Every year, hundreds of patients travel from Abkhazia and South Ossetia to Tbilisi to take advantage of free medical treatment provided by the Georgian government. However, a cut to coverage of diagnostics, a lack of clear information, and opposition from Tskhinvali are putting the success of the programme at risk.

‘When I first arrived, I didn’t know what to expect from Georgians,’ says Gunda (not her real name). ‘I thought people would be aggressive towards us, but I was amazed to find out it was quite the contrary.’ 

Gunda has been bringing her young son from Abkhazia to Tbilisi for cancer treatments for several years. When OC Media caught up with her, she was staying at a housing facility rented by the Abkhaz Foundation, a group providing assistance to patients from Abkhazia seeking to access healthcare services in Georgia.

Gunda does not have to pay anything for her son’s treatment since all the costs are covered by the Georgian Referral Programme. ‘A huge relief’, she tells OC Media.

According to data provided by the Georgian Health Ministry, since the Referral Programme was launched in 2010, over 5,000 Abkhazian and 3,000 South Ossetian patients have benefited from free healthcare services. The government has spent over ₾29 million ($9.6 million) to date.

The programme is often hailed as a model confidence-building measure between Georgians and ethnic Abkhaz and Ossetians.

However, cuts to the coverage of diagnostic tests as well as a lack of readily available information for prospective patients threaten to change this. A lack of enthusiasm from officials in Abkhazia and South Ossetia — particularly the latter — have also compounded the problems.

Many of those involved in assisting patients have now warned that the success of the entire programme may be at risk.

An unexpected cost

In 2017, the Georgian Government ceased funding the cost of diagnostic tests under the Referral Programme, with exceptions for cancer patients and some other cases.

‘I did not support these amendments,’ says Eliko Bendeliani, from the Institute for the Study of Nationalism and Conflicts. 

‘A lot of the time, patients arrive with an incorrect diagnosis. Also, they sometimes only need a diagnosis and a minor medical intervention,’ Bendeliani tells OC Media.

According to her, patients usually arrive under the assumption that everything will be provided for free, and when they find out that they have to pay for tests, they have no means of doing so up-front.

‘Usually, patients come with a diagnosis given by local [Abkhazian or South Ossetian] doctors, but Georgian clinics don’t trust them and refer them to have their diagnostic tests redone,’ says Bendeliani. 

‘Sometimes it’s necessary to conduct additional expensive procedures, such as a CAT scan. They can only enrol in the Referral Programme after having undergone these tests.’ 

Bendeliani cites one typical case in which the cost of diagnosis was ₾500 ($160) after which the Ministry funded an operation costing ₾11,000 ($3,600). 

‘Five-hundred lari is almost nothing compared to ₾11,000’, she concludes, arguing that saving money from the comparatively low cost of diagnostic tests is not worth ‘damaging the programme like this’.

Several health officials told OC Media that funding for diagnostics was scrapped because the programme was being abused by clinics.

‘It was private clinics that became the problem,’ says Tamaz Bestayev, head of Health and Social Care at the South Ossetian Administration, a Georgian state body. ‘Doctors knew that a patient did not need a CAT scan but still referred them because they knew everything would be funded by the state… patients were referred for MRI scans too.’ 

‘In a field like medicine, a doctor can always claim that a particular test is needed,’ Bestayev tells OC Media.

Bestayev says the Health Ministry likely made the right decision to stop funding diagnostic tests because they were not able to control the spending. However, he insists it is still a good deal for patients. ‘A patient must manage to allocate ₾200–₾300 ($65–$98) [of their own funds] for diagnosis.’

‘They then get 100% of their inpatient treatment covered, unlike Georgian citizens.’ 

‘In contrast, the state programme doesn’t cover diagnosis for our internally displaced persons (IDPs). It’s a strange situation that we provide this coverage for residents of the occupied territories but not for our IDPs’, he says.

Ketevan Bakaradze, the Health Minister at the Government of the Abkhazian Autonomous Republic (AAR), a Georgian state body dealing with Abkhazian affairs, also defended the cut. 

Bakaradze tells OC Media that by saving money on diagnoses, they can now cover medical costs for residents of Abkhazia’s eastern Gali (Gal) District as well.

Gali is predominantly populated by ethnic-Georgians. As most of them hold Georgian passports, they are already covered by Georgia’s Universal Healthcare Programme, but this only covers a certain percentage of healthcare costs. 

