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ORIGINAL ARTICLE
The Armenian healthcare system: recent changes
and challenges
Arsen Torosyan & Piotr Romaniuk &
Krzysztof Krajewski-Siuda
Received: 25 June 2007 / Accepted: 4 October 2007 / Published online: 13 November 2007
#
Springer-Verlag 2007
Abstract
Background Armenian healthcare reforms have been car-
ried out since independence in 1991, but achieved their full
scale starting in 1995–1996. Although the healthcare
system has already been modified and changed for 10 years,
there is a lack of researc h in this regard.
Objectives This paper aims to present the organization of the
healthcare system in Armenia, its changes and challenges
throughout the refor m process.
Methods This paper is mainly based on a review of the
relevant professional literature, a review and interpretation
of legal acts in the healthcare field, and a review of research
and assessment works done by severa l international and
local organizations.
Results There are still large numbers of elements typical for
the Soviet Semashko model in Armenian healthcare
structures. Implemented reforms have separated the institu-
tions of the public payer and the providers, but did not
manage to change the model of financing to be based on
compulsory insurance. The level of finan cing is similar to
the average in Central and Eastern Europe, but is based
mainly on out-of-pocket payments contributing to about
80% of all system resources. The informal payments reach
even 45% of expenditures. The structure of hospital beds
remains ineffective, and there are still no mechanisms of
increasing the quality of services. Privatization has been
applied, but the role of private providers is still limited.
Conclusions The reforms have not caused satisfactory
improvement in healthcare performance, although the
health indicators are better than at the beginning of the
transformation period. The stability of the reform ing
processes in previous years as well as the engagement of
international institutions is a chance for positive changes in
the near future.
Keywords Healthcare system
.
Healthcare reforms
.
Armenia
.
Post-communist countries
Introduction
The Republic of Armenia is one of the smallest of the
former Soviet republics. This mountainous country covers
29,743 km
2
and has a population of about 3.2 million
(National Statistic Service of RA 2006). After declaring
independence in September 1991, Armenia became a
sovereign republic headed by a president. Since this time
the countr y has entered a path of transition towards a free
market economy, although impeded by numerous difficul-
ties. The dissolution of the Soviet Union exacerbated ethnic
and national tensions, contributing to the outbreak of armed
conflict between Armenia and Azerbaijan over the
Nagorno-Karabakh region. Although a cease-fire has been
held since 1994, tensions remain high, causing the borders
with Azerbaijan and Turkey still to be closed.
Armenia’s early years of independence have been
impacted by severe economic decline and energy shortages.
The transition to a market economy has been hampered by
the legacy of central planning, major economic shocks
J Public Health (2008) 16:183–190
DOI 10.1007/s10389-007-0160-y
DO00160; No of Pages
A. Torosyan
National Institute of Health, Ministry of Health of Armenia,
Yerevan, Armenia
P. Romaniuk
:
K. Krajewski-Siuda (*)
Department of Health Policy, Faculty of Public Health,
Medical University of Silesia,
ul. Piekarska 18,
41-902 Bytom, Poland
e-mail: zpz@slam.katowice.pl
arising from the collapse of the Soviet Union and then the
“ruble crisis” (the former Soviet Union currency). The
country was also involved in regional conflicts, and reforms
were hampered by the limited ability and political will of
decision-makers to undertake the critical steps needed to
restructure the country’s economic and governmental
systems. All of this also influenced the healthcare system,
resulting in its collapse. During the Soviet era, the
government guaranteed–at least in theory –access to a wide
range of services for the whole population, which was in
line with the assumptions of the Semashko model. After
independence the economically weakened state withdrew
the financing of healthcare, which became dependent on
out-of-pocket payments and was highly perverted by the
omnipresent corruption (Mossialos et al. 2002). Since the
mid 1990s the government has started to work on a radical
program of reform aimed mainly at strengthening primary
healthcare and introducing an insurance-based system of
financing, but many of these efforts, similarly to those in
other post-Soviet republics, particularly those from the
South Caucasus region (Azerbaijan, Georgia), have had no
effect (Dixon et al. 2004 ).
