The Atlanta-Tbilisi Health Partnership is part of a larger effort by Emory University and School of Medicine, Grady Hospital, and Morehouse School of Medicine to improve health care in Georgia in the former Soviet Union. A team from the R ollins School of Public Health, including David DeLozier, has provided technical assistance to the Georgian Ministry of Health in health care financing and the legal aspects of reform. In Tbilisi, DeLozier completed a survey of health status indicators, which took him to medical records storage in City Hospital No. 2. "Tbilisi has been a gold mine for research for students. It is a great laboratory for health care reform." - David DeLozier

ast December, MPH student David DeLozier found himself seated in the grand offices of the Minister of Health of Georgia in the former Soviet Union. He was there as part of a team from the World Bank to advise the minister about health care reform in the country. "It was pretty intimidating," DeLozier says. The meeting took place by candlelight because there was no electricity, a common occurrence in Georgia during the winter. Many of the buildings in Tbilisi, Georgia's capital and Atlanta's sister city, lack heat in the winter. Interruptions to services, such as running water and electricity, are also frequent. These problems are among many which the Ministry of Health must overcome in revamping the country's health care system. Its hospitals have outdated equipment, crucially low supplies of medicines, and soaring rates of nosocomial infections. DeLozier's specific involvement in Georgia was to conduct a survey of health status indicators there. He was collaborating with faculty members Deborah McFarland, Jim Setzer, Richard Saltman, and Rose Nathan, wh o are providing technical assistance in health care financing and the legal aspects of health care reform to the Ministry of Health. "The faculty here have been great in organizing projects for students and getting them involved in real-world activities," according to DeLozier. DeLozier's December mission was sponsored jointly by the World Bank and the Atlanta-Tbilisi Health Partnership. A $20 million Georgia Health Project, financed by the World Bank, will allow Georgia to implement major components of its health care reform s. The project's components include health care financing, maternal and child health, rehabilitation of existing facilities, and promotion of health and wellness. The Atlanta-Tbilisi Health Partnership is a government-funded program designed to foster men toring relationships between American health sciences centers and those in the former Soviet Union. DeLozier's role and that of the school of public health in the Atlanta-Tbilisi Health Partnership is part of a larger effort by Emory University, Grady Hospital, and Morehouse School of Medicine to improve health care in Georgia. Managed under the ausp ices of the US Agency for International Development (AID), the partnership assists the Georgian Ministry of Health in defining national health care issues, improving education at the state medical school in Tbilisi, and helping establish City Hospital No. 2 as a model facility. Dr. Kenneth Walker, a professor in the medical school, oversees Emory's role, which includes participation by doctors, nurses, engineers, professors, and development officers from throughout the university. Since December, DeLozier has returned three times to Georgia to continue supporting health care reform in the country. In fact, he came directly from a conference there to his graduation ceremonies in May at the Rollins School of Public Health. "It has been exciting to study health care reform in class and to take the theories to Georgia and see them happening," DeLozier says. "Tbilisi has been a gold mine for research for students. It is a great laboratory for health care reform."

In off-hours, the researchers from the Rollins School of Public Health enjoyed the magnificent architecture and rich culture of the country, including Jvari, the oldest cathedral in Tbilisi.

hen Georgia gained independence from the former Soviet Union in 1991, its leader, Eduard Shevardnadze, made health care reform a priority. By December of 1994, he had helped draft Decree 400, which created a basic package of health care services for the population. The social insurance fund, financed from tax revenues, is set up similarly to a bank account, allowing people who need medical care to draw on it. However, already the fund has fallen into debt, a ccording to DeLozier. "The Georgians are not monitoring claims," he says. "The health fund may be a good idea, but they need basic accounting training to be able to manage it." In May, DeLozier assisted McFarland in presenting this finding and others at a conference held in Tbilisi that was attended by representatives from the Ministry of Health, US AID, and the World Bank. The report summarized the first phase of reform, inc luding conceptual thinking about the structuring of health care financing, quality assurance systems, and legal frameworks. Specifically, it focused on the number of Georgians who use the health fund and how they use it as well as the health status indica tors of the country. These indicators include infant and maternal mortality rates, death rates by categories, the number of physicians per hospital, hospital occupancy rates, and the number of available hospital beds. DeLozier collected the health status indicators in a survey of ten hospitals. He also interviewed high-level officials in the Ministry of Health and the Georgia Parliament. For the past three years, the Georgians have collected no health status indicators, according to DeLozier. By contrast, when Georgia was still a part of the Soviet Union, "a huge team collected information," DeLozier says, "but they never looked at it." Based on the report DeLozier helped prepare, the Georgians can make better decisions about where to downsize their facilities and how many physician positions to eliminate. "When we present our findings, we don't tell them what to do or not to do," DeL ozier says. "That's the Minister's decision. Instead, we put the issues on the table and work together to come up with a solution." With the research gathered and the feedback from representatives at the May conference, the public health team will draft an immediate needs list. Their next assignment is to create a long-term plan to allow a steady flow of technical assistance from t he school to the Georgians, including training and monitoring of reform.

When traveling from Tbilisi to more rural areas of Georgia, David DeLozier and other researchers found few Western-style restaurants. Rather they often ate in homes, where Georgian women offered meals for sale. Crucially low supplies of medicine, such as those in this pharmaceutical cabinet in City Hospital No. 2, plague medical facilities thoughout Tbilisi.

he challenges faced by the Georgian health care system are enormous. No partnership can remedy some of the fundamental problems that must be overcome unless reform is allowed to take root and grow. McFarland , who chairs the department of health policy and management, however, makes a positive prognosis for reform. "Of all the countries in the former Soviet Union, Georgia has tremendous resources in terms of human capital," she says. "And they have a very creative, courageous, and forward-thinking Minister of Health." "They realize that they can't do everything for everybody because their resources are scarce. But they are facing the issue of resource allocation, which bodes well for the future." In small and meaningful ways, individuals like DeLozier can help. This year, for example, he helped instigate the donation of laboratory equipment from AVL-Scientific, an American company, to City Hospital No. 2 in March. During his schooling, DeLozier worked in Emory's Pulmonary Function Laboratory to help finance his education. When representatives from AVL-Scientific came to work on blood gas analyzers in the laboratory, DeLozier approached them with the suggestion that they donate similar equipment to the effort in Georgia. Company representatives followed through, attending a conference at Emory in December 1995, where they met delegates from Georgia's Ministries of Health and Finance. As a result, they donated two analyzers, worth some $20,000, as well as personnel to i nstall the equipment and train the Georgians on how to use and maintain the machines. In addition, the Pulmonary Function Laboratory has agreed to donate four of its analyzers to City Hospital No. 2. Through his work in Tbilisi, DeLozier has been in "a position most students his age don't reach," McFarland says. "He's had the opportunity to work with senior faculty as well as directly with the Minister of Health and other senior ministers in Georgi a to direct and set policy." Having completed his MPH degree, DeLozier wants to devote himself full-time to efforts in Georgia before returning to school to pursue doctoral studies in international health, epidemiology, and health policy and management. Currently, he is working wi th the Georgian Ministry of Health and the school's department of international health to bring training in micronutrient malnutrition to Georgia. "My end goal is to go into a country or community and to assess the health care needs, then to go a step further to make policy," DeLozier says. "In a way, it's what I'm doing now. It's been a dream for me."