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CONTENTS Acknowledgments ................................................................................................................... iii About the authors .................................................................................................................... iv Acronyms ................................................................................................................................ vi Executive summary ................................................................................................................. 1 Background ............................................................................................................................. 2 Responding to the growing burden of NCDs in Armenia through more effective primary healthcare ................................................................................................................................ 2 Purpose of the report ............................................................................................................... 3 Key findings ............................................................................................................................. 6 The effectiveness of primary healthcare in Armenia ................................................................ 6 The current capacity of Armenia’s PHC system ....................................................................... 7 Insufficient financing of PHC and misaligned incentives affect access to quality care for Armenians ............................................................................................................................... 11 Policy recommendations ......................................................................................................... 12 CHAPTER 1. Introduction ........................................................................................................ 15 The economic, social and political context of Armenia ................................................. 16 The health and economic burden of disease in Armenia .............................................. 18 Primary healthcare: The foundation of a strong health system ..................................... 20 Primary healthcare in Armenia ...................................................................................... 21 Moving towards universal health coverage in Armenia through stronger primary healthcare ..................................................................................................................... 23 Informing primary healthcare improvement through better data ................................... 24 CHAPTER 2. Enhancing effectiveness of Armenia’s PHC ...................................................... 27 CHAPTER 3. The current capacity of Armenia’s PHC system (inputs): health workforce, infrastructure, equipment, and supplies ............................................................ 34 CHAPTER 4. The current capacity of Armenia’s PHC system (processes): organization and management of primary healthcare, including integration of service delivery .. 40 CHAPTER 5. The current capacity of Armenia’s PHC system (structures): primary healthcare governance, financing, collaboration, and data-driven decision making ......................................................................................................... 44 CHAPTER 6. Recommendations ........................................................................................... 50 Interventions to improve access to PHC for NCDs ....................................................... 52 Interventions to improve the quality of PHC care for NCDs .......................................... 53 Mechanisms to support effective PHC governance that will create an enabling environment for PHC improvement .............................................................................. 54 Appendix 1. The definition of PHC facility and provider throughout this report ...................... 56 Appendix 2. Service Delivery Indicators Survey (SDI) ........................................................... 56 Appendix 3. The Vertical Integration Diagnostic and Readiness Tool .................................... 59 Appendix 4. Primary Healthcare Vital Signs Profile ................................................................ 60 Primary Healthcare Progression Model .............................................................. 64 Appendix 5. Analysis of Ambulatory-Care Sensitive Conditions ............................................. 65 Armenia PHC Assessment Report ACKNOWLEDGMENTS The World Bank task team co-led by Adanna Chukwuma, Christine Lao Pena and Fatimah Ajus appreciates the Ministry of Health for supporting the “Primary Healthcare and Integration of Service Delivery Assessment for Armenia” activity, under the leadership of the Deputy Minister Lena Nanushyan. We thank Dr. Shant Shekherdimian, Adviser to the Minister, for his continuous collaboration, advice, and contribution throughout the report preparation, as well as S. Avdalbek- yan of the National Institute of Health (NIH) for supporting and contributing to the implementation of all the assessments. The team also appreciates the International Center for Human Development (ICHD) for the completion of Service Delivery Indicators (SDI) and Vertical Integration and Readiness Tool surveys in collaboration with the NIH. We are also grateful to Gavi, the Vaccine Alliance, for co-financing the preparation of the assessment and the Korean-World Bank Partnership Grant for co-financing its revision and publication. The team would also like to thank Ruben Orion Conner, Juan Muñoz, Kathryn Gilman Andrews, and Jigyasa Sharma for their advice during the sampling and data collection for SDI surveys, as well as the team of the Primary Health Care Performance Initiative (PHCPI) for their guidance and support. The team is also grateful for the guidance received from Carolin Geginat, Rekha Menon, and Tania Dmytraczenko, as well as inputs and feedback provided by Artemis Ter Sargsyan, Baktybek Zhumadil, Narine Tadevosyan, and peer reviewers (Dinesh Nair and Manuela Villar Uribe). Finally, we thank Aram Ghulijanyan for conducting the analysis of Ambulatory-Care Sensitive Conditions (ACSCs) in Armenia which informed the report. Finally, we thank Aram Ghulijanyan for conducting the analysis of Ambulatory Care Sensitive Conditions (ACSCs) in Armenia, which informed the report, and Khushboo Gupta for her valuable help and contribution to the SDI analysis. - iii - Armenia PHC Assessment Report ABOUT THE AUTHORS Serine Sahakyan is a public health specialist and health consultant specializing in primary health- care at the World Bank. She led the data collection and synthesis for the Progression Model and contributed to the implementation of the Primary Healthcare Assessment for Armenia. Currently, she is pursuing her PhD in Health Systems Research at the University of Toronto. Before this, Serine was a senior researcher at the American University of Armenia, where she designed and implement- ed nationwide quantitative and qualitative research in public health, operational research, program evaluation, and clinical and behavioral studies. In recent years, her work has focused on assessing and strengthening the primary healthcare system in Armenia. Serine holds a Master in Public Health (MPH) from the American University of Armenia. Stephanie Ngo is a health systems specialist and global health consultant who works across pol- icy, research, and practice to support the implementation of people-centered health service delivery reforms. Between 2013 and 2021 she worked at the World Health Organization (WHO) (Geneva, Western Pacific Regional Office, and Cambodia), where she provided technical and operational sup- port to advance a number of global and regional agendas in low-, middle- and high-income country settings, including: integrated people-centered services; primary health care; human resources for health; health policy and systems research; and universal health coverage. During this period, she also worked on the WHO Cambodia Health Emergencies/Incident Management Team where she led the coordination of the clinical management, infection and control, and local preparedness pillars of the country’s early response to COVID-19. Stephanie holds degrees in integrated sciences and nursing from the University of British Columbia (Canada) and a Master of Science in Health Policy, Planning and Financing from the London School of Economics and Political Science and the London School of Hygiene and Tropical Medicine. Adanna Chukwuma is a senior health economist in the Health, Nutrition, and Population Global Practice, at the World Bank, where she has led the Bank’s support for the design, implementation, and evaluation of investments in the health sector in Armenia, Bosnia and Herzegovina, Moldova, Roma- nia, and Sierra Leone. Adanna is also an Associate editor on the Health Systems and Reform Editorial Board, primarily supporting peer-reviewed publications in health financing. She has a medical degree from the University of Nigeria, a Master of Science in Global Health from the University of Oxford, and a Doctor of Science in Health Systems from Harvard University. Gianluca Cafagna is a health specialist at the Health, Nutrition and Population Global Practice of the World Bank. Gianluca is leading and contributing to operations and analytical works in Central America and Caribbean countries. Since he joined the Bank in February 2020, Gianluca has also contributed to country engagements of the Primary Health Care Performance Initiative (PHCPI). Prior to the World Bank, Gianluca worked as an Associate Professional Officer at the Inter-American Devel- opment Bank in Washington DC and as a Fellow at the United Nations Development Program in Pan- ama City. An Italian national, Gianluca holds a Ph.D. in Healthcare Management from the Sant’Anna School of Advanced Studies in Pisa and a MSc in Economic and Social Sciences from the Bocconi University in Milan. - iv - Armenia PHC Assessment Report Federica Secci is a senior health specialist in the Health, Nutrition and Population Global Practice of the World Bank. She joined the Bank as a Young Professional in 2013 and has supported and led operations and analytical work across different countries in Latin America, Europe and Central Asia, East Asia, and South Asia, mainly related to primary health care strengthening and to COVID-19 emergency response. She leads the Primary Health Care Performance Initiative (PHCPI) at the World Bank. Prior to joining the Bank, she was a research fellow at Imperial College London, focusing on quality of care and behavior change related to infection prevention and control in hospitals. Her doc- toral research was a comparative, qualitative analysis of the PHC reforms in Estonia and Lithuania, drawing from sociology and institutional theory. She holds an undergraduate and a master’s degree in economics and management of public administration and international institutions from Bocconi University, Milan. Huihui Wang is a senior economist at the World Bank. She has 20 years of experience working in low-, middle- and high-income countries with a focus on supporting them to achieve Universal Health Coverage. She led the World Bank’s lending operations and technical support in health system re- forms in East Asia, Europe and Central Asia, and Africa regions. Currently working with the global en- gagement unit, she is leading global initiatives related to transforming and improving primary health- care, knowledge programs on COVID-19 impact and response, as well as financing for nutrition. She has a multi-disciplinary background: a medical degree from Beijing Medical University, a Master of Art in economics, and a Doctor of Philosophy in health services and policy analysis from University of California, Berkeley. Manuk Mikaelyan is a data analyst and consultant at the World Bank. He led data collection and the analytical part of the SDI survey. He contributes to the implementation of the Primary Healthcare Assessment for Armenia and analytical activities of the Primary Healthcare Vital Signs Profile and Progression Model in Armenia. Prior to the World Bank, Manuk worked as a head of the analytical de- partment of the Competition Authority of Armenia and as a lecturer at Yerevan State University. Manuk holds a master’s degree in mathematical modeling in economics from the Yerevan State University, with his experience involving quantitative research in the healthcare and financial sectors, predictive modeling, and economics of competition. Lorky Libaridian is a United States board-certified physician in both Internal Medicine and Pediat- rics and has been in practice for over 15 years. Dr. Libaridian also has significant experience in health systems improvement, having held leadership positions in performance and quality improvement, with a focus on population health, chronic disease management, and preventive care and screening. She has co-chaired and been on numerous committees and projects aimed to improve health outcomes through the maximization and integration of resources, including work on various electronic health systems, outreach systems, primary care workflows, staff and provider skills and knowledge, and team strengthening. In addition, Dr. Libaridian has over 10 years of work experience in Armenia and currently works with the Children of Armenia Fund, and the Primary Care Strengthening Task Force of the Ministry of Health, to help improve healthcare care delivery systems, especially as they pertain to primary care. -v- Armenia PHC Assessment Report ACRONYMS ACSC Acute Care Sensitive Condition AMD Armenian Dram BBP Basic Benefits Package CHE Current Health Expenditure CME Continuing medical education CVD Cardiovascular deceases FAPs Feldsher-akusher posts GAVI GAVI, the Vaccine Alliance (formerly Global Alliance for Vaccines and Immunization) GDP Gross Domestic Product GGE General Government Expenditure ICHD International Center for Human Development MoH Ministry of Health NCD Non-communicable disease NGO Non-governmental organization NIH National Institute of Health OOP Out-of-pocket PBF Performance-based financing PHC Primary Healthcare PHCPI Primary Healthcare Performance Initiative PM Progression Model RA Republic of Armenia SDI Service Delivery Indicators STEPS STEP-wise approach to surveillance UHC Universal Health Coverage UMI Upper-middle-income UNICEF United Nations Children’s Fund WB World Bank WBG World Bank Group WHO World Health Organization VI Vertical Integration VSP Vital Signs Profile - vi - EXECUTIVE SUMMARY Armenia PHC Assessment Report BACKGROUND they could have been if raised under ideal health and educational conditions. This score Armenia’s public health indicators have shown is similar to that of neighboring countries slow but steady improvements in recent (Georgia: 0.57, Azerbaijan: 0.58), but is lower decades. For example, its life expectancy at than the average for Europe and Central Asia birth, which has been consistently higher than (0.69). that of its Caucasus neighbors (Azerbaijan, and Georgia), increased from 73.1 to 75.2 Failure to reduce the burden of NCDs years from 2009 to 2019, corresponding to also puts populations, health systems, an average annual rate of +0.14 percent. and economies at increased risk of major However, non-communicable diseases impacts from future pandemics. For instance, (NCDs) continue to be one of Armenia’s top individuals who suffer from one or more public health issues. According to World NCD conditions, including hypertension, Health Organization (WHO) estimates, cardiovascular disease, diabetes, chronic lung the premature mortality rate of individuals disease, kidney disease, and obesity, have an aged 30–69 years from four major NCDs increased risk of contracting a severe case (cardiovascular diseases, diabetes, chronic of COVID-19. In addition, people living with respiratory diseases, and cancer) was NCDs faced additional challenges in meeting 470.22 per 100,000 in 2016, which is above their healthcare needs, given the reduced the average of 380 per 100,000 in the WHO access to services attributed to the preventive European Region. Armenians have a 19.9 measures against COVID-19. Clearly, it is percent chance of dying before the age of 70 urgent and imperative to invest in preventing from one of these four most common NCDs. and reducing NCDs. This would not only save This is above the global average of 17.8 lives and promote economic growth but would percent and the European average of 16.3 also strengthen the country’s preparedness percent. NCDs also have a significant negative for health security and resilience to respond impact on a country’s economy. Experts to future pandemics. estimate that every 10 percent increase in Responding to the growing burden of NCDs NCD mortality causes a 0.5 percent reduction in Armenia through more effective primary of economic growth, on average, globally. In healthcare Armenia, the estimated economic losses from NCDs in Armenia amount to nearly US$9 Primary healthcare (PHC) is the most billion (362.7 billion Armenian Dram (AMD)) inclusive, equitable and efficient approach annually, which corresponds to 6.5 percent to organizing and strengthening healthcare of Armenia’s gross domestic product (GDP). systems for universal health coverage and The burden of NCDs also has negative health security, and for mounting a robust implications for human capital development response to NCDs through prevention and through increasing premature mortality and control. When appropriately resourced and reducing workforce productivity. The human planned, PHC can effectively meet up to 90 capital index of Armenia in pre-pandemic percent of a person’s health needs throughout 2020 was 0.58, meaning that a child born in their lifetime by providing a comprehensive Armenia was statistically predicted to grow range of services – from health promotion up to be only 58 percent as productive as and prevention to treatment and palliative -2- Armenia PHC Assessment Report care – in a continuous, integrated, and financing for health. Only 1.67 percent of GDP people-centered manner, thus reducing is allocated to health – the lowest in the region, NCD-related hospitalizations and mortalities. which has implications for the organization, Moreover, PHC can empower people management, and delivery of PHC services. and communities to optimize their health For example, with the exception of a small by promoting health literacy, supporting proportion of the population of people with caregivers, and encouraging self-care. While disability and socially vulnerable people, effective PHC systems are a key component costly diagnostic care and medications, of high-performing healthcare in the absence including those for prevalent NCDs (e.g., of crisis, the recent pandemic and disruption antihypertensive, antidiabetic) are