In Tbilisi, students at the State Medical University are protesting a new testing fee the Georgian government has imposed just days before residency qualification exams begin.

Eighty lari (£21) may not mean much for some, but for medical students who have finished their degree and are already dismayed at the prospect of paying for a residency, the introduction of further fees has triggered their feelings over on-going problems. Residency, a mandatory stage in becoming a doctor, can be expensive, with students having to pay 150 lari (£39) a month to public healthcare providers and 250-600 lari (£66-£158) to private providers for the privilege.

Coming in a holiday month when money is already tight, this new decree is a fresh example of the problems plaguing Georgia: the alienation citizens feel towards the state and society, the outsourcing of responsibility to individuals, the driving factors of emigration, disrespect towards labor performed, the subpar education system, and the deeply flawed and commodified medical system.

Many parts of Georgian society have become burned out and hopeless from being treated like numbers on a screen. This ongoing alienation is compounded with each decision the current Georgian Dream government takes without input from and care towards its citizens.

Alienation is being estranged from the university you attend, the block you live on, the public transport you take, your workplace, the prices of goods you buy - the inability to see or influence the world around you. Losing control over our everyday environment is the mainstay of alienation - the impersonal forces deciding our lives getting stronger, while our input and participation diminishes.

It’s no surprise that medical students who thought that they had done the administrative work of registering for the qualifying exam - and were spending their time preparing for their most important test - were horrified to learn that now they had to come up with further funds. But these students’ indignation grew and they started organising protests, marches, banner drops and other stunts designed to force Georgia’s Ministry of Health to revoke the new decree.

A recent meeting with the Rector of Tbilisi Medical University has further angered students. In response to the protests, Zurab Vadachkoria promised that the university would cover half of the testing fee - a move seen as going against the grain of recent university statements. Since starting university, these students have repeatedly asked for improved facilities, translated texts, new books and better organised education. These requests, though, have been met with the president’s standard response: “There isn’t money for that.”

The new fees that have been imposed in a new government decree - which not only sets fees for this exam but other services too - are a continuation of the Georgian state’s austerity policies, shifting the responsibility of the state onto its citizens.

Privatising education to introducing tuition and fees in public universities has been the modus operandi not only of this government, but the previous ones as well. Budgets are limited: progressive taxation is outlawed by the Georgian constitution and a zero to 15% percent profit rate has made the budget vulnerable - it has to be filled by the poorest of the population through income taxes and VAT. With only excise taxes at the government’s disposal, cigarette and alcohol taxes have been rapidly increasing. Georgian Dream’s policies thus intentionally make the budget small in order to justify cuts to public spending and the complete disregard to the needs and wants of its citizens, so it’s easy to see how Georgia’s Ministry of Health, Labour and Social Affairs can issue a completely new testing fee system 10 days before the most important tests begin for new medicine graduates. The content of government policies looks like outsourcing all their responsibilities to citizens, while the form they use to let people know is pretty close to “f*** you.”

This brings us to a more critical point: the commodification of Georgia’s healthcare and education systems. Georgia’s health system is over 90% privatised with very little regulations. Medical students pay providers every month for their residency while performing almost the same duties as a doctor. In most countries resident doctors get paid for their work; in Georgia, the residency students pay the hospitals in order to work for them. It’s even worse than free labour: this labour is not only unpaid, it also costs money. More lucrative residencies like radiology cost the most (for example, 600 lari or £158), which means most medical students will never be able to afford higher paying specialisations.

Healthcare experts state that “Georgia overproduces doctors.” While the number of doctors is supposedly three times more than what is standard for a country of our size, the nursing shortage is three times less than required. But Georgian universities still churn out medical students every year. Indeed, universities have every incentive to admit as many students as they can because with each student, they receive more money.

To make ends meet during their studies, most medical students work as nurses’ aides or nurses. After graduation, they provide not only free labour as doctors, but actually subsidise the revenues of healthcare providers. This setup keeps nurses’ salaries low, despite staff shortages - medical students fill those shortages with their abundant and cheap labour. The entire institution of nursing suffers: nursing is treated as a temporary job on the way to something better. The patient suffers because they pay the same amount for treatment regardless of who the doctor or nurse is or how much experience they have. The medical students suffer because most of them can barely pay the residency fees every month and work without any income and/or are barred from specialising in fields with potential for higher incomes.

At the same time, many Georgian medical students are left without a residency altogether - either due to their inability to pay or the lack of residency opportunities. They either get stuck working as a nurse for years or emigrate in search of better opportunities elsewhere. From the day a person finishes high school and wants to become a doctor, there are dozens of hurdles they have to overcome to actually work in their field - it’s illustrative of the unequal access to education and professional development for the majority of potential doctors.

These protests against the 80 lari fee and other new fees set by Decree 586 are significant in the context of Georgia’s poor quality education, students being burdened with residency costs, a broken healthcare system and systematic alienation. It will hopefully lead to a more dynamic healthcare movement by residents and students - as well as future coordination with nurses, patients’ rights groups and health access advocates.

We are hopeful.