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Articles Health Care in Armenia Today RICHARD G 331 Articles Health Care in Armenia Today RICHARD G. FARMER, MD, MACP, Washington, DC, and ARAM V. CHOBANIAN, MD, Boston, Massachusetts Although one of the smallest of the new independent states of the former Soviet Union, the Republic of Armenia has an ancient tradition and a strong ethnic identification, greatly enhanced by the dias- pora. In addition to the problems following the dissolution of the Soviet Union, Armenia has had to contend with a draining war in Nagorno-Karabakh and the after-effects of a devastating earthquake in 1988. Humanitarian efforts have ranged from emergency supply deliveries to longer-term sustain- able health care partnerships. The United States government, through the Agency for International Development, has organized such partnerships, partially as a result of a multinational mission in 1992 and a subsequent hospital-to-hospital program developed by the American International Health Al- liance. We describe the current state of health care in Armenia and some of the problems that need to be addressed to improve health care services to its citizens. (Farmer RG, Chobanian AV: Health care in Armenia today. West j Med 1994; 160:331-334) T he dramatic events following the dissolution of the sibility to health care services for the entire population, Soviet Union affected the health care system of its 15 free of charge, is theoretically possible. The medical com- republics as it did all aspects of the society. In December munity has been isolated, however, and a rigid hierarchy 1991, US Secretary of State James Baker requested that has developed in the system over the years. Despite the humanitarian and other forms of aid to the new indepen- breakup of the Soviet Union politically, this system re- dent states of the former Soviet Union be organized and mains largely intact because virtually all health care coordinated. As a result, a coordinating conference was workers have known no other. Almost all have trained in held in Washington in January 1992 and attended by rep- their local region, and ethnic Russians are often in posi- resentatives of more than 50 countries. Five working tions of authority, particularly in Central Asia. The "sys- groups were established for food, shelter, energy, medi- tem" begins centrally, at the Ministry of Health or the city, cine, and technical assistance. A delegation was formed at the state or oblast, or at the district or rayon, from that consisted of some 30 health care professionals repre- whence the budget issues, and spreads peripherally. senting 14 countries and international organizations. Ten One of the great shocks to the management of the sys- republics were visited during the period of February 27 tem has been its separation from Moscow, as well as, of to March 31, 1992, to survey firsthand the medical and course, the disruption of the system that has been provid- other health care needs of the new republics and to for- ing equipment, supplies, and especially drugs. Until 1991, mulate recommendations based on the following four budgets were centrally determined and health care facili- points of the action plan determined at the January 1992 ties were given a fixed amount of money based on the conference: number of beds in hospitals and number of visits in poly- * Emergency medical needs; clinics. This formula sometimes varied for special cir- * Developing international health care partnerships; cumstances such as "institutes" created in one or more * Assessing pharmaceutical manufacture, vaccines, fields, such as cardiology. The per capita population allo- and medical supplies, and the possibility of private and cation has changed rapidly, and more leeway has been joint ventures in the health care support area; and given to the managers, most of whom are physicians * Technical assistance needs including help with without any management training. Increased freedom in management and financial planning. management has been offset by the loss of central fund- ing from Moscow. Health Care in the Former Long-term centralization has resulted in gigantic hos- Soviet Union pitals, with 1,000 to 2,000 beds being common, and poly- The republics of the former Soviet Union have a clinics that see more than 1,000 patients a day, six days highly centralized and well-organized health care system per week, in two 6-hour shifts. At the periphery of the with a large number of health care professionals. Acces- system are smaller hospitals and polyclinics, down to From the Bureau for Europe, US Agency for Intemational Development, Washington, DC (Dr Farmer), and the Office of the Dean and Department of Medicine, Boston University School of Medicine, Boston, Massachusetts (Dr Chobanian). Reprint requests to Richard G. Farmer, MD, Senior Medical Advisor, Bureau for Europe, US Agency for International Development, 320 21 st St NW, Washington, DC 20523. 332332WJM,IMApiApril 1994-Vol194-o 160,10 No. 4 Health CaeiCare in.