# Social and Health Assessment of Residents, Refugees and Internally Displaced Persons in Azerbaijan

# 

By:

Tim A. Clary

Mamuka Djibuti

Barry Silverman

Ronald Wilson

Submitted by:

LTG Associates, Inc.

and

TvT Associates, Inc.

Submitted to:

The United States Agency for International Development

Under Contract No. HRN-I-00-99-00002-00, Task Order Number 39

February 2002

![](media/image1.wmf){width="1.7819444444444446in" height="0.875in"}

*Social and Health Assessment of Residents, Refugees and Internally
Displaced Persons in Azerbaijan,* was prepared under the auspices of the
U.S. Agency for International Development (USAID) under the terms of the
Monitoring, Evaluation, and Design Support (MEDS) project, Contract No.
HRN-I-00-99-00002-00, Task Order No. 2, TD#39. The opinions expressed
herein are those of the authors and do not necessarily reflect the views
of LTG Associates, TvT Associates, or USAID.

Information about this and other MEDS publications may be obtained from:

Monitoring, Evaluation, and Design Support (MEDS) Project

1101 Vermont Avenue, N.W., Suite 900

Washington, DC 20005

Phone: (202) 898-0980

Fax: (202) 898-9397

<cbillingsley@medsproject.com>

[www.medsproject.com](http://www.medsproject.com/)

Acronyms and Foreign Terms

ADRA Adventist Development Relief Agency

AIDS Acquired Immune Deficiency Syndrome

ARI Acute Respiratory Infection

BCG Bacille Calmette-Guerin

CDC Centers for Disease Control

CIDA Canadian International Development Agency

CIF Curatio International Foundation

DPT Diphtheria-Pertussis-Tetanus Immunization or Vaccine

EPI Expanded Program on Immunization

FSA Freedom Support Act

FSU Former Soviet Union

GOA Government of Azerbaijan

GDP Gross Domestic Product

GNP Gross National Product

HFA Health For All

HIS Health Information System

HIV Human Immunodeficiency Virus

ICRC International Committee of the Red Cross

ICD-10 International Classification of Disease, Version 10

IDD Iodine Deficiency Disorders

IDP and IDPs Internally Displaced Person and Internally Displaced
Persons

IEC Information, Education, Communication

IFRC International Federation of Red Cross and Red Crescent Societies

IMC International Medical Corps

IMR Infant Mortality Rate

KAP Knowledge, Attitudes, and Practice

MCH Maternal and Child Health

MDR-TB Multi-Drug Resistant-Tuberculosis

MICS Multiple Indicator Cluster Survey

MIS Management Information System

MMR Maternal Mortality Ratio

MOH Ministry of Health

MSF Medecins Sans Frontiere

NGO Non-Governmental Organization

ORS Oral Rehydration Salts/Solution

PHC Primary Health Care

PVO Private Voluntary Organizations

RFA/RFP Request for Abstract/Request for Proposal

RHS Reproductive Health Survey

SES Sanitary-Epidemiological Service

STI Sexually Transmitted Infections

TB Tuberculosis

UNAIDS Joint United Nations Program on HIV/AIDS

UNDP United Nations Development Program

UNFPA United Nations Population Fund

UNICEF United Nations Children's Fund

USAID United States Agency for International Development

WB The World Bank

WHO World Health Organization

Contents

ACRONYMS AND FOREIGN TERMS

EXECUTIVE SUMMARY i

I. Background \...\...\...\... 1

II\. Objectives and Scope of Assessment 3

III\. Assesment Methodology and Activities Undertaken 5

IV\. Highlights of Observations, Analyses, and Key Findings 7

A. Quality of Data and Principal Sources 7

B.  Demographic Overview 8

C.  Environmental and Socioeconomic Overview 9

D.  Health System Analysis 12

E.  Health Status and Current Health Challenges 14

V. The Determinants of Health, Inequities in Health and Health Care, and

Vulnerable Population Groups at Highest Risk 21

A. The Principal Determinants of Health 22

B.  Equity in Health and Health Care 24

C.  Vulnerable Population Groups at Greatest Risk 25

VI\. Conceptual Framework for Planning a Synergistic Social and Health

Development Strategy and Assistance Program for Azerbaijan 27

VII\. Strategic Recommendations: Building a Foundation for Synergistic
Social,

Health and Microeconomic Development 29

A. Develop Multi-sectoral Integrated Development Initiatives in Areas
where

Resident and/or Refugee/IDP Populations are at Highest Rist 29

B. Improve Economic (Family Income), Social Security (Food Security) and

Physical Environments through Community, Micro Credit, and

Enterprise Development 30

C. Strengthen Health System Facilities, Performance, and Financing

Mechanisms 31

D. Strengthen Health System Management, Quality of Data, and Quality of

Service\...\..... 32

E. Strengthen Health Promotion, Knowledge, Practices, and Behavior 34

VIII\. Process Recommendations: Proposed Next Steps to Build a Shared
Vision,

Strategic Plan, and the Essential Partnerships for Synergistic
Development 35

IX\. Conclusion: Prospects for Productive Partnerships to Advance
Social, Health

And Microeconomic Development for All Azerbaijanis 39

ANNEXES

A.  Scope of Work 43

B.  References 55

C.  Persons Contacted 61

D.  Key Findings of the Reproductive Health Survey, Azerbaijan, 2001,
    ADRA, MC, SCS, CDC, USAID and UNHCR 65

Executive Summary

The people and Government of Azerbaijan (GOA) currently face multiple
transitions that are having serious effects on social, health and
economic development. After the dissolution of the Soviet Union and
independence in 1991, the economy crashed but is now transitioning to a
free market economy. The conflict with Armenia created new economic
challenges, took 20 percent of Azerbaijan's territory, and uprooted
800,000 refugees/internally displaced persons (IDPs), the assistance for
whom is transitioning from humanitarian to development. The population
is in an epidemiological transition that creates a double burden of
disease and need for services, while the under-financed health system
struggles as it transitions from a single-provider to a pluralistic
system. Health policy and system reform are inevitable. Such challenging
transitions create refreshing opportunities for socioeconomic and health
development.

Given this context and the recent repeal of Section 907 of the Freedom
Support Act (FSA) that enables USAID to engage the GOA in substantive
strategic planning as a basis for future bilateral development
assistanc, the team took a broad, comprehensive approach to assess the
social and health situation, identify the determinants of health and the
population groups at highest risk, conceptualize a framework for
strategic planning, and make strategic recommendations for consideration
by USAID and the GOA.

Most health, social and economic indices have deteriorated during the
past decade: some have recently improved, others continue to worsen, and
new challenges loom (TB, HIV/AIDS). While the health system has a
surplus of doctors, nurses and other personnel, it is financially
starved; many facilities are poorly maintained, equipped and supplied;
quality of care falls while costs to consumers rise, so utilization
declines. Health data of varied quality are rarely used for management.
The dominant approach to health development is medical, not preventive;
uni-sectoral, not multi-sectoral.

The determinants of ill health in Azerbaijan are related to
[economics]{.underline} (low family income, high unemployment, few
opportunities); [social and food security]{.underline} (low quality
food, malnutrition, pensions); [physical environment]{.underline}
(pollutants; inadequate sanitation and housing; unreliable supplies of
water, fuel, electricity); [health education]{.underline} (inadequate
health knowledge and practices); and [health services]{.underline}
(inadequate health promotion, disease prevention). While health system
and policy reform are crucial, sustainable improvements in social and
health status can be achieved through a synergistic, integrated, and
multi-sector development strategy. The strategic approaches and program
options recommended below are submitted to USAID for strategic planning
purposes, but the team suggests that they be seriously considered by the
MOH/GOA in an iterative process with USAID to develop a shared vision,
strategic plan, and the essential partnerships for synergistic
development.

**Five strategic approaches are recommended**: 1) develop multi-sector
integrated development initiatives in areas where residents/IDPs are at
highest risk in order to build synergism for rapid and sustainable
social, health, and microeconomic status improvements; 2) improve family
income, social and food security, and the health-related physical
environment (water, sanitation, housing, fuel, electricity, etc.)
through microcredit, enterprise development, and community development
initiatives; 3) strengthen health system facilities, performance, and
financing mechanisms; 4) strengthen health system management, the
quality of health data, and the quality of services; and 5) strengthen
health promotion, knowledge, practices and behavior.

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Within the contexts of the conceptual framework and these five strategic
approaches, the team recommends the following strategic and program
options:

-   Support proven or new innovative microcredit and enterprise
    development initiatives with the potential for alleviating poverty,
    increasing food security, and improving the health-related
    environment (water, sanitation, housing, fuel, electricity, etc.) at
    family and community levels.

-   Support proven or new innovative community development programs that
    are directed towards improving food security and family income,
    alleviating poverty, and/or improving the health-related physical
    environment of households and communities.

