Efecto de la ausencia del dominio amino terminal de IF3 (IF3-NTD)

The collapse of the USSR meant extensive healthcare reforms involving the reorganization of financing and delivery of care and treatment in many former Soviets (Chen & Mastilica, 1998; DeBell & Carter, 2005; Fister & McKee, 2005; Walley, Mossialos, Mrazek, & de Joncheere, 2005). At independence, Georgia inherited an extensive and highly centralized Semashko health system (Chanturidze, Ugulava, Duran, Ensor, & Richardson, 2009), featuring under-resourced and overburdened health care facilities lacking in basic supplies and staffed by demoralized personnel who were poorly remunerated (or simply unpaid) (Koch, 2013). The extensive infrastructure was impossible to retain upon independence, leading to a drastic decrease in the number of hospital beds (from 10 per 1,000 population in 1992 to 3.3 per 1,000 population in 2007), though the number of doctors per capita (454.6 per 100,000 in 2007) has remained very high compared to both the Commonwealth of Independent States4 _{(CIS) average}

(approximately 380 per 100,000 in 2007) and the European Union (EU) average (approximately 320 per 100,000 in 2007) (WHO, 2009). However, retaining physicians in rural locations in Georgia has been an issue, with more than 3 times as many doctors in the capital city of Tbilisi than in other regions (Chanturidze et al., 2009).

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Due to the chaotic nature of Georgia’s transition period (described later in this Chapter), it was effectively left without an official health care system from the early 1990s until 1995 (Gotsadze, Zoidze, & Vasadze, 2005). Rates of infectious diseases quickly increased. For instance, Georgia was second only to Russia in the increase of tuberculosis from the mid- to late 1990s (Lomtadze et al., 2009). There was an increase of 13.4% in the mortality rate between 1989 to 1995 (Collins, 2006). Such public health crises were met with continual under-funding; the proportion of GDP spent on healthcare in Georgia dropped from 3.5% in 1991 to just 0.4% in 2000 (Glinkina & Rosenberg, 2003). In 2005, this had risen to 8.6% of GDP, not far below the EU average of 8.9% and substantially higher than the CIS average of 5.5% for the same year (WHO, 2009). In 2011, the percentage increased to 10.1% (Ministry of Labour, 2011b).

In 1995, a Health Care Reform Package was introduced in Georgia which introduced new concepts into the health care system such as health insurance and user fees (Koch, 2013; Rukhadze, 2013). This package was part of an overall ‘rationalisation’ process which radically privatised the health system (Koch, 2013), which offered unaffordable and low- quality care (Machavariani, 2007). It is estimated that about 80% of hospitals in Georgia were sold to the private sector during health reforms from 2007 to 2009 (Rukhadze, 2013). Out-of-pocket payments to access to medical care acts as a deterrent to seeking medical treatment and accessing pharmaceuticals (Karavasilis, 2011; Skarbinski et al., 2002), though insurance is covered for household living below the poverty line (Chanturidze et al., 2009; Rukhadze, 2013). Out-of-pocket payments are now the main source of funding for the health system in Georgia (Rukhadze, 2013). The polyclinics under the Semashko system have been gradually replaced by family medicine centres, though this process has been uneven across Georgia which has led to dual systems in operation in some areas (Rukhadze, 2013).

Georgian independence and the reorganization of the centralized heath care system has had a profound impact on health status of Georgians (Koch, 2013), though they have a longer life expectancy than the majority of other former Soviet Republics (Hinote et al., 2009). For female Georgians, life expectancy at birth was 74.8 years in 2002, which has

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remained relatively consistent since 1989. Male life expectancy at birth was 68.0 years in 2002, which was slightly less consistent than the female trajectory (for instance, a notable decrease was observed in 1993, when it lowered to 64.4 years) (UNICEF, 2004). More recent statistics show a much improved life expectancy at birth; 71 and 78 years for men and women respectively (WHO, 2015c), with heart disease and stroke the most common causes of death (WHO, 2015a).

Though psychiatric services in the former Soviet Union were characterized by high rates of institutionalization (Makhashvili & van Voren, 2013), resource shortages led to a chronic paucity of psychiatric hospital beds since the early 1990s. As of 2007, Georgia had one of the lowest numbers of psychiatric beds in the European region (28 beds per 100,000 population) (WHO, 2009). Outside of the hospital system, primary care services across post-Soviet countries are generally not oriented toward managing mental health problems (Jenkins, Klein, & Parker, 2005). In Georgia, primary care provides insufficient mental health services to general and war-affected populations alike (Makhashvili, Tsiskarishvili, & Drozdek, 2010). As of 2013, in addition to psychiatric hospitals, there were 18 outpatient psychiatric clinics in Georgia (Makhashvili & van Voren, 2013). However, the mental health services available in rural locations are less accessible and of poorer quality than those available in urban areas, with almost half of licensed psychiatrists working in Tbilisi (Makhashvili & van Voren, 2013).

A number of specialist mental health groups provide psychosocial support to Georgian IDPs, including the Georgian Society of Psychotrauma (Georgian Society of Psychotrauma, 2008) and the Georgian Association of Mental Health (Georgian Association of Mental Health, 2009). In addition, NGOs such as the GIP-T (The Global Initiative on Psychiatry) serve IPD settlements. Such NGOs have been instrumental in reforming mental health services in Georgia, creating momentum towards humane care (Makhashvili & van Voren, 2013).

Whether the prevalence of psychiatric morbidities such as problematic alcohol use increased, decreased, or remained consistent in the former Soviet Union is a matter of debate and may depend on the specific former state in question. Various authors (Bridger, 1997; Crate, 2004; Dudwick, 2003) have observed an increase in men’s consumption of

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alcohol in Russia since the demise of the USSR, though it is acknowledged that this was a problem in the Soviet era as well. Though Georgia-specific information is difficult to access, a notable increase in alcoholism in rural Russia occurred in the 1950s after state- operated farms were consolidated into even larger farms, as part of the collectivisation process which occurred from 1927 onwards. Other increases occurred during an economic downturn in the 1980s, and into the 1990s as the Soviet Union disintegrated (Crate, 2004). Bridger (1997), who interviewed rural health care workers and residents in rural Russia in 1993, described the struggles faced by women whose male partners had turned to heavy alcohol use. These women often perceived that they had little choice but to work hard to support their families, while their male counterparts took to heavy drinking in the wake of the USSR collapse. One female interviewee stated, “The women take absolutely everything on themselves. The man are alcoholics, they won’t do anything” (Bridger, 1997, p. 51). Crate (2004) concurs, arguing that the rise in alcoholism among men rendered them an unreliable and irresponsible workforce, perpetuating and compounding problems in obtaining a job in an economic environment which provided scarce employment opportunities. Crate (2004) also contends that male alcoholism has led to an increase in households headed by single women, reasoning that women would rather shoulder the burden of raising a family alone than live with an alcoholic who strained the family finances.