Healthcare in Armenia: Quality, Access, Affordability

Publisher-Editor

Suren Deheryan

Stories by:

Arusyak Kapukchyan

Garik Harutyunyan

Lilit Poghosyan

Lilit Hovhannisyan

Karine Darbinyan

Seda Ghukasyan

Infographics & Visualization

Anush Baghdasaryan

Garik Harutyunyan

Karine Darbinyan

Typesetting and Layout

Rob Yegoryan

Anush Baghdasaryan

Photos

Photolure News Agency

Some of the images were provided by the sources cited in the stories and others from online open sources.

Project partner

Friedrich Ebert Foundation

The “Healthcare in Armenia: Quality, Access, Affordability” special issue published by Ampop Media is an attempt to clearly and graphically represent the situation that exists in the healthcare system of the Republic of Armenia.

We were curious in revealing how effective the state's healthcare policy is, especially after the large-scale upheavals because of COVID-19 pandemic and the second NK war in 2020.

What are the lessons the Government learned and what are the reforms initiated to overcome the entrenched problems as promptly as possible and get ready to respond to new challenges.

In this context, it was also important to understand the level of access and affordability of medical services for the country's population, particularly among the special groups and people in need.

We tried to fit the answers within the scope of two dozen stories which include about 70 infographics and charts in the Armenian publication. Meanwhile, we translated 10 of the stories, those we thought would be interesting for the international audience as well, for the English version of the issue.

In almost all the stories, experts of the field have shared their observations and suggestions which, according to them, need to be implemented to make the system more affordable and effective.

This publication became possible due to the partnership between "Journalists for the Future" NGO and Friedrich Ebert Foundation.

We sincerely hope that it will be useful to all those who are interested in contributing to the formation of healthy society in Armenia.

Suren Deheryan President, Journalists For the Future NGO

The views and opinions expressed in this issue are those of the authors and do not necessarily reflect the official policy or position of Friedrich Ebert Foundation.

Ⓒ Journalists For the Future NGO, 2023

Ⓒ Friedrich Ebert Foundation, 2023

The demographics of a country highly depends on the quality of healthcare

Social - economic indicators of RA directly affecting citizens' health

Paying out of the pocket: How state funded healthcare services are budgeted

Workforce and facilities of Armenia's healthcare system

Unattractive work terms keep medical workers back from taking up jobs in RA regions

State funding of healthcare and a transition to health insurance

Hindering to affordable treatment options

Patients' personal information rights get violated in Armenia

Pathologies and complications on rise in pregnant women

Little Adam undergoes a successful bone marrow transplant surgery

THE DEMOGRAPHICS OF A COUNTRY HIGHLY DEPENDS ON THE QUALITY OF HEALTHCARE

A

piece of advice from a doctor who has recently repatriated to Armenia

It all started on 24 April 2022 on board of the Moscow-Yerevan flight, or, probably, earlier. At least that was the day Hasmik’s dream seemed to come finally true. Hasmik Aharonyan, who had moved to Moscow upon her parents’ decision from Armavir at an early age of three, had long made her mind to return to Armenia. The only reason of the delay were Hasmik’s studies. Yet, returning to Armenia, she believes, has never been an aim in itself: it meant commitment and a vision to bring a positive change in young doctor’s ancestral country.

“As a child I used to have a suitcase with all my personal belongings, which seemed important to me, ready to hit the road any moment my parents decided to return to Armenia. No one has ever taught me to love my fatherland. I don’t think that’s something you learn… You just love your land,” Hasmik Aharonyan, a children’s nephrologist shares with Ampop Media. [Editor’s note: a nephrologist specializes in diagnostics, treatment and prevention of kidney-related health conditions].

Hasmik has spent 27 years of her life in Moscow, has studied medicine, and has worked at the Moscow National Medical Scientific Research Center for Children’s Health.

Hasmik says, her main motivation at all levels of learning all the way from baccalaureate to doctorate has been to gain knowledge and experience that would later serve to the development of the healthcare system in Armenia.

Hasmik kept her finger on pulse of events in Armenia and was well aware of the problems existent in the healthcare system of Armenia, even when she was in Moscow. To support Armenian doctors studying in Moscow, Hasmik and her friends [including her nonArmenian peers], initiated the Armenian Medical Association. The association organized workshops and meetings with established professionals for young Armenian doctors, and

created opportunities for duty shifts in Moscow based medical centers.

The war in 2020 changed a lot, including the perceptions she had about the industry and made it clear to her that working with doctors in Armenia and Artsakh was a priority. “As the war erupted, I felt unable to do anything in Moscow, and so, I came to Artsakh that December. That was my fifth visit to Artaskh and the first one following the war. I have first been to Stepanakert when I was 26, and I had feelings there I never had anywhere else. I felt I was finally home…,” Hasmik recalls.

After moving to Armenia, Hasmik started studying the deep-rooted problems of the country’s healthcare system. Hasmik decided she would be travelling to regional medical centers at least once a month to get to know their operation better.

In Yerevan, though, she joined the center, which, she believes, works by a model best fit to her understanding of it. The doctor has already visited 5 regional medical centers since moving to Armenia. She says, the mapping of the problems helps her understand that there is an urgent need to improve management approaches in the healthcare system.

The fact is, in the last 3 years (2019 through 2021) the budgetary funds allotted to the healthcare system have grown in average

by 27.4%, against 2018; in 2021 the share of healthcare in the budget was equal to 8%. Yet, the quality of medical services lags dramatically behind.

“A quality healthcare system is always grounded on proper and efficient management. If the head of a medical center does not have enough management skills, the resources at hand cannot be distributed properly,” Hasmik believes.

Despite the increase of expenses in healthcare, mortality rates remain high in Armenia

Sources: RA Ministry of Health, Statistical Committee of Armenia

Where to start?

The demographics of a country highly depends on the quality of healthcare. To ensure demographic growth in a long-term perspective, a healthcare system capable to provide the growth is needed. Hasmik says, the only way to reach that goal is to have a national strategy for healthcare development, a truly national one, localized to meet the needs of the country: “National strategy has no alternatives. It includes protocols of treatments; and instead of applying a general protocol, it is preferable to opt for the one that is closest to our needs, and is surely localized,” she says.

The young specialist says task groups are needed to keep direct contacts with regional doctors. We have to reach a point, where patients

in regions have an opportunity to get timely and proper treatment in their local medical centers.

Involvement of Diaspora Armenian doctors in the development and efficient organization of healthcare system, pediatrician Hasmik Aharonyan says, is fundamental.

Daily analysis of statistical data provided by medical institutions is vital for assessment of efficiency of the medical centers globally.

Hasmik says, she clearly understands introduction and development of such practices in Armenia is going to take time and effort, but a doctor’s performance is assessed against data such as the number of hospital beds, prescribed antibiotics, and diagnoses.

The growth of chronic illnesses, a cause or an effect of paying out of pocket?

*The data on out-of-pocket payments for 2021 are not published yet

Source: National Institute for Helath

Analysis of such statistical information also helps get a picture of how efficiently the resources provided by the state are used.

“With those data at hand, we will be able to understand which diagnoses result in prescription of antibiotics most often. That in turn will help understand which specialists need more retraining. The data will also help get morbidity rates of diseases,” the doctor says.

She also believes that the morbidity rates and geography of diseases shall be put in the basis of preventive practices that have to be developed. Here the primary care clinics play a fundamental role, and, so, have to be kept in the focus of attention.

The doctor underlines the expediency of preventive healthcare in terms of demographics, as well as from financial perspective, has been

proven long time ago. Early diagnostics of a condition increases the chances to prevent complications and to ensure full treatment. Preventive measures also require less investments and imply less expenses than a treatment course.

