The next topic of importance is healthcare, given its prominence in human and economic costs and subsequent national implications. Healthcare delivery encompasses access, care process, efficiency, equity and care quality. It is built on an underlying system designed to perform well, along with education, research and societal norms, each worthy of its own in-depth analysis. Armenia spends approximately $408 per capita on health (10.4 percent of its GDP). However, less than 15-percent of its health spending is publicly sourced. In contrast, the United States spends $12,530 per capita, or a whopping 19.7-percent of GDP. The average European expenditure on healthcare is around the 10-percent mark. While funding is an important component of the healthcare system, it does not directly correlate with the quality of the delivered care. This is an extensive topic in and of itself and outside the scope of the current work. However, critical thinking and re-evaluation of the healthcare system in Armenia from the ground up is a daunting task that must be undertaken.
As a major governmental expenditure, the development of a strong and functioning healthcare system is fundamental to any nation with aspirations of becoming a regional or world contributor. A well-informed colleague once made an astute observation that Armenia does not have a healthcare system. It merely has a collection of healthcare providers who happen to practice at the same place, with little developed by way of a systemic approach, conflict of interest, competent training and a functioning health insurance system. Armenia produces too many mediocre physicians employing outdated and obsolete training, creating a saturated marketplace in and around Yerevan with little incentive or infrastructure for caregivers to practice elsewhere. This is dangerous nationally, as a concentrated care delivery in and around one area provides imbalance, lack of access and significantly diminished quality of care. Owing to the zero-sum game mentality that is prevalent in all corners of Armenian life, caregivers establish their own turf (livelihood) and defend it fiercely through unhealthy competition, misguided efforts and little attention to their impact on the nation’s overall healthcare delivery. Most Armenian physicians consider themselves to be the authority and other colleagues lacking any. This environment does not encourage healthy and constructive competition, collaboration and an optimized healthcare delivery system to benefit citizens. The lack of a systemic approach has created a dog-eat-dog environment where every caregiver must carve out his/her space and focus predominantly on his/her financial well-being.
For a small nation, we may have 50 to 250 specialists per field at most, with some specialties fielding much smaller numbers. Yet, there is a significant lack of communication and collaboration among these colleagues. They reach out to their Diasporan colleagues for consultations, rather than consulting amongst themselves first, which is how a functioning system should operate. If a conference or symposium is held on a topic, the specialists will only join if they are specifically invited to the event (an uncommon practice in the developed world); or they will flatly refuse to participate because a rival colleague from across town might be an organizer or a guest speaker. It is clear that pettiness is not the exclusive domain of the less educated, further highlighting the need for a rethinking of our educational processes at the fundamental level. Teaching academic content and rigor, critical thinking skills, national values and history and societal/personal responsibilities is essential.
Medical education is outdated and in need of a complete overhaul, as evidenced by the number 5,724 ranking of the Yerevan State Medical University (YSMU) in the world. Medical education through residency and fellowship programs is designed to train the next generation of care providers. In Armenia, new medical graduates must pay to do their residency and are not highly regarded, as they can become competition. The US changed this model of pay to play for medical residency in the early 20th century, given the innumerable problems associated with it. Yet, this is the norm in Armenia in the 21st century, just like vote buying, a practice prevalent in England in the 17th century. An anecdotal note from a surgical colleague in the US exemplifies this attitude. He had invited a surgeon from Armenia to visit and observe healthcare delivery in his hospital. The surgeon from Armenia was shocked by my colleague’s absolute dedication to mentoring his residents and fellows. Why was he teaching them so readily? Was he not afraid of them taking his position?