excluded of the provision of essential health services from the Basic Benefit Package (BBP) at brought PHC into a keen interest globally the PHC-level. In addition, underutilization of and in Armenia. It highlighted that investing in PHC is common with an estimated 67 percent PHC as the frontline of routine services and of patients seeking care directly at hospitals outbreak response can prevent the economy in part due to the perception of poor-quality from dramatic consequences and help the care at the PHC level. The insufficient policy country to respond to pandemics in a faster attention and financing to PHC in Armenia and more effective way. results not only in systems inefficiency but also higher household spending on healthcare and In Armenia, primary healthcare refers to worse health outcomes. services delivered in an outpatient setting, which form the basis of medical care, and The RA Ministry of Health (MoH) has initiated include primary, secondary, and tertiary policy discussions on Universal Health prevention and diagnosis of diseases, Coverage (UHC) reforms in the country, as an management of pregnancy, as well as raising integrated solution for financial risk protection awareness of healthy lifestyle and anti- of the population along with improvement of epidemic activities. Several categories of access, quality of delivered care, and efficient PHC facilities provide services guaranteed public expenditure. In this context, special by the Republic of Armenia (RA) and have attention has been given to ensuring the an enrolled population. These include: 1) readiness of service providers, including at the polyclinic units of medical centers and health PHC level, to deliver high-quality services as centers, 2) polyclinics, 3) primary healthcare a prerequisite for achieving improved health centers, and 4) rural ambulatories and health outcomes. These discussions follow a three- centers. Feldsher-akusher posts (FAPs) are year engagement between the World Bank health posts that are considered a part of (WB) and the MoH, during which a Steering these PHC facilities but only employ mid-level Committee was established to serve as a staff (nurse, feldsher, midwives). PHC facilities platform for inter-institutional policy dialogue may operate as public or private entities and on PHC in Armenia and to build momentum for the purpose of this report, primary care for PHC reform. providers are considered to be internists, pediatricians, family doctors, and nurses. Purpose of the report Despite the promise of PHC, Armenia faces This report responds to a request made by a number of challenges including low public the MoH to the World Bank Group (WBG) -3- Armenia PHC Assessment Report and GAVI, the Vaccine Alliance, to provide care integration among health services at technical assistance and recommendations different levels of care. Four key assessment for improving the performance of the PHC studies were undertaken to support these system and integration of service delivery, with aims: 1) a Service Delivery Indicators (SDI) a particular emphasis on the PHC system’s survey to measure the quality and capacity response to the growing burden of NCDs, as of PHC facilities across the country through part of its broader efforts towards the design a nationally representative survey of over 300 of UHC reforms in Armenia. facilities, 2) the Vital Signs Profile, the core tool of the Primary Health Care Performance The report is based on the WBG’s technical Initiative (PHCPI), to provide a snapshot of assistance which aimed to 1) provide a a PHC system across four pillars: financing, baseline of current PHC performance, capacity, performance, and equity, 3) Vertical understand the strengths and weaknesses of Integration Diagnostic and Readiness Tool to the PHC system, and where to target initiatives assess linkages between PHC and hospital for improvement; 2) identify and understand care, and 4) an assessment of Ambulatory variation in PHC performance, especially in Care Sensitive Conditions to examine if all terms of quality, between facilities in urban uncomplicated care is managed at the PHC and rural areas and in Yerevan; and 3) assess level (Figure 1). Figure 1. The Primary Healthcare Assessment Studies in Armenia SERVICE DELIVERY INDICATORS VITAL SIGNS PROFILE A national survey of capacity in A snapshot of PHC financing, 278 PHC facilities capacity, performance, equity VERTICAL INTEGRATION TOOL AMBULATORY CARE SENSITIVE CONDITIONS Assessing linkages between PHC and hospital care Examining if all uncomplicated cases are managed in PHC Source: Authors of the report The WHO-UNICEF PHC measurement four key determinants of effective PHC systems conceptual framework, which builds on a relevant to the Armenian context (Figure 2): 1) number of established global and regional inputs with adequate infrastructure, workforce, health systems strengthening, primary and supplies; 2) financing with sufficient healthcare, and universal health coverage and strategic allocation of PHC funding; frameworks, guided the early design of 3) governance and effective leadership, Armenia’s PHC performance assessment. which is based on collaborative and data- This framework was then adapted to focus on driven decision-making; and 4) processes, -4- Armenia PHC Assessment Report which include effective organization and care. The State Health Target Program, management at facility level and linkages which articulates what services should be to other levels of care, with the idea being available at PHC facilities – together with an that targeted investments in these areas, assessment of health facility capacity and informed by data and evidence, can improve patient perspectives of constraints/barriers the effectiveness of PHC to respond to NCDs to accessing quality care – is needed to and support efforts to improve universal understand where and how PHC facilities can access to quality care. It should be noted that deliver more effective care. the indicators used for data collection within This report’s target audiences are policy- these four focus areas, taken alone, do not makers and senior technical staff involved in reflect the capacity of PHC to deliver effective determining service delivery policies. Figure 2. Adapted PHC framework for the Armenian context EFFECTIVE PHC EQUITABLE ACCESS QUALITY CARE INPUTS FINANCING GOVERNANCE PROCESSES Adequacy of PHC Sufficiency and Effective PHC Effective PHC infrastructure, work strategic allocation of leadership and organization and force, supplies, and data PHC funding collaborative and data- linkages to other care driven decision-making Source: Authors’ adaptation of the WHO-UNICEF framework -5- Armenia PHC Assessment Report KEY FINDINGS Primary healthcare tends to be bypassed in favor of curative care in hospitals and, when The effectiveness of primary healthcare in care is provided at PHC level, diagnostic Armenia accuracy averages 80 percent. Despite close geographical access to PHC The assessment revealed that many facilities, overall PHC utilization is low Armenians receive costly curative care in with some differences across age groups, hospitals that could, otherwise, have been locations, and wealth quintiles; the low rate is managed by PHC providers, with data from driven by concerns about the unavailability of the assessment showing that 64 percent of services, their quality, and cost. PHC-manageable visits received hospital The assessment revealed that overall, care. However, when care is received in PHC Armenians have excellent geographical access facilities diagnostic accuracy is low, especially to PHC facilities. The average Armenian is when delivered by pediatricians and by PHC within 14 minutes of a PHC facility, and closer providers in Yerevan. The percentage of cases in rural areas. However, despite PHC facilities correctly diagnosed based on the number of being located close to where people live, simulated patients assessed by PHC providers utilization is generally low, particularly among through clinical vignettes overall was about certain population groups. Within the last 12 80 percent. Accuracy of diagnosis varies months, 32 percent of people had visited their significantly among PHC providers in Yerevan PHC facility on average. A lower number of (71 percent) compared to those in urban visits to PHC within the last 12 months was (85 percent) and rural facilities (88 percent). reported by adolescents aged 15-19 years old Following this, internists and family doctors (18.7 percent) compared to other population performed relatively better (79 percent and 85 age groups (23 - 39.6 percent); by Yerevan percent, respectively) than pediatricians (68 residents (29.4 percent) compared to rural percent). (30.8 percent) and other urban areas (34.2 The challenge with diagnostic accuracy is percent); and by households in the lowest two likely multifactorial and, in part, due to poor wealth quintiles (29.3 – 31 percent) compared adherence to internationally accepted clinical to the highest three wealth quintile groups (34 standards for patient examination and history - 35.2 percent). taking. Based on the clinical vignettes with The main drivers of underutilization among simulated patients, provider adherence to those who reported not obtaining needed international standards was found to be only 33 healthcare were the unavailability of services percent nationwide and was lower in Yerevan (15.1 percent), concerns about the quality of (26 percent) compared to rural (30 percent) care (10.8 percent), and cost of services (8.2 and other urban facilities (43 percent). There percent). Interestingly, the unavailability of was no significant difference between public services was more frequently cited by patients and private facilities. An additional factor in Yerevan (27.4 percent) and least frequently contributing to the diagnostic accuracy might cited by patients in urban areas (5.6 percent). be the limited availability of internationally recommended clinical guidelines at PHC facilities. All 28 required guidelines for -6- Armenia PHC Assessment Report management of different conditions were within the rural facilities (10.7 nurses versus available in only 34 percent of the facilities. 3.8 physicians) is significantly larger in rural The availability of guidelines was less in rural areas compared to Yerevan and other urban facilities (23 percent) and higher in private (56 areas. Moreover, there is more shortage of percent) than in public facilities (33 percent). PHC providers, with unfilled vacancies in rural areas, including up to 10 percent of physician Despite the challenges mentioned above, positions being vacant when compared to among those who consulted PHC providers, urban areas. Despite efforts by the MoH to there is very high patient satisfaction with fill rural health provider gaps by subsidizing PHC providers. More than 90 percent of medical training, they continue to persist. patients surveyed during the assessment were satisfied with their providers’ skills and Gaps in PHC infrastructure, equipment, and with the clear explanations and respectful supplies impact the ability of PHC workers in communication they received from them. Armenia to deliver quality care, with care in rural facilities being particularly affected. The current capacity of Armenia’s PHC system The assessment found that while access to water and hand hygiene are adequate, less The inadequate supply, inequitable distribution than 5 percent of PHC facilities in the country and existing skill mix of PHC providers, have recommended sanitation services (at particularly in rural areas, may be hindering least one toilet for staff, one gender-separated the delivery of effective PHC. and at least one accessible for those with The assessment found that approximately limited mobility), with large gaps observed 61 percent of all PHC providers are nurses, between Yerevan, other urban and rural with the rest consisting of family doctors facilities (Table 1). Rural facilities were the (15 percent), internists (14 percent), and worst off, with only about 1 percent having all pediatricians (10 percent). The density and types of recommended basic infrastructure. distribution of PHC providers vary across There was also a large difference between the country, with more nurses and fewer public and private facilities: 2 percent vs. 13 primary care physicians (internists, family percent, respectively (Table 1). doctors, and pediatricians) per 10,000 Most PHC facilities have computers and people in rural areas. Interestingly, when internet, but there is low access to mobile and including all PHC providers, i.e., combining landline phones (Table 1). Computers were the numbers of physicians and nurses, the the most widely available piece of equipment, density of providers is higher in rural areas followed by access to an internet connection (14.5) compared to both Yerevan (12.6) and – 99 percent and 96 percent, respectively. other urban areas (12.7). However, when There was a large gap in the availability of nurse and physician density are calculated cell phones and landline phones, particularly separately, two findings are noteworthy. First, in rural facilities. the density of physicians is much lower in rural areas (3.8) than in both Yerevan (6.2) and other urban areas (5.9). Second, the gap between the density of physicians and nurses -7- Armenia PHC Assessment Report Only 20 percent of rural facilities had, at least, one functioning landline telephone and only 10 percent had one regular cell phone. Table 1. Availability of infrastructure and equipment in the PHC facilities by location, % AVAILABILITY OF SPECIFIC TYPES OF INFRASTRUCTURE Total Yerevan Urban Rural Private Public Overall 2.4 5.9 6.8 0.8 12.5 1.9 Water 86.9 100 93.2 83.6 100 86.2 Sanitation 4.5 5.9 12.0 2.5 31.3 3.2 Hand hygiene 89.7 100 93.2 87.4 100 89.2 Waste 38.7 82.4 58.1 28.0 62.5 37.5 AVAILABILITY OF COMMUNICATION Total Yerevan Urban Rural Private Public Overall 0.6 2.9 1.7 0.0 6.3 0.3 Landline telephone 39.9 97.1 88.9 20.3 87.5 37.5 Regular mobile/ 20.3 32.4 37.6 14.4 37.5 19.4 cellular telephone Short-wave radio/’ 0.6 2.9 1.7 0.0 6.3 0.3 walkie-talkie’ Computer 99.4 100.0 100.0 99.2 100.0 99.4 Internet connection 95.7 97.1 98.3 94.9 100.0 95.5 MEDICAL EQUIPMENT AVAILABILITY Total Yerevan Urban Rural Private Public Basic 97.4 100.0 100.0 96.4 100.0 97.3 Enhanced 14.2 64.7 34.2 2.4 62.5 11.8 Source: SDI facility survey 2022 -8- Armenia PHC Assessment Report The assessment also noted that less than Furthermore, all PHC-recommended 24 15 percent of facilities have emergency essential medicines were available in 60 transport; however, this number rises to percent of facilities, with the lowest values nearly 50 percent in urban areas. Access to in rural areas. There was variation in the emergency transport for inter-facility transfer availability of medicines by subnational area allows access to necessary care when it is – about 68 percent in Yerevan, 57 percent in not available at the site. Urban facilities were rural, and 70 percent in urban facilities. more likely to have access than Yerevan and rural facilities – 47.9 percent, vs. 11.8 percent While empanelment of the population to PHC and 7.2 percent, respectively. facilities can improve access to care, current capacity, protocols, processes are insufficient Almost all facilities had basic medical to facilitate proper integration of service equipment, but enhanced diagnostic delivery within and between healthcare equipment such as X-ray, ultrasonography, facilities. and echocardiogram were lacking. The percentage of facilities with all five basic The assessment revealed that, in practice, types of equipment (scales, measuring tape, the entire population is assigned to a PHC thermometer, blood pressure apparatus, facility, with the right to choose a provider. and stethoscope) available was quite high, However, clinical pathways, clear processes, at about 98 percent. Of the 278 assessed and expectations for multi-directional facilities, all but six public facilities in rural communication do not exist to link PHC areas were equipped with a complete suite providers to other levels of care for key of basic equipment hardware. In contrast, conditions. Therefore, the health facilities enhanced equipment necessary for advanced and healthcare providers from different levels diagnostic services was available in about (primary, secondary) are unaware of their 15 percent of all facilities, with the highest responsibilities and even their capacities percentage (65 percent) in Yerevan. when it comes to referring patients to the right care or specialist that would contribute to the All five types of basic diagnostic supplies/ provision of comprehensive care. tests (hemoglobin tests, blood glucose tests, urine dipsticks for protein, urine dipsticks for Referral systems between healthcare facilities glucose, and urine pregnancy tests) necessary are generally effective within state-guaranteed for adequate PHC services were found to be healthcare services, especially those from available in only 4 percent (n=13) of assessed PHC to hospital. To organize state-guaranteed facilities. Facilities in Yerevan and other urban diagnostic or hospital care, an electronic areas were better equipped than those in referral from a PHC provider is required. This rural areas. For example, about 6 percent of can only be arranged through the ArMed facilities in Yerevan and 14 percent of facilities national electronic health management in other urban areas have all five types of system. In contrast, for non-state-guaranteed necessary diagnostic supplies, whereas only care, the paper version of referrals may also 1 percent of rural facilities have comparable be used. However, there were mixed opinions supplies. from survey respondents on the effectiveness of the ArMed. -9- Armenia PHC Assessment Report The transfer of patient medical information The assessment revealed that there is between health institutions was found to be leadership commitment to maintaining the fragmented and incomplete. Due to the absence right-to-health legislation in Armenia and of a unified electronic system, incomplete the existence of national health policies registries between health institutions, and lack oriented to PHC and UHC; however, there is of interoperable and interconnected systems, no standalone strategy for PHC. In addition, most of the information exchange between decision-making for PHC was found to different levels of care is done manually. be neither systematically data-driven nor The consequence of this is the incomplete participatory. For example, administrative transfer of information between institutions and survey data on health outcomes, service (e.g., hospital and PHC, diagnostic center utilization and spending are routinely collected; and PHC). The assessment also found that however, the available data is used for priority while more than 2/3 of the PHC facilities have setting at the national and subnational level trained managers, feedback