Sexual and Reproductive Health in Armenia

Fact-finding mission Ans Zwerver to Armenia in the framework of the preparation of the report on the impact of the reinstatement of the Mexico City Policy by President Bush of the United States of America
(24-28 March 2002, Yerevan)

Introduction

I went on a fact-finding mission to Armenia from 24 to 28 March 2002, accompanied by Olga Kostenko, Co-Secretary of the Committee. The programme of the visit was prepared in co-operation with the Family Planning Association of Armenia (FPA) and its Executive Director Mrs Mary Khachikyan, whose help was very precious.

The programme of the mission included meetings with governmental and parliamentary officials, representatives of international organisations and non-governmental organisations working in the fields of family planning and reproductive rights, as well as visits of health care institutions.

My visit was covered by Armenian TV news programmes and several major newspapers.

General situation

I was welcomed and briefed on the situation in the country by the Family Planning Association of Armenia "For Family and Health" (FPA of Armenia), which is a non-governmental, not-for-profit public organisation. The FPA of Armenia became a member of the International Planned Parenthood Federation (IPPF) and it's European Network in 1999. The organisation has 9 affiliate branches and representative offices throughout Armenia. Its main goals are to a) advance the basic human rights of all women, men and young people, to make free and informed choices regarding their own sexual and reproductive health, b) to advocate in favour of the means to exercise this right and c) to ensure that women’s equality and rights to family planning, sexual and reproductive health remain a priority in national and international development policies.

The members of FPA pointed out that the transition period in Armenia resulted in the crisis of social-economic and cultural life in the country, and consequently the situation of women has worsened. The result is a high rate of migration, poverty, and unemployment which in turn has led to the impossibility for women to fully realise their reproductive rights.

The following obstacles stand in the way of improving women's health:
-low living standards;
- health care facilities’ poor budget;
-lack of a clear state policy directed to the effective development of health;
-unemployment - lack of social welfare;
-unavailability of free medical services.

The State health service now run on a fee basis is paid now and no social security coverage is provided to the population.

At present, the rate of childbirth has decreased, connected with the above-mentioned points as well as with a high rate of migration (including of men).

The number both of single mothers and women who leave their children has increased. Growth of prostitution may be observed among juveniles as well, and a new phenomenon - trafficking in women - has appeared. As a result the number of sexually transmitted diseases, pregnancy among teenagers, and illegal abortions has increased.

Abortion and contraception are legally permitted in Armenia. Induced abortion is one of the most popular methods of contraception. This is partially connected with the sexual ignorance of women as well as with the unaffordability of contraception.

The other method of contraception is coitus interruptus, and only a small part of women use condoms and intrauterina devices because they have to pay for them (according to an Armenian social survey).

As it is indicated in the 2000 Armenia Demographic and Health Survey, there are increasing trends towards beginning antenatal care late and giving birth at home. Armenia also has a high rate of induced abortion, an average of 2,6 abortions per woman over her lifetime.

Impact of the “Global Gag Rule” on Armenia

The FPA representatives informed me that the FPA was not working directly with USAID and its funding was not effected by the cuts on abortion-related activities.

Mr Daduryan, United Nations Population Fund (UNFPA) programme officer informed me that UNFPA has been working in Armenia since 1997 in close co-operation with the Government. 200 000 USD to 300 000 USD are provided by the UNFPA to Armenia each year on reproductive rights programmes. They work in co-operation with other donors, but in general donors interest in this country was not vry high.

He considered that the Global Gag Rule had no direct impact on the reproductive health programmes in Armenia, but had definitely effected the budget of UNFPA, which was reduced up to 40% in some countries. Nevertheless, so far the UNFPA had been successful in protecting its programmes in Armenia.

He also mentioned that money accorded by the USAID to reproductive rights programmes were distributed through different American organisations and, therefore, were not used very effectively.

The first priorities in the reproductive rights programmes should be given to the purchasing of medical equipment, contraceptives, financing of informational campaigns and support to the governmental priorities.

UNFPA gives 30% of their money to local NGOs, 30% to the Government and 20 % to their administrative needs; the rest of the funds are used to support 77 consultation cabinets with medical equipment. In comparison to the Soviet time, when 3 billion USD had been spent for health care, now the budget could offer only 400 000 million USD.

In the discussion with the members of Parliament it was mentioned that USAID had supported the national anti-AIDs programme and had provided assistance for legislative development and the publication of international conventions and other related documents.

During the meeting with NGOs, several representatives of these organisations stated that they had been involved and continued co-operation in different projects financed by USAID, such as PRIME II (a partnership combining leading global health care organisations dedicated to improving the quality and accessibility of family planning and reproductive health care services throughout the world) and the “Reproductive Sexual Rights and Gender Violence” project. The implementation of these projects was successful and efficient. However, the project on family planning conducted by John Hopkins University and financed by USAID was strongly criticised by the society and created difficulties in the adequate understanding of family planning problems by Armenians. Such a reaction had been provoked by the advertising campaign for this project, which was not adapted to the particular situation in the country.

