Azerbaijan. Healthcare system structure
The formal structure of the health system in Azerbaijan is highly centralized and hierarchical, and most decisions about key health policy initiatives are made at the national level. The Ministry of Health formally has ultimate responsibility for the management of the health system, but it has limited means to influence health care providers at the local level as they are financially dependent on the local district health authorities or the village authorities. The district authorities and the administration of the central district hospital have direct managerial responsibilities for health providers in their area.
The considerable parallel health service provision is also outside the influence of the Ministry of Health, as providers are subordinated to and financed through the relevant line ministry. The private sector is licensed by the Ministry of Health but is otherwise completely independent; it is not included in the diagram below which represents just the state health system.
Healthcare system structure in Azerbaijan
The Soviet Semashko system sets the context for the health system in Azerbaijan as the country inherited this model health system from its membership of the Soviet Union. The Semashko system was organized around the guiding principle of universal access to health care free at the point of use. It was a tax-based system with highly centralized planning of resources and personnel based on a hierarchy of facilities at the district, regional, republican and all-union levels.
All health care workers were employed by the state, and private practice was not allowed. Care was focused on inpatient treatment and, consequently, primary care was very weak. There was an emphasis on the continuous expansion of staff and facilities and an extensive system of parallel health services, which were attached to large industrial enterprises and certain ministries.
The extensive coverage and universal access to free care meant that the Semashko system was equitable, despite qualitative differences in provision between geographical regions and mainstream and parallel health services. However, it was also inefficient and resource intensive – particularly in the reliance on inpatient care. Moreover, while the Semashko system proved reasonably effective in the control of communicable diseases, with the epidemiological shift towards a noncommunicable disease burden, the system was insufficiently flexible and primary health care and health promotion too weak to enable the control of such diseases, which predominated towards the end of the Soviet era.
Until independence in 1991, the Ministry of Health in Azerbaijan simply administered policies that had been initiated in Moscow, as part of a centrally planned system managed through a hierarchical structure. Following independence in 1991, the health system faced increasingly serious economic challenges in financing the inherited extensive services. Quality and access to services deteriorated and the combination of inherited rigidities and limited managerial capacity made change difficult. The current organizational structure of the health system retains many of the key features of a Semashko system and faces many of the same key challenges. The focus on hospital provision has persisted despite intentions to reorientate the system in favour of primary care.
While universal access to the health system was a key feature of the Semashko model, severe lack of funding and the resultant out of pocket (OOP) payments by patients have effectively reduced access to health care for large sections of the population. The situation has been exacerbated by the disruptions to inherited systems of pharmaceutical and equipment supply following the breakdown of trading relations after independence. The government has tried to address some of these issues with a number of pilot schemes as part of a substantial health reform project that focuses on developing primary care and promoting the efficient use of resources. The development of a mandatory social health insurance scheme is also being discussed.
The considerable parallel health service provision is also outside the influence of the Ministry of Health, as providers are subordinated to and financed through the relevant line ministry. The private sector is licensed by the Ministry of Health but is otherwise completely independent; it is not included in the diagram below which represents just the state health system.
Healthcare system structure in Azerbaijan
The Soviet Semashko system sets the context for the health system in Azerbaijan as the country inherited this model health system from its membership of the Soviet Union. The Semashko system was organized around the guiding principle of universal access to health care free at the point of use. It was a tax-based system with highly centralized planning of resources and personnel based on a hierarchy of facilities at the district, regional, republican and all-union levels.
All health care workers were employed by the state, and private practice was not allowed. Care was focused on inpatient treatment and, consequently, primary care was very weak. There was an emphasis on the continuous expansion of staff and facilities and an extensive system of parallel health services, which were attached to large industrial enterprises and certain ministries.
The extensive coverage and universal access to free care meant that the Semashko system was equitable, despite qualitative differences in provision between geographical regions and mainstream and parallel health services. However, it was also inefficient and resource intensive – particularly in the reliance on inpatient care. Moreover, while the Semashko system proved reasonably effective in the control of communicable diseases, with the epidemiological shift towards a noncommunicable disease burden, the system was insufficiently flexible and primary health care and health promotion too weak to enable the control of such diseases, which predominated towards the end of the Soviet era.