The aim of this paper is to describe the recent trans-
formations implemented in the healthcare system of
Armenia, as well as to make a presentation of its current
situation and possible development in the near future.
Organization of the system
There are several laws regulating the Armenian healthcare
system. The most important are:
– the law “On Medical Aid and Medical Servic es for the
Population,” which has four main chapters: (1) human
rights in the healthcare sphere, (2) healthcare providers,
their rights and responsibilities, (3) particular forms of
healthcare services and their organizational structures,
and (4) healthcare financing (RA Law 1996). Recently,
the Ministry of Health has initiated two new legislative
projects: “On Healthcare Services”—a draft of the
law—and “On Public Health Safety”—a project of
the law—which are assumed to be the upgrades of the
previous law, fixing many of its defects.
– The laws “On Medications” (RA Law 1998), “On
Reproductive Health and Reproductive Rights” (RA
Law 2002a), “On Prevention of Disease Caused by
HIV” (RA 1997), “On Drugs and Psychotropic
Agents” (RA Law 2002b), “On Human Organs and
Tissues Transplantations
” (RA Law 2002c), and “On
Sanitary-Epidemic Safety for the Population” (RA Law
1992).
– The healthcare services are also regulated by the
government decre es as well as th e orders of the
Minister of Health.
Although a sort of structural reform was undertaken
during the first years of transition, the organization of the
system still has many elements typical for the centralized
Semashko model. The Ministry of Health is responsible for
supervising the system, for financing the state-guaranteed
health services and delivering some of them through the
subordinate institutions, as well as for projecting and
implementing the reform processes. The Ministry also
stimulates the legislative processes for the health sector,
which are generally placed in the National Assembly
(Hovhannisyan et al. 2001). The lower levels of the
hierarchy have a limited independence in decision making,
although some of the former reforms were aimed at
improving it, as for example the changing of the status of
medical facilities (to economically independent state enter-
prises and to state closed joint-stock companies afterwards)
and the new administrative-territorial division of the
Republic. This, however, unexpectedly resulted in substan-
tial weakening of the mechanisms of quality control and
management of the healthcare system (Hovhannisyan et al.
2001).
An important institution in the system is the State Health
Agency established in 1997. The agency fulfills the role of
a payer, being responsible for covering the costs of state-
guaranteed health servi ces (RA Government 1997). This
role was taken by the agency from the district authorities.
However, unlike the analogous institutions in many other
post-communist countries, the agency is not the insurance
fund. Although its aim was to introduce and develop
compulsory health insurance, it has not been implemented
yet.
Generally, the agency is responsible for: efficient and
effective utilization of state healthcare funds in the
framework of annual state guaranteed healthcare pro-
grams; contracting with healthcare providers on provision
of the services financed from public resources and paying
for these services; supervising the volume and quality of
provided care by the facilities; organizing and conducting
the observation of accounting data provided by the
healthcare facilities; participating in the development,
introduction and implementation of the organizational,
managerial and financial modern mechanisms in the
Armenian healthcare system (Hovhannisyan et al. 2001
and RA Government 1997).
The regional and local authorities have a limited range of
functions concerning the organization of the healthcare
system. The regional level authorities have the ownership
of most of the secondary care facilities; since 1998 most
184 J Public Health (2008) 16:183–190
rural outpatient clin ics have come under the ownership of
the communities (the lowest level of self-government) and a
few of them under the ownership of regional authorities.
The ministry still maintains the ownership of the tertiary
level institutions (Hovhannisyan et al. 2001).
Finances of healthcare
General matters
Since the establishment of the State Health Agency, the model
of financing health services has been based on a division
between the purchaser of the services and the providers.
Nevertheless, the general taxes and central budget are still the
basic source of health system finances. In spite of the necessity
for healthcare development, there is no compulsory health
insurance system in Armenia (Carrin 2002).
