Preliminary observations by the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Mr. Dainius Pūras on his Country Visit to Armenia, 25 September to 5 October 2017

Armenian

Yerevan, 5 October 2017

Members of the press,
Ladies and gentlemen,

I would like to begin by sincerely thanking the Government of Armenia for inviting me to assess, in a spirit of dialogue and cooperation, the realisation of the right to health in the country. During my visit, I have met with high-ranking Government officials, members of the Parliament, the Constitutional Court, and heads of relevant health-related institutions. I had a meeting with the Human Rights Defender’s Office and I also met with representatives of international organizations, diplomatic corps, and with a range of civil society actors, including professionals of the healthcare sector.

I have had the opportunity to visit different health facilities in Yerevan, Abovyan, Sevan, Dilijan, Vanadzor and Spitak, including polyclinics, medical centres, and mental health care institutions. I have visited the National Centre for AIDS prevention, the Narcological Centre, and the National Centre for Tuberculosis Control. I have also visited a number of penitentiaries throughout the country as well as primary and secondary schools, including those providing inclusive education programmes. I take this opportunity to thank the UN Resident Coordinator and the UN Country Team for their crucial support to my visit.

You will find in this room a short document that explains my responsibilities as the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (the right to health), as well as the focus issues for this visit. I am an independent expert who reports to, and advises, the UN Human Rights Council and UN General Assembly on the realisation of the right to health.

After almost two weeks in the country, I have gathered a wealth of information and testimony that enables me to assess the realisation of the right to health in Armenia. Today, I will only present some of my preliminary observations, which I will elaborate in more detail in the report I will present to the UN Human Rights Council in Geneva, in June 2018.

General context: achievements and challenge

Armenia gained independence from the Soviet Union in 1991 amidst an armed conflict over Nagorno-Karabakh region, which remains unresolved to date. Armenian economic growth and development has been hampered by the lack of progress towards a peaceful solution to the conflict.

Armenia is party to all international human rights treaties, but has yet to ratify most of the Optional Protocols including the Optional Protocols to the Convention on Rights of Persons with Disabilities and the Convention on the Rights of the Child. In 2006, Armenia issued a standing invitation to Special Procedures of the Human Rights Council, and has since received the visits of a few mandate-holders. Armenia has ratified the UN Framework Convention on Tobacco Control and the main UN Conventions related to drug control.

Armenia’s transition from a semi-Presidential system to a parliamentary republic is nearly complete, and the amended Constitution, new electoral law and new President will be voted in spring 2018. The new Constitution and the ongoing normative and policy reform process will have an impact on the enjoyment of the right to health by the population.

Since the 1990s, most indicators under the Millennium Development Goals showed considerable improvement with important achievements in life expectancy, maternal and child mortality as well as poverty reduction. Since 2000, economic growth has slowed down and, with it, poverty reduction. This deceleration is due to the weaker performance of its main trading partners and a slowdown in remittance-providing countries.

I will now briefly outline my main observations regarding the issues in focus for this visit, mainly the healthcare system and universal health coverage; mental health and the rights of persons with intellectual and psycho-social disabilities; the right to health of those living with HIV/AIDS and tuberculosis; and drug policy and control.

Healthcare system

As a post-Soviet State, Armenia inherited a centralized healthcare system which guaranteed free medical care and access to a range of services for the population but with excessive emphasis on hospital care and important geographical imbalances in terms of access and quality. In recent years, the system has undergone important reforms, including a rationalisation process, as well as the decentralization of services and transfer of health competencies to local and provincial authorities. There have been important efforts to strengthen primary care and other outpatient services, which should be commended. However, the health sector faces serious challenges related to workforce, including shortage of family doctors, low pay and low motivation, insufficient incentives to work outside the capital, and weakness of relevant professional associations. I will elaborate further on these issues in my report.

One structural challenge of Armenian healthcare is the low level of public expenditure in health, which is below 2% of the GDP, one of the lowest in the world. Health expenditure per capita is among the lowest in the European region. An important part of existing investment in health infrastructure, equipment, and service provision is donor-based, which raises concerns about sustainability.

In spite of the efforts made to ensure access to services for the most vulnerable groups of population, including through the Basic Benefit Package, out-of-pockets payments (OOP) are very high in Armenia accounting for over 50% of the health expenditure and affect mainly inpatient care and pharmaceuticals. This constitutes an important barrier to access care and can create inequalities in the health system. There have been important initiatives to address this, such as the State certificate reforms (2010-2011) to ensure women and children have access to affordable quality maternity and paediatric services, respectively.