“Prevention also ensures maintaining employability and extends life expectancy of patients,” doctor Aharonyan points, bringing Japan as a best example of preventive healthcare practices. Despite the high rates of gastric cancer, the country’s healthcare system has managed to undertake measures to ensure that about 80 percent of patients, are diagnosed in the first or the second stage of the tumor, and given higher recovery perspectives.

The doctor is hopeful that Armenian professionals all over the world will combine their knowledge and efforts to ensure a quality healthcare system is built, capable to render high quality services that would set conditions needed for demographic growth.

SOCIAL - ECONOMIC INDICATORS OF RA DIRECTLY AFFECTING CITIZENS' HEALTH

Can a society with the below-mentioned indicators be healthy?

Increase in ageing indicators of the RA population

Increase in chronic diseases

The WHO constitution states: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

Therefore, all efforts of the healthcare system are doomed if proper attention is not paid to human living conditions and environment.

Increase in out-of-pocket healthcare costs

High level of poverty

High unemployment rate

PAYING OUT OF THE POCKET: HOW STATE FUNDED HEALTHCARE SERVICES ARE BUDGETED

– Are you a beneficiary of the state funded health services?

– I don’t really know; how do I check?

We had this short conversation at one of the medical centers as we were preparing one of my relatives for a surgery. The costs of the surgery were the double of the average salary in Armenia [editor’s note: as of April 2022, the average monthly salary in Armenia was equal to AMD 217 000].

A poster on the announcement board in the medical center would prompt the 8003 hot line number of the Ministry of Heath, which we called.

In response to our inquiry, the operator on the line read out loud the list of social groups, who are beneficiaries of the state funded health services, including political prisoners, family members of military servicemen, some of those who are below a certain social line, and some others.

The list seemed a long one, unlike the patience of the operator.

“You would definitely know, if you were a beneficiary,” the operator said.

We took it for granted, for we were running out of time. We paid for the surgery out of own pocket. The medical procedure went successfully.

We fell short of taking the advantage of getting state funding for the sought health service, yet, we will share about the mechanism of operation of the state funded health services, the groups it is intended for and the ways it is distributed.

Growing regularly, the state funding is never enough to cover the actual demand

The expenses steered to covering the state funded healthcare services grow consistently year by year.

The funds directed by the state over the last 5 years

State funds directed to healthcare services to military (as well as rescuers) and their family members are highlighted in orange

Source: RA Ministry of Health (upon the request of Ampop Media)

* The data on 2022 are provided as of April 22

That’s a fact. The budgetary means steered to state funded healthcare services equaled to AMD 66,524 billion in 2017; in 2021 the expenses exceeded AMD 107,194 billion, growing by more than 60%. Yet, the fact is, the funding never proves enough, and the proof of it follows shortly.

The infographics show that the funds allotted for state financed services have been near equal in 2017 and 2018; the funding for 2018 has been less against the budget in 2017. In 2019 the

The interactive chart can be accessed here: https://bit.ly/3JsGwBr

financing was increased by over AMD 18 billion.

The next major leap in the amount of sums allotted from the state budget for health services was registered two years later, in 2021, in the post-COVID and post-war year, which, probably, is conditioned by the need to overcome the consequences of the pandemic and the war, treatment of injured soldiers, and for other expenses.

As to allotments for a wide range of health services, the budgetary means directed for this purpose to specialized services as a rule grow on yearly basis, with only few exceptions, when the allotment size decreases.

And yet, every fifth citizen of Armenia refrains from getting medical treatment on the grounds of the lack of financial means. According to the draft concept for introduction of comprehensive health insurance system in Armenia,

about 20,1% of the country’s population refuses to see a doctor at the primary health services provider institutions for financial reasons.

But is there an available comprehensive data on beneficiaries of the state funded health services? The Armenian legislation defines groups of people, who are eligible for free state funded health and medical services.

The RA government decision on the free and privileged medical help and services guaranteed by the state (N 318-N, 4 March 2004) says the population of the country is provided in-hospital medical help and services of the following types:

• reanimation procedures

• medical help services related to tuberculosis,

• medical help services related to mental and narcological diseases,

• medical help services related to intestinal and other infectious diseases, HIV/AIDS,

• Maternity care

• medical help services to persons of military conscription age,

• obstetric services,

• medical help services to children under 18,

• hemodialysis services.

Now let’s suppose that you are well aware of your eligibility to get medical services by state funding. And, yet, you may be surprised to learn that, despite submitting all the required documents proving your eligibility, the clinic you visit has run out of the funding. And that is totally possible.

However, the website of the Ministry of Health, Armed.am, gives you opportunity to find out how much funds are still available under state financing program for each medical center. As of mid-June, there were medical centers that had already used the state funds allotted for the whole year.

For example:

• Only AMD 1800 were remaining from about AMD 8 mln intended for out-of-hospital and hard-to-reach diagnostics in the Yerevanbased medical center “Slavmed”;

• Only AMD 7800 were remaining from about AMD 12 mln intended for first aid medical services in the Jermuk Health Center in Vayots Dzor; and so on.

The sectors getting most funding from the state (billion AMD)

The indexes are brought in billion AMD. The state funding is provided in 27 directions. In the case of 13 presented directions the funding exceeds 1 billion AMD per year. Source: RA Ministry of Health (upon the request of Ampop Media)

It seems the demand for a certain type of service has been so high in the mentioned medical centers that the funds intended for that service for 12 months have depleted in less than six months. That is, the medical centers have received the funding for the whole year, yet, have spent it on services way before the end of the year.

In such case the same services may be rendered to patients in medical centers, where the funds are still remaining. And yet this raises another set of questions: what if you prefer a doctor in a certain medical center, or a center that is closest to your home?

The answer is still the same: you either choose another medical center, or pay out of own pocket.

The Armed.am website says there are 40 types of services rendered through state funding. The financing of each such service is distributed across months, and in the case of most of those services there are still remaining funds, which means that the funds allotted for the upcoming months are not spend yet.

Sources of funding healthcare services in RA

At the roundtable on the health insurance system organized by the “Journalists for the Future” NGO in late April, Ara Sinanyan, expert of the standing committee for healthcare at the National Assembly, confirmed that the state funding gets depleted in a number of medical centers by mid-year. “The reason may be the poor planning,” the expert said.

Indistinctness about insurance

And yet, there is a significant number of people who do not use the option, because of incompliance to any of the described social groups eligible for the state funded services, and are forced to pay out of own pockets, when facing the need to undergo an expensive surgery.

This mechanism of payment is called as is: an out-of-pocket payment.

The lion’s share of all health related services in Armenia are actually out-of-pocket payments. And though the budgets allotted by the state for health services grow year by year, the amounts

paid out of pocket for healthcare services grow, too. The most up-to-date complete information is available in the National Healthcare Аccounts 2018 report.

Presumably, this problem can be potentially solved through introducing health insurance. The idea is to safeguard people from unexpected health related expenses through regular payments to insurance companies of a certain portion of their income, in order to have the companies pay for the healthcare services, when such necessity arises.

The incumbent government of Armenia had developed the first draft of the comprehensive health insurance strategy back in 2019. The second draft is currently under development.

The government’s action plan for 2021-2026 envisions exact dates when the concept on comprehensive health insurance is anticipated to be passed, along with respective legislation, as well as the timeframes of establishing a special fund intended for accumulation of the means of insurance, and other related functions. Most of the set deadlines have long been exceeded.

The initiative is currently getting funding. Last February Minister of Health Anahit Avanesyan told the “Sputnik Armenia” news agency that according to the ministry’s estimates employed citizens of Armenia will pay approximately 3% of their income, with their employers paying a portion equal to another 3% of employees’ income.

