168: Why aren’t those who eat billions in prison when they pay a doctor for 1000 drams?

Satik Seyranyan’s guest in the “Lessons” program is Anush Poghosyan, president of the “Health Rights” human rights organization, doctor-expert.

• On August 7, I, like many others, was in the yard of the court of first instance of Armavir region, where the trial of the Catholicos of All Armenians started. The followers of our Armenian Apostolic Church were there in thousands. And it inspires hope, the Armenian people have the realization that all of us must stand by the side of the Armenian Apostolic Church in these difficult days.

• There are many sectarian organizations in our country, and they often target people who have certain psychological problems, these people are manipulated by them. Often, many people, including many young people, who experience certain problems and stresses during their life or at some stage, fall into the network of these sectarian structures and end up in addiction. Those heavy addictions later cause psychological and mental health problems in those people. Such people are easily manipulated, also in terms of involving them in various types of financial machinations. And, yes, the activities of these organizations are encouraged by the authorities, and the servants of the Armenian Apostolic Church are persecuted. And, yes, that sectarian resource is used during elections.

• This also causes serious health problems because over time these manipulated citizens are already facing deeper mental problems. Any addiction leads to the fact that they end up in a mentally unbalanced state, conflicts arise in families because in many cases family members do not share their choices, etc., families break up… It’s a matter of national security.

• We also have a very serious health problem with some sectarian organizations. For example, there are sects that do not allow blood transfusions, and a very serious problem arises when such a need arises to save a patient’s life.

• Why has the universal health insurance system failed? The introduction of the universal health insurance system is one of the most important reforms in the socio-economic development of the country, which, however, had to be done with a very detailed calculation, very correct and risk assessment. For years, the previous authorities discussed it, we even approved the concept, but considering the risks, they did not go for it, and that is why the state order system was introduced, which was in a large way a transitional stage to health insurance.

These authorities, however, without assessing the possible risks, introduced the law with impunity. By the way, after many criticisms, at least some changes were made in the problematic law, otherwise we would be in a worse situation today. They used it during the elections, they blew dust into people’s eyes, as they say. That was the key to the campaign of the authorities in the NA elections, they had nothing else to talk about. And some people, yes, took advantage, we also urged people to go and take advantage as much as they can. And we came out right, because they introduced the whole package of co-payments.

I warned and today we see that we actually have a situation where the co-payment is applied not only to people aged 18, but also to our children aged 0-18, who should have used health services for free. For tens of years, children’s medical care and service, especially out-of-hospital, was mostly free, today they pay even for the consultation of a narrow specialist, which indicates that the introduction of insurance was an imitation, and in many cases we no longer have the service of the state order, even the previous state order. And there are many complaints. people have received, for example, free medicine for years within the scope of the state order, and today they receive that medicine with a co-payment, people have been going to a narrow specialist for years and did not pay, today they have to pay.

• Business organizers of medical institutions understand that the money given is small, and today they use co-payments to cover the costs of their services, and doctors, who do 3-4 times the volume of work, today receive ridiculous salaries.

• In the out-patient unit, many narrow specialists are being cut. This means that very soon we will have such a situation when there will not be narrow specialists in polyclinics, they will be exclusively in hospitals, because their presence in polyclinics will no longer be beneficial to either the doctor or the polyclinic. We raised that issue. Directors of medical institutions used to compensate the salaries of doctors and medical personnel during the pre-election period, but now there is no such compensation, therefore, these doctors will be reduced.

In fact, the co-payment is applied so that the doctor receives an adequate salary, because the state has not planned a normal salary for the doctor. If those doctors received a fixed, per capita, base salary, and a percentage of their consultations, their paid services was added to it, then the concept of “per capita” has disappeared. In other words, those doctors no longer have basic salaries, although the workload has increased.

• We are a country with social problems… general poverty is 21-22%, and we also have an extremely large number of migrants… We have also repeatedly spoken about the need for control of migrants who come to work in Armenia, involved in service sectors, and the need for passports. For example, in terms of tuberculosis, we are a risk zone. We also have outward labor migration. citizens of our country go, work in other countries and return. In other words, if there is no prophylaxis in the relevant service, after 2-3 years we will see an increase in the number of tuberculosis, and it is an airborne disease. Again, it is a matter of national security.

