What does ‘free treatment’ mean in Azerbaijan and what kind of malpractice issues exist in the country?
State clinics and hospitals in Azerbaijan are free of charge – in theory. There are also a number of private medical institutions.
Healthcare is one of the most criticised aspects of life in Azerbaijan – the salaries are low (about $130 per month according to official data), and generally of low quality.
What’s the difference between private and state medicine? Where can you get the best treatment and attention in Azerbaijan for medical issues? What should you look for when looking for doctor? We decided to ask doctors themselves.
Dentist Murad Ibrahimov:
“My parents said: ‘Murad, we have friends in this profession. It will be easier to find a job, so go study medicine’. Then I came to like the field while I was studying – it’s a good profession.”
Where to find the best clinics
“I immediately went into the private sector. Even during my studies, I went to work in private clinics, and after graduation I got a job as a doctor in the private sector too.
“People come to private clinics because they believe that the level of service there is much higher, and this is partly true. But when they see the prices, they ask: ‘Doc, why’s it so expensive here?’
“Public clinics do not work as effectively as private ones. The difference is not catastrophic, but there is a strong difference nonetheless.
“And you can see it in basic practices, such as sterilization. I remember once at a state institution, an orthodontist took some of his tools after using them with a patient, and placed them in a vat of alcohol for just five minutes. Never mind the fact that alcohol is a poor antiseptic – you have to leave it in there to disinfect for at least 20 minutes.
“The problem is in financing – I’m sure that the man had many years of experience, and knew perfectly well that just a few minutes in rubbing alcohol cannot be considered sterilization. But he had to do it like that because there was simply no other option.”
‘Tips’ of ‘respect’
The word hörmət [Az. respect] is more often used to mean monetary compensation for a service – that is, a bribe.
While in private clinics you pay your fee at the cash desk, in state clinics you generally give your money straight to the doctor. The amount you should give is relative to your socio-economic status. If you don’t have the means to pay, then whether or not your case is taken on by the doctor is determined by the humanity of the doctor in question.
It’s not all bad though – you might be able to get a consultation and prescription from a doctor for free. But if you need an operation, doctors and patients forget about the hypothetical “free” aspect of medicine in Azerbaijan.
Murad says that in private clinics it is forbidden to take a ‘tip’ from the patient in order to get around the cash desk. However, patients still sometimes try to put money into a doctor’s pocket out of habit.
“I can take a box of chocolates and share it with everyone at work, but money is an absolute no-no. That’s not allowed here.
“As for public institutions, medicine is free only on paper. If you don’t pay the doctor there, at best, they will treat you as one would a dying dog or cat. Or they’ll torture you with bureaucratic procedures. So you can either run away to a private clinic or go home and be sick there.”
What can a doctor be fired for?
“A doctor can be fired, for example, for being rude. We work with insurance companies, and if a patient complains to them, we run into problems. Nothing ever good happens from a patient having a conflict with a doctor. Finally, treating all patients equally is our professional duty.
“I even had to be polite to a patient who complained of ‘debauchery’ after I had to consult with a nurse. The patient said: ‘What, is this a room for romance?’ You even have to address patients that curse you formally, which is difficult because sometimes you can run into patients that just drive you mad.
“I remember one funny case of the dismissal of a doctor – a friend of a friend.
“This doctor worked in a public clinic and it was rumored that he was, so to speak, a lady-lover. But there seemed to be no complaints, as he did not take women to the clinic. At least that’s what people thought. But one fine day, when the junior medical staff came to the clinic in the morning — to clean up before receiving patients — they open his office, and a condom was hanging off the lamp above the dental chair. Naturally, he was kicked out of the clinic for this.
“But not for the condom or just the act, but rather because he forgot to sanitize his office.”
“In private clinics, doctors are generally paid per patient and per the patient’s final account. Others ‘rent’ – they pay for an office and location, and take in all that the patients pay.
