Helsinki Citizens’ Assembly-Vanadzor

Due to the spread of COVID-19, on 16 March 2020, according to the RA Government’s decision N 298-Ն, an emergency state was declared in Armenia and a number of restrictins were imposed, which affected psychiatric institutions, as well as persons getting treatment and care in those institutions. Persons getting treatment and care - already under strict restrictions - now faced new prohibitions. In psychiatric institutions, it was prohibited “1) to get parcels and packages, and 2) to have visits (except video calls)”. Though this decision set forth measures to mitigate
consequences of the pandemic, they were not implemented effectively in practice. In 2020, the Group observed how COVID-19 and emergency state conditions affected the rights of persons getting treatment and care and the staff’s performance of their functions. In particular, the Group focused on the institutions’ preparedness to respond to the pandemic, equipment with personal protective equipment, food organization and communication with the outside world. The Group observed how the institutions were prepared to respond to the pandemic, how they were equipped
with PPE, how they organized food and communication with the outside world (in particular, psychiatric institutions were not provided with the devices and items necessary for video calls), as well as measures taken by competent bodies and their effectiveness. The results of the monitoring conducted in 2020 are presented in the Group’s report.

It should be mentioned that during April-May 2021, Helsinki Citizens’ Assembly Vanadzor Office (hereafter referred to as HCA Vanadzor) provided computers to 5 institutions in order to ensure communication with the outside world for persons getting treatment and care.

This report is continuation of the first one. In addition to the previous report, in January-June 2021, the Group implemented assessment of the situation of prevention and control of somatic diseases in psychiatric institutions in Armenia in the conditions of COVID-19.

Results of the study show that 1,5 years after the spread of COVID-19, pandemic-compliant regulations regarding admission of persons in need of inpatient treatment still have not been developed and introduced, and implementation of additional mandatory examinations has not been set in place. For example, in Gyumri Mental Health Center CJSC (hereafter referred to as Gyumri institution), rapid tests are used for newly admitted persons if they have any complaints or fever; whereas, in Sevan Mental Health Center CJSC (hereafter referred to as Sevan institution), such persons are isolated; and in Armash Health Center named after Academician A. Hayriyan CJSC (hereafter referred to as Armash institution), patients are admitted only provided that they have a negative PCR test.

The approach used in Armash institution is not acceptable, though comprehensible, as it violates the right of persons with mental health problems to get a timely necessary treatment. The number of persons applying to those institutions is also worrisome. In April – the month following the decision to declare an emergency state and impose movement restrictions in Armenia – the number of citizens applying to these institutions sharply decreased. The shortage of the relevant community services and their absence in certain provinces generated a situation where the right to psychiatric aid was compromised.

The institutions’ need for personal protective equipment and disinfectants was not assessed, either, and no mechanism was developed and introduced to meet this need. It was up to the institutions to solve these issues.

No specific regulation was in place for COVID-19 vaccination, either. In particular, it is not clear why different dates are set for the launch of vaccination process in the institutions. For example, all the 85 persons receiving treatment and care in Armash institution have been vaccinated, but no vaccination has been done in Lori Regional Neuropsychiatric Dispensary State CJSC (hereafter referred to as Lori institution). As of 31 July 2021, 48.7% (501 out of 1028 persons) of persons receiving treatment and care in the institutions were vaccinated.

It also remains unclear how the institutions guaranteed informed consent of persons receiving treatment and care to get vaccinated, though the issue and the related concerns of civil society were raised in the session of the Council under the RA Minister of Health in March 2021.

With regard to control and prevention of somatic diseases, the study results show that there is no unified regulation regarding maintenance of somatic health, except medicine registration, which is done in almost the same procedure in all the institutions. Monitoring results show that though medical examinations are carried out in all the psychiatric institutions, their list, volumes and regularity differ and are conditioned by each institution’s possibilities and resources. There is also no unified regulation regarding the planned examinations and screening of persons receiving treatment and care. This means that the list and regularity of the minimum medical examinations for somatic diseases – based on which the relevant criteria are to be developed – are not determined, either. The list of mandatory examinations – based on which institutions should either be provided with equipment and specialists or the relevant conditions should be ensured for delegating that service - is not determined, either.

It was also revealed that persons receiving treatment and care have problems concerning their treatment expenses in medical centers (hereafter referred to as MC). The fact that a person with mental health problems is in a psychiatric institution does not amount to grounds for medical aid and service to be provided free of charge or with concessions.

The legislation clearly establishes the list of persons/groups who have the right to free-of charge medical aid and service or medical aid and service with concessions, as well as the types of medical aid and services provided in these conditions. Taking into account that a person with a mental health problem, who does not have any disability group, can be left out of the established list and the necessary medical service – prosthesis, for example – might not be provided free of charge or with concessions, the relevant person’s relative might refuse to pay for the medical examination/treatment, and the institution might refuse or not have the necessary financial resources, the person may be left without the necessary medical aid and service. This issue is aggravated in institutions located in provinces, since a number of medical examinations are not available in provinces and a need arises to cover the cost of transporting the relevant person to the capital city Yerevan.

Psychiatric institutions also face another problem: MC employees have a stereotypical attitude and avoid persons with mental health problems.

The state of control and prevention of oral cavity and eyesight problems of persons receiving treatment and care was also observed. It should be mentioned that the competent bodies do not manifest proper attitude to these problems, which are left at the discretion and good will of the institutions.

