WHO advocates for UHC, which Georgia has implemented since 2013. With a broadened benefit package, 90% of the population was covered. However, this expansion did not improve financial protection as measured by the IHEs, particularly for the poor, a challenge also observed in other countries (30).

Several factors could be at play. Firstly, the expansion of UHC in Georgia primarily focused on increasing inpatient benefits compared to other services. The highest budget allocations were made for inpatient services, which grew fast over the past decade (31). During 2009-2023, overall public spending on health grew faster from 0.35 billion Gel to 1.1 billion (and increased more than 3 times), which was accompanied by a reduction in the share of out-of-pocket payments in the current health expenditure from 68.91% in 2009 to 40.45% in 2022 (31,32). Consequently, compared to a previous study from 2009 (33), the population in 2023 seems better protected against hospitalization expenses, as the odds of catastrophic payments and consequent impoverishment appear to have declined significantly. Most likely, this highlights a positive outcome of UHC implementation, which helped safeguard the patients from the impoverishing effects of inpatient care costs, while improving access to inpatient services for those in need (4). However, offering outpatient drug benefits has been postponed for some years since 2013 (34). The delayed inclusion of pharmaceutical coverage most likely harmed the levels of impoverishment, which were not reduced as expected.

As noted earlier, the reforms in pharmaceutical coverage took some years and only started in 2017, albeit with poorly defined benefits, small budgetary allocation, and weak implementation arrangements that led to low program uptake by beneficiaries (35). Impactful reforms in pharmaceutical benefits only picked up in 2020 when the package began covering treatments for four non-communicable conditions (NCD), expanded covered population groups, and streamlined implementation arrangements (36). This led to a greater uptake of NCD medicines, which are undoubtedly beneficial in reducing outpatient drug costs for the population.

Nonetheless, state-funded pharmaceuticals are still a small share (about 17% in 2023), of total pharmaceutical expenditures, with the population bearing 83% of these costs. Conversely, the state budget is the predominant funding source for inpatient services—81% in 2023, and the population only pays 19% (19,37). Although Georgia is a middle-income country, the expectation that the government’s fiscal capacity will allow a significant shift in this public-private balance for pharmaceutical payments in the near future is less likely without a major change in the government’s overall budgetary priorities.

The significant reduction in the odds of impoverishment observed during 2009-2013, followed by no progress after that, suggests that early government interventions—likely through targeted, mostly emergency outpatient and planned and emergency inpatient benefits for the poorest and pensioners — had a higher protective financial effect. Particularly when the initial barriers to coverage were removed by 2012, and most of the intended beneficiaries were able to benefit (38). However, the pace of reduction in odds was not sustained by later reforms after the implementation of the UHCP. The government shifted towards universal coverage by extending outpatient and inpatient benefits to include other, relatively better-off population groups, who may have experienced less impoverishment as a result of the expenditures on these services, without expanding coverage for another major determinant of IHE -outpatient drug expenditures - for the poor and better-off alike. Additionally, this transition from the targeted to the universal approach in a context of limited funding may have disproportionately benefited the better-off at the expense of more poor or vulnerable, who received less targeted support.

Although there is considerable controversy in published literature around universal arrangements versus targeting public subsidies to poor or vulnerable groups, we argue that going forward in Georgia and improving coverage for targeted population groups with greater needs, including people with chronic conditions from low-income households, could help reduce impoverishment resulting from health spending. While solid arguments exist in favor of a well-funded, publicly led, and universal approach to coverage (39,40), Georgia’s case reveals that UHCP has delivered on its objectives for inpatient services but not for pharmaceuticals because the universal approach has failed to provide adequate financial protection for the lowest income groups. Given current resource limitations, “progressive universalism,” coined by Gwatkin and Ergo, (41) looks more appropriate for Georgia’s context. It seems necessary to target the expansion of the state-funded pharmaceutical benefits to those who face the highest financial risk (i.e., the poorest 20% of the population) who may not have the greatest need compared to the pensioners, but even a small amount of payment for prescribed medicines could have an impoverishing effect and push almost half of these households into poverty or further impoverish them. Therefore, our findings suggest that the government should focus on and significantly expand pharmaceutical subsidies for the poorest as the initial step before considering other population groups for expansion. This suggestion builds more on recommended solutions to target resources to the poorest (42,43), noting limitations that there is little evidence that targeting is cost-effective relative to broader approaches to service provision (44,45). However, as mentioned earlier, Georgia has an administrative mechanism to identify the poor and deliver state assistance, and implementing this suggestion seems rather feasible in a given context.

In conclusion, achieving the Sustainable Development Goals of Universal Health Coverage requires more granular analysis and adaptation to each country’s context based on this evidence. Simply increasing coverage is insufficient to meet UHC goals without closely examining the local circumstances, determining which benefits should be prioritized, and identifying the population groups that would benefit most. No country has the resources to meet all health needs, so trade-offs are inevitable (46). Future healthcare reforms in Georgia and elsewhere should focus on expanding coverage and improving equity, with an emphasis on identifying the benefits that could provide the greater financial protection for the poor and other vulnerable groups. This approach could help ensure equity while progressing toward UHC goals.