Sexual and reproductive
health
Determinants of health
Health system
Universal health coverage Quality
of health care
Maternal and newborn
health
Child and adolescent
health
Azerbaijan
Assessment of sexual, reproductive, maternal, newborn, child and adolescent
health in the context of universal health
coverage in Azerbaijan
Assessment of sexual, reproductive, maternal, newborn, child and adolescent
health in the context of universal health
coverage in Azerbaijan
Abstract
Achieving universal health coverage (UHC) – meaning that everyone, everywhere can access essential high-quality health services without facing financial hardship – is a key target of the Sustainable Development Goals. Sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) is at the core of the UHC agenda and is among the 16 essential health services that WHO uses as indicators of the level and equity of coverage in countries. In this context, WHO undertook an assessment of SRMNCAH in Azerbaijan.
This report examines which SRMNCAH services are included in policies concerning UHC in the specific country context; assesses the extent to which the services are available to the people for whom they are intended, and at what cost; identifies potential health system barriers to the provision of SRMNCAH services, using a tracer methodology and equity lens; and identifies priority areas for action. A set of policy recommendations provides the basis for policy changes and implementation arrangements for better SRMNCAH services and outcomes in the context of UHC.
Keywords
SEXUAL AND REPRODUCTIVE HEALTH MATERNAL AND NEWBORN HEALTH CHILD AND ADOLESCENT HEALTH UNIVERSAL HEALTH COVERAGE HEALTH CARE SYSTEM QUALITY OF HEALTH CARE DETERMINANTS OF HEALTH AZERBAIJAN
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Contents
Acknowledgements ... iv
Abbreviations ... iv
Executive summary ... v
Introduction ...1
Methodology ...2
Tracer interventions ... 2
Limitations ... 3
Country context ...3
Health system overview ... 6
Findings ...6
Health system governance for SRMNCAH ... 8
Health system financing for SRMNCAH ... 10
Essential medicines and health products for SRMNCAH ... 13
Delivery and safety of SRMNCAH services ... 14
Health workforce for SRMNCAH ... 17
Health statistics and information systems for SRMNCAH ... 18
Tracer interventions ... 19
Policy recommendations for SRMNCAH ... 35
Conclusion ... 38
Acknowledgements
The authors express their sincere gratitude to the government officials of Azerbaijan. This assessment and report would not have been possible without the open-hearted support and welcome of all the interviewees, who took the time to participate and shared their views, ideas, concerns and visions with the authors.
The country assessment was produced by Dr Susanne Carai and Dr Ketevan Chkhatarashvili under the overall guidance of Dr Bente Mikkelsen, Director, Dr Nino Berdzuli and Dr Martin Weber, programme managers, of the Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe. Ms Fidan Talishinskaya, Public Health Officer at the WHO Country Office in Azerbaijan, was also part of the assessment team. Dr Melitta Jakab of the WHO Barcelona Office for Health System Strengthening provided input to the health systems aspects of the assessment methodology. Ms Asa Nihlen and Ms Isabel Yordi Aguirre of the Division of Policy and Governance for Health and Well-being, WHO Regional Office for Europe, provided useful contributions to the gender, equity and rights aspects of the assessment. The authors are very grateful for the final technical revisions suggested by Dr Hande Harmaci, WHO Representative in Azerbaijan.
The assessment and report were realized with financial support from the Federal Ministry of Health of Germany.
The authors’ views expressed in this report do not necessarily reflect the views of the World Health Organization or the Ministry of Health of Azerbaijan.
Abbreviations
C-section caesarean section
EU European Union
GDP gross domestic product
HIS health information system
HPV human papillomavirus
IUD intrauterine device
MHI mandatory health insurance
OOP out-of-pocket [payment]
PHC primary health care
PPP purchasing power parity
SRMNCAH sexual, reproductive, maternal, newborn, child and adolescent health STI sexually transmitted infection
TB tuberculosis
UHC universal health coverage UNICEF United Nations Children’s Fund
Executive summary
The Government of Azerbaijan set out to achieve universal health coverage (UHC) when adopting the Sustainable Development Goals in 2015. Recently, it initiated major reforms in the health sector aimed at improving coverage and financial protection for citizens and advancing the UHC agenda.
To delineate which sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) services are included in policies concerning UHC, an applied health system assessment was conducted in March 2019 by WHO in collaboration with the Ministry of Health of Azerbaijan. The assessment used a tracer methodology and an equity lens to:
•
assess the extent to which SRMNCAH services are available to the people for whom they are intended, and at what cost;•
identify potential health system barriers to the provision of SRMNCAH services;•
identify priority areas for action collaboratively and engage in a policy dialogue.The tracers used were:
•
antenatal care, with a focus on pre-eclampsia;•
sexually transmitted infections (excluding HIV);•
neonatal transport;•
case management of common childhood conditions, with a focus on pneumonia;•
adolescent-friendly health services (sexual and reproductive health);•
immunization.WHO’s six building blocks of UHC1 were used as an analytical framework for the findings to aid identification of barriers and challenges for access to and utilization of SRMNCAH services. The assessment included a desk review of national documents and policies and key informant interviews with stakeholders, policy-makers, patients and health care professionals at primary, secondary and tertiary health care facilities in urban and rural settings.
The findings in relation to the six tracer interventions point to a number of health system constraints.
Antenatal care, with a focus on pre-eclampsia
Pre-eclampsia is estimated to affect 2–8% of all births. At primary health care (PHC) facilities where pregnant women are routinely tracked, providers often stated that no or very few cases of pre-eclampsia had been diagnosed in recent years. This points to problems with the detection of pre-eclampsia, which indicates issues with the quality of antenatal care provided. This finding was corroborated by key informants at the referral level, who stated that women with pre-eclampsia arrive late and without proper management, indicating problems with health workers’ skills at the primary care level.
Interviewees identified lack of equipment (such as urine analysis/test strips) and lack of knowledge and skills of primary care providers to detect and manage the condition as causes for these findings. Maternal mortality in Azerbaijan is one of the highest in the WHO European Region, and pre-eclampsia/eclampsia is among the three leading causes of maternal death. Improvements in early identification at the primary care level, timely referral and proper management could prevent 30% of maternal deaths.
1 Universal health coverage [website]. Geneva: World Health Organization; 2019 (http://www.who.int/universal_health_coverage/en/, accessed 21 November 2019).
