Health Insurance Plan Stalls in Azerbaijan

A reform introducing medical insurance in Azerbaijan is now years overdue, and the old system is creaking at the seams – notionally free, but with patients paying numerous informal fees for treatment.

A law providing for medical insurance came out in 1999, but a decree setting up a state insurance agency did not appear until 2007. The agency has received funding every year since then, including an allocation of 30 million manats for 2012, about 38 million US dollars, but the system has yet to start operating.

Once the reform is completed, Azerbaijanis will still receive free basic healthcare at the point of access, but additional items and treatment will be charged to their insurance scheme, which will be compulsory for all.

In theory, the most essential treatment is provided free by the state. Reforms in 1994 and 1998 moved away from the Soviet system where everything was free by introducing charges for an expanding list of services.

The hope was that this would stop hospital staff levying unofficial fees which often amounted to bribes. That did not happen. A study published by the Azerbaijani Centre for Economic and Social Development in 2009 found that in reality, people were paying 75 per cent of their medical expenses themselves – five per cent in official fees and the rest in unofficial payments.

Photographer Adel Aliyeva described staff at a state clinic in the capital Baku demanded money for maternal health treatment, which is nominally exempt from charges in Azerbaijan.

“Blood tests [at maternity clinics] are supposed to be free, as are examinations by doctors. But they wouldn’t take blood without a payment of two or three manats. They wouldn’t let me into the hospital without a payment of 50 manats [63 dollars] for the head doctor…. When I handed over my medical card, that cost me another 20 manats,” she said. “When I was reluctant to pay, they made me wait in line until I fainted. They were rude and arrogant.”

Experiences like this make Azerbaijanis like Aliyeva believe compulsory health insurance is the only way to impose order. “I think it would be very convenient,” she said.

The insurance scheme would require all Azerbaijanis to pay affordable monthly insurance contributions, and the scheme would pay out for treatment as they accessed it.

Medical staff say they have no option but to ask for cash from their patients under the present system.

“You have to understand that doctors are people, too, and they need money to live on,” a medical practitioner who asked not to be named said. “I am a doctor, a professor and a head of department, and my official salary comes to 240 manats [300 dollars a month]. Really, can I survive on that? So I’m obliged to take money from patients for operations. If I was on a salary of several thousand manats, like my colleagues from advanced countries, I’d have no reason to take money from patients.”

Azer Mehtiyev, head of the Civic Movement for Assisting Economic Initiatives, which has conducted research into how compulsory insurance could work, says the current system is no longer workable.

“The current system of state healthcare, where the services of a state doctor are free, is a hangover from the Soviet system,” he said. “The state builds hospitals and buys equipment – but that hasn’t led to any particular improvement. As before, people are paying for treatment themselves and doctors are on low salaries.”

For those who can afford it, Mehtiyev said, “the private sector charges very high prices and doesn’t exactly offer the best quality because there’s little competition. Many private hospitals recruit foreign doctors, but people here go abroad for treatment, to Iran, Turkey or Russia.”

Mehtiyev said compulsory insurance would fix many of these problems, along with other modernising reforms such as higher pay for staff in the state healthcare sector.

Hadi Rajabli, chairman of parliament’s social policy committee, blamed government officials for the failure to get a nationwide insurance scheme off the ground.

“There are sluggish, incompetent and indecisive officials who just don’t want to get involved in this work,” he said.

Rajabli said parliament would set about resolving all the outstanding issues over the next year.

Within government, there seems to be some confusion about who is supposed to get the insurance reform rolling.

Health ministry spokesman Anar Gadirli told IWPR that all questions about the insurance scheme should be directed to the central cabinet office, whose social affairs department was responsible for implementation.

The cabinet office’s spokesman, Akif Ali, who has previously said the reform would be handled by staff there, told IWPR they were not involved.

“Questions about state insurance do not pertain to government officials,” he said. “You need to address them to the health ministry.”

Vafa Zeynalova is an IWPR staff reporter.