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

Achieving Universal Health Coverage (UHC) requires robust risk protection schemes to secure access to services while shielding households from the financial burden of out-of-pocket (OOP) payments for healthcare. While many countries have introduced or expanded such schemes and improved access, high OOP expenditures persist in some cases despite significant population coverage. This paper examines this paradox using the case of Georgia, where a tax-funded UHC scheme introduced in 2013 now covers nearly 90% of the population. Despite this, the country continues to exhibit some of the highest OOP levels in the WHO European Region. A mixed-methods approach was employed, combining 35 in-depth interviews with policymakers, providers, and key stakeholders; an online survey (94 complete and 18 partial responses); and secondary analysis of national health expenditure data and policy documents. Thematic analysis of qualitative data was conducted using NVivo12™, and findings were triangulated across data sources. Results reveal that high OOP payments in Georgia are not merely a result of limited public financing but stem from complex, reinforcing interactions among health system components. Key contributing factors include a narrow benefit package, outdated reimbursement tariffs, balance billing practices, limited pharmaceutical coverage, weak regulation, excessive market liberalization, and fragmented service delivery. Stakeholders described provider responses to financial and competitive pressures including demand inducement, patient-paid services and commission-based referrals, while survey respondents perceived several of these practices to be common. The findings suggest that interactions between financing arrangements, provider incentives and weak regulatory oversight can sustain exposure to OOP payments despite broad population coverage. Georgia’s experience illustrates that expanding public coverage alone is insufficient to ensure financial protection. Structural reforms are needed across health financing, governance, and service delivery. Strengthening the purchasing role of the National Health Agency, updating tariffs, expanding the benefit package, regulating market entry, and aligning provider incentives are critical to realizing the full promise of UHC and reducing the financial burden of ill-health on households.