-   Support the development of prepaid health insurance schemes and
    revolving drug funds.

-   Support the regulated privatization of selected facilities and/or
    services in areas of need.

-   Support the training of master trainers, health leaders, medical
    directors, and managers in health care financing, financial
    management, revolving drug funds, and health insurance.

-   Support the development of a management information system (MIS),
    the strengthening of the health information system (HIS), and
    development of a national disease surveillance system.

-   Support development of diagnostic and treatment protocols, and
    produce clinical guidelines.

-   Support training of medical and health personnel in key clinical and
    public health subjects.

-   Support the development of a national health information, education
    and communication (IEC) capacity through the development of an IEC
    Training Unit with master trainers, the training of district-level
    personnel, and implementation of selected district-level IEC
    activities.

## Background 

Many key indicators of social, health, and economic development in
Azerbaijan deteriorated rather dramatically after Azerbaijan regained
its independence in 1991 with the dissolution of the former Soviet Union
(FSU). Adding insult to socioeconomic injury, the 1988-1994 conflict
with Armenia resulted in Azerbaijan losing productive use of some 20
percent of its territory to occupying Armenian troops, while gaining
some 220,000 refugees from Armenia and 570,000 internally displaced
persons from Nagorno-Karabakh who moved into other areas of Azerbaijan.
These 790,000 refugees/IDPs represented over 10 percent of the total
population of Azerbaijan at that time. The number of refugees/IDPs in
Azerbaijan has declined in recent years: United Nations Development
Program (UNDP) estimated that in 1999 there were 576,000 registered
refugees/IDPs, and the United Nations High Commission on Refugees
(UNHCR) estimated that in January 2000 the number of registered
refugees/IDPs in Azerbaijan had fallen to 550,000. The decline can be
attributed to assimilation, death, and perhaps some migration, driven in
part by harsh conditions and the need to seek income.

Since 1993, USAID has provided substantial humanitarian assistance for
refugees/IDPs in Azerbaijan within the framework of the provisions of
FSA, Section 907 which states that *"United States assistance under this
or any other Act may not be provided to the Government of Azerbaijan
until the President determines, and so reports to Congress, that the
Government of Azerbaijan is taking demonstrable steps to cease all
blockades and other offensive use of force against Armenia and
Nagorno-Karabakh."* In FY 1999, six types of assistance were exempted
from the provisions of FSA, Section 907, including humanitarian
assistance.

In 2001, USAID/Azerbaijan sought to conduct a social and health
assessment of the IDP/refugee situation in Azerbaijan. Initially
scheduled for September-October, the assessment was rescheduled to
February 2002 following the terrorist attacks of September 11. While the
original Scope of Work (SOW) called for a six-person team to spend three
weeks in country, the slightly revised SOW provided for a three-person
team to spend 14 workdays in country for the assessment. A fourth team
member from USAID spent nine workdays in country assigned to this
assessment.

## Objectives and Scope of Assessment

The original objectives of the assessment were to provide
USAID/Azerbaijan with:

-   A synthesis of the social and health status of refugees/IDPs
    currently living in Azerbaijan;

-   Options and recommendations for a set of activities that are
    technically, economically, socially, and politically sound;

-   Suggestions for the future direction of USAID-funded activities in
    the social/health sector in Azerbaijan for the next three years.

Shortly before the team's arrival in Baku, the FSA, Section 907
restrictions were repealed. Thus, during the team's initial in-country
briefing, USAID/Azerbaijan instructed the team to:

-   Broaden the scope of the original Terms of Reference (TR) for the
    Social/Health Assessment of Refugees/IDPs in Azerbaijan to include
    all population groups in Azerbaijan;

-   Make site visits to selected facilities in various areas of
    Azerbaijan that serve non-displaced residents (approximately ¾ of
    site visits) and refugees/IDPs (approximately ¼ of site visits);

-   Make recommendations that serve the national social and health
    development needs of residents, as well as the humanitarian
    assistance needs of refugees/IDPs; and

-   Make recommendations of particular strategic and conceptual value to
    USAID, rather than recommendations on specific projects or other
    specific program interventions.

## Assessment Methodology and Activities Undertaken

The methodology of this assessment involved:

-   Studying a broad collection of key documents (see Annex B);

-   Conducting consultations with key informants (see Annex C);

-   Collecting secondary data and information on demographics, social
    and health status, the health system, the availability of and access
    to health services (see Section IV and Annex D);

-   Assessing various determinants of health, risk factors, and social
    indicators (employment/income, housing, education, and so forth), in
    order to define and characterize the most vulnerable population
    groups at highest risk (see Section V); and

-   Conducting site visits to various areas in the country in order to
    assess health facilities and projects, and meet with health
    officials, physicians and other health workers, NGO leaders, and
    community representatives (see Section IV and Annex C).

Site visits were made to Sabiribad, Saatly, Shaki, Masally, Sigdash
Village, Salyan, Shamakhi, Goychay, Gabala, Gusar, Khizi, Sumgait, two
IDP camps at Barda and Bahramtapa, and the Republican (Mirkasimov)
Hospital in Baku. Consultations were conducted with the district head
doctors and other health officials at the district level, physicians and
other health workers at a wide range of health and medical facilities,
PVO/NGO leaders, community leaders, and representatives of Executive
Committees and Village Councils. Consultations were also conducted with
leaders of various PVOs/NGOs, and international organizations in Baku.
Significantly, on February 14, a USAID delegation (led by Bill McKinney,
USAID Country Coordinator) and the team leader briefed Minister Ali
Insanov, First Minister of the MOH, about the assessment, and then a
debriefing was provided to Professor Alexander Umnyashkin, Adviser to
the First Minister of Health by the entire team and a USAID delegation
on February 26. Both interactions with the MOH were useful to the team
and appreciated by the Ministry. Mr. McKinney promised Minister Insanov
a copy of the Executive Summary when the final report is received by
USAID Azerbaijan.

Highlights of the team's observations, analyses, and key findings are
presented below (Section IV) under topics on the quality of data and
principal sources, demographic overview, environmental and socioeconomic
overview, health system analysis, and health status and current health
challenges. Section V presents an analysis of the key determinants of
health, inequities in health and health care, and the vulnerable
population groups at greatest risk. Based on these findings and
subsequent deliberations, the team formulated a conceptual framework for
strategic planning of a health and social development assistance program
for Azerbaijan (Section VI). The team's strategic recommendations are
presented in Section VII; the recommended next immediate steps are
presented in Section VIII; and the report concludes with a positive note
on prospects for productive partnerships to advance social, health and
microeconomic development for all Azerbaijanis.

## highlights of observations, analyses, and key findings

### Quality of Data and Principal Sources

The most pervasive problem that was identified early in the assessment
team's work is the difficulty of finding high quality data and reliable
statistical information from administrative sources in Azerbaijan, which
are the principal sources of data reported to and used by international
organizations and bilateral development assistance agencies. The
statement that "Some of the data from administrative sources are
reliable, while others are decidedly unreliable" generously sums up the
problem.[^1]

The problem is well known to the assessment team leader who had
previously undertaken an assignment for the World Health Organization
(WHO) to assess the completeness, accuracy and timeliness of reporting
from hospitals, clinics and district health facilities, which are the
primary sources of health data in Azerbaijan. Beyond the problem of
incomplete and inaccurate reporting at the local level, there are
methodological problems created, for example, by the use of outdated
definitions of stillbirth and infant death, and by not using the 10th
International Classification of Disease (ICD-10) and the international
usage of classifications of the causes of death and morbidity. Also,
there is often faulty communication between local and central
authorities for a variety of reasons, such as the use of various "norms"
(e.g., the number of hospital beds) for determining budgetary
allocations.

A costly and hopefully temporary solution to the problems of unavailable
data or unreliable data from administrative sources is to conduct sample
surveys. However, sample surveys can also produce unreliable data
because survey methodology is complex with respect to sampling,
questionnaire design, interviewer training and control, analysis and
reporting. The assessment team found six surveys to be particularly
useful for the purposes of this assessment:

-   Health and Nutrition Survey of Internally Displaced and Resident
    Population of Azerbaijan -- April 1996, USAID, WHO, and UNICEF;

-   Azerbaijan Poverty Assessment, Vol. I and Vol. II, 1997, the World
    Bank;

-   Azerbaijan -- Multiple Indicator Cluster Survey, December 2000,
    UNICEF (unpublished);

-   Population Health Needs and Health Service Utilization in Southern
    Azerbaijan, November 2000, IMC/CIF/USAID;

-   Primary Health Care Network Survey for Southern Azerbaijan, November
    2000, IMC/CIF/USAID; and

-   Reproductive Health Survey, Azerbaijan, 2001, Center for Disease
    Control (CDC)/Adventist Development Relief Agency (ADRA).

