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The Canadian Society for International Health (CSIH), composed of over 900 members, has been active in the South Caucasus since 1996. Building on our work in Eastern Europe in the early 1990s, we implemented two small health projects from 1996 to1998, and we are now engaged in the Trans Caucasus Health Information Project, a two-year, $1-million, capacity-building effort funded by the Canadian International Development Agency (CIDA). Currently, we are considering further work in the fields of health information and environmental health.

Like most Canadians, we feel we have much to learn about the region encompassing Armenia, Azerbaijan, and Georgia. Nevertheless, we have gained enough experience to learn some basic lessons about health and environment in these countries, and how these issues inter-relate with Canada’s key foreign policy objectives, as set out in Canada in the World: supporting global prosperity and human security, and projecting Canadian values.

Our main concern is that Canada should not rely on trade and economic development alone to solve the serious problems of the South Caucasus. Canada should consider a long term, strategic investment in social development of the region, including the promotion of human health and environmental sustainability.  

While many rejoiced when Soviet domination ended in the Caucasus in 1991, the sad truth is that there has been a dramatic decline in standards of living and of health. Life expectancy for men has fallen in the Caucasus, as it has in most of the Newly Independent States (NIS) of the former Soviet Union. High maternal and infant mortality rates are common to all three countries of the South Caucasus. Tuberculosis, diphtheria, cancer and cardiovascular disease are all on the rise. New or re-emergent health problems are also affecting the region, such as malaria and HIV/AIDS. Many who once had access to free medical care cannot afford the cost of the new fee-for-service systems. As an example, in Georgia in 1998 only 20% of seriously ill people were treated in a clinic and only 5% in a hospital, mainly due to lack of money. Nutritional standards have also fallen. In Azerbaijan, nearly 22% of children aged 6 to 59 months suffer from chronic malnutrition.

The decline in health standards has been in process since the mid-1980s, when the Soviet health system, which had emphasized curative medicine and quantitative results, began to show signs of strain. The economic collapse and political upheaval associated with the fall of the Soviet Union worsened the situation dramatically. Violent conflicts in Nagorno-Karabakh, South Ossetia, and Abhkazia have also caused negative health effects, through the direct casualties of war, the creation of huge populations of refugees and internally displaced people (IDPs), and the disruption of health care systems. In Azerbaijan, there are an estimated one million refugees and IDPs, amounting to 11% of the population. Many of them live in deplorable conditions in camps or sub-standard housing.

Ironically, the physical infrastructure of health care systems in the Caucasus is very developed. There are more hospital beds per capita than in some countries of Western Europe, and there is a higher ratio of doctors and nurses to total population than in Western Europe. But it is a huge challenge for the financially strained Ministries of Health to put these historical resources to good use for the present situation. Thousands of trained medical doctors are now un- or under-employed, as the health system cannot afford to pay them. Many hospitals and clinics are underutilized due to lack of staff or equipment. Health professionals and administrators lack training in preventive medicine and public health.

 Health Reform Efforts

Armenia, Azerbaijan, and Georgia are all making efforts to improve the health situation. All three countries are active members of the World Health Organization (WHO – European Region), and as such have benefited from programs promoting health policy reforms. Georgia has developed a policy framework along the lines of the WHO "Health for All" approach, emphasizing the principles of justice, accessibility and equity. One of the features of Georgia’s new health strategy is a state health insurance scheme, which is planned to cover the whole population by the year 2010. Armenia has made strides in the re-training of medical professionals, emphasizing a new role in public health. Azerbaijan has collaborated with foreign agencies in addressing the serious health problems of the refugee population, such as malaria, tuberculosis, and high maternal mortality.

In general terms, following the advice of the World Bank and other Western donors, the three countries have all opted for some sort of public-private mix in their health care systems, though the transition from the former Soviet system is by no means complete. Until now, most of the models they have examined as options range from the highly-privatized American system to the highly-public health systems of the Nordic countries. Through Canadian initiatives such as the Trans Caucasus Health Information Project, health professionals from Armenia, Azerbaijan, and Georgia are now learning about the Canadian approach.

