Armenian project improves access to healthcare during first year

"At first people thought we were simply giving drugs away and they turned up with plastic bags in the hope that they could stock up on their own little home pharmacies. Self-prescription of drugs is just one of the attitudes to health care that we are trying to change," says Dr. Hemant as he walks towards the mayor's house to lobby on the woman's behalf.

 

An old woman slowly descends the steep Armenian mountainside dragging behind her a used, USAID flour sack filled with about 20 kilograms of dried sheep dung. It is summertime and she is gathering the dung to use as fuel during the harsh Caucasian winter when temperatures can sink as low as minus 40 Celsius.

As she nears her decrepit house we see that the 82 year old woman is limping badly. She removes several socks and bandages from her right foot to reveal a neglected ingrown toenail that has turned septic and needs immediate treatment. The MSF doctor explains to her that the risk of gangrene is high and that, unless she comes to the nearby clinic, she runs the risk of amputation.

Of equal concern to the doctor are the living conditions of the woman. The roof of her house is riddled with holes. The woman blames the neighbours for stealing the tiles. The neighbours deny the accusations and explain that the roof was damaged by artillery during the conflict between Armenia and Azerbaijan in the early 1990s (the woman is, like many in the area, a refugee from this conflict) and has remained in a state of disrepair. They say that the woman is on a waiting list for an old people's home but that the local mayor, who can decide such matters, has been dragging his feet. It later turns out that the mayor hopes to receive a bribe from MSF as a reward for assisting the elderly woman.

Dealing with these sort of minor medical and social issues is routine for MSF volunteer Dr. Hemant from India as he works in local villages in the Gegharkunik region of Armenia, on the eastern side of Lake Sevan.

A year ago MSF established five rural ambulatories, the local term for a health clinic, in the region in order to improve the health status of the most vulnerable members of the population. The ambulatories offer free health care and free essential drugs to patients. They cover an area with a population of approximately 62,000 people and the project targets those deemed to be the most excluded and neglected in society.

The problems in the region are immense. High unemployment and a large refugee population facing discrimination from local health structures due to lack of paperwork (as well as a poorly financed and antiquated health system) are just some of the reasons that prompted MSF to renovate, and maintain, these five ambulatories as models that MSF hopes the authorities will eventually copy.

"At first people thought we were simply giving drugs away and they turned up with plastic bags in the hope that they could stock up on their own little home pharmacies. Self-prescription of drugs is just one of the attitudes to health care that we are trying to change," says Dr. Hemant as he walks towards the mayor's house to lobby on the woman's behalf.

While changing attitudes of patients is a priority of the project, changing attitudes of the local health staff is also high on the agenda. When the project began, it quickly became clear that the local doctors and nurses recruited by MSF shared many of the same prejudices and misconceptions as their patients about health care.

Wannes Vermander, a volunteer nurse from Belgium, explains some of the challenges that he has faced during his nine-month mission.

"We really had to start from scratch with some of our local staff. Every thing from waste disposal management to attitudes towards the patients had to be tackled. When we first arrived, waste disposal management simply consisted of throwing things out the window," he explains.

A lot of progress has been made during the first 12 months of the project and now 'sharps bins' are the norm - to dispose of needles - and more respect is shown towards the patients. Previously patients had to bribe doctors for a consultation as the doctors received their low salaries from the state irregularly. An incentive scheme set up by MSF and administered by the local polyclinic now augments state salaries and guarantees the medical staff a minimum income.

© Alexander Glyadyelov
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But there is still a lot of room for improvement. While Wannes demonstrates a hemoglobin metre to the nurses of the ambulatory in one village a man struggles into the waiting room. He is visibly in extreme pain but the duty nurse tells him to wait as important foreigners are making a demonstration.

 

But there is still a lot of room for improvement. While Wannes demonstrates a hemoglobin metre to the nurses of the ambulatory in one village a man struggles into the waiting room. He is visibly in extreme pain but the duty nurse tells him to wait as important foreigners are making a demonstration.

His groans attract the attention of Wannes who stops the demonstration and explains to the nurses, not for the first time, that the patient must always be the priority.

