Coverage Programme (UHCP) – launched in 2013 and covering nearly 90% of the population – the incidence of impoverishing and catastrophic health spending remains notably high, surpassing levels in other European countries and showing little improvement over the past decade. This study, therefore, emerges as an essential resource for policymakers seeking to strengthen Georgia’s health system and inform financing decisions.
Key Objectives and Methodological Rigor: This comprehensive analysis set out to identify the specific factors driving impoverishing health expenditures (IHEs) among Georgian households. Unlike catastrophic health expenditure, IHEs offer a context-specific understanding of financial hardship, directly reflecting how healthcare spending can push households below a national relative poverty line or deepen existing poverty.
Utilizing an extensive dataset from the Georgian Household Income and Expenditure Surveys (HIES) spanning 2009 to 2023, encompassing 198,292 households, the researchers employed a survey-weighted logistic regression model. The study was rigorously guided by Andersen’s behavioural model of healthcare utilisation, providing a robust framework to examine how socioeconomic factors influence IHEs.
Transformative Findings and Policy Implications: The research uncovers several critical determinants of financial hardship:
- Out-of-Pocket Spending on Drugs: The Primary Impoverisher. The most striking finding is that out-of-pocket (OOP) spending on drugs emerged as the strongest determinant of impoverishment, with an astounding adjusted odds ratio (OR) of 43.3 (95% CI 39.3 to 47.7, p<0.001). This highlights pharmaceutical costs as a primary driver of healthcare-related impoverishment.
- Disproportionate Burden on the Poorest Quintile. The study revealed a profound disparity, with the poorest quintile facing 3845 times higher odds of impoverishment due to health expenses compared to the wealthiest 20%. For these households, drug expenditures were particularly devastating (OR 44.5, 95% CI 22.1 to 89.7, p<0.001).
- Pre-UHCP Targeted Benefits Offered Greater Protection. Interestingly, the odds of impoverishment declined significantly from 2009 to 2013, a period when benefits were specifically targeted to the poor, reaching their lowest in 2013 (OR 0.28). Post-2013, with the broader, less targeted UHCP, this progress was not sustained, suggesting that earlier interventions may have offered stronger financial protection.
- Other Vulnerabilities. Households with at least one member with a disability (OR 1.59) or a chronic illness (OR 1.50) also faced significantly elevated odds of impoverishment.
A Call for Progressive Universalism: The authors conclude that simply increasing public spending and coverage without a granular analysis of local circumstances and specific population needs may not be sufficient to achieve UHC goals. The findings strongly advocate for enhanced coverage for outpatient drug costs, particularly for the poorest 20% of households, through increased public investment and a strategy of “progressive universalism”. Given Georgia’s existing administrative mechanisms for identifying and assisting low-income families, this targeted approach is deemed feasible and could provide substantial financial relief with relatively less public investment.
This study offers actionable insights for policymakers not only in Georgia but also in other upper-middle-income countries facing similar health financing challenges in Eastern Europe, the South Caucasus, and Central Asia.
Reference: Gorgodze, T., Zoidze, A., Catalan, J. M., & Gotsadze, G. (2025). Financial protection and universal health coverage in Georgia: An analysis of impoverishing healthcare costs using household income and expenditure surveys. BMJ Global Health, 10(e019150). https://doi.org/10.1136/bmjgh-2025-019150