Sexually transmitted infections
In the light of advances in rapid tests moving towards testing and treatment at the point of care, the assessment revealed deficiencies in availability of sexually transmitted infection (STI) services at the PHC level, leading to multiple referrals and fragmentation. At the referral level, diagnostic tests for STIs are – according to policy – covered by the government.
Medicines for the management of STIs are not covered, and prescribed treatments need to be purchased by the patient at a pharmacy. The reactants for laboratory tests are reportedly insufficient to cover all needs, so
patients are referred to private laboratories for testing, where they are required to pay. These findings point to a lack of services at the PHC level, a need for out-of-pocket (OOP) expenditure for diagnosis and treatment and de facto rationing of services at the referral level.
Neonatal transport
Neonatal transport is a critical phase of perinatal care, requiring a specialist team and equipment to ensure maximum safety and efficiency in provision of care for sick neonates. Vehicles used for neonatal transport in Azerbaijan are not equipped properly, and the capacity of members of transport teams is limited. No helicopters are available for emergency transport.
According to key informants at the referral level, neonates often arrive following long delays, with hypothermia and in poor condition. Specific data monitoring transfer times and status of the neonates arriving are not collected. These findings point to a lack of a mechanism for primary stabilization of sick neonates and referral, as well as lack of equipment and capacity for neonatal transport.
Case management of common childhood conditions with focus on cough and pneumonia
Key informants stated that the most frequent complaint of children presenting at polyclinics is viral respiratory tract infections. Doctors carry out home visits if required. Treatment prescribed is often not evidence-based and in line with international guidelines, but includes medication with unclear benefits such as interferon, immunity boosters and homeopathic medication. Prescribed medications must be purchased in private pharmacies and paid for by the parent. In case of hospitalization, inpatient care and the required medicines are covered by the state.
During the hospitals ward visits, admitted children often seemed well and not to require hospitalization. At the same time, there seemed to be excess bed capacity, as wards of the hospitals visited were predominantly empty.
Non-evidence-based practices of prescribing unnecessary medication contribute to the high share of OOP payments.
Adolescent-friendly health services (sexual and reproductive health)
Adolescent birth rates are high in Azerbaijan: of 1000 girls aged 15–19 years, 53 give birth. Sexual and
reproductive health services for adolescents and policies and interventions focusing on adolescents are a major challenge. No budget has been allocated for the procurement of contraceptives; nor are contraceptives included in the national essential drug list. According to key informants, health care providers often uphold myths
regarding contraception, such as it being harmful or having negative effects on fertility, particularly in
adolescents. Lack of state coverage for contraceptives poses a significant problem and can dramatically reduce this very important preventive health care use among women and adolescent girls. Given the low contraceptive prevalence rate of 14% and high unmet need, abortion is used as a fertility regulation method.
No adolescent-friendly services or specifically trained providers are available. Specialist adolescent doctors exist only to carry out exams for army enrolment. Other services delivered to adolescents consist mainly of routine screening, which is without proven benefit, rather than services according to global standards for quality health
care services for adolescents. Dispensarization visits (a comprehensive system of examination and surveillance for all types of illness in the population) are mandatory and take place annually for all children aged 0–18 years, including adolescents.
The age of consent for accessing health care services is 18 years; without parental consent, health care providers are not allowed to provide services to adolescents. While in most cases parental involvement would be
beneficial for the adolescent, in certain circumstances it can be detrimental to their health and well-being, particularly when concerning sexual and reproductive health. The United Nations Convention on the Rights of the Child, signed by Azerbaijan, clearly states that the best interests of the child and adolescent should be the primary consideration of the health care provider. Furthermore, absence of a policy on sexuality education leaves adolescents with little support and few options for accessing information on sexual and reproductive health.
Immunization
Vaccination coverage is reported to be near universal, at 96–98%. At the time of the assessment, a measles outbreak was recorded. Human papillomavirus (HPV) vaccine has not been introduced and rotavirus vaccine is only available in the private sector. Key informants reported concerns of the population and providers that some vaccines are not of adequate quality. Those who can afford to do so refuse to vaccinate their children in the public sector, particularly against hepatitis B, and turn to the private sector.
Health system challenges identified
The following root causes were identified when analysing the findings in relation to the health system building blocks.
Increasing the public share of health financing is a critical reform area. Public spending on health is currently the lowest in the WHO European Region, both in relative terms as a percentage of gross domestic product and in absolute terms in United States dollars per capita at purchasing power parity. The limited allocation of public resources to the health sector is reflected in low salaries of health workers in the public sector and high OOP payments for health care. Salaries of health personnel are among the lowest in the country, averaging less than half the average monthly salary and representing only twice the current minimum wage of 105 United States dollars. Spending on outpatient medicines is the largest category of OOP payments (60%); the remaining 40% is spent on consultations and laboratory tests. The practice of informal payments is reported at all levels. Reliance on informal payments to supplement salaries may – at least in part – explain non-evidence-based treatment and prescribing practices.
The private sector has grown rapidly in recent years. While salaries are higher and informal payments less likely in the private sector, this trend is causing widening inequities and skyrocketing supplier-induced demand, as evidenced by caesarean section rates.
Reorienting service delivery away from hospital care and towards primary care is necessary to improve health outcomes and generate efficiency savings. The current system remains biased toward hospital care, leaving PHC underfunded and underdeveloped. This is shown by the limited services available at the PHC level and salaries that are much lower than those in hospitals. Key diagnostic tests (such as urine analysis, blood tests, ultrasound) are currently not available in PHC, and patients are routinely referred for essential diagnostic and treatment services (such as insertion of intrauterine devices, testing and treatment of STIs), leading to fragmentation of services and a lack of population trust in PHC’s ability to provide services. Screening for and treatment of iron deficiency anaemia, folic acid supplementation and guidance on modifiable lifestyle risks such as malnutrition and obesity are areas of high-impact intervention, particularly during preconception care and pregnancy, but they are currently underutilized by PHC.
Data show that PHC facilities are not the first point of contact with the health sector but are bypassed by patients, who access hospital care directly. This is further exacerbated by reimbursement schemes incentivizing hospitalization.