At the roundtable on the health insurance system organized by the “Journalists for the Future”, Paylak Tadevosyan, chairman of the Taxpayers’ Rights Protection NGO, insisted that introduction of a comprehensive health insurance will come at a price for the working part of the population, implying increased taxes and imposing heavier burden on employers.

“This system is unacceptable to me also from the perspective of social justice, because it seems an employed citizen is going to pay for those who are jobless,” says Tadevosyan.

Violetta Zopunyan, head of the “Center for Rights Development” NGO points to problems, which may potentially pop when the system is rolled out.

“We deal with lots of those patients, who are eligible for state funded services, but in fact are unable to entertain their right for that. And now, as we hear everybody needs the right and will be using those packages, we have the fears people will face quite a different situation. I am afraid that even those rare [editor’s note: vulnerable groups] who have an opportunity to get those services to some degree owing to the decision 318-N, will be left out in case the insurance system is introduced,” Zopunyan says.

She recalls the introduction of the Armed system: “It was deployed in 2017 and was intended to move from paper-based documentation to electronic circulation of documents in the sphere of healthcare. Yet, even today, the search for patient charts [widely known as anketa] at the policlinics is there.”

The expert at the National Assembly points practical situations need to be studied in more than one direction before the system is introduced.

“The state increases the funding of the healthcare system every year, extends the list of medical services covered by state. But there are problems, such as the queues for those services, which were to a certain degree generated by the situation with the COVID and the war. And the problem is not solved yet. Imagine the queues that will be, when the comprehensive insurance gets deployed,” the expert believes.

Ara Sinanyan adds that introduction of the system is unacceptable unless the problems get solved; otherwise, he predicts both a stressful situation and a crisis of services.

WORKFORCE AND FACILITIES OF ARMENIA'S HEALTHCARE SYSTEM

Number of hospital beds by regions of Armenia in 2020 (per 1000 population)

Since the 1980s, the number of hospital beds per 1,000 population has continuously decreased in all three countries of the South Caucasus by more than 50%, making an average of 4.6 beds in 2020

In 2020 medical care of the country was provided by 1251 health facilities

The workforce in total was 31,140 people

Most of the healthcare facilities and workforce are concentrated in Yerevan

The animated version of visual content can be accessed here: https://fb.watch/ir4MO7729E/

UNATTRACTIVE TERMS KEEP MEDICAL WORKERS BACK FROM TAKING UP JOBS IN RA REGIONS

Ani, mother of a 4-year-old boy, Henry, is in Yerevan to get medical advice over the regular complications observed in her son’s health condition. The frequent increase in the boy’s body temperature seems too risky to keep him in Kapan, the specialists at the pediatric department of the local medical center have told Ani. The head of the department has referred him to examination in one of the Yerevan-based clinics suspecting a kidney dysfunction case.

“We rushed him straight to Arabkir Medical Center. We were supposed to see a nephrologist; but we had to wait in a queue for hours before we could actually see the doctor. The doctors’ suspicions were confirmed; a complication of streptococcal infection has ended up as a kidney dysfunction,” Ani Sargsyan, the boy’s mother, shares with Ampop Media.

The mother and the child are back in Kapan now. Despite Henry has been discharged from the hospital, the health problem may return at any moment; so, Henry remains under doctors’ control at the Arabkir MC.

Nephrologist is not the only specialist required

at the Kapan MC. Henry, 4, too, is neither the first, nor the last patient to be rushed to a hospital in Yerevan some 300 kilometers away from his home, because of the lack of specialists in his hometown.

Further yet, the lack of specialists is not the only problem persisting in regional hospitals. Senior level medical workers are mostly available in Yerevan. According to statistical data, there are 59 doctors per 10 000 people in Yerevan; the ratio in the regions is 3.5 times higher: only 17 doctors are available for the same number of population.

To fill the vacancies in regional medical centers, the Ministry of Health has started a clinical residency program at the Yerevan State Medical University since 2011; the program envisions tuition-free education in the departments of the university that train specialists in the disciplines most demanded in the regions.

Kristine Gyurjyan, the head of the Staff Management Department of the Ministry of Health, says the vacancies in the regions are announced twice a year in order to get a full

picture regarding the most needed specializations. “We provide targeted clinical residency vacancies specifically for those disciplines, which are most wanted in the regions,” says Gyurjyan in a conversation with Ampop Media, adding that as part of the program the ministry signs a contract with the students, who apply for the mentioned places at the university.

The contract envisions an obligation on the part of the graduating student to work in a regional hospital for at least three-year period, as designated by the ministry.

Gyurjyan assures the program helps fill some 30 to 40 % of the vacancies in the regions.

Offering attractive terms of work in regional medical centers

The statistical data shared by the provost for postgraduate and continuous education of the Yerevan State Medical, Garnik Avetisyan, shows an interesting trend: this year alone, there have been 42 students majoring in pediatrics for their clinical residency program.

“The Ministry of Health has announced 22 vacancies for pediatricians on its official website

as of the month of February, which could be filled shortly. The Muratsan University Hospital alone accepts some 1300 to 1400 children a week, which come from all over Armenia,” Avetisyan says. He adds, though, that the creation of work conditions more attractive than those offered in the capital is an urgency to meet the need of specialists in the regions.

Gyurjyan, too, tends to think that the reluctance of the young professionals to work in the regions has social underpinning. She believes, a young professional, especially the one with a family, looks for some satisfying living conditions and some interesting pastime options in order to agree to live away from the capital.

There were times when doctors were assigned to remote regions for a 5-year term; today, though, the numbers of vacancies have grown, whereas the contract period has dropped to 3 years.

“Our conversations with doctors prove 5 years are too long period for them, especially for those, who consider moving from Yerevan. People want some pastime [after work, which is hard to find] in the regions, and they face problems of organizing their routine. Those problems need to be solved when offering more attractive work and life conditions,” says Gyurjyan.

Vacancies for doctors, by region (as of September, 2021)

Source: National Institute for Health

Source: National Institute for Health

Another program, relaunched by the Ministry of Healthcare in 2020, which has the purpose of filling in vacancies in regional medical centers, offers more or less attractive terms of employment. The program is partially shown on the picture.

Eight specialists have been assigned to fill the open vacancies in medical centers in Kapan, Noyemberyan, Meghri, as well Tashir and Vanadzor.

The main specializations required at the regional medical centers include surgeons, anesthetists and emergency physicians, as well as obstetricians and gynecologists.

Kristine Gyurjyan says students oftentimes choose to major in disciplines that may prove potentially more profitable in future, or, alternatively, have wider scope of application. That is the reason that financially less attractive, yet highly demanded specializations are left out of the preference list.

Rebranding medical disciplines; might the COVID-19 have brought a positive change?

“Potential students were reluctant to choose emergency medicine. The salaries of emergency doctors have increased since the pandemic broke out, and students seem to opt for it more often. We have envisioned 12 targeted vacancies for clinical residency in emergency medicine, and have already managed to fill in even the pediatric emergency vacancies. The competition was high, because the specialization was made financially more appealing,” Gyurjyan says.

The provost of the Yerevan State Medical University believes the chosen majors shall meet the market expectations. To ensure employment opportunities, Avetisyan suggests limiting oversupplies in the job market.

“There are specializations that are both vital and interesting, but those are not perceived properly by the public, and, so, applicants opt for other

The order and terms of compensations for senior and middle range medical workers temporarily assigned to regional medical centers

According to a govenrment decision, AMD 100 mln envisioned for 2022-2025

Source: Decree of the RA Minister of Health N 567-A,12 February 2020

specializations; those are forensic medicine or clinical pathology, for example. The applicants have quite vague understanding of the essence of the job and the opportunities it offers,” Avetisyan underlines.