The problem of the paucity of high quality data is presented here as the
team's first observation in order to: 1) alert readers to this problem
as the principal reason for some inconsistencies of data taken from
various sources given within this report; and, 2) prompt readers to
seriously consider the importance of advocating for:

a.  A strengthened health information system (HIS) at the district
    level, which is the primary source of data, along with other data
    reported by the Sanitary and Epidemiological Service (SES), used by
    the MOH Statistics Department and by the Bureau of Statistics;

b.  The design, testing and development of a national disease
    surveillance system; and

c.  A district-oriented management information system (MIS), as high
    quality data is critically needed for planning, implementing, and
    managing primary health care and social services at the district
    level, and for assessing the effectiveness and efficiency of the
    health system at both the district and central levels.

At such time that the MOH undertakes a comprehensive health system and
policy reform initiative, the various health data record keeping,
reporting, and information systems should be consolidated into a single
National Health Management Information System, but this will require
substantial organizational, policy, and regulatory changes within and
outside the health sector.

### Demographic Overview 

The United Nations Statistic Division estimates that in 2002 there are
approximately 7.84 million people residing in Azerbaijan, 27 percent of
which are under 14 years of age. Males constitute 51 percent and females
49 percent of the population. Population growth for the last several
years has averaged near or less than one percent per year. Consistent
with this slow growth, the estimated total fertility rate is 2.1 (CDC,
2002) and the net migration rate is --5.67/1000 (CIA, 2002). Of the
total population of Azerbaijan, more than one-half (57 percent) live in
urban areas and one-third live in Baku, the nation's capital, and the
surrounding areas.

Ninety percent of the total population is ethnically homogenous Azeri
(SCS, 2001); three percent are Russian, two percent are Armenian, and
about six percent are other ethnic groups (UNFPA, 1996). Like the other
14 republics of the former Soviet Union (FSU), life expectancy in
Azerbaijan decreased during the mid-1990s, but began to rise later in
that decade. In 1996, life expectancy was 70.0 years, but then rose to
71.5 years in 1999 (WDID, 2001). Of course, national averages can mask
broad differences between various sub-population groups and geographical
regions.

The Azerbaijan population is in the midst of an epidemiological
transition, moving from a predominance of infectious and nutritional
diseases, generally characteristic of Third World countries, to a
preponderance of chronic and degenerative diseases characteristic of
industrialized countries. During the transition, the population faces a
"double burden of disease." It is experiencing increasing rates of
chronic degenerative diseases (cancer, diabetes, and cardiovascular
disease, especially heart disease and stroke), while the population
continues to suffer from health problems of the poor countries (malaria
and other infectious diseases, malnutrition, anemia, iodine deficiency
disorders, and poor reproductive health). The double burden of disease
not only challenges the population, it also challenges and strains the
health system.

### Environmental and Socioeconomic Overview

#### Why Consider Conditions Outside the Health Sector?

Health development, social development, and economic development are
inextricably linked in a complex but mutually dependent relationship.
While the health and social benefits of economic development,
particularly environmental and infrastructure developments (agriculture,
water, sanitation, roads, housing, electrification, and so forth) have
been long recognized, it is only in the past 20-25 years that
investments in "human capital" and improvements in health and social
status have been recognized to have powerful positive benefits to the
quality and rate of economic development. Investments in social and
health development and the subsequent improvements in health status and
performance are now recognized as crucially important for improving
productivity. Higher levels of productivity generally lead to higher
income; higher income leads to increased quality of life and greater
levels of disposable income that, in turn, can be spent on health,
preferably health promotion and disease prevention, rather than curative
care alone. Of the principal determinants of health (see Section V), the
education of women, even informal education, has the strongest positive
effect on improving health status at the family level. Poverty reduction
also has a powerful influence on improving health status. For these
reasons, a social and health assessment must consider environmental,
socioeconomic, and other conditions outside the health sector that have
a positive or negative impact on health status.

#### Physical Environment: Housing, Water, Sanitation, Electricity, Fuel

Numerous improvements in the physical environment are needed and the
situation could worsen. Although most Azerbaijanis do not consider their
housing situation to be a serious problem now, this situation could
change because of reduced family income and the relative inability to
make repairs and provide maintenance. Currently, most complaints with
regard to housing relate to utilities. Water is cited as the most
problematic service because of irregular supply and poor water quality
(World Bank, 1997). The links between poor quality water supply and poor
sanitation with diarrheal disease and other gastrointestinal infections
are well understood, and these are common problems in Azerbaijan.
Similarly, the links between irregular electrical power, perishable food
and gastrointestinal disease is well understood. The links between
irregular electrical power, interruption of the vaccine "cold chain,"
and the occurrence of immunizable diseases among immunized children,
which is happening in Azerbaijan, is also understood. Surveys reveal
that 90 percent of the population has electricity, and six percent have
no electrical service in their community. Significantly, groups in all
areas reported frequent interruptions in the supply.

The more serious energy problem is related to gas supplies in areas
outside of Baku. In the winter of 1995-1996, most areas outside Baku had
no gas supplies, which led to the use of wood to heat homes.[^2] In
homes without adequate ventilation, wood burning in homes led to
increased rates of respiratory infections and asthmatic distress. While
the winter of 1995-96 was dramatic, this situation still occurs in most
rural areas. Most homes and many health facilities, some of which are
very cold in winter, have a wood stove in the room to provide some heat
when the gas supply is interrupted, which happens frequently.

The situation for refugees/IDPs in many areas deserves attention: while
many IDPs have assimilated into host communities, the majority of IDPs
have inadequate shelter, poor access to clean water and sanitary
services, and severely limited supplies in proportions higher than the
general population.[^3]

#### Poverty and Unemployment

Poverty is a major contributor to most of the numerous health issues in
Azerbaijan. Although annual GDP growth in recent years has been quite
high (10 percent in 1999), the per capita GDP is just \$537, and per
capita GNP remains low at only \$550 in 1999 (World Bank, 2001). And
these figures are misleading in terms of the real situation at the
family level, which is severe, because national figures are buoyed by
foreign investment, little of which reaches to the purse of the average
family.

Unemployment is approximately 20 percent.[^4] Twenty-four percent of the
population is classified as very poor and 68 percent is classified as
living below the national poverty line.[^5] No reliable estimates are
available for either of these estimates from the GOA. The government
records only the number of people who have registered as unemployed,
which amounts to just one percent of the labor force.[^6] Within this
limited number of registered unemployed persons, women account for 60
percent. And most women who are employed are typically in the lower
paying professions. Unofficial labor markets where people are hired on a
daily basis at low rates now exist in most large settlements throughout
the country. The emergence of these markets is a clear signal that a
large number of people are desperately searching for work. A substantial
number of people have migrated to other countries during the last decade
seeking employment. Some of these people have returned periodically and
imported new health problems, such as HIV/AIDS.

Poverty and unemployment have changed patterns of household spending and
consumption. In 1997, 70 percent of the average family income was spent
for food. Even with that high proportion, the quality of food purchased
and consumed diminished well below what is needed for adequate growth
and nutrition (such as meat, fish, and diary products).[^7] When
families are forced to concentrate their expenditures on basic food
products, their ability to pay for other categories of products and
services, such as health care, is diminished for most and non-existent
for many. To say that economic issues, poverty and unemployment are
having a negative effect on health status and on access to health care
in Azerbaijan would be a vast understatement.

#### Social Status of Women

In Azerbaijan, like most other regions in the world, the status of women
is closely linked to issues of health. Women are typically the primary
caretakers in families and their educational and social status will
determine to a great extent their own health and their family member's
health. In Azerbaijan, women and men possess equal rights and liberties
under the constitution, and the country's labor law explicitly prohibits
wage discrimination based on gender. However, a greater percentage of
women than men remain unemployed and those employed are in lower paying
professions. One important area where Azerbaijan has achieved near
gender equality is educational enrollment.[^8] However, significant
asymmetries are noteworthy: women comprise only 10 percent of people
with D.Sc. degrees, Azerbaijani's highest scientific degree, and only 30
percent of people with Ph.D. degrees.

#### Social Status of Children

The social status of children and how it links with their health is also
important. In the World Bank's 1997 poverty assessment, focus groups
stated that it had become increasingly common for children as young as
six years of age to work in the informal labor market, despite the fact
that Azerbaijan law forbids the employment of children less than 16
years of age.[^9] The overall level of child labor is difficult to
estimate, as school records do not give good estimates of dropout and
truancy rates. However, estimates of the number of school age children
who had dropped out of school or were spending a substantial amount of
school time working have ranged between 10 and 25 percent with that
number increasing dramatically once children reached 10 to 12 years of
age. This figure also has regional variation: informal child labor was
much more common in urban areas. The main reason given for the increase
in child labor was low family income.