Despite previous efforts to consolidate the hospital infrastructure, the system still has a relatively high number of hospital beds and significant overcapacity. Bed occupancy rates in Azerbaijan are among the lowest in the Region, while average lengths of stay are among the highest. Previous efforts to optimize the care delivery network seem to have stalled and even slightly reversed when several regional hospitals were constructed; this points to inefficiencies in use of resources. Combined with non-evidence-based resource-intense activities, such as mass screening, it constitutes significant scope for efficiency gains.
Improving health workforce capacity at the PHC level to deliver essential SRMNCAH services and rational distribution of health personnel must be a key policy priority. PHC doctors and nurses are not always skilled;
they may lack confidence in delivering essential SRMNCAH services, causing multiple referrals and fragmentation of services. Primary care providers have to play a critical role in supporting underserved patients in both rural and urban settings. For family doctors and general practitioners to fulfil this role, the task profile needs to be expanded and pre-service medical education, postgraduate training and continuing professional development prioritized in key areas of population health. Although staff shortages were mentioned by several interviewees, Azerbaijan has the highest number of paediatricians per 100 000 population in the WHO European Region (42 versus a regional average of 19), a similar number of general practitioners and a slightly lower number of nurses.
While some rural areas may have shortages of doctors, nurses and midwives, in areas visited the assessment found high doctor:patient ratios.
Conclusion
The Government of Azerbaijan is in the process of rolling out a mandatory health insurance programme and is therefore uniquely positioned to advance the UHC agenda for its citizens. Modernizing health systems, improving health outcomes and reducing inequities are within reach, if sufficient resources are efficiently allocated and the benefits covered under the health insurance scheme are realistic, transparently selected and evidence-based.
PHC should be strengthened to allow provision of comprehensive SRMNCAH services; health care providers should be enabled to adhere to evidence-based guidelines; and the private sector should be appropriately regulated. With careful planning and coordination, the Ministry of Health can implement the changes required to address the findings of the assessment, which would result in much needed improvements of the health system and services for women, children and adolescents.
Introduction
UHC means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. This definition of UHC embodies three related
objectives:
•
equity in access, meaning that everyone who needs health services should get them, not only those who can pay for them;•
health services of good enough quality to improve the health of those receiving services; and•
protection against financial risk, ensuring that the cost of using services does not put people at risk of financial harm.Achieving UHC is one of the targets the nations of the world set when adopting the Sustainable Development Goals in 2015.
SRMNCAH is at the core of the UHC agenda and is among the 16 essential health services in four categories that WHO uses as indicators of the level and equity of coverage in countries. Essential SRMNCAH services used as indicators for UHC are:
•
family planning•
antenatal and delivery care•
full child immunization•
health-seeking behaviour for pneumonia.An assessment of SRMNCAH in the context of UHC was conducted in Azerbaijan in March 2019. The specific objectives of the assessment were to:
•
delineate which SRMNCAH services are included in policies concerning UHC in the specific country context;•
assess the extent to which the services are available to the people for whom they are intended and at what cost;•
identify potential health system barriers to the provision of SRMNCAH services, using a tracer methodology and an equity lens;•
highlight good practices and innovations in the health system, with evidence of their impact on SRMNCAH services;•
identify priority areas for action and develop policy recommendations jointly with the country to address health system barriers to the provision of SRMNCAH services.The assessment was carried out on behalf of the WHO Regional Office for Europe and the WHO Country Office in Azerbaijan, and it is the intention that similar assessments will be conducted in other countries in the Region.
Methodology
A methodological approach was developed prior the country visit and underwent several revisions. This was the sixth in a series of assessments that took place from September 2018 to March 2019 in Albania, Azerbaijan, Kazakhstan, Kyrgyzstan, Republic of Moldova and Romania. The steps in the assessment included:
•
a preliminary document review, including health policy and strategy documents, sexual and reproductive health and child and adolescent health strategy documents, UHC guiding documents, service package descriptions and similar;•
a country visit, including:ͳ interviews with policy-makers from the Ministry of Health, health facility managers (PHC and hospital), service providers (doctors, nurses and others) and beneficiaries (patients, clients);
ͳ visits to health care facilities at primary, secondary and tertiary levels;
•
a presentation and discussion of findings and recommendations with key stakeholders at the end of the visit.Semi-structured questionnaires were developed to conduct interviews with key informants, including:
•
representatives of the Ministry of Health;•
health facility managers (hospital and PHC);•
health workers including nurses, doctors, midwives, where applicable;•
patients and clients, including adolescents;•
partners and stakeholders, including representatives of the United Nations Children’s Fund (UNICEF) and United Nations Population Fund.Tracer interventions
Given the limited amount of resources and time available, six tracer interventions were identified and analysed in depth to assess the extent to which services are available to the people for whom they are intended and at what cost. These were:
•
antenatal care•
STIs (excluding HIV)•
transport of sick neonates•
case management of common childhood conditions•
adolescent-friendly health services (sexual and reproductive health)•
immunization.The findings are analysed and reported according to WHO’s six building blocks of UHC (Fig. 1).
Fig. 1. The building blocks of UHC
Source: Universal health coverage [website]. Geneva: World Health Organization; 2019 (http://www.who.int/universal_health_coverage/en/, accessed 30 December 2019).
Limitations
The methodology aims to triangulate information through document reviews, visits to health facilities and interviews with policy-makers, health managers, providers and clients. The depth of the assessment depends on the completeness of documents provided by the Ministry of Health and partners, as well as the extent to which the health facilities visited and key informants interviewed are representative and reflect the national context and situation. The appraisal of tracer interventions and health systems barriers and challenges represents the judgement of the assessment team, based on the information obtained.
Country context
Azerbaijan’s economy has experienced stable growth since independence following the dissolution of the former Soviet Union, mainly because of increasing gas and oil exports. Since 2009, however, gross domestic product (GDP) growth has fluctuated, even reaching negative numbers (Fig. 2). But, further supported by stable oil production and modest acceleration in domestic demand, real GDP expanded by 1.4% in 2018.2 Since the economic outlook largely depends on gas exports, the projected acceleration may not be stable.
2 Overview: economy. In: The World Bank in Azerbaijan [website]. Washington DC: World Bank Group; 2019 (http://www.worldbank.org/en/
country/azerbaijan/overview#3, accessed 6 May 2019).