Unlike pathology, which the management of the university has successfully promoted by revealing its attraction for applicants, forensic medicine still remains a less preferred discipline. There is no much demand for forensic medicine professionals in the market, despite a certain shortage of human resources.

The case is the same for epidemiologists and specialists in communicable diseases. The COVID-19 pandemic seems to have somewhat changed the public perceptions and the scope of applicants’ interests.

The pandemic has also proven the importance of pulmonologists. Last year for the first time ever, the state funded clinical residency

vacancies have been envisioned in angiosurgery, pulmonology, as well as thoracic surgery.

Gyurjyan observed that the NK war and the pandemic showed the urge for these specializations.

To balance the supply and the demand in the market and to prompt the potential students to view options for majoring in disciplines beyond the trendy ones, the State Medical has undertaken some tactical steps by offering privileged terms for the professions on high demand. As part of these steps, the university has decreased the tuition for those who will choose pediatric specializations for about 50%.

In fact, the number of this year’s residencies points that the model of management chosen by the university does work. Finding ways of need-based distribution of graduates to clinics and medical institutions will be the next step of the efforts made in this direction.

STATE FUNDING OF HEALTHCARE AND A TRANSITION TO HEALTH INSURANCE

The 2023 state budget of Armenia envisions an increase in the funding of the healthcare by 4%, as compared against this year’s funding; and yet, the index will only comprise 1.6% of the country’s GDP.

The state budget of Armenia is expected to collect 2 trillion 364 billion Armenian drams (about US$ 5,91 billion) in revenues, with 2 trillion 652 billion AMD (about US$ 6,63 billion) anticipated expenses for the next year. This means the deficit is expected to reach some 288 billion AMD (about US$ 720 mln).

The overall amount envisioned for the healthcare is expected to reach 146 bln 373 mln AMD (about US$ 365.8 mln). Despite being declared to be a priority the healthcare still gets lesser portion in the state budget.

As an example, the amount envisioned for the maintenance of the state debt is nearly the double of that allotted for the healthcare, equaling to 272 bln 122 mln AMD. And it is likely that the portion of healthcare in the overall structure of the country’s GDP remains unchanged due to the urge to steer the budget to covering the debt.

Tigran Khachatryan, the Minister of Finances of Armenia, reminded during the debates over the draft budget of the republic in the National Assembly, that ongoing expenses will set restrained growth in case the government’s debt is above the 50% benchmark. At the same time, the minister assured of an agreement reached during the discussions held at the government on that a major growth in the financing of the sphere shall be ensured for a mid-term perspective.

The minister also explained that the overall amount allotted to the healthcare has not decreased; the growth in the financing in the past years has been due to the programs aimed at the neutralization of the consequences of the pandemic, which have dropped this year, because of more forecasted predictability of the situation. Anahit Avanesyan, the Minister of Healthcare, underlines that the ministry tries to ensure the portion of the sphere reaches at least 4% of the country’s annual budget.

Professor at the Yerevan State Medical University Davit Melik-Nubaryan, PhD, says the financing of the healthcare has nearly doubled since 2018, which is

Healthcare in the 2023 state budget (bln AMD)

Source: Draft State Budget The interactive chart can be accessed here: https://bit.ly/3wNRaet

definitely a positive move, yet, the professor says, it is not enough to ensure provision of comprehensive healthcare services.

Melik-Nubaryan says that might require at least twice the amount provided now; the index has to be at least doubled in the structure of the GDP. The expert reminds of the European countries, where the healthcare makes some 7 to 10% of the GDPs, and that is believed to be an optimum index to ensure a proper level of healthcare services.

“A system evolving around hospitals makes it a system

concentrating on treatment, and, so is inefficient in terms of ensuring public health,” Melik-Nubaryan says, adding: “A system that is structured to treat patients is extremely inefficient in terms of budget expenses, because the WHO data indicate hospitals are the top source of healthcare inefficiency. From that perspective, strengthening the primary care institutions shall have an immensely positive impact.”

The next year’s budget envisions 1.7 billion AMD for the planned increase in salaries of primary care medical workers.

The healthcare budget over the last 5-year period

The actual funding for 2022 exceeded that of 2018 by 78%.

Aharon Barseghyan, the head of the State Health Agency (SHA), details on the mechanism of salary revisions in a conversation with Ampop Media.

“There are problems in the sphere of healthcare and their solution is mostly connected to the increase of efficiency of primary care institutions, which is why we are planning to set indexing of primary care workers’ performance, so that doctors get bonuses for meeting the set benchmarks or exceeding the anticipated results.”

This means that starting from 2023 the salaries paid to doctors of the primary care institutions (district physicians, pediatricians, and family doctors) will be calculated based on the load and the quality of performance. The official says the envisioned bonuses may be quite substantial and motivating. The ministry envisions growth in 55,000-60,000 AMD (about US$ 150) per specialist.

Barseghyan assures the changes are not about the salary increases conditioned by the professional qualification of doctors, but the actual load and the quality of services. For instance, a patient suffering hypertonia (high blood pressure) requires a regular medical supervision; in case the supervision is organized on proper level in the primary care institution and the blood pressure of the patient gets controlled and the medication is used in time, most likely a patient will not need hospitalization. The expert says the doctors at the primary care institutions will not need to develop new skills to perform the job, because that’s what they do on a daily basis.

“We want to gradually switch to strengthening the out-of-hospital services to limit medical care and services provided at hospitals, because that’s the most efficient method in terms of prevention.”

The problems in polyclinics, the expert says, are due to years of poor financing of the institutions. Hospitals have been prioritized over the polyclinics in terms of budgetary allotments. He believes that is the reason the polyclinics today are far from providing satisfactory level of services, yet the experts prioritize the vision.

“We want to have well set up efficient primary care institutions, to make sure only the complicated cases are referred to hospitals for medical help,” Barseghyan says.

Davit Melik-Nubaryan says people have inaccurate perceptions of the possibility to treat complicated cases such as the liver transplant at polyclinics. “It’s been our own fault to let those perceptions spread. But the polyclinics are not supposed to deliver those services. The material and the technical furbishing of the clinics lets them perform their functions. People have to revisit their attitudes. Why would someone with hypertension appear in a hospital?! A primary care institution is definitely much better at handling it,” says Melik-Nubaryan.

The program for the mother and child healthcare remains priority for the sphere and envisions about 7.2% increase in costs. The budget is planned to reach more than 21 billion AMD (about US$ 52.5 mln).

The treatment of cardiovascular diseases, diabetes, and malicious tumors is expected to get more than 20,1 billion AMD (about US$ 50.3 mln).

Source: RA Statistical Committee The interactive chart can be accessed here: https://bit.ly/3wNRaet

Armenia on the brink of state insurance of health

The head of the State Health Agency says despite a concept of the medical insurance has been circulating starting from the 1990s, the state has not been prepared for its introduction in terms of infrastructures to the extent it is today.

“The government is in the stage of finalizing the technicalities of the concept. We have near final drafts of legislative initiatives and supplementary acts, and, what’s more important, there is a political consensus on that medical insurance has to be introduced. I have to underline that this will be specifically a state medical insurance,” Aharon Barseghyan says.

The expert says the state guarantees services of medical insurance to citizens of Armenia. The system will be introduced on a stage by stage basis; it will be introduced for certain target groups at inception, and most likely, those will be public servants, and the groups covered by the insurance will be expanded gradually. Before making the insurance mandatory to all, the state plans to give an opportunity for voluntary engagement by subsidizing payments to a certain degree.

Barseghyan believes the concept is likely to be passed by end of year, with another year envisioned for preparations. The prices are expected to be defined in the preparatory stage; and that will be followed by the actual introduction of the system. Barseghyan assures following the introduction of the system, the state will continue including some of the target groups and providing health insurance to those occupying key state positions.