The AAR Government also runs a separate healthcare budget from the referral programme, which Bakaradze says they have used to pay for diagnostic tests for patients coming from Abkhazia.

She says that the AAR Government has much more control over how these funds are spent than those from the Referral Programme, which has prevented the system from being abused.

‘We procure these medical services through open tenders and [therefore] we don’t have to deal with the [financial] interests of clinics’, she explains. 

‘This [system] is much more transparent and cost-effective. Most importantly, we now meet directly with our beneficiaries and get to know them.’

Others say, however, that the Government of the Abkhazian Autonomous Republic is selective in who they cover the diagnostic costs for. 

‘Out of those who have come to us, [since the coverage of diagnosis was stopped] I have never had a case where the patient’s diagnostics costs were covered’, says Alu Gamakharia, the director of Peaceful and Business Caucasus, a peacebuilding organisation. 

Gamakharia has been aiding Abkhaz patients for eight years, seeking funds for those who either cannot afford to pay for their diagnostic tests or whose medical costs exceed the ₾15,000 ($4,900) limit of the Referral Programme. 

‘From what I observed, 90% of those who come here for treatment can’t afford to pay to get diagnosed,’ he adds.

Additionally, the ₾15,000 limit is sometimes not enough. 

‘One of the patients I know was charged ₾28,000 ($9,200); the Referral Programme gave them only ₾13,000 ($4,300),’ Gamakharia tells OC Media. ‘Some of the clinics say that they will not administer treatment until they have a guarantee that they will be paid.’ 

‘This programme is a very good venture for peacebuilding, it shouldn’t be spoiled like this’, he concludes.

A poorly-advertised service

Patients are often aided by NGOs in submitting their applications, as detailed information about the Referral Programme or other relevant programmes is not readily available on the websites of Georgian state bodies.

Irma Osia is an ethnic Abkhaz journalist living in Tbilisi who also works on translations into Abkhaz for the website of the Government of the Abkhazian Autonomous Republic. 

Quite often, she is asked by Abkhaz patients for guidance on how to access healthcare in Georgia. Even she was previously unaware that diagnostic tests were covered by the budget of the AAR Government.

‘Abkhaz people know very little about this programme. The AAR Government’s website has been viewed by 3,000 people, which means there’s a high interest from Abkhaz people and that this information should be on the website’, Osia tells OC Media. 

‘Those who come here for treatment struggle a lot. They have no money, they have nothing. Some people can take care of themselves, but such patients are rare.’ 

The website of the AAR Government lists only healthcare programmes intended for IDPs. It does not state that similar services are also available for the Abkhaz.

‘You cannot find such information [on our website]. It is there, but you won’t be able to find it. We don’t promote it’, says AAR Health Minister Ketevan Bakaradze. She admits that this is because of concerns of a backlash if it were widely publicised that Abkhaz and South Ossetian patients can receive free healthcare in Georgia. 

‘This might aggravate our IDP population’, she says. The Ministry does, however, promote the programme through clinics in Gali, in eastern Abkhazia. 

Tamaz Bestayev, who heads the Health and Social Care Service at the South Ossetian Administration, insists that residents of South Ossetia are quite well informed about the programme. 

‘They get information from each other. Nobody uses the internet [to search for this information], they call [Dmitry] Sanakoyev [Head of the South Ossetian Administration in Georgia]. Tskhinvali is small and everybody knows each other, they learn about it from each other. Some of them have relatives here’, says Bestayev.

However, he recalls one South Ossetian mother whose son was diagnosed with Leishmaniasis, a rare illness in Georgia. He says she subsequently took him for treatment in Vladikavkaz, in the Russian Republic of North Ossetia, not realising she could have accessed free treatment in Georgia.

‘It happened in 2017. First, she took the child to Tbilisi for diagnosis but then took him to Vladikavkaz, because she thought all treatment procedures [in Georgia] required payment. She started calling us from there because her child had a high fever. We rushed an ambulance to the Lars checkpoint [on the Russian-Georgian border]’, says Bestayev. 

He adds that the child almost died because doctors in Vladikavkaz were giving them the wrong medicine for Leishmaniasis.

‘Not everyone is informed’, says Alu Gamakharia, director of Peaceful and Business Caucasus. ‘They are told to go to Georgia and they will be taken care of. They come with only money for food in their pockets and find that they have to pay [for diagnostic tests]. They get disappointed. Unfortunately, the system doesn’t work well. On the flip side, we feel so satisfied — We brag that we have such a great programme.’

