HEAD OF THE UN WORLD HEALTH ORGANIZATION’S AZERBAIJAN OFFICE, PROF. HANDE HARMANCI IN AN EXCLUSIVE INTERVIEW WITH THE AZERI OBSERVER MAGAZINE SPEAKS ON THE STRENGTHS AND WEAKNESSES OF THE HEALTH CARE SYSTEM IN AZERBAIJAN AND THE NEW PROJECTS INTENDED TO IMPROVE IT. SHE EXPLAINS HOW ‘WHO’ CONTRIBUTES TO HUMAN HEALTH AND WHAT WORLD EXPERIENCE IN THIS SPHERE COULD BE USEFUL FOR AZERBAIJAN.
BY ELENA KOSOLAPOVA
AZERI OBSERVER STAFF WRITER
Question: Tell us about the main mission of World Health Organization, WHO.
Answer: WHO is the UN’s international health organization. We have a mandate to coordinate international health, which encompasses a huge variety of illnesses, including emergencies, chronic diseases, communicable diseases and everything related to human health. WHO Headquarters are in Geneva, Switzerland, with 6 regional and 149 country offices around the world. The Azerbaijan office is one of 149 offices globally and is in the European region. WHO was established in 1948 and the office here was established in 1994. Until my appointment one year ago, it used to be a local office. Upon my arrival in Baku, its status has changed to international. As the local office, we do what our mandate tells us to do – monitor issues related to human health, help prevent diseases, and promote health. Like other UN organizations, we work mainly with the government to support them in their work. The new status of the office is an indicator of WHO’s commitment to provide Azerbaijan with more international, technical support.
Q.: You said WHO country office has been working in Azerbaijan since 1994. What are the main achievements in this period?
A.: The achievements of WHO are very much reflected in the achievements of the government. WHO office has been supporting the government and especially the Ministry of Health in their work for the past 25 years. For example, we have very close technical relationships with the Public Health and Reforms Center. We worked with them on various projects, for instance, tobacco control. Significant progress has been made in the country with the new legislation on tobacco. Azerbaijan has approved the international Framework Convention on Tobacco Control, which means that the country tries to ensure that its public is protected from the ill effects of smoking, by measures such as banning smoking in public places, increasing taxes on tobacco products and restricting the sale of tobacco products to children.
WHO is very strong in settings norms and standards globally. We collect all the evidence about health issues and come up with evidence-based recommendations to protect and promote human health. For example, smoking is bad for your health, so we collect all the evidence to prove this, and develop recommendations on what the government should do to protect their population’s health. Then, the countries use this guidance to change their policies. We work mainly at the policy level with governments, national parliaments and scientists, and try to encourage them to follow WHO’s recommendations. In addition, we are excellent in promoting the exchange of information and expertise around the globe throughout. There are more than 180 WHO Collaborating Centers around the world, which are excellent in providing solutions for different problems. There are Collaborating Centers on tobacco, HIV, communicable diseases, occupational health, tuberculosis, medical education and many others. These Centers help us translate evidence into policy, create evidence, train healthcare workers, etc. I am very happy to say that there is one WHO Collaborating Center in Azerbaijan under the Ministry of Justice, which focuses on tuberculosis control in prisons. They test inmates for tuberculosis, and treat them if required. They even ensure that people continue with their medication after release so not to spread the disease further into the community.
Q.: Could you tell us about the new projects that WHO is working in Azerbaijan now?
A.: We are working with the government to provide them with technical and normative support in the transformation of the health system. They have set up the State Agency on Mandatory Health Insurance and are piloting its work in Mingachevir, Yevlakh and Agdash. Starting from the 1st of January 2020, this new system will be scaled-up to the whole country. This should decrease the informal expenditures for health, because currently Azerbaijani people are paying a lot of money out of their own pockets for healthcare, and the quality of health services in some places is not very high. So, I believe these are two main reasons that the government of Azerbaijan decided to undertake this transformation. WHO has a lot of expertise in reforming health systems in other countries, and we will use this experience to support the government of Azerbaijan.
WHO is particularly interested in strengthening primary healthcare services in Azerbaijan. This is the first level of care, and it is extremely important if we want to achieve good quality and financially sustainable healthcare in the country. For example, in Europe about 80-90 percent of all diseases are diagnosed and treated at primary healthcare level. It is very convenient for patients as well because they don’t have to travel to go to hospitals, and be forced to take absence from work, and it is much cheaper to treat the disease before it progresses into later stages. Besides, people become empowered at this level through health education, allowing them to take better care of their health issues.
