Health

Accessibility to adequate health services for children:

The Health Care System in Armenia was primarily hospital-based, with heavy emphasis on curative care.  Health institutions were over-staffed, excessive in number, and irrationally distributed.  For example, in 1990, Armenia had 4 physicians, 10 nurses and 9.9 hospital beds per 1,000 population (compared to 2.5, 5 and 8 per 1,000 population in established market economies). Health care services for children are provided through children’s hospitals, ambulatory polyclinics and sanatoriums. There are fourteen independent children’s hospitals in the Republic.  Six of these hospitals operate under central government supervision, and eight under municipal supervision.  An additional 52 children’s departments are located in 43 urban hospitals and 9 scientific-research institutions and speicialized centers. However, both number of beds in children’s hospitals and the practising number of paediatricians in the Republic decreased between 1990 and 1997.

Child Health Service indicators in Armenia  

Indicators

1990

1997  

Percent of change  

Absolute number of practising paediatricians  

2066

1651

-20%

Average number of children per practising paediatrician   524 617 +18%
Absolute number of hospital beds 4114 3371 -18%
Average number of children per hospital bed 263 302 -15%

Source: Ministry of Health, RA, 1998

The decline in practising paediatricians can be attributed to several factors. Among those factors is decrease of number of medical graduates from Yerevan Medical University due to tighter restrictions on the number of admissions over the past several years.  The graduates themselves are sometimes unable to find employment in the medical field and move into other activities.  For practising paediatricians, the decreased utilization of health care services has resulted in reduced patients’ loads. The low number of patients combined with the token salaries received by doctors has pushed many paediatricians into alternative professions or emigration out of the country.  It should be mentioned that paediatricians are disproportionately distributed throughout the country, with most practising in urban locations.

The public expenditure on health care fell from 2.7% of GDP in 1990 to 1.3% in 1997. The actual amount is only US$20 million or US$5.4 per capita. This is far below the recommended figure of US$12-20 per captia offered by the World Bank Development Report for basic health programs in low and low-medium income countries. Since 1997, the health-care system budget has been based on a government-funded Basic Benefits Package (BBP) for the population. The contents of the BBP were outlined in a government decree issued on March 13, 1998.  The services provided for children under the BBP are, for the most part comprehensive. However, the package is grossly under-funded.  In addition, there are some points of concern regarding the age groups defined for certain child benefits.  Only children 0-15 years of age are entitled to receive free (state-funded) medical treatment and specilized care.  For children with disabilities, children from refugee, families and children from other socially vulnerable groups, the age group defined for these benefits is 0-18 years of age.  Children in the 15-18 year age group are considered to be adults as far as health care services in Armenia are concerned, and they must register at the adult polyclinic for services.  These age limitations are most likely remnants of the Soviet era, when the age of a child was defined as 0-15.  The limitations severely restrict access to medical care for older children in socially vulnerable families, particularly those children with disabilities that may need special care and rehabilitation services. In reality, the majority of health care expenses are paid by patients, through either formal of informal payments. Inevitably, this has resulted in widespread dissatisfaction among the population with the present minimally financed health care system.  

Accessibility to Reproductive Health Services:

There is well-developed net of hospitals, clinics and drug stores, as well as impressive number of medical personnel in Armenia. The country has one of the highest numbers of doctors and of medical service units per capita in the world. In 1997 the number of population per doctor was 291, and there was 14.8 population per hospital bed. However, the state budget fails to meet its liabilities, and people have to pay for supposedly subsidized reproductive health services. The public health expenditures from limited governmental budget are very low (1.4% of GDP in 1997). In 1997 medical services, which were subsidized by the state operated at only 40-50% of their capacity. Both outpatient and ward attendance has drastically decreased in Armenia, mainly due to the financial obstacles.

Privatization of the health care services primarily affected the health of the poor. Though socially vulnerable groups should be still covered by the state, in the reality for many of them access to the health care is hampered. The obligatory medical insurance system is not yet introduced. And although some indicators of morbidity improved, it would be misleading to explain this by improved health. In the reality, severe social and economic conditions primarily affected people’s health, resulting in increased morbidity and mortality rates. The Caucasus Health Assessment that has been carried out in 1998 by the consulting firm, recruited by the USAID, shows that the health indicators related to vulnerable groups are becoming worse. A plausible explanation could be that the lag effects due to economic hardships that started in the early 1990’s, the deterioration of health service coverage and quality as well as other associated factors are just the start of influencing on health indicators.