In practice, the three countries are undergoing both formal and informal privatization of health services. While the governments gradually build new systems that theoretically will be available to rich and poor alike, private clinics are already being established to accommodate the wealthy minority. Some very modern health technology and practices are available, for a fee, while many people are unable to receive basic medical treatment. Unfortunately, this process seems destined to increase the already growing gap between rich and poor, keeping health standards low for the majority of the population.

Health financing is obviously a key factor limiting the pace of reform. All three nations in the Caucasus have extremely low per capita GDPs, which have fallen to the level of developing countries in Africa and Asia. In turn, the percentage of that GDP spent on health is also very low – between 2% and 4%, compared with an average of 8% in Western Europe and over 9% in Canada. This translates into a tiny amount of health spending per inhabitant. An Armenian health analyst who visited Canada on an educational tour sponsored by CSIH pointed out the huge difference between total annual health spending per capita in Canada and Armenia: whereas Canada spends $2,608 per inhabitant, Armenia spends just $8!

However, according to the United Nations Development Program (UNDP), taking Georgia as an example, "insufficient financing is only half of the government’s problems. The other half involves the management of these resources." The UNDP and other international agencies believe that, while it will take a long time to generate sufficient resources to fund the health care system adequately, there are some shorter-term measures that can be taken to improve efficiency.

 The Role of Health Information

Reliable health information is essential for effective decision-making in the health system of any country. According to the Canadian Institute for Health Information (CIHI), which has been involved in the Trans Caucasus Health Information Project, "we can’t come up with long term solutions until we have a better understanding of what the problems are." The current health information systems in the South Caucasus are largely inherited from the Soviet period. These were highly centralized, lacking in reliability and comparability due to the use of different definitions and standards. With the breakup of the Soviet Union and consequent political and economic upheaval, information systems were disrupted, leading to dangerous gaps in knowledge about health trends.

In the past few years, all three countries of the South Caucasus have begun to reform their health information systems, following international standards set by the World Health Organization. Their goal is to base their systems on data that is valid, reliable, and comparable, and to integrate clinical, administrative, and financial health information so that it becomes an effective support for choosing priorities, optimizing investments, avoiding duplication, and improving the quality of care. Noting the similarity of health issues in the region, the three countries are also interested in establishing an inter-country health information network in the South Caucasus.

The Trans Caucasus Health Information Project started in 1999 with a needs assessment, the formation of a regional steering committee, and the initiation of training activities, using Canadian experts from the School of Health Information Science at the University of Victoria. A collaboration agreement was signed between the Canadian Society for International Health, the World Health Organization, and the Ministries of Health of Armenia, Azerbaijan, and Georgia. While this project is based on initial capacity building, much more work is necessary to strengthen health information systems at the local, national, and regional levels.

 Environmental Health

During the Soviet period, the South Caucasus was an important source of petrochemical, metallurgical, and chemical products for the Soviet Union. The vast oil and gas reserves of the Caspian Sea were exploited in Azerbaijan, and several major industrial and chemical plants were concentrated in Armenia. These activities were located close to urban areas, with little regard for the negative health effects they caused. Agriculture in this region supplied other Soviet states, using high amounts of fertilizers, pesticides, and herbicides, as was common practice at the time. The presence of nuclear power plants and military installations was another source of concern about environmental health. Due to the lack of environmental regulation, there has been a high degree of soil and water contamination, and air pollution in the South Caucasus, tempered only by the dramatic reduction in economic activity in the early 1990s.

Additional environmental health problems are caused by dilapidated water and sewage systems. There have been several outbreaks of waterborne diseases in the region, including bacillary dysentery, shigellosis, and intestinal diseases – all of which are preventable.

The devastation of war in Nagorno Karabakh and in parts of Georgia have caused environmental problems such as deforestation and soil erosion, making it more difficult for the rural population to secure their livelihood. Land mines are a continuing risk for the population in these areas.

Armenia, Azerbaijan, and Georgia have all drafted national environmental action plans, with the support of the World Bank, the World Health Organization, and other international agencies. However, there is a long, hard road ahead to carry these plans to fruition, and ensure a common commitment to sustainable development involving actors from government, business, and civil society.

Canada has much to offer this region in the fields of environmental protection and promotion and human health, given our expertise in these two related areas. The process known as Environmental Health Impact Assessment was developed in Canada over twenty years ago, as a way of highlighting the risks to human health when examining the environmental impact of proposed projects. CSIH is currently developing a project proposal concerning environmental health for the Caucasus.