The Armenian healthcare system has undergone a radical
transformation in its system of finance as of March 1996,
when a law “On Medical Aid and Medical Services for The
Population” was adopted by the National Assembly. This
act legalized the alternative means of financing, including
private out-of-pocket payments (RA Law 1996), whi ch in
fact is a main source of covering the costs of services.
The range of services financed from the public resources is
defined in the Basic Benefit Package (RA Law 1996 and RA
Government 2004a). In 2005 it covered the following
services: hygiene and anti-epidemic control, primary health-
care, medical care for children, obstetrics, medical care for
socially vulnerable groups, communicable and non-commu-
nicable disease control, and the emergency healthcare
program (RA Government 2004a). In 2006 the Basic Benefit
Package was expanded and now includes all ambulatory-
polyclinic services: i.e., primary healthcare services and
specialized services provided at the ambulatory-polyclinic
institutions (RA Government 2004a).
Socially vulnerable groups are defined as including the
following: disabled persons, war veterans, children under the
age of 18 with one parent, orphans under the age of 18,
disabled chil dren under the age of 18, children under the age
of 7, families with four or more children under the age of 18,
families of war victims, arrested persons and prisoners,
children of disabled parents, retired persons, persons under
the age of compulsory drafting and persons to be drafted to
the army, participants in the Chernobyl disaster elimination
activities, and military servants and their families (RA
Government 2004a). The Basic Benefit Package is renewed
every year, and services/groups may be deleted or added
accordingly. All services that are not included in it must be
paid directly by the patient. There are official prices for the
services set by the government, but these are recognized as
being too low to cover the actual costs of a particular
service, which is one of the factors increasing the informal
payments (Ho vhannisyan et al. 2001).
Sources of finance
Table 1 presents the basic data concerning the level and
sources of financing healthcare in Armenia. The data are
based on the estimations by WHO (2007).
As the table shows, out-of-pocket payments are the main
source of covering the costs of health services, contributing
to nearly 89% of the total expenditures on health in
Armenia. Public expenses amounted to only 1.7% of the
GDP in 2005 (National Stati stical Service). Interestingly,
the total expenditures as a percentage of GDP do not vary
significantly from the average for all Central and Eastern
European countries (WHO 2005). The significant differ-
ences between consecutive years within the period 1998–
2004 should however not be omitted. The expenditures
Table 1 Expenditures on healthcare in Armenia
Indicator 1998 1999 2000 2001 2002 2004
Total expenditure on health (THE) as % of GDP 5.8 7.1 5.2 7.0 5.8 5.4
General government expenditure on health (GGHE) as % of THE 27.6 25.0 16.7 22.4 23.6 26.2
Private sector expenditure on health (PvtHE) as % of THE 72.4 75.0 83.3 77.6 76.4 73.8
Private households’ out-of-pocket payment as % of PvtHE 94.6 84.3 92.7 81.8 89.1 89.2
Total expenditure on health per capita at exchange rate (US $) 35 36 39 45 42 63
Total expenditure on health per capita at international dollar* rate 119 133 150 176 173 226
General government expenditure on health per capita at exchange rate (US $) 10 9 6 10 10 16
General government expenditure on health per capita at international dollar rate* 33 33 25 40 41 59
Source: World Health Organization 2007
Online at http://www.who.int/entity/nha/country/ARM.xls accessed on 23 August 2007
*The international dollar is a hypothetical currency unit that has the same purchasing power as the U.S. dollar has in the United States at a given
point in time. It shows how much a local currency unit is worth within the country’s borders. Conversions to international dollars are calculated
using purchasing power parities (PPP). It is used for comparisons namely of gross domestic products (GDP) both between countries and over time
J Public Health (2008) 16:183–190 185
given in amounts per capita are much lower than the
average for the region, where in 2004 it amouted to 437.3
international dollars in the CIS countries (Commonwealth
of Independent Countries: most of t he former Soviet
Republics; WHO Health for All database 2007) and nearly
2,334.3 in the whole European Union (WHO Health for All
database 2007), giving the scale of collapse of the system
during the transition period–the general government expen-
diture on health in the Soviet period was about US $300 per
capita (Ter-Grigoryan 2001).
