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In the Communist era, Armenia enjoyed one of the best health-care systems of all the Soviet republics, delivering comprehensive care on a centralized basis. Since then the system has fragmented along partially free-market lines and is today failing the majority of the people it is supposed to serve. Skewed towards expensive hospital interventions that swallow up more than 50% of the national health budget, the Armenian health system falters at the local community level and is often totally absent from rural areas. The Armenian government is trying to redress the problem, notably by introducing primary health care reforms with an emphasis on preventive care and the management of chronic diseases. But as Dr Ara Babloyan, Armenia's minister of health between 1991 and 1997, puts it, "Despite efforts in the area of primary health care, the health system requires new improvements", he said, adding that the scope and definition of primary health care should be revised and enlarged. One of the most pressing concerns is the cost of treatment and medicine for working Armenians who don't benefit from the minimal social programmes that are in place. To address this, the ministry of health has implemented several programmes since independence in 1991 including a Basic Benefits Package (BBP) established in 1999. The package provides specific health-care services, including medicines, at no charge to vulnerable segments of the population, including children, the elderly and disabled, impoverished people and injured military personnel. Since 2006, primary health care services have been free of charge under the BBP. But, of course, being eligible is not the same as being covered. And concern about the BBP being stretched a little thin is expressed in the highest places: "Each year the number of people included on the 'vulnerable' list is increased by the Armenian authorities and as a consequence, the money attributed to each individual decreases," explains Babloyan. In concrete terms this means that people like Naira Thovmasian, a 34-year-old woman living in Yerevan, who since 1999 has needed dialysis to compensate for her failing kidneys, cannot always get the medicines they need. "By law, the hospital has to provide the medicines for me, but what happens if they don't have them?" Thovmasian asks. When the hospital can't provide them, Thovmasian has to pay. And she is not alone. Elizabeth Danielyan, head of the World Health Organization's (WHO) Armenia country office, notes private financing constitutes about 50% of total health expenditures in Armenia, with 84% of that coming directly out of the consumer's pocket, according to the national health accounts monitoring project. Just one month's supply of albumin, one of the treatments Thovmasian takes, costs her the equivalent of US$ 32. Under the BBP, she receives a disability pension equivalent to US$ 27 per month. In other words this one drug costs more than her pension. So how does she manage? "Usually I can't," she says. "That's why my blood pressure drops constantly. But, if we can't afford to eat, what hope is there to pay for medicines and treatment we need?" [ILLUSTRATION OMITTED] The stark choice Thovmasian faces every month--between food or medicine--is familiar to many Armenians, and becoming more so in the current global economic downturn. According to the Central Bank of Armenia the economy will shrink by 5.8% in 2009, after several years of double-digit GDP growth driven by construction. According to the World Bank, the current downturn could push an additional 172 000 people below the poverty line, currently set at 12 600 dram (equivalent US$ 21) per month in Armenia, bringing the total number to 906 000 by 2010, that is to say one-third of Armenia's three million population. …

Armenians struggle for health care and medicines