As observed by the World Health Organization, "economic growth may be conducive to better income, social tolerance and welfare, and finally health, but such a positive effect is not automatic. The prerequisites of health can even be adversely affected under economic growth if the appropriate social policies are not in place."

As Canada contemplates growing involvement in this part of the World, we should be mindful of this warning. If we simply promote trade and industrial development without also promoting effective social policies and concern for environmental sustainability, we run the risk of harming people rather than helping them. As the region begins to re-establish economic activity in industry, mining, and agriculture, it is important to ensure that human development is deliberately promoted through capacity building, policy development, public participation, and concern for equity.

Risks to human health must be adequately identified and mitigated in the process of development, otherwise negative trends will simply continue. By the same token, promotion of health and wellbeing can contribute to economic development through productivity improvements and reduced health care costs.

Women’s health is of particular importance to CSIH in its work in the Caucasus. Through our project activities, we have learned that, while differences in population health outcomes have historically not been significant between males and females, there have been some worrisome trends during the transition years of the 1990s. Unemployment has placed a particular burden on women, as they struggle to provide for their families while searching for a means of income.

Maternal mortality is a big problem in all three nations, especially as access to the health system has declined. Georgia’s maternal mortality rate of 68.5 per 100,000 births is five times the WHO target for Europe. Reduction of these rates has become an important priority for the Ministries of all three countries in the South Caucasus.

A Georgian participant at a CSIH regional event in the South Caucasus commented, "the mosquitoes don’t stop at the border." If malaria is a problem for one country of the region, it is likely to be a problem in the other two. While official governmental relations are tense, health authorities see a ready need to collaborate and are willing to do so without hesitation.

Though often faced with practical difficulties of transportation and communication, CSIH has made an effort to take a regional approach to its work, giving equitable attention to the health information needs of each nation while attempting to build consensus for a regional network. We plan to do so as well in the area of environmental health, another area of mutual concern to the three countries.

The Carnegie Commission on Preventing Deadly Conflict, which has studied diverse conflict situations throughout the world, has recognized the value of attention to environmental concerns in a conflict area. "The Commission believes that more strenuous and sustained development assistance can also reduce the risk of regional conflicts when it is used to tie border groups in one or more states to their shared interest in land and water development, environmental improvement, and other mutual concerns."

The Commission argues that attention to human well-being has a positive effect on peace building. They caution, however, that development must be equitable to be effective, supporting people’s own efforts to improve their situation. "Economic growth, by itself, will not reduce prospects for violent conflict and could, in fact, be a contributing factor to internal conflicts."

While Canada may not be a major player in the South Caucasus, we believe that our country can make a positive contribution to building peace and human security in this region, which ultimately benefits Canadians as well.

Canada can help Armenia, Azerbaijan, and Georgia work together by supporting diplomatic initiatives for peace as well as development efforts targeted at issues of common concern, such as health and the environment. Our own trade interests must be balanced by support for social development and sustainability, and we should make ourselves aware of the impact of our economic and development activities.

Collaboration with European-based international agencies is essential, in order to maximize the impact of small-scale Canadian initiatives and ground them within broader, longer-term processes of social reform that are closer to the region, not just in geographic terms but also culturally and politically.

Special attention should be paid to the politics of oil development in the region, as it is of strategic importance not only for the people of this region but beyond.

In the areas of health and environment, CSIH believes that the Canadian experience can be particularly useful to the South Caucasus as these nations build their own capacity to maintain social services and ensure ecological sustainability while stimulating the market economy. Our own equity-based model of health care and our experience with environmental health can be tapped in capacity-building efforts in the region. In the process we may learn some lessons ourselves about how to face human needs with tiny budgets and adverse conditions.

 Recommendations

1. Consider a long term, strategic investment in social development of the region, including the promotion of human health and environmental sustainability.

2. Promote greater awareness of our own impact in this region, by bringing together Canadian actors from government, the private sector, and NGOs.

3. Pay special attention to the oil and gas sector, including an analysis of the potential impact of future development on the environment and human health.

4. Work closely with international organizations active in the region, especially those based in Europe, to promote peace and human security in the region.