Fig. 2. Annual GDP growth
–4.0 –2.0 0.0 2.0 4.0 6.0 8.0 10.0
2009 2010 2011 2012 2013 2014 2015 2016 2017
Percentage growth
Year 9.4
4.9
0.1
2.2
5.8
2.0
1.1
–3.1
0.1
Source: World Bank Development Indicators [online database]. Washington DC: World Bank Group; 2019 (https://databank.worldbank.org/
source/world-development-indicators/preview/on, accessed 1 June 2019).
Azerbaijan is a resource-rich country with the financial potential to provide its citizens with equitable access to high-quality and efficient health care services, while protecting them from the risk of catastrophic health
expenditure. The resources allocated to health are, however, the lowest among former Soviet countries and well below the European Union (EU) average (Fig. 3).
Fig. 3. Total health expenditure and government health expenditure as proportions of GDP
4
5.2 4.7 4.5 4.9 5 5.4
6.7 6.6 6.6
0.8 1.1 1 0.9 1.1 1.6
1.1 1.3 1.1 1
0 2 4 6 8 10
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Proportion of GDP (%)
Year
Health expenditure as a proportion of GDP
Government health expenditure as a proportion of GDP
Source: World Bank Development Indicators [online database]. Washington DC: World Bank Group; 2020 (https://data.worldbank.org/country/
azerbaijan, accessed 15 June 2020).
To facilitate the management of wealth created by Azerbaijan’s oil production, the State Oil Fund was established by the government in 1999. The Fund creates some stability for the national currency, shielding it from external shocks. It is also supposed to support development strategies and ensure equal distribution of wealth, but this has not been achieved: while wages for those working in the oil industry have risen rapidly, wages in the social sector remain low.3 Table 1 sets out key socioeconomic, macroeconomic and health expenditure indicators for Azerbaijan.
Table 1. Socioeconomic, macroeconomic and health expenditure indicators
Indicator Value Year
Socioeconomic indicators
Population, totala 9 939 800 2018
Population growth (annual)a 0.9% 2018
Population ages 0–14 (proportion of total)b 22.9% 2015
Life expectancy at birth, total (years)a 73% 2018
Inflation, consumer prices (annual)a 2.6% 2019
Unemployment, total (proportion of total labour force, modelled International Labour Organization estimate)a
4.9% 2018
Macroeconomic indicators
GDP per capita (current US$)a 4722 2018
GDP per capita growth (annual)a 0.5% 2018
GINI index (World Bank estimate)a 26.6 2005
Revenue, excluding grants (proportion of GDP)a 39.6% 2018
Gross national income per capita growth (annual)a 2.7% 2012
Gross national income per capita, Atlas method (current US$)a 4050 2018 Health expenditure indicators
Proportion of population incurring catastrophic expenditurec 30% 2015
Total health expenditure as a proportion of GDPb 2.6% 2010
Current health expenditure per capita (current international dollars, reflecting purchasing power parity (PPP))a
1163.9 2017
Public sector expenditure on health as a proportion of total government expenditure (WHO estimates)b
3.9% 2014
Sources:
a World Bank Open Data [online database]. Washington DC: World Bank; 2020 (https://data.worldbank.org/);
b European Health for all Database (HFA-DB). In: European Health Information Gateway [online database]. Copenhagen: WHO Regional Office for Europe; 2015 (https://gateway.euro.who.int/en/datasets/european-health-for-all-database/);
c Bonilla-Chacin ME, Afandiyeva G, Suaya A. Challenges on the path to universal health coverage: the experience of Azerbaijan. Washington DC:
World Bank; 2018 (Universal Health Coverage Series No. 28; http://documents.worldbank.org/curated/en/854751516196004430/Challeng- es-on-the-path-to-universal-health-coverage-the-experience-of-Azerbaijan).
All accessed 5 June 2020.
3 Ibrahimov F, Ibrahimova A, Kehler J, Richardson E. Azerbaijan: health system review. Health Syst Transit. 2010;12(3):1–117.
Health system overview
The health system in Azerbaijan is highly centralized and most decisions about key health policies are made centrally. The Ministry of Health formally has ultimate authority for management of the system, while health care providers at the local level also depend financially on local health authorities.
The overall structure of health system reflects the Soviet Semashko model. Many services are still provided by state providers, while there is an extensive and expanding private sector, particularly in the capital city. In addition, a considerable number of services are provided via line ministries, such as the Ministry of Finance.
The Government of Azerbaijan is planning to roll out a mandatory health insurance (MHI) programme from 1 January 2020. The State Agency for Mandatory Health Insurance was established in 2016 based on Presidential Order No. 2592 of 2007, operationalized through Presidential Decree No. 765 on the regulation and structure of the Agency. The government is planning to introduce a complementary payroll tax (2% from employers; 2% from employees). This will be collected by the tax collection agency to ensure that contributions to the MHI are paid.
Findings
Azerbaijan reported that a national UHC policy or strategy exists (Fig. 4), but the relevant policy or strategy document was not shared with the assessment team; nor did key informants at the national level seem to be aware of it during the assessment.
Fig. 4. Countries in the WHO European Region with a national UHC policy or strategy
Yes
Azerbaijan: Yes No
Did not participate in survey No response Unknown
Source: National universal health coverage policy or strategy exists. In: European Health Information Gateway [online database]. Copenhagen:
WHO Regional Office for Europe; 2019 (https://gateway.euro.who.int/en/indicators/ehealth_survey_1-national-uhc-policy-or-strategy-exists/
visualizations/#id=31680, accessed 3 June 2020).
Tables 2 and 3 summarize key UHC and SRMNCAH indicators for Azerbaijan.
Table 2. UHC indicators for tracer interventions
Indicator Value Year
Family planning (proportion of demand satisfied with modern methods among women aged 15–49 years who are married or in a union)
30.6% 2020
Antenatal and delivery care (proportion of antenatal care performed with four or more visits)
66.1% 2011
Full childhood immunization (proportion of 1-year-old children who received three doses of diphtheria-tetanus-pertussis vaccine)
95% 2018
Health care-seeking for pneumonia (proportion of children under 5 years with acute respiratory symptoms in the last two weeks for whom medical advice or treatment was sought)
36% 2000
Source: Maternal, newborn, child & adolescent health data portal. In: World Health Organization [website]. Geneva: World Health Organization;
2020 (https://www.who.int/data/maternal-newborn-child-adolescent/indicator-explorer-new, accessed 5 June 2020).