#### Food Security

While malnutrition is a problem for the general population, food
security is especially difficult for the IDP population. Food security
is defined here as "having the quantity, quality and diversity of food
needed at all times to lead a healthy and productive life" (CARE, 1994).
By 1996, 90 percent of IDPs indicated that they had no more assets to
sell (WHO, 1996). Based on general income and food security parameters,
WHO in its 1996 survey found that IDPS were substantially worse off than
the resident population. It is important to note, though, that the poor
among the resident population also suffer from food insecurity.
Female-headed households, particularly those with many children, can
have severe food insecurity. On a national scale, regardless of
displacement status, female-headed households with many children
comprise a highly vulnerable population group at high risk.

### Health System Analysis

The health system in Azerbaijan, which has been deteriorating for most
of the past decade, can be generally and succinctly characterized as
follows:

-   Declines in real public spending on health;

-   Reliance on historic "norms" based methods of resource allocation;

-   Inefficiency and inequity of health resources allocation;

-   Over emphasis on secondary hospital care at the expense of primary
    care;

-   Long lengths of hospital stay (17-18 days), the longest lengths of
    stay among all FSU countries;

-   Low hospital occupancy rates (42 percent), among the lowest in the
    FSU countries;

-   Over provision of hospital beds and infrastructure;

-   Aged and often non-functional medical equipment, and few if any
    medical supplies or drugs;

-   Reduction in the quality of care;

-   Over provision of doctors and medical staff; all staff underpaid;

-   Unofficial informal payments for services; new privatization and
    user fees policy accepted;

-   Up to 70 percent of the population is experiencing a reduction in
    access to health care;

-   A lack of public confidence in the health system; and

-   Low utilization of the health system.

#### Availability of Health Personnel, Facilities, Equipment and Supplies

Azerbaijan employs nearly four doctors per 1,000 population, twice the
number employed in the United Kingdom (1.6) and Canada (2.1). Even with
the over-supply of doctors, their distribution within the country is
very uneven, as most of them are specialists and they prefer to work in
large hospitals at the expense of the primary care facilities.
Nurse-to-population ratios in Azerbaijan are also far higher than in the
health care systems in the industrialized countries of Europe and North
America. Earning salaries that are well below subsistence levels,
medical and health personnel in Azerbaijan must seek other means of
earning an adequate income.

In rural areas, the feldsher-midwife posts, called Feldsher-Accousherski
Punkt (FAP) provide basic primary care to population groups of
600-3,000. In other areas, the FAPs, the rural polyclinics and small
rural hospitals are being replaced by a number of outpatient health
centers serving populations of about 10,000. Large hospitals are found
in every district, some of which are reference hospitals serving several
districts; and the largest tertiary care hospitals are located in Baku.

The number of hospital beds per 1,000 population has gradually declined
from 10.5 in 1992 to 8.4 in 1998, but remains much higher than the
average for Europe (7.8), Sweden (6.4) and the United Kingdom (5).
Except for the large reference hospitals and tertiary hospitals, most
facilities in Azerbaijan have a serious lack of medical equipment,
drugs, and supplies. This is particularly true at rural facilities, but
the worst situations were observed at some of the IDP/refugee
settlements.

#### Accessibility to and Utilization of Health Services

Given the over-provision of physicians, medical staff, and hospitals
beds, it is not surprising that there is an over emphasis on secondary
hospital care at the expense of primary care. Most clients go directly
to the hospital for primary care, in stark contrast to the practice in
Europe and North America where 80-90 percent of clients receive care at
primary care facilities.

Despite high levels of available health facilities and personnel, these
resources are underutilized. Azerbaijan has the dubious distinction, for
example, of having the second lowest hospital occupancy rate within the
FSU countries at a very low 41.5 percent nationwide average, and the
longest hospital stays among all the FSU countries at 17.9 days in 1994
and 17.1 days in 1998.

The principal reasons for such low and inappropriate use of hospitals
and other medical facilities are: low quality of care related to the
relative unavailability of equipment, supplies, and drugs; the outdated
resource allocation methods used; the informal costs of medical
consultations which are unaffordable to large segments of the
population; and worsening levels of poverty in Azerbaijan.

#### Health Care Financing, Privatization, Equity, and Monitoring Inequities

Reliable data on government health expenditures are difficult to obtain.
According to the MOH, government spending on health was \$9.92 per
capita in 1998 and slipped to \$7.58 in 1999; however, another source
(Azerbaijan Economic Trends) indicates that these figures should be
\$4.41 and \$5.25, respectively. As most of these expenditures are
allocated to personnel costs, little remains for other costs associated
with quality health and medical services (diagnostic and therapeutic
equipment, supplies, and drugs), seriously compromising the quality of
services. Given low-quality services, the increasing costs to patients
of "informal" fees-for-service, and the low affordability of these
services because of increasing levels of poverty, utilization can be
expected to remain low until new methods for the financing of health
services can be found.

Current trends towards the privatization of health services and
fee-for-service charges can, if not properly regulated, introduce new
inequities in access to health services, particularly where people are
already spending 70 percent of their income on food, leaving little or
nothing for health care. The introduction of privatization and the
application of user fees are doomed if family income cannot support
these new costs; hence, the introduction of microcredit, enterprise
development, and other potential income-producing initiatives should be
given a priority and precede the introduction of privatization and
user-fees in poor areas. Low-cost health insurance schemes, whereby
health care costs are spread out over large populations might be
feasible if large numbers of families participate and especially where
the population covered includes people with varying incomes, and where
multi-rate premiums are scaled according to the families' ability to
pay.

Poverty is a multi-dimensional phenomenon characterized by a denial of
the choices and opportunities necessary for gainful employment or other
means of generating family income, accessing health care when needed,
and improving one's health and social status. Moving out of a state of
multi-dimensional poverty is reflected by improvements in health status
indicators, especially those of children. And conversely, the
introduction of new inequities in access to health care that might be
introduced by privatization and user fees can be detected among children
before being seen in adults. Therefore, monitoring the health of
children of poor families is one means of detecting inequities
experienced by poor families when introducing privatization and user
fees.

### Health Status and Current Health Challenges

#### Mortality, Morbidity, Longevity

Determining an accurate picture of population health status in
Azerbaijan is very difficult, as there are serious problems with the
reliability of official statistics; and population-based data available
from scientifically sound sample surveys and special studies are
relatively scarce. Nevertheless, it is clear that many indicators of
health status in Azerbaijan worsened dramatically in the period of
economic transition that started after independence in 1992, as happened
in most FSU countries.

The infant mortality rate (IMR) increased in the years immediately
following independence and reached a peak in 1993, but it has since
fallen to below the 1990 level (WHO, HFA Database, 2000). The official
IMR for 2000 is 13 deaths per 1000 live births (Health Statistics of
Azerbaijan Republic, www.mednet.az). However, the estimated IMR derived
from more reliable surveys is 79-80 deaths per 1000 live births.[^10]

While the official maternal mortality ratio (MMR) for 2000 is reported
as 37.6 maternal deaths per 100,000 live births),[^11] the more reliable
population-based estimate of the MMR for 2000 is 79 per 100,000 live
births.[^12]

The overall mortality rate increased between 1990 and 1995, but has
since diminished to its pre-independence level. Correspondingly, there
was a significant decrease in life expectancy, more pronounced among
men, which has since increased to 1990 levels.

Disability-adjusted life expectancy in Azerbaijan is presently 65 years:
66.7 for women and 63.7 for men, (World Health Report, 2000). However,
the quality of government reported statistics is of uncertain
reliability, so the indicators given above might not reflect the real
situation.

According to "official" statistics, the three leading causes of
mortality in Azerbaijan are: 1) cardiovascular disorders, 2) cancer, and
3) injuries. And, according to the same source, the highest occurrences
(incidence/prevalence) of disease are reported as: 1) diseases of the
nervous system and sensory organs, 2) cardiovascular disorders, 3)
infectious and parasitic disease, 4) mental disorders, 5) genitourinary
diseases, and 6) gastrointestinal diseases (Health Statistics of
Azerbaijan Republic, *www.mednet.az*). However, it must be emphasized
that these classifications of disease are not in accordance with the
ICD-10.

#### Nutritional Status and Micronutrient Deficiency Disorders

##### Growth indices

The Azerbaijan Multiple Indicator Cluster Survey 2000 (unpublished)
revealed poor nutritional status among children under the age of five
years: eight percent of children have acute malnutrition
(weight-for-height Z score \<-2), 20 percent of children have chronic
malnutrition (height-for-age Z score \<-2), and seven percent of
children were severely stunted. Children whose mothers have at least a
college or vocational school education are the least likely to be wasted
or stunted compared to children of mothers with less education. There
were regional disparities: more than 12 percent of children under five
in Nakhichivan and the west and southwest regions were severely stunted,
compared to the national average of seven percent (Azerbaijan MICS,
2000). According to the results of the 1996 Health and Nutrition Survey,
chronic energy deficiency (Body Mass Index \< 18.5) was found in 12
percent of elderly people.