The assessment of the situation in the health sector that has been carried out by the Armenian Family Health Association in 1997, revealed common areas of concern such as lack of financial resources, de-motivated and excessive staff, inadequate and ineffective management, and shortage of essential drugs, contraceptives and supplies. Lack of alternative financing and budget constraints challenge the further development and even the existence of many hospitals and outpatient clinics. Presently a great portion of hospitals and outpatient clinics are in need of capital renovation or repair. 

Utilization of health services in general has been declining over the past decade.  Office visits (per capita/year) fell by 41% between 1990 (7.8) and 1996 (4.6).  In the same time period, hospital bed occupancy rate decreased by 40%, the number of home visits by physicians fell by 53%, and ambulance visits decreased by 60 %.  High costs and a perceived decline in quality are the primary reasons attributed to the decreased utilization rates. Access to medical care in general, defined as treatment for an illness, was assessed in a 1996 survey in north, south and central regions.  The survey found that a substantial proportion of ill persons received no treatment, especially in the north, south, and rural areas. Access was worse for poor households, where almost half (48.2%) of the ill members received no treatment.  The main reason mentioned for not receiving treatment was the high cost (57.4% of all cases).  This was especially true in the case of a chronic disease, when there were ongoing costs for treatment and drugs.  For the poor, who finance treatment costs primarily through the sale of assets and borrowing, a single acute illness episode, not to mention treatment for a chronic disease, can cripple the family’s resources.

Modern Contraceptive use:

According to the Governmental statement on Reproductive Rights that appears in the Low on Medical Service and Care (1996), citizens of Armenia have the right to decide freely and responsibly the number and spacing of their children. However, in spite of the increasing use of modern methods of contraception, thousands of women face unwanted pregnancies each year as a result of failure to use family planning methods. Results of the nation-wide survey[7] that was carried out in 1997-1998 among men and women of reproductive age show that the majority of respondents had ever used some method of contraception and at the time of the survey-interview were current family planning users.

Specific Contraceptive Methods currently used*

Methods currently used*

Percent of total replies

(n=801 females)

Percent of total replies

(n=953 males)

Withdrawal 57.1 50.7
IUD 16.7 22.6
Condom 14.7 39.5
Rhythm method 9.1 10.4
Vaginal douching 7.4 1.4
Pills 1.1 1.0
Female sterilisation on occasion of other surgery 1.0 0.1
Diaphragm or female condom 0.1 0.6
Spermicides 0.5 0.5
Other 1.0 0.1

* Note:  more than one method is possible

Source: M. Khachikian and R.Abrahamian, - Reproductive Health in Armenia: the nation-wide survey, 1997-1998,  (Armenian Family Health Association and MOH of Armenia, with support of the UMCOR), Yerevan, 1999.

As it is demonstrated above in Table, the most popular methods previously and currently used are withdrawal, condom, and the IUD. The hormonal contraceptive pills and not popular. Other modern methods, such as voluntary sterilization, injectables, implants, etc. are not yet widely available. Most of married couples are using family planning methods for child spacing, but not for postponing first birth.  

Principle obstacles to contraception:

An assessment of the reproductive health situation shows that a significant demand for fertility regulation exists in Armenia, but this demand is not adequately met. Generally speaking, Armenian people still do not have access to modern means of family planning because of the financial obstacles. Most couples are using unreliable methods, which are free or have little cost (See chart).

Incidence of Abortion:

Available information from series of Reproductive Health surveys suggests that induced abortion is the main method of fertility regulation in Armenia. The majority of ever-married women of reproductive age have history of at least one induced abortion during their life-time, and significant proportion have history of more than 5 abortions (See chart). According to the results of recent surveys in women and men of reproductive age, the figures on the average number of self-reported abortions per families/unions are varied from 2.1 up to 2.7.

The limited access to family planning services and the lack of contraceptive education are the main reasons for unwanted pregnancy. The lack of income, inappropriate housing and poor health are the most frequent determinants of abortion use. The average number of induced abortions is higher in women with the low socio-economic status, as compared to those who live in better living conditions (see chart).

There is still significant number of unsafe abortion cases with the high rate of the serious and potentially life-threatening complications and consequences (see chart). Self-induced abortion with the high risk of complications is also common, but officially was neglected (See chart). To overcome financial difficulties and fear of abortion, many women in Armenia try to induce spontaneous abortion themselves through unsafe, unhygienic, and often-dangerous interventions, facing the high risk of complications and even death. Most women, who have experienced self-induced abortion are never referred to a health facility for medical care, therefore these kinds of unsafe abortions are not officially registered. The rates of the immediate complications and the late consequences of self-induced abortion are quite high. The most alarming is the fact that some women try to induce miscarriage repeatedly, like a method for birth control. 