The informal payments are widely expanded in the
Armenian health system, similarly to the general national
economy. One of the factors causing the increase of this
phenomenon is the fact that very low prices are paid by the
state for state-funded services. As these prices are too low to
cover the costs of provided services, providers are forced to
request payments from patients even in those cases where a
patient falls within the Basic Benefit Package (Hovhannisyan
et al. 2001). Due to the estimations, the scale of informal
payments in Armenia may exceed 45% of the total health-
care resources (State Budgets of RA 2002 to 2006). To
compare this with the Transparency International Estima-
tions, this level is lower than in Azerbaijan (84% of all health
expenditures), slightly more than in Georgia (about 35–40%)
and noticeably more than in Russia or Poland (30%; all data
based on: Transparency International 2006).
Structure of expenditures
The lack of a system of data collection in Armenia, as well
as the unclear mechanisms behind the flow of funds, makes
the precise estimation concerning the structure of expendi-
tures impossible. The only available data are for public
expenditures, which are presented in the table below.
The most evident trend indicated by these data is the
systematic decrease of expenditures on hospital care and
the increase of financing of ambulatory care. This is the
positive resu lt of t he i mple ment ed ref orms t ha t wer e
assisted by USAID/Armenia, the World Bank, WHO and
other international organizations (State Budgets of RA 2002
to 2006). There is no separate position for health promo-
tion, since this is among the responsibilities of the primary
healthcare.
The healthca re providers
The structure of providers still has many elements of the
former Semashko model, although a sort of change was
implemented during the period of transition. For example,
the state-owned hospitals and polyclinics are now semi-
autonomous, self-financing enterprises with considerable
decision-making powers (each time a new enterprise is
formed from a public institution, it is supported by a
government decree). Since 1999, the healthcare facilities
have been able to set prices for chargeable services (not for
services within the BBP), to some extent to determine
staffing levels and to negotiate contracts with the staff. The
facilities are responsible for covering their own costs and
should autonomously make efforts to attract a sufficient
volume of patients to secure their financial stability (each
facility has its bylaw defining policies and procedures). The
number of hospital beds in Armenia in 2004 was 443 per
each 100,000 population (Ministry of Health 2004). It was
similar to the number in Georgia (407 per 100,000
population), and much lower than in Azerbaijan (824 per
100,000) or the whole CIS regio n (866 per 100, 000
population). This is even lower than in the European
Union, where in 2004 it had 586 hospital beds per 100,000
population (all data: WHO Health for All Database 2007).
A maj or problem is the low effectiveness of the hospital
sector; in the late 1990s the average length of stay in the
hospital was nearly 13 days. In 2004 it decreased to
10 days, which was much lower than in Azerbaijan
(16.4 days), slightly lower than the average for the CIS
region (13.4 days) and only slightly more than the average
for the European Union (9.25: WHO Health for All
Database 2007). At the same time the level of utilization
remains dramatically low, being only slightly higher than
41.8%, compared to 75.9% in the European Union and
85.7% in the CIS region (WHO Health for All Database
2007; data for year 2004).
The RA law “On Medical Aid and Medical Services for
The Population” of March 1996 allows patients to freely
choose their primary healthcare physicians (RA Law 1996).
“Open enrollment” (the selection of the primary healthcare
provider by the patient), however, has not been fully
implemented due to the absence of necessary procedures
and mechanisms, as well as the lack of information and
education about the system. On 30 March 2006 the
government adopted a decree “
On Procedures of PHC Doctor
Selection and Registration with Him” (RA Government
2006b). The new regulation assumed that the right to choose
a provider would start functioning in practice on 1 January
2007, after making all necessary preparations, such as
training of staff for filling in registration forms and entering
them into the automated Health Information System, IT
equipment procurement, etc. (RA Government 2006a).
Before, patients were obliged to be registered with a doctor
working in a facility according to where they lived.