• 2 years ago, I raised the issue that in the service sector, where there is a risk, all workers, regardless of nationality, should have a sanitary booklet, they should be examined for various infections every 6 months, and in some cases once a year.

I even gave examples, in the same tuberculosis dispensary we had migrants from other nations who were treated there… Finally, if I’m not mistaken, 5-6 days ago there was an announcement that from now on, migrants, from the service sector, etc., not only migrants, but everyone should have passports, should be examined. As for how much we lost in those 2-2.5 years and what epidemiological chains we missed, I can’t say, but they just decided, they listened, that these people should be examined.

• 3 years ago, we had a shameful outbreak of measles in Armenia, right here. Do you remember that case, it was revealed by me again, when a nurse who had visited some country had caught measles, returned to work, went to her work and infected the children there with measles.

• We have a serious problem related to border medical-sanitary control points (BMSCs). previously, these points operated at the border crossing points of the Republic of Armenia (for example, at “Zvartnots” airport, Bagratashen, Bavra, Gogavan) and carried out sanitary and epidemiological control. isolation of patients with fever, they were checking which country they come from, what is the epidemiological situation of that country… However, if I’m not mistaken, those HCWs were optimized in 2020, removed from the Health and Labor Inspection Authority (HAIA), and what’s happening today, to be honest, I don’t know. In addition to the fact that citizens of our country go to work abroad and return, we have many migrant workers who can bring specific diseases from their countries, which will later become a problem for us from an epidemiological point of view.

• Today, regional branches of the National Center for Disease Control and Prevention are being actively closed and workers are being laid off. We are losing specialists: epidemiologists, epidemiologists, hygienists. During the Covid, we had a serious problem with these specialists, and now infectious disease specialists are being reduced in polyclinics.

Health universal insurance system at the beginning, the state increased the budget of the health sector by tens of billions of drams. In particular, in the year of introduction of the system, the total amount allocated to health care reached about 210.9 billion drams (compared to the previous year, increasing by about 44.3 billion drams due to the launch of the insurance system itself). By: according to official forecasts and calculations, in the case of the final and complete implementation of the system (when it will include the entire population), the total annual costs required may reach about 300 billion drams.

The state has committed to fully pay the insurance premiums for socially vulnerable and target groups of the population (children under 18 years old, people over 65, people with disabilities and families included in the unemployment system), which implies stable and long-term financial injections for the state budget.

• The fact that they say 44.3 billion was increased, I have the calculations made by me as a result of official requests made to the SRC as to how many workers there are who have a salary of 200,000 drams or more. According to calculations, at the time of introduction of insurance, 53 billion were collected from the population. In other words, that manipulation that we increased by 44 billion… I repeat: at the time of the introduction of the system, the population paid 53 billion, but now that amount has increased even more, where according to their publications, the number of insured persons has increased. According to international calculations, about 550-600 billion drams are needed to organize medical care and insurance services for our 3 million inhabitants (in the context of insurance). That is, regardless of everything, even if they make that amount up to 300 billion, they will not be able to cover the insurance completely. They know these calculations very well, that’s why they take the co-payments as a red line. And, interestingly, the co-pays are sometimes double.

For example, if a citizen goes for a consultation, the consultation fee is set by the hospital at 18,000 AMD, 6,000 is transferred by the insurance, 12,000 is paid by the resident, and here it turns out that the residents pay double the amount for their service, that is, one part is given to the insurance fund, and one part is co-paid at the hospital itself. This is a serious problem, this is going to get out of control and our citizens will be the biggest victims as a result.

• To use the system, a strictly hierarchical procedure is required: first to register at the polyclinic with a family doctor or therapist, to get a referral, which is often accompanied by long queues. In the event of an urgent or urgent need, this process makes it difficult to get medical help promptly.

Citizens prefer to go, without queuing, to receive their service for a fee, regardless of the fact of being insured.

• Who controls the activity and financial movement of this insurance fund? According to the law that was adopted, all financial activities must be managed by the board of trustees of the fund, which appoints the director of the fund. A committee headed by Nikol Pashinyan was created, which was supposed to elect the board of trustees. They announced that the board of trustees of the fund should be elected. To tell you the truth, I sent my documents myself, because when you get into the process, you understand what they are doing, and something very strange happened. By chance, I see an announcement on the website of the Ministry of Health, according to which those who want to take part in the competition should start the next day.

