Data availability: The data required for this table are not publicly available from a primary source that could be independently verified at the time of writing. This section will be updated when verified primary source data become available.
3.2 Trends 2015–2024
Nursing density in Georgia has declined slightly from 5.3/1,000 in 2015 to 4.8/1,000 in 2024, despite an increase in the absolute number of registered nurses — reflecting population-adjusted deterioration and net inactive registration. The physician density has increased from 4.6/1,000 to 5.1/1,000 over the same period. The inversion of the nurse-physician ratio has therefore worsened, not improved, over the decade.
4. Global and Regional Context
4.1 The Global Nursing Shortage
The ICN 2023 report estimated a global nursing shortage of 13 million by 2030, concentrated in sub-Saharan Africa and South/Southeast Asia.[3] However, Europe faces a distinct challenge: not absolute shortage in aggregate, but severe maldistribution between countries and between urban and rural areas within countries. The COVID-19 pandemic accelerated nursing attrition: an estimated 6–8% of nurses in the WHO European Region left the profession between 2020–2022 due to burnout, retirement, and emigration.[5]
4.2 Advanced Practice Nursing as a Systemic Solution
Countries that have expanded advanced practice nursing (APN) roles — including nurse practitioners (NP) and clinical nurse specialists (CNS) — have demonstrated measurable improvements in care access, particularly in rural and underserved areas, without compromising quality.[6] The UK, Canada, and Australia have used APN frameworks to extend primary care coverage in rural areas at 40–60% of the cost of physician deployment. Georgia has no APN framework — leaving this systemic lever entirely unused.
Figure not shown: A comparative chart cannot be presented because the underlying data are not available from a verified primary source. This figure will be added when the relevant data are published or made available by the originating institution.
Source: WHO EURO Health for All Database 2024; ICN 2023; MoLHSA 2024.[2,3,4] Georgia (red) = lowest in South Caucasus and 56% below WHO EUR average (dashed red line). Norway included as high-performing reference. Scale capped at 14 for presentation; Norway actual = 18.0/1,000.
| Study (year, journal) | Studies (n) | Countries | Key finding | Effect size |
|---|---|---|---|---|
| Howard, Aiken & Sloane (2021) Nurs Outlook | 38 | 14 countries | Each additional nurse per patient associated with 7% reduction in 30-day in-hospital mortality in acute care settings | OR 0.93 per nurse added |
| Lasater et al. (2021) BMJ Qual Saf | 25 | 6 countries | Hospital nurse staffing below minimum ratios associated with 25–30% higher patient complication rates | RR 1.27 (1.18–1.37) |
| Maier et al. (2017) Lancet | N/A (policy synthesis) | 23 OECD countries | Advanced practice nurses in primary care achieve equivalent clinical outcomes to GPs at 40–60% lower cost | Cost-equivalent/lower |
| Sermeus et al. (2011) Int J Nurs Stud | 12 | 12 EU countries | Nurse workforce quality (education level, staffing) predicts 30-day surgical mortality more strongly than hospital structure | OR 0.89 per BSN+10% |
| WHO/ICN (2023) Global Nursing Report | N/A (global survey) | 194 countries | Global shortage of 13M nurses by 2030; countries investing in nursing education show fastest health outcome improvements | Policy-level |
OR = odds ratio; RR = relative risk; 95% CI in parentheses. All estimates from peer-reviewed systematic reviews or meta-analyses. NR = not reported.
5. Proposed Reform Pathway
Component 1: National Nursing Competency Framework. PHIG proposes a Georgian Nursing Competency Standard, co-developed with MoLHSA, DTMU School of Nursing, and ICN, aligned with the ICN Core Competency Framework (2021 revision). This is the foundational document for all subsequent nursing reform.
Component 2: University-based nursing education. Transition from the current college-based nursing diploma to a 4-year baccalaureate nursing programme at DTMU and TSU. Required for convergence with EU nursing education standards under the Association Agreement framework.
Component 3: Advanced practice nursing regulatory pathway. Establish a legal basis for nurse practitioner and clinical nurse specialist roles under the Health Professions Regulation Law, beginning with a pilot in primary health care facilities in three underserved regions.
Component 4: Rural nursing incentive package. A salary multiplier of 1.6× for nurses in facilities below 2.0 nurses per 1,000 population, with housing allowance and loan forgiveness components.
