Report: Human Rights Monitoring - Healthcare

PROTECTION OF THE RIGHT TO FREE HEALTH CARE PROVISION IN ARAGATSOTN REGION

MONITORING REPORT

Introduction The right to free basic health care services is guaranteed by Article 35 of the Armenian Constitution.

Information received from mass media, NGOs, complaints sent to attorneys’ offices and from other sources furnishes evidence that people’s right to get basic medical care for free is frequently violated. In particular, such information is available in Aragatsotn region in attorneys’ offices and NGOs that people often turn to in search of legal counsel. The studies have shown that only a part of the region’s population is knowledgeable about the terms and conditions and the procedure for getting basic medical care for free. The greater part of the population is not aware of the rights and of the mechanisms for their enjoyment and protection and, therefore, ends up in complicated situations. Not infrequently these people face health-related problems since they do not have the amount of money demanded by doctors.

With the aim of finding out how the free health care-related right is enjoyed and how the law is applied in Aragatsotn region a study was conducted among the citizens who have the right to get health care and medication for free.

The RoA Law and the Government decree on provision of medical care and services to the population define the main types of medical care and services as well as the list of social groups that qualify for and of diseases that entitle patients to get medication for free or at a discount (See the 23 November 2006 RoA Government Decree № 1717-N).

The goal of the monitoring is to contribute to the exercise of the right to make use for free of the maximum accessible level of physical and mental health.

The following objectives were set to achieve the goal of the monitoring.

Objective 1was to ascertain the extent to which the law on getting medical care for free is effective.

2

Objective 2 was to identify the degree of awareness of the individuals entitled to get medical care for free and medication at a discount.

The Report is intended for: the Armenian Government the RoA Ministry of Health non-governmental organizations charities The study was conducted in Talin, Aparan, Ashtarak and Arteni communities in Aragatsotn region from September 20 till November 20, 2007.

Some obstacles impeded the implementation of the project: failure on the part of several branches of the Medical Center of Aparan (Aparan M.C.) to submit the required documentation; submittal of not particularly reliable information on the part of Ashtarak Medical Center (Ashtarak M.C.).

The monitoring was conducted by Elya Parvanyan (graduate student, Theology Department, Yerevan State University) from Aparan, by Khanum Mkrtchyan (member of the RoA Attorneys’ Chamber, Head of Attorneys’ Office in Talin) from Talin and by coordinator Anyuta Tonoyan (member of Communities’ Development NGO).

The team that conducted the monitoring

We wish to express our gratitude for the support provided in the course of the monitoring conducted within the framework of the Protection of the right to free health care provision in Aragatsotn region Project: 3

-

to Ms Ruzan Movsisyan, Chairperson, Sphere of Education NGO,

-

to Ms Tamara Gevorgian, Director a.i., Talin Medical Center,

-

to Ms A. Hovhannisyan, Director, Ashtarak Medical Center,

-

to Attorneys’ offices of Aragatsotn region,

-

and to Communities’ Development, Education Development Academy and Hope NGOs.

Methodology for conducting the monitoring Analysis of legislation Examined were the Armenian Constitution, the Universal Declaration of Human Rights (adopted on 12 December 1948), the (UN) International Covenant on Economic, Social and Cultural Rights (adopted on 16 December 1966), the RoA Law on medical care and services for the population, the 23 November 2006 RoA Government Decree № 1717-N as well as the RoA Health Minister’s Orders № 1532-A and № 1526-A (27 December 2006) and Orders № 1535-A, № 1558-A, № 1559-A, № 1565 and № 1565-A (29 December 1996).

Observation The study was conducted in Talin Medical Center, Aparan Medical Center, Ashtarak Medical Center and Arteni Healthcare Center (hereinafter Talin M.C., Aparan M.C., Ashtarak M.C. and Arteni H.C.) to ascertain the presence of notification posters and the degree of their accessibility.

Analysis of documents Examined in Talin M.C., Ashtarak M.C., Aparan M.C. and Arteni H.C. were the reception and distribution logs for the medication guaranteed by the State, the registration logs of relevant departments, the patients’ medical files and case histories.

The distribution logs included the beneficiaries’ registration numbers, first and last names, home address and the type of medical services provided and acknowledged with the beneficiary’s signature.

Surveys Interviews were conducted with 4 chief medical officers, 20 staff members, 8 individuals that were receiving inpatient treatment on that day or their family members, 20 individuals who came to those health care institutions on that day or individuals that were

4

accompanying them, 20 individuals that received treatment earlier and 20 individuals from social groups entitled to privileges (their addresses were taken from the logs in the appropriate departments). Interviews were held with 68 individuals entitled to get medical care for free.