During 1990--1999, the average number of calories consumed per person
per day decreased from 2600 to 2200 kcal. The lowest intake, 2000 kcal,
was reported for 1995. Correspondingly, the proportion of total energy
available from proteins decreased from 14.5 percent to 12 percent during
this period. The lowest proportion, 11.5 percent, was reported for 1997.
In 1996, around 12 percent of households reported a lack of food
security, which was defined as those who: 1) ate no meat in the last
week, 2) skipped at least one meal because of insufficient food in the
last week, and 3) have no access to a garden.[^13]

##### Anemia

The 1996 Health and Nutrition Survey revealed very high rates of anemia
among IDPs and residents in Azerbaijan: 44 percent of children 12-59
months of age (Hgb \<11.0 g/dl); 36 percent of non-pregnant women (Hgb
\<12.0 g/dl); 26 percent of men (Hgb \<13.6 g/dl). Anemia was highly
prevalent among both rural and urban populations, the rural populations
had higher prevalence compared to their urban counterparts (49.8 percent
vs. 40.0 percent in children, 39.6 percent vs. 33.5 percent in women,
and 31.9 percent vs. 21.2 percent in men).

The anemia levels found in the Reproductive Health Survey 2001 (blood
samples collected from women with children under five) were in a similar
range: 41 percent of non-pregnant women with at least one child under
five years of age were anemic (i.e., had hemoglobin levels under 12.0
g/dl). Seventy-six percent of all anemic women had mild anemia (Hgb
10.0-11.9 g/dl) and less than one percent had severe anemia (Hgb\<7.0
g/dl). The continuing high and apparently increasing rates of anemia
among women, children and unusually, men in Azerbaijan should be studied
further to determine the clear causes of this widespread problem. Is it
related to the deteriorating nutritional patterns resulting from the
worsening economic situation at the family and community levels? Once
the causes are understood, intervention programs can be created and
targeted to women of childbearing age and children.

##### Iodine deficiency disorders

Azerbaijan has a very serious problem concerning highly endemic Iodine
Deficiency Disorders (IDD): 23 of a total of 59 districts have endemic
IDD. UNICEF reports that up to 80 percent of schoolchildren in these
highly endemic districts suffer from IDD, and half of them have already
developed goiter.[^14] As IDD among infants and young children arrests
brain development, producing cretins and children of low intelligence,
this situation constitutes a public health emergency with grave
long-term consequences.

As revealed by the 1996 Health and Nutrition Survey, an estimated 11
percent of the adult population in Azerbaijan suffers from goiter
(enlarged thyroid glands detected by clinical examination). The
prevalence is higher among IDPs than the resident population (23.0
percent vs. 9.8 percent) and is higher among women than men (13.3
percent vs. 5.8 percent). The higher prevalence in women was
consistently found regardless of geographic location or resident status.
\[Note: Although this difference was statistically significant, it might
not be reflective of a true difference in iodine deficiency between
women and men, as men have muscular necks that can hide goiter.\] Goiter
was found to be more prevalent in urban areas than in rural areas (15.1
percent vs. 6.1 percent), and this difference applied to both IDP and
resident populations. On a positive note, the MOH has launched an IDD
control program in endemic districts where iodinated oil is given to
children by mouth and iodized salt is available in the marketplace.

#### Infectious and Communicable Diseases

Infectious and communicable diseases remain a widespread problem. Among
children, acute respiratory infections and diarrheal diseases are very
prevalent. Acute respiratory infections, particularly pneumonia, are
leading causes of child deaths in Azerbaijan as elsewhere.[^15]
Dehydration caused by diarrhea is a major cause of mortality among
Azerbaijani children. In the 2000 Multiple Indicator Cluster Survey
(unpublished), seven percent of children under five years of age had
diarrhea in the two weeks preceding the survey. Only one out of ten
children received ORS, though, a larger percentage received some form of
a recommended liquid (breast milk, gruel, soup, or other food-based oral
rehydration solutions) during a diarrheal episode.

The prevalence of malaria, endemic in southern Azerbaijan, increased in
the years following the breakup of the Soviet Union. In 1967, there were
only three recorded cases of malaria in Azerbaijan, but after the
dissolution of the Soviet Union the number of malaria cases increased to
667 in 1994. By 1996, there were more than 13,000 cases. In response,
the MOH worked with both private and public organizations to conduct a
malaria eradication campaign and reduce the number of malaria cases.
Activities included training medical personnel, providing treatment, and
reducing the population of mosquitoes. By 1999, less than 2,000 cases
were reported. But 1999 was a dry year with a low mosquito population
and decreased transmission. The malaria situation deserves vigilant
monitoring.

Tuberculosis is a continuing problem. In 2000, the case notification
rate was 64.45/100,000 (5,187 cases), which is average for the region
but contrasts with countries in Western Europe, such as Italy, which has
a rate of 7/100,000 (WHO, 2002). Currently, the treatment success rate
approximates 80 percent, but this may change as multi-drug resistant
tuberculosis (MDR-TB) becomes more prevalent. There is little to no
information regarding MDR-TB in Azerbaijan at the present time, but
given the emergence of MDR-TB in other countries of the FSU it can be
reasonably expected that Azerbaijan will soon face similar problems.

The number of HIV infections in Azerbaijan is relatively low compared to
other countries in the region, but it is clearly increasing. By April
2000, there were a total of 193 registered people with HIV/AIDS;[^16]
however, this number is probably underestimated by a factor of two- to
ten-fold. Most reported cases have been in Baku (65 percent); the
remaining cases being registered in 21 districts. A main source of
transmission is intravenous drug use, but several other factors could
contribute to a future epidemic: a large displaced population, growing
sexual activity among youth, a highly mobile rural male population, an
increase in commercial sex workers, and a highly medical, rather than a
public health, approach to the disease. The official Sexually
Transmitted Infection (STI) rate has increased three-fold since 1991,
which can facilitate the transmission of HIV, and is further cause for
concern about the future of HIV/AIDS in the country.

#### Chronic and Degenerative Diseases

##### Atherosclerosis, Heart Disease, and Stroke

Atherosclerosis, coronary heart disease, and stroke combine to form the
greatest disease burden for the overall population in Azerbaijan.[^17]
The population's poor cardiovascular health is likely to worsen because
of high and often increasing prevalence of hypertension (Health
Statistics of Azerbaijan), obesity,smoking,[^18] the escalating
socioeconomic hardships and poverty,[^19] the very limited access to and
low utilization of health services, and the low quality of care.[^20]

##### Cancer

In 1990-2000, Azerbaijan reported a decreasing trend in cancer incidence
and prevalence, which can probably be attributed to under-reporting of
cases, as one should expect to see cancer morbidity and mortality rising
given the serious environmental hazards (e.g., industrial pollution, oil
refinery by-products, low quality petrol, chemical fertilizers) and the
concentration of the population in large cities.[^21]

Among men, the incidence of cancer is highest for tracheal, bronchial,
lung and stomach cancers. Among women, the incidence of cancer is
highest for breast, cervical and uterine cancers (Health Statistics of
Azerbaijan Republic). Of great concern is the fact that less than 30
percent of sexually experienced women of childbearing age have ever
heard about breast self-examination techniques and only 10 percent have
ever done self-examination. Only two percent of sexually experienced
women have ever had a cervical cancer screening (Pap test) service and
less than one percent had received a Pap test within the past three
years.[^22]

The increasing use of tobacco products contributes to the high morbidity
and mortality of cardiovascular disease and cancer, as well as to the
development of many chronic diseases. Twenty-seven percent of the adult
population (age 15+ years) are regular smokers with over 1000 cigarettes
consumed per person/year.[^23]

#### Women's Reproductive Health

There are approximately two million women of reproductive age in
Azerbaijan. Although there are few reliable statistics on reproductive
health indicators from official sources, survey date shows that
reproductive health status remains low and in many areas women's
reproductive health is declining. For example, there has been a doubling
of maternal mortality and morbidity from vaccine-preventable
diseases.[^24] While the official estimate of the maternal mortality
ratio for 2000 is reported to be 37.6 per 100,000 births, this ratio
does not contain any deaths caused by unsafe abortions performed outside
of the medical establishment and is acknowledged to be underestimated.
While the MMR in 2000 is almost four times higher than that of the 1991
level of 10.4 deaths per 100,000 live births. A more accurate,
population-based estimate of the MMR for 2000 is 79 per 100,000 live
births, which is more than double the officially reported MMR of 37.6
for 2000.[^25]

Many pregnant women have shifted from delivering in government
hospitals, assisted by government-employed physicians, to delivering at
home, assisted by local midwives, apparently because of costs. The 1996
National Health and Nutrition Survey found that as many as one-third of
all children under one year of age had been born at home. Regional
household cluster surveys of women with children under five years of age
conducted in Northwest Azerbaijan in 1997 and 1999 documented that 25
percent of women had no prenatal care visits and the proportion of
newborns born at home increased from 37 percent in 1997 to 44 percent in
1999. According to the Azerbaijan MOH, the number of deliveries recorded
in "obstetrical establishments" decreased dramatically by 48 percent
(from 168,605 to 87,357) between 1988 and 2000. Caesarean deliveries
increased from 15.1 per 1,000 labors to 34.5 per 1,000 over the same
period.

