Baku, 23 May 2012
Members of the press,
Ladies and gentlemen,
Allow me to begin by warmly thanking the Government for inviting me to Azerbaijan and for facilitating a rich and interesting programme of meetings and visits. During my visit, I have met with Government officials, as well as representatives of international organizations and civil society. I have visited health facilities, prisons and prison hospitals, and specialized clinics for people suffering from tuberculosis (TB) and multi-drug resistant tuberculosis (MDR-TB). Throughout my visit, I have been met with warm hospitality and courtesy. There has been a candid and frank exchange of views with senior Government officials. I take this opportunity to thank all those who have given me the benefit of their time and experience. I am grateful to the Government and relevant ministries for all their efforts in organizing and facilitating my mission.
You will find in this room a short document that explains my UN responsibilities as Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (the right to health). In brief, I am an independent expert who reports to, and advises, the UN Human Rights Council and UN General Assembly on the realization of the right to health. Although appointed by the Human Rights Council, I am not employed by United Nations and the position I hold is honorary. As an independent expert, I exercise my professional judgment in order to arrive at my conclusions and recommendations.
Today, I would like to confine myself to discussing some of my preliminary observations, which will be explored in more detail in the final report to be presented to the Human Rights Council in June 2013.
The objective of my mission was to understand, in the spirit of co-operation and dialogue, how Azerbaijan has implemented and endeavours to implement the right to health. The focus of the mission was on four major issues that I find of particular importance in Azerbaijan: health systems and financing, health in prisons and detention centres, prevention and treatment of tuberculosis, and sexual and reproductive health.
I would first like to commend the Government of Azerbaijan for its impressive economic growth since independence and reduction of poverty in the country. However, substantial inequalities continue to persist. The Government is committed to improving health in the country, which is evident from its increasing expenditures on health. For example, from 2003 to 2012 the budget allocation for health increased tenfold, including an 18% increase from 2011 to 2012. Capital investment in the health sector has also increased. Allocation for government investment in health in 2012 has risen by 40% from 2011 and 400 health facilities have recently been renovated or newly built.
However, current government expenditure on health has not kept pace with Azerbaijan’s economic growth and government spending in other sectors. The government currently spends 1.5% of the country’s GDP on health. This is low by international standards, and lower than the averages in the Americas (8.1%), Europe (7.4%), the former Soviet republics (5.9%), and Africa (3%) in 2010. Only 4.5% of Azerbaijan’s state budget is allocated to health expenditures, while the European average was 15.3% in 2010. The Government itself has acknowledged that spending on health is too low. Increasing expenditure on health to meet international standards, including those regarding the right to health, should be of the utmost priority in order to ensure the country’s considerable wealth is utilised toward improving the health of its people.
Out-of-pocket expenditures and informal payments are prevalent throughout the health system in Azerbaijan. In 2010, out-of-pocket expenditures accounted for up to 70% of total spending on health in Azerbaijan, a large percentage of which comprises expenditures on pharmaceuticals. Even though health services are legally required to be provided free of charge in public health facilities, in practice, informal payments for services are all pervasive. This is due in large part to the low salaries paid to doctors and other health care professionals, which in some instances are just above the national minimum wage. Low salaries also contribute to low quality of health services, which in turn erodes the public’s confidence in the health system. Salaries for doctors and other health care professionals should be substantially increased.
The Government introduced mandatory health insurance in 1999, but implementation of the program was initially delayed. In 2008, the Concept for Health Finance Reform and Introduction of Mandatory Health Insurance was introduced and the State Agency for Mandatory Health Insurance was established. However, as of yet, the law on mandatory health insurance has not been implemented. Unfortunately, during meetings with government officials, no one was able to inform me when and how the program will be implemented. I strongly urge the Government to prioritize the implementation of the mandatory health insurance program.
If the mandatory health insurance program is to effectively address the basic health needs of all the people of Azerbaijan it must be funded progressively and prioritize primary health care services. However, as of now it is unclear how the program will be funded and what the scope of the basic benefits package will be. Until these details are available, it is impossible to evaluate whether the program will ensure equitable and sustainable financing for health in accordance with the right to health.