When I tried to find out where the competition is, what time the competition is, what format it is in, through very long calls, they either didn’t answer me, or they promised to call me back… until the next day, 1 hour after the end of the competition, I received a letter saying that my documents do not meet the requirements of the law to participate in the competition. I didn’t understand what point I didn’t meet, I was short, I was overweight, because there was no point, no link, they just wrote that you don’t meet. Then we see the composition of the board of trustees of the already selected fund.

And we noted an interesting thing: the advisor of the Ukrainian office of the World Health Organization, the regional medical director of the largest American healthcare organization “Kaiser Permanente” are also part of the board… in the event that it is clearly stated that the member of the board of trustees must be a citizen of the Republic of Armenia.

Do you understand that these people have to manage the fund with the largest budget in the Republic of Armenia, and they should also have access to our personal data generated in that fund? I ask: who are those people, what is their business in that fund, what interests do they pursue? Since the work of the board of trustees of that fund is not yet done, at the moment we just see that they have been selected, I do not give evaluations yet, but the fact that we have already seen the selection process, it is clear that it was not a competition, it was a formal procedure and appointments.

• For years, Armenian doctors have been serving as cheap labor for European countries and the UAE, which, in turn, have an outflow of personnel to Canada and Switzerland. Our doctors, especially under these conditions, prefer to leave the country.

• As a result of the insurance system and new regulations, the number of paid patients has decreased, due to which the directors of medical centers are unable to pay doctors a decent salary.

• 100% state-owned hospitals are often unable to receive timely reimbursements from state and insurance funds, which directly results in delays in the salaries of health workers.

• The Ministry of Health does not have a clear and transparent economic rationale for introducing mandatory insurance and calculating the costs of services (for example, consultations, laboratory tests).

• There are cases when the price of a doctor’s consultation was initially estimated at 2,000 drams (according to the previous logic of the state order), while the price of the same service at the “St. Grigor Lusavorich” Medical Center under the Ministry’s authority varied between 10,000-20,000 drams. 

• Attestation Threat: The system of individual licensure and attestation being introduced is rigid and unaccounted for, which may lead to large numbers of qualified doctors being left out of the system and a new wave of emigration.

• Prohibiting specialists who graduated from medical university and completed clinical residency to work without a license limits the right to professional activity.

• Most of the heads and directors of medical institutions are involved in the activities of the ruling “Civil Contract” party (council members, officials), which leads to the use of administrative resources and violations of electoral legislation.

• Pressure is applied to doctors, nurses and average medical staff for expressing political views or critical opinions on social networks, up to the point of dismissal and ban on employment in other medical institutions.

• There are tendencies to avoid responsibility and remain in a privileged position in case of possible financial abuses (for example, waste of budget funds) by directors and officials belonging to pro-power circles.

• At the time of Covid, a huge report of the Chamber of Accounts was presented, where it was written about inefficient expenses amounting to billions of drams, about purchases, about a large number of violations. Arsen Torosyan and Tigran Avinyan played an important role, but did not take responsibility.

• While the waste of billions of the state budget remains inconsequential, insurance funds apply severe sanctions to doctors for minor (for example, a 1000-dram examination) deviations in documentation or reasoning.

• When the ministry acquired a large amount of “Gensulin”, you remember, I raised the alarm, received letters from about 100 patients, collected signatures that our health is at risk. At that time, the ministry maintained its opinion that the drug is safe, until a few months ago, after our alarms, we saw a statement by the inspection body that the batch of “Gensulin” was recalled, taking into account the quality indicators, etc.

By the way, I have talked about it many times. when I announced that the Republic of Thailand had recalled the drug because there was a quality problem, the Ministry of Health’s drug department initially denied it, saying, “There is no such thing.” When I published the records of the Republic of Thailand, they said, well, there was a batch, it was recalled. And today the Republic of Armenia is recalling that drug, but 4 years have passed. perhaps for 4 years our residents have received “Gensulin” because they could not convince the Minister of Health and the drug expert center that the drug has a problem.