It is still unclear exactly how the system is going to be introduced; whether it is expected to set a fixed amount of income to be paid for insurance, or there will be a certain amount proportionate to the income for the insurance. The head of the SHA says the discussions are still underway.

The Minister of Health Anahit Avanesyan shared some details on the stage by stage introduction of the system during the discussion of the draft budget at the full parliamentary session on November 13.

Some 134 billion AMD (US$ 335 mln) are envisioned for the introduction of the health insurance system. The number of beneficiaries is expected to be levelled in 2024.

175 billion AMD (US$ 437.5 mln) are planned for the program in the same year to ensure comprehensive coverage; a pilot program is also expected to be introduced in 2024. The introduction of the system for citizens is planned for 2025.

The insurance will cover cardio-vascular conditions, oncological diseases, diabetes and other health related issues. The package will not include dentistry, plastic surgery, as well as a number of other services.

HINDERING TO AFFORDABLE TREATMENT OPTIONS

Routes to import medication blocked by legislation

Armenia is the only country in the world, where the packaging of medicines is opened at pharmacies to make buying only a certain number of the pills possible, says expert Hovhannes Martirosyan.

“Opening packaging of drugs is forbidden elsewhere. How come it has been made possible in Armenia?! The reason is that majority of people cannot afford buying a whole package. Why? Because the prices are too high,” the expert said in a conversation with Ampop Media.

Martirosyan says with proper policies the prices of medications in Armenia can be reduced by 40%, to make them affordable enough for the people to buy them in closed packaging and help pharmacies avoid going against a major regulation of the sphere to never open a package before sale.

Hovhannes Martirosyan is a pharmacist and holds a PhD degree in biology. In 1992-1998,

Martirosyan has been the first head of the Licensing Department of the Scientific Center of Drug and Medical Technology Expertise, and has worked in the healthcare system till 2005.

Opening a pharmaceutical company in Moscow in 2015, Martirosyan had decided to import drugs to Armenia at prices that he said would be lower than the market prices. For that he was planning to operate “Vita pharm”, a company that would help him organize the imports. Yet, it never proved to be an easy endeavor.

The company’s attempts to import some 10 types drugs were rejected by the Center for Drug Expertise on a wide range of grounds. Martirosyan recalls cough syrups manufactured by a Hungarian pharmaceutical company “Egis” were imported to Armenia in those days.

“Egis” was registered in Armenia as the company that manufactured the type of syrups, yet, in the

status of an open joint stock company, whereas according to its documents the company was in fact a closed joint stock company, something that was indicated clearly on the packaging of the batches imported by “Vita pharm”. And since the change was not registered in the drug database in Armenia, the Center for Drug Expertise had concluded the importer was not registered in Armenia.

“We were told the status of the company would be updated once the right holder company that had registered the medication in Armenia applied for that, so that the drug we imported would be classified as registered. I did make attempts to reach to the right holder, but was told the application would be submitted when the right holder wished so. Of course, the right holder delayed the updating procedures until the batch it had imported was sold. That’s why the syrups we had imported from Russia planning to market at prices 40 to 50 percent lower, were prohibited by the state, pointing to a requirement of the law,” Martirosyan recalls.

It looks like for a permission to import in parallel a certain type of drug, the pharmaceutical products that are intended for import and those registered in the database have to totally coincide.

To obtain a permit for parallel import the drug to be imported shall be fully identical to the one registered. The Law on Drugs says all the batches of the drug shall be recalled from the market shall the insert slip of the product submitted by the registered drug right holder has the slightest difference from the registered version or the packaging of the imported drug, even when the difference refers to the design, an issue that is beyond the competence of the Drug Agency.

Meanwhile, the parallel imports of drugs are allowed globally, in case the registered and the imported drugs differ in a way as to not question their safety and efficacy.

The routes to import pharmaceutical products are blocked by legislation

The registration in the state database of drugs is a precondition for the import of medication to Armenia. According to the law regulating the drugs only the right holder of the drugs is authorized to import to Armenia. And the right holder is the entity that registers the drug at the Drug Agency. Martirosyan says this clause of the law blocks any option to import drugs to the country and monopolizes imports.

Examinations required to get certificate of importer of pharmaceutical products include

Source: RA Ministry of Health

Upon receiving a certificate of importer, an importer organization undertakes verification for compliance of the imported drugs to the requirements set in the Republic of Armenia before the start of sales (except for the drugs imported as part of charity and humanitarian programs)

Vahe Varsanyan, the head of the “Vaga Pharm” company, one of Armenia’s largest importers of drugs, shares Martirosyan’s position; according to the legislation regulating the circulation of drugs a lion’s share of imports belongs to the right holders, whereas importing through supplier companies is practically unfeasible.

Varsanyan says the legislation is devised to protect the interests of the registration right holders, forcing other companies to import drugs from them.

“So, as a matter of fact, the right to import the lion’s share of the drugs belongs to the right holders of drug registration. The legislation bans importing the same drug from other markets, specifically, the EU and the EAEU. The legislation was designed by the experts of the drug agency, and in a way that best meets their own interests,” Vahe Varsanyan says.

Varsanyan believes, in a situation where there is lack of competition, and the right to import and sell drugs belongs solely to its right holders, the latter the ones who set the prices in the market.

Prices on drugs dropped during the coronavirus pandemic and the 44-day war; What made it possible?

In 2020, the prices on certain drugs dropped amid the pandemic and the war. Those were mostly drugs that were not registered in the country, and there was a certain degree of shortage of their equivalents against the rising demands.

Registration of drugs is a time consuming endeavor that implies a wide range of procedures, which means entering local markets for much needed drugs may be a long process. The import of non-registered pharmaceutical products to Armenia was permitted by a government decision, something that was a favorable move for those importers, who were not right holders. The purpose was to ensure the population was provided with the needed medicines.

Drug importers say the pharmaceutics market won from the situation as the market got

decentralized, the prices dropped dramatically, while their range grew.

Vahe Varsanyan, the head of the “Vaga Pharm”, thinks the decision allowed for vitally important non-registered drugs reach Armenia, as there were no alternatives to them in the country by that time. He says the market prices dropped tangibly, as the import of vital drugs from EU and the EAEU was permitted.

Varsanyan underlines there is no reason to question the quality and the safety of nonregistered drugs. Those are mostly drugs that have been registered in Russia and the European Union and meet international standards. “There are many drugs in Russia that are vital, for which the state enforces low prices. We benefit from that at importing those vital drugs to Armenia. There are also drugs that have dropped in price by 5 or 6 times. And there are EU member states that are poor and get subsidized, and so we benefit from importing drugs from those countries at lower prices, too,” he explains.

Varsanyan adds around 700 types of drugs had become more affordable in Armenia owing to the competition that was formed in the market during two years. However, permission to import non-registered pharmaceutical products expired on 31 December 2021. The government says extending the permission was unnecessary out of the fears the market could be hard to control.

The Ministry of Health justifies the decision by the concerns that unregistered drugs of questionable quality could be imported to the country and the process could become uncontrollable. Vahe Varsanyan argues the position by pointing that no case of unsafe drug imports had been registered and no problems had been identified while the imports were allowed.

“Furthermore, the permission hit the black market of pharmaceutics. Before, there were numerous cases when the drugs that were in short supply were imported in violation of customs requirements overriding the perspective of criminal investigation. The drugs were marketed at much higher prices. The prices on the black market had dropped significantly, while the

permission was still in effect,” Varsanyan recalls.

The Ministry of Health confirmed to Ampop Media that no cases were registered on nonregistered drug quality or safety in Armenia in 2020-2022.

Varsanyan says the permission to import nonregistered drugs parallel to right holders let small and new companies to enter the market.

The prices of drugs dropped in the result of decentralization and the competition that was shaped in the market.

