Armenia. Healthcare System Overview.

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 centralised 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 programme.

Despite the radical nature of health sector reform in Armenia, the core organisational structure of the system has undergone very little change. All the hospitals and polyclinics, rural health units (including village health centres), 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-epid” 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 centres 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 programme 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.

Public health
The State Hygiene and Sanitary-Epidemiological Inspectorate provides public health services and consists of a head office in the Ministry of Health, 7 operational offices in Yerevan and 10 regional offices. In addition, 14 independent laboratories provide testing, expertise and public protection and a number of mobile laboratories. Core public health programmes include epidemiological surveillance, a programme to prevent HIV transmission and an immunization programme (managed by the Ministry of Health and implemented in primary care). Health education has not yet been developed, but activities such as information and awareness campaigns, organized by government and nongovernmental organizations, are becoming more common.

Primary care
Primary care services differ in rural and urban areas. The country has inherited the system from before independence, when primary care was underdeveloped and investment was focused on secondary and specialized inpatient care rather than outpatient services. However, there has been a substantial shift towards primary care since independence. The ownership and management of primary care facilities has been devolved from the central to local governments in recent years. Feldsher-midwifery posts are the first point of consultation for people in rural areas, providing very basic curative antenatal and postnatal care and immunization. They also give health advice and referrals and are supervised by nearby polyclinics and ambulatory facilities. To access more advanced primary care services, people have to travel to villages and towns with ambulatories and polyclinics. Polyclinics provide most primary care in cities. People are free to choose their primary care provider. Specialization in primary care was introduced in 1993. Family medicine, in which health professionals are trained and retrained to provide a more holistic approach to care for all members of the family, is becoming a more common feature of the primary care system.

Secondary and tertiary care
Numerous facilities provide secondary care, including freestanding hospitals at the district and regional levels, hospitals with associated polyclinics, health centres primarily designed for outpatient care with about 20 beds for inpatient care, maternity homes and specialized dispensaries. Highly specialized tertiary services are mainly concentrated in Yerevan in institutions equipped with sophisticated equipment.

Public/Private mix
Private providers have gradually entered Armenia’s health care system because of changes in the legislative framework and an extensive sale of government facilities to entrepreneurial individuals, groups and companies. More than 200 formerly state-owned health facilities, mostly pharmacies and dental units, have been privatized. As a result, almost all pharmacies and most dental services and medical equipment support are now private. About six hospitals (9% of all hospital beds) in Yerevan providing secondary and tertiary care have also been privatized. Physicians in private practice are still relatively rare and mostly confined to some specialists in gynaecology and obstetrics and psychiatrists.

Feldsher-midwifery posts have deteriorated since independence, although they are still an important point of access to care for people living in remote areas.

During the past decade, an imbalance of geographical access to services developed between rural areas and urban areas. 

Utilization of primary care services has traditionally been low. Health services utilization has further dropped since independence to a level much below that of the EU, more for primary care than for hospital services.
Access remains a concern, especially among vulnerable groups.

 
Coordination between the different levels of care remains a major challenge. 

According to patient surveys, private service providers are associated with reduced access to services and concerns about quality and safety.

Human resources for health
The number of physicians has decreased since independence, mostly due to migration, and the number is comparable to those in most EU countries. The decrease is also due to reduced admission to medical school. A specific feature is the large number of specialists, a high proportion (almost 50%) of physicians working in hospitals. However, the number of health professionals trained and retrained as family medicine practitioners has increased in the past decade as basic and postgraduate training programmes in family care were introduced. The increased emphasis on primary care led to some unemployment among specialists. The number of nurses has decreased since independence to a level that is now substantially below the levels in the CIS and EU. In addition, most nurses are poorly trained and skilled. The number of dentists has remained nearly unchanged since independence, whereas pharmacists seem to have declined substantially. Low levels of prestige and remuneration comprise a particular problem for all health professionals.