systems, such on an ad-hoc basis. It is not used for priority as performance evaluation and opportunities setting or planning by local authorities. for promotion, are lacking. The percentage of Moreover, there is no systematic mechanism PHC facilities that are led by a manager who to engage stakeholders from the national has official management training, including level or committees and formal groups from a certificate or diploma, is about 68 percent. a sub-national level in PHC decision-making. However, about 60 percent of facilities did not In recent years, the MoH has engaged non- receive an annual review and feedback on their governmental organizations in specific management capabilities and performance in activities related to PHC, such as vaccine- the last 12 months. related awareness-raising, as well as outreach to people living with human immunodeficiency Moreover, there are obstacles to collaboration virus, tuberculosis, and cancer. However, and communication among healthcare involvement is often fragmented as these non- professionals that prevent the delivery of governmental organizations run externally- team-based care. Mechanisms and structures driven projects that are often focused on to promote team-based care at the PHC level, vertical programs and single diseases. In such as regular meetings, team-building addition, service users and private providers exercises, identification of shared goals, or have limited or no involvement in healthcare defined communication channels to promote a decisions, and, when they do have an team culture, are limited. Team-based culture opportunity to contribute, engagement is often at PHC facilities is often influenced by the unilateral. managerial style of the director of the facility. Gaps were also evident in the regulation of Primary healthcare governance structures lack the guidance of a PHC strategy, a strong quality standards for PHC in the following quality assurance system, and evidence- areas: provider licensing, facility licensing, based and consultative mechanisms for standards of care, and supervision. The informing policy and planning and monitoring assessment found that the capacity of the compliance and progress. system to ensure that all active primary healthcare workers are qualified to practice is - 10 - Armenia PHC Assessment Report weak. For example, while the PHC workforce Insufficient financing of PHC and misaligned in Armenia, including PHC physicians (family incentives affect access to quality care for physicians, internists, pediatricians) and Armenians nurses are graduates of public or private Armenia spends less from public sources licensed institutions and accredited programs, on PHC compared to other middle-income there has been no licensing implemented for countries in the WHO European Region. The healthcare worker practice in the country since public share of total PHC spending was only 2001. Furthermore, during the assessment, 11 percent in 2018. The package of the state- there was no registry of qualified workforce funded medical care and services provided by for PHC or healthcare in general. PHC facilities is defined in The State Health Until May 2023, facility licensing happened only Target Programs for 2021. The package once when a PHC facility opened or extended includes the majority of preventive services, its scope of care. The Licensing Agency of the including immunizations, some specialist MoH carried out the procedures of medical consultations, laboratory tests, and some care licensing, license renewal, suspension diagnostic services. Though the government and termination, and medicines legislation, for covers the PHC service for the entire all medical institutions and pharmacies in the population, most of them have limited coverage country. Following this, the Health and Labor for outpatient medicines and diagnostics, Inspectorate conducted inspections of PHC leading to high out-of-pocket payments. facilities and checked the minimum technical The assessment revealed that those with standards; for example, if the facility met the full state coverage receive the necessary mandatory licensing requirements in terms of diagnostic services, while those who are equipment, personnel, and documents. This not covered discontinue care. Moreover, the process followed Law HO-193, which was unwillingness to add a financial burden on the recently updated to transition from termless patient results in physicians avoiding referring licensing to licensing with a five-year term. these individuals to undergo other necessary diagnostic testing and/or levels of care. The National Institute of Health, in collaboration with the Outpatient Healthcare In addition, provider remuneration is low Policy Department of the Ministry of and contracting of PHC services does not Health, is responsible for the development reward better quality. The main PHC provider of clinical guidelines for different health payment mechanism is per capita funding with conditions, including communicable and non- supplementary performance-based financing communicable diseases. However, there (PBF) for PHC providers, which rewards is no systematic procedure that supports improvements in service coverage for 27 continuous monitoring of healthcare provider indicators, including screenings for NCD. compliance with clinical guidelines. In addition, However, the payments for these discrete PHC facilities lack other quality standards of indicators are quantifiable and are not linked to care such as accreditation and assessment improvements in quality. Under the per capita of the clinical quality of care, adverse event mechanism, PHC facilities receive a fixed reporting, safety protocols and safety annual amount for each enrolled patient. The checklists, and clinical decision-support tools. low reimbursement levels of PHC providers contribute to informal co-payments. - 11 - Armenia PHC Assessment Report POLICY RECOMMENDATIONS To address the constraints to delivering effective primary healthcare in Armenia and consequently strengthen the health system’s response to the growing burden of NCDs, reforms are recommended in three main directions: 1) interventions to improve access to PHC, 2) interventions to improve the quality of PHC and 3) mechanisms to support effective PHC governance. INTERVENTIONS TO IMPROVE THE QUALITY OF PHC RECOMMENDATION 1 (short-term measures)։ Enhance demand-side interventions targeting underserved groups, particularly low-income households and adolescents, by implementing a range of strategies. These may include both financial and non-financial incentives, such as targeted messaging, monetary rewards, and the establishment of adolescent-friendly clinics, to effectively boost utilization rates, e.g., the World Bank-co-funded Disease Prevention and Control Project increased screening by 15 and 32 percentage points, respectively, with targeted messaging and financial rewards. RECOMMENDATION 2 (short-term measures)։ Increase investments in a strong and skilled rural PHC workforce, through targeted public budget programs that finance higher salaries, bonuses, and subsidies for living costs; targeted admissions of students from rural backgrounds; and introduce rural health topics and practicum into medical school training. RECOMMENDATION 3 (medium and long-term measures)։ Progressively increase public spending on PHC to cover a package of essential outpatient medicines for prevalent NCDs (hypertension, diabetes, CVD, cancers) and ensure services are reimbursed at appropriate prices. Medicine inclusion and prices should be informed by evidence-based Health Technology Assessments and broad stakeholder consultations. RECOMMENDATION 4 (medium and long-term measures)։ Increasing incentives for rural practice by investing in rural infrastructure and services and introducing education subsidies for health workers who agree to return to rural services. - 12 - Armenia PHC Assessment Report INTERVENTIONS TO IMPROVE ACCESS TO PHC RECOMMENDATION 5 (short-term measures)։ Revise the providers’ reimbursement rates and performance-based contracting mechanisms to include quality (e.g., bonuses for achieving hypertension control in empaneled patients) and more access-oriented PB indicators, including public reporting of performance on quality to strengthen accountability. RECOMMENDATION 6 (short-term measures)։ Strengthen quality assurance at the facility level by introducing a mandatory skills-based training program for PHC facility management, including in finance, strategy, communications, quality, and operations. RECOMMENDATION 7 (medium and long-term measures)։ Improve diagnostic accuracy of PHC providers, as well as facilitate care integration and decision support for physicians, using targeted and high-quality training, clinical decision support tools, and clinical audits, (e.g., ArMed can include algorithms that flag probable diagnoses from patient data; charts can be randomly sampled and assessed for accuracy), and develop integrated pathways, especially for high prevalent NCDs. RECOMMENDATION 8 (medium and long-term measures)։ Improve integrated care by boosting multidisciplinary teams in the model of care delivery in the new PHC reforms plan for Armenia, as well as creating mechanisms to promote communication and teamwork between healthcare providers in PHC and other levels of care. RECOMMENDATION 9 (short and medium-term measures)։ Strengthen rural PHC infrastructure and equipment, including emergency transportation (vehicles, drivers, and maintenance costs); communication equipment (such as mobile or landline phones); gender-based and accessible toilets; and diagnostic supplies for prevalent NCDs, such as blood glucose tests, urine protein, and glucose dipsticks. RECOMMENDATION 10 (medium and long-term measures)։ Implement an interconnected and interoperable electronic healthcare system throughout medical facilities on all levels (tertiary, secondary, diagnostic). This would help overcome the main barriers connected with the transfer of information regarding medical services provided to patients by reducing the human factor of error. RECOMMENDATION 11 (medium and long-term measures)։ Expand the recently updated licensing program for PHC facilities to encompass all essential PHC services. This will ensure a compulsory, transparent, and quality-based regulation of patient health and safety. - 13 - Armenia PHC Assessment Report MECHANISMS TO SUPPORT EFFECTIVE PHC GOVERNANCE THAT WILL CREATE AN ENABLING ENVIRONMENT FOR PHC IMPROVEMENT RECOMMENDATION 12 (short-term measures)։ Develop a national health facility master plan that specifies targets for facility density at different levels, required enhanced equipment and supplies, and the necessary health worker distribution, to respond to the projected service user needs and reduce hospital-centric service delivery. RECOMMENDATION 13 (short-term measures)։ Develop and periodically update an evidence-based and costed PHC strategy, drawing on stakeholder engagement, that serves as a roadmap to address priority challenges to providing effective PHC, that includes a plan to finance key investments in infrastructure, benefits coverage, human resources, etc. RECOMMENDATION 14 (short-term measures)։ Ensure the operational functionality of the established PHC task force by convening regular meetings and fostering active participation. This initiative is integral to effectively managing and enhancing the overall strength of primary healthcare services. RECOMMENDATION 15 (short-term measures)։ Stop reimbursing PHC-manageable conditions at the hospital level and train PHC providers to manage these conditions, adjusting their reimbursement levels to reflect the additional scope of work. Ensure a proper data system to track, monitor, and report regularly on the process. - 14 - CHAPTER 1 Introduction Armenia PHC Assessment Report THE ECONOMIC, SOCIAL, led to the emergence of Nikol Pashinyan, a AND POLITICAL CONTEXT member of the opposition group as the prime OF ARMENIA minister, with a commitment to reducing poverty and investing in human capital.4 In the -1- most recent Government Program for 2022- The Republic of Armenia is the smallest of 2026, adopted by a government decision on the Caucasus nations, covering an area August 18, 2022, the government highlighted of just under 30,000 km.2 The country is the importance of a stable democratic bordered in the South by Iran, in the East environment for continuity in investments to by Azerbaijan, in the North by Georgia, and improve the welfare of citizens.5 Among other the West by Turkiye.1 Administratively, the priorities, the section on healthcare in the country is divided into ten provinces (marzes) Government Program highlights the priority and Yerevan, the capital, where each marz is of strengthening health service delivery in the a self-governing state and consists of urban country.5 and rural communities.2 Armenia is an upper- -3- middle-income (UMI) country with a GDP per capita of US$ 4,623 (Table 1). Robust Armenia’s demographic structure has fiscal rules with disciplined borrowing, sound important implications for the government’s financial sector oversight, and pro-competition ability to mobilize revenue for human capital reforms have helped Armenia weather the twin spending, as well as for trends in social needs economic crises brought on by COVID-19 and in the population. In 2019, the population was the regional conflict. Government mitigation about 2.9 million, of whom 63 percent lived measures helped shield both households in urban areas.6 Over the past few decades, and firms, limiting the increase in poverty the total population has been on the decline, to 0.6 percentage points. The economy has having fallen from 3.54 million in 1990.7 In recovered since; GDP increased by 12.6 2020, the annual population change was percent in 2022, fueled by the inflow of 0.2 percent.8 The key contributors to this people and money transfers, and a re-routing trend are changes in total fertility rate, net of trade flows. In 2023, while the inflow of migration, and an aging population. Since money transfers started to gradually taper off, 1990, Armenia has continued to experience economic growth exceeded expectations and significantly negative net migration, with is projected to remain robust above 7 percent. significant emigration to the Russian Federation, United States of America, and -2- Ukraine.9 Total fertility rates have also fallen Since gaining independence from the Soviet from 2.5 births in 1990 to 1.8 in 2020, which Union in the early 1990s, Armenia has is below the replacement rate.10 Furthermore, undergone significant political shifts. The post- the proportion of the population aged 65 and independence challenges were characterized older is 11 percent and rising.11 An aging by socioeconomic polarization in society, population and emigration of the working-age protests by citizens over the performance of population will increase the need for health the economy, and a lack of accountability in and long-term care while reducing the ability political offices.3 In 2018, the Velvet Revolution of the government to mobilize revenue via direct taxes. Armenia’s total healthcare cost - 16 - Armenia PHC Assessment Report relative to Gross Domestic Product (GDP) (12 percent) is among the highest in the European and Central Asia Region but, as shown in the following section, out-of-pocket spending has consistently accounted for the highest share of current health spending. Table 2. National Health Indicators in Armenia and comparator countries in 2019 Total General Current 65+ Net fertility Urban GDP per Govt. Exp. Health Popula- population, emigra- rate, population, capita as a % Exp, as a tion % of total tion births per % of total (US$) of GDP % of GDP (million) population rate woman population Armenia 4,623 25 11 2.9 11 -24,989 1.8 63 Azerbaijan 4,782 33 4 10 6 6,002 1.8 56 Belarus 6,814 38 6 9.4 15 43,648 1.4 79 Croatia 14,904 47 7 4.1 21 -40,004 1.5 57 Estonia 23,755 39 7 1.3 20 19,555 1.7 69 Georgia 4,373 29 7 3.7 15 - 50,000 2.1 59 Kazakhstan 9,793 20 3 18.5 8 -90,000 2.9 58 Kyrgyz 1,383 33 4 6.5 5 -20,000 3.3 37 Republic Russian 11,568 34 6 144.4 15 912,279 1.5 75 Federation Tajikistan 871 29 7 9.3 3 -99,999 3.6 27 Türkiye 9,127 36 4 83.4 9 1,419,610 2.1 76 Turkmenistan 7,612 14 7 5.9 5 -24,001 2.7 52 Ukraine 3,496 41 7 43.8 17 55,001 1.2 69 Uzbekistan 1,755 28 6 34.9 5 -44,314 2.8 50 Source: WHO Global Health Expenditure Database, World Bank Open Data which is consistently high compared to that of THE HEALTH AND neighboring Caucasus countries - Georgia and ECONOMIC BURDEN OF Azerbaijan (Figure 1),12 increased from 73.1 to DISEASE IN ARMENIA 75.2 years from 2009 to 2019, corresponding to an average annual rate of +0.14 percent.12 -4- However, it is slightly below the average In recent decades, Armenia’s public health life expectancy at birth (76 years) in upper- indicators have shown slow but steady middle-income countries (UMI).13 Similarly, improvements. Life expectancy at birth, the healthy life expectancy increased from - 17 - Armenia PHC Assessment Report 66.3 to 67.1 years between 2005 and 2019.14 Figure 1: Life expectancy at birth in Caucasus The increases in life expectancy at birth and countries from 2009 to 2019 (years) healthy life expectancy reflect the increases in 76 child survival in Armenia, owing to increased 75 74 household welfare and improved access 73 to care. For example, the infant mortality 72 rate decreased from 16 to 10 per 1,000 live 71 births within ten years.15 However, the gap 70 between life expectancy at birth and healthy 69 life expectancy (Figure 2) reflects the high 68 and growing incidence of non-communicable 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Armenia Azerbaijan Georgia Russia diseases (NCD), and, thus, unhealthy life years discussed below. Source: Statista 2022 -5- Figure 2: Life expectancy and Health life expectancy at birth in Armenia NCDs continue to be one of Armenia’s top from 2000 to 2019 (years) public health issues. According to World 78 Health Organization (WHO) estimates, 75 the premature mortality rate of individuals 72 aged 30–69 years for four major NCDs 69 (cardiovascular diseases, diabetes, chronic 66 respiratory diseases, and cancer) was 63 60 470.22 per 100,000 in 2016, which is above 2000 2010 2015 2019 the average of 380 per 100,000 in the WHO Life expectancy at birth Healthy life expectancy at birth European Region.16 Armenians have a 19.9 Source: World Health Organization 2020 percent chance of dying before the age of 70 from one of these four most common NCDs17. only 0.1 percent of women consume alcohol This is above the global average of 17.8 regularly. The same survey revealed that 20 percent and the European average of 16.3 percent of adults are insufficiently active. Salt percent (Figure 3). However, this mortality rate consumption is estimated to be about twice is below the levels seen in Azerbaijan 27.2 the WHO-recommended consumption level. percent, Georgia 24.9 percent, and Russia One-third of adults are believed to oversalt 24.2 percent17. This high prevalence of NCDs their food habitually.19 The high prevalence of in Armenia is driven by behavioral risk factors, exposure to behavioral risks points to gaps in such as tobacco and alcohol consumption, the implementation of population public health physical inactivity, and salt intake, which have measures and essential healthcare services all increased in recent years. According to the that promote prevention. 