Ampop Media requested the State Revenues Committee to provide a list of drug importing companies in Armenia. The statistics shows a dramatic growth of the number of importers in 2020, and a proportionate drop following the January 2022.

Experts and heads of drug importer companies share the opinion that Armenia has once again found itself at the starting point of 2020. There is less competition now, which explains the rise of prices on drugs.

The importers suggest extending the permission to import vitally important unregistered drugs to at least the end of 2025 to avoid collapse in the sphere.

Starting 1 January 2026 the drugs in the territory of the EAEU will have to be undergone the registration and procedures compliant to the rules of the union. That will let import drugs that will be officially registered in the territory of the EAEU.

The Scientific Center of Drug and Medical

Technologies Expertise after Academician Emil Gabrielyan responded to Ampop Media’s request to comment on the decision to suspend the permit of the parallel imports of non-registered drugs to Armenia. Anna Tsaghikyan, the head of the Center’s Department for the Control of Imports and Exports of Drugs says the very wording vitally important is not correct from the agency’s perspective.

“I respond to letters regarding postal delivery of drugs, which are not registered in Armenia on a daily basis. Judging from those letters, those vital drugs, which were not registered and were not imported during those two years, were not imported following the decision, either. The gaps regarding the treatment of some health conditions that have existed before have remained unsolved to this day.”

Number of pharmaceutical product importing companies in Armenia

Source: RA State Revenues Committee

Commenting on the legislative gap pointed by both the experts and the importers to give the right of imports solely to right holders who register the drug, Vardanyan said: “Any legislation may have gaps; the center is open to every suggestion, but we have not received any reasonable offer from any economic entity so far that could be worth submitting to an authorized body.”

Expert Hovhannes Martirosyan believes the pharmaceutics market has been controlled by medical representatives rather than the Ministry of Health or the drug control agency for the last 30 years. “They have serious leverages in their hands and are the ones to actually decide which drug to register in Armenia and what type of decision to make. They are the ones to define policies. And they do that guided by their own corporate interests rather than Armenia’s interests. An elderly patient with a health condition complains of high prices on drugs and blames importers, who earn millions, while the elderly remain unable to buy the needed drugs. Yet, the importers are fully dependent on the medical representations operating in Armenia”.

PATIENTS' PERSONAL INFORMATION RIGHTS GET VIOLATED IN ARMENIA

A patient’s personal data confidentiality rights get violated every time other people (other patients for that matter) are present at a screening a patient is undergoing or other patients are there at the doctor’s, while the patient shares about his or her complaints.

Healthcare experts say information related to patients’ health condition is treated with much neglect in Armenia’s medical practice; the core issues pertaining to the confidentiality of patient information remain unsolved.

Violations of patient rights pertaining to confidentiality of personal information can be observed on more than one level.

Violating confidentiality rights: medical ethics

The issues related to the confidentiality of health condition of patients are regulated by international law. Zhenya Mayilyan, head of the

Real World, Real People NGO, says in Armenia, though, the protection of information related to patients’ health condition is not there as a social demand.

“We were on a regional visit recently for a training intended for doctors. At some point one of the participating doctors left the room and said out loudly in front of some 20 doctors of a small community: ‘The diagnosis has been confirmed with Gohar’s daughter-in-law’,” says Mayilyan in a conversation with Ampop Media, adding: “I don’t think the person meant anything evil: we just have that culture-specific tendency of sharing everything with everyone.”

Mayilyan believes the problem is observable anywhere across the country, not just the regions.

The head of the non-governmental organization that is providing services of medical care and

support to people with HIV, says the cases of violations of personal information rights are more frequent among the socially vulnerable groups of the society. Those are people with HIV/AIDS, drug-addicted people, people with mental problems, and so on.

“A person is not stigmatized for having pneumonia. But when health information about people from socially vulnerable groups becomes available for public, others’ attitudes to those people change dramatically,” Mayilyan says.

Rights advocate says breaking the confidentiality of health related information about people from vulnerable groups simply harms those people.

“We have had a case of a woman, whose health-related information became a word of mouth in her community, and shut the doors of employment for her and for kindergarten for her kid , forcing her to change her place of residence.”

Mayilyan says the organization also had cases, when the patient’s medical chart had HIV written in huge red letters. The answer that would follow an inquest into the reason of such stigmatization would be – to warn the doctors working with the patient to take precautions. Yet, diseases are given special coding, which helps specialists learn of them to avoid problems.

Zhenya Mayilyan says her organization prepares reports covering the cases of violations of patients’ health-related information confidentiality rights in vulnerable groups. The reports are anticipated to be followed by a task force to address the issue.

Confidentiality of patient information is protected by law

RA Law on Amendments in the Law on Medical Aid and Services to Population entered into effect in 2020. It defines, among other things, the idea of the confidentiality of patient information, stipulating the requirements to it in a legislative act. According to the passed amendments into the law, even a visit to a medical institution is viewed as a confidential information.

Violetta Zopunyan of the Center for the Rights Protection NGO views the amendment as a positive move, but points to the issues of its application in practice.

“That the idea of patient confidentiality concept was defined two years ago was a positive move; yet, we face lots of issues in practice. Let’s take the pregnancy registration process: the document is circulated in a given medical institution in a way as to have every chance to be read by anyone, being left on top of a doctor’s desk and making the health information on it totally visible to others; the first page on pregnancy registration chart includes information on a woman’s HIV status.”

The expert says the obligation to guarantee patient confidentiality has to be made part of employment contract for anyone being accepted into a medical institution.

The Healthcare and Employment Inspectorate responded to Ampop Media inquest informing that it does not consider including protection of patient information into employment contract of people rendering medical aid and services a mandatory measure.

The inspectorate says it obtains no information on whether any employee of a medical institution has ever lost a job due to the failure to provide protection of patient confidentiality.

“A patient’s medical history is quite accessible to others. A doctor works, while a patient history is on the desk, and will be left there in case the doctor gets an emergency call,” Melik-Nubaryan says.

Melik-Nubaryan believes amendments in law will not bring the sought for results unless a culture of confidentiality is formed.

“People have to know that their health issues are very sensitive matters. It is highly important to make sure changes are there on cultural level, besides the legislation. So, it is fundamental to speak about those things. People have to understand that is not normal to share about health issues, nor letting anyone do so. I have never heard of a case of standing responsible for making patient information public.”

Laws are not a guarantee; it is the culture that needs to be changed

“Even the most perfect legislation is unable to guarantee an anticipated result,” Davit MelikNubaryan, an expert in public health matters, says.

“People come see a doctor accompanied by family members, doctors talk to family members. It’s a matter of culture, not just regulations. This is viewed as something quite normal on both sides. We need to shape public awareness on these issues,” Melik-Nubaryan says.

The expert recalls a number of situations frequently observed at policlinics: doctors consult or provide medical help to patients in rooms along with other doctors, because oftentimes the clinics lack proper conditions to ensure privacy, or make sure documents do not pile up on doctor’s desk not to be exposed to nurses or third parties.

The law envisions punishment for the transfer or publication of health-related personal information by an individual or an organization entitled to process such information as prescribed by law through publishing it in mass media outlets or by sharing in channels of communication without the written consent of the person or the person’s legal representative.

Going public with patient information shall invoke criminal responsibility

The actions described in part 1 Article 145 of the Criminal Code, which have resulted in harsh consequences through negligence may lead to up to 4 years in jail.

“Years ago, parents in settlements would inquire a patient history of the bride-to-be for their son at policlinics to make sure they knew the woman who was going to become part of their family. Doctors would share about it, but people would prefer to ignore that,” Gevorg Hayrapetyan, the head of the agency for the protection of personal information of the Ministry of Justice of Armenia, said to Ampop Media.