Three-fourths of sexually active women have had at least one induced
abortion in their lifetime, according to a small area survey conducted
by Relief International.[^26] Although the abortion rates reported by
the MOH (calculated from reports of abortions conducted in governmental
facilities) have declined from over 25 abortions per 1,000 women of
reproductive age in 1988 to 7.7 per 1,000 in 2000, abortion continues to
be the most common birth control practice in Azerbaijan and remains a
very serious problem due to the high rate of post-abortion
complications.

The fertility rate started to decline prior to 1990 but the decline
during the previous decade had been at a higher rate; from 3.3 births
per women in 1980, the total fertility rate decreased slowly to about
2.7 in the period 1981-1993 but has fallen abruptly to slightly below
replacement level of two births per woman in 1998. Women typically marry
and begin families at a young age. The average age at marriage for women
is 20.5 years. Most women do not have pre-marital sexual relationships
and births out-of-wedlock are rare (less than five percent of all
births, according to the MOH). Unmarried women usually do not live on
their own, no matter what their age, educational or professional status.
More than 50 percent of women suffer from pelvic inflammatory diseases,
endocrine disorders, miscarriage and infertility. Increased incidences
of STDs and HIV/AIDS have been reported among young people as a result
of increased drug addiction, alcoholism and prostitution. A National
Reproductive Health Strategy has been drafted but not yet been finalized
or approved.

A reproductive health survey (RHS) has recently been conducted (2001) by
the Division of Reproductive Health, US Centers for Disease Control and
Prevention (CDC), and the Adventist Development and Relief Agency (ADRA)
in Baku. USAID (through an umbrella agreement managed by Mercy Corps),
the United Nations Population Fund (UNFPA), and the United Nations High
Commissioner for Refugees (UNHCR) provided funding for the survey. Key
findings of the RH Survey are summarized in Annex D.

##  The Determinants of Health, Inequities in Health and Health Care, and the Vulnerable Population Groups at Highest Risk

Given the multiple determinants of health, efforts to identify
population groups at greatest risk should take a comprehensive approach.
Such an approach is also useful for purposes of developing a conceptual
framework for planning an effective health and social development
strategy. The identification of the most vulnerable population groups at
highest risk was performed by:

-   Assessing the health status and current health challenges of the
    entire reference population, as has been summarized in a previous
    section;

-   Assessing the principal determinants of health (and of ill health)
    as summarized in the following section; and

-   Assessing inequities in terms of health status, health challenges,
    and determinants of health.

### The Principal Determinants of Health

[The economic environment]{.underline}, especially as it influences
employment and family income, is a major determinant of health status.
The erosion of economic opportunities, employment, and family income in
Azerbaijan over recent years has led to deteriorating health and
nutritional status, micronutrient deficiencies and reduced immunity,
increased incidence of many diseases, and increased mortality,
especially among financially challenged residents, refugees and IDPs.
Reduced family income has also made health services financially
inaccessible for many people, leading to an underutilization of health
services. Given the low level of government spending on health in
Azerbaijan, the currently high levels of poverty among both resident and
refugee/IDP population groups, and new policies promoting user fees and
privatization of health services, there is an increasingly urgent need
to launch innovative grassroots initiatives that can help to improve
family income by providing low-interest credit and supporting enterprise
development at the local level.

[The physical environment]{.underline} has a major impact on health. The
availability of environmental sanitation, clean water, vector control,
fuel, and electricity services, and the quality of housing have positive
effects on health status. As many of these determinants of health are
seriously affecting rural poor populations and IDP/refugee populations,
as well as some urban populations, assistance programs that support
community development, enterprise development, and microcredit
initiatives can strongly and rapidly influence health status, social
status, and quality of life in a very positive way.

[The social security environment]{.underline}, including food security;
family; community and societal support; political and social security;
freedom from war and civil disturbances; law and order; and other social
services, including pensions, have a strong influence on health status.
In Azerbaijan, food security improvements relate more to the quality of
food than to the quantity of food, given the need to prevent specific
micronutrient deficiencies, such as iodine deficiency and iron
deficiency.

[Education services and educational opportunities,]{.underline}
especially for women, have a powerful impact on women's health and on
the health of their families because women strongly influence health
practices and health-related behavior of family members. While female
literacy rates are commendably high in Azerbaijan, as is women's
awareness about modern contraceptive methods, more health information,
education and communications activities are needed in order to increase
levels of health knowledge but also to encourage healthier practices
concerning modern contraception, STI, HIV/AIDS prevention, IDD and
anemia prevention, oral rehydration for prevention of death from
diarrheal disease, cancer prevention, and so forth.

[Personal and family health knowledge, attitudes and
practices]{.underline} enable people to take greater responsibility for
promoting and protecting their own health. Improving health-related
knowledge, attitudes and practices (KAP) is one of the most
cost-effective ways to improve health status (such as women's
reproductive health status) prevent acute and chronic diseases, and
promote healthy behavior within their family and community.

[Integrated health promotion, disease prevention, and curative and
rehabilitative services]{.underline} can influence the health status of
the population of Azerbaijan much more than can be done by the current
medical care model that emphasizes curative care and costly high tech
diagnostic and therapeutic procedures. The impact of integrated health
services on health status depends largely on the availability of these
services to population groups at highest risk and equitable access to
these services according to need.

The most effective efforts to improve health and social outcomes will
involve consideration of each of these determinants of health, where
feasible to apply an integrated development approach for greater synergy
and economy, ensuring equitable access to information and education
services, food, employment and other economic opportunities, and
integrated health services of high quality.

### Equity in Health and Health Care

Equity in health means minimizing avoidable disparities in the
determinants of health and in health care services between various
groups of people who have different levels of underlying social
advantage.[^27] Efforts that aim to improve health status generally
apply a multi-sector strategy that aims to improve the determinants of
health. The development and implementation of effective integrated
development strategies and intervention programs can be facilitated by
the creation of a multi-sector policy, strategy and coordinating entity
with authority over the key sectors and their respective programs and
resource allocation functions.

Equity in health care means equal access to available care for equal
need, equal utilization for equal need, and equal quality of care for
all.[^28] Equal access to available care for equal need means equal
entitlement to the available services for everyone, a fair distribution
throughout the country based on health care needs and ease of access in
each geographical area, and the removal of other barriers to access.
Equal utilization for equal need requires the removal of any
restrictions on essential services, such as immunizations, resulting
from social or economic disadvantage, including the reduction of
inappropriate use or overuse of services for unnecessary treatments. The
concept of equal quality of care for all means that every person has an
equal opportunity of being selected for attention through a fair
procedure based on need rather than social influence.[^29]

Inequities in health and health care are evidenced by inequalities in
health status, risk factors, and the utilization of health services
between individuals or groups, especially when these differences are
unnecessary, avoidable and unfair.[^30] Inequities in the provision of
care are often related to inequalities in socioeconomic status,
geographic location, gender, and ethnicity.

Observed inequities in Azerbaijan are mainly related to: 1)
socioeconomic inequalities experienced by refugees, IDPs, and residents
whose income levels are below the national poverty line and whose access
to health care has been affected by the introduction of informal
charges, which will become even more severe with privatization and the
introduction of formal user fees; 2) geographic factors relating to the
incidence of IDD; and to some extent 3) gender issues relating to women
and the various factors that result in the high rates of abortion as a
contraceptive method, placing women at higher risk than need be the
case, given the availability of safer modern contraceptive methods. Such
issues and concepts of equity could usefully be addressed with GOA and
MOH leaders in the context of planning a synergistic social and health
development strategy.

### Vulnerable Population Groups at Highest Risk

The team identified the following population groups to be at high risk.
Within each of these groups, the most vulnerable sub-population groups
are identified.

