On 28 June, 2019, Imamverdi Ismayilov, 29, set himself on fire in front of Mingechevir City Hospital in Azerbaijan; he died two days later.
According to his family members, the reason for his suicide was negligence by doctors toward his four-year-old son, daughter who suffers from epilepsy.
Imsayilov’s wife, Sabira Ismayilova, says they brought their daughter to the hospital around midnight with a temperature of almost 41 degrees (105 F). She claims the doctor refused to provide necessary medical service and suggested they come back the next day.
“My husband once again asked him to help, but the doctor insulted him. So he pushed the doctor back. The doctor punched him a few times, and after all this Imamverdi went out and burned himself.”
Imamverdi thought his child was dead. He left the hospital but soon returned with a bottle of gasoline, and set himself on fire.
A nurse in the hospital’s child care department who asked to remain anonymous says Ismayilov was told the daily limit for patients using health insurance had been reached; hence, the doctor did not want to accept another patient.
After Ismayilov’s death, the hospital treated his son and he is presently in good health.
Compulsory health insurance costs 120 manat ($71) annually for Mingachevir city residents. This mandatory pilot program was announced in 2016 and took effect on Janury 1, 2017. One major problem with the program is that doctors can treat only 20 patients daily.
“His son was brought to our department,” the nurse said. “We can accept only 20 patients per day. If the doctor does not want to, he does not have to accept more patients.”
The program does not bar doctors from seeing more than 20 patients, but this information didn’t always get communicated to doctors working in the regions.
“The workload is high, and the number of doctors is very small.” the nurse said. “Due to the overload, treatment for the boy was delayed, and his father couldn’t bear it.”
Javid Alakbarov says he lost his 10-month-old son Turkel around 10 pm on July 7, 2019, due to the lack of doctors and medical equipment at the Aghdash region central hospital.
His son was having trouble breathing. Alakbarov was told there were no doctors and equipment, and that his son should be taken 240 kilometers away to Baku.
Eldar Karimov, head doctor at Mingachevir City Central Hospital, told iFact.ge that the child arrived in very poor condition. “Once they were here, we took the child right to the Department of Pediatric Resuscitation,” the doctor said. “But it was too late for him. We tried hard to save his life, but unfortunately we couldn’t do anything.”
Alakbarov said he still doesn’t have the results of his son’s autopsy. “I’ve written many letters to the General Prosecutor, and all I get every time is that the examination is still ongoing. It has been almost a year.”
According to a Cabinet of Ministries decision, working hours for medical personnel should be 33-36 hours per week and shouldn’t exceed 6 hours per day. Exact schedules vary based on a clinic’s internal regulations.
“Until 2017, my salary was 180 manat ($106) per month. Now I get 450 manat ($265),” said a nurse. “Doctors have limits and sometimes it is impossible to accept uninsured patients.” (The insurance plan covers only Azerbaijan citizens who are registered in the same district as the hospital.)
“We tell our patients and their relatives that if they want, they can pay us a little extra if we take them after we’ve reached our limit. But patients don’t want to do this.” The nurse said patients might be asked to pay 3 manat ($1.75) for an exam and 15 manat ($8.80) or more for a cardiogram or ultrasound.
The pilot program for compulsory medical insurance was supposed to begin covering all of Azerbaijan beginning in January of 2020, and it is supposed to be implemented in the capital of Baku on a step-by-step basis throughout 2020. But it hasn’t happened yet and the government has not announced any reason for the delays.
On December, 20, 2018, President Ilham Aliyev signed a decree creating the Management Association of Medical Areas (MAMA). All city and village hospitals, clinics, outpatient facilities and ambulances were placed under the control of MAMA, instead of the Ministry of Health.
A Law on Health Insurance was adopted back in 1999.
In 2008 an Agency of Compulsory Health Insurance was established under the Cabinet of Ministries.
In 2011, Hadi Rajabli, chairman of the Social Policy Committee in Parliament, said that 1.5 billion manat ($882 million) was allocated from 2009-2011 for compulsory health insurance. He blamed government officials for the failure to launch a program. In 2014, Rajabli conceded that it was a complicated process.
The 2020 national budget allocated 1.4 billion manat ($824 million) At a November 2019 discussion in Parliament, Health Committee deputy chairman Musa Guliyev estimated the government would collect 500 million manat ($294 million) in insurance payments from employers and workers, and that 70-80 percent of that money would be spent on the program.
The State Agency of Compulsory Health Insurance received national budget allocations of 24.5 million manat ($14.4 million) in 2017, 37 million manat ($21.8 million) in 2018, and 224 million manat ($131.8 million) in 2019.
In 2017, pilot programs were launched in only two regions — Yevlakh and Mingechevir. Aghdash was launched in 2018.
These regions were selected based on the numbers of children, pensioners and people with jobs, and the financial and technological conditions of medical services and staffs.
Vugar Gurbanov, director of the Agency of Compulsory Health Insurance, says these pilot programs are a success.
He says salaries have increased and that lab technicians and nurses earn 350-370 manat ($206-$218) per month while doctors and surgeons earn 850-870 manat ($500-$512).
In addition, The Fund to Support Fight Against Coronavirus was established by President Ilham Aliyev. 20 million manat ($11.8 million) was allocated from the national budget; Aliyev donated his annual yearly salary, which publicly is unknown. By 31 May, the Fund had collected 113,473,885 manat ($ 66,887,352 million).
All hospitals including those in the pilot program in Mingachevir, Yevlakh and Agdash regions, have extended working hours in anticipation of the added workload.