“Medical graduates who simply want to practice and earn money usually go to private clinics right away because the decent income lies in the private sector. If you want to do science, get a degree and teach, then they go into the public sector. Becoming an employee of a department at a medical university is only possible by working in a public hospital.
“It is much more difficult to get in there than into private clinics – firstly, there are fewer state hospitals and clinics, and secondly, only students who have completed residencies are taken there. In a private clinic, this choice – whether or not to take on a specialist – falls on the shoulders of the head physicians.
“You can get a job in a private clinic without connections and acquaintances. They can’t have empty positions. This does not mean, however, that just anyone is taken there.”
How to choose a doctor or clinic?
“To be absolutely sure that the doctor is good, you need to talk to him. If he has good, coherent speech and uses medical terms but you understand them well, the choice is right.
“If after a conversation with a doctor you feel smarter, this is the doctor for you.”
Trauma surgeon (name withheld):
“I work in a state clinic. My official salary is 132 manat (approx. $78). But, in Azerbaijan, people in the public sector do not live off of their official wages. It was during the times of the Soviet Union that they decided that the army and police need to be fed by the state, but that the people should feed the doctors and teachers. We still have this system. Doctors live mainly due to what is called ‘hörmət’ (respect).
Why do doctors not go into the private sector?
“In a private clinic, salaries are higher, but in order to work in a private clinic you must have a client base. In order to establish a client base, you still need to work in the state clinic. There you create a name for yourself so that patients come to you and to the private clinic, and pay how much you tell them to.”
In recent years, there have been several high-profile incidents associated with medical malpractice in Azerbaijan:
One girl died on a plastic surgeon’s operating table, one woman had the wrong leg cut off, another was not allowed into a clinic at all, and other such scandals. In such moments, all Azerbaijani doctors are condemned, and there are few that wish to intervene in favor of them.
“Of course, no doctor wants to intentionally harm the patient, despite what some patients sometimes think. The errors generally arise due to inexperience or negligence, and sometimes an accident – for which the doctor is not guilty.
“I had a case when I made a hurried diagnosis. My friend fell down, I examined him, and, in order to calm him down, said: do not worry, the leg is whole. As we drove into the city, I realized that the bone had indeed fractured. He still resents me for it!
“When a patient dies on the operating table, it is 99% of the time the fault of the anesthesiologist. I remember a case of a person who had an allergy that occurs in just 1 of 200,000 people. We did all the tests, but you can’t find it that easy. During the operation, when anesthesia was given, he went into shock and we could not save him. I don’t know what we could have done.
“In general, the responsibility for medical errors is excessive. The doctor is responsible, firstly, to the law enforcement agencies, and secondly, to relatives who will never forget. In most of the cases I encountered, the doctor was tortured unnecessarily, even when he was right on all sides.
“Before some operations, a patient signs a document freeing the doctor of all responsibility. But when a criminal case is launched, this paper is not taken into account. It’s just a formality.”
Not just Baku
“I went to the rural areas to consult with the local doctors a couple of times. It is difficult for me to assess the level of their qualifications, but the equipment there leaves much to be desired, and many combine specialties. One doctor can be a trauma specialist, a general practitioner, an anesthesiologist and a surgeon, all at the same time. Nobody from Baku goes there.”
“There was, for example, a case when I put an Ilizarov apparatus on (metal rings on which there are spokes that pass through bone tissue) a patient’s shin. The device was supposed to be removed in two months, but the patient disappeared.
“Three years later, I ran into the guy accidentally. He was still in the apparatus. He thought that’s the way it had to be.”
How much does treatment cost
For a clearer image regarding the availability of medicine, a look needs to be taken at how the costs of treating various diseases and the average salary in Azerbaijan correlate [real expenses of Baku residents are given – ed.] to each other:
– The average salary in Azerbaijan is 540 manat, or 318 dollars.
Hip fractures – accounts for 10 to 20 average salaries.
Dental caries – about 10% of the average salary.
Removal of fibroids – 2.5 average salary.
Childbirth – from 2 to 4 average salaries.