**Children under five years of age**. The health status of children
relate to a number of factors, such as the equitable provision of health
and education services, food security, housing, environmental safety,
employment and financial security. Iodine deficiency, iron deficiency
anemia, Vitamin A deficiency, and food security are of particular
concern in Azerbaijan. Guidelines and practical tools to enable health
workers to assess and monitor these conditions should be used regularly.

*The most vulnerable children in Azerbaijan are those who: 1) live in
the IDD endemic districts, particularly those who have already developed
goiter; 2) live in IDP/refugee camps; 3) live in poor households; 4)
live in environmentally hazardous areas; 5) are malnourished,
particularly those with acute malnutrition; 6) have not yet been fully
immunized; and 7) have iron-deficiency anemia and/or other micronutrient
deficiencies.*

**Women, especially during the childbearing years**. The health status
of women in Azerbaijan is related to cultural factors, their social
status, access to health services, employment or other income generating
opportunities, and geographic location.

*The most vulnerable groups of women are those who: 1) are unemployed
heads of households with no adult male in the household but with any
number of children, recognizing that the greater the number of children
the greater the vulnerability; 2) have insufficient knowledge of modern
contraceptive practices and other measures to protect and promote
women's reproductive health, including prevention of STIs and HIV/AIDS;
3) have iron-deficiency anemia; 4) have IDD, particularly with palpable
goiters; 5) are below the national poverty line; and 6) have no access
to health services.*

**Poverty-stricken Refugee/IDPs and Residents**. The health of
poverty-stricken residents and most of the remaining 500,000
refugees/IDPs is compromised by high levels of poverty with very limited
income generating and economic opportunities, and limited health and
social services, food supplies, limited potable water, often inadequate
housing, and limited sanitary and other environmental conditions. Any
one of these factors can place these groups at high risk, but the
various combinations of these factors, which are often compounded at
refugee/IDP camps, can combine to make them extremely vulnerable.
NGO-government partnerships and well-coordinated multi-sector approaches
are needed. Improved health and social services are also needed, but not
if such services are provided on a fee-for-service basis, as this would
introduce new inequities in health care.

*The most vulnerable groups of IDPs/refugees and residents living in
poverty are those whose households: 1) have no one who is employed and
there are no opportunities for employment or income-producing
activities; 2) are headed by a woman with any number of children; 3)
include one or more aged persons (over 65); 4) are situated in one of
the IDD endemic districts; 5) are living in tents or sub-standard
housing without adequate water, sanitation, fuel, and/or electricity;
and 6) have no access or only very limited access to health and/or
social services.*

**HIV/AIDS and Tuberculosis Patients**. Although these are still
emerging public health problems in Azerbaijan, the global experience of
these pandemics suggest that their prevention and/or control in
Azerbaijan should be given a high priority because both infectious
agents produce highly vulnerable population groups, and they have a
synergistic effect when co-infections occur. The inequities and
discriminatory treatment experienced by people with AIDS and HIV
infections, and to a lesser extent tuberculosis patients, have been well
documented in many countries.

*The most vulnerable HIV-infected and tuberculosis-infected people are
those who: 1) have AIDS; 2) live in poverty and have very limited access
to health services; 3) have poor nutritional status, micronutrient
deficiencies, or poor diets; and 4) live alone without family or other
social support.*

## conceptual framework for planning a synergistic social and health development strategy and assistance program for azerbaijan

The Conceptual Framework for planning a synergistic social and health
development strategy and assistance program for Azerbaijan that was
developed by the team (next page) takes into account the following
realities:

-   Health and social status have multiple determinants, some of which
    are within the conventional health sector and many of which are
    outside the conventional health sector, as discussed above;

-   Poverty is one of the strongest determinants of health status (and
    social status), particularly in the context of Azerbaijan where most
    IDPs/refugees and many residents have little or no income;

-   The current economic situation in Azerbaijan is unlikely to change
    very rapidly with respect to benefits that would be felt by the
    poorest population groups (oil and gas revenues are unlikely to be
    channeled to meet social or health needs);

-   The health system has deteriorated, is under-financed, and remains
    in disarray, not only because of the scarcity of financial resources
    but also because of the serious need to plan and execute extensive
    health system and policy reform.

Interventions that can substantially improve the health and social
status of the most vulnerable population groups at highest risk need not
await execution of health system and policy reform. USAID's strategy for
social and health development should be broad-based, multi-dimensional,
and multi-sectoral for optimal synergistic effects and long-term
sustainable development.

![](media/image1.wmf)

## strategic recommendations: building a foundation for synergistic social, health and microeconomic development

The social and health assessment team has formulated five strategic
approaches, given below under the five numbered sub-sections. Within
these approaches, the team has also recommended consideration of various
strategic elements (identified by bullets), and provided additional
rationale and illustrative or elaborative material. The team is not
recommending that USAID support all of these proposed initiatives but
rather that USAID present the recommendations to the GOA and possibly to
other selected development assistance organizations and agencies for
further deliberation and strategic planning discussions. A more
definitive USAID strategy and various programs and activities would flow
and be defined during the proposed next steps (see Section VIII).

### Develop Multi-Sector Integrated Development Initiatives in Areas Where Residents and/or Refugees/IDPs are Most Vulnerable and at Highest Risk in Order to Build Synergism for Rapid and Sustainable Social, Health, and Microeconomic Status Improvements

As discussed in greater detail below, the foundation for synergistic
social, health, and microeconomic development would be based on four
strategic pillars that would:

-   Improve the economic environment (family income), social security
    environment (food security), and the health-related physical
    environment (e.g., water, sanitation, housing, fuel) through
    innovative micro credit, enterprise development, and community
    development initiatives;

-   Strengthen health system facilities, performance and financing
    mechanisms;

-   Strengthen health system management, the quality of health data and
    of health services; and

-   Strengthen health promotion, knowledge, practices and behavior.

### Improve the Economic Environment (Family Income), Social Security Environment (Food Security) and the Health-related Physical Environment (e.g., water, sanitation, housing, fuel) through Innovative Micro Credit, Enterprise Development, and Community Development Initiatives

#### Support proven or new innovative micro credit and enterprise development initiatives that have the potential for increasing family income, alleviating poverty, improving food security, and improving the health-related environment (e.g., water supply, sanitation, housing, fuel) at the family and/or community levels.

Well-designed microcredit and enterprise development initiatives have
had considerable impact on the health and social status of beneficiaries
and their communities in many countries, particularly when the local
initiatives are planned in a participatory manner, are managed locally,
and have the full consensus and active support of all community members
who will be beneficiaries.

Microcredit and enterprise development initiatives that give priority to
women entrepreneurs, organized women's groups, or women-led
organizations are most likely to have a positive impact on the social
and health status of women, and on the social and health status of their
family members. This would be particularly useful in Azerbaijan.

Microcredit and enterprise development initiatives can provide grants
and/or low-interest credit for innovative projects that would create job
opportunities for local residents and have the potential of expanding to
larger areas or being replicated at low cost elsewhere. Some enterprise
development initiatives could, for example, provide the financing needed
for the renovation or acquisition of health facilities, the upgrading of
medical equipment, or the provision of medical supplies, possibly for
the launching of a revolving drug fund.

#### Support proven or innovative [community development programs]{.underline} that are directed towards improving food security and family income, alleviating poverty, and/or improving the health-related physical environment of households and communities.

In addition to addressing the various determinants of health, community
development initiatives can promote democratization and the advancement
of civil society. Support for community action groups, village health
committees, municipal councils and/or other local organizations with
proposed innovative community development projects can be awarded on the
basis of prescribed criteria relating to the degree of social and health
benefits to be derived, such as improving the supply of quality foods
for local consumption or improving the physical environment in ways that
reduce health risks or promote health (improving community water supply,
sanitation, schools, sports facilities).

In areas where health facilities need renovation or where privatization
of health facilities and services is planned, the organization of local
health committees could help establish local voluntary labor or
employees, the promotion of services, and develop local health insurance
schemes. Similar initiatives have already proven successful in some
areas of Azerbaijan.

### Strengthen Health System Facilities, Performance and Financing Mechanisms

#### Support the development of prepaid health insurance schemes, revolving funds for drug supplies, and other health financing mechanisms at the community or district level.

There are a number of prepaid health insurance schemes and revolving
drug funds currently being implemented by various organizations in
Azerbaijan. As discussed in the next section, the assessment team
recommends that USAID conduct a comprehensive evaluation of these
programs and their specific interventions in order to determine which
schemes and strategies are most feasible to be replicated in other
areas, taking into account socioeconomic, demographic, and cultural
characteristics of the various regions of the country. The results of
the evaluation could be very useful for the planning of USAID's next
health and social development assistance program.

