The collapse of the Soviet Union resulted in the disruption of normal functioning of the whole healthcare system in Armenia. The budget for healthcare remained the same, but only on paper, as the great empire fell apart, leaving member states such as Armenia to fend for themselves.
The decay of social services, including state-provided medicine, hit Armenia at a particularly devastating time. The Spitak earthquake of 1988 left thousands badly injured and thousands more suffering psychologically. War in Karabakh put thousands more in need during the 1991-94 fighting. As if those calamities weren't enough, Armenians also suffered some of the worst winters in decades, faced during a time of energy crisis that contributed to generally unhealthy conditions.
Proper healthcare was never more needed, and never more challenged.
Republic of Armenia Ministry of Healthcare spokeswoman Ruslanna Gevorgian has served through the worst of those times—having been at the ministry since 1989.
"During those years, on the one hand, our doctors worked without salaries, while, on the other, our population would sustain the doctors (often "paying" in bartered goods when money wasn't available). So, despite multiple difficulties, we managed not to lose what we had in the healthcare sector in the Soviet years and started to build on it in the past decade," says Gevorgian.
State Budget allocation that grows from year to year primarily enables progress in healthcare. Whereas in 2002 the State Budget assigned only some $44 million for the sphere, in 2006 it more than doubled to reach $108 million, and continued to grow, reaching $125 million in 2007 and $149 million in 2008. An increase by some $31 million had been planned in healthcare financing for 2009 (to reach about $180 million); however the global economic crisis has scuttled those plans and the budget financing has remained at the level of last year.
Specialists in the healthcare sector consider one of the main achievements in their sphere in recent years to be free primary medical service introduced in 2006 as well as simultaneous development of family medicine, free obstetrics introduced in 2008, and achievements made by Armenian specialists in several branches of medicine.
"Primary medical care is very important for us, since early diagnostics allow patients to get treatment at the early stages of a disease and avoid complications as well as save money for themselves and the state. At present, outpatient and polyclinic medical care is free for all," says Gevorgian.
Measures aimed at improving the quality of primary medical care were implemented last year, with special attention paid to the needs of the rural population. A total of 66 rural medical outpatient clinics and aid stations have been repaired and rebuilt, and 245 have been fitted out with medical equipment and instruments as part of cooperation with the World Bank's Healthcare Crediting Program and the United States Agency for International Development (USAID).
Family medicine—particularly crucial in distant regions where one specialist usually works with the whole community—has developed in Armenia along with primary healthcare.
"We are still short of some 1,500 family doctors. The program of training family doctors and nurses is continuing as part of the crediting program of the World Bank, and we hope that we will no longer have this shortage in the next few years," says Gevorgian.
Vice-rector on the issues of specialized and continuing education at the Yerevan State Medical University, micro-surgeon Gevorg Yaghjian says that medical education in Armenia has also been subjected to great changes with the purpose of raising its quality and bringing it in conformity to international standards.
Four years ago, the Medical University switched to the credit system, due to which instead of six years students now attend university for five years and receive a medical bachelor's degree. After that, they can continue their education in master's courses—in nine medical branches. For a narrower specialization graduates can apply for clinic internship where studies will be organized in corresponding hospitals. This may last two to five years, depending on the medical student's specialty.
Yaghjian says that education of Medical University students has become more intensive in the past several years.
"Lecture rooms have multi-media options, we have a large library, students can use electronic databases... Besides, many lecturers are enabled to go abroad for retraining purposes, which is very important," says Yaghjian.
The Medical University is planning to build a modern teaching hospital nearby. This hospital, to be fitted out with state-of-the-art equipment, will enable graduating students to apply their knowledge and skills in practice during internship programs.
Every year, about 100 doctors with various specializations graduate from Yerevan State Medical University. This year, the number was 108.
A total of 844 family doctors and 835 family nurses were trained from 2000-2008. At present, another 238 family doctors are in training. Training sessions are held in the National Institute of Healthcare, in Yerevan.
Ministry spokeswoman Gevorgian also sees a positive shift in public attitude as people become more attentive to their healthcare concerns. The trend is seen in the number of applicants for state-funded ultrasound examinations.
In 1996, the Jefferson Ultrasound Research and Education Institute and AGBU, under the direction of AGBU Central Board Member Dr. Levon Nazarian, Professor of Radiology at Jefferson University Hospital in Philadelphia, established ultrasound departments serving thousands of patients at the Oncology and Erebuni hospitals.
Four years later, AGBU and Jefferson opened a new ultrasound training center at Yerevan State Medical University. Medical personnel receive instruction and hands-on training at the Ultrasound Center in all applications of ultrasound, significantly including obstetrics and gynecology.