As has been mentioned, due to the lack of health
insurance and the collapse of the system of public health
financing, the main method of payment for providers is out-
of-pocket payments. For services included in the Basic
Benefit Package, the State Health Agency at the beginning
of each year signs the contracts with the healthcare facilities
186 J Public Health (2008) 16:183–190
to provide them. In the mid 1990s there was a major change
in the method of financing the services. In the case of
hospitals and large ambulatory medical facilities with
hospital beds, quasi-contracts and case -ba sed paym ent
methods were introduced. Presently, every year the Minis-
try of Health fixes the price for one bed/1 day of stay and
calculates the average length of stay in any given in-patient
category and hospital s. Providers are then paid according to
this approach. The methods of payment are, however, not
comprehensive. Since June 2000, the SHA has begun to
cover the hospitals' expenses (for services included in the
Basic Benefit Package) by the model of the global budget
(Ter-Grigoryan 2001). This means that the facility receives a
certain pool of financing per year and within that certain
reimbursement for one completed hospital case. In fact the
manage rial bo dy of the hospital is responsible for the
allocation of the global budget funds inside the hospital. They
define the structure of internal allocations: salary remunera-
tion, administrative expenses, medical equipment and supply
(each facility has its bylaw defining policies and procedures
for how to act). The rate for 1 day/one bed was about US$ 19.3
in 2005 and US$ 25.7 in 2006 (USD exchange rate versus
Armenian Dram, AMD, has been dramatically decreasing
since 2004, and the actual rise in 1 day/one bed in Armenian
Drams was 3.4%-from 8,700 AMD in 2005 to 9,000 AMD in
2006). In state-owned facilities the average salary of physi-
cians in 2006 was US$ 110, and for nurses US$ 87 (State
Simplified Health Budget 2006).
Primary healthcare facilities are paid on a “per capita”
basis. Since the catchment area for the appropriate facility is
defined by the Regional Health Authorities and it cannot be
changed by either the facility or the patient (since 1 January
2007 the Open Enrollment System has allowed changing the
physician, but the financial implications will start on 1 January
2008), in fact it can be said that the primary care physicians’
(therapeutists, pediatricians and family physicians) salaries are
set preliminarily. There is a defined minimal, optimal and
maximal number of the population that can be assigned to one
physician: for 2006 it was as presented in the table below
(Minister of Health 2003).
The role of private health facilities is becoming more and
more crucial in the whole healthcare framework of
Armenia. They are recognized as being much more well
organized, ensuring a higher quality of services, and
familiarized with the client-oriented approach and modern
costing mechanisms. The first document outlining privat-
ization of healthcare facilities was submitted by the
Ministry of Health to the government in 1 994. In
subsequent years additional approaches to privatization
were developed. Presently, nearly all pharmacies, medical
technical services and a lmost all huge medical centers are
privatized under private companies and non-profit organ-
izations. Besides, any kind of hospital and/or independent
practice is allowed to practice if it meets all the require-
ments for and obtains its license. In 2005 17% of hospitals
(24.9% of hospital beds) and 11% of primary healthcare
facilities were private (Ministry of Health 2005). For
comparison, private hospital beds in 2004 in the following
countries and regions were: EU–20.1%, CIS–2.4%, Azer-
baijan–0.21%, Estonia-10.1%, Kazakhstan–6.6%, and Lat-
via-5% (WHO Health for All database 2007).
The general changes and challenges of the recent
transitions
During the So viet era, Armenia had one of the best
developed healthcare systems in the Soviet Union (Ter-
Grigoryan 2001 ). However, the economic crisis has
decreased the government’s ability to provide adequate
funding for healthcare, with major implications for health
status. Life expectancy, which in the early 1980s was the
highest in the Soviet republics (73 years), fell in the early
years after independence (71 years in 1991-Ministry of
Health 2004). Since the mid 1990s, this factor has been
climbing steadily and reached 72.5 in 2000 and 73.4 in
2004 (Minist ry of Health 2004). This was much higher than
in Russia (65 years) or the average for the CIS region
(67 years), and comparable to the average for the “new” EU
Member States (74 years; WHO Health for All Database
2007). At the same time the infant mortality factor was
improving systematically and reached 11.6 cases per every
1,000 live births in 2004, to be compared with 18.5 cases
per 1,000 live births in 1990 (Ministry of Health 2004
). It
was lower than the average for the CIS region (more than
13 cases per 1,000 live births), but much higher than the
average for the EU Member States (5.25 cases per 1,000
live births; WHO Health for All Database 2007).