Until independence in 1991, the Ministry of Health in Azerbaijan simply administered policies that had been initiated in Moscow, as part of a centrally planned system managed through a hierarchical structure. Following independence in 1991, the health system faced increasingly serious economic challenges in financing the inherited extensive services. Quality and access to services deteriorated and the combination of inherited rigidities and limited managerial capacity made change difficult. The current organizational structure of the health system retains many of the key features of a Semashko system and faces many of the same key challenges. The focus on hospital provision has persisted despite intentions to reorientate the system in favour of primary care.
While universal access to the health system was a key feature of the Semashko model, severe lack of funding and the resultant out of pocket (OOP) payments by patients have effectively reduced access to health care for large sections of the population. The situation has been exacerbated by the disruptions to inherited systems of pharmaceutical and equipment supply following the breakdown of trading relations after independence. The government has tried to address some of these issues with a number of pilot schemes as part of a substantial health reform project that focuses on developing primary care and promoting the efficient use of resources. The development of a mandatory social health insurance scheme is also being discussed.
Organizational overview
The overall structure of the health system in Azerbaijan reflects the inherited Soviet Semashko system, but as in other smaller former Soviet republics, there is no oblast (region/province) tier between the national (Republican) level and the district (rayon) level. Most services are still provided by state structures, but there is a growing private sector and a considerable amount of services are provided in parallel via line ministries.
Ministry of Health
The Ministry of Health owns the central institutions and the tertiary level (Republican) hospitals, research institutes and the Sanitary-Epidemiological Service; funding for these facilities comes through the Ministry of Health from the Ministry of Finance. The Ministry of Health is represented at the local level through the district health authorities. Since 2006, the Ministry of Health has also been responsible for the direct management and financing of services provided in the capital, Baku. Within the Ministry, each head of department develops policies within their own sphere on an ad hoc, often reactive, basis.
Local governments and health authorities
Local governments own the district hospitals, polyclinics and specialized clinics (dispanser), and state funding for these providers comes from the local government budget through the district health authority. District health authorities are subordinated to the Ministry of Health in matters of health policy, although they are financially dependent on local governments. Each district health authority is also the administration for the central district hospital, so the chief doctor of the local hospital is in charge of all health services in the area – polyclinics, specialized clinics, village hospitals and feldsher-midwife points (FAP).
Ministry of Finance
The Ministry of Finance defines the annual health budget (in collaboration with the President and National Assembly) and then allocates funds to the Ministry of Health for services under its control and to local governments for services provided at the district level.
Parallel providers in industry and line ministries
The following ministries and enterprises run parallel health services for their current and former employees: Ministry of National Security, Ministry of Defence, Ministry of Internal Affairs, Ministry of Justice, State Customs Committee, State Oil Company (SOCAR), State Caspian Shipping Company and State Railway Company. It is estimated that they serve approximately 5% of the population (Holley et al., 2004). Excess capacity in some of the parallel hospitals is used for private practice.
Private sector
There has been only limited privatization in the health system. In 2003, the government privatized approximately 350 health care facilities (mainly dental practices and pharmacies). However, there has been a considerable growth in private service providers that cater for those who have profited from the recent oil boom. A wide range of services are provided in private hospitals and clinics, which are mainly located in Baku. Oncology services can only be provided in state hospitals, but otherwise private providers are entitled to include any other services and make their decisions on the basis of the relative profitability of different fields. Private providers also contract with the multinational companies operating in Azerbaijan for occupational health services and to provide services for workers with private health insurance.
International partners
International partners were particularly important in providing services to the large groups of IDPs, who otherwise had problems with accessing services. By 2008, almost all of the IDP camps had been closed and the former residents moved to new settlements. International partners have also played a significant role in assisting the Ministry of Health with developing and piloting different approaches to health care reform.