During my visit, I learned that the country is moving towards a mandatory health insurance scheme which will involve private insurers as third party administrators for a revised set of benefits for certain sectors of the population, mainly civil servants and socially disadvantaged groups. In the context of a broader universal health coverage reform, this could have significant implications regarding eligibility, coverage and financing of the system, and could potentially create inequities and inefficiencies if strong oversight and transparency are not ensured.

I would like to emphasize that a human rights approach to health implies the incorporation of the principles of non-discrimination, accountability, participation and empowerment, and the need to go beyond the narrow biomedical model so that holistic, equitable and ethical care is provided to the population, in particular to those in most need.

For healthcare systems to be efficient, sustainable investment in primary care and other community-based services should be a priority. In this respect, disparities in terms of availability and accessibility of care need to be addressed with emphasis on primary care and the role of general practitioners as gatekeepers and coordinators of care. This is of special importance when it comes to the right to physical and mental health of women, children and other groups in vulnerable situations, such as migrants and refugees.

Mental health and persons with psychosocial and intellectual disabilities

Armenia is in a good position to develop a mental healthcare system based on human rights and modern public health principles and standards. The successful implementation of the Sustainable Development Goals and Agenda 2030 for Sustainable Development and the current ambitious reforms of the healthcare system can only be achieved if all elements of a modern approach to mental health are properly addressed.

The most important of such elements are a) increased investments in the area of mental health and services through the promotion of mental health and the prevention of common mental health problems among children and adults; b) the integration of mental health in primary care; c) the development of community-based services for children and adults with intellectual and psychosocial disabilities; and d) a fundamental change in attitudes both among the general population but also among health professionals.

During my visit, I have assessed the situation in Armenia with respect to all these elements; I will now briefly discuss some of them.

A great deal of mental health promotion can be done in schools and educational settings; this is why I have visited a number of educational institutions during these two weeks in the country. Mental health promotion is about prevention of bullying and other forms of violence against children. But it is also about inclusive education, which is not only crucial for integration of children with disabilities but also to promote emotional well-being of all children and society at large. I visited kindergarten N.92 in Yerevan, and I can say that this is an example of what needs to be replicated throughout the country. However, for the moment, there are good practices but they are limited to a number of pilot initiatives that still need to be mainstreamed in the general system of education, and more investment is needed. In primary and secondary schools, more efforts are needed to ensure awareness of issues such as bullying, which exists in all countries, and the sooner they are identified and properly addressed, the more effective investments in mental health would be.

I also visited Spitak Care Centre, which provides community-based services to adults with psychosocial disabilities based on the existing Mental Health Strategy. I was impressed by this centre and how services are provided with a human rights and evidence-based approach to guarantee the dignity and autonomy of the users. I strongly recommend the Government of Armenia to accelerate mental health reforms and ensure that such community based services go beyond pilot project are scaled up and replicated in all marzes.

The experiences I mentioned indicate that Armenia is able and ready to follow best international practices in mental health and abandon the legacy of outdated mental health policies and services reliant on large psychiatric hospitals and long term care institutions. However, these pilot initiatives are, for the moment, only exceptions from the rule. There does not seem to be enough political will to replicate modern community-based services throughout the country, with the consequent risk that funding for mental health reform could be invested in the renovation and expansion of segregated psychiatric institutions that still dominate the mental healthcare system in the country

I have identified signs of this vicious cycle in Armenian mental health system, when people with mental health conditions are too easily and too often hospitalized in psychiatric hospitals, tend to be overmedicated, and then confined for long periods of time in large institutions, labelled as chronic patients. Existing legal provisions and practices, which allow for involuntary confinement and treatment as well as deprivation of legal capacity, disempower, stigmatize and discriminate people living with mental health conditions and should be abandoned. Financial and other incentives need to be in place to expand community-based services that empower these people, integrate them into communities, and support their needs and rights to enjoy independent living in society. In this respect, Armenia has received many good recommendations from international organizations, especially the United Nations Committee on the Rights of Persons with Disabilities, and I will expand on these in my report.

People living with HIV/AIDS and tuberculosis

Armenia has made a strong commitment to fight the HIV/AIDS, joining all international initiatives adopted in this field, and providing access to testing and treatment of those living with the disease. In 2016, Armenia became one of the four countries in the world to have eradicated mother-to-child transmission of HIV/AIDS.