2016 STEP-wise approach to surveillance -6- (STEPS) survey, 51.5 percent of men in Armenia use tobacco.18 Alcohol consumption NCDs also have a significant negative impact has also been gradually rising, although not on a country’s economy. Experts estimate that alarmingly so: about 11 percent of men and every 10 percent increase in NCD mortality causes a 0.5 percent reduction of economic - 18 - Armenia PHC Assessment Report growth, on average, globally.20 The greatest Figure 3: Probability (%) of dying between effects are experienced by low- and middle- ages 30 and 70 from any cardiovascular income countries, and poorer households.20 In disease, cancer, diabetes, or chronic respiratory in 2019 Armenia, the estimated economic losses from NCDs amount to nearly US$9 billion (362.7 billion AMD) annually, which corresponds to 6.5 percent of Armenia’s (GDP).21 The burden of NCDs also has negative implications for 27.2 24.9 24.2 human capital development, with increasing 17.8 16.3 19.9 14.8 premature mortality and reducing productivity of the workforce. The human capital index WHO Global average European region Armenia Azerbaijan Georgia Iran Russia of Armenia in pre-pandemic 2020 was 0.58, meaning that a child born in Armenia was statistically predicted to grow up to be only 58 percent as productive as they could have been if raised under ideal health and Source: World Health Organization 2021 educational conditions.22 This score is similar to that of neighboring countries (Georgia: complications and deaths.27 Therefore, it is 0.57, Azerbaijan: 0.58), but is below average urgent and imperative to invest in reducing compared to Europe and Central Asia (0.69).23 the burden of NCDs. This would not only save lives and promote economic growth but would -7- also strengthen the country’s preparedness Failure to reduce the burden of NCDs also for health security and resilience to respond puts populations, health systems, and to future pandemics.28 economies at increased risk of major impacts from future pandemics.24 For instance, PRIMARY HEALTHCARE: individuals who suffer from one or more THE FOUNDATION OF NCD conditions, including hypertension, A STRONG HEALTH cardiovascular disease, diabetes, chronic SYSTEM lung disease, kidney disease, and obesity, -8- have an increased risk of contracting a severe Primary healthcare (PHC) is the most case of COVID-19.25 In addition, people inclusive, equitable, and efficient approach living with NCDs face additional challenges to organizing and strengthening healthcare in meeting their healthcare needs, given the systems for universal health coverage and reduced access to services attributed to the health security, and for mounting a robust preventive measures against COVID-19. response to NCDs through prevention and For example, an assessment in Armenia control.29 When appropriately resourced and revealed that during the pandemic, public fear planned, PHC can effectively meet up to 90 and the pandemic restrictions disrupted the percent of a person’s health needs throughout regular services at the PHC level including for their lifetime by providing a comprehensive NCDs.26 The provision of services to people range of services – from health promotion and living with NCDs were significantly affected, prevention to treatment and palliative care with increases in the incidence of preventable - 19 - Armenia PHC Assessment Report – in a continuous, integrated, and people- align with agreed objectives and targets.35 centered manner, thus reducing NCD- In addition, this needs to be supported by related hospitalizations and mortalities.30,31 sustained high-level political commitment For example, empirical studies show that in and leadership, strong governance, adequate countries where patients have continuous financing, and ongoing engagement of the relationships with their PHC providers, the rates community and other stakeholders.29 of avoidable diabetes-related hospitalizations are lower.32 Moreover, PHC can empower PRIMARY HEALTHCARE people and communities to optimize their IN ARMENIA health by promoting health literacy, supporting -9- caregivers and encouraging self-care.33 While As a post-Soviet country, Armenia inherited effective PHC systems are a key component the Semashko model of primary healthcare of high-performing healthcare systems in the which was characterized by the dominance of absence of crisis, the recent pandemic and publicly owned medical facilities (polyclinics). disruption in the provision of essential health The first generation of service delivery reforms services brought PHC into a keen interest took place following Armenia’s independence globally.32 It highlighted that investing in PHC in 1991. This was subsequently followed as the frontline of routine services and outbreak by a specific focus on PHC strengthening response can prevent the economy from which began in 1995. To increase the quality dramatic consequences and help the country and effectiveness of PHC, the concept of to respond to pandemics in a faster and more “family medicine” was introduced in Armenia effective way.31 For example, well-organized as a part of these reforms, and training and PHC systems, while playing an instrumental retraining programs for family physicians role in responding to the pandemic, have the and nurses were launched. Currently, in potential to continue the provision of essential Armenia, PHC refers to services delivered in health services without interruption, including an outpatient setting, which form the basis of reproductive, maternal and childcare, and medical care and include primary, secondary, management of communicable and non- and tertiary prevention and diagnosis of communicable diseases.34 Moreover, PHC diseases, management of pregnancy, as well not only contributes to the direct organization as raising awareness of healthy lifestyles and and implementation of immunizations against anti-epidemic activities.36 Facilities offering the virus but can also provide communities primary healthcare must hold the appropriate with accurate information on the safety license for outpatient medical care and can and effectiveness of COVID-19 vaccines.34 operate as a public or private entity. Several Finally, PHC providers and systems can categories of PHC facilities provide services identify, manage, and monitor most cases guaranteed by the Republic of Armenia and of COVID-19, which in turn reduces the have an enrolled population. These include: burden on hospitals.29 Ensuring the ongoing 1) polyclinic units of medical centers and effectiveness of PHC is a continuous and health centers, 2) polyclinics, 3) primary iterative process of improvement that requires healthcare centers, and 4) rural ambulatories countries to assess PHC performance and health centers. Feldsher-akusher posts systematically to ensure that priority actions (FAPs) are health posts that are considered - 20 - Armenia PHC Assessment Report a part of these PHC facilities but only employ all Armenian citizens, with co-payments for mid-level staff (nurse, feldsher, midwives). some services and exemptions or reduced The workforce responsible for providing co-payments for the poor and vulnerable. The PHC services varies in different facilities and BBP covers essential outpatient medicines may include internists, pediatricians, family (e.g., antihypertensive, insulin), those that are doctors, and nurses.36 In Armenia, however, a fundamental component for the prevalent the term primary healthcare is often defined NCD management, and full or partially state- as the facility in which services are delivered, funded diagnostic and inpatient services for rather than by the actual type of provider or a small portion of the population, including services, themselves. This means that some people with disability and socially vulnerable of the sub-specialists (e.g., endocrinologists, individuals. Among these groups, a PHC cardiologists, gynecologists) at the polyclinics facility serves as a gatekeeper for referrals are considered to be primary care providers. to specialist care. Nevertheless, the rest of They often complement the internists and the population can access hospitals and family medicine physicians (family doctors) specialized care on demand by paying who, due to either professional or practical out of pocket, thus bypassing the national limitations, have limited scopes of practice. PHC system. An estimated 67 percent of It is important to note that for the purpose of sick people do not visit PHC for advice or this report, the primary care providers were treatment, in part, due to perceptions of considered to be internists, pediatricians, poor quality at the PHC level.38 Indeed, family doctors, and nurses (Appendix 1). most of the Armenian population considers the quality of care provided by the national - 10 - PHC to be poor,39 which contributes to the There are multiple challenges to providing common practice of bypassing the PHC effective PHC in Armenia. Total health to obtain specialist care. As a result, PHC expenditures in 2017 amounted to 10.4 remains underutilized. In 2017, for example, percent of GDP, or approximately US$ the average number of PHC visits in Armenia 408 per capita, whereas public healthcare was 4.1,40 which is substantially lower than financing of only 1.6-1.67 percent of GDP has the average of 7.6 within the WHO European been the lowest in the region for decades. Region41 (Figure 4). In addition, the utilization Out-of-pocket payments for healthcare have of ambulance services in Armenia is one of historically been extremely high in Armenia, the highest in the world.42 The ambulance reaching 85 percent in 2019, and presenting service receives approximately 600 calls per financial barriers to healthcare access, day, of which only 25 percent are considered including at the primary level.37 The low public true emergencies.42 Literature suggests that financing for health has negative implications emergency ambulances are often used for for coverage, including at the PHC level. problems that could be managed in primary Since 2006, the Government has financed care.43 a Basic Benefit Package (BBP) that covers PHC services (including services of a general - 11 - practitioner/family doctor, pediatrician, and Nevertheless, better access to healthcare sub-specialists) and emergency services for is unlikely to improve health outcomes if the quality of that care is poor.44 A recent - 21 - Armenia PHC Assessment Report systematic review conducted to estimate quality of delivered care, and efficient public the proportion of deaths in low- and middle- expenditure. In this context, special attention income countries due to poor quality of care has been given to ensuring the readiness versus non-utilization of care found that nearly of service providers, including at PHC level, 8 million people die every year due to a lack to deliver high-quality services as a pre- of access to high-quality care.45 In Armenia, requisite for achieving improved health the share of the annual amenable deaths (of outcomes. These discussions follow a three- 3,996) due to poor quality was estimated to be year engagement between the WBG and the 53 percent.45 Therefore, the provision of high- MoH, during which a Steering Committee was quality primary care is essential for managing established to serve as a platform for inter- NCDs and reducing mortality rates in Armenia. institutional policy dialogue on PHC in Armenia As the Lancet Global Health Commission on and to build momentum for PHC reform. financing argues, to drive improvements in PHC service delivery, and to make it function - 13 - effectively, countries need to both invest more To support these reforms, the MoH and invest better in PHC.31 requested the WBG and GAVI, the Vaccine Alliance to provide technical assistance Figure 4. PHC visits per capita per year and recommendations for improving the in Armenia performance of the PHC system and 9,0 integration of service delivery, with a particular 8,0 7,8 emphasis on the PHC system’s response to 7,0 the growing burden of NCDs, as part of broader 6,0 efforts towards the design of UHC reforms 5,0 4,8 4,0 3,8 4,0 4,2 in Armenia. More details are presented in 3,3 3,0 2,8 3,4 3,6 4,0 4,1 4,1 Appendices 1-4. In response to the MoH’s 2,4 2,0 1,9 2,8 request, the WBG’s technical assistance 2,1 2,0 2,1 1,0 1,8 aimed to: 1) provide a baseline of current 0,0 PHC performance, understand the strengths 1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 and weaknesses of the PHC system, and Source: Armenia health system performance assessment, where to target initiatives for improvement; 2018. 2) identify and understand variation in PHC performance, especially in terms of quality, between facilities in urban and rural areas and MOVING TOWARDS UNIVERSAL in Yerevan; and 3) assess care integration HEALTH COVERAGE IN ARMENIA among health services at different levels of THROUGH STRONGER PRIMARY care. Four key assessment studies were HEALTHCARE undertaken to support these aims (Figure 5): 1) the SDI survey to measure quality and - 12 - capacity of PHC facilities across the country The MoH has initiated policy discussions on through a nationally representative survey of UHC reforms in the country, as an integrated over 300 facilities; 2) the Vital Signs Profile, the solution for financial risk protection of the core tool of the PHCPI, to provide a snapshot population along with improvement of access, - 22 - Armenia PHC Assessment Report of a PHC system across four pillars: financing, care; and 4) an assessment of Ambulatory capacity, performance, and equity; 3) Vertical Care Sensitive Conditions to examine what Integration Diagnostic and Readiness Tool to proportion of uncomplicated care is managed assess linkages between PHC and hospital at the PHC level. Figure 5. The Primary Healthcare Assessment Studies in Armenia SERVICE DELIVERY INDICATORS VITAL SIGNS PROFILE A national survey of capacity in A snapshot of PHC financing, over 300 PHC facilities capacity, performance, equity VERTICAL INTEGRATION TOOL AMBULATORY CARE SENSITIVE CONDITIONS Assessing linkages between PHC and hospital care Examining if all uncomplicated care is managed in PHC Source: Authors of the report INFORMING PRIMARY integrated health services), which, in turn, affect HEALTHCARE improved outcomes for UHC, such as service IMPROVEMENT THROUGH coverage and financial protection.35 Within the BETTER DATA WHO-UNICEF framework, particular attention was given to the PHCPI framework, which - 14 - differs from other frameworks due to its focus The WHO-UNICEF PHC measurement on service delivery processes. Specifically, conceptual framework, which builds on service delivery is examined across four areas: several established global and regional access, availability of effective PHC services, health systems strengthening, primary people-centered care and organization and healthcare, and universal health coverage management. frameworks guided the early design of Armenia’s PHC performance assessment. The framework incorporates the key concepts and measurement domains of PHC covering 14 levers of PHC (Figure 6).35 It illustrates how investments in key elements of PHC: structures and inputs, such as governance, health workforce, and financing can lead to improved performance of PHC processes and outputs (e.g., access, utilization, and quality of - 23 - Armenia PHC Assessment Report Figure 6. WHO-UNICEF PHC monitoring conceptual framework HEALTH SYSTEM DETERMINANTS SERVICE DELIVERY STRUCTURES INPUTS PROCESSES OUTPUTS Governance Physical infrastructure Models of care Health workforce Systems for improving Access and availability Adjustment to Medicine quality population needs Quality care Health information Resilient health Financing system facilities and services Source: World Health Organization and the United Nations Children’s Fund (UNICEF), 2022 - 15 - understand where and how PHC facilities can The WHO-UNICEF framework was then deliver more effective care. further adapted to focus on four key - 16 - determinants of effective PHC systems relevant to the Armenian context: 1) inputs The remainder of the report, including with adequate infrastructure, workforce recommendations for improving the and supplies; 2) financing with sufficient effectiveness of PHC, will be structured around and strategic allocation of PHC funding; these four determinants and is outlined as 3) governance and effective leadership follows: Chapter 2 presents the effectiveness which is based on collaborative and data- of PHC (equitable access and quality) in driven decision-making; and 4) processes, Armenia, the next three chapters discuss the which include effective organization and current capacity of PHC in Armenia across management at facility level and linkages to three areas: inputs (health workforce, facility other levels of care (Figure 7), with the idea infrastructure, equipment, and supplies) being that targeted investments in these areas, (Chapter 3); processes (organization and informed by data and evidence, can improve management, including the integration of the effectiveness of PHC to respond to NCDs service delivery) (Chapter 4); and structures and support efforts to improve universal (governance, collaboration, and data-driven access to quality care. It should be noted that decision-making) (Chapter 5). The report the indicators used for data collection within concludes with a summary of findings from these four focus areas, taken alone, do not the assessment and recommendations reflect the capacity of PHC to deliver effective categorized into short-, medium-, and long- care. The State Health Target Program, term time horizons (Chapter 6). The target which articulates what services should be audiences for this report are policymakers, available at PHC facilities – together with an vested stakeholders, and senior technical assessment of health facility capacity and staff involved in determining service delivery patient perspectives of constraints/barriers to policies. accessing quality care – is needed to better - 24 - Armenia PHC Assessment Report Figure 7. Adapted PHC framework for the Armenian context EFFECTIVE PHC EQUITABLE ACCESS QUALITY CARE INPUTS FINANCING GOVERNANCE PROCESSES Adequacy of PHC Sufficiency and Effective PHC Effective PHC infrastructure, work strategic allocation of leadership and organization and force, supplies, and data PHC funding collaborative and data- linkages to other care driven decision-making Source: Authors’ adaptation of the WHO-UNICEF framework - 25 - CHAPTER 2 