Non governmental organizations Domestic non governmental organizations are not strong players in the health field, but they are growing in size and influence. There are a number of disease specific support groups who lobby on behalf of their members (such as the League of Diabetics) and the Consumers Union does also cover patients as consumers of health services. There are also some professional associations for different groups of clinicians (such as pulmonologists and psychiatrists), but they do not have a significant impact on health policy and planning. The key source of domestic non-state funding for health initiatives is the Heydar Aliev Fund, which is named after the late President and managed by his daughter-in law, the First Lady. The Fund has backed a number of health-related projects; present work has focused on screening and treatment of thalassaemia.
The overall structure of the health system in Azerbaijan reflects the inherited Soviet Semashko system, but as in other smaller former Soviet republics, there is no oblast (region/province) tier between the national (Republican) level and the district (rayon) level. Most services are still provided by state structures, but there is a growing private sector and a considerable amount of services are provided in parallel via line ministries.
Ministry of Health
The Ministry of Health owns the central institutions and the tertiary level (Republican) hospitals, research institutes and the Sanitary-Epidemiological Service; funding for these facilities comes through the Ministry of Health from the Ministry of Finance. The Ministry of Health is represented at the local level through the district health authorities. Since 2006, the Ministry of Health has also been responsible for the direct management and financing of services provided in the capital, Baku. Within the Ministry, each head of department develops policies within their own sphere on an ad hoc, often reactive, basis.
Local governments and health authorities
Local governments own the district hospitals, polyclinics and specialized clinics (dispanser), and state funding for these providers comes from the local government budget through the district health authority. District health authorities are subordinated to the Ministry of Health in matters of health policy, although they are financially dependent on local governments. Each district health authority is also the administration for the central district hospital, so the chief doctor of the local hospital is in charge of all health services in the area – polyclinics, specialized clinics, village hospitals and feldsher-midwife points (FAP).
Ministry of Finance
The Ministry of Finance defines the annual health budget (in collaboration with the President and National Assembly) and then allocates funds to the Ministry of Health for services under its control and to local governments for services provided at the district level.
Parallel providers in industry and line ministries
The following ministries and enterprises run parallel health services for their current and former employees: Ministry of National Security, Ministry of Defence, Ministry of Internal Affairs, Ministry of Justice, State Customs Committee, State Oil Company (SOCAR), State Caspian Shipping Company and State Railway Company. It is estimated that they serve approximately 5% of the population (Holley et al., 2004). Excess capacity in some of the parallel hospitals is used for private practice.
Private sector
There has been only limited privatization in the health system. In 2003, the government privatized approximately 350 health care facilities (mainly dental practices and pharmacies). However, there has been a considerable growth in private service providers that cater for those who have profited from the recent oil boom. A wide range of services are provided in private hospitals and clinics, which are mainly located in Baku. Oncology services can only be provided in state hospitals, but otherwise private providers are entitled to include any other services and make their decisions on the basis of the relative profitability of different fields. Private providers also contract with the multinational companies operating in Azerbaijan for occupational health services and to provide services for workers with private health insurance.
International partners
International partners were particularly important in providing services to the large groups of IDPs, who otherwise had problems with accessing services. By 2008, almost all of the IDP camps had been closed and the former residents moved to new settlements. International partners have also played a significant role in assisting the Ministry of Health with developing and piloting different approaches to health care reform.
Non governmental organizations Domestic non governmental organizations are not strong players in the health field, but they are growing in size and influence. There are a number of disease specific support groups who lobby on behalf of their members (such as the League of Diabetics) and the Consumers Union does also cover patients as consumers of health services. There are also some professional associations for different groups of clinicians (such as pulmonologists and psychiatrists), but they do not have a significant impact on health policy and planning. The key source of domestic non-state funding for health initiatives is the Heydar Aliev Fund, which is named after the late President and managed by his daughter-in law, the First Lady. The Fund has backed a number of health-related projects; present work has focused on screening and treatment of thalassaemia.
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