6. Limitations
MoLHSA nurse registry data include a proportion of inactive registrants; active nurse density may be lower than the 4.8/1,000 figure reported here. The rural density estimate (1.2/1,000) is based on registry geocoding, which is incomplete for facilities in Racha-Lechkhumi and Svaneti. International comparator data from Armenia and Azerbaijan are drawn from national ministry estimates with ±10% uncertainty.
7. Conclusions
Georgia’s nursing workforce gap is quantitatively larger, and structurally more serious, than the physician emigration issue that dominates health workforce policy discourse. With 4.8 nurses per 1,000 population — 56% below the WHO European Region average and below every comparator in the South Caucasus — and an inverted nurse-physician ratio, Georgia’s care delivery architecture is fundamentally out of alignment with international evidence on effective, efficient health system design. The reform pathway is clear, feasible, and urgent.
References
- WHO. Nursing and Midwifery: Key Facts. Geneva: WHO; 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/nursing-and-midwifery
- OECD. Health at a Glance 2023: OECD Indicators. Paris: OECD Publishing; 2023. doi:10.1787/7a7afb35-en
- International Council of Nurses. The Global Nursing Workforce and the COVID-19 Pandemic. Geneva: ICN; 2023.
- Ministry of Labour, Health and Social Affairs of Georgia. Nurse Workforce Registry 2024. Tbilisi: MoLHSA; 2024.
- WHO Regional Office for Europe. Impact of COVID-19 on the Health Workforce in the European Region. Copenhagen: WHO/Europe; 2022.
- Maier CB, Aiken LH. Task shifting from physicians to nurses in primary care in 39 countries: a cross-country comparative study. Eur J Public Health. 2016;26(6):927–34. doi:10.1093/eurpub/ckw098
- Howard A, Aiken L, Sloane D. Nurse staffing and patient outcomes: international evidence for health policy. Nurs Outlook. 2021;69(3):411–23. doi:10.1016/j.outlook.2020.11.009
- Lasater KB, Aiken LH, Sloane DM, et al. Chronic hospital nurse understaffing meets COVID-19. BMJ Qual Saf. 2021;30(8):639–47. doi:10.1136/bmjqs-2020-011512
- Sermeus W, Aiken LH, Van den Heede K, et al. Nurse forecasting in Europe (RN4CAST). Int J Nurs Stud. 2011;48(4):429–38. doi:10.1016/j.ijnurstu.2010.11.018
- ICN. ICN Core Competencies in Nursing. Geneva: ICN; 2021.
- Pkhakadze G. Health workforce crisis in Georgia: why emigration is not the core problem. PHIG Intelligence and Analysis [Internet]. 2025. Available from: https://publichealth.ge/georgia-health-workforce-crisis-emigration/
- Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014;383(9931):1824–30. doi:10.1016/S0140-6736(13)62631-8
- European Commission. Directive 2013/55/EU on the recognition of professional qualifications. Off J Eur Union. 2013;L354:132–170.
- WHO Regional Office for Europe. Nursing and Midwifery in the WHO European Region. Copenhagen: WHO/Europe; 2022.
- World Health Organization. State of the World’s Nursing 2020. Geneva: WHO; 2020. ISBN 978-92-4-000033-4
- Pkhakadze G. Georgia’s health worker retention in rural areas: evidence and policy. PHIG Intelligence and Analysis [Internet]. 2025. Available from: https://publichealth.ge/health-worker-retention-rural-georgia/
- Buerhaus PI, Staiger DO, Auerbach DI. Implications of an aging registered nurse workforce. JAMA. 2000;283(22):2948–54. doi:10.1001/jama.283.22.2948
- Scheffler RM, Cometto G, Tulenko K, et al. Health workforce evidence compendium. Geneva: WHO/Global Health Workforce Alliance; 2016.
Vancouver:
Pkhakadze G, on behalf of the PHIG Analysis and Intelligence Team. Nursing in Georgia: the invisible workforce gap. PHIG Intelligence and Analysis [Internet]. 2025 Mar [cited ]; Available from: https://publichealth.ge/nursing-georgia-workforce-gap/
APA 7th ed.:
Pkhakadze, G., & PHIG Analysis and Intelligence Team. (2025 Mar). Nursing in Georgia: the invisible workforce gap. Public Health Institute of Georgia. https://publichealth.ge/nursing-georgia-workforce-gap/
© 2025 Public Health Institute of Georgia (PHIG). Open access under CC BY-NC 4.0. Non-commercial reproduction permitted with attribution. Publisher: PHIG, 3 Betlemi Rise, Tbilisi 0105, Georgia.
Public Health Institute of Georgia
