Health care system in Armenia
The Soviet domination of the health system in Armenia was such that no traces of pre-Soviet healthcare traditions were discernible at the time of independence in 1991. Rather, the country inherited a highly centralized system. The entire population was guaranteed free medical assistance, regardless of social status, and had access to a comprehensive range of secondary and tertiary care.
Immediately after independence, Armenia faced devastating economic and sociopolitical problems, which led to a decline in health status and put overwhelming strain on the healthcare system.1 However, the most compelling pressure for the health sector reform was the impossibility of sustaining existing health services in the new economic climate. Armenia was simply not in a position to continue to fund a cumbersome, expensive, and insufficient system and was obliged to devise a broad reform programmer.
Despite the radical nature of health sector reform in Armenia, the core organizational structure of the system has undergone very little change. All the hospitals and polyclinics, rural health units (including village health centers), and health posts from the previous system continue to function. Formerly hospitals were nominally accountable to the local administration and ultimately answerable to the Ministry of Health; now they are autonomous and increasingly responsible for their own budgets and management. Local government continues to monitor the care provided, however, and the Ministry of Health retains regulatory functions. The ministry also maintains the network of “san-epic” stations inherited from the Soviet system, ensuring the collection of epidemiological data and a first line response to environmental health challenges or outbreaks of infectious disease. These stations were renamed in 1997 and are now centers of public health and epidemiological surveillance, but many of their rules and regulations are obsolete and need to be revised and upgraded.
By 1997, private, out of pocket, payment had become a main source of financing for the healthcare system, and the government set out to establish a state health target programmer in which certain services will be provided free to targeted segments of the population. All patients falling into a priority group are to receive an all but comprehensive package of free outpatient and inpatient services. In practice, however, many patients end up paying. Hospitals do not normally provide food, and even vulnerable inpatients continue to be responsible for providing their own meals. Drugs are, in principle, free to inpatients, and outpatients are expected to pay a token fee for them, but most inpatients in priority groups pay for most drugs. The very low prices paid by the state for state funded services have worked to increase under the table payments. These prices are too low to cover costs of services provided, so providers are forced to request payments from patients even when a patient falls within a vulnerable group and is entitled to free health care.
A fundamental problem in primary care concerns access, which has become excessively difficult for a large segment of the population because of their inability to pay for health care. In Armenia, the sense of individual responsibility for one’s health is low. There is widespread misunderstanding or confusion regarding public health services. Health promotion was not particularly developed during Soviet era, and what provision there was collapsed during the post-independence crises and left the country with no established health promotion or education programmes.
The article by von Schoen-Angerer (p 562) presents quite an insight on issues relating to sexually transmitted infections (STI) and mental health in Armenia.2 The reform strives to address the problems in those fields, and international organizations that bring in Western approaches to settling new and modern standards provide valuable support.
Following recommendations from the World Health Organization, the dermatology and STI prevention center (which is centralized in Yerevan, with a network in the regions) changed its priorities and regulations. It is now working on improving people’s knowledge about sexual health and hygiene and changing their outlook, and establishing simple, symptom based treatment protocols. In Yerevan in January 2004, in collaboration with IntraHealth International (an independent, non-profit organization that works with local health workers to improve healthcare services and training), the center ran a four day course on integrated management of sexually transmitted infections for obstetrician-gynecologists and STI specialists from one of the regions of Armenia and medical faculty members. The course conformed with the unified family medicine curriculum adopted by the Ministry of Health in 2003,3 and included training on the responsibility of family physicians in the management of sexually transmitted infections and mental health problems, based on international standards.
In 2003, many non-governmental organizations worked together to revise the existing legislation and to elaborate a law on mental health, and in May 2004 the National Assembly of the Republic of Armenia adopted it.4 This law corresponds to international standards and Western approaches and contains articles about rights and responsibilities of patients with mental problems and of physicians. Now Armenia has already implemented these new approaches into its public health system.