Falling life expectancy in the first half of the 1990s was
a reflection of worsening adult health due to increases in
Table 2 Government health expenditure structure. Source: National
Statistical Service of RA
Indicator 2002 2003 2004 2005 2006
State healthcare
management
0.5 1.1 2 1.6 1.8
Hospital services 55.3 55.3 51.6 43.5 36.9
Primary healthcare services
(ambulatory-polyclinic)*
23.2 33.4 34.9 38.7 36.7
Hygienic and sanitary-
epidemiological services
5.3 2.8 4 4.5 5.3
Other healthcare services
and programs
15.7 7.4 7.5 11.7 19.3
*Including narrow specialists’ services provided within the framework
of primary healthcare facility
J Public Health (2008) 16:183–190 187
cardiovascular diseases, cancer, diabetes, tuber culosis and
others. The incidence of major comm unicable diseases such
as tuberculosis and HIV/AIDS has increased. Outbreaks of
waterborne diseases were caused by the degradation of
poorly maintained water supply networks (Hovhannisyan
et al. 2001). According to the “Nat ional Survey on the
Drug, Alcohol and Smoking Prevalence among the General
Population of Armenia” conducted in 2005, tobacco was
smoked by 29% of the population of 16 to 75 year olds,
including 60.5% of men and 2.2% of women. The number
of respondents to the aforementioned survey who knew
drug users showed that the proportion of people who knew
persons who were taking hashish or marijuana was
relatively high (5.4%) and was followed by persons who
knew cocaine (0.9%) and heroin (0.6%) users (ICHD, NSS,
NIH and SCAD 2005) (Tables 2 and 3).
The decreasing health status may therefore be the result
of unhealthy behavior. Nonetheless, the inefficient health
system could also play a significant role, especi ally in case
of the maternal and child health. Table 4 presents data that
may prove such a correlation (United Nations Development
Program 2005).
In the context of the recent transitions and current main
health problems of the Armenian population, the basic
challenges for public health in Armenia may be character-
ized as follows:
– Primary healthcare should be emphasized. A fundamental
problem in primary care is its accessibility for people,
which has become difficult for a large segment of the
population due to their inability to pay out-of-pocket for
health services. The number of outpatient contacts in
1999 per person per year in Armenia was 2.3, while the
average for EU countries was 6.2 and for NIS countries
8.3 (United Nations Development Program report 2005)
(Hovhannisyan et al. 2001). Since the above-mentioned
decision concerning extending the Basic Benefit Package
for all ambulatory services was declared, the flow of
patients to primary healthcare has been enormously
increased. This caused another problem with the inadequate
salaries of the healthcare personnel, which has increased,
but is said not to correspond to the increase of visits.