Table 3. SRMNCAH indicators
Indicator Value Year
Maternal mortality ratio estimatesa 26/100 000 live births 2017
Under-5 mortality ratea 19/1000 live births 2018
Neonatal mortality ratea 11/1000 live births 2018
Adolescent birth rateb 45/per 1000 women aged 15–19 2018
Sources:
a Maternal, newborn, child & adolescent health data portal. In: World Health Organization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/data/maternal-newborn-child-adolescent/indicator-explorer-new);
b Global SDG Indicators Database. In: Sustainable Development Goals [website]. New York: United Nations Statistics Division; 2020 (https://
unstats.un.org/sdgs/indicators/database/).
Accessed 5 June 2020.
Estimated under-5 mortality is relatively high in Azerbaijan compared to the averages in the Commonwealth of Independent States and EU countries, as well as to those in other countries of the Region. Further, public health expenditure in international dollars, reflecting PPP, is very low (Fig. 5).
Fig. 5. Under-5 mortality and public health expenditure in Azerbaijan and other countries in the WHO European Region
Azerbaijan
Kazakhstan Kyrgyzstan
Russian Federation Tajikistan
Turkmenistan
Ukraine
Commonwealth of Independent States average
0 10 20 30 40 50 60
0 200 400 600 800 1000 1200
Under-5 mortality per 1000 live births
Health expenditure per capita in international dollars (PPP)
Note: Bubble size relates to public health expenditure in international dollars, reflecting PPP.
Source: European Health for all Database (HFA-DB). In: European Health Information Gateway [online database]. Copenhagen: WHO Regional Office for Europe; 2019 (https://gateway.euro.who.int/en/datasets/european-health-for-all-database/#health-care-utilization-and-expenditure, accessed 1 October 2019).
Health system governance for SRMNCAH
A state programme on mother and child health for 2014–2020 is in place and the funding for 2015 was 1 704 000 Azerbaijan manat (US$ 1 000 000). The amount and status of funding for 2018 or 2019 could not be ascertained by the assessment team. Assuming a similar funding level, the programme made available US$ 5.63 per mother and her newborn in 2018, given the birth cohort of 177 543.
A law and programme on reproductive and sexual health have been in development for several years, as areas related to reproductive health were controversial and could not be agreed upon by stakeholders. It seems, however, that progress is being made, and stakeholders expect the law to be passed in the near future.
Azerbaijan is the country with the lowest public spending on health in the WHO European Region, both in relative terms as a percentage of GDP (Fig. 6) and in absolute terms in United States dollars per capita, reflecting PPP (Fig. 7).
Fig. 6. Public sector expenditure on health as a proportion of GDP (WHO estimates)
1.0 0.9 0.9 1.0 0.8
1.3 1.2 1.1 1.2 1.2 1.2
5.1 5.2 5.3 5.3 5.5
6.0 5.8 5.7 5.8 5.8 5.7
0 1 2 3 4 5 6 7
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Public sector expenditure on health as a percentage of GDP
Year
Azerbaijan WHO European Region
Source: European Health for all Database (HFA-DB). In: European Health Information Gateway [online database]. Copenhagen: WHO Regional Office for Europe; 2019 (https://gateway.euro.who.int/en/datasets/european-health-for-all-database/#health-care-utilization-and-expenditure, accessed 3 June 2020).
Fig. 7. Public expenditure on health per capita (WHO estimates)
56 62 83 120 112 199 182 169 197 197 214
1161 1250
1380 1458
1593
1697 1708 1756 1799 1829 1879
0 200 400 600 800 1000 1200 1400 1600 1800 2000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Public expenditure on health per capita, US$, reflecting PPP
Year
Azerbaijan WHO European Region
Source: European Health for all Database (HFA-DB). In: European Health Information Gateway [online database]. Copenhagen: WHO Regional Office for Europe; 2019 (https://gateway.euro.who.int/en/datasets/european-health-for-all-database/#health-care-utilization-and-expenditure, accessed 3 June 2020).
Public expenditure on health as proportion of total government expenditure is also low (Fig. 8).
Fig. 8. Public expenditure on health as proportion of total government expenditure (WHO estimates)
Azerbaijan WHO European Region
6 5
4 5
3
5 4
4 4 3 4
13 13 13 13 13 13 13 13 13 13 13
0 2 4 6 8 10 12 14
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Public sector expenditure on health as a percentage of total government expenditure
Year
Source: European Health for all Database (HFA-DB). In: European Health Information Gateway [online database]. Copenhagen: WHO Regional Office for Europe; 2019 (https://gateway.euro.who.int/en/datasets/european-health-for-all-database/#health-care-utilization-and-expenditure, accessed 3 June 2020).
Health system financing for SRMNCAH
The health system in Azerbaijan is financed through a combination of tax revenues and OOP payments (Fig. 9).
Fig. 9. Financial flow
Ministry of Taxes
State Oil Fund Ministry of Finance
Ministry of Health
Republican hospitals, polyclinics and specialized clinics, scientific research institutes, Baku city hospitals and polyclinics
Centres of hygiene and epidemiology
Health facilities serving special groups of the
population through parallel health
care systems Central district hospitals,
village hospitals and primary care clinics District administrations
Line ministries with parallel health
care systems
State companies with parallel health
care systems
Private health facilities and providers
Flow of tax funds Patients
Population
Out of pocket payments Company profits Source: Ibrahimov F, Ibrahimova A, Kehler J, Richardson E. Azerbaijan: health system review. Health Syst Transit. 2010;12(3):1–117.
As a consequence of the low public expenditure on health, Azerbaijan is characterized by a very high share of OOP payments – particularly informal payments – made at the point of service provision. This affects access to care for the population and particularly exposes poorer households to the risk of catastrophic health care expenditure.
OOP expenditure as share of total health expenditure in Azerbaijan is the highest among the former Soviet republics, and significantly above the average in EU countries (Fig. 10).
