The Health Care System in Armenia (The Historical, Social, and Theological Perspective: Past, Present, and Prospects) Bishop Bagrat (Vazgen) Galstanyan A Thesis in the Department of Theological Studies Presented in Partial Fulfillment of the Requirements for the Degree of Master of Arts at Concordia University Montreal, Quebec, Canada September 2012 © Bishop Bagrat (Vazgen) Galstanyan CONCORDIA UNIVERSITY School of Graduate Studies This is to certify that the thesis prepared By: Bishop Bagrat (Vazgen) Galstanyan Entitled: Health Care System in Armenia (The Historical, Social, and Theological Perspective: Past, Present, and Prospects) And submitted in partial fulfillment of the requirements for the degree of Master of Arts (Theological Studies) complies with the regulations of the University and meets the accepted standards with respect to originality and quality. Signed by the final examining committee: _____________________________________ Chair: Jean-Michel Roessli PhD ______________________________________ Examiner: Paul Allen PhD, ______________________________________ Examiner: Lucian Turcescu PhD _______________________________________ Supervisor: Christine Jamieson PhD ABSTRACT The Health Care System in Armenia (The Historical, Social, and Theological Perspective: Past, Present, and Prospects) Bishop Bagrat (Vazgen) Galstanian The history of Armenia and Armenians remains little known to the world. Yet, it has contributed to the global enrichment and advancement in many areas such as culture, science, religion, politics etc. This thesis, in its entirety is aimed at disclosing and presenting a very small part of the rich experience and practice of Armenians in the field of science and that of medical science. It explores the profound heritage and past practice of medicine in Armenia and how it can apply to the modern day health care system and serve as a valuable tool for the betterment and progress of health care performance. It has been 20 years since the Republic of Armenia has declared independence and is going through many changes on all levels of society. Being in a transition period there are still internal and external unresolved issues, hardships, difficulties and challenges that the people are facing. In this environment the health care system is not an exception. By illustrating the historical background and by giving the ethical and theological perspective, this thesis aims to provide valuable assistance that could impact the performance of medicine in Armenia and provide a necessary means in the bioethical decision-making process. The thesis examines the modern health care system through a theological and bioethical prism; a first attempt to apply a theological analysis of the field of medicine in a cultural context. iii The thesis proceeds in three parts: first, it illustrates the historical background of medicine and its development in Armenia beginning from pre-Christian era up to the Middle Ages and the definition of sickness and the moral code of the doctor. Second, it presents the current status of the health care system of Armenia, the reform process and challenges, ethical deliberation and the specific issue of gender abortion. Third, it analyzes the basics and foundations of theology in relation to medicine and the questions that are nowadays pertinent in Armenia. iv ACKNOWLEDGEMENTS I wish to thank Professor Christine Jamieson, for her guidance, encouragement and valuable advice during the writing of this thesis. In fact, she has suggested and pointed out to me to write this thesis on the Health Care System of Armenia, of which I had neither the expertise nor the knowledge. I greatly thank her for creating this opportunity for me. As well, I want to thank all the professors, who throughout these four years have shared their wisdom and knowledge with me. Special, thanks to Connie Di Fruscia, who has been very helpful and always ready to lend a hand when needed. My heartfelt thanks to Rev. Manuel Jinbashyan who encouraged me to pursue my higher education at Concordia University and also my appreciation to my Dn Hagop Arslanyan who assisted me throughout my studies. My utmost and very deep gratitude to Ana Afeyan, who has edited and refined the text from day one, generously offering her assistance and sacrificing her time and energy towards the completion of this work. I also want to thank Mrs. Gayane Zavaryan, Mrs. Marine Adamyan, Mrs. Emma Sargsyan-Martirosyan and Dr. Agop Hacikyan for their valuable contribution for sharing their knowledge and expertise in the field. I extend my appreciation to Dr. Ara Babloyan, Dr. Razmik Abrahamayan, Dr. Vazgen Kololyan and Mrs. Susanna Tadevosyan as well as the directors, doctors, nurses and patients in the regional hospitals for facilitating the survey process in Armenia and providing important information on the subject. My sincere thanks go to Mrs. Anahid Manoukian for her constant care and encouragement to pursue this endeavor. Also, I want to express my appreciation to my v clergy, diocesan staff and the faithful who have extended their support by enabling me to allocate the necessary time required to complete this research. Finally, my humble thanks to my Lord who has blessed and given me the strength and patience to walk through this most exciting learning process and thrilling journey. vi TABLE OF CONTENTS Table of Contents vii Introduction: The Health Care System in Armenia (The Historical, Social, and Theological Perspective: Past, Present, and Prospects) 1 Chapter 1: Medicine in Ancient and Medieval Armenia 1.1 Overview: Medicine in Pre-Christian Era 6 1.2 Medicine and Health Care in Armenia in the 4th-9th centuries 14 1.3 The Rise and the Advancement of The Armenian Medical Science in the 10th14thCenturies 19 1.4 The Definition