According to official news, since March more than ten thousand medical employees have been involved in fight against Covid-19.
The health workers were promised to get their salaries for overtime work. According to the decree signed by the president, the medical workers will be given an ‘urgent bonus’ to their salaries due to their working conditions during the pandemic. The bonus will be 3-5 times their official monthly salaries.
The nurse of Mingachevir City Central Hospital complains that they haven’t got any additional payment for overtime work: “When we ask about it, we are told that we voluntarily work overtime.”
There are many medical stuff across the country haven’t got their overtime payments.
“Sometimes either the personnel misunderstand the regulations or the directors of the hospitals give them wrong information. Regulations read that the medical personnel gets the additional payment for overtime working hours, but not for the whole month,” says Zaur Aliyev, the chairman of the State Agency for Compulsory Medical Insurance.
Regarding to problems of the pilot program, Vugar Gurbanov says the main problem with the pilot program is lack of surgeons and gynecologists.
Before the pilot program, surgeons’ base salaries were lower — 350-500 manat ($206-$294) — and people were expected “to give respect to a doctor” by paying on average 150 manat ($88) for appendix surgery, 300 manat ($176) to deliver a child, or 500 manat ($294) if it required a Caesarean section. Surgeons sometimes perform two operations daily.
Aghayev (who asked to be identified by surname only) is a 45-year-old general practitioner who worked at Mingachevir City Central Hospital from 2009-2017. He said after implementation of the pilot compulsory insurance program, at least 30 percent of the doctors left government hospitals and started to look for positions in private clinics in the regions or in private hospitals in Baku.
“Before the pilot program, my official salary was 250 manat ($147). I was surviving thanks to (the extra) my patients paid,” he said.
“It’s obvious doctors survive because of the additional money they get from patients. It’s worked like this for decades. My monthly income was more than 1,000 manat ($588). That’s a really big amount of money in the regions.
“A surgeon should do at least two operations a day. But in private hospitals, a surgeon can earn the same amount of money from one operation.”
“This insurance can be really helpful to patients, but it is an exploitation of doctors,” says a neuropathologist in one of the pilot programs who wants to be anonymous for fear of losing his job.
“We make appointments with patients at our homes after work and live with the 5-10 manat ($3-6) these patients give us. Even surgeons often do operations at private hospitals to make more money.” This outside work is not allowed and the rules are being more strictly enforced.”
It’s also a problem if there are not enough patients. “We were told by hospital administration that if a doctor has no patients, he/she will be fired,” the neuropathologist said. “Because after the pilot program ends, hospitals should be able to finance themselves.”
The hospitals have been reorganized as public legal entities and will be expected to survive on insurance payments plus any extra money they collect from uninsured patients who come in.
“In the regional government hospital, usually only two or three doctors are well known, so they make more bonus money because people are fighting to get appointments with them,” said a Yevlakh region central hospital doctor.
A gynecologist at the central hospital in Aghdash complains that his salary of 768 manat ($452) is similar to other doctors with easier practices.
“Other doctors are just doing some checkups, reviewing the medical tests, and that’s all. Their monthly salary is 600-700 manat ($US353-$412). But our work is really hard; we do surgeries, we deliver the babies.
“Aghdash is very small place with few places to work, so we don’t have any other choice but to agree to everything we are offered.”
Adil Geybulla, who works in Baku private clinics, says most doctors are not satisfied with the pilot insurance program because it takes the wrong approach.
“World practices should be followed in this program,” he said. “Monthly salaries should be fixed — 1,500-2,000 manat ($882-$1,176) — based on seeing 10 patients daily. If a doctor sees more than 10, there should be additional payment.
“This program should work to improve medical care, and not to treat patients as if they are business customers.”
A 2017 Compulsory Health Insurance Agency report makes it clear that the number of doctors at government hospitals is decreasing.
Shukur Eyvazov, head of the Department for Regional Centers at the Azerbaijani State Agency for Compulsory Medical Insurance, told iFact.ge that the number of doctors employed under the pilot project is 565 and that there are 15 vacancies.
“Patient admission rules are used to improve the efficiency and quality of medical services. According to international medical standards, excluding emergency situations, a doctor should spend on average 20-25 minutes per patient. According to the Labor Code of the Republic of Azerbaijan, doctors at medical institutions work 6 days in a week and 6 hours a day, from 9:00 to 15:00. Thus, during a six-hour working day, one doctor can serve up to 20 patients, which is written in the “Regulations on Amendments to the Rules of Standards,” Eyvazov wrote in reply to a reporter’s questions.
Eyvazov says gynecologists and surgeons should examine at least 10 insured patients daily, and no more than 20. He says that according to the pilot program, 15 percent of the payment for every surgery or child delivery over 10 patients in one month will be paid to these doctors as a bonus.
“Mingachevir is a city with a large population (104,500 in 2018),” says the anonymous surgeon working there. “But what about the less populated regions? You don’t do 10 surgeries in a month in those areas. How can those doctors get bonuses?
“I can say for sure that compulsory medical insurance will not help anyone except 3-5 well-known doctors working in hospitals in Baku.”
According to Eyvazov, Emergency Medical Departments (EMD) at medical facilities in pilot areas provide 24-hour service to citizens. There are no restrictions on medical care calls, or on direct referral of patients to EMD. Patients are treated on an out-patient and in-patient basis.
In the cases of the children of Imamverdi Ismayilov and Javid Alakbarov, nobody was punished after their deaths.