Illustration by Armine Shahbazyan.
Preventive healthcare can improve long-term health, increase lifespan and mitigate high medical expenses. Today, a number of programs are being implemented in Armenia to improve the basic health indicators of the population, to prevent illnesses and disease, and to prevent complications caused by diseases among people who are already ill.
Article 85 of the Armenian Constitution stipulates that “Everyone shall, in accordance with law, have the right to health care.”
The Law On Medical Assistance and Services for the Population was first adopted in 1996. The first article of the law states: “Medical Assistance and Services [shall be understood as referring to] advisory, preventive, medical, pharmaceutical, diagnostic, rehabilitative, examination, paramedical and other services․”
There are three levels of disease prevention։
- Primary prevention: awareness-raising campaigns to eliminate or reduce the impact of risk factors prior to the onset of the disease (for example, public health education, supervision of environmental hygiene, smoking cessation counseling, immunization and vaccination, family planning counseling, etc.);
- Secondary prevention: early or latent detection of disease (for major forms of cancer via screening, such as administering a pap smear to test for cervical cancer or the human papillomavirus [HPV] test);
- Tertiary prevention: prevention of complications of an existing disease (for example, advice on stroke prevention in patients with hypertension, etc.).
Preventable diseases are divided into communicable and non-communicable diseases․ Vaccines are considered to be the best way to prevent communicable diseases, both worldwide and in Armenia. As a result of vaccinations, the number of deaths and disabilities due to previously-rampant infectious diseases has sharply decreased. In particular, since 1995, not a single case of polio, which used to cause permanent disability in at least 2 or 3 children each year, has been reported in Armenia. Cases of diphtheria have not been reported in Armenia since 2000 (the situation has stabilized since the outbreak of 1994-1995). Similarly, cases of measles and rubella have not been reported in Armenia since 2007, while cases of mumps, whooping cough and tetanus are reported only very rarely.
Through a December 17, 2020 Decision, the Government of Armenia approved the National Immunization Program for 2021-2025 and the list of priority measures of the National Immunization Program. The document states that, in recent years, there has been major improvement in reducing infant mortality in Armenia; in 2019, it was at 6.2 per 1000 compared to 10.8 in 2008 (per 1000 live births). The pentavalent vaccine with haemophilus B component, and hexavalent vaccines with pneumococcal and rotavirus vaccines included in the National Vaccination Calendar have played a unique role in the efforts to reduce infant mortality.
The decision also reports that the contagious infectious diseases managed through planned vaccinations include diphtheria, whooping cough, tetanus, measles, rubella, mumps, polio, viral hepatitis A and B, tuberculosis, rotavirus, meningococcal and pneumococcal infections, tularemia, seasonal flu, human papillomavirus (HPV) infection and rabies, which are all included in the National Vaccination Calendar.
Despite the intensified anti-vaccination campaign in recent years, more than 92% of children falling within the target age groups for vaccinations in Armenia receive the full package of immunizations required for their age.
As for the prevention of non-communicable diseases, in 2008, the Minister of Health approved the Program for Prevention, Early Detection and Treatment of the Most Common Non-Communicable Diseases, and later approved the National Strategic Plan for the Three Diseases With Higher Mortality Rates: Circulatory Diseases (Cardiovascular Diseases), Malignant Neoplasms and Diabetes.
These three diseases are singled out based on data from 193 member countries of the World Health Organization (WHO), including Armenia, according to which the main burden of poor health lies not with communicable but with non-communicable diseases, of which diseases of the circulatory system are the leading cause of death.
The Practical Guide for the Management and Treatment of Non-Communicable Diseases published in 2014 by the Ministry of Health for primary care workers, states that the increase in mortality due to these non-communicable diseases (compared to communicable diseases such as AIDS, tuberculosis and malaria) is self-evident. It is predicted that this trend will continue for the next 20 years, and non-communicable diseases are the most common and most debilitating diseases, mainly affecting the working age population.
According to the data presented in the guide, the overall mortality rate from non-communicable diseases in Armenia is about 80%, with cardiovascular mortality leading the way (48%), malignant neoplasms in second place (19.8%), diabetes in third (4.9%) and injuries and poisoning in fourth (4.8%). Out of the 10 main reasons for the increase in the number of disability-adjusted life years (DALY), eight are non-communicable diseases, four of which are cardiovascular diseases (ischemic heart disease, cerebrovascular diseases, hypertension, and other heart diseases), three belong to malignant neoplasms (malignant neoplasms of the trachea, bronchi and lungs, breast and stomach) and one to diseases of the endocrine system (diabetes).
Yervand Elibekyan, Director of the Ministry of Health’s Health Programs Implementation Office, told EVN Report that the screening component of the disease prevention and control program was launched in Armenia in 2015. It is aimed at the prevention and early diagnosis of hypertension, diabetes and cervical cancer.