Since its establishment, the Center has trained about 85 doctors in the certificate program and more than 150 students in the medical internship program. With the sponsorship of Dr. Nazarian, the Ultrasound Center obtained a CT scanner in 2005. In addition, over the past two years, an AGBU donor and Council of Trustees member, Mr. Nazar Nazarian, has provided many hospitals in Armenia, Karabakh and Javakhk (the Georgian province primarily populated by Armenians) with 22 new ultrasound machines.
Specialists, however, consider the introduction of free obstetrics to be the greatest achievement of the healthcare sphere. Despite the fact that obstetrics in Armenia was free of charge by law, it remained such only on paper. For years people would pay for obstetrical services. Illicit payments for obstetrical services would reach 250,000 drams (or about $685) at some maternity hospitals in Yerevan in the years before the enforcement of the free obstetrics provision.
"Great will and obstinacy were needed to achieve results," says Gevorgian. "The custom of a 'thank-you payment' to the doctor survived still from the Soviet times. It still baffles many that one can have a child and not 'thank' the doctor with cash. This was something practiced for years, but in current conditions when many do not have jobs and wages are rather low and the state wants the nation's demographic growth, this has become an issue of strategic importance for us."
Now the state pays attending doctors for each birth. A doctor receives 124,000 drams (about $340) for each assisted natural child delivery at third-class maternity hospitals (the highest class). At ordinary maternity hospitals, the payment from the state is 110,000 drams (about $300). For each Caesarean section at a third-class maternity hospital a doctor receives 215,000 drams (some $590), and at an ordinary maternity hospital—180,000 drams ($493).
To enforce regulations curtailing "thank-you payments," the Ministry of Healthcare set up a telephone hotline for reporting abuse. Initially the Ministry received up to 40 calls per day.
"Now we hardly ever receive such calls, since we consistently investigate each and every call and some doctors and nurses have even been punished," says Gevorgian.
This year, the Healthcare Ministry considers its top priority to be modernization of ambulance services, adding new ambulance vehicles, upgrading the sector and fitting it out with modern equipment.
"Our stock of ambulance vehicles is very old. Were it not for the economic crisis, we would have been able to fully modernize it with the increased State Budget financing; however a solution to this problem is still pending," says Gevorgian.
Another priority is the development of provincial healthcare systems, which should be aimed at raising the quality and increasing the availability of medical services rendered to the population as well as providing new medical equipment to hospitals and polyclinics in the provinces.
Cardiology sets a standard
Armenia has registered considerable progress in the areas of orthopedics and cardiology in recent years. Considering the particularly high quality of heart surgeries in Armenia, the country can be considered to be the regional center in cardiology.
The Nork-Marash Medical Center, where American-Armenian surgeon Hrair Hovakimian has practiced and trained young doctors, rightfully enjoys a sparkling reputation. As word of the Center's good work has spread, the former children's hospital has become a regional center for heart surgeries. It now receives patients from Georgia, southern Russia, and Middle Eastern countries.
Director Lida Muradian, first of all, links this success with Hovakimian's work there, and secondly with the medical personnel that passed a very strict selection process to practice at Nork Marash.
A pediatrician by specialty, Muradian says that in November 1993, when she was still director of former children's hospital N2, she received a phone call from then Minister of Healthcare Ara Babloyan. The minister asked Muradian to receive an American-Armenian cardiologist, Hovakimian. Until then, Hovakimian had worked at the Mikaelian Surgery Institute and had successfully performed several heart surgeries on children and adults, but had plans to leave Armenia.
"We did not want to lose Hrair," says Muradian, adding that bringing him to the children's hospital was a godsend. "During those years of hardship, the number of children who needed surgeries was quite high, and very few could afford to get surgeries abroad."
In mid-November 1993, Muradian met Hovakimian and promised him that at least one surgeon's theater, one post-surgery rehabilitation department and one catheterization laboratory would be built by May 1994. "During those years it seemed impractical for many. In that confusing political situation, in conditions of absence of electrical power and poor budgets it was very difficult to realize our promise. We passed through hell before we achieved this situation.
"However, by seeking assistance from different businessmen, we managed to ensure the construction of the needed facilities by that time," Muradian remembers.
Hovakimian returned to Armenia in late May 1994, bringing with him the needed equipment purchased through charity. (Though honored in Armenia and Diaspora for his skill and dedication, the surgeon himself shies from media attention and his reputation is built on the accounts of others.)
"Due to the budget provided by different charitable organizations and some individual philanthropists, we had an opportunity to perform surgeries on some 150-170 children annually. That charitable program lasted for five years and, during those years, older patients were also knocking at our door and asking why we did not provide surgeries to adults," says Muradian.
Considering this circumstance and understanding the importance of the medical center, Muradian received permission from the Ministry of Healthcare to expand the hospital and perform surgeries on adults as well. In 1994, the hospital had only a 37-member staff; now it has 450, and the number of beds has been increased from 10 to 70.