Hayrapetyan says years ago it used to be a matter a system. Only few were aware of the importance of confidentiality of personal data.

“People used to silence the problem, but the situation is different these days,” Hayrapetyan assures.

He says following a number of leakage cases in the COVID-19 days, the agency he heads, got a chance to organize a training on the protection of personal information for several hundred medical workers.

“Unlike the regular routine, in the period of pandemics, the number of players increased, and so we organized lectures for everyone on how to deal with personal data,” Hayrapetyan recalls.

As to problems voiced by healthcare professionals, Gevorg Hayrapetyan assures the agency has not received any complaints so far. “We haven’t heard any grievances on that and no one has so far come to get some advice. We will at least have some statistics, if anyone raises an issue.”

Ruzanna Durgaryan, the director of policlinics N13, says one of the most frequent cases of such breach is when a mother-in-law visits the medical center to get an excerpt from the medical chart of a pregnant woman.

“We don’t know in person, since most often than not the person is registered at some other medical institution. Whatever the case, the

district physician first checks whether a person is ok if the document is handed over to the person who visits the clinic, and only then do we hand it over to the requestor,” Durgaryan says in response to an inquiry by Ampop Media.

Regulations pertaining to confidentiality of patient information

Tatev Tokhyan, an expert in social rights, thinks despite the assurances of the Ministry of Health that a series of TV programs are underway to increase public awareness of the issue, the confidentiality remains a problem among medical workers.

Tokhyan says well-designed qualification trainings are required to ensure proper awareness. “Way too often medical workers do not really realize they are making third party health information public. Patients shall be equally informed about the essence of patient information confidentiality.”

The Vanadzor chapter of the Helsinki Citizens’ Assembly has received inquiries from citizens and organizations into the possibility of having health-related confidential information.

The inquiries particularly referred to the order by which a health-related confidential information may be made available, as well as the bodies, which may get access to such information. The investigation undertaken by the assembly has shown that there is no such order by which any information related to the health of a patient may be made available to third parties unless such consent has been given by the patient.

Article 11 of the law on help and services rendered to population envisions cases and bodies that are entitled to disclose the health related personal information classified as confidential to third parties.

“However, unless the procedure is defined, it seems those bodies and individuals, possessing personal information, disclose the confidential information without a legal ground”, Anahit Ghazaryan, a representative of the Helsinki Citizens’ Assembly-Vanadzor, told Ampop Media

The draft regulation on setting the procedures of disclosing the confidential health related personal information without the patient’s or his legal representative’s consent was put to a public debate. Ghazaryan adds, the draft act does not define the grounds on which the provision of such information may be rejected.

The law on help and services rendered to population defines the agencies, which are entitled to inquest and get the respective information without patient’s consent. In such case, a justification shall be submitted, Ghazaryan says. “The Law on Psychological help and services, which has the definition of confidential information pertaining to patient’s health, does not stipulate requirement for a justified decision [to inquire respective information], which raises further concerns,” Ghazaryan explains.

Ghazaryan predicts situations, when applications are submitted on standardized forms, without any substantial justification and reason, which will not have anything to do with any investigative activity, and information gets leaked from medical institution for purposes other than that.

That is why, Ghazaryan says, procedures and clear guarantees, as well as justified decision requirements, are much needed.

Police, investigative bodies, bodies authorized to hold medical and social examinations request medical information on daily basis. Since the procedures are not set up yet and so patients do not give a consent for sharing their personal information, it looks like the confidential information is shared without a definite procedure.

One of the objectives of introducing electronic system of healthcare is the organization of proper storage of patient information. Healthcare experts say the system may help in increasing the safety of personal information.

The move from paperback patient histories and registry books to the system Armed will ensure the confidential personal information gets available only to those with appropriate access. Yet, the experts say, any system, ideal as it may be, bears risks, which have to be foreseen and precautioned before the roll out for public use.

The

role that electronic healthcare system may play

PATHOLOGIES AND COMPLICATIONS ON RISE IN PREGNANT WOMEN

Lena would love to have another baby, but her fears are bigger than her desire. She had almost died while delivering her first two babies; and, so, all the thoughts of getting pregnant for the third time end up with a refusal to. Her daughters are now 11 and 10, but she vividly remembers the problems that rose during her pregnancies and labor.

Lena was diagnosed with Preeclampsia, a hypertensive pregnancy disorder accompanied with multi-organ damage. That’s a pre-terminal stage of the disease, which means neither the mother nor fetus may survive in case it reaches a terminal condition.

“That was my first pregnancy, I had all the checkups, and they [the doctors] would say everything was just fine, and insisted my health condition was as good as that of a school-aged girl. But

I had a feeling that something was not going the way it should. The more the fetus grew, the more issues I noticed: my limbs would swell, even my face, so, I had to sleep in a seated position. Meanwhile doctors would keep saying that everything was fine. So did the test results,” Lena recalls.

Throughout the seven months of her pregnancy she continued to tell her doctors she had the feeling she had problems, but had been getting advice to calm down. Well into the seventh month of her pregnancy Lena was undergoing a regular check-up. The results seemed bothering to the doctor, who sent Lena for another test, and called Lena back in two hours to tell her she needed to get back to the clinic.

“The additional tests had shown an immense amount of protein in my urine and a major and

uncontrollable hypertension. After hours of failed efforts to decrease my blood pressure, my husband and my family were told I needed an urgent intervention otherwise neither my baby nor I were going to survive.”

The disease could claim lives. Lena says it was the doctors’ negligence of her complaints that had resulted in the situation. She believes otherwise her condition would be prevented at an earlier stage, and her baby wouldn’t be born premature and there wouldn’t be a need to fight for its survival in the early days of her life.

“My second pregnancy went smoothly, but I was having a C-section to deliver the baby, and got skin burns because of malfunction of the device used during the surgery. I don’t really know what was it that went wrong then, but my belly was totally covered in burns, as did the doctor’s hand,” Lena shared with Ampop Media

Numbers of delivery and post-partum complications grow among women

According to the Annual Statistical Report on Mother and Child Health the number of complications arising in women during and

post-partum have shown dramatic growth in the last 30 years. For example, in 1990s anemia was diagnosed in 13.8 pregnant women out of 1,000 (which made just 1.4%); to compare, in 2021 the number reached 135.1, or the 13.5% of women.

In 1990s problems of genitourinary system (previously known as the kidney diseases) were registered in only 3 out of 1,000 women; in 2021 the numbers reached 83 (i.e. in more than 8%).

Ruzan Martirosyan, head of the Mother and Reproductive Healthcare Section of the Mother and Child Healthcare Department at the Ministry of Healthcare told Ampop Media the growth in numbers of complications may have multiple reasons.

“The growth in the number of thyroid diseases may be a result of iodic deficit in Armenia. Venous pathologies may have more than one origin; that may be an inherited predisposition, sedentary life or a job requiring a woman staying in standing position for long hours in a row. Any of these may bring complications in the period of pregnancy.”

Delivery and post-partum complications in the Republic of Armenia (per 1,000 births)

Sources: Annual Statistical Report on Mother and Child Health, National Institute of Health The interactive chart can be accessed here: https://bit.ly/3Rk3EE2

According to the data for the year 2021 every second pregnant woman in 1,000 appeared to develop either delivery or post-partum complications Anemia and hypertension conditions are among the most growing cases

Another type of frequent complications, that of placenta increta, may be a result of C-sections a woman has undergone throughout her life. In case of frequent reliance on C-sections, more

women may encounter the problem. Martirosyan says diseases and complications may also be typical to time period or changes in lifestyle of a pregnant woman.