Personal data on the individuals randomly selected from the distribution logs were obtained and then a check was run on the extent to which data correspond to reality.

Findings As per Article 38 of the Armenian Constitution, everyone has the right to get medical care and services through the procedure established by law and everyone has the right to get basic medical services for free. The list of those services and the procedure for their provision are set by the RoA law.

The RoA law on medical care and services for population sets the right to free medical care and services provided within the State healthcare programs guaranteed by the State.

Article 2 of the Universal Declaration of Human Rights establishes that everyone is entitled to all the rights and freedoms set forth in the Declaration without distinction of any kind, such as race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.

The right of everyone to the enjoyment of the highest attainable standard of physical and mental health is guaranteed also by Article 12 of the International Covenant on Economic, Social and Cultural Rights. It makes it incumbent on the State Parties to take steps necessary for the creation of conditions, which would assure to all medical service and medical attention in the event of sickness.

As per the 23 November 2006 RoA Government Decree № 1717-N and the RoA Health Minister’s Orders № 1532-A and № 1526-A (27 December 2006) and Orders № 1535-A, № 1558-A, № 1559-A, № 1565 and № 1565-A (29 December 1996), the main types of medical care and services as well as the list of social groups that qualify for and of diseases that entitle patients to get medication for free or at a discount have been defined.

In particular, in case of tuberculosis, mental diseases, malignant growth, cardiac infarction, familial paroxysmal polyserositis, pancreatic diabetes and diabetes insipidus and some

5

other diseases the medication and medical services are provided to patients for free through outpatient clinics, health centers and hospitals.

Pregnant women’s antenatal care, laboratory tests, diagnostic examination with the use of medical devices and medical assistance at childbirth are for free, as guaranteed by the State.

Annual targeted healthcare programs are approved concurrently with the RoA Budget Law. Each year the Armenian Government and the Ministry of Health design and approve the instructions, methodological guidelines and procedures in line with that Law (See Annex 1).

Talin In the outpatient department of Talin M.C. the information documentation, including the lists of persons entitled to medical care for free, of diseases, social groups and of relevant documents as well as of the provided services, was posted in conspicuous places. In the inpatient department, however, it was posted only near the chief medical officer’s room, which is inaccessible for the hospital visitors.

To check the departments’ registration logs data on medical services provided for free the data on 17 randomly selected patients were taken out. It was subsequently ascertained through interviews whether those individuals indeed qualified and whether they indeed received medical services and medication that they are entitled to.

Bulletin board with information documentation in Talin M.C.

The records in medical files matched the respondents’ answers. The examination of documentation did not reveal a single violation. (“Complaints & Suggestions Book”)→ The collection of money for obstetric assistance during childbirth is not a rare occurrence in the obstetric-gynecologic department.

BOX 1 During a conversation with a woman recently confined it was discovered that that 6 after the childbirth the doctor took 30,000 AMD from her husband without

In both cases the law on medical care and services to population was violated, including Annex 2 to the Health Ministry’s 29 December 2006 Order № 1558 (See Annex).

The services provided by the ambulance are not up to the mark and do not meet the requirements of the Law.

According to one of the respondents, her husband fell seriously ill but when they called the ambulance (at 1 a.m.), they were told “We do not have any medication other than Aspirin and Analgin; besides, it is already our bedtime so we cannot come.”

A member of a medical staff told us that the State sets free medical care provision quotas for healthcare institutions. The quotas are determined based on the departments, diseases and age groups. However, the healthcare institutions are not authorized to manage at will the resources within those quotas. As a result, in some departments (e.g. obstetricgynecological, surgery and therapeutic departments) the resources run out and some people are denied medical care guaranteed by the State. In other departments (e.g. children department), the quotas are not fulfilled because of a relatively small scale of service provision. The medication quotas, which are set based on the list of diseases and social groups specified by the Government decree, are limited and do not suffice, when medication is handed out, while the quota set for children of 0 to 7 years of age is met only by one-fourth.

7

The medical staff also complained that professional development courses are not organized on a regular basis. As a result, the majority of the staff members did not take such courses within the last five years.

Ashtarak In Ashtarak M.C. the information documentation is posted in hallways and near the entrances in conspicuous places.

The records in medical files matched the respondents’ answers. Here, too, the examination of documentation did not reveal a single violation.

Bulletin board with information documentation in Ashtarak M.C.

It was found out that patients are frequently forced to pay for medical and laboratory tests and for medical

care, including for visits to a women’s antennal clinic, for obstetrical assistance and for the medication guaranteed for free by the State.

All the 17 patients who underwent diagnostic examinations made payments.

