Engaging with Armenia’s healthcare system is not unlike venturing into the Minotaur’s labyrinth—absent the beast, thankfully. That is why it takes the skills, savvy and allegiance to Armenia’s patient population embodied in the person of the Human Rights Defender aka Ombudsman Arman Tatoyan.
Since the Artsakh War, his name and face appear front and center across the media landscape, as he leads the charge against the mistreatment and for the release of Armenian POWs still held in Azerbaijan. He is also hard at work representing Armenian residents in the Syunik region, who woke up after the Russia-brokered ceasefire to find their lands and homes arbitrarily split between Armenia and Azerbaijan, due to the redrawn borders.
These issues are an extension of Tatoyan’s larger mission—to protect the human rights of every Armenian citizen under national and international law. This includes the rights of patients seeking everyday medical attention.
In the system of free medical aid to the public, patients often feel like they are in a tennis match. They are sent from one institution to another and wind up with nothing.
In ordinary times, Tatoyan and his team are often occupied leading the vulnerable, voiceless and unsuspecting out of the bureaucratic obstacle course that stands between them and the reliable health care they deserve. For when all is said and done, quality care begins with easy access and ends with continuing education, not only among the country’s health care providers, but perhaps more important, the people themselves.
The Tangled Web Woven
To understand how Armenia’s healthcare system became such a patchwork of inequities is to revisit the harsh socioeconomic realities that came with the dissolution of the Soviet system—bloated with institutions and physicians but notoriously underfunded. The nascent independent Armenia state was no longer able to sustain the Soviet-style top-down, command-and-control model of administration on account of dwindling finances, and was thus compelled to decentralize, affording individual healthcare providers financial and managerial autonomy under their local governments.
Yet Soviet health care did provide the building blocks for state-sponsored health coverage, which was reintroduced in 1997 in the form of a safety net, called the Basic Benefits Package (BBP) for the socially vulnerable. Over the next three decades, other legislative reforms widened the tent of who is covered, but still left large swaths of citizens to fend for themselves. But according to Tatoyan, even those covered by BBP are alarmingly ill-informed of their rights. “In the system of free medical aid to the public, patients often are like in a tennis match. They are sent from one institution to another and wind up with nothing.”
An Independent Counterweight
As Human Rights Defender, Tatoyan wields a double-edged sword. On one side, his office is the constitutional official public entity that leads the Armenian National Human Rights Institution and functions independent of all branches of the state. On the other, the recommendations it makes are addressed to public authorities and may have two aims: to help individuals; and to improve the national legal framework and legal practices. The latter may go as far as the politicians who enact legislative reforms—the Armenian parliament. That leaves Tatoyan, a world-class legal expert in his own right, with the daunting job of fighting against maladministration and cases of abuse while lobbying for systemic healthcare reform.
Elected by the Parliament of Armenia, Tatoyan is guided only by the Constitution and laws. This is the only institution in the country that is vested with three United Nations Convention Mandates: torture prevention; protection of persons with disabilities; and protection of children’s rights. The institution of Ombudsman exists in many countries; and they pass through the accreditation process led by an independent committee operating under the overall guidance of the Office of the UN Human Rights Commissioner. Only in some countries, including Armenia, these institutions have an “A” Status, which is an international recognition of the highest level of independence.
Formerly Armenia’s deputy minister of Justice, Tatoyan, who currently acts as a deputy representative of Armenia before the European Court of Human Rights, is a force of nature whose authentically fierce interest in the human dignity of his compatriots is what drives the production of a comprehensive annual report on the state of human rights in Armenia. A substantial section of this nearly 800-page document accounts for the numerous complaints and grievances that pour into his office daily for him and his staff of more than 100 to review, investigate, and resolve.
The Right Leader for Patient Rights
Outmaneuvering the twists and turns of the Armenian healthcare system puts Tatoyan squarely in his element, bolstered by his impressive credentials: a PhD in Law; a master’s degree from the University of Pennsylvania and Executive Education for Lawyers from the Wharton Business School, credited with the distinguished lawyer in the class of 2013; and experience as the advisor to both the president of Armenia’s Constitutional Court and the chairman of the Criminal Chamber of Cassation Court. He also serves as the member of the Council of Europe Committee for the Prevention of Torture elected in respect of Armenia.