Diseases complicating the labor and post-partum periods by marzes, 2021 (per 1,000 births)

Source: Annual Statistical Report on Mother and Child Health, National Institute of Health The interactive chart can be accessed here: https://bit.ly/3Rk3EE2

Martirosyan questions some of the information in the annual report. For example, she says it is unclear whether the growth in numbers of diseases is caused by their actual occurrence, or the poorer data available for the 1990s; or, because the numbers are available now because of the more actively performed check-ups and better diagnostics. Yet, Martirosyan is sure not all complications represented in the statistical data are directly relatable to pregnancies. Too often, pregnancy is not a reason for a certain health condition, but rather a trigger for it to reveal itself.

“The culture of visiting a doctor is still far from being perfect. As a rule, an adult woman first sees a doctor when she is already pregnant and needs supervision of an obstetrician. It is only then that tests are done, and oftentimes it is those tests that reveal abnormalities. On the other hand, a woman who has never seen a doctor before, is unaware of symptomless complications, and the pregnancy (which brings additional load on a woman’s body in terms of hormonal and physical changes it undergoes) triggers those diseases. All that gets reflected in the statistics.”

Check-ups are required before planning a baby

By a decree of the Minister of Health of Armenia starting 2020 newly married couples have opportunity to undergo free medical check-ups to identify the risks during potential pregnancy. The check-up is available three months following the registration of the marriage by a visit to polyclinic with a marriage certificate.

“The available tests vary. For example, some vaccination against certain infections may be required, for the lack of one may have certain consequences, in case a woman gets infected in the period of pregnancy. The check-up may identify a chronic condition at an early stage, because in some cases medication cannot be prescribed in the period of pregnancy. Couples are also checked for infections, as they may seriously affect the pregnancy. The list of free tests is pretty long, in fact,” the expert says.

The opportunity is available for both women and men.

The number of visits grows on a slow pace, despite the experts say there is still a lot to be done to increase awareness among the population.

and trust one’s life to doctors, despite the efforts may sometimes require months to show results. And doctors plead to undergo check-ups. Complications are only numbers in an annual report; in real life they may bring to irreversible problems. Check-ups may not always guarantee against problems

Adelle is a mother of two, although she has had three pregnancies. The birth of her first child, a girl, has been very easy. And yet her second pregnancy that occurred five years following the birth of her daughter had to be interrupted at the fifth month.

“In the third month of my pregnancy I appeared to have uterine hypertonia and a hematoma; my blood was extremely thick. I spent the third to fifth months of pregnancy in bed. I sometimes happened to get by intravenous medication with needles in my both arms at a time. But all that proved useless,” Adelle shared with Ampop Media.

Adelle says she took all the tests following the abortion to make sure her health was fine. The blood issue was gone, her health was restored, and she was psychologically prepared to get pregnant once again.

“I learned I had developed a hematoma right after I learnt of my third pregnancy. I was under doctors’ supervision from the first day, but my health deteriorated again during my fifth month, and, so, I was forced to spend the next two months in bed again. As I reached the seventh month of my pregnancy, we ran out the ability to fight for it further, and so I gave birth to my boy with the help of a C-section. It was extremely complicated, but, fortunately, everything is just fine now.” Now, after the pregnancy, Adelle’s blood issue is gone.

Complications that are developed or are identified during pregnancy may be unmanageable and unpredictable. Lena says her story shall prompt women to listen to the signals of own body and insist to be checked, because negligence may cost a life.

Adelle also calls on everyone to be consistent

LITTLE ADAM UNDERGOES A SUCCESSFUL BONE MARROW TRANSPLANT SURGERY

Meline Avetisyan and Gor Ohanjanyan are in the seventh year of their married life together; they say, this period has made them grow up, separating life into periods before and after the year 2021.

The unexpectedly deteriorated health condition of their firstborn child, Adam, in January 2021, made them put aside the worldly life they had before and start living in daily prayers.

Their son Adam was only 1.5-year-old, when they took him to hospital. It took the doctors some while before they could tell the reason Adam’s body temperature would keep high for 30 days in a row. A blood test at the medical center “Arabkir” showed the boy had contracted COVID-19.

The acute myeloblastic leukemia, a malignant tumor of blood and bone marrow, was diagnosed at the Center for Hematology after Prof. Yolyan.

“We celebrated Adam’s second birthday at the

intense care unit in ‘Arabkir’. Doctors’ prognoses were pessimistic about Adam. His chances of survival were just 3 percent… By the grace of God, we somehow overcame the COVID, but stayed under doctors’ supervision at the hematological center for 3 months, because the doctors had suspected a blood condition with my son,” Meline, the boy’s mother, recalls.

Doctors were unanimous in that the only way to save the boy’s life was to have a bone marrow transplant, an option unavailable in Armenia. It was decided to take Adam to Saint Petersburg for the surgery.

To pay the bills of the surgery, a fundraising was organized on Facebook. Little Adam grew popular owing to the fundraising. The needed sum was raised in just six days; the transplant of the bone marrow was successful.

It’s been several months now little Adam and his parents are back from Saint Petersburg.

Luckily, Adam’s body shows positive response to the therapy. Meline is cautiously optimistic about the dynamics of her son’s health condition. Restraining the feeling of happiness and managing own emotions is a skill that came with the life situation she found herself in. This maybe the reason Meline’s and her son’s the daily life has not changed.

“Adam has a very strict routine. We visit the hospital thrice a day to get the medication there. We closely follow the prescribed diet, get outdoors only after the sun is down, and refrain from contacts in closed areas, except for visiting grandparents, whom we see only once a week,” Adam’s mother says.

A testament that made see the world in a new light

Meline, a keen traveler and friend, does not complain of being forced to get isolated with Adam. Neither do her friends and family: everyone gets along with whatever options the virtual communication may offer. Adam’s health is at the core of everything; Meline knows she will catch up with the friends rather soon.

Meline says she has been contemplating about past and the present life every now and then these days, feeling the situation has added her some 10 years in the last 1.5.

“I am much more relaxed now. I used to get upset and started panicking literally with any difficulty I faced; now I know there is a way out of any situation, you just need to find the best solution. I have started seeing the world in a different light after Adam’s disease.”

Strength, patience, and faith; those were the fundamental things that have helped the young couple to overcome the situation. Meline underlines that her faith has helped her the most. Despite there were many of those who would give them hope, it is owing to their inner faith that they have survived the hard times, she says.

“Leukemia is a tough matter for a child. Whether a child overcomes the disease or not, depends much on its parents. If the parents are not strong

enough, the child will hardly be able to survive. Anything must be done to make the child feels happy and keeps the spirit high at all times,” Meline believes.

Meline and Gor have received psychological support both at the hematological center in Yerevan, and the hospital in Saint Petersburg. Meline says, now, whenever a psychological help is needed, the couple refers to Armen “Armos” Martirosyan, the founding director of the Health Fund for Children of Armenia, who helped raise the full amount of the money needed for Adam’s therapy. The family has not encountered any financial issues regarding the child’s treatment; the medication is being provided through the “City of Smile” Foundation.

“I plead people be kind. A donation as little as AMD 500 may seem miserable and hardly be able to help, but that is not true; it’s been through AMD 500 donations that we have managed to save Adam’s life. And there are so many kids with serious health conditions, who can be saved, if we join hands for that,” says Meline.

Following their son’s case, Meline and Gor try to participate in every fundraising they can. They believe the kindness boomerangs.

HEALTHCARE IN ARMENIA Quality, Access, Affordability

This special issue became possible due to the joint efforts of the “Journalists for the Future” NGO and “Ampop Media” data research studio in partnership with the Friedrich Ebert Foundation.

It consists of thematic stories and infographics in the genre of data and explanatory journalism, clearly and graphically reporting the quality of medical services provided by the RA healthcare system, as well as entrenched problems, course of reforms initiated by the Government and new challenges of the system.