Enhancing effectiveness of Armenia’s PHC Armenia PHC Assessment Report - 17 - WHO to be an appropriate catchment area An overarching goal for health systems is around a PHC facility.35 In Yerevan and urban equity in health, which is defined as where areas, the average time to reach the nearest “everyone has a fair opportunity to attain PHC facility from home is about 15 minutes, their full health potential and that no one and about 10 minutes in rural areas (Figure should be disadvantaged from achieving this 8). potential because of their social, economic, Figure 8. Average time to reach PHC facility demographic or geographic circumstances.”30 from home by regions (minutes), mean Multiple factors can contribute to inequity in access to quality care and health outcomes, Total 13,8 including “the social determinants of health, Rural 10,2 stigma, and discrimination, as well as the settings in which people live and work.”46 At Urban 15,3 the service delivery level, inequity in access Yerevan 15,5 to care can be influenced by various supply- side dimensions including the approachability, Source: SDI Patients Survey 2022 acceptability, availability/accommodation, affordability, and appropriateness of health - 20 - services.47 PHC, through its focus on However, despite PHC facilities being located empowering people and communities, multi- close to where people live, utilization is sectoral policy and action, and due to its generally low, particularly among certain proximity to communities, is well positioned population groups. The Health System to improve access to care, particularly for the Performance Assessment 2022 (household most vulnerable population groups.29 survey) showed that within the last 12 months, - 18 - 32 percent of people had visited their PHC facility on average (Figure 9) in Armenia. A Despite close geographical access to PHC lower number of visits to PHC within the last facilities, overall PHC utilization is low 12 months was reported by adolescents aged with some differences across age groups, 15-19 years old (18.7 percent) compared to locations, and wealth quintiles; the low rate is other population age groups (23.0 percent - driven by concerns about the unavailability of 39.6 percent), which can be explained by the services, their quality, and cost. fact that this population group is relatively healthier and has less need and demand for - 19 - services; by Yerevan residents (29.4 percent) The assessment revealed that overall, compared to rural (30.8 percent) and other Armenians have excellent geographical urban areas (34.2 percent); and by households access to PHC facilities. The average in the lowest two wealth quintiles (29.3 percent Armenian is within 14 minutes of a PHC facility, – 31 percent) compared to the highest three and closer in rural areas. The vast majority wealth quintile groups (34 percent - 35.2 of Armenians travel less than one hour by percent) (Figure 10). Differences in PHC preferred method to arrive at a PHC facility, utilization within the last 12 months were also with one hour (or 5 km) being considered by observed between females (36.5 percent) - 27 - Armenia PHC Assessment Report and males (25.3 percent). - 21 - Figure 9. The proportion of people who had While unavailable services are the main seen their PHC provider during barrier to PHC use, the cost of services is the last 12 months also a challenge among the poor. During the SDI survey, patients at PHC facilities were asked if they needed healthcare during 68,10% the last 12 months but did not visit the PHC, 31,40% and to provide reasons for this. The main 0,50% drivers of underutilization among those who No Yes Unknown reported not obtaining needed healthcare Source: Health System Performance Assessment 2022 were the unavailability of services (15.1 percent), concerns about the quality of care Figure 10. Proportion of people who visited a (10.8 percent), and the cost of services (8.2 PHC doctor within the past 12 months percent). Interestingly, the unavailability by different demographic groups of services was more frequently cited by patients in Yerevan (27.4 percent) and least Place of res. Yer. 29,40% City 34,20% frequently cited by patients in urban areas Vil. 30,80% (5.6 percent). Meanwhile, across all areas, the most commonly mentioned barrier to Gender 36,50% F PHC use was a lack of time (Figure 11). Cited M 25,30% barriers between males and females had a similar distribution (Figure 12). However, it is Below Sec. 31,60% Level worth mentioning that the survey respondents Education Sec. 31,10% reporting these barriers were patients and Voc. 33,40% Incomplete visitors who accessed the facility (for more HE 27,90% HE 31,30% details about the patients’ survey methodology see Appendix 2). This means that the actual scale of the barriers might be underestimated Quintile of welfare I 34,80% II 35,20% as the survey missed to capture the perception III 34,00% of the population who do not visit the PHC at IV 29,30% all. V 31,00% 15-19 18,70% 20-34 23,00% Age 35-49 29,10% 50-64 41,80% 65+ 39,60% Source: Health System Performance Assessment 2022 - 28 - Armenia PHC Assessment Report Figure 11. Barriers for not visiting a PHC comprehensiveness, and people- facility by place of residence (% of patients) centeredness of services.48 Delivering quality care means ensuring that care is evidence- 49.3 53.0 based and adheres to established standards; 56.0 64.3 that waste is minimized and the capacity to deliver care is maximized; and that harm 6.3 15.9 10.8 3.4 5.0 19.3 is avoided in the delivery of care. Primary 4.0 1.7 8.2 11.0 9.5 healthcare, through its focus on integrated 3.5 12.1 5.2 27.4 15.1 2.0 11.3 health services, empowering people and 5.6 Total Yerevan Urban Rural communities, and with its emphasis on Service not available Distance to facility primary level care, is well positioned to ensure Cost Concern about quality of care that quality care is provided at the right time, Did not feel the need Did not have time in the right place, and in the right way to keep Source: SDI Patients Survey 2022 people healthy and free of illness.29 Figure 12. Barriers to not visiting a PHC - 24 - facility by gender (% of patients) The assessment revealed that a large number of Armenians receive costly curative care in hospitals that could, otherwise, have been 51.7 56.1 managed by primary healthcare. 67.3 - 25 - 6.7 6.3 12.0 WHO developed Ambulatory Care Sensitive 10.8 5.4 8.2 7.5 2.9 10.3 Conditions (ACSCs) as a marker of healthcare 3.5 3.8 2.7 15.1 14.3 15.4 system performance quality and effectiveness. ACSCs are defined as all PHC-manageable Total Male Female Service not available Distance to facility health conditions during which hospitalization Cost Concern about quality of care can be avoided in case of proper management Did not feel the need Did not have time and treatment at the PHC level. The list Source: SDI Patients Survey 2022 of ACSCs can be divided into three main groups: 1) Acute conditions - cases when - 22 - the hospitalization was done due to an acute Primary healthcare tends to be bypassed in condition requiring specialized hospital care (e.g., acute peptic ulcer with both hemorrhage favor of curative care in hospitals and, when and perforation (K27.2)); 2) Chronic conditions care is provided at PHC level, diagnostic - cases of patients with some chronic illness accuracy averages only 44 percent. that were hospitalized at the secondary or - 23 - tertiary care level due to inappropriate care at the primary care level (e.g., diabetic foot ulcer Quality care is safe, effective, efficient, timely, (E11.6)); 3) Preventable conditions – primarily and integrated, and takes into account the key cases which could have been prevented, attributes of patient experience including first for instance, by vaccines, but have been contact accessibility, continuity, coordination, - 29 - Armenia PHC Assessment Report hospitalized because of the insufficient primary varies significantly among PHC providers care coverage (e.g., measles complicated by in Yerevan (71 percent) compared to those otitis media (B05.3)). The analysis of data in in urban (85 percent) and rural facilities (88 Armenia showed that between 2017 and 2020, percent) (Figure 14). Internists and family over 18 million visits were served under the doctors correctly diagnosed 79 percent and Basic Benefit Package (BBP), which costed 85 percent of the assigned conditions, while over 285 billion AMD. Of these visits, over two pediatricians could accurately diagnose 68 million visits (11 percent) were patients with percent of conditions. ACSCs (costed ~29 billion AMD). Only about 36 percent of the aforementioned ACSCs Figure 14. Diagnostic accuracy observed were served in the PHC facilities (costed via clinical vignettes and simulated patients among PHC providers facility location and ~1,8 billion AMD). The remaining 64 percent provider position (% of providers) of ACSC visits were registered in hospitals of which 77 percent went to full hospitalization and the rest received outpatient care (Figure 13). As a result, between 2017 and 2020, ~ 80.4% 71.5% 84.8% 88.2% 78.6% 85.2% 68.5% 27 billion AMD was reimbursed for hospital services that could have been managed by PHC. Internist/GP Average Yerevan Urban Rural Pediatrician Family Doctor Figure 13. BBP visits due to ACSC conditions between 2017-2020 (N of visits) Source: SDI Providers Survey 2022 1,017,347 (50%) 736,236 - 27 - (32.6%) 279,123 In addition, the diagnostic accuracy rate (13.7%) Inpatient Visit Outpatient Visit Primary Care varied across case conditions, ranging to Hospital to Hospital Visit from 99 percent accuracy for diabetes to Source: Analysis of Ambulatory Care Sensitive 17 percent for anemia with stunting (Figure Conditions 2022 15). Hypertension and type 2 diabetes were correctly diagnosed by most providers (84 - 26 - percent and 99 percent, respectively), in However, the assessment found that contrast to other cases that were significantly when care is received in PHC facilities, lower: pulmonary drug resistant TB – 61 diagnostic accuracy is not high, especially percent, anemia with stunting –17 percent when delivered by pediatricians and PHC and depression – 69 percent. providers in Yerevan. The percentage of cases correctly diagnosed based on the number of simulated patients assessed by PHC providers (internists, pediatricians, family doctors) through clinical vignettes overall was about 80 percent. Accuracy of diagnosis - 30 - Armenia PHC Assessment Report Figure 15. Diagnostic accuracy observed via Figure 16. Adherence to internationally clinical vignettes and simulated patients accepted clinical standards for patient among PHC providers by care conditions examination and history taking by providers (% of correctly diagnosed conditions) location (% providers) 98.8% 84.0% 42.7% 79.4% 79.8% 68.7% 33.0% 30.4% 33.1% 31.5% 60.6% 25.7% 17.4% Diabetes type 2 DST TB Pneumonia Moderate depression Hypertension, Obesity and Anemia and moderate stunting Pulmonary Hyperlipidemia Diarrhea with severe dehydration Average Yerevan Urban Rural Public Private Source: SDI Providers Survey 2022 - 30 - Source: SDI Providers Survey 2022 An additional factor that could potentially - 28 - contribute to poor diagnostic accuracy is Moreover, following a diagnosis, less the limited availability of internationally than 35 percent of patients in Armenia recommended clinical guidelines at PHC initiate appropriate treatment.49 A recent facilities. All 28 required guidelines for the publication by Lancet indicates that only 23 management of different conditions were percent (men) and 33 percent (women) of available in only 34 percent of the facilities. diagnosed hypertension cases start treatment The availability of guidelines was less in rural in Armenia.49 facilities (23 percent) and higher in private (56 percent) than in public facilities (33 percent) - 29 - (Figure 17). The challenge with diagnostic accuracy is likely multifactorial and in part due to poor Figure 17. Availability of clinical guidelines in PHC facilities by facility location and adherence to internationally accepted ownership (% of facilities with all clinical standards for patient examination required guidelines) and history taking. Based on the clinical vignettes with simulated patients, provider adherence to international standards was found to be only 33 percent nationwide and 61.8% 63.3% was lower in Yerevan (26 percent) compared 56.3% to rural (30 percent) and other urban facilities 33.9% 32.8% 23.1% (43 percent). (Figure 16). There was no significant difference between public (33 Average Yerevan Urban Rural Public Private percent) and private (32 percent) facilities. Source: SDI Providers Survey 2022 - 31 - Armenia PHC Assessment Report - 31 - - 32 - Despite the challenges mentioned above, a These subjective perceptions of healthcare high share of surveyed patients expressed quality, however, do not match the assessed satisfaction with PHC providers. More than effectiveness of PHC. More on this is described 90 percent of patients from the SDI survey in the chapter below. stated they were satisfied with their providers’ skills and with the clear explanations and respectful communication they received from them (Figure 18). Moreover, the majority of patients were satisfied with most of the indicators reflecting the quality of PHC services. Around 88 percent of patients were satisfied with the overall quality of services they received at the PHC, and more than 80 percent of patients were satisfied with the attitude of staff, and the visual and auditory privacy they received at the facility (Figure 19). Figure 18. Patients’ satisfaction with the care they receive (% of patients) 93.2% 92.2% 91.6% Providers Providers provide Respectful skills clear explanation communication Source: SDI Patients Survey 2022 Figure 19. Patients’ satisfaction with quality indicators at PHC (% of patients) 94.4% 88.5% 85.1% 83.5% 76.2% 63.2% 54.5% Waiting time Visual privacy Auditory privacy Staff attitude Room conditions Facility infrastructure Overall quality Source: SDI Facility Survey 2022 - 32 - CHAPTER 3 The current capacity of Armenia’s PHC system (inputs): health workforce, infrastructure, equipment, and supplies Armenia PHC Assessment Report - 33 - - 36 - The availability and readiness of the health Similar to other countries in the WHO workforce, infrastructure, and supplies European region, there is a lower supply of are necessary conditions for PHC to PHC providers in rural areas,50,51 and nurses be effective.48 This includes the presence make up the largest occupational group.52 of basic foundations such as clean water, Approximately 61 percent of PHC providers reliable electricity, good hygiene, and safe are nurses, with the rest consisting of family waste disposal in healthcare facilities, as doctors (15 percent), internists (14 percent), well as reliable access to safe and effective and pediatricians (10 percent) (Figure 21). medicines, devices, and technologies. A The density and distribution of PHC providers trained, skilled, and motivated workforce vary across the country, with more nurses that is appropriately distributed, available in and fewer primary care physicians (internists, adequate numbers, and that is acceptable family doctors, and paediatricians) per 10,000 to people receiving care is also crucial for people in rural areas. Interestingly, when ensuring the presence and effective delivery including all PHC providers, i.e., combining the of care. number of physicians and nurses, the density of providers is higher in rural areas (14.5) - 34 - compared to both Yerevan (12.6) and other The inadequate supply, inequitable urban areas (12.7) (Figure 21). However, when distribution, and existing skill mix of PHC nurse and physician density are calculated providers, particularly in rural areas, may be separately, two findings are noteworthy. First, hindering the delivery of effective PHC. the density of physicians is much lower in rural areas (3.8) than in both Yerevan (6.2) - 35 - and other urban areas (5.9). Second, the The assessment revealed that across the gap between the density of physicians and country, the density of PHC facilities varies nurses (10.7 nurses versus 3.8 physicians) is – from 0.47 in Yerevan to 2.17 in Tavush per significantly larger in rural areas compared to 10,000 people (Figure 20). Yerevan and other urban areas (Figure 22), while there are more of all PHC providers on average in Yerevan than other regions (Figure Figure 20. Facility density per 10,000 people, by marzes 23). This finding could be related to numerous factors, including (but not limited to) part-time staffing, licensing and other legal regulations regarding staffing ratios, social and cultural aspects of employment, and potentially 2.17 2.14 2.12 different staffing strategies utilized by private 1.84 1.68 1.63 1.54 1.37 1.24 1.17 versus public facilities. 1.12 0.47 Yerevan Syunik Shirak Lori Gegharkunik Kotayk Vayots Dzor Aragatsotn Armavir Ararat Tavush Armenia Source: SDI Facility Survey 2022 - 34 - Armenia PHC Assessment Report - 37 - PHC providers are relatively experienced. Figure 21. Distribution of the PHC providers by type (% of providers) Pediatricians have the highest years of experience and nurses have the lowest (Figure 24). Moreover, there is a shortage of PHC providers, with unfilled vacancies in rural 53.5% 51.3% 61.0% 73.6% areas, including up to 10 percent of physician positions being vacant. Despite efforts by 12.1% 18.4% 9.9% 2.6% the MoH to fill rural health provider gaps by 2.1% 17.2% 14.8% 22.0% 27.8% subsidizing medical training, they continue to 14.3% 17.2% 2.3% persist.53 Total Rural Urban Yerevan Internist Family Doctor Figure 24. Average work experience of all Pediatrician Nurse PHC providers and by type (years) Source: SDI Facility Survey 2022 Figure 22. PHC providers’ density per 10,000 population, by providers type and location 29.6 25.2 19.8 18.9 18.2 Average Internist Family Pediatrician Nurse 14.5 Doctor 13.3 12.7 12.6 10.7 Source: SDI Providers Survey 2022 8.0 6.8 6.5 6.2 5.9 5.3 3.8 Rural Urban Yerevan Total - 38 - Total Density Density by nurse Gaps in PHC infrastructure, equipment, and Density by FD/PD/Internist supplies impact the ability of PHC workers to Source: SDI Facility Survey 2022 deliver quality care, with care in rural facilities being particularly affected. Figure 23. Average number of PHC providers per facility, by regions - 39 - The assessment found that while access to water, hand hygiene, and waste management are adequate, less than 15 34 percent of primary healthcare facilities have sanitation services (Table 3), with 20 13 large gaps observed between Yerevan, 7 urban and rural facilities. Less than three Average Yerevan Urban Rural percent of PHC facilities had access to all Source: SDI Facility Survey 2022 four types of basic infrastructure components: water, sanitation1, hand hygiene,2 and waste 1. Improved facilities with at least one toilet for staff, one sex-separated and at least one accessible for those with limited mobility 2. Functional hand hygiene facility (water with soap and/or ABHR) at points of care and within 5 metres of toilets - 35 - Armenia PHC Assessment Report management;3 the indicator is a weighted Figure 25. Access to telecommunication by average of these four components (Table location (% of facilities with telecommunication) 3). Rural facilities were found to be worst off compared to facilities in Yerevan and other urban areas. There was also a large difference 98.3% between private and public facilities: regarding 97.1% 97.1% 94.9% 95.7% 88.9% all five types of infrastructure. 