This cumulative experience makes Tatoyan a master of the inner workings of institutional structures that perpetrate patient abuses. Currently a professor of Law at Yerevan State University and an associate professor of law at the American University of Armenia, Tatoyan is well versed not only in criminal procedure and international criminal law, but also the laws of basic human rights—knowledge necessary for fulfilling his oath to support the entire Armenian nation.
An outspoken Tatoyan was quite clear-headed in his assessment of what government and citizens must do in their respective capacities to overcome the challenges facing health care in Armenia. Frank and openhearted, he outlined the three main areas that compromise positive health outcomes, which he believes is ultimately the role of government to overcome.
Lack of Access and Availability
“We basically have services that are not accessible for people, especially those who live in remote areas in the regions. These citizens face many challenges—especially if they have special needs,” he notes. Citing complaints from frustrated parents of children with cognitive disabilities who cannot access the private medical clinics of Yerevan, Tatoyan is determined to help them sidestep these obstacles.
“The other issue is the availability of doctors who work in these regions. There is clear lack of numbers especially when it comes to psychiatric needs.” Tatoyan points to the Syunik region, where only two psychiatrists practice for the entire province—and both are on the brink of retirement. “In a couple of years, or even months, we may end up with a situation when we do not have psychiatrists in this region at all.” This is one of the biggest provinces.
The public benefit program provides access to a list of certain drugs and medicine that are free of charge. Unfortunately, many are ineffective.
Ironically, even if there were an abundance of doctors, Tatoyan notes that residents do not trust those who work in the regions. “They tend to believe that if doctors had the capacity or qualifications, they would move to Yerevan or some other country instead.” However, Tatoyan clarifies that his job requirements don’t include evaluating the professional merits of these doctors.
Another key concern for Tatoyan is the inequity in medication along the private and public divide. “The public benefit program provides access to a list of certain drugs and medicine that are free of charge. Unfortunately, many are ineffective.” He reports several instances whereby physicians actually have advised patients to avoid government-purchased medicine, especially when dealing with the elderly population. “What we do is highlight the issues that people face because of problems the government fails to solve.”
In his view, the root of the problem is the questionable list of prescriptions that are endorsed by the Ministry of Health. “We’ve submitted proposals to change the drugs that are included in this basic plan, and to extend and enlarge this list to be more inclusive of all needs.” Tatoyan receives grievances stating that certain critical prescriptions are unavailable to the population despite the ever-pressing demand, which is in even more urgent need by the elderly patients who face difficulties managing the paperwork and bureaucratic runaround.
“When it comes to full or partial compensation of medicine, people face huge tribulations. Oftentimes, we see people over 65 from low income families who have already been sent from one institution to another and are kept waiting for several months. This is most alarming.” Tatoyan intends to put his foot down, saying, “The government often writes off these justifications as a result of insufficient resources, but they can’t validate bureaucratic problems. They must create these resources. In the eyes of citizens, the delivery of health care by the state should be very effective and efficient.”
Low Public Awareness
Above all, Tatoyan plans to tackle the lack of awareness of basic rights among citizens, a deep-rooted problem in the nation. “Every-day citizens are not well informed of their legal rights or how to apply for certain programs, not knowing that they are eligible to receive such services free of charge,” he says. “Because of this, government officials can take advantage. Or, some of the polyclinics don’t know the rules and regulations. This two-fold problem leads to violation of patient rights.”
Tatoyan continues to urge the health ministry to organize mass awareness campaigns. “I have to say that it is my duty to point out that human rights education is a constitutional function. We need to do better to spread the word among citizens. Armed with knowledge, they have a fighting chance to find relief for their pain and suffering.”
Incremental Steps Forward
In an attempt to streamline the system and even the playing field among diverse segments of the population, the Armenian government began to take healthcare reform seriously, as far back as 1997. Here are two illustrative cases that show how the BBP, along with other demographically targeted state benefits, have delivered positive outcomes for patients who understood their rights and privileges.