We are currently planning to work with the Ministry of Health and the State Agency on Mandatory Health Insurance to test some innovative approaches to primary health care in Azerbaijan. We’ve already had 2 study visits of national counterparts – employees of the Health Ministry, the Medical University, technical people, doctors, Parliament members – to different European countries to observe well-functioning primary healthcare systems. And after the visits, a working group under the National Parliament was formed to make the necessary legislative changes in primary health care. Now, there will be a year-long trial of the new approaches to primary health care in a test area in Azerbaijan, which is a very exciting project for the health of Azerbaijani people. We are very happy that we are contributing into it.
Q.: How many people work in WHO office in Azerbaijan?
A.: Our office is not very big in numbers, but it is a technically competent office. Currently, we have 7 people in the office, but we are growing. After I came here, I recruited 2 more people, and we are currently recruiting 3 more people, including one international member of staff, because it is important to have international experts in the country, in addition to the local experts. So, by the end of this year, we will be 10. It is a respectable number of people for an upper-middle income country office.
Q.: How do you assess the situation of health care in Azerbaijan?
A.: There is always something to improve upon in every health system. For example, the UK, whose National Health Service (NHS) is an example for the whole world in many aspects, is still evaluating and cultivating their processes. Diseases change, people change, medicines change, approaches change, so you have to change with them. I know the Azerbaijani government have invested a lot in their medical infrastructure in the last 10-15 years. They have built many hospitals, primary health care centers and they are still building. Five more hospitals will open in Azerbaijan by the end of this year. I have been to Zaqatala, Sheki, Gabala, Mingachevir and other cities and they have excellent medical facilities. However, medical infrastructure in other areas still requires renovation and refurbishment. I believe we can assist the government in improving the quality of health care services and making sure it works to their advantage.
Q.: What are the areas, which require improvements to the Azerbaijani health system?
A.: The main weakness is that people spend too much money from their own pockets, and this deprives them of the health care they really need. If someone has cancer, for example, it does not matter how rich they are, because at the end of the treatment period, they will be considerably poorer. If they were financially disadvantaged to start with, they would probably lose everything and become impoverished. This is a global phenomenon; nowhere in the world can people afford to pay for such medical services themselves. That is why it is very important to have a mandatory all-encompassing health insurance. This was the missing link in Azerbaijan’s health system and that is what the government is working on. From our part, we are trying to ensure that they are well informed of the global experiences in this area. The new system will start on January 1 next year, but that does not mean that everything will be perfect and will fix everything from the very beginning. We will continue to support the government, as they will continue to improve the system.
The second weakness is the uneven quality of services and imbalanced distribution of doctors and nurses. Most of the doctors and nurses in Azerbaijan and most medical services are concentrated in Baku, Ganja and Sumqayit. It is important to ensure that people want to go and work in other regions. The government has already identified this problem and I am sure they will work to solve this. One of the solutions is to train people from those regions to be doctors and nurses. Big cities and capitals always attract many people, but there is always a group of people who would rather live in their own cities. We know that the government has improved the salaries of healthcare workers by more than double over the past 2 years, however, there is still room for improvement. I believe the Mandatory Health Insurance Agency will look into this even further.
Q.: What are the main diseases in Azerbaijan?
A.: The main killers of people over the age of 30 in Azerbaijan are non-communicable diseases like heart disease, diabetes, strokes and cancer. This is similar to almost everywhere else in the world. However, there are some issues that surprised me in Azerbaijan. One of them is the low level of exclusive breast-feeding. For optimum health, babies should be exclusively breast-fed in the first 6 months of life; they do not need anything else – no cow’s milk, no tea, no sugar, water, nothing. However, in Azerbaijan the level of exclusive breast-feeding is about 12-14 percent, which is incredibly low. The global target is 70%. We have to look into why this is happening here. There are also important steps the government can take about this. Regulating actions of breast-milk substitute companies, enacting supportive workplace policies, promoting breast-feeding from healthcare facilities and creating community support programs are important steps in the right direction.
The second observation, which has surprised me, is regarding the status of reproductive health. Azerbaijani women have a very high number of abortions, which means they have many unwanted pregnancies. This demonstrates that family planning services are not very strong in Azerbaijan. I think this is an area we should try to strengthen as well.
Q.: Are any projects being prepared to solve these two problems?