When we asked a woman with a second-degree disability whether she avails herself of free medical services, medication and tests, she replied that the doctor demanded money for the analysis of the blood test telling her that is she wanted a correct diagnosis she must pay or else they will just write that everything is OK. In another case, a surgeon in the outpatient clinic told a patient who had undergone surgery in another hospital but who was registered in this outpatient clinic and was from a vulnerable social group that he cannot diagnose him and suggested that the patient go to the surgeon who had operated him and to seek professional advice on a commercial basis.

A woman with a second-degree disability told us that a staff member in a pharmacy in an outpatient clinic had not given her the medication prescribed by a doctor contending that the medication in question is not provided by the State for free and suggested that the woman buy that medication from another pharmacy specified by her. We ran a check on that address and found out that the said pharmacy was owned by that staff member in a pharmacy in the outpatient clinic.

Some doctors confirmed that there were cases of money taking from patients. Thus, To the question of whether they currently have in-patients from social groups entitled to free medical care getting treatment in their department, a traumatologist from the surgery department of the hospital replied with an ironic smile, “Is there anything for free now?”…

8

Arteni In Arteni H.C. the information documentation is posted near the entrance. However, it was not normally visible or legible because of inadequate lighting. It was found out in the course of surveys and of the examination of the distribution logs for the medication guaranteed by the State and dispensed on a privileged basis that not all individuals entitled to get medication for free were given it.

Within one month, the medication was distributed for free or at a discount from time to time to 11 out of 22 individuals entitled to get medication for free. The medication given to the patients did not match the doctors’ prescriptions.

For example, instead of getting an antidiabetic agent, the patients with pancreatic diabetes were Study of documentation in Arteni H.C.

given Askofen, Aspirin and valerian tablets.

It was discovered in the medication distribution logs that the same person (having the same first and last names and the same diagnosis) was registered twice as two different individuals, first as a patient with a third degree of disability and then as a patient with the second degree of disability. As a patient with the same disease, that person exploited the status of both the third-degree disability to get a 50% discount on medication and the second-degree disability to get medication for free. In the medication distribution log the names of 5 patients out of 22 were registered twice within one month, i.e. one-fourth of the patients were friends and family of the medical staff. Often, the medication was not given to other patients who were in need of it.

9

The interviews conducted with 17 randomly selected persons registered in the logs of laboratory tests revealed that fee was charged for all laboratory tests instead of making them for free.

Sometimes mandatory vaccinations are not made. The examination of medical files and vaccination logs

and the comparison of their

entries with those in the children’s vaccination cards (which are kept by parents and filled out by pediatricians) demonstrated that in reality children are not vaccinated, even though “vaccinations� are registered in the vaccination cards.

Interview with medical personnel in Arteni H.C.

It was found out through the survey of the patients randomly selected from the medication distribution logs that the person registered in the log (and who had a disability and was entitled to free medication) had died 7 years ago. (Now his three-year-old grandson, who has the identical first and last name, lives at the same address but he does not have a disability).

Medical assistance at childbirth is provided for a fee.

An employee from the office of the Village Head told us in an interview that children born in Arteni H.C. do not get birth certificates. As a result of a failure on the part of Arteni H.C. to present a certificate concerning the birth of the child, the birth is not recorded and entries concerning the newborns are not made in the economic registries of the community. The reason is non-payment by the woman who gave birth to a child or by her relatives of the money demanded by Arteni H.C. for assistance at childbirth.

Aparan The information documentation was not posted in Aparan H.C. The only bulletin board was in one room identified by nurses as an admission room. It was not accessible to people coming to the clinic.

The study of documentation was not conducted in Aparan H.C. because the director was absent and the deputy director did not provide the documentation.

10

When asked whether assistance at childbirth in the clinic is for free or for a fee, the head of the obstetric-gynecologic department replied that since the State remuneration of work is too low, they charge for medical services. “ - For the treatment, Hippocrates would take gold that weighted as much as the organ that was cured, and if I am given money, I take it.”

Conclusion Medical care for free is not provided adequately in Aragatsotn region. The rights of individuals entitled to free medical care are frequently violated. The main reasons are the following ones: 1. Inadequate application of legislation on free medical care; 2. Lack of diversity of the medication, which is guaranteed by the State for the provision for free; 3. Lack of quotas established by the State for the provision of free medical care; 4. Lack of powers of healthcare institutions directors in terms of distribution and at-will management of the resources within those quotas; 5. Low salaries of medical personnel; 6. Lack of adequate tools, appliances and devices; 7. Insufficient level of professionalism of some medical staff; 8. Not particularly caring attitude often displayed by medical staff; 9. The manifestations of corruption in the system; 10. Lack of transparency in the actions of medical staff; 11. Lack of public awareness; 12. Public apathy towards the existing violations in the field; 13. Absence of civic control.

