Azerbaijan's Flawed Healthcare System

A spate of high-profile allegations of medical malpractice, which has led to several fatalities, has served to increase many Azerbaijani’s already jaundiced view of their country’s public health system.

Most citizens have little faith in Azerbaijan’s healthcare, even though life expectancy has markedly improved over the past quarter of a century.

The average lifespan rose from 60 years for men and 66 years for women in 1990 to 69 years for men and 76 years for women in 2015, according to the World Health Organisation (WHO).

Maternal mortality dropped from 64 to 25 per 100,000 live births over the same period, while the mortality rate of children under five fell from 20 per 1,000 children to seven.

Yet in spite of these positive developments, the perception is quite different. Many ordinary people distrust doctors and medical institutions, reporting experiences of corruption and malpractice in the medical sector.

Media reports of recent incidents have spurred public debate over substandard care.

In June alone, seven deaths in hospitals across the country were widely presumed to be the result of medical negligence, although a subsequent official enquiry found evidence of misconduct in only two cases.

On June 21, two babies of a set of triplets born prematurely in the Salyan district in the southeast died.  A week later, the third baby died as well.  The relatives say the babies died because they were not put into an incubator for preterm children in a timely manner.  The incubator did not work because there was no electricity in the hospital.  

“What century do we live in? Why does the hospital not have a generator in case of a power outage,” the grandmother said.

On June 25, six-month old Salim Lachinov, who was suffering from an intestinal obstruction, died after surgery at the Central Hospital in Zagatala.  His parents said their baby was a victim of negligence, although the hospital said the child had been gravely ill and they had done all they could to save him.  

That same day, 82-year-old Tarlan Aliyeva, a diabetic, was to have her gangrenous left leg amputated at the Angiology and Microsurgical Centre in Baku.  Instead, her right, healthy leg was amputated by mistake.  The left leg was amputated a few days later.  A month later, she died. 

On June 26, 35-year-old Lumu Veyisova underwent a gallbladder operation in an emergency hospital in Sumgayit and died on the operating table.  The 81-year-old surgeon, Jafar Guliyev, whose hand was seen to be shaking during the operation, nicked an artery causing her to bleed to death.

Then on June 30, three-year-old Arzu Gurbanli died in a private clinic in the city of Sumgayit after an adenoma operation. 

In response to this series of deaths, the ministry of health created a special commission. Guliyev was dismissed and the chief doctor of the hospital where he had been working was reprimanded, a ministerial spokesperson told the Azerbaijan Press Agency (APA).

The ministry´s press secretary, Liya Bayramova, defended the fact that Guliyev was still operating at his advanced age.

“The doctors have to go through certification every five years, and during this time their level of performance is established.  If a doctor has a scientific degree, a name held in high regard and ability to work, then the contract with him can continue regardless of age.  Jafar Guliyev, despite his advanced age, was certified.  How this came about should be for the commission to find out,” Bayramova told IWPR.

A criminal case was also opened against the surgeon who amputated Aliyeva’s leg on charges of causing grievous bodily harm through negligence.  He faces a fine of 500 manats (300 dollars) or six months in jail.

In the other cases, the commission concluded that no negligence was involved.

WIDESPREAD MISTRUST

Khadija Hajili, a doctor and a member of the opposition Republican Alternative movement (ReAl), said that medical staff were often able to act with impunity.

 “Doctor’s negligence often goes unpunished,” she said. “The second reason is the lack of independent experts and mandatory health insurance.  Citizens faced with doctors’ negligence simply cannot prove it.

“On the other hand, the ostensibly free medical services make patients dependent on public hospitals.  In private clinics, the service is expensive.  In the state [clinics], one has to [bribe] doctors informally but less than private ones [cost]. And if people had insurance, they would have the opportunity to be treated where they want,” Hajili continued.

The main reason for the sorry state of public health in Azerbaijan was endemic corruption, she concluded.

“At [Azerbaijan’s] Medical University, as in all other state universities, students pay bribes for good grades.  At health facilities, [medical] personnel pay bribes to get a job, and then they take bribes from the patients to again pay a bribe to stay in this job.  All this causes mistrust in the healthcare system of the country,” Hajili said.

However Galib Aliyev, chairman of the Association of Physicians of Azerbaijan, argued that the central problem was a lack of effective management within the Azerbaijani health system.

He said that 70 per cent of the budget was spent on equipment, clinics and the construction of new hospitals, while only per cent went towards paying the salaries of medical personnel.

“Doctors’ salaries in Azerbaijan are three times less than unemployment benefits in Europe,” he said.

The average salary of a public hospital doctor ranges between 130 - 450 manats (80 to 277 US dollars), depending on qualifications.

Aliyev said that low salaries were the main reason why doctors and nurses often violated medical ethics.

“As a result, people lose confidence in the whole system.  Clear legislation is needed, according to which the work of doctors will be closely evaluated, and they will carry responsibility for their negligence.  In 2008, our organisation developed a draft law entitled ´doctor´s code´ and proposed it to parliament.  But parliament has still not considered it,” he told IWPR.

In 2012 – the only year for which figures are available - the ministry of health recorded 235 cases where people were prosecuted for public health violations.  Of these criminal cases, 52 were connected to maternity hospitals and pre-natal clinics.

Meanwhile, the government is planning to introduce compulsory health insurance in two districts of the country next year as a pilot project.  The aim is for citizens to receive high-quality medical care while creating a competitive environment among public hospitals and eliminating unofficial payments.

“We are going to implement this process in stages,” Zaur Aliyev, director of Azerbaijan’s state agency for compulsory medical insurance under the cabinet of ministers, told the Azerbaijan Press Agency (APA).

“This process will cover all the country after the hospitals in Mingachevir and Yevlakh districts make use of compulsory health insurance. It will be introduced in most parts of the country in 2018.”

However, there are some doubts whether the government´s efforts will go very far. 

“Since the late 1990s, this question has been discussed.  But its introduction has been dragging on,” said Azer Ismayil, an advisor to the chairman of the opposition Musavat party.

“I think during the time of the oil boom the resolution of this problem should have been a priority for the government.  How far it will be possible to implement mandatory health insurance now, when the country is going through an economic crisis, I do not even know,” he said. 

Gulnur Kazimova is an Azerbaijani journalist who lives abroad.