Universal coverage without financial protection: why out-of-pocket payments persist despite universal coverage in Georgia

A mixed-methods study of Georgia’s universal health coverage system found that high out-of-pocket payments persist despite the tax-funded scheme introduced in 2013 and coverage of nearly 90% of the population. The abstract identifies a narrow benefit package, outdated reimbursement tariffs, balance billing, limited pharmaceutical coverage, weak regulation, excessive market liberalization and fragmented service delivery as contributing factors. The study was published in BMC Health Services Research as peer-reviewed research.

The study combined 35 in-depth interviews with policymakers, providers and other key stakeholders; an online survey with 94 complete and 18 partial responses; and secondary analysis of national health expenditure data and policy documents. Researchers conducted thematic analysis of the qualitative data using NVivo12 and triangulated findings across the data sources. Georgia was selected as a case in which broad population coverage coexists with high household out-of-pocket spending in the WHO European Region.

Stakeholders described provider responses to financial and competitive pressures that included demand inducement, patient-paid services and commission-based referrals, while survey respondents perceived several of these practices to be common. The findings indicate that out-of-pocket payments are associated with interactions among financing arrangements, provider incentives and regulatory oversight, rather than being attributable only to limited public financing. The authors report that expanding population coverage alone did not ensure financial protection.

The abstract proposes structural changes across health financing, governance and service delivery, including strengthening the purchasing role of the National Health Agency, updating tariffs, expanding the benefit package, regulating market entry and aligning provider incentives. These are the study authors’ policy implications, not evidence that the measures have already reduced out-of-pocket spending. The supplied evidence is limited to the abstract and article overview, so the detailed sample characteristics, survey measures, expenditure results and limitations of the full analysis cannot be independently described here.

Subject of Research: Mixed-methods analysis of persistent out-of-pocket health payments under Georgia’s universal coverage scheme

Article Title: Universal coverage without financial protection: why out-of-pocket payments persist despite universal coverage in Georgia

Article References: Tvaliashvili, M., Sulaberidze, L., Gotsadze, G., Goodman, C., & Hanson, K. (2026). Universal coverage without financial protection: why out-of-pocket payments persist despite universal coverage in Georgia. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15668-8

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15668-8

Keywords: Georgia, universal health coverage, out-of-pocket payments, financial protection, health financing, provider incentives, health regulation, benefit package, mixed methods, health services research, Universal, coverage