Fig. 10. Categories of expenditure on health as share of total health expenditure
20 24 24 23 24 22 22 21 20 15
1 2 1 1 2
1 1 1 1
1
79 74 75 76 74 77 77 78 79
84
0 10 20 30 40 50 60 70 80 90 100
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Proportion of total health expenditure (%)
Year
Government health expenditure External health expenditure Out-of-pocket expenditure
Source: World Bank Development Indicators [online database]. Washington DC: World Bank Group; 2020 (https://data.worldbank.org/country/
azerbaijan, accessed 15 June 2020).
Although in principle all health consultations in public facilities are meant to be free of charge, in practice most patients provide informal payments to medical personnel.
Following the adoption of the National Concept on Health Financing Reform, the Ministry of Health discontinued formal user charges in all state health facilities. Effectively, this means that all services provided at state health facilities are fully state funded, although the exemption of many specialist services does create the space for user charges and charges for pharmaceuticals, which are still not covered.
Although listed in the current legal framework, the majority of SRMNCAH services are not currently covered by the benefit package, with the exception of antenatal care and delivery (Table 4).
Table 4. SRMNCAH services covered by the basic benefits package
Service PHC Hospital care
Antenatal care in accordance with WHO recommendations
7 visits NA
Micronutrient supplements No No
Vaginal delivery/caesarean section No Yes
Postpartum care Yes No
Home visits for postpartum/postnatal care Yes No
Family planning services Yes Yes
Abortion Yes (mini)* Yes: vacuum and
medical
Emergency contraception No Yes (prescribed)
Syphilis and gonorrhoea diagnosis Smear collection for testing Diagnosis
Syphilis and gonorrhoea treatment No Syphilis: no (sent to
venerology) Gonorrhoea: yes
Cervical cancer screening No Yes
Cervical cancer treatment No Yes
Vaccination by type
•
Diphtheria, tetanus and pertussis•
Measles, mumps and rubella•
Pneumococcal conjugate•
Inactivated poliovirus•
Rotavirus•
Human papillomavirus•
Yes•
Yes•
Yes•
No•
Only in private facilities•
NoNA
Treatment for cough for children under 18 years Yes NA
Diagnosis of pneumonia (including X-rays, physical examinations and blood tests) for children under 18 years
Yes, but if pneumonia is suspected based on symptoms, patient is sent to hospital
NA
Treatment of pneumonia for children under 18 years No Yes
Access to contraceptives by adolescents:
•
Oral hormonal pills•
Intrauterine device (IUD)•
Condoms•
Other•
No•
No•
No•
No•
Prescribed, but not provided (all categories) Access to abortion by adolescents:•
Medical abortion•
Vacuum aspiration•
Against the law, unless with parent’s consent (both categories)Neonatal transport between referral levels Neonatal transport supposedly exists but paediatricians reported insufficient properly equipped automobiles
*A mini abortion is induced by any abortifacient pharmaceuticals or such surgical methods of induced abortions as manual or electric vacuum aspiration.
The Government of Azerbaijan is planning to roll out an MHI programme from 1 January 2020. The State Agency for Mandatory Health Insurance was established in 2016, based on Presidential Order No. 2592 of 2007,
operationalized through Presidential Decree No. 765 on the regulation and structure of the Agency.
Coverage will be on an individual basis, which may be a challenge for non-working family members. There is recognition that enrolling those in the informal sector (such as agricultural workers) and those not in the labour force (such as non-working spouses and dependent children over 18 years) is likely to be difficult and will leave some citizens without coverage. Digital solutions will certainly help, and the plan is to be able to link eligibility to contributions at the provider level. It is important to monitor uninsured people and understand their
vulnerability. For example, women living in rural areas may be a particular group with low enrolment. Offering family enrolment and other group-based enrolment policies could be helpful. In the long run, commitment to UHC may require other measures to scale up coverage for those not in the formal sector through mandatory contributions, with strengthened enforcement or further increases in general tax financing.4
The implementation process needs to be monitored closely, although the results of the pilot project
implemented in two regions were assessed as promising. The government also plans to change the provider payment mechanisms, which are not currently linked to performance and seem to be complex.
Table 5 sets out a summary of the assessment’s findings on health system financing.
Table 5. Summary of findings on health system financing
Policy Rating Criteria for rating
Coverage under the basic benefits package
Considerable need for improvement
Health service coverage for the population is not universal. High OOP rates affect access to health care. The basic benefits package of the MHI is being defined and inclusion of essential SRMNCAH services need to be ensured.
Financing mechanisms for health providers
Some need for
improvement
Financing mechanisms differ between types of provider: state providers are paid based on historical budgets; these are mainly input-based; private providers are paid by fee for services. In both cases payments are not linked to performance.
Financing mechanisms for PHC
Considerable need for improvement
PHC facilities receive funding per capita. PHC is supposed to be free of charge for everyone, but it is underutilized, mainly because of the perceived low quality of care.
Underutilization is also caused by a lack of availability of services, including drugs.
Essential medicines and health products for SRMNCAH
Strengths
Various government policies are in place with the aim of:
•
increasing the list of pharmaceuticals and medical supplies provided at no cost for inpatient care;•
increasing the number of and resources for state national programmes that provide free pharmaceutical and medical supplies for the control of specific diseases or conditions, such as maternal and child care, diabetes and HIV/AIDS;•
increasing the availability of outpatient drugs provided at no cost to specific beneficiary groups.4 WHO Regional Office for Europe, unpublished travel report on Azerbaijan’s mandatory health insurance rollout and related health system reforms, February 2019.
In 2005 the Ministry of Health established the first list of 60 pharmaceutical products and 23 medicals supplies fully funded by the state budget and provided free of charge to hospitalized patients. In 2008 the list was expanded to include an additional 51 items. Some drugs for outpatients are also covered by the state, such as those included in various state health programmes for specific conditions (such as tuberculosis (TB), cancer and diabetes). All remaining medicines for both inpatients and outpatients must be paid for at full cost out of pocket, although this is sometimes also the case for pharmaceuticals included on the Ministry of Health’s defined list.5 Over the years this list has increased significantly, as has the budget allocated to procurement of these
pharmaceuticals and medical supplies. By 2015 the list of drugs provided free of charge in hospitals included 305 pharmaceuticals and medical supplies.
Challenges
Most OOP expenditure was on pharmaceutical products – mainly those prescribed in outpatient care settings.