-Armenia-Farmerrei-Farmer-- et- al feldsher (first-aid) stations, with thousands of nonphysi- population served. Some of the hospitals are tied to a state cian workers. It is here that primary care, including pre- system and funded by the federal government, and others ventive care, immunizations, and maternal and child care, are municipal hospitals that are supported by cities. Un- takes place. Patients are then transferred "up the line" as der the Soviet system, some of the most advanced institu- needed. Extensive ambulance systems that provide care tions were linked to Moscow and received their support on site are also common. There is no patient choice, little from Moscow. Their funding was recently taken up by the quality control, not much continuing education, and little federal government, and they are being added to the fed- of the medical educational structure familiar in many eral system. Many of the hospitals, particularly those in other countries. A small but growing private health care the major cities, deal primarily with specific specialties- sector coexists with this hospital-clinic system. In many pediatrics, obstetrics, infectious diseases, otolaryngology, of the newly independent states, private practice is al- cancer, rehabilitation, and specialized surgery, for exam- lowed, but often only in specialties not requiring hospital ple. As in the other newly independent countries, Arme- privileges. nia has a large number of polyclinics and other outpatient facilities, but these generally are not well integrated into Health Care in the Republic the hospital systems. Networking between medical insti- of Armenia tutions continues to be poor, and links between the med- Nowhere have the adverse effects of the breakup of ical school and teaching hospitals are not well developed. the Soviet Union been felt more severely than in the The medical facilities typically are more than 20 years newly independent Republic of Armenia, which has also old and in fair or poor repair. Some new hospitals and had to cope with the devastating earthquake of 1988 and clinics have been built since the earthquake as a result of the war between Nagorno-Karabakh and Azerbaijan. Our contributions from foreign countries and charitable orga- brief summary of the current health care system in Arme- nizations. Modern equipment is often lacking in the hos- nia is based on visits as part of the previously mentioned pitals. For example, as of 1993, only one computed Medical Working Group Experts delegation to the new tomographic scanner was present in all of Armenia. Since states (R.G.F.) and as a member of a team of experts the earthquake and war, routine medical supplies such as sponsored by the American International Health Alliance sterile bandages, disposable needles, syringes, surgical that traveled to Armenia in September 1992 with the in- gloves, intravenous solutions, and many medications are tention of developing hospital-to-hospital medical part- in short supply. There is also a serious need for such items nerships (A.V.C.). as autoclaves, anesthesia equipment, and large generators The Republic of Armenia has a population of about of electrical power. The last have become particularly im- 3.4 million, with about two thirds living in an urban set- portant because of the frequent disruption in electricity. ting. Life expectancy at birth in 1989 was 69 years for Armenia has many physicians and nurses. There is men and 74.7 years for women.' About 30% of the popu- currently approximately 1 physician for every 250 inhab- lation is younger than 14 years.1 itants, a number that is greater than that in most western Cardiovascular disease ranks as the major cause of countries. Salaries for physicians are low, only slightly death, followed by cancers and pulmonary diseases.2 Ac- higher than that of average workers. The quality of physi- cidents represented one of the major causes of death in cians varies. Under the Soviet system, strict medical 1989,' and their number remains relatively high, in part school admission policies were not practiced, and fre- because of the ongoing war. Infant mortality has been in quently more than 1,000 medical students were admitted the range of 20 to 25 deaths per 1,000 live births,3 lower per year to the Yerevan Medical Institute. Armenian med- than the rates in many of the new independent states other ical leaders are well aware of the need for establishing ad- than Russia, but higher than the values reported for devel- missions and accreditation policies and are in the process oped countries. For instance, infant mortality in the of developing these. They also have begun reducing med- United States is 9.8 per 1,000 live births (World Health ical school class sizes. Students usually are admitted to Organization data, February 1994). Maternal mortality in medical school out of high school, with an average of five Russia is also high, probably reflecting the use of abortion years being spent before a medical degree is obtained.
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