Winter 1995 (3.4)
Infants at Risk - Society at Risk
by Roberto Laurenti
Left: Roberto Laurenti, Head of UNICEF in Baku.
UNICEF's Pilot Program in Guba
Guba-these days, it's known as the place where an infant's chances for survival are the lowest in all of Azerbaijan. No one quite knows all the reasons why this district close to the northern Dagestan border has the highest infant mortality rate (IMF) in the country. But in 1994, for every 1,000 live births in Guba, there were 70 infant deaths-which means 70 babies died before, at, or slightly after birth. It's an alarming figure. It doesn't even approach Azerbaijan's IMR of 32/1000 which in itself is disturbing when compared to the West-for example, the U.S. (10/1000) while Germany and Norway boast the world's lowest rate (7/1000).
These statistics were the reason UNICEF (United Nations Children's Fund), working together with Azerbaijan's Ministry of Health (MOH), decided to combine their efforts and set up a pilot program to try to reverse this disturbing trend. In tackling the problem of infant mortality, they hope to lower morbidity (the ratio of sick to well persons in a community) and the mortality rate (total number of deaths to the total number of population).
But goals for the project extend beyond Guba. If they succeed, the model can serve to revitalize the entire health system in Azerbaijan and be studied, modified and implemented in other countries with similar anthropological, social and economic characteristics.
Left: Head of UNICEF's office in Azerbaijan, Roberto Laurenti (center) with children from the village of Khinalig in the Caucasus Mountains.
The Soviet Health System
Under Soviet policy, the Constitution guaranteed unlimited, free medical care to everyone. The State picked up the bill. But these days, the financial burden is on private citizens. In practice, the existing health structure-which had been conceived to function in a different socio-economic context-no longer works.
The inherent consequences are visible everywhere, starting with Azerbaijani medical personnel who are extremely poorly paid and thus not motivated (about $10 per month). There are incredible shortages of pharmaceuticals. Much of the equipment is old, malfunctioning or broken. Many medical practices are outdated. Consequently, disease, illness and death are on the rise.
Consequences of Delay
Although everyone recognizes the need for changing this obsolete health system, there is no consensus on how to proceed. In the meantime, there is danger in delaying. Undoubtedly, Azerbaijan will become a very rich country one day, but five or ten years may be needed before the effects of the oil production is felt by the general public. It's wrong to expect that wealth will automatically bring about effective reforms in social or health spheres. Such programs must be planned.
During the interim, desperate needs could lead to social discontent which could jeopardize the political stability which, in turn, could directly effect economic development which is necessary to make medical services available in the first place. It's a vicious circle. The prompt introduction of welfare reform on a national level is, therefore, of vital political importance. The solution is to develop an "equilibrium" between the individual contribution and collective responsibility. The "Guba Project" aims directly at trying to find a workable balance.
No Models during Transition
Obviously, the actual reduction of public expenditures and budget deficits is the driving force behind reform. The challenge is to offer quality health care in the most cost-effective way. In the former Soviet Republics such a program must be more responsive to the fast-changing socio-economic environment. The transition from a centralized to market economic system has never occurred before in history. There are no ready-made solutions to the current challenges these countries face. The situation is further complicated in countries such as Azerbaijan, which are simultaneously caught by economic recession and devastating effects of war. What is needed is a "Revolution" without the "R" to create a viable health system without jeopardizing past achievements.
Preventive Medicine Emphasized
UNICEF is conscious of the complexity and delicacy of the issue. But it is also conscious that if reform is delayed, health indicators will deteriorate more rapidly and require even more funding. The "Guba Project" emphasizes preventive medicine, community-financing, and community-management. Specifically, the Guba district will have a leaner structure by favoring out-patient rather than in-hospital treatment. The number of hospital beds will be reduced and some services consolidated. Unlike the Soviet period when decisions originated from the top; decisions will become the local responsibility.
In the town of Guba itself, all specialized clinics (including maternity, dermatology, tuberculosis, and psychiatric) will be consolidated at the central hospital. In the villages, 15 out-patient health centers, each serving a population of 10,000 people will replace ambulatory and intermediate hospitals. Health Councils and Health Committees on the local level will be responsible for determining service fees, salaries for staff, drug prices and exceptional cases.
The Guba Project is the first experimental project of its kind among the Former Soviet Republics. UNICEF knows that they will face various obstacles but they're aware that these kinds of projects are critical to the health of Azerbaijanis and to others living beyond the borders of this country.
Roberto Laurenti is the UNICEF Representative in Azerbaijan. Tel: (99412) 98-05-78; Fax: (99412) 93-82-78; e-mail: <firstname.lastname@example.org. az>.
From Azerbaijan International (3.4) Winter 1995.
© Azerbaijan International 1995. All rights reserved.