20.3% 20.3% 14.4% 39.9% 37.6% 32.4% Table 3. Availability of specific types Average Rural Urban Yerevan of infrastructure Mobile telephone Landline telephone Computer / Internet % Facilities Total Yerevan Urban Rural Private Public Source: SDI Facility Survey 2022 All 2.4 5.9 6.8 0.8 12.5 1.9 Water 86.9 100 93.2 83.6 100 86.2 - 41 - Sanitation 4.5 5.9 12 2.5 31.3 3.2 The assessment also revealed that less Hand hygiene 89.7 100 93.2 87.4 100 89.2 than 15 percent of facilities have emer- Waste 38.7 82.4 58.1 28.0 62.5 37.5 gency transport; however, this number rises to nearly 50 percent in urban areas. Source: SDI Facility Survey 2022 Access to emergency transport for inter- facility transfer allows access to necessary care when it is not available at the site. Figure 26 shows that the access of PHC facilities to - 40 - ambulance transportation is very low (14.7 With respect to information and percent). Urban facilities were more likely to communication technologies, most PHC have access than Yerevan and rural facilities facilities have computers and internet, but – 47.9 percent, versus. 11.8 percent and 7.2 there is low access to mobile and landline percent, respectively. phones. Computers were the most widely available piece of equipment, followed by access to an internet connection – 99 percent and 96 percent, respectively (Figure 25). There was a large gap in the availability of cell phones and landline phones, particularly in rural facilities. Only 20 percent of rural facilities had at least one landline functioning telephone and only 14 percent had one regular cell phone.4 3. Waste is safely segregated into three bins and sharps and infectious waste and treated and disposed of safely 4. Cellular phones include only cell phones which belong to the facility itself. Cell phones which belonged to a staff of the facility are not included in computing the indicator. - 36 - Armenia PHC Assessment Report Figure 26. Access to emergency transport for - 43 - inter-facility transfer by sub-national level (% of facilities with emergency transportation) With respect to supplies, all five types of basic diagnostic supplies/tests7 necessary for adequate PHC services were found to be available in only 4 percent of facilities 47.9% (n=13) across the country. Facilities in Yerevan and other urban areas were better 7.2% 14.7% 11.8% Rural equipped than those in rural areas (Figures Total Yerevan 28 and 29). For example, about 6 percent of Urban Rural Source: SDI Facility Survey 2022 facilities in Yerevan and 14 percent of facilities in other urban areas have all five types of - 42 - necessary diagnostic supplies, whereas only With regards to equipment, almost all 1 percent of rural facilities have comparable facilities had basic medical equipment, supplies. About 50 percent of rural, 9 percent but enhanced equipment, such as X-ray, of urban, and 6 percent of Yerevan facilities ultrasonography, and echocardiogram, were completely without these five test were lacking. The percentage of facilities with capabilities. all five basic types of equipment5 available Figure 28. Availability of enhanced equipment was quite high, at about 98 percent (Figure by facility type and location (percent of facilities) 27). Of the 278 assessed facilities, all but six 56.8% public facilities in rural areas were equipped 46.2% Overal 25.0% with a complete suite of basic equipment 0.4% 9.1% hardware. Enhanced equipment6 necessary 14.5% for advanced diagnostic services was 66.7% available in about 15 percent of all facilities, 60.0% Yerevan 66.7% with the highest percentage (65 percent) in 0% 0% Yerevan. 64.7% 40.0% Figure 27. Availability of basic and enhanced 44.1% Urban equipment by facility location 0% 0% (percent of facilities) 0% 35.9% 100.0% 37.5% Rural* 0% 100.0% 100.0% 0.4% 97.4% 96.4% 12.5% 64.7% 14.5% 2.4% 35.9% 2.4% Polyclinic Polyclinic unit of MC PHC Ambulatory Overall Rural Urban Yerevan Health Center Total Basic Enhanced * Across all rural areas, there was only 1 polyclinic, and it had all 3 types of equipment Source: SDI Facility Survey 2022 Source: SDI Facility Survey 2022 5. Basic equipment included: scales, measuring tape, thermometer, blood pressure apparatus, stethoscope 6. Enhanced: X-Ray, ultrasonography, echocardiogram 7. Diagnostic supplies include hemoglobin tests, blood glucose tests, urine dipsticks for protein, urine dipsticks for glucose, and urine pregnancy tests. The lists of basic equipment and diagnostic supplies were extracted from the SARA survey, the SPA survey, the SDI, and the WHO “List of Medical Devices by Facility” - 37 - Armenia PHC Assessment Report Figure 29. Availability of diagnostic tests by facility location (percent of facilities) 3.8% 1.2% 5.9% 13.7% 50.0% 58.6% 77.8% 88.2% 48.8% 37.6% 8.6% 5.9% Average Rural Urban Yerevan None Partially Fully Source: SDI Facility Survey 2022 - 44 - Furthermore, all PHC-recommended 24 essential medicines8 were available in 60 percent of facilities with the lowest values in rural areas (Figure 30). There was variation in the availability of medicines by subnational area – about 68 percent in Yerevan, 57 percent in rural, and 70 percent in urban facilities. Figure 30. Availability of PHC-recommended 24 medicines facility location (percent of facilities with medicines) 67.6% 70.1% 60.4% 57.1% Overall Yerevan Urban Rural Source: SDI Facility Survey 2022 8. The list is recommended by the SARA survey and WHO, and adapted for Armenia - 38 - CHAPTER 4 The current capacity of Armenia’s PHC system (processes): organization and management of primary healthcare, including integration of service delivery Armenia PHC Assessment Report - 45 - is the continuous process of identifying and Delivering effective PHC requires a clear assigning populations to PHC facilities and vision of what services should be covered providers who have a responsibility to know and how they should be delivered, including the individuals in their assigned population processes of care, organization of providers and to deliver PHC services regardless of and management of services, supported by whether those individuals actively seek out the identification of roles and responsibilities care in their PHC facility. According to the at different levels of care (WHO 2020, PHC government decree on the Procedure of Operational Framework). Within this vision, Selecting the Primary Healthcare Doctor and care at the PHC level should be prioritized, Registering to the PHC Facility adopted in and integrated health services should be 2006, every citizen and resident in Armenia promoted to ensure adequate coordination of has a right to choose a PHC provider they care, including referrals between healthcare want in any facility of their place of residence facilities. Compulsory or voluntary assignment or in other regions of the RA (or the city of of individual patients or populations to PHC Yerevan). providers or facilities (empanelment of the - 48 - population), team-based care, and digital health technologies are important strategies There are laws that specify the roles of for supporting this vision (WHO 2020, PHC inpatient and outpatient institutions. The Operational Framework). Key to implementing RA law “Medical Care and Service to the the above is the availability of strong and Population” provides general regulation effective management in PHC facilities, which for various relations pertaining to the can be achieved “by ensuring adequate organization of medical care and services to competencies and deployment of managers the population. The RA Government Order and creating an enabling environment that N 312-N specifies the particularities in the contributes to managers’ motivation and organization of inpatient and outpatient enables them to perform well” (PHCPI, medical services. However, clinical pathways Progression Model). and clear processess and expectations for multi-directional communication do not exist - 46 - to link PHC providers to other levels of care Empanelment of the population to PHC for key conditions. Therefore, health facilities facilities can improve access to care; however, and healthcare providers from different levels current capacity, protocols, and processes in (primary, secondary) are unaware of their Armenia are insufficient to facilitate proper responsibilities and even their capacities when integration of service delivery within and it comes to referring a patient to the right care between healthcare facilities. level or specialist that would contribute to the provision of comprehensive care. - 47 - - 49 - The assessment indicated that in practice, the entire population is assigned to a PHC Referral systems between healthcare facilities facility, with the right to choose a provider. are generally effective within state-guaranteed Armenia has an empanelment system, which healthcare services, especially those from PHC to hospital. - 40 - Armenia PHC Assessment Report - 50 - fundamental problem.” To organize state-guaranteed diagnostic or “…from a purely medical point of view, it is not hospital care, an electronic referral from a PHC at all a suitable system.” provider is required. This can only be arranged through the ArMed9 system; in contrast, - 52 - for non-state-guaranteed care, the paper The assessment also found that while version of referrals may also be used. When more than 2/3 of the PHC facilities have 25 respondents, including facility managers trained managers, feedback systems, and frontline practitioners, physicians, such as performance evaluation and and head nurses from different healthcare opportunities for promotion, are lacking. system levels were interviewed using open- The percentage of PHC facilities that are led ended questions, interestingly, there were by a manager who has certified management contradicting opinions on the effectiveness training, including a certificate or diploma is of the ArMed system on integrated care in about 68 percent (Figure 31). The majority of general. When asked about what measures them had a certificate and about 17 percent could be taken to improve patient referrals, of them had a diploma with a bachelor’s or a many respondents provided positive feedback master’s degree. However, about 60 percent of that the introduction of ArMeD and the use of facilities did not receive an annual review and e-referrals have significantly simplified the feedback on their management capabilities organization of service delivery. According and performance in the last 12 months. About to some respondents, it is preferable to use 35 percent reported that they received some e-Referrals for paid services as well. kind of feedback from the facility staff only “In the past, this was done on paper, and now (3.6 percent), from the external leadership or it has gotten much easier after the introduction governing authorities (22.9 percent), or both of electronic health system.” from facility staff and external leadership (8.6 percent). - 51 - Figure 31. PHC facility managers that have However, several respondents reported that official management training ArMed is inefficient and complicated. The main (percent of facilities) reasons given were that it is not deployed by 2.2% 5.9% 1.7% 1.6% all facilities. Moreover, physicians are often 24.1% 30.2% 30.2% incapable of using it due to a lack of digital 36.6% 17.2% skills. As a result, they request assistance 16.5% 12.9% 35.3% from computer operators to enter or extract the necessary information from the system, 51.1% 48.9% 58.9% 52.9% which complicates the work and takes time. “The system does not provide the opportunity Average Rural Urban Yerevan to receive complete care information provided Management certificate Diploma No training Unknown at other health centers. That right there is our Source: SDI Facility Survey 2022 9. ArMed or the E-health system as stated in the policy documents or government strategies, is a unified health information management system including information of all citizens and residents in the RA who are empaneled to a PHC facility. It is a synchronous data-transmission platform for three types of data: administrative, financial, and clinical. All facilities providing state-guaranteed PHC services are attached to the ArMed system and must use it. - 41 - Armenia PHC Assessment Report - 53 - their hospital documentation, and referral Moreover, there are obstacles to responses are either made available with collaboration and communication among delay, or not made available at all, and in healthcare professionals that prevent the some instances, results are either incorrect delivery of team-based care. Mechanisms or illegible. Additional barriers to transferring and structures to promote team-based care information between medical facilities at the PHC level, such as regular meetings, that were reported by participants include team-building exercises, identification of administrative and bureaucratic hassles and shared goals, or defined communication overloaded medical staff. channels to promote a team culture, are “[Ideally] there would be a platform where I limited. Team-based culture at PHC facilities would write [the patient’s medical information], is often influenced by the managerial style and 3-4 responsible individuals in the hospital of the director of the facility. In urban areas, could see why the patient was referred; [in communication among PHC providers another scenario], I could put the patient’s and specialists generally takes place medical history on the platform, rather than during referrals and mostly occurs through have the patient or the relative pick up the phone conversations. In rural areas, team paper, and then [the paper] may or may not collaboration tends to be stronger. Family get to where it needs to go.” physicians, as a part of their job responsibilities, are responsible for managing patient and community care in health posts and health centers, sharing the responsibility of care delivery with nurses in those facilities. The teams in rural facilities have defined roles that are mainly based on the team members’ job responsibilities which have been developed over many years. - 54 - The transfer of patient medical information between health institutions was found to be fragmented and incomplete. Due to the absence of a unified electronic system, incomplete registries between health institutions, and lack of interoperable and interconnected systems, most of the information exchange between different levels of care is done manually. The consequence of this is the incomplete transfer of information between institutions (e.g., hospital and PHC, diagnostic center and PHC). For example, complete medical folders of patients, - 42 - CHAPTER 5 The current capacity of Armenia’s PHC system (structures): primary healthcare governance, financing, collaboration, and data-driven decision making Armenia PHC Assessment Report - 55 - oriented to PHC and UHC; however, there Strengthening PHC requires leadership is no standalone strategy for PHC or for at the highest levels to make bold political the health sector in general. In addition, the choices, build partnerships within and beyond RA Government’s Five-year Action Plan for the health sector, and to ensure consistent 2021-2026 includes activities related to PHC priorities are presented.29 Robust governance reforms;55 however, the Plan is not centered structures are also needed to promote local on PHC as the foundation for strengthening and community leadership and accountability health services and UHC. Meanwhile, the to communities and to ensure people are not government decree on the State Health Target put at serious risk due to weak regulation Programs 2022 that focuses on PHC defines of health services and systems.29 National the provision of PHC services as a priority health sector policies, strategies and plans among the state-funded health programs of should also be designed with the goals and 2022. The same program defines the service objectives of PHC, through an inclusive, package provided by PHC, which includes pluralistic process in which service providers the majority of preventive services, including and communities participate in decision- immunizations, specialist consultations, making as well as in follow-up, monitoring laboratory tests, and some diagnostic and evaluation.29 People and communities, services. especially those most disadvantaged, - 57 - should also be able to express their needs and preferences to inform health services There is also a leadership commitment design, planning, and management.54 Crucial to improving the quality of PHC care in to supporting decision-making processes Armenia. This is reflected in the following is the availability of timely and reliable data activities from the government side: 1) the and analysis on PHC performance that can existing results-based financing mechanism enable within and cross-country comparison for improving coverage since 2009 and the as well as guide collective efforts for PHC government’s willingness to pay for it; 2) improvement.29 Financing mechanisms that the establishment of a PHC Task Force by encourage and enable primary healthcare, the MoH in 2022: although its operational from the collection and pooling of funds to effectiveness is still in progress, it is positioned the purchasing of PHC-level services that to serve as a key mechanism for developing align closely with local needs and incentivizes and implementing recommendations for PHC coordination of care, prevention and quality, reforms across the country; and 3) the approval are also critical for effective PHC.48 of a strategy and a plan of action by the MoH in 2022 to improve the quality of healthcare - 56 - services – which all have to be sustained for The assessment revealed that national effective stewardship of the health sector. action plans reflect PHC orientation, but there is no specific, costed strategy. There - 58 - is leadership commitment to maintaining the right-to-health legislation in Armenia PHC governance structures lack evidence- and the existence of national health policies based and consultative mechanisms for - 44 - Armenia PHC Assessment Report informed decision-making and a strong quality external organizations. In addition, service assurance system to monitor compliance. users and private providers have limited or no involvement in healthcare-related decisions, - 59 - and, when they do have an opportunity to Decision-making for