The share of total expenditure on drugs, however, decreased from 75% in 2008 to 56% in 2015. This includes all pharmaceutical products, with or without a prescription. This decrease in the share of expenditure on drugs occurred at all income levels but was highest among people from the richest consumption deciles. In contrast, expenditure on consultations and laboratory tests increased from 14% to 39%, while payments for gifts to health personnel decreased from 11% to 6% between 2008 and 2015.
Nevertheless, almost 60% of OOP expenditure and 40% of total health expenditure in 2018 was on
pharmaceuticals. The lists of drugs to be provided free of charge do not include contraceptives or micronutrient supplements recommended by WHO during pregnancy, among others. Drugs provided free of charge are mainly for treatment purposes and not prevention.
Delivery and safety of SRMNCAH services
Overall, several stakeholders reported that patients who can afford to seek care either outside Azerbaijan – travelling to Iran (Islamic Republic of), Turkey and other countries – and/or in the private sector.
The process to develop clinical guidelines and pathways for the area of SRMNCAH in Azerbaijan was described by key informants as follows.
•
The protocol development process is initiated at the request of the Ministry of Health; the national perinatal, paediatric or gynaecological centre; or the public health institute, based on epidemiological data.•
Leading specialists are involved from the Ministry of Health, the relevant institutes and the provider level.•
A prototype protocol from another country, such as the United States of America, is used as a template and adapted to the local context.•
This is sent to the Ministry of Health for approval: the scientific department of the Ministry reviews and approves the protocol.•
After approval, the protocol is sent to all institutions, including those in the regions and community health facilities staffed by doctors’ assistants and midwives. Protocols are also distributed to the private sector and published on the Internet.•
Implementation is controlled by the chief doctor of the relevant region or hospital.Interviewees stated that over 100 protocols exist for the area of SRMNCAH. Quality assurance or improvement processes at the facility level to monitor adherence to guidelines are not currently in place nationwide, although medical doctors are required to undergo re-examination every five years (see the section on health workforce for SRMNCAH).
5 Ibrahimov F, Ibrahimova A, Kehler J, Richardson E. Azerbaijan: health system review. Health Syst Transit. 2010;12(3):1–117.
Outpatient care for SRMNCAH services is provided through polyclinics for children and women’s consultation centres, to which patients are assigned, based on their residence. Patients can, however, refer themselves to specialists or hospitals.
In 1990, with a World Bank loan for health sector reform, the Ministry of Health instituted family medicine within the university undergraduate curriculum and retrained existing therapists and paediatricians to serve as family doctors. A plan is in place to add family medicine will be added to postgraduate education as a two-year postgraduate course in 2019. According to interviewees, family medicine is not a popular profession among students, and young doctors are not pursuing this specialism. The task profile of the PHC provider is relatively narrowly focused. Doctors working in hospitals are better regarded.
Many of the key diagnostic tests for SRMNCAH are currently not available at the PHC level but require referral to the laboratory – for example, no urine dipsticks are available, and blood for haemoglobin testing needs to be drawn in a laboratory. Vaccination takes place at the PHC level and is reportedly carried out by specific vaccination-only staff. Screening for cervical cancer and STIs is not available at the PHC level.
The current method of health system funding does not encourage investment in comprehensive universal PHC.
Given that providers rely on informal payments to supplement their salaries, incentive systems do not encourage providers to provide evidence-based care and ensure equitable coverage for patients from different
socioeconomic groups; rather they lead to concentration on ability to pay.
The setup of PHC leads to multiple referrals of patients from primary care to specialist and laboratory services.
Providers know where to refer their patients. Coordination among care providers including back referral and/or follow-up after referral remains challenging, as no formal system or mechanism seems to be in place to refer patients back to the primary care level.
The system remains heavily biased toward hospital care, leaving PHC underfunded and underdeveloped. Salaries are lower in PHC than in hospitals and key informants stated that “Everyone would rather work in the hospitals”.
According to their terms of reference, primary care paediatricians work six hours per day: three hours in the polyclinic and three making home visits. The cost of transport for home visits is reportedly not reimbursed. One of the polyclinics visited, with a catchment area of around 17 000 children, had 173 staff, of whom 56 are doctors. The corresponding doctor:child ratio of 1:300 seems to contradict reported staff shortages.
PHC facilities are not the first point of contact with the health sector; rather, it is often hospital care. Fig. 11 shows that more than 50% of outpatient care visits across all consumption deciles occur in hospitals – both public and private.
Hospitals do not have emergency departments, and emergency transport also does not seem to be organized in a systematic way across the country. Key stakeholders mentioned a parents’ initiative to organize emergency transport.
Fig. 11. First point of care 100
80 60 40 20 0
1
Central region hospital Clinic Doctor’s outpatient center
Other Primary health center Private hospital
Republican hospital Traditional healer Village hospital
2 3 4 5 6 7 8 9 10 Total
Percentage
Economic regions of Azerbaijan
Source: Bonilla-Chacin ME, Afandiyeva G, Suaya A. Challenges on the path to universal health coverage: the experience of Azerbaijan. Washington DC: World Bank; 2018 (Universal Health Coverage Series No. 28; http://documents.worldbank.org/curated/en/854751516196004430/Challeng- es-on-the-path-to-universal-health-coverage-the-experience-of-Azerbaijan, accessed 10 June 2020).
Health workforce for SRMNCAH
Health care providers working in public facilities are salaried, at rates officially ranging from 180–200 Azerbaijan manat (US$ 106–118) to 300 Azerbaijan manat (US$ 177) per month. Salaries have been increased recently and – in a few settings – complemented with the introduction of fees for services, but they remain low. The average monthly salary of health personnel is among the lowest in the country, averaging less than half the average monthly salary and only twice the current minimum wage of 105 Azerbaijan manat (US$ 62).6 The low salaries in the public sector give rise to the need to generate additional income, often through informal payments.
Interviewees reported that doctors working in the public sector moonlight in the private sector.
According to key informants, doctors understand that their salaries will increase to 5000 or even 10 000 Azerbaijan manat once the MHI programme has been introduced.
Family doctors are not always skilled in providing essential SRMNCAH services (for example, referrals take place for prescription of iron for pregnancy-related anaemia, IUD insertion and simple STI treatment). This causes multiple referrals and fragmentation, and incurs additional financial and opportunity costs. Reportedly, family doctors refer adolescents who present with pregnancy to the obstetrician/gynaecologist and “do nothing as it is not under our terms of reference”.