– In Armenia, the sense of individual responsibility for
one’s health is low. Probably the main reason for this
Table 3 Number of attached population to the primary care physician
Minimal Optimal Maximal
Theraputist
(urban areas)
1,000 2,000 2,500
Theraputist
(rural areas)
1,000 2,000 2,700
Pediatrician
(urban areas)
500 1,000 1,200
Pediatrician
(rural areas)
500 1,000 1,400
Family physician 1,000
(300 children +
700 adults)
1,700
(500+1,200)
2,300
(800+
1,500)
Source: Minister of Health order “On RA State-Owned Primary
Healthcare Facilities Medical Personnel Remuneration Setting Proce-
dures,”
1
195, 28 March 2003
Table 4 Population’s morbidity, not seeking medical care and lack of access to healthcare (percentages)
Population’s
morbidity*
Proportion of those
who did not seek
medical care in the
total number of people
with sickness
Of which the proportion
of those who did not seek
medical care due to lack
of access**
Proportion of those
who were sick but did
not seek medical care
in the total number of
people with sickness
Total population surveyed 34.3 42.8 97.1 41.6
Urban 35.4 41.6 96.8 40.2
Rural 33.2 44.2 97.6 43.2
Women 36.6 43.7 97.2 42.5
Men 31.6 41.0 97.0 40.3
Age 0–7 20.0 18.9 97.0 18.4
Age 8–15 13.6 36.9 98.9 36.6
Age 16–64 35.4 45.7 98.8 44.4
Age 65+ 66.9 42.6 97.1 41.4
*Population’s morbidity is calculated as the ratio of the number of people who in the 12 months preceding the survey suffered from a disease that
limited their ability to the total number of respondents
**For NHDS purposes, the lack of access to medical care is defined as the combination of three components: (1) material lack of access or
inability to pay for the cost of medical care; (2) physical lack of access or difficulties in reaching a doctor and/or healthcare facility; (3) lack of
time needed for seeing a doctor
Source: NHDS database 2003
188 J Public Health (2008) 16:183–190
situation is the absence or low level of health education.
Health education and health promotion are core
components of primary healthcare (RA Government
2004c).
– The situation with the health workforce is inefficient in
Armenia. Particularly, the Armenian healthcare system
has suffered from an overproduction of medical
personnel, unemployment and underemployment. Tak-
ing this situation into account, the Ministry of Health
expects the healthcare reforms to affect future require-
ments and the supply of health specialists. In spite of an
overproduction of medical personnel, there is a
shortage of health specialists in rural areas, because
there are no incentives for physicians to move there.
Simila rly as in most of the other post-communist
countries, there is also a problem of overspecialization
and insufficiency of primary healthcare personnel-
family physicians and general practitioners (Ministry
of Health 2004). One of the Ministry of Health
initiatives-the Family Medicine introduction—was also
aimed to reduce the number of medical personnel and
to integrate some particular specialties into one (RA
Government 2004c).
– Health planning is not adequately developed in
Armenia. One of the main reasons is the absence of
effective tracking mechanisms for health expenditures.
The planning process cannot be completed if the
government does not have the actual figures for
expenditures. The whole state budget is formed by
the estimation principle. The NHA calculation system
is in the formative process, and almost all current data
have been estimated. Unless the government pays
attention to the present situation and considers the first
stage of planning, the whole cycle of planning cannot
be effectively completed (Green 1992).
– Informal payments remain one of the most vulnerable
issues in the Armeni an healthcare system. It is said that
it can be solved by the introduction of compu lsory
health insurance, the implementation of effective
costing model s and decreasing taxes (Carrin 2002).
Conclusions
1. The whole period of transition that started with the
independence of Armenia resulted in the improvement
of the healthcare system in the country, but still the
majority of the aims of the reforms has not been
achieved. There are still no adequate finance tracking
mechanisms, and the planning of health financing is
insufficient. Hopefully, actions taken recently by the
National Health Accounts working group will manage
to prepare the ground for the proper mechanisms for
data collection and suitable future health planning.
2. There is still a need to enforce the mechanism of health
financing based on the state's compulsory health insurance
and complementary private insurance, which should lead
to a more adequate allocation of financial resources in
healthcare. It will have a significant role in the process of
eliminating out-of-pocket and informal payments.
3. Due to many health education campaigns and other
health promotion activities, each year the Armenian
society becomes more informed about its health, thus
demonstrating healthy lifestyles and health-seeking
behavior. Nevertheless, health education is still a great
challenge for Armenia.
4. Armenian healthcare legislation and regulations are
relatively well developed. Nonetheless, there are still
proble ms with the practical implementation of the
existing law due to the lack of political will and
corruption.
Acknowledgements The Department of Health Policy of the
Medical University of Silesia uses computer equipment purchased
by the Medical Aid for Poland Fund in London.
Conflict of interest statement The authors disclose any relevant
associations that might pose a conflict of interest.
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