Introduction

Health care in the south Caucasus has suffered as a result of the socioeconomic decline that followed the collapse of the Soviet Union and the ensuing—still unresolved—conflicts between Armenia and Azerbaijan over Nagorno-Kharabakh and between Georgia and its breakaway republics Abkhazia and South Ossetia. As in most parts of the former Soviet Union, these places have increasing cardiovascular mortality, a high burden of mental illness, and spreading infectious diseases such as tuberculosis, sexually transmitted infections, and HIV.1 2 However, the widespread underreporting in dysfunctional and collapsing health systems leaves considerable uncertainty about actual figures.3

Collapse of healthcare services

Access to health care and the role of the state as healthcare provider are open questions in the south Caucasus. Instead of questioning and contributing funding to the extremely low government health budget of about US$10 (£5.4; €8.1) per capita—as low as in many sub-Saharan countries in Africa2—the World Bank has explicitly encouraged health reform that aims to contain healthcare spending and reduce the state's role in healthcare delivery.4 It promoted introduction of user fees for public services in Armenia and Azerbaijan and of health insurance in Georgia. Although efforts to reform a vast and hugely inefficient system are laudable,5 they are insufficient to compensate for the lack of state health funding, which exacerbates the medical poverty trap.6 7

Stigma and isolation are two of the main problems for people with mental illness and their families: woman with psychotic disorder in her home (credit: German Avagyan 2003)

Healthcare services are in a state of almost complete collapse. This is obvious in the state of many health facilities, especially in rural areas, where collapsing buildings remain unheated during extremely cold winters; …