of Sickness and the Model of Doctor in Medieval Armenia 22 1.5 Conclusion 35 Chapter 2: The Modern Health Care System and Its Socio-Ethical Perspective 2.1 Overview of the Health Care System in Armenia 37 2.2 Health Care Organizational Ethics 56 2.3 Abortion: The Unborn Daughters of Armenia 79 Chapter 3: Theological Perspective 3.1 The Contribution of Theology in the Health Care System in Armenia 93 3.2 Concluding Remarks 112 Bibliography 115 vii Introduction: The Health Care System in Armenia (The Historical, Social, and Theological Perspective: Past, Present, and Prospects) The purpose of this thesis is to explore the current health care system in one of the former Soviet Republics, Armenia, to analyze and discuss its historical background, current situation and future prospects examined and analyzed through the ethical and theological perspective. Compared to the other Republics, Armenia has suffered severely in the aftermath of the collapse of the Soviet Union. The country had inherited a vertically centralized system, officially free of charge services, planned budget, reimbursement based on reporting where quality indicators were undermined, the focus was on in-patient care but in reality it had a poor clinical practice. There were number of incidents that resulted in harsh effects on the Armenian reality. Besides the very rigidly centralized economic breakdown, the newly independent country had to cope with the devastating earthquake, the war with Azerbaijan, to protect the rights of the Armenian population of the Armenian enclave of Nagorno Kharabagh, and a total blockade by Turkey and Azerbaijan. It has become a landlocked country with no safe, open borders, which further complicated the situation, harsh winters, lack of electricity, and heating, scarcity of food, the poor quality of drinking water and a shortage of supplies, had put the country at the edge of collapse. 1 In summary, to characterize the inherited system and to depict the general conditions of the health care system, a number of issues stand out, which clearly demonstrate the state of affairs that the country was going through and can be identified as follows: excess capacities and deteriorated facilities, outdated technologies and scarce human resources, poor financial resources, disparities between the urban and rural sectors, poor health indicators; earthquake, severe energy crisis, imposed war, economic collapse and poverty. It is noteworthy that in the post-Soviet era, where almost all socio-economic sectors of the former soviet republics were paralyzed and had collapsed, there was an urgent need to re-create new social structure in accordance with the changing value- system within the society. A change of political order required new political, social, economic structures, constitutions, and rules and regulations to secure the transition to and appropriation of a new democratic, free market society with all its challenges. All these factors tremendously affected the healthcare system also. While discussing the historical aspect of ancient Armenian medicine, this thesis presents the rich cultural heritage of medical science of Armenia, which has a history of almost 4000 years. It has contributed richly to the advancement of the universal treasury of natural medicine, which is an inseparable part of ancient Armenian culture and is deeply rooted in the practice of modern-day medicine. It explores the health and social institutions and the healthcare concept in ancient Armenia, the definition of sickness and the perception of the doctor in medieval Armenia. However, it has to be mentioned that it presents only a brief account of the extensive medical history of Armenia as it was not the main purpose of this thesis. It is very important to outline the history and practice of 2 medical perception in ancient Armenia as it still has its implications in today’s performance. By comparing the past and the present, it is obvious that the trend in the modern health care system is more inclined to focus on primary health care, prevention and patient-centered care, just as was the practice of by-gone centuries. Thus, the first chapter illustrates medical practices and perceptions relevant in Armenia in the pre- Christian era, its transformation after adopting Christianity in the 4th century, its rise and development, conceptualization and systematization of medical science in the Middle Ages, and the high standards that were ascribed to the doctors and their calling. This practice of the past centuries is still pertinent and remains a valuable source in present day applications, especially when dealing with some ethical issues. Subsequently, this thesis examines and evaluates the state and trends of health care, as well as the comprehensive reform program in Armenia. It portrays the overall description of the socio-economic situation of the Republic of Armenia throughout early years of its independence (1991-1995), which has gradually normalized and seen many reforms in all segments of life particularly in the health care system. Despite facing serious problems and hardships, the health care system and quality of medical care has gone through many changes and has improved tremendously. Throughout these years, the Armenian diaspora, as well as the International community have been assisting in these efforts by providing substantial expertise, material aid, modern technology and equipment. Thus, the thesis reviews the information, available sources and materials concerning the results of reforms that are to meet all the objectives of health care policy. It deals with the challenging issues of health care services, the impact of socio-economic factors, the principle of equality and corruption. It discusses the resources required while 3