Annually, the center performs about 1,350 surgeries, about 800-900 of which are open-heart.
Various types of complex heart surgeries are performed at the center, their price ranging from 1.5 million to 3 million drams (about $4,000-$8,200). Muradian says that the same surgeries in Europe cost $60-70,000 and more.
From disaster, invention
Armenia is known to have made considerable progress also in traumatic surgery and orthopedics.
Head of the Orthopedics and Traumatic Surgery Clinic at the Erebuni Medical Center Dr. Armen Charchian, who also heads the Chair of Traumatic Surgery and Orthopedics at Yerevan State Medical University, says that the main reasons for this development were the earthquake and the war.
"Throughout history, surgery has developed during wars," says Charchian. "In our country its development was also driven by an acute need. During those years we saw things that a surgeon working in ordinary conditions might not see during his whole career."
The link with Western countries and exchange of experience also had a great significance in the development of such specialties in Armenia.
"We followed the Russian school, then suddenly the curtain dropped and we also learned the experience of the Western-European school. We, in fact, saw a collision of those two schools, from which we only benefited," says Charchian.
Charchian says that their main and most important achievement in 1988-1998 was osteo-synthesis—a simultaneous treatment of several fractures.
"That is, we treat it so that the recovery of function is greatly ahead of anatomical recovery. There are biological absolutes that cannot be broken, such as fracture healing, which takes 4-6 months no matter what you do. But to prevent the patient from being confined to bed for six months, we perform a surgery so that he can recover function and capacity for work in two months. In this case, we have been greatly helped by equipment imported from abroad that we didn't have in the past," says Charchian.
Another achievement pointed out by Charchian is the installation of artificial joints, then arthroscopic surgery (a non-invasive surgery of joints) and development of field military surgery.
"During a standard surgery, a surgeon is supposed to make a large cut, then do his work with instruments. In the case of arthroscopy, a very thin camera is inserted into a joint and we see the picture on the screen. From a second hole the surgeon inserts a microsurgical instrument and starts to solve the problem," explains Charchian.
Now successful orthopedic surgeries are performed in Armenia mainly at the Erebuni, St. Nerses, and Nairi hospitals, as well as at the Mikaelian Surgery Institute.
The Yerevan Center of Limb Lengthening and Reconstruction, headed by Dr. Arshak Mirzoyan, currently operates within the Nairi Medical Center.
"We mostly work with children who have both acquired and congenital osteo (bone) problems. Since treatment is lengthy and costly ($4-8,000 and more), in 2000 we founded the Armaveni charitable foundation that itself finds money for children's surgeries," says Mirzoyan.
The foundation's workers present a list of children who require surgery, and potential sponsors themselves select a child or children they want to sponsor.
Eliza Koshtoyan, 19, underwent a surgery under this charity program in June. One of her legs was 12 centimeters shorter than the other, because of a femur trauma at birth. Eliza had undergone many surgeries since she was four and a half years old, and in 2000 she even underwent a surgery in Germany, which, however, did not solve her problem.
"When she stood on both legs for the first time after this [latest] surgery, she got very excited; that was a big experience for Eliza," says Eliza's mother Susanna Koshtoyan.
So far, 50 patients have been operated on at the center under this sponsorship program, with another 50 on the waiting list.
Apparatus surgeries, which are micro invasive surgeries, have been mainly developed at the Mikaelian Institute during these years.
"In the case of complicated splintered fractures, surgeries are performed in a non-invasive method, with a small loss of blood and, in this way, it is possible to perform a surgery on two, three or even four segments. There were patients who had fractures of two thighs, shanks and collar-bones. Surgeries on all those fractures can be done at the same time," says Mikaelian Institute Orthopedics and Traumatic Surgery Department Head Seyran Saroyan.
Limb lengthening and growth of the absent part of the bone and correction of joint deformities are also done here.
Department doctor Armen Rafaelian invented three apparatuses in 2000, 2001 and 2004 (a compression-distraction apparatus, a reposition apparatus, and an apparatus for the osteo-synthesis of proximal parts of the femoral bone). These inventions (registered with the Armenian Intellectual Property Agency) provide greater flexibility and are installed with greater ease during fracture treatment surgeries.
As with any society, complaints—justified as well as irrational—remain at hand from would-be patients of Armenia's healthcare. Old-timers still paint Soviet times in rosy hues, because nobody had to pay (officially)—and often got care that matched the cost.
But any objective evaluation of current conditions finds the practice of medicine in Armenia remarkably advanced from even the past decade, as old equipment has been replaced (due greatly to Diaspora donations and efforts), and young doctors emerge prepared to make further strides.