Elibekyan explains that the program provides people aged 35-68 the opportunity to undergo free examinations for high blood pressure and diabetes. Pap smears for women over 30 are also publicly-funded, for early diagnosis and prevention of cervical cancer. “Examinations are carried out all over the country at primary health care facilities,” he says. “In rural areas, these are at rural dispensaries and healthcare centers, and in urban areas they are precinct polyclinics or polyclinics included in medical centers.”
According to Elibekyan, more than 3,100,000 examinations have been carried out since 2015—approximately 325,000 Pap smears, 933,000 blood glucose tests and 1,700,000 citizens underwent screening for high blood pressure. Another screening examination is done for pregnant women; blood and urine are tested at 36-38 weeks of pregnancy.
“Deviations found as a result of these examinations do not mean that so many people are sick; these are purely symptoms. In the case of cervical pre-cancer, it takes many years for the cancer to develop, and the main purpose of such tests is to know in advance what the problem is. If necessary, a small intervention can prevent, for example, cervical cancer. The same applies to diabetes and high blood pressure,” says Elibekyan, adding that, before proceeding to the main stage of the examinations, preparatory work was done, guidelines were developed, training courses were organized for the doctors involved in this work, and the laboratories were outfitted for carrying out Pap tests.
Elibekyan says that there are countries that have managed to reduce this type of cancer. “For example, in Finland the prevalence of cervical cancer has dropped to 1% as a result of these screenings and prevention,” he explains. “The only and proven way to avoid diseases is to prevent them in time, by undergoing the needed examinations regularly, whether in the form of screenings or annual visits to the primary care units.”
The novel coronavirus has created new challenges; however, other health issues have not been put on the back burner.
In January 2021, the Ministry, funded by the Eurasian Fund for Stabilization and Development (EFSD), launched a 2.5-year pilot program in three regions—Lori, Tavush and Syunik—to provide mammograms to women aged 50-69 through a mobile mammography service.
“About 6,000 women have already been examined. Abnormalities were observed among some 460 women, who have been referred to the National Oncology Center,” Elibekyan says, adding that 61 women were diagnosed with breast cancer.
The 24 primary health care units (polyclinics) in the capital city of Yerevan provide preventive medical services and are administered by the municipality.
Anahit Charkhifalakyan, Acting Deputy Head at the Health Department of the Yerevan Municipality, told EVN Report that the burden of implementing preventive care programs is mainly on the shoulders of general practitioners, pediatricians and gynecologists working in polyclinics. She says that one of their largest programs is the National Vaccination Program. “We have been vaccinating citizens from infancy, as a result of which Armenia has made progress in preventing communicable diseases, such as tuberculosis, whooping cough, diphtheria, tetanus, hepatitis B, hemophilia, rotavirus, measles, mumps, tularemia and pneumococcus,” says Charkhifalakyan.
Thus, in addition to organizing the vaccination process, pediatricians also carry out a number of screening programs, such as testing for anemia, early detection of weight disorders in children aged 7-18, eye tests for 12-year-olds, assessment of sexual maturity of 15-year-old girls, etc.
General practitioners work with patients 18 and older, and also carry out early detection of weight disorders and ischemic heart diseases, determine total blood cholesterol levels, promote a healthy lifestyle and advise against smoking. In the case of 35-68 year olds, measures are taken for hypertension and the early detection of diabetes.
Gynecologists are entrusted with measures for the detection and prevention of malignant tumors of the cervix in women aged 30-60—measures such as Pap smear screening. Early diagnosis of malignant neoplasms is also carried out, and a general register is maintained.
“All over the world, early detection and prevention of health problems are both more economical and the effectiveness is quite high; that is, early detection allows us to expect greater results. It is easier to prevent than to cure the disease,” says Charkhifalakyan, adding that the municipality is implementing numerous screening programs. In 2017, a program for the prevention of chronic venous diseases was implemented in Yerevan; 895 people were examined, 840 of whom were diagnosed with various diseases.
“In the polyclinic system, the general practitioner—the family doctor—is the one responsible for the patient; they know both the diagnoses and the issues of the patients in their service area,” Charkhifalayan says, noting that they have emphasized chronic venous diseases as they are not part of the Ministry of Health’s screening programs although there is a considerable need for them. “Patients who were suspected of having a slight deviation beforehand were referred to a vascular surgeon, who examined and performed a duplex examination, as a result of which we have the picture that we have,” says Charkhifalakyan.
This year, five polyclinics serving a large number of the population were selected, and undertook the detection of chronic venous and lymphatic system diseases. They worked with 281 patients, and registered that all of them had a problem; 26 of them had stagnation in their lymphatic system.