In all medical centers the payments are not made of the patients’ own free will.

Some patients pay money since, suffering from chronic diseases, they are dependant on medical personnel and they cannot but pay the amounts demanded by the staff. Some patients pay because they are unaware of their rights.

11

In some medical centers the information documentation is not posted in the places that are immediately accessible to the public.

Adequate control over healthcare institutions is lacking.

Not infrequently, while making a diagnosis of and prescribing a course of treatment for patients, the medical personnel are not aware of new methods and of new medication, as a result of which the efficient treatment is not administered sometimes.

Recommendations For the Armenian Government and the RoA Ministry of Health: The quotas for medical care provided for free should be increased.

The distribution, by departments and diseases, of the quotas allocated by the State for the provision of medical care for free should be left to the discretion of the directors of healthcare institutions.

Medical personnel and their family members as well as individuals who live on an old-age pension should be added on the list of the social groups and the diseases that entitle to get medical care and medication for free or at a discount from healthcare institutions as established by the RoA Law on medical care and services for the population and by the Annexes 1, 2 and 3 to the 23 November 2006 RoA Government Decree â„– 1717-N. The salaries of the medical staff should be raised.

For the Ministry of Health and charitable organizations: Modern medical equipment and appliances should be provided to healthcare institutions (since the medical centers in question do not have adequate medical devices and appliances, they cannot provide some services to the people; as a result, patients have to get treatment in Yerevan for a fee or do not get treatment at all because they cannot afford the transportation expenses).

Professional development courses should be organized for the medical staff so that they could deepen their knowledge and develop skills for using the modern medical equipment.

12

Interview with acting director of Talin M.C.

Interview with director of Arteni H.C.

For non-governmental organizations: In order to raise public awareness the fact sheets and notification posters on the procedure and list of medical care provided for free should be published and posted in post-offices, offices of Village Heads and in Social services departments.

Monitoring should be conducted from time to time in various fields of health care.

SUMMARY Even though both the Armenian laws and international standards guarantee Stateprovided medical care for free and medication for free or at a discount as well as provision of medical care for free to the qualifying social groups and in emergencies such as fits, life-threatening and chronic disease, including antenatal care of pregnant women and medical assistance at childbirth, nevertheless, money is collected in Talin, Aparan, Ashtarak and Arteni communities in Aragatsotn region for medical assistance at childbirth, for emergencies and for free medication and medical care.

13

ANNEX 1 Article 38 of the Armenian Constitution “Everyone is entitled to receive medical care and services through the procedure established by law.

Everyone is entitled to receive basic medical services for free. The list and the provision procedure of those services shall be established by law.”

Article 2 of the Universal Declaration of Human Rights “Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.”

International Covenant on Economic, Social and Cultural Rights, Article 12 “1. The State Parties to the Present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

2. The steps to be taken by the State Parties to the Present Covenant to achieve the full realization of this right shall include those necessary for: (a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child; (b) The improvement of all aspects of environmental and industrial hygiene; (c) The preservation, treatment and control of epidemic, endemic, occupational and other diseases; (d) The creation of conditions which would assure to all medical service and medical attention in the event of sickness.”

Article 4 of the RoA Law on medical care and services for the population “Everyone in the Republic of Armenia is entitled to receive medical care and services without distinction of any kind, such as ethnicity, race, sex, language, religion, age, health status, political or other opinion, social origin, and property or other status.

Everyone is entitled to receive medical care and services for free within the framework of the targeted State healthcare programs guaranteed by the State.”

14

Annex 1 to the 23 November 2006 RoA Government Decree â„– 1717-N The list of social groups entitled to receive medication for free or at a discount 1. Medication shall be given for free to sick patients from the following social groups of the population: a) persons with the first or second degree of disability; b) children with disability; c) World War II participants and individuals equated with them; d) children left without parental care and children with a single parent; e) children from families with many children (with four or more minors under 18 years of age); f) family members of military servicemen who dies while defending the Republic of Armenia or while discharging their professional duties; g) children in the families of the persons with disabilities; h) children under 7 years of age.

2. Medication shall be given at a 50% discount to sick patients from the following social groups of the population: a) persons with the third degree of disability; b) individuals who took part in the Chernobyl accident elimination; c) victims of political repressions, d) single unemployed pensioners; e) families consisting only of unemployed pensioners (including those who have minors in their care); f) children of single mothers.