A.: Yes, we are happy to contribute on supporting a new law on reproductive health, which is currently with the Parliament. This law will create a basis for improving services within this domain, and I am sure that when it is passed, a lot of positive things will start to happen. We are also working with the Ministry of Health to try to and decrease unnecessary Cesarean sections. A Cesarean section is a very important lifesaving operation, when it is needed. But when it is not needed, it might be dangerous for the mothers’ and babies’ health. Therefore, we want to ensure that it is used effectively and when necessary. For breast-feeding, we are working with the government and UNICEF to promote baby-friendly hospitals in Azerbaijan, which will provide a lot of support to women, to understand the importance of exclusive breast-feeding for their children.
Q.: You mentioned cancers and heart attacks as the main killers of people in Azerbaijan. What kind of measures could improve the situation with these diseases?
A.: Heart attacks and strokes are outcomes of high blood pressure. If you have high blood pressure, you have a higher risk of bleeding or a blood clot, which could obstruct your arteries. If this happens in the brain, it is called a stroke, if it happens in the heart, it is called a heart attack. It is very important in hypertension to diagnose it early, and this is very easy to do by regularly checking your blood pressure. When diagnosed; medicines, improved diet and other lifestyle changes could help maintain blood pressure at a normal level, thus preventing heart attacks or strokes in the future. This brings us back to primary health care. You do not need a sophisticated hospital to diagnose blood pressure elevation. The only thing you need to ensure, is to diagnose it in time, recognize it’s an important problem and manage the disease correctly.
With regard to cancers, a good proportion of them are caused by smoking, an unhealthy diet, alcohol use, some infections, and environmental pollution. If you can neutralize these factors, you can decrease a good number of cancers. So, again, we go back to primary health care – to informing people, giving them education, raising awareness and regular screening. For instance, cervical cancer and breast cancer are diseases you can easily screen for, and if you catch them at their early stages, you will save many lives. It is much more difficult, costly and painful to treat cancers at later stages. Therefore, in some Western European countries, breast cancer screening (mammograms) and colon cancer screening (colonoscopies) is covered by mandatory health insurance, starting from the age of 50. These are very cost effective, because performing these procedures saves insurance companies a lot of money in the future. It would be a great initiative if the State Agency on Mandatory Health Insurance could consider screening for some cancers as part of the new benefits package.
Q.: You said that two things negatively impacted you in Azerbaijan – low breast-feeding and the high level of abortion. Is there anything that positively impressed you?
A.: The reforms. When I arrived here, I saw a lot of enthusiasm and a high level of energy within the government. Many government officials in various ministries are very well informed and interested in what is happening in the area of healthcare. I see a lot of young, enthusiastic, motivated people, who believe in what they are doing in the State Agency on Mandatory Health Insurance. It is really very encouraging. The dedication to improve health services in this country most impressed me. The initiatives are coming from the highest level; from the President and the Vice-President, therefore it is inevitable that good things will happen with such a high-level political will.
Another thing that I felt very good about is a personal one. When people hear that I am Turkish, everyone has a big smile on their face. It does not happen anywhere else in the world. I feel very welcomed here. Everybody says “One nation, two states” and people don’t just say it, but they feel it and live it. So, I am very happy to be here. Besides, I can speak Turkish when I meet with national counterparts, and we understand each other without translation, despite some differences in the language. That changes the dynamics of the relationship, and I believe it will have a good impact on our cooperation.
Q.: Could you speak a little more in regards to your personal impressions about our country? What are the main similarities and differences between Azerbaijan and Turkey for you?
A.: I think the size of the country makes some difference. Turkey is big; Azerbaijan is rather small in comparison. I believe it has a psychological impact, and sometimes an advantage because I feel that Azerbaijan can transform and support its health system more easily. Female empowerment is also a big issue for me. When I go to different countries, I try to see if there are women on the streets, and if they look comfortable walking alone. In Baku, I see a lot of women walking alone, even at night, and they look very comfortable. This gives me a very good feeling about the status of women in Azerbaijan. I also like Azerbaijani art – you have a vibrant art community here with excellent painters, musicians, writers; it is really very impressive. I love the museums here as well; they are very well organized, using modern tools and approaches. Since moving here, I have been to more classical music concerts in Baku than in Turkey. The accessibility of such events is better in Baku. And I must say that I love Azerbaijani food! Yes, it is similar to Turkish food but the taste is different here. I hope my Turkish friends forgive me, but I really find your kebabs and dolma tastier than ours! Regarding our similarities, the main ones of course, are our language and culture. I am sure I will discover many more similarities during my stay here.