• For obvious reasons, all pilot programs in Armenia are carried out either in the polyclinic of Saint Grigor Lusavorich Medical Center, or in the best case they can take a region, and there is always Gyumri Medical Center. Regarding several screenings, I have formally asked for the summary results of the screening pilot to understand what the results were, how many people were screened, how many had the disease, how many were at risk…and I was told that there is no summary. The most important function of the insurance program is to prevent the disease, not to have a sick citizen, so that the sick citizen does not become disabled and does not have severe effects on the socio-economic condition of the country. But for us, preventive medicine is completely on the back burner today, and our primary care physicians today only do paperwork, they only manage to hang referrals, give some reports, and those screening programs have been completely pushed into the background.

• Citizens should request screening examinations for their age groups from their family doctors or therapists, pediatricians. And health insurance doctors have a duty to inform their population that they are in such and such an age group and must undergo appropriate examinations. I would urge our citizens to definitely find out what screenings are planned for their age group, and to perform those screenings without fail.

• Why do we have a shortage of drugs, because for drug manufacturers, registering a drug in Armenia is not effective from a business point of view, and also causes a lot of hassles in the drug expert center… registration processes can take months, maybe even 1 year, after paying the payments, duties, the company may receive an answer that, for example, you do not have some kind of research, and that is why the drug will not be registered.

• 2 years ago, I sounded the alarm about drinking water pollution, particularly on the example of Armavir marz. Recently, various human rights defenders have been talking about drinking water, but it was strange for me, and I even informed them that it is wrong to place the responsibility only on “Veolia water”. Water control in the Republic of Armenia is carried out by the Health Labor Inspection Body. if there are violations, deviations, and the investigations about deviations are carried out by the National Center for Disease Control and Prevention. I already said that they are reducing those regional central structures, in the event that we have natural plague foci, natural cholera foci…

In those areas, those facilities have always done research, soil sampling, water sampling, to see if those spores are active or not, if there are any dangers or not. Armavir marz is especially active with cholera in the summer. We have foci of tularemia in Gegharkunik marz, foci of plague, foci of anthrax in Vardenis region. In other words, in the direction of all of these, field work should be done on the spot, appropriate conclusions should be made, and in case of concern, areas should be closed, appropriate actions should be taken, etc., etc.

Therefore, if the issue is raised, it should be fully discussed. We need to talk about control bodies. I told Arpine Hovhannisyan about this when she wrote to me. Why is only “Veolia water” targeted when the control bodies are different? When deviations are found in research, for example, water catchments are called in marzes (Water catchment is a complex of engineering and technical measures to extract groundwater (springs, underground streams) to the surface of the earth, collect it and transport it in a clean state to an aquifer system or to a place of consumption.

The purpose is to ensure the protection of groundwater from pollution, dust and surface flows), they take samples from them and see deviations, it is mandatory that they inform the inspection body about it, and the inspection body performs control and other functions. For example, stop the water supply until they solve the problem. At one time, the inspection body received the answers, and the Centers for Disease Control and Prevention took samples at several points from the water collection point to the resident’s home. There used to be a lot of research done on water quality and infections, electrolytes, and chlorination percentages to get the right amount and not harm the health of the population…and the issues of pipe damage…to figure out where to start controlling and how to fix the problem.

For example, if Veolia water says, all the way down my road, my labs show that the water is clean, but the state, through its Centers for Disease Prevention and Control, must present its research in its public health function. Most importantly, if “Veolia water” detects a deviation with its laboratory, naturally it does not write to the inspection body, it says: I am not the control body, the state has its obligations for that. It is very sad for me that the state, in the form of the Ministry of Health, these important centers for disease control and prevention optimization of regional branches led to this situation. If you remember, I asked Anahit Avanesyan in the National Assembly: why are you closing those centers…

We are dealing with the criminal inactivity of state bodies… They received salaries and did nothing.

• The inspection body of the Ministry of Health does the monitoring of the quality of Zri. The inspection body can also delegate, on its own initiative, to carry out sampling and research, to carry out epidemiologic controls. So, the questions should be addressed both to the Ministry of Health, and to the inspection body, and to Veolia water. Everyone is equally responsible for it, and unfortunately we see that somewhere there is an epidemic, they declare that it is from drinking water, and then all new structures start working in some places. The same does not apply only to water, there are many epidemiological problems. For example, recently I raised the issue related to brucellosis, sounded the alarm, until I made it public, the Ministry of Health did not go, did not take samples.