PHC was found to contribute, engagement is often unilateral. be neither systematically data-driven nor Occasionally, PHC doctors receive strategic participatory. Administrative and survey data plans from the national level and are asked to on health outcomes, service utilization, and comment on them or make suggestions. spending are routinely collected. However, the available data is used for priority setting at - 61 - the national and sub-national levels on an ad- There is also a lack of a functional multi- hoc basis. It is not used for priority setting or sectoral government team that deals planning by local authorities. The Healthcare specifically with PHC. The main established Policy (HCP) department at the MoH uses the cross-government group engaged in general available data, mainly on disease burden and health-related decisions is a parliamentarian cost-effectiveness, to provide justifications committee called “The Standing Committee on and inform priority setting. It requests data on Healthcare and Social Affairs of the National disease burden from the Health and Social Assembly.” The committee consists of 12 Departments of the regional administrations deputies and is responsible for the preliminary and sets priorities based on the data received. discussion of draft laws and other proposals The Health and Social Departments of the developed by the MoH. Other governmental regional administrations request data from bodies that collaborate with the MoH on PHC PHC facilities in the region to set service is the Ministry of Finance, and the only related delivery priorities. activity is the approval or prior discussion before the approval of yearly PHC-related - 60 - activities. Other collaborators on health- Moreover, there is no systematic related matters are the National Institute of mechanism to engage stakeholders from Health and Health and Social Departments the national level or committees and at regional administrations; however, these formal groups from the sub-national level engagements are not specific to PHC. in PHC decision-making. In recent years, the MoH has engaged non-governmental - 62 - organizations in specific activities related to Moreover, there are no mechanisms in PHC, such as vaccine-related awareness- place to ensure communities or patients raising, as well as outreach to people living with provide their inputs on the design, human immunodeficiency virus, tuberculosis, financing, and governance of PHC services and cancer. However, involvement is often across the country. Priorities are defined at fragmented as these non-governmental the national and regional levels. Municipal organizations run externally driven projects communities do not collect and use data to that are often focused on vertical programs translate national and/or regional policies and single diseases. There are no established into local PHC priorities and strategic action mechanisms to align or prioritize the work of plans. There is no established system in - 45 - Armenia PHC Assessment Report place to ensure communities and patients are receive calls from the community and perform engaged for their input on how PHC services health promotion and education activities, are structured and delivered. such as “maternity schools” for pregnant women or awareness raising programs on - 63 - immunization. In addition, the ArMed system Gaps were evident in the regulation of recently updated the platform to allow data quality standards for PHC in the following about the patient’s health status regarding areas: provider licensing, facility licensing, some communicable and non-communicable standards of care, and supervision. The diseases (e.g., hypertension, diabetes, capacity of the system to ensure that all active cancer, HIV/AIDs, Hepatitis B, C) to be PHC workers are qualified to practice is weak. entered. This registry can be used to identify The PHC workforce in Armenia, including the risk groups or vulnerable patients when PHC physicians (family physicians, internists, needed and facilitate proactive management pediatricians) and nurses, are graduates of and a population-based approach. public or private licensed institutions and accredited programs. However, there has - 65 - been no licensing implemented for healthcare Nevertheless, there is a national system worker practice in the country since 2001. in place for continuing professional Graduates from nursing schools are free to development. Continuing medical education be employed after obtaining their diploma, (CME) for practicing healthcare providers, and Yerevan State Medical University and including PHC nurses and doctors, requires National Institute of Health graduates can be a “certificate of professional activity” employed after completing their residency. renewable every five years to continue the Furthermore, there is currently no registry of clinical practice. The certificate is awarded to qualified workforce for PHC or healthcare in healthcare workers who obtain the required general. It is under development. CME credits and have been in active clinical practice for at least three of the past five - 64 - years. The National Certification Center for Despite the above shortcomings, one of Professional Development, NIH, and MoH the strengths of Armenia’s PHC system is are responsible for quality assurance and population outreach. Proactive population monitoring, accreditation of CME courses, outreach involves health systems actively and certification of CME participants. reaching out to communities, particularly those that are underserved or marginalized, - 66 - to provide necessary services aligned with The NIH, in collaboration with the Outpatient local priorities and the burden of disease, and Healthcare Policy Department, is responsible link those in need to PHC. In almost all sub- for the development of clinical guidelines regions, family physicians and nurses of the for different health conditions, including FAPs provide care through home visits for for communicable and non-communicable vulnerable groups, such as pregnant women, diseases. Sometimes they collaborate infants, and people with severe chronic with international or local organizations to diseases. They do visits also when they develop those guidelines. However, there - 46 - Armenia PHC Assessment Report is no systematic procedure that supports continuous monitoring of healthcare provider Figure 32. Supervision visits to PHC facilities compliance with clinical guidelines. In addition, (percent of facilities) PHC facilities lack other quality standards of care such as accreditation and assessment of the clinical quality of care, adverse event reporting, safety protocols and safety 95% checklists, and clinical decision-support tools. 88% 87% 84% - 67 - Average Yerevan Urban Rural Facility licensing used to happen only once when a PHC facility opened or expanded its Source: SDI Facility Survey 2022 scope of care until a Ministerial Order approved in May 2023 introduced an amendment to Figure 33. Challenges shared during switch to five-year term licensing. The MoH’s supervision visits (percent of facilities) Licensing Agency carries out the procedures of medical care licensing, license renewal, Not suspension and termination, and medicines applicable, 29,40% legislation, for all medical institutions and pharmacies in the country. Following this, Yes, the Health and Labor Inspectorate conducts 46% inspections of PHC facilities and checks compliance with the minimum technical No, 38% standards; for example, if the facility meets the mandatory licensing requirements in terms of equipment, personnel, and documents. - 68 - Source: SDI Facility Survey 2022 Most PHC facilities are supervised annually - 69 - but often do not engage in collective problem- solving. During the survey, about 87 percent Armenia spends less from public sources of the assessed facilities reported that they on PHC compared to other middle-income had more than one supportive supervision countries in the WHO European Region.56 visit in the last 12 months. The urban facilities The public share of total PHC spending was reported more visits (95 percent) than only 11 percent in 2018 (Figure 34).56 The Yerevan (88 percent) and rural (84 percent) package of the state-funded medical care and facilities (Figure 32). Most of these visits services provided by PHC facilities is defined were conducted by the Health and Labor in The State Health Target Programs for Inspectorate (41 percent). However, less 2021.57 The package includes the majority of than half (46 percent) of the facilities shared preventive services, including immunizations, problems during these visits (Figure 33). some specialist consultations, laboratory tests, and some diagnostic services. Though - 47 - Armenia PHC Assessment Report the government covers the PHC services Figure 34. Public PHC spending as a share of for the entire population, most of them have PHC spending, 2018 limited coverage for outpatient medicines and diagnostics,57 leading to high out-of- pocket payments to cover the gap. Outpatient medication is available only to treat specific 54% conditions (e.g., mental health disorders, 45% 45% 35% diabetes, tuberculosis) without any co- 22% 21% payments while socially disadvantaged 13% 11% groups might have coverage of medication RUS KAZ MKD MDA UZB TJK GEO ARM for outpatient treatment free of charge or with partial co-payment.58 Expensive diagnostic Source: World Health Organization, 2021 services are covered without co-payment for state employees, low-income earners, and specified social groups while the rest of the - 70 - population remains without any coverage.58 Provider payments are low and contracting As a consequence of the same factor (i.e., that of PHC services does not reward better state-funded services are “not for everyone”), quality. The main PHC provider payment the physicians’ actions are also affected. mechanism is per capita funding according During the assessment, PHC providers shared to the number of people enrolled with each their experience of observing that those with provider and supplementary performance- full state coverage receive the necessary based financing (PBF).53 The PBF has diagnostic services, while those who are been designed to improve the performance not covered discontinue care. Moreover, the of providers. It is based on rewards for unwillingness to add a financial burden on a improvements in service coverage using patient results in physicians avoiding referring 27 indicators, including screenings for these individuals to undergo other necessary NCDs. However, due to the low financing, diagnostic testing and/or to other levels of and that the payments for these discrete care. indicators are quantifiable and are not linked “…The problem of distribution of finances. I to improvements in quality, the PBF has not need to be able to just work, without thinking fully met its goals. Low reimbursement levels about finances. Those residents who have to PHC providers have also contributed to social packages come and are able to informal co-payments. Under the per capita undergo testing, and those residents who mechanism, PHC facilities receive a fixed don’t have social packages are unable to annual amount for each enrolled patient.53 undergo testing.” - 48 - CHAPTER 6 Recommendations Armenia PHC Assessment Report - 71 - areas of provider licensing, facility licensing, PHC is the most inclusive, equitable standards of care, and supervision further and efficient approach to organizing and hinder the delivery of quality care. Finally, strengthening healthcare systems and is key decision-making for PHC was found to not be to addressing the growing burden of NCDs systematically data-driven or participatory. in Armenia and to helping the country make - 72 - progress towards UHC. However, findings from this assessment revealed that PHC We conclude this report with recommendations performance in Armenia is suboptimal, with to address constraints to universal access to data indicating low PHC utilization, particularly equitable and quality PHC in Armenia. We among certain population groups due to recommend reforms in three main directions: financial barriers, and due to perceptions that (1) interventions to improve access to PHC for services are unavailable or of poor quality. The NCDs, (2) interventions to improve the quality assessment also revealed that compared to of PHC care for NCDs, and (3) mechanisms internationally recommended evidence-based to support effective PHC governance that standards, PHC providers, including family will create an enabling environment for PHC doctors, internists, and pediatricians, lack improvement. In proposing these reforms, we the adequate knowledge, skills, and ability to identify actions that are feasible to implement properly diagnose and treat different conditions. in the short, medium, and long term. Most In addition, there is inequitable distribution of of the recommendations are grounded in the PHC workforce, with a disproportionately international literature and are bolstered by lower supply of PHC providers in rural areas. successful examples from other countries that The ability of PHC providers to deliver quality have implemented similar strategies as part of care is also affected by inadequate facility their healthcare reforms. A detailed summary infrastructure and insufficient equipment and with specific examples is presented in Box 1 supplies, especially in rural areas. Gaps in below. regulating quality standards for PHC in the - 50 - Armenia PHC Assessment Report INTERVENTIONS TO IMPROVE THE QUALITY OF PHC RECOMMENDATION 1 (short-term measures)։ Enhance demand-side interventions targeting underserved groups, particularly low-income households and adolescents, by implementing a range of strategies. These may include both financial and non-financial incentives, such as targeted messaging, monetary rewards, and the establishment of adolescent-friendly clinics, to effectively boost utilization rates, e.g., the World Bank-co-funded Disease Prevention and Control Project increased screening by 15 and 32 percentage points, respectively, with targeted messaging and financial rewards. RECOMMENDATION 2 (short-term measures)։ Increase investments in a strong and skilled rural PHC workforce, through targeted public budget programs that finance higher salaries, bonuses, and subsidies for living costs; targeted admissions of students from rural backgrounds; and introduce rural health topics and practicum into medical school training. RECOMMENDATION 3 (medium and long-term measures)։ Progressively increase public spending on PHC to cover a package of essential outpatient medicines for prevalent NCDs (hypertension, diabetes, CVD, cancers) and ensure services are reimbursed at appropriate prices. Medicine inclusion and prices should be informed by evidence-based Health Technology Assessments and broad stakeholder consultations. RECOMMENDATION 4 (medium and long-term measures)։ Increasing incentives for rural practice by investing in rural infrastructure and services and introducing education subsidies for health workers who agree to return to rural services. - 51 - Armenia PHC Assessment Report INTERVENTIONS TO IMPROVE ACCESS TO PHC RECOMMENDATION 5 (short-term measures)։ Revise the providers’ reimbursement rates and performance-based contracting mechanisms to include quality (e.g., bonuses for achieving hypertension control in empaneled patients) and more access-oriented PB indicators, including public reporting of performance on quality to strengthen accountability. RECOMMENDATION 6 (short-term measures)։ Strengthen quality assurance at the facility level by introducing a mandatory skills-based training program for PHC facility management, including in finance, strategy, communications, quality, and operations. RECOMMENDATION 7 (medium and long-term measures)։ Improve diagnostic accuracy of PHC providers, as well as facilitate care integration and decision support for physicians, using targeted and high-quality training, clinical decision support tools, and clinical audits, (e.g., ArMed can include algorithms that flag probable diagnoses from patient data; charts can be randomly sampled and assessed for accuracy), and develop integrated pathways, especially for high prevalent NCDs. RECOMMENDATION 8 (medium and long-term measures)։ Improve integrated care by boosting multidisciplinary teams in the model of care delivery in the new PHC reforms plan for Armenia, as well as creating mechanisms to promote communication and teamwork between healthcare providers in PHC and other levels of care. RECOMMENDATION 9 (short and medium-term measures)։ Strengthen rural PHC infrastructure and equipment, including emergency transportation (vehicles, drivers, and maintenance costs); communication equipment (such as mobile or landline phones); gender-based and accessible toilets; and diagnostic supplies for prevalent NCDs, such as blood glucose tests, urine protein, and glucose dipsticks. RECOMMENDATION 10 (medium and long-term measures)։ Implement an interconnected and interoperable electronic healthcare system throughout medical facilities on all levels (tertiary, secondary, diagnostic). This would help overcome the main barriers connected with the transfer of information regarding medical services provided to patients by reducing the human factor of error. RECOMMENDATION 11 (medium and long-term measures)։ Expand the recently updated licensing program for PHC facilities to encompass all essential PHC services. This will ensure a compulsory, transparent, and quality-based regulation of patient health and safety. - 52 - Armenia PHC Assessment Report MECHANISMS TO SUPPORT EFFECTIVE PHC GOVERNANCE THAT WILL CREATE AN ENABLING ENVIRONMENT FOR PHC IMPROVEMENT RECOMMENDATION 12 (short-term measures)։ Develop a national health facility master plan that specifies targets for facility density at different levels, required enhanced equipment and supplies, and the necessary health worker distribution, to respond to the projected service user needs and reduce hospital-centric service delivery. RECOMMENDATION 13 (short-term measures)։ Develop and periodically update an evidence-based and costed PHC strategy, drawing on stakeholder engagement, that serves as a roadmap to address priority challenges to providing effective PHC, that includes a plan to finance key investments in infrastructure, benefits coverage, human resources, etc. RECOMMENDATION 14 (short-term measures)։ Ensure the operational functionality of the established PHC task force by convening regular meetings and fostering active participation. This initiative is integral to effectively managing and enhancing the overall strength of primary healthcare services. RECOMMENDATION 15 (short-term measures)։ Stop reimbursing PHC-manageable conditions at the hospital level and train PHC providers to manage these conditions, adjusting their reimbursement levels to reflect the additional scope of work. Ensure a proper data system to track, monitor, and report