Interviewees noted that pre-service training does not prepare providers sufficiently to deliver SRMNCAH services. Family medicine was planned to be introduced as a postgraduate training course in 2019.
No plan for human resources for health is in place. The Ministry of Health determines student admissions to universities. While staff shortages were mentioned by key informants, Azerbaijan has the highest number of paediatricians per 100 000 population in the WHO European Region (at 42/100 000 versus the regional average of 19/100 000), a similar number of general practitioners per 100 000 population to EU countries (at 92/100 000
6 Bonilla-Chacin ME, Afandiyeva G, Suaya A. Challenges on the path to universal health coverage: the experience of Azerbaijan. Washington DC:
World Bank; 2018 (Universal Health Coverage Series No. 28; http://documents.worldbank.org/curated/en/854751516196004430/Challeng- es-on-the-path-to-universal-health-coverage-the-experience-of-Azerbaijan, accessed on 8 June 2020).
versus an EU average of 84/100 000) and a slightly lower number of nurses (at 605/100 000 versus a WHO European Region average of 691/100 000).
Despite earlier attempts to consolidate the hospital infrastructure, the system still has relatively high number of hospital beds and significant overcapacity. Previous efforts to optimize the delivery network seem to have stalled, and even slightly reversed when several regional hospitals were constructed. This reflects large inefficiency in the use of these resources. Indeed, bed occupation rates in Azerbaijan are among the lowest in the WHO European Region. Large numbers of empty beds could be observed in hospitals during the assessment visit. In addition, there is considerable inefficiency in the use of the beds that are occupied: the country has one of the longest average lengths of stay in the Region. In the Republican Paediatric Centre, the assessment team could not visit the paediatric wards. In the regional hospital visited only one child was hospitalized who, judging from the patient history, should probably have been treated as an outpatient according to international
standards, such as the WHO Pocket Book of Hospital Care for Children.
While there is an imbalance between staffing in urban and rural areas, no policy exists to incentivize doctors to provide services in rural areas, according to interviewees.
All medical doctors, including those working in the private sector, are required to undergo re-examination every five years, and need to accumulate 240 credit hours of continuing education to attend the exam. The Ministry of Health issues certificates for the credit hours and pharmaceutical companies fund the continuing education. If doctors fail the exam, they cannot practice for five years. The test consists of 100 multiple-choice questions, of which 60 need to be answered correctly. A practical simulation test on mannequins was abolished. Doctors stated that no training is needed to pass the exam, and nobody fails.
While reportedly an explicit policy to strengthen PHC and restructure or downsize the hospital sector is not available, in the regions where the MHI programme was piloted, some facilities such as the TB dispensary and endocrinology facility were closed or moved to hospital facilities, according to interviewees.
Health statistics and information systems for SRMNCAH
The state programme on the improvement of official statistics for 2018–2025 relies on Multiple Indicator Cluster Surveys for collection of disaggregated data “characterizing the life quality of children and the population at reproductive age”. Assessment of trends in health service utilization and outcome data for SRMNCAH with a population denominator could not be identified during the assessment visit. Azerbaijan did not report data on hospitalization rates in response to the WHO survey of child and adolescent health in Europe in 2017.7
In an excellent initiative, a database that includes all pregnant women and births across the country has been set up and was shared with the WHO country office for further analysis. Reportedly, 25% of the pregnancies
recorded in the database are classified as “high-risk”, which seems very high; it is also particularly surprising given the young average age of pregnant women. The criteria for classification of high-risk pregnancy and the consequences of such a classification may have to be reviewed. Further, improvements in protecting patient confidentiality are required, as the database reportedly includes passport data for individual patients alongside diagnosis of medical conditions and pregnancy status.
Data reported at the subnational level and outcomes for different socioeconomic groups could not be found during the assessment visit. Disaggregation by age and sex was limited. No data could be found on hospitalization rates for children, prevalence and incidence rates of pneumonia in children or pre-eclampsia rates.
Key informants voiced some concern about the reliability of vaccination coverage and mortality data. An increase in maternal mortality rates was expected with the adoption of the 10th revision of the International
7 Situation of child and adolescent health in Europe. Copenhagen: WHO Regional Office for Europe; 2018 (http://www.euro.who.int/en/
publications/abstracts/situation-of-child-and-adolescent-health-in-europe-2018, accessed 4 June 2020).
Statistical Classification of Diseases and Related Health Problems in 2019. Concerns raised regarding maternal mortality data included cases of reclassification of maternal death – reporting non-pregnancy-related conditions as causes of death. Clinics try to avoid reporting maternal deaths for reasons of prestige and fear of punitive measures. An external commission of the Ministry of Health, which may include the police department, reviews cases of maternal death. Doctors in charge may face fines, depending on ability to pay, and imprisonment and job loss.
Four key issues surround the implementation of a uniform health information system (HIS):
•
a lack of funds for such a monitoring and evaluation system;•
a lack of qualified human resources (data analysts) to check the reliability and feasibility of data – it is difficult to recruit these professionals because of the low salary levels compared to other health system areas;•
a lack of continuous education and training schemes for staff working with data at all levels – central and local;•
a lack of political demand for an integrated HIS that would feed into policy- and decision-making processes at the strategic and operational levels.Tracer interventions
Antenatal care: pre-eclampsia
According to interviewees, all pregnant women need to be registered with a women’s consultation centre (primary care unit) at their place of residence – even those who are followed in the private sector. Pregnant women require a certificate of this registration to be admitted to hospital for delivery.
Data from the Demographic and Health Surveys of 2006 and 2011 show an improvement in coverage of antenatal care services in the country, with improvements more marked among the poorest 20% of the population (Fig. 12). However, coverage of antenatal care services still varied considerably across the wealth quintiles in 2011. More recent data could not be accessed.
Fig. 12. Pregnant women receiving antenatal care from a skilled care provider, by income quintile
53.2
69.9
81.5
91.3 95.3
78.4
87 92.6 96.5 99.2
0 20 40 60 80 100
Lowest II III IV Highest
Pregnant women receiving antenatal care from a skilled care provider (%)
Income quintile
2006 2011
Sources: Demographic and Health Surveys of 2006 and 2011.