The primary health care system in Azerbaijan remains underdeveloped and underfunded. This is especially acute in rural areas, where clinics are often inaccessible and understaffed and the quality of services is low. Individuals and families living in these areas affected by poverty face the greatest challenges in accessing quality primary health care services. The Government has acknowledged this problem and, in cooperation with development partners, it has begun to invest in the improvement of rural primary health care facilities. However, in order to ensure access to and availability of preventative care goods, services and facilities, I strongly urge Azerbaijan to substantially increase its efforts and resources toward strengthening the country’s primary health care system. This should include, among other things, the training and utilisation of general medical practitioners. Strengthening the primary healthcare system would also ensure government spending on health is more effective in directly improving the health of the people of Azerbaijan.
During my visit, I also looked into the realization of the right to health in prisons and detention centres. I am concerned with the inadequate sanitation and unhygienic conditions in prisons generally, and in prison medical facilities in particular. Such conditions are detrimental to the general health of prisoners and contribute to the spread of disease. The right to health requires medical facilities in prisons to be of the same quality as facilities outside. I am also concerned about reports of the understaffing of prison medical units, which is due in part to the poor conditions in these facilities. The absence of mental health services and services for persons living with disabilities, as well as difficulties faced by prisoners in obtaining transfer to external health facilities for specialized treatment are also of significant concern.
However, I am pleased to learn that the Government is investing in the construction of new prisons and detention centres and the renovation of old facilities.
I commend the Government for the substantial progress it has achieved in addressing the prevalence of TB in prisons through the implementation of universal testing and access to first and second line treatment, which has dramatically reduced the number of deaths due to TB in prisons. However, I am concerned about prevalence of TB, and MDR-TB in particular, among prisoners who may experience interruptions in treatment upon their release. This is due to physical and financial inaccessibility of treatment outside of the prison and the stigmatization of TB within society. I urge the Government to consider establishing a program, in coordination with civil society and community groups, to ensure prisoners receiving TB treatment do not experience interruptions in their treatment upon their release from detention. This is critical to the prevention and treatment of TB outside of prisons and detention centres.
The Government has acknowledged that TB is a serious challenge for Azerbaijan. In response the government has done the following: implemented a national TB program; instituted free first line treatment for TB and free second line treatment for MDR-TB, which is based on DOTS; and established a national reference laboratory and a specialized MDR-TB clinic. However, I have been unable to determine the true extent of progress made on the prevention and control of TB in the general population because of a lack of validated epidemiological data. The dissonance between government statistics and data from independent sources is a major problem throughout the health system. This is of particular concern with regard to the incidence of MDR-TB, which is among the highest in the world. I am concerned that funding for second line MDR-TB treatment, which is largely provided by the Global Fund to Fight AIDS, TB and Malaria, may not be available in the near future.
The stigmatization of individuals affected by TB in Azerbaijan is a serious concern. Stigmatization prevents people from getting tested for TB and discourages affected individuals from seeking treatment. In some cases, affected individuals hide the fact that they are suffering from TB even from their loved ones or obtain medicines obtained illicitly from private pharmacies and discretely engage in self-treatment. Stigmatization is partly rooted in low public awareness about the prevention and transmission of TB. Regrettably, the Government has not involved the participation of affected communities in the prevention and treatment of TB. In particular, former TB patients are not being encouraged to raise public awareness and empower people living with TB to undergo treatment. I would like to emphasize that the participation of affected communities is central to the realization of the right to health and is necessary to ensure sustainable and effective prevention and control of TB in Azerbaijan.
I am also concerned with the pace of the realization of the right to sexual and reproductive health in Azerbaijan. The abortion rate in the country is one of the highest in the world. This is due in part to the practice of sex-selective abortion and the lack of sexual and reproductive health education and awareness programs. I call upon the Government to urgently address the problematic use of abortion as a method of family planning. This should include ensuring contraceptives are available and accessible and that adolescents in particular have access to education and information concerning sexual and reproductive health, both of which are required under the right to health.
Dear members of the press,
I am very grateful to the Government of Azerbaijan for inviting me to visit, enabling me to deepen my understanding of the right to health-related issues. The Government’s invitation, and much of what I have learnt during my visit, confirms that it is taking positive steps in ensuring the enjoyment of the right to health in the country. I would like to use this opportunity to encourage the Government to extend a standing invitation to all special procedures mandate holders, to afford others the same opportunity I have had.
I am happy to be in Azerbaijan during the celebration of the Eurovision song contest. It is clear that when the government is determined, it can achieve results. Now is an opportune time to pause and think whether the government’s investment in people’s health is sufficient to realize the right to health for all. The time has come for Azerbaijan to show the same determination and embrace a Healthvision before the music dies—the people of Azerbaijan deserve nothing less.