The assessment shows that unwanted pregnancy and induced abortion are either results of unprotected intercourse or contraceptive failure. The failures of the contraceptive method of choice, as well as incorrect use of the methods are the main background factors of unwanted pregnancy and induced abortion. In most of the cases, unreliable withdrawal method was used prior to the both first and the last abortion. Women who have undergone abortion are at risk of another unwanted pregnancy and unsafe abortion. However, a significant number of couples did not receive adequate post-abortion family planning counselling or care.

Disease morbidity and malnutrition among children and preventive measures:

The official reported incidence of the Pneumonia and Diarroheal Diseases (DD) for children under 5 do not provide the total picture of morbidity for either illness, since many of those cases are not seen at the health facilities and treatment at home is now quite common. The data provided by the MOH indicate, however, that the number of children under 1 years old died of Pneumonia during 24 hours after hospitalization decreased considerably, as compared to 1980-th (19 in 1998, versus 214 in 1980). While in 1980-th 54% of under-1 mortality rate in the hospitals was related to Pneumonia, in 1998 this proportion decreased up to 9,5%. The reported average incidence of the Diarrhoeal Diseases among children under five remained roughly the same during the last decade. But there is wide variability between regions. In 1998, 47 children under 1 years old died of Diarrhoeal Diseases during 24 hours after hospitalization, while in 1988,  total  number of 365 children died (almost eight-fold decrease). Infant mortality from DD varies by region, with reported rates ranging from 0.5 to 3.2 in 1997

Cyclical outbreaks of measles continue to occur, the last one in 1996 when the number of new cases among children under 14 increased over ten times from the previous year  (164 per 100,000, in 1996 as compared to 15, in 1995).  The number of new cases fell again in 1998 (4,4 per 100,000). There have been no deaths attributed to measles in the past five years.

According to the reports of Ministry of Health of Armenia, the acute Malaria cases increased considerably during the last 5 years (see chart)  

Results of the nation-wide RH survey indicate that the reported incidence of low birth weight babies in the last five years was 9%. This dramatic increase may be explained by the deteriorated economic condition of the country at this time and the attendant consequences that poverty has on maternal nutrition (see chart).

The National Immunization Programme (NIP) was a focus of intensive efforts in the Armenian health services since the Soviet era. In the years since Armenia’s independence in 1991, coverage levels reported by the MOH for each of the vaccine provided by the NIP, including measles, have exceeded 80% almost every year. However, independent data suggest  that these figures may be higher than actual coverage levels. In 1994 a comprehensive review of the NIP was carried out. The WHO immunization schedule was adopted, the cold chain storage system was strengthened, and the official list of contraindications to immunization was drastically reduced. A National Nutrition Survey conducted in 1998 by the MOH with support of the UNICEF, UNHCR and WFP, found that measles coverage in 15-18 month old children, as reported by the child’s guardian was 72.4%, well below the official MOH figure of 93.5%.

Since in the mountainous regions of Armenia, where iodine deficiency disorders are a widespread problem, the potential effects on child development are of growing concern. However, mechanisms to sustain the iodization program in Armenia are week.

The Year 2000 World Summit Health Goals for Children, established in 1990, have served as a framework throughout the decade for measuring Armenia’s progress towards fulfilling the child’s right to health. The President of RA signed the World Declaration on the Survival, Protection, and Development of Children on July 6, 1994, and the Decree on Protection of the Mother and Child on March 28, 1996.  On May 21, 1996, the Armenian National Assembly adopted the Armenian Law on the Rights of the Child (LRC), which was based on the Constitution of Armenia and Convention on the Rights of the Child (CRC).  It defines the Rights of the Child and the responsibilities of the Government for protection of these rights.  

The monitoring of Armenia’s progress towards fulfilling the Year 2000 World Summit Goals for Children (See Table) [1_2] indicate that while some of the indicators have improved in the past decade, a number of them have either remained the same or deteriorated. There were no cases of deaths from measles on record since 1990-th, although it could happen, since the record of that will normally state the cause of death as the complications from the measles, such as pneumonia. The links between increased immunization coverage and decreased vaccine-preventable morbidity suggests that intensified efforts by the MOH to strengthen the NIP over the past few years may be achieving their intended effect.

Incidence of AIDS/HIV in Armenia:

Total number of 126 HIV positive cases have been officially reported in Armenia up to the end of the year 1999, mainly among drug users and prostitutes.