3. Medication shall be given at a 50% discount to unemployed pensioners.

Annex 2 to the 23 November 2006 RoA Government Decree â„– 1717-N The list of diseases, in which case medication will be dispensed for free through outpatient clinics, health centers and hospitals: Tuberculosis (antituberculous medication), Mental diseases (psychotropic drugs), 15

Malignant neoplasms (antitumor drugs, anesthetic drugs, narcotic drugs), Pancreatic diabetes and diabetes insipidus (antidiabetic agents), Epilepsy (anticonvulsant drugs), Cardiac infarction (medication that improve coronary circulation – within first 2 months after the patient has been discharged from the hospital), Familial paroxysmal polyserositis (Colchicine or equivalent medication), Valvular heart disease (anticoagulating agent after the valve replacement), Malaria (antimalarial drugs), Chronic renal insufficiency (in case of kidney transplantation and prescribed hemodialysis (cyclosporine, erythroporetine and other equivalent medications)).

The 27 December 2006 RoA Health Minister’s Order № 1526-A The list of diseases and conditions qualifying for State-funded medical care in hospitals for free 1. a) For persons of 18 or more years of age: Conditions requiring medical intervention for resuscitation: 1. Shock conditions, 2. State of coma, 3. Acute respiratory failure, 4. Ventrical fibrillation and tachycardia, cardiac arrest, 5. Acute myocardial infarction, 6. Acute hemolytic attacks and/or insufficiency, 7. Epileptic seizure, 8. Stroke, 9. Poisoning, 10. Overall chill-blain.

Diseases and conditions requiring emergency medical intervention: 1. Paroxysmal tachycardia, 2. Hypertension stroke, 3. Serum attack, 4. Acute renal insufficiency, 16

5. Renal colic, 6. Acute retention of urine, 7. Frost-bitten (body parts), 8. Acute exacerbation of glaucoma, 9. Fit of organs of vision, 10. Sepsis, 11. Acute abdominal (internal or external) hemorrhage, 12. Craniocerebral injuries, spinal cord injuries, 13. Penetrating gunshot wounds, 14. Burns.

ANNEX 2 Surveys were conducted in Talin M.C., Ashtarak M.C., Aparan M.C. and Arteni H.C. Interviews were held in 4 communities with 68 individuals who received medical care and who are entitled to get medical care for free: 1.

2 individuals that were receiving inpatient treatment on that day (or their family members)(2 persons in each of the 4 communities, the total of 8 persons);

2.

5 individuals who came to those health care institutions on that day (or individuals that were accompanying them)(5 persons in each of the 4 communities, the total of 20 persons);

3.

5 individuals from socially vulnerable groups that earlier received treatment for free and that had a degree of disability)(5 persons in each of the 4 communities, the total of 20 persons);

4.

Interviews were also conducted with directors of healthcare institutions, heads of departments and medical staff.

17

ANNEX 3 The results of the surveys conducted in Talin, Ashtarak, Arteni and Aparan communities within the framework of the monitoring:

18

1. Are you aware of the procedure for receiving free medical care?

Talin

Ashtarak

yes 11

no 6

yes 5

Arteni no 12

yes 8

Aparan no 9

yes 6

no 11

2. Have you ever availed yourself of medical care provided for free or at a discount?

Talin yes 13

Ashtarak no 4

2

People around me 2

Ashtarak Can’t say 13

Aparan

yes no yes no 2 15 6 11 3. From whom did you find out that you have to pay?

Talin Medical staff

Arteni

People around me 0

Medical staff 15

yes 7

Arteni Can’t say 2

Medical staff 11

People around me 0

no 10

Aparan Can’t say 6

People around me 0

Medical staff 10

Can’t say 7

4. Have you been given a receipt?

Talin yes 0

Ashtarak no 4

yes 0

Arteni no 15

yes 0

Aparan no 11

yes 1

no 9

5. Have you been given medication for free or at a discount?

Talin yes 13

Ashtarak no 4

yes 2

Arteni no 15

yes 6

Aparan no 11

yes 15

no 2

6. Have you undergone a diagnostic examination? If yes, for a fee or for free?

Talin for a fee 0

Ashtarak for free 17

for a fee 17

Arteni

for free 0

for a fee 17

Aparan for free 0

for a fee 11

for free 6

7. Are you informed about your right to receive medical care and medication for free?

Talin yes 11

Ashtarak no 6

yes 2

Arteni no 15

yes 6

Aparan no 11

yes 11

no 6

8. Source of information Talin Medical staff

Mass media

6

2

Ashtarak People around me 3

Medical staff

Mass media

2

0

Arteni People around me 0

Medical staff

Mass media

1

3

Aparan People around me 2

Medical staff

Mass media

5

0

19

People around me 5