In the frame of the study, death cases in institutions and their causes were also observed. The number of death cases recorded during 2016-2020 shows that the lower the number of persons receiving long-term care in the institutions, the lower the mortality rate.

Results of our monitoring also show that the more persons receiving inpatient treatment and care there are, the greater resources are needed for control and prevention of somatic diseases. In particular, those institutions need to be provided with more equipment and narrow specialists.

With regard to the impact of the COVID-19 pandemic on the control and prevention of somatic diseases, our monitoring results show that even regular medical examinations are now canceled or conducted only if the patient has complaints. For example, in 2020, fluorographic examination of persons receiving treatment and care was not organized in National Centre for Mental Health Care CJSC (hereafter referred to as NCMHC), while in Armash institution, regular medical examinations are conducted either if the patient has complaints or if there is a doctor’s
instruction, in order to avoid penetration of the virus.

We find it important to stress that because persons receiving treatment and care are a risk group, preventive examinations are vital. Especially taking into account the danger of COVID-19 in terms of affecting the lungs, and implementation of tuberculosis prevention measures as established by annual healthcare programs approved by the RA Government’s decision, it would be purposeful for the competent bodies to organize fluorographic examinations in all closed institutions in 2020, and develop alternative mechanisms for other preventive examinations. 

Moreover, psychiatric institutions were not included in 2021 state health care program measures, whereas it was already possible to collect data and assess the impact of the pandemic on provision of psychiatric aid, and to plan the necessary preventive measures.

During the COVID-19 pandemic, a number of institutions encountered difficulties, which were mainly related to the need to transfer and hospitalize certain patients in other MCs and the MCs’ refusal to admit patients due to their workload in the intensive care unit. In certain cases, ambulance brigades arrived late or did not arrive at all. The Ministry of Health should have taken the necessary measures to ensure proper medical service for persons receiving treatment and care in psychiatric institutions. We find it important to stress that the state has a positive obligation to ensure proper medical aid and care for everyone.

At the same time, taking into account that there is a need for a regulation and unification of control and prevention of somatic diseases of persons receiving treatment and care, below we present recommendations aimed at solution of the identified problems in the short term.

Legislative 

 Establish the volume of compulsory somatic medical examinations, as well as somatic medical examinations performed where necessary, when the person is receiving psychiatric aid.
 Establish the list of standard clinical tests not only for hospitalization, but also for treatment and discharge of patients.
 Establish that in case of hospitalization, the patient shall undergo a medical examination within 24 hours.
 Establish, by law, the list of free of charge medical services in case of somatic diseases and the procedure of delivering those services.
 Establish the terms for filling in the disease history about the initial, periodic diagnosis.
 Legislatively enshrine compulsory procedures of preventing and treating HIV/AIDS and tuberculosis.
 Develop guidelines for psychiatrists regarding the types and procedures of somatic medical examinations while diagnosing a mental health illness.
 Make a database similar to Kapan electronic database, and develop it, if necessary. This will allow for a unified approach to collecting and processing the data concerning persons receiving treatment and care.

Practical

Control and prevention of the COVID-19 pandemic

 Develop and establish a concrete infection control program, which shall also include an operative plan regarding admission and isolation of persons, and measures to ensure safety of the medical personnel and persons receiving treatment and care, as well as the environment, taking into account the lessons learnt and recommendations of international organizations.
 Ensure proper awareness raising among persons receiving treatment and care (including availability of visible and easy-to-understand posters) about virus symptoms, sources, transmission routes and preventive measures.
 Ensure mechanisms of temporary replenishment of the staff upon necessity in order to guarantee their labor rights and protection against occupational burnout.
 Ensure admission of persons needing inpatient treatment in line with the legal norms and requirements in force.
 Develop and introduce an effective procedure of delivering services to persons in need for psychiatric aid in emergency situations.
 Ensure proper measures for control of the COVID-19 pandemic for persons receiving treatment and care (including for persons who need additional preventive measures) and consistency in implementing them.
 Develop and implement an effective procedure for providing the institutions with personal protective equipment and disinfectants, ensuring the right to receive the necessary treatment.
 Ensure safeguards for informed consent of persons receiving treatment and care.

Control and prevention of somatic diseases

 Develop and introduce a unified regulation regarding maintenance of somatic health by assessing the measures taken in the institutions, their efficiency, current problems and challenges.
 Develop mechanisms for more effective organization of purchasing medications and other necessary items and equipment in psychiatric institutions.
 Develop unified standards for periodic medical check-ups and examinations.
 Guarantee implementation of check-ups and examinations based on the need and necessity, as well as ensure their unobstructed and regular implementation.
 Guarantee priority inclusion of persons receiving treatment and care in psychiatric institutions in screening and preventive examinations implemented in the frame of state programs, as well as proper awareness-raising among administrations of psychiatric institutions regarding those programs and measures.
 Guarantee availability of treatment in MCs for persons receiving treatment and care, based on peculiarities of each case, and not the fact of having or not having a disability.
 Regularly organize trainings for employees of medical centers to ensure proper and dignified services for persons with mental health problems, without discrimination and stigma.
 Guarantee the list of measures necessary to prevent oral cavity and eyesight problems of persons receiving treatment and care, and provide the necessary means in the frame of state programs.

See the report HERE