“With the help of Yerevan’s chief cardiologist and the polyclinic system of the city of Yerevan, we conducted a study of the detection of risk factors in the endocrine system, ischemic heart diseases and hypertension. 9,818 citizens participated in the program; at the time of screening 4,088 citizens were found to have high blood pressure. Professional consultations were held with the citizens. Booklets on excess weight, obesity and a healthy lifestyle were provided. In addition, we referred patients to the appropriate specialists to continue further treatments and to organize their lifestyle properly,” says Charkhifalakyan, adding that diabetes is also an ongoing issue for which awareness raising and detection campaigns are being carried out.
“Diagnosis is very important in the early detection of health issues. In order to be able to make a correct diagnosis, we must have equipment, which is why we attach importance to the modernization of equipment. With next year’s program, we will be able to provide healthcare organizations administered by the Yerevan Municipality with modern x-ray equipment. We also plan to purchase a portable digital x-ray device, with which we will be able to serve citizens who are not able to reach the centers. We regularly carry out training for doctors and nurses, and organize conferences. We have a big project with vascular specialists on general problems with veins and arteries, but due to the situation created as a result of the coronavirus, it is still pending,” she points out.
Anna Sargsyan, 33, a resident of Yerevan, tells EVN Report that, as soon as she turned 30, she began receiving regular calls and messages from the polyclinic urging her to make an appointment for a Pap smear, but she kept postponing it․ “I never had any pain or complaints. I thought I didn’t have any issues and did not visit the polyclinic for a year, but the nurse had called me so many times,” Sargsyan explains. “I felt embarrassed and went for the test and then went about my daily life. I got calls again, but was not able to answer them. When I finally did, the gynecologist of the polyclinic informed me that they had seen a problem and that I must go for another examination.”
The follow-up examinations revealed that she has a neoplasm. Fortunately, the disease was in its initial stage and treatment was started immediately. “It terrifies me to think about the irreversible consequences if they had not called from the polyclinic so many times and insisted that I undergo an examination,” Sargsyan says. “Now, knowing about the problem and its possible development and consequences, we have been able to prevent it.”
Narine (name has been changed), a 36-year-old resident of Sevan, in the Gegharkunik region, regularly receives calls from the precinct gynecologist, who urges her to visit and get examined. However, she has not yet been able to go. She remembers that, when she had her third child four years ago, the gynecologist made a home visit to examine her․ “When I had my first and second children, no specialist ever showed interest in my condition,” Narine says. “Yet when I had my third child, the gynecologist made a house visit and examined me. Truth be told, I was very surprised and happy.”
Although Narine was pleasantly surprised, she says that in general, the professionalism of pediatricians in her area is questionable. “All three children had different problems with their eyes, nose and bones, but during the visits, examinations were done poorly and we only found out about the problems when we went to another hospital and by then it was too late,” Narine says. “If, for example, the surgeon had noticed the indentation on my son’s chest, maybe we could have corrected it sooner.” She also said that her children were not properly screened prior to their vaccinations. “I know that various specialists are supposed to check, and only after that are they allowed to be vaccinated. However, no such examinations were carried out here. When I would ask if, for example, a neurologist was going to examine them, they would say ‘They are not here, do you really want to wait? Let me fill in the form and go.’ It turns out that the state makes decisions for everyone, but not everyone can avail themselves of the opportunities, and it’s left to the good will of the doctors.”
Melanya Grigoryan, a family doctor at Artik Medical Center, also mentions that specialists—a neurologist, an ophthalmologist and a nasopharyngeal specialist—must examine the child before receiving vaccinations at 1.5, 3 and 4.5 months. A prophylactic visit is made at nine months. In addition to the examinations of these specialists, a hemoglobin examination is also performed. “These screenings, as well as vaccinations, are very important. There have been pandemics in the history of mankind that have destroyed entire cities. Today, thanks to vaccines, those diseases have been eliminated,” Grigoryan told EVN Report, also emphasizing the importance of screening women over the age of 30.
According to the doctor, although women are interested in these screenings, they still do not fully make use of the opportunity due to certain stigmas. “We call regularly, urge them to visit and get tested. For the most part, they are interested, they come. Sometimes they feel uncomfortable, but we explain the importance of it, tell them about cases when others did not come, and in the end it turned out that the problem had reached the third or fourth stage. Of course, it is better to know about the problem in advance; at the initial stage it can be easily prevented, treated and controlled,” says Grigoryan.
Yervand Elibekyan also urges residents to take advantage of the screening programs provided by the state: “The only way to prevent diseases is to be examined in time, which the state provides for. We have brought these screenings as close as possible to the residents; the public should start changing existing stigmas and start visiting their precinct or chosen primary health care establishment, whose main goal is preserving health, not treating diseases.”
Public Health
Magazine Issue N13
Armenia’s healthcare system, for the last three decades, has suffered from an absence of vision, lack of strategic planning, poor quality and widespread corruption and nepotism. The country’s healthcare system, broadly speaking, is inefficient, relatively ineffective, and for these reasons has produced a less healthy population. In the wake of the COVID-19 pandemic and the 2020 Artsakh War, now more than ever, systemic reform in the healthcare sector must be a priority.