A difficult journey 

The authorities in Abkhazia generally permit people to travel to Georgian-controlled territories for medical treatment. The same cannot be said for the South Ossetian government.

The authorities in Tskhinvali (Tskhinval) have long expressed concerns about the large number of local residents travelling to Tbilisi for treatment. In 2013, they restricted such travel for all but emergency cases, in which case patients are transported to Georgian-controlled territory by the Red Cross. 

In other situations, a South Ossetian patient seeking treatment in a Georgian hospital must take a roundabout route all the way through Vladikavkaz in Russia and then into Georgia — a 360-kilometre journey from Tskhinvali to Tbilisi. What would be a two-hour journey takes around six-and-a-half hours.

‘They can’t cross directly unless they get approval from the local authorities,’ says Tamaz Bestayev. ‘There have been cases where they weren’t allowed to. One woman was calling me, saying she had uterine bleeding. She was admitted to a Tskhinvali clinic but she felt she had to get out of there because they were telling her no surgical intervention was needed, that they were going to treat it with medication.’

He adds that she wasn’t given permission to cross the border into Georgian-controlled territory so she fled the hospital and went to Vladikavkaz.

‘I don’t know how she managed it. She came to Tbilisi by taxi. She was calling me, asking where she should go. I sent her to a clinic where she was immediately taken to the operating theatre. She was anaemic, her face was white.’

Despite the relatively easier process for patients from Abkhazia, the journey is not always simple.

‘There are many problems at the border,’ says Lali (not her real name), a patient from Gali who has come to Tbilisi for treatment. ‘They close it during the night, they make calls [before they allow people through], it takes time and so on. Many cases ended with [the patient] dying,’ Lali tells OC Media.

‘I don’t know if I should say this, I’m afraid,’ Lali says, before her 15-year-old daughter intervenes. ‘Say it all,’ her daughter says, nudging her. 

‘There is a hospital in Gali [in which] there really aren’t [proper] conditions. I was suffering from fatigue. Neighbours encouraged me to go there, to at least have my blood pressure taken. I went there and asked them to put me on a drip because I was feeling so weak and fatigued. They couldn’t even do that. You should only go there if you’re dying. And still, they call it a hospital.’ 

‘Nothing else matters; family comes first’

All of the patients with whom OC Media spoke to for this story said that the cost of their treatment had been fully covered — All of them also spoke highly of the programme.

‘This programme contributes to the process of Georgians, Abkhaz and Ossetians getting to know each other,’ says Eliko Bendeliani, from the Institute for the Study of Nationalism and Conflicts. 

As much as she speaks positively of the programme, she believes that cutting off coverage for diagnosis was the wrong move. 

She also criticises the Referral Programme for a lack of proper systematisation.

‘The system should work for the individuals; patients find it hard to find people who will guide them through the procedures. They don’t know where to go, where to stay.’

‘Often they are afraid. They think that Georgians will be hostile towards them but then find that people here are very welcoming, that they are trying to help them,’ she says.

Bendeliani argues that the Georgian government should do everything in their power not to disappoint Abkhaz and South Ossetian patients who make the trip.

Eduard, a 65-year-old patient from Sukhumi (Sukhum), is not disappointed with the results of his trip. 

Eduard has come to Tbilisi for radiotherapy accompanied by his relative, Vakhtang. They are both spending the night at a temporary housing facility for patients and their companions, administered by the Government of Abkhazian Autonomous Republic.

While Eduard does not speak much, Vakhtang, who describes himself as ethnic Mingrelian (an ethnic subgroup of Georgians), rather than Georgian, opens up about why they chose Tbilisi for treatment.

Options besides Tbilisi included Sochi, Krasnodar, and Moscow, he says. They chose Tbilisi because of its relative closeness and because Vakhtang has friends there.

‘The technology that is available here may not be available in Abkhazia. When Abkhazian healthcare can’t help a patient, they seek opportunities elsewhere. One destination is Georgia. It’s great that this opportunity exists and we benefit from it,’ says Vakhtang. 

‘When there’s sorrow in a man’s family, when there’s illness, he will resort to anything — nothing else matters for him, politics included. Family comes first.’

 For ease of reading, we choose not to use qualifiers such as ‘de facto’, ‘unrecognised’, or ‘partially recognised’ when discussing institutions or political positions within Abkhazia, Nagorno-Karabakh, and South Ossetia. This does not imply a position on their status.