The man's legs are covered in bleeding ulcers. As the nurses clamor to give him attention all the training goes out the window. Nobody take his temperature or blood pressure, nobody asks him if he is on medication, nobody takes his pulse. In fact, nobody asks him how he feels. Instead the four nurses immediately begin openly debating the diagnosis with each other the while the rest of the patients in the waiting room look on.

Wannes takes control and leads the man to a more private area. His varicose veins had become infected over time. Then they swelled and eventually burst. Without urgent treatment with antibiotics, gangrene will soon set in and he will loose his leg. (Several months later the patient's ulcerous infection has completely healed, and he now regularly visits the ambulatory for monitoring of his diabetes.)

Later in the day Wannes makes a house call to a young woman who recently gave birth to a baby boy. Mother and child health care is high on the MSF agenda and the woman participated in a scheme where MSF paid 3,000 Drams (6 Euro) to transport her to the local hospital for the delivery.

Home delivery is illegal in Armenia due to the risks involved. Even though the law was passed several years ago, up to 40% of childbirths still take place at home. Unfortunately, people are so poor that unless they receive assistance for the trip to hospital they end up staying at home and relying on a local midwife or their mother-in-law.

The sparsely furnished room where the woman is lying with her infant has bare cement walls. Her unemployed husband cannot afford either plaster or wallpaper. The window has only a single pane of glass that will provide little protection from the cold during the winter months. Wannes has come to give advice on breastfeeding. He tells her that she should not use supplementary milk formula for the first four months. The baby is eleven weeks old but still only weighs three and a half kilos. The standard western weight at this age is 5 kilos.

"Quite often the biggest problem is not with the mother but with the mother-in-law. Although they have the best of intentions, they are still deeply superstitious in this region and rely on a lot of folk medicine which is ultimately detrimental to the health of the mother and the child', explains Wannes.

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Rehabilitation of the ambulatories is a vital component of the project. Before MSF arrived very few of the existing ambulatories had heating or running water so in winter there was little motivation for the staff to turn up. The lack of water also meant that hygiene standards were minimal.

 

Down the coast of Lake Sevan in the village of Karchaghpyur, Brian Eby, a volunteer construction specialist from San Francisco surveys the MSF financed renovation being carried out at the local ambulatory.

Armenia suffered a devastating earthquake in 1988 and has the same seismic potential as the San Andreas Fault in California. As a native of that area, Brian was at first surprised at the lack of regulation and inspections in Armenia. A construction contact cynically explained to him that the main reason for this is that the inspectors know there is hardly any money to pay bribes.

"It's certainly different and I've learnt a lot. Even though they don't have that many materials, or tools for that matter, they still seem to get the job done. I've seen them use a hatchet to chop bricks, cut metal piping and even hang a door," he tells us.

Rehabilitation of the ambulatories is a vital component of the project. Before MSF arrived very few of the existing ambulatories had heating or running water so in winter there was little motivation for the staff to turn up. The lack of water also meant that hygiene standards were minimal.

"I just completed a similar project in Tchambarak in the north of the region. The staff had been getting cynical at the slow pace of the renovation but yesterday there were smiles all over their faces because we finally got the job done. Now I feel that I have helped the professionals do their job in the right environment that they deserve. Before it was a hovel," Brian says.

Six months later and winter has returned to Gegharkunik region. The staff and patients no longer have to wear their coats during consultations and money is no longer changing hands under the table. And the context of primary care in Armenia has changed too. From January 1, 2006, primary health care is now free for all patients and official staff salaries are increasing, although they are still low and 'under the table fees' are likely to remain a problem (MSF plans to monitor the impact of these changes on access to care in 2006).

Dr. Hemant reflects on the progress of the last year:

"There's a huge difference in the approach of our local staff towards the patient. Before the project, the patient was considered a burden by the health staff as the patient often had no money to pay. I think we have raised the self-esteem of our staff and this is reflected, I am sure, in the manner in which they accept and treat the patients. For me in the space of a year to achieve that is real progress."