Little Stepan’s Big Toothache
Nine year old Stepan K. had spent several days with an infected tooth. Though poor and from Ashtarak in rural Armenia where dental care is generally wanting, his mother felt compelled to act. Armed with their Family Benefit Program (FBP) documents, issued to families living below the poverty line since 1999 as part of a social assistance program of unconditional cash transfers, Stepan and his mom headed to their local polyclinic as the first port of call on their journey to healing. Here, in the absence of an in-house dentist, the boy is examined by the family physician—a cornerstone of Armenia’s early effort to reorganize the primary health sector, who after a quick look, sees him off to the only private dental clinic in town.
But distrustful of the level of qualification of both the general practitioner and the town dentist, Stepan’s mom opts to have her son treated at one of the many private practices in the capital.
As FBP recipients, they automatically qualify for BBP, which exempts them from any co-payments for services provided at the private clinic. When the funds are there, these are taken up by the Ministry of Health subordinated State Health Agency, established in 1998 as the third-party payer for services covered by the BBP on behalf of the state.
The approval last year of a 12bn Armenian dram ($25m) proposal by government to provide free health coverage to all citizens under 18 has since extended that right to every child regardless of its social-economic status, adding some 200,000 youth to the roster. Previously, only children below seven were insured by the state.
Madeleine’s First Baby
At 24, Madeleine M. and her husband are expecting their first child any day.
Under the government’s new 2020-2023 program to improve reproductive health and increase birth rates in Armenia, all newlyweds are offered free, state-sponsored screenings and preconceptive care advice at their local polyclinic upon legal registration of their marriage with the Ministry of Justice. Its aim is to combat the rising numbers of infertility and STDs among young couples and bolster the country’s demographic standing.Programs like these are helping buttress earlier initiatives like the 2008 Obstetric Care State Certificate program that guaranteed Madeleine and others like her access to free, high-quality maternity services. Because, prenatal and postnatal care were always fully covered under the BBP, expectant mothers were still required to make informal out-of-pocket payments to incent quality service.
Now a major success, the OCSC program, together with its twin Child Health State Certificate program, has made significant headway in bringing down barriers to care for mothers and children across the country—thanks to commitment of the state to cover the full costs of maternity and pediatric services. But in an environment of persisting low salaries for health specialists, chances are Madeleine will be coaxed into a more expensive intervention by her OB-GYN to compensate for lost gratuities in a field where they are at their highest.
Under the current state reimbursement system, the price of a natural birth is 140 thousand Armenian drams ($290). A caesarean (C-section), on the other hand, can fetch anywhere between 220 and 250 thousand AMD ($460-520) depending on the level of complexity of the delivery. As a result, the rate of C-sections has skyrocketed since 1990 from a low of 34 per 1000 live births to a staggering 310 in 2017, despite the greater risk of postnatal complication for the mother.
And though caesareans require prior approval from the patient, the general lack of awareness of their rights among women and absence of financial incentive for the system to change mean the numbers are sure to grow.
Toward Universal Health Insurance
Armenia has contemplated the idea of universal health coverage for quite some time now. First, it was that same State Health Agency that purchases BBP services on behalf of the state, meant to be Armenia’s first step in the way of national social health insurance. Then came the 2004 Law on Insurance, designed to grant legal status to voluntary health insurance, which was later followed by the government social package of 2012 that offered insurance vouchers to its employees and a few other civil servants. All failed to secure the insurance industry a stronger presence in the country, nor did they do much to improve equity in health financing.
Still, the government social package did help boost private voluntary health insurance revenues, even as their share in its total health expenditure remains meager, at just 2.3 per cent in 2018. Mandatory health insurance is absent altogether. Much of this can be explained by the widespread unawareness of insurance schemes among the public and the inability of the industry to compensate for the large-scale informal payments that plague Armenia’s health system. But the thorniest impediment to the expansion of private health insurance in Armenia is the high cost of commercial insurance premiums.
Armenia’s post-revolution Minister of Health Arsen Torosyan is now working on universal health coverage. Built around a single payer system with just one public health fund to service the medically insured, part of the money will come from government subsidies to insure the one-million-or-so vulnerable in society, while the rest will be collected from legally-registered employees. Initial contributions from the latter would hover around 2-3 per cent of gross monthly income.
However, with Armenia’s economy weakened by the pandemic and other factors depressing growth in employment income and national revenues, these sweeping changes remain on the drawing board. In the meantime, for patients across Armenia, both urban and rural, health care is tricky business as usual.
Banner illustration by Peter Ryan