The prevalence of HIV/AIDS remains concentrated amongst certain key affected populations, in particular people who use drugs, including prisoners, and migrants. Since 2004, most new cases are infected through heterosexual contact and linked to the migration experience of male Armenians who leave the country to work abroad, mainly in the Russian Federation. These key populations are exposed to heightened risks and face barriers, both in law and in practice, as well as stigma and discrimination when accessing testing and treatment services. Armenian legislation still criminalizes HIV exposure and transmission, and there are serious concerns about the respect of the right to confidentiality of patients.

Since 2005, access to anti-retroviral treatment is free of charge and in 2009 travel and movement restrictions to migrants living with HIV/AIDS were removed from legislation. Provider initiated counselling and testing is available in State-owned outpatient health centres, and self-testing will be introduced shortly. However, most of public health efforts to fight HIV/AIDS in Armenia are funded by external donors, which raises concerns about the sustainability and ownership of the initiatives. In addition, awareness and access to information remain low, including on sexually transmitted diseases and modern contraceptive methods, both amongst the general population, youth and adolescents included, and the key target groups mentioned.

Tuberculosis (TB) is an important public health concern in Armenia, which has one of the highest incidence rates in the European region. Low treatment outcome in Armenia is partly explained by the high prevalence of multi-drug resistance form of TB, as well as by high levels of stigmatisation of patients which could make adherence a problem. TB treatment has traditionally not been patient-friendly and has excessively relied on hospitalisation due to a reverse incentive system which discouraged ambulatory care. Although there have been important efforts to address this, including through the introduction of a performance-based financing model in primary care, essential community-based TB care and treatment centres are yet to be fully developed.

Legislation should ensure non-discrimination on the basis of health status, and all people in Armenia should have access to quality TB diagnosis, prevention, treatment care and support, ideally through essential community-based services. The needs of those in most vulnerable situations, including prisoners, migrants and refugees, and those living in poverty, should be addressed as a matter of priority.

Drug policy and access to controlled medicines

The approach to drug control, including drug use and access to controlled medicines for pain relief, remains punitive and restrictive undermining the right to health of people who use drugs and of those in need of palliative care.

Armenian health care system provides for opium substitution therapy but such treatment is not always voluntarily and can be imposed through court treatment orders which are part of prison sentences for drug-related offences. There is reportedly late diagnosis of HIV/AIDS among drug-injecting users which points to low levels of trust in the health system and low levels of awareness and access to other harm reduction services. Armenia needs to invest more in prevention, education, and information programmes about drug use, especially among adolescents and youth. The health and related sectors need to be more pro-active in promoting evidence-based prevention, services and treatment for people who use drugs respecting their autonomy, dignity and privacy.

Due to the advocacy and support of external donors and partners, Armenia developed a Palliative Care Concept (2012-2016) and a Palliative Care Strategy (2017-2019) to integrate palliative care into the national health system. And I would like to commend the authorities for these initiatives. However, many patients with life-limiting illnesses still end their days in unbearable pain; they do not have access to pain medications due to restrictive and complex procedures for the prescription of injectable opioids, and tight police control. Only oncologists can prescribe injectable opioids, and only to cancer patients. Available data shows that morphine has not been available in sufficient quantities and, despite the fact that oral morphine was registered in the country in 2017, it is not yet available. Moreover, health professionals are not properly trained and certified to provide palliative care services, and such services are to be privately paid, which could have devastating consequences for a sector of the population and their families.

Members of the press,
Ladies and gentlemen,

There are good opportunities to achieve the progressive realisation of the right to health in Armenia but public authorities need to step up efforts to address structural and systemic challenges, both in law and practice, in order to fulfil its obligations under international law to promote and protect human rights. For this, it should make use of the good recommendations made by various regional and international bodies, in particular in the field of human rights, to move forward.

I will elaborate on these opportunities but also on the challenges as well as on the ways to address them in my report with the hope that my recommendations will contribute not only to the realisation of the right to health in the country, but also to the attainment of health-related sustainable development goals, including the goal to reach universal health coverage.

I will conclude now thanking the Government of Armenia for extending me an invitation to visit the country and for the open and candid exchange of views during these two weeks, which has enabled me to have a better understanding of the realisation of the right to health and related rights in the country.

Thank you.