Research, development and innovation are not priorities. Figure 8 highlights peer-reviewed publications linked to YSMU. To date, 743 academic publications have been linked to YSMU, in contrast to the 237,000 linked to Harvard Medical School, as a reference. These 743 publications encompass work originating from YSMU, work conducted elsewhere with collaborators from YSMU, and most recently, inclusion of work by Diasporan scientists and physicians who have been given an affiliated faculty status at YSMU. This is meant to improve the profile of the university by linking high-producing Diasporan faculty with the institution to increase the number of publications linked to YSMU (a metric to assess the quality of an academic institution). This is not an uncommon practice, as countries such as Saudi Arabia have used this model to increase the profiles of their recently established universities. In these cases, foreign faculty are handsomely rewarded financially, whereas in the case of YSMU, Diasporan faculty members work pro bono to support the institution. While an effective means to jump start the profile of the university, this is by no means a substitute for fundamentally changing the curricula, improving teaching standards and didactic training and having quality research (basic, translational and clinical) supported by and conducted at the institution.
Figure 8 (Created by the author)
Communication and collaboration are of little value to clinical practitioners at the moment. Fundamentally, the Ministry of Health and the medical school are at odds with one another. Technology is limited to a few centers in and around Yerevan, and the existing technology is not used well. For instance, it took years for the Armenian Center of Excellence in Oncology to open in Yerevan, given efforts by successive government entities to privatize the facility for their own gains, going so far as the previous health minister, who declared that Armenia did not need nuclear medicine. For a nation with high rates of breast, colorectal and cervical cancer among females and lung, bladder and colorectal cancer among males, and a 20-percent risk of cancer for the citizens before the age of 75, having access to such a state-of-the-art cancer center is invaluable. The Radioisotope Production Center with the only PET scanner in the country remains largely unutilized. Completed in 2015, it was made operational by the nuclear physicists of A. Alikhanyan National Science Laboratory in June of 2019 and started accepting new patients the following spring. The isotope production from each of the cyclotron runs is enough for hundreds of patients, but the facility can only scan a maximum of 15 patients per day. The remainder of the isotopes are available for sale, but they cannot be utilized in the absence of PET scanners. Such a center with scanners and genotyping capabilities would be essential in diagnosing people at risk for specific types of cancer, both for Armenia and for the region. Yet, it took years, significant delays and crony politics to introduce the beamline and open the center to the public.
There is a lack of understanding of the latest developments and breakthroughs in medicine. There are no established clinical care guidelines and best practices in different specialties. Diasporan experts have tried to make inroads in establishing care guidelines in Armenia with varying degrees of success and opposition. There is no culture of morbidity and mortality rounds, where physicians evaluate and discuss their challenging and difficult cases with their colleagues, to learn from one another and to help prevent similar mistakes in future.
We must outline a functioning health insurance system that will readily and adequately address the healthcare needs of the population. Qualified people in Armenia have looked into this and have outlined plans, but there has been no real incentive to do anything about it.
Smoking is a top public health concern in Armenia. The prevalence of smoking in men is at almost 51 percent and 3.2 percent among women (as if there was a need for yet another point to establish how outclassed Armenian men are compared to Armenian women). This translates into approximately 300,000 premature deaths. Levying a 100-percent to 200-percent tax on cigarettes is an attractive option to help reduce smoking and allocate the proceeds toward healthcare expenditures. This will raise the ire of the tobacco industry, but that is one ire that is worth raising for the long-term good of the nation.
The 2020 Artsakh War also made the lack of preparedness and infrastructure in the country painfully clear. Significant efforts were made by the Diaspora to support the wounded and the COVID-19 patient population simultaneously, which experienced a higher casualty rate than the war at times (directly resulting from the lack of employing preventative measures by the population). However, so much of this effort was wasted, with significant resources never being utilized, and those that did get utilized were done so with much delay, all in a chaotic and unprepared environment, imbued with incompetence. The nation, landlocked with hostile neighbors, lacks a basic civic aviation system with two planes for short/medium and long hauls, respectively, for supplies to be brought in. The Diaspora had to charter planes for hundreds of thousands of dollars to get supplies to Georgia, as charter planes did not fly into a “war zone” (Yerevan hardly resembled a city in war at the time). That necessitated landing in Georgia and being subjected to its hostile customs practices, delaying the release of key medical supplies to Armenia, yet simultaneously giving Turkish planes open air access to send weapons to Azerbaijan. A native civic aviation system would have bypassed this major hurdle. Furthermore, the medical warehouses did not have an electronic system in place to keep track of the inventory and/or asset tag them properly for prompt identification and deployment. The exception to this chaotic mess was Artsakh’s Ministry of Health, which was diligent in clearing items destined for Artsakh immediately and taking them to their facilities for use. This disaster also requires in-depth evaluation for future preparedness, if we ever choose to behave as a serious nation.