In September 2002 the Ministry of Health and the PRIME II project, with support from USAID, organised a Forum on Improving Quality of and Access to Reproductive and Child Health Care. The Forum made policy and programme recommendations to the Ministry of Health for action to strengthen health services.

In general, as it was stated by Mr Abrahamyan, Consultant to the Minister of Health on Maternal Child Issues the projects financed through USAID partner organisations spent their money on administrative needs and only a small amount of money went directly to the country, while UNFPA had developed a very efficient approach to the elaboration of their programmes. They took into consideration local needs and implemented their programmes with local partners.

Sexual education

The FPA organised several meetings with mass-media and non-governmental organisations. The representatives of the NGOs especially highlighted the problem of sexual education in Armenia. Presently only two health facilities in the city of Yerevan (created by the AFHA) provide free FP/SRH counselling and health care services to young people. The lack of communication and the economic constraints made it difficult for young people from rural areas to travel to Yerevan and benefit from those services at the optimum level. The counselling on STIs/HIV was provided mainly at the STI and AIDS Centres, however, young people had very limited access to those facilities mainly due to the cultural stigma associated with the sexuality of adolescents. Thus, sexual and reproductive health-related needs of adolescents and people of reproductive age were left unprotected and un-addressed.
The representatives of the Youth Forum of FPA spoke of their activities on sexual and reproductive rights education in the regions of Armenia.
They had organised a seven days training-seminar for young peer educators in reproductive and sexual security rights. Young people expressed their need in exchanges with partner organisations from other European countries. They also insisted on the co-operation of the government with NGOs in the implementation of reproductive rights. Young people should also be represented at the international conferences dealing with the problem of reproductive rights in order to represent their position and have a possibility of international exchanges.

Very interesting was the position of Bishop Paren Avedikian, the representative of the Armenian Apostolic Church, regarding the problem of health care for women and unsafe abortions. He said that his Church had never condemned contraception and would support sexual education in schools.

Mr Yeritsyan and Mr Tadevosyan, members of the Armenian Parliament, spoke about the adoption by the Parliament of the Law on reproductive health and reproductive rights. This law gives women the right to decide freely and responsibly on the number and spacing of their children. Abortion is legal and sexual education should be provided in schools and other educational establishments. Unfortunately, few funds were available to implement it.

Sexually transmitted diseases

As it was stated my the members of Parliament, the most dangerous problems related to family-planning and reproductive rights were the increase of sexually transmitted infections and abortions and the limited access of population to health care services.

Mrs Yeritsyan said that the Parliament had developed a programme for 2003 approved by the government on the support to health care services for women in rural areas. Regional medical establishments provided low quality services and because of migration the spread of STI and HIV/AIDs diseases has significantly increased.

Mr Yesayan, Deputy Minister of Social Affairs and Mr Abrahamyan Consultant of Minister of Health on Maternal Child Issues said that sexually transmitted infections created a great danger for the population of Armenia.

Starting from 1988 and up to the end of 2001, in total 169 cases of HIV carriers had been officially registered in Armenia, and 19 of them had already died. However, according to UN data, the estimated number of HIV carriers was about 1500-2200, and most of them were young persons. The main background factors were the lack of sex education, increased migration, and the limited access to preventive and curative medical services.

Governmental policy

In the discussion with the representatives of the government, Mr Yesayan, Deputy Minister of Social Affairs, and Mr Abrahamyan, Consultant to the Minister of Health on Maternal Child Issues, I was informed on the present situation in Armenia regarding reproductive health and governmental policy on family planning and reproductive rights.

The national budget allocation for the Ministry of Health was extremely poor, and there were plans for even further cuts. There was a vicious circle in the system of the Health Service: neither the people nor the government disposed of enough funds to pay medical services.

The government had no resources to implement the Law on reproductive rights and asked international donors to help with the financing. The government had no resources to support the NGOs which were working in this area, but was willingly co-operating with them.

Another important problem was that there were no national educational programs in the field of health care, particularly sexual health.

A National Program of Family Planning had been implemented in Armenia in the framework of which a large number of contraceptives had been supplied. The program was supported by UNFPA.

The government of Armenia had launched an ambitious programme to expand primary health care through the introduction of family medicine and more efficient service delivery mechanisms.

The resources for family planning activities should be invested first of all into technical equipment for the State health services, then to training of health care providers, especially in the regions and to the public awareness campaigns and the improvement of the access to health care facilities.

Recommendations

As a result of this mission I suggest several recommendations aimed at the improvement of the situation in Armenia regarding reproductive rights and a family planning policy:
- encourage international donors and European governments to accord financial assistance to the Government of Armenia for use in the improvement of reproductive and sexual health;
- encourage international donors to develop their assistance programmes in close co-operation with Governmental institutions and NGOs working in this area;
- encourage humanitarian assistance organisations to provide Armenia with contraceptives and medicines for STI treatment;
- encourage the Government of Armenia to include the representatives of youth organisations in the national delegations to international forums;
- encourage the US Administration to continue its assistance to the reproductive and sexual health programmes in Armenia.