regularly on the process. - 53 - Armenia PHC Assessment Report Box 1. International Examples Supporting Recommendations for Strengthening PHC Thailand stands out as a notable example of successfully increasing public spending on primary healthcare (PHC).62 In 2002, the country launched the Universal Coverage Scheme, significantly boosting funding for PHC services and ensuring accessibility, particularly in rural areas previously lacking healthcare access. The Ministry of Public Health in Thailand has implemented policies to enhance resource sharing, including financial, human, and technological resources while incentivizing healthcare professionals to practice in rural areas. Strategies such as financial incentives, recruiting rural-background students, and mandatory rural service for medical graduates have been pivotal. The success of Thailand’s rural healthcare strategies has gained global recognition, with the World Health Organization highlighting it as a model for achieving Universal Health Coverage and improving rural healthcare access.62 Global studies consistently affirm that medical professionals with rural backgrounds are more inclined to practice in rural areas.63,64 Australia’s targeted recruitment and training programs for rural medical students, alongside incentives like competitive salaries and loan repayment schemes, have boosted rural retention rates.63 Similar efforts in Canada echo these trends, reinforcing the effectiveness of strategic incentives and training programs in addressing rural healthcare shortages.63 In Thailand, comprehensive PHC services, including health promotion and disease prevention, are provided through Family Care Teams (FHTs).62 These teams, comprising family physicians and multidisciplinary health personnel like nurses and community workers, deliver integrated care spanning preventive to chronic disease management across various healthcare levels.62 Elsewhere, Brazil’s adoption of multidisciplinary FHTs has similarly enhanced healthcare integration and effectiveness, illustrating the collaborative potential of diverse health professionals in improving outcomes and addressing broader health determinants.65,66 In England, Torbay pioneered integrated care supported by multidisciplinary teams, benefiting older people and those with chronic conditions in regional communities.67 In terms of provider payment mechanisms, Croatia has updated its provider payment agreements with provider performance being monitored, evaluated, and further financially stimulated by including performance and quality indicators such as service standards (e.g., online scheduling of patients). Croatia introduced changes to incentivize healthcare providers to increase the provision of certain types of services (for example, preventive care, diagnostics), and improve the quality and efficiency of care.68 - 54 - Armenia PHC Assessment Report APPENDIX 1 The definition of PHC facility and provider throughout this report PHC facility PHC provider Medical centers (PHC units only) The health workforce engaged in delivering services specific to PHC: Polyclinics Internists / General practitioners PHC centers Rural ambulatories, and health centers Family doctors Private and public Pediatricians FAPs (feldsher-akusher posts) or health posts were not included as they are the part of a Nurses rural ambulatory APPENDIX 2 Service Delivery Indicators (SDI) Survey Methodology and Implementation Implementation The SDI survey was conducted in 278 across all types of facilities providing PHC services in Yerevan and all 10 marzes (regions), including rural and urban areas (Table 1A). The assessment took place from fall 2021 to spring 2022. The table below represents the location of facilities assessed in Armenia. Table 1A. SDI-assessed facilities in marzes and Yerevan Total Polyclinics Ambulatory Health Other types of facilities Center (e.g., medical centers) REGION (MARZ) N n n n n Aragatsotn 21 0 14 1 6 Ararat 40 0 35 1 4 Armavir 38 1 34 0 3 Gegharkunik 30 2 25 1 2 Kotayk 31 2 17 1 11 Lori 22 4 13 0 5 Shirak 24 7 10 2 5 Syunik 11 0 6 0 5 Tavush 20 1 12 3 4 Vayots Dzor 7 0 4 1 2 Yerevan 34 21 0 0 13 Total 278 38 170 10 60 - 55 - Armenia PHC Assessment Report Sampling Health facility sampling The natural stratification of the facility sampling frame included: Stratum A, composed of the 236 facilities that deliver ambulatory services; and Stratum B, composed of the remaining 130 facilities. The strategy for selecting 300 facilities consisted of selecting all 130 facilities in Stratum B, and taking a sample of 170 out of the 236 facilities in Stratum A. This sample permitted estimating, without sampling error, all facility-level indicators relevant to the private sector, to Yerevan and other cities, and facilities without an enrolled population. PHC facility list: Stratum A - 236 rural ambulatory facilities (rural) 366 Stratum B - 130 facilities (urban) SDI Sample: 170 out of the 236 facilities in Stratum A 300 All 130 facilities in Stratum B Number of surveys 2 - incomplete 12 - not providing service completed: 278 6 - refused 2 - pilot Healthcare provider sampling Up to 10 eligible healthcare providers were selected at every facility, including family doctors/ internists, pediatricians, and nurses. In facilities where the number of providers was less than 10, all providers were included. PHC Providers conducting patient 10.7% unavailable on survey day consultations: 3,508 Number of providers 202 - Internists/general practitioners 135 - sampled for absenteeism questions: 1,991 368 - FDs Number of providers 215 - Internists/general practitioners 111 - sampled for vignettes: 681 355 - FDs Patient sampling Patients were selected based on random sampling technique during their visit to the PHC facility after seeing a physician. The data collection team, during their first visit, estimated the daily expected number of patients with the support of the facility officer. We acknowledge the limitations of this approach. The patient survey only captured the perception of individuals who have accessed PHC facilities and been able to utilize their services. It did not encompass individuals who did not visit the facility or declined to use PHC services. - 56 - Armenia PHC Assessment Report Instruments Three questionnaires were used, each distinguished by who the intended respondent was – facility manager, healthcare providers, and patients – for clarity and ease of administration. More about the questionnaire development and principles are described in the SDI Health Survey factsheet.59 The following domains and subdomains were covered across the three questionnaires: Facility Basic characteristics, management, supervision, staffing, services, availability of guidelines/documentation, infrastructure, equipment and supplies, medicines Diagnostic and treatment capacity of key health conditions (hypertension, diabetes, Providers Healthcar tuberculosis, depression, stunting, malaria, diarrhea, pneumonia), adherence to clinical guidelines, user focus and respectful care, work environment, workload, job satisfaction, training and career advancement opportunities, absenteeism Demographics, user focus, including wait time, services received, antenatal care, Patients sick child visit, non-communicable disease care experience, referrals, time cost, satisfaction with care 75. The World Bank Group. Service Delivery Indicators (SDI) Health Survey Refresh.; 2021. - 57 - Armenia PHC Assessment Report APPENDIX 3 The Vertical Integration Diagnostic and Readiness Tool Study Methodology Guided by the principle of maximum variation sampling, the representative participants were recruited via purposive sampling technique from 18 public and 7 private facilities, Study participants and in both rural and urban areas, as well as the capital Yerevan. The respondents were facility managers and practitioners, such as PHC doctors, specialists, and head nurses sampling from different health system levels, inpatient and outpatient health facilities, PHC facilities, maternity hospitals, diagnostic units, and laboratories. The study team selected the medical institutions, contacted the administrations of those institutions, and explained the study purpose. The administrations assigned a representative from their institutions who they believed could be a good informant to participate in the interviews. The Instrument was developed based on the Vertical Integration (VI) in the Healthcare and data collection Study instrument System, Organizational Environments, and Front-Line Service Delivery Settings tool.60 The tool aims to examine policy, organizational, and front-line readiness for VI as well as to assess existing VI initiatives. This instrument can be applied to systems with or without VI application. The questions cover organizational policies, leadership, nuts-and-bolts features of VI in the respondents’ healthcare organization, and the degree to which VI has been introduced and incorporated into the delivery system.60 As the tool allows being adapted to local contexts and priorities, the study team modified questions accordingly. After the adaptation to the country context and translation, the study instrument was pre-tested and improved further before the main interviews. The final instrument included close-ended and open-ended questions on several domains of VI and the healthcare system, organizational environment, front-line service delivery, and patient transitions across different levels of healthcare. The National Institute of Health (NIH) Ethics Committee approved the study protocol. Overall, 25 interviews took place from August to October 2021 and were conducted on the Zoom platform by trained interviewers. The responses to open-ended questions were transcribed into the original language. Data analysis Textual data were coded and analyzed manually using directed content analysis. Coding meaningful phrases and sentences of responses helped identify themes and sub-themes that emerged from the data. The themes were labeled with self-explanatory titles and triangulated with descriptive quantitative data from the interviews to enrich the findings. - 58 - Armenia PHC Assessment Report APPENDIX 4 Primary Healthcare Vital Signs Profile The VSP, the core tool of the PHCPI, for Armenia,61 provides a snapshot of the PHC system across four pillars: FINANCING prioritization of financing for PHC PHC spendings Prioritization of PHC Sources of PHC spending $251 Overall health spending Government 48% on PHC 11% per capita Government health spending 42% on PHC Other 89% functional capacity, including governance, inputs, and management of CAPACITY population health and facilities Governance Inputs Population Health and Facility Management 2.0 2.3 2.2 PERFORMANCE access to services, quality of the services, and service coverage Access Index Quality Index Service Coverage Index Household’s Integrated Living Conditions Survey (2020) SDI (2021-2022), WHO/UNICEF (2021), UHC (2021), WHO TB data (2021), DHS Statcompiler WHO TB data (2021) (2015-2016), WHO/UNICEF (2021) 91 69 49 0 100 0 100 0 100 EQUITY differences related to wealth, geography, and education Access: % with perceived Coverage of RMNCH Outcomes: Under-five barriers du to cost, services, by mother’s mortality, by residence by wealth quintile education The Demographic Handbook of Armenia (2021) Household’s Integrated Living Conditions Survey (2020) HIGHEST LOWEST URBAN RURAL 0 11 27 100 0 100 0 100 1.4 1.9 - 59 - Armenia PHC Assessment Report COUNTRY CONTEXT AT-A-GLANCE GDP per capita Living in poverty Government health spending (PPP int’l dollars) (Under $2,15 int’l dollars/day) as % of GDP WDI (2021) WDI (2020) WHO GHED (2019) $15,592 0,4% 1,4% Life expectancy Maternal Neonatal Premature at birth mortality mortality NCD mortality (Years) (per 100,000 live births) (per 1,000 live births) (Probability) GHO (2019) GHO (2017) GHO (2020) GHO (2019) 76 26 6 20% Causes of death GHO (2019) 7% Communicable and Other Conditions 88% Non-Communicable 5% Deseases Injuries - 60 - Armenia PHC Assessment Report CAPACITY DOMAIN: DETAILED VITAL SIGNS PROFILE INDICATORS Armenia SCORE GOVERNANCE 2.0 Governance and Leadership 2.0 Measure 1: Primary health care policies (1/2) Measure 2: Primary health care policies (2/2) Measure 3: Quality management infrastructure Measure 4: Social accountability (1/2) Measure 5: Social accountability (2/2) Adjustment to Population Health Needs 2.0 Measure 6: Surveillance Measure 7: Priority setting Measure 8: Innovation and learning INPUTS 2.3 Drugs and Supplies 2.0 Measure 9: Stock-out of essential medicines Measure 10: Basic equipment availability Measure 11: Diagnostic supplies Facility Infrastructure 1.0 Measure 12: Facility distribution Measure 13: Facility amenities Measure 14: Standard safety precautions and equipment Information Systems 3.3 Measure 15: Civil Registration and Vilat Statistics Measure 16: Health Management Infromation Systems Measure 17: Personal care records Workforce 2.0 Measure 18: Workforce density and distribution Measure 19: quality assurance of primary health care workforce Measure 20: Primary health care workforce competencies Measure 21: Community health workers Funds 3.3 Measure 22: Facility budgets Measure 23: Financial Management Information System Measure 24: Salary payment POPULATION HEALTH AND FACILITY MANAGEMENT 2.2 Population Health Management 2.5 Measure 25: Local priority setting Measure 26: Community engagement Measure 27: Empanelment Measure 28: Proactive population outreach Facility Organization and Management 1.8 Measure 29: Team-based care organization Measure 30: Facility management capability and leadership Measure 31: Information system use Measure 32: Performance measurement and management (1/2) Measure 33: Performance measurement and management (2/2) - 61 - Armenia PHC Assessment Report PERFORMANCE DOMAIN: DETAILED VITAL SIGNS PROFILE INDICATORS Armenia SCORE PERCENTAGE SOURCE YEAR ACCESS 91 FINANCIAL Perceived access barriers due to theatment cost 18% Household’s Integrated Living Conditions Survey 2020 GEOGRAPHIC Perceived access barriers due to distance 0,4% Household’s Integrated Living Conditions Survey 2020 QUALITY 69 COMPREHENSIVENESS Avg. availability of 5 tracer RMNCH servicess 24% Service Delivery Indicator (SDI) Survey 2021-22 Avg. availability of services for 3 tracer communicable deseases 10% Service Delivery Indicator (SDI) Survey 2021-22 Avg. availability of diagnosis & management for 3 tracer NCDs 91% Service Delivery Indicator (SDI) Survey 2021-22 CONTINUITY DTP3 dropout rate 3% WHO/UNICEF Joint Reporting Form on Immunization 2021 Treatment success rate for new TB cases 81% WHO TB data 2021 PERSON-CENTEREDNESS % of caregivers who were told sick child’s diagnosis 76% Service Delivery Indicator (SDI) Survey 2021-22 PROVIDER COMPETENCE Adherence to clinical guidelies (%) 33% Service Delivery Indicator (SDI) Survey 2021-22 Diagnostic accuracy (%) 47% Service Delivery Indicator (SDI) Survey 2021-22 PROVIDER AVAILABILITY % of family planning, ANC, and sick child visits over 10 minutes 55% Service Delivery Indicator (SDI) Survey 2021-22 Provider absence rate 10% Service Delivery Indicator (SDI) Survey 2021-22 SAFETY Adequate waste disposal 93% Service Delivery Indicator (SDI) Survey 2021-22 Adequate infection control 99% Service Delivery Indicator (SDI) Survey 2021-22 SERVICE COVERAGE 49 REPRODUCTIVE, MATERNAL, NEWBORN AND CHILD HEALTH Demand for family planning satisfied with modern methods 42% UHC Global Monitoring Report 2021 Antenatal care coverage (4+ visits) 96% DHS Statcompiler 2015-15 Coverage of DTP3 immunization 93% WHO/UNICEF Joint Reporting Form on Immunization 2021 Care-seeking for suspected child pneumonia 94% DHS Statcompiler 2015-16 INFECTIOUS DISEASES Tuberculosis cases detected and treated with success 42% WHO TB data 2021 People living with HIV receiving anti-retroviral treatment 48% UHC Global Monitoring Report 2021 Children under 5 with diarrhea receiving ORS NON-COMMUNICABLE DISEASES (NCDS) % of population with normal blood preassure 21% UHC Global Monitoring Report 2021 - 62 - Armenia PHC Assessment Report The Financing pillar reflects how much the government spends on PHC; the Capacity pillar shows if the Armenian PHC system has the policies, infrastructure, and other physical and human resources required to deliver primary healthcare; the Performance pillar shows if the PHC system delivers quality care that meets people’s health needs; and finally, the Equity pillar illustrates if the PHC system effectively serves the most marginalized and disadvantaged groups in society. Information sources To populate the VSP, the team used data from a national SDI survey 2022, and alternative data sources that were collected and reported within 5 years, including Statistical Committee of RA (Armstat), World Development Indicators (WDI), WHO estimates, Households Integrated Living Conditions Survey 2020, WHO/UNICEF Joint Reporting Form on Immunization 2021, UHC Global Monitoring Report 2021. Sources were chosen after several rounds of review with local and international experts to make sure that the data is consistent with the framework. Primary Healthcare Progression Model A critical part of completing the VSP is conducting a Progression Model assessment, a mixed- methods evaluation of the functional capacities – like governance, inputs, and population health management – of a country’s PHC system. The Progression Model collects evidence on 33 measures of the capacity pillar and attributes a score from 1 (lowest) to 4 (highest) to each of those measures, following pre-specified rubrics. Within the VSP, a Progression Model (PM) enabled standardized and systematic mixed-methods assessment of the PHC capacity through a series of performance measures. Each of the 33 measures focusing on a specific PHC system, input, or service delivery element was assessed and assigned the country to one of four performance categories ranging from Level 1 (low) to Level 4 (high). The data for the Progression Model was collected via in-depth interviews with stakeholders, document reviews, and data analysis (including SDI). The PHC Progression Model assessment used participatory design and brought together diverse stakeholders who have complementary knowledge of PHC functioning in Armenia. The assessment was implemented by a team of WB experts and stakeholders from the MoH, development partners, and civil society organizations and non-governmental organizations. Before finalizing the assessment and scores of the PHC measures, the document underwent an internal scoring process with the stakeholders and an external validation. - 63 - Armenia PHC Assessment Report APPENDIX 5 Analysis of Ambulatory Care Sensitive Conditions This study (secondary data analysis) was based on the list of Ambulatory-Care Sensitive Conditions (ACSCs) applied by the World Health Organization in several studies and aimed to examine the extent to which ACSCs have been treated in PHC facilities and hospitals. 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