A few shiny hospitals have been set up by oligarchs or other well-connected individuals with varying degrees of public funding to build and furnish them, yet they function in a private setting (the perfect extractive economic model of publicly funding the expenditure and privately collecting the profits). We have a gluttony of Diasporan medical professionals with excellent education and experience. Some of these experts are engaged in decentralized, one-off efforts to contribute in any way they can. The medical education system in the country must undergo a major overhaul to bring it up to the best international standards and leverage the extensive Diasporan network for training and guidance on a systematic, non-voluntary basis. Serious work cannot be conducted voluntarily. A plan must be put in place to use Diasporan resources and compensate them for their professional contributions. Medical conferences that are little more than vacations for Diasporan healthcare professionals (the author has participated in these efforts himself) are not the answer to improve healthcare in Armenia. Diasporan professionals have responsibilities in their residing countries. If a proper rotation system is put in place to invite them to Armenia to teach at the medical school and offer their expertise at hospitals and clinics, they can make a very meaningful contribution to the medical system. They can teach medical students, residents and fellows and introduce state-of-the-art treatments to physicians.
The government is mandating Continuing Medical Education (CME) for physicians for the coming year. Again, while an important step, the implementation is anything but in the spirit of the creation of the CME process. Caregivers are supposed to participate in CME courses throughout the year to stay abreast of the latest trends and developments in the field to continue to become better practitioners. In Armenia, everyone is waiting for the last minute to pay a sum and receive their certificate, all facilitated by businesses predominantly interested in making money, and not moving the needle with respect to the quality of care provided. Caregivers are also happy to oblige to pay and check the box, as opposed to engaging in a real CME learning process.
A system must be put in place to engage Diasporan expertise and their non-Armenian colleagues to translate and adapt clinical guidelines for all specialties for use in Armenia in accordance with local needs and culture. This cannot be done voluntarily and has to be approached professionally. Armenia’s hospitable nature and low costs make the country a perfect destination for medical tourism. Diasporan physicians can bring western training to these settings to work, train local doctors and set up a burgeoning medical tourism industry to offer western world-class care to the region and beyond. Once the industry has taken hold, the well-trained and experienced local expertise will be in place to move this forward.
Biomedical research must be a serious investment to address unmet medical needs of developing nations, an area of significant potential for growth. Again, appropriate leveraging of Diasporan expertise and connections must be used to put a system in place to develop solutions for these needs for local and external markets. There is no shortage of Armenian expertise in biotech, device, pharma, CRO, regulatory and financing domains. None of these resources yield any fruits for Armenia, because there are no plans to leverage them. The innovation presented in the previous article of this series outlines the vision for this. Regulatory, intellectual property and innovative processes in Armenia must be brought up to western standards to encourage and promote this work; so do rules and regulations regarding conflicts of interest in the medical setting, which resemble more of a western cowboy setting than a system designed to protect patients and caregivers. In other words, Armenia needs a ground-up approach to make an actual, cohesive system out of its existing patchwork, where each entity/person is looking out for his/her/its own benefit.
Fundamentally, the authorities in the country are risk averse and do not and cannot make big decisions. The reasoning most likely lies somewhere along a combination of the following options: they don’t care enough; they won’t be there to claim the success; they have no vision; they are too corrupt or lazy to do something meaningful other than biding their time, lining their pockets and moving on to their private enterprises afterwards; or they are too afraid to do something. As a result, we don’t have proper health insurance or a healthcare delivery system. Look no further than high-ranking officials of the country traveling to other nations for their own and their loved ones’ healthcare needs.