The World Health Report 2006 documents the widespread health workforce crisis across the globe [1
]. Similar to other regions and specialty areas, there has been a shortage of well trained public health workers in the Central and Eastern Europe/New Independent States (CEE/NIS) region as well [2
Public health is defined as the science and art of preventing disease, prolonging life and promoting health, through the organized efforts of society. It has a population rather than an individual focus and involves mobilizing local, regional, national and international resources to ensure the conditions in which people can be healthy [3
]. Performance of the public health system depends on multiple factors, among which human resources (HR) are one of the most important components [5
]. The public health workforce requires up-to-date knowledge and skills to deliver essential public health services. To meet the training and continuing education needs of an evolving workforce, a clearer understanding of the functions and composition of the public health workforce both now and for the future is required [6
Under the Soviet era, a highly centralized 'San-Epid' (sanepid) network focusing on environmental and epidemiological health was put in place in Georgia. Perhaps the most tangible achievement of the sanepid system was high immunization coverage and communicable disease control; however, it was relatively ineffective in combating environmental pollution, occupational diseases and noncommunicable diseases [2
]. Public health workers employed by the sanepid system were mainly graduates from sanepid faculties of State medical institutes/universities, having completed a five-year course largely focusing on environmental health and infectious disease epidemiology and control. Graduation was followed by centralized training within continuous professional education programs. The 5-year course also included basic medical education (anatomy, physiology, biochemistry, etc.) as well as some clinical training (internal medicine, infectious diseases, surgery, etc.), and graduates were given an MD degree with specialization in epidemiology, environmental health, nutrition, etc. Sanepid system was a part of the entire health care system under the Ministry of Health umbrella management, and human resources were mainly managed by employing Soviet command and control approaches and style. Reporting lines were clearly defined under regulations of the Ministry of Health, and there was a strong accountability framework put in place.
Following independence, Georgia embarked on health sector reforms, the main focus of which was a modernization of public health services combined with decentralization efforts. In 1996, a dedicated Department of Public Health (DPH) was established to give greater emphasis to health promotion and disease prevention, ensure sufficient budget allocation for health promotion activities and encourage innovative community initiatives contributing to prevention of diseases [7
]. The role of the DPH, which is part of the Ministry of Labour Health and Social Affairs (MoLHSA), was to monitor and assess the epidemiological situation of the population and to promote good health through education and management of preventive health services. In line with the decentralization policy implemented in the country, the MoLHSA supported establishment of local centers of public health (CPH), responsible for implementing public health activities on a district level [8
Ten years later, after the initiation of health sector reforms in Georgia, investments in system building innovations had not resulted in sustainable health gain: over the past decade there has been a substantial increase in the incidence of sexually transmitted diseases, drug abuse, cardiovascular diseases, cancer, injuries as well as prevalence of smoking [9
Recognizing the diversity of factors influencing unfavourable population health status, including low budget allocations to public health, weaknesses in organizational structure, poor legislation, lack of stewardship, the gap between private and public medicine, etc. [12
], it could be argued that having an inadequate public health workforce (given that in Georgia, public health workers are mainly physicians, – i.e. graduates of sanepid faculties – 'public health workforce' here is defined as physicians providing essential public health services to promote physical and mental health and prevent diseases, injury, and disability), which has not been successful in assuming new roles and responsibilities, is also a significant contributing factor. The problem might be that while embarking on reforms there was no clear understanding of what are the competing needs for workforce supply in public health programs and activities considering the new mission, i.e. giving greater emphasis to health promotion and diseases prevention? What resources are available at central and district level? How does the new mission fit with human resource existing capacities? What do we need to do? This is an incomplete list of important questions that have to be answered to enable the public health system to deliver the necessary interventions.
The aim of this study was to assess adequacy (which denotes numbers, necessary skill mix, and adequate geographical distribution) of human resources of public health relative to the needs of the system under health care reforms. To the best of our knowledge, it is the first study in Georgia which has assessed the current status of the public health system by analysing the influence of multiple factors of human resources development, supply and distribution.