#### Support the regulated privatization of selected facilities and/or services.

At the present time, there are very few private healthcare facilities in
Azerbaijan. One private clinic is located in Gusar near the Russian
border. The assessment team visited the clinic and observed that the
facility was in better condition than most government health clinics, as
it had modern and functioning equipment, was well organized, appeared to
have good quality services, and was well utilized in contrast to most
government clinics. It charged user fees that were less costly than the
informal payments required at most government facilities where services
are of dubious quality.

As there is a strong interest among many physicians to work in private
health facilities, and as the quality of care in private facilities is
likely to surpass that of government facilities, while offering quality
services at a lower cost than the informal fees charged at government
facilities, USAID is encouraged to support the regulated privatization
of selected health facilities and/or services. However, the
registration, site selection and development of private health care
facilities should be regulated by the MOH to ensure that such clinics
are located in areas of need (rather than create new problems of
maldistribution of facilities and resources), that they offer a
reasonable range of services, meet minimum standards of quality, and
comply with MOH reporting requirements.

The start-up financing of private clinics and/or services might possibly
be covered in part by enterprise development initiatives, as discussed
above. Some financial institutions might be given some incentives, such
as reduced taxes, for providing long-term loans at relatively low rates
for initiatives that offer a social development or health service
benefits.

#### Support the training of master trainers who would, in turn, train health care leaders, medical directors, and managers in health care financing, financial management, accounting, and the operation of revolving funds for drug supply and of pre-paid health insurance schemes.

There is a great deal of interest among health care leaders, medical
directors, and managers who work in both public and private
institutions, to undertake training in health financing, financial
management, and accounting. Such training programs could also cover the
operation of revolving funds for drug and medical supplies, and
prepaid-health insurance schemes. Provision of such training would
enable health leaders, directors and managers to budget and manage
financial resources more accurately, and operate facilities more
efficiently and effectively. The development of master trainers would
enable the MOH to train personnel at all levels of the health system.

### Strengthen Health System Management, the Quality of Data, and the Quality of Services

#### Support for the development of a national health management information system (MIS), the strengthening of the health information system (HIS) and the related reporting system, and the design and testing of a national disease surveillance system.

The current health data record keeping and reporting system in
Azerbaijan has been regularly criticized by various international
organizations and assessment missions for its poor data management
(collection and recording of data, classification of data because of
inadequate case definitions, lack of timeliness, and general
unreliability). Thus, the data have limited utility for the formulation
of health policies, the management of facilities and personnel, or
clinical practice.

The World Bank-UNICEF-MOH Primary Health Care (PHC) Revitalization
Project has undertaken the initial design and testing of a local,
district level MIS to support the effective and efficient delivery of
PHC services, but additional effort and resources will be necessary to
carry the work forward and eventually launch a new national MIS more
broadly. USAID has substantial experience in this field and could make
substantial contributions, both technically and financially, in order to
enable the MOH and GOA to overcome a major health system problem -- the
unavailability of reliable high quality health data.

An efficient disease surveillance system with a rapid response capacity
also needs to be developed. The Sanitary Epidemiological Services (SES)
and MOH reporting systems should be integrated or, at least, coordinated
so that relevant data can be shared efficiently in order to support
their respective needs for high quality data.

#### Support for Development of Diagnostic and Treatment Protocols, and Clinical Guidelines.

The development of diagnostic and treatment protocols, and of clinical
guidelines for the diagnosis, treatment, and prevention of diseases and
conditions that have the greatest burden on the population's health
should be given a very high priority by the MOH and USAID. These
important guides could be developed and distributed nationally under a
national policy to improve the quality of care at the primary health
care level throughout Azerbaijan. Specific areas for guideline
development need to be identified in close cooperation with the MOH and
national professional organizations in order to facilitate consensus
building, endorsement, promotion, and accountability for their use in
all facilities.

#### Support Training of Medical and Public Health Personnel in Key Clinical and Public Health Subjects.

In order to facilitate the broad application of the new clinical
guidelines, and related materials such as clinical records and report
forms, training programs for both medical and public health personnel
will be necessary. Such programs would strengthen the clinical
competence of primary care providers and others at the doctor-patient
interface by promoting the concept of evidence-based medicine and use of
the new clinical guidelines, clinical records, and report forms. Such
training must be done rapidly as a means of strengthening both the
quality of health and medical services and the quality of data.

While there are many possibilities to support out-of-country training
through fellowships and short-term courses, such training can have an
adverse effect by raising expectations beyond reality or by learning
material not entirely relevant to the situation in Azerbaijan. \[Note:
Recently, a group of physicians and nurses from the Republican Hospital
in Baku visited Baylor University, and returned with an extensive
high-tech equipment "wish list" for use with donors. They dreamed of
performing expensive high-tech diagnostic and therapeutic procedures,
and high-tech surgery, if they could find a donor to provide the
high-tech equipment. The MOH cannot afford to procure or even maintain
the equipment, except at the expense of primary health care, disease
prevention, and health promotion services, which could entirely prevent
such diseases. Is the USA's expensive, high-tech, tertiary care-focused,
medical care-oriented health care system appropriate for Azerbaijan,
given its economy, and the social and health challenges it faces
today?\] Short training courses of relevance to the needs of Azerbaijan
should be conducted in country or within the region, although culturally
sensitive instructors for such courses could come from institutions
based in the United States or elsewhere.

Three fields of particular importance for capacity building among
medical and health personnel in Azerbaijan are the important fields of
preventive medicine, public health, and applied epidemiology. The
strengthening of competencies in these fields are needed at central,
district, and local levels. Supporting state institutions that provide
undergraduate and postgraduate education and continuous professional
development would foster the sustainability of these training programs
and of competence in these fields, which provide the medical and health
intelligence needed for evidence-based patient management and
evidence-based health system management. Such courses should be
conducted in country or within the region (including the European
region) and use high-quality national or regional data for greatest
relevance and post-training applications of knowledge gained.

### Strengthen Health Promotion, Knowledge, Practices and Behaviors

#### Support the development of a National Health Information, Education and Communications Capacity.

The development of a National Health Information, Education, and
Communications capacity would enable the MOH to develop materials and
messages for dissemination through school health education programs,
national public media outlets, local NGOs, international NGOs, health
care workers and medical professionals, reproductive health centers,
private sector health facilities, and private sector employers. USAID
support would foster the development of a national policy and plan for
IEC and for selected IEC interventions and practices. An IEC
Coordination Unit could be established to coordinate national and local
IEC activities, to coordinate with other Ministries, and to ensure the
effectiveness, efficiency, and consistency of the overall national
program.

#### Support the Development of an IEC Training Capacity through an IEC Training Unit with Master Trainers. 

USAID support could most productively be directed to the development of
a national IEC Training Unit with master trainers. These trainers would
employ the training of trainer methodology to develop a critical number
of IEC trainers. Master trainers would be trained in training
methodology as well as IEC practices to perfect training proficiency
that could later be applied to other health areas. Support for the
development of IEC training curricula and materials should also be
included.

#### Support the Development of IEC Capacity at the District Level by Training Designated Staff Who has the Authority and Responsibility for Launching IEC Activities in their Districts.

USAID could usefully support the development of an IEC capacity at the
district level by supporting 1) the training of designated staff,
doctors or nurses, and 2) the implementation of IEC activities within
their respective districts, in accordance with guidelines set by the MOH
and/or in cooperation with USAID funded programs in the area.

##  process recommendations: proposed steps to build a shared vision, strategic plan, and the essential partnerships for synergistic development

The assessment team recommends that the following steps be taken in the
immediate future in order to develop and refine the Mission's social and
health development strategy, determine its main program foci, and plan
future USAID social and health development programs and activities in
Azerbaijan.

#### 1. Conduct a Program Evaluation

In order to capture lessons learned from current and past USAID-funded
programs, projects and activities, an in depth evaluation of the
umbrella grant and its sub-grantees should be conducted as soon as
possible this year using external evaluators.

#### 2. Engage the Government of Azerbaijan in Strategic Planning Discussions

Initiate strategic discussions with the Ministry of Health, other
development-oriented ministries and, as appropriate, the Cabinet of
Ministers in order to build the rapport, mutual trust and long-term
relationship necessary to enter into a partnership for sustained
development that can have substantial impact on the social and health
status of Azerbaijanis, particularly people who are most vulnerable in
health, social and economic terms.

Strategic planning discussions could usefully involve two levels of the
GOA and be sustained for the time necessary to develop an integrated
development strategy and plan, and enable the government to design and
begin implementing the policy and organizational reforms that might be
necessary to implement the integrated development strategy in the agreed
districts. The two levels for strategic planning and for policy and
organizational reform might include:

-   [The Cabinet of Ministers or a strategic planning board appointed by
    the Cabinet]{.underline} that would authorize the development of an
    integrated multi-sector development plan, review and adopt (or
    modify) the plan, and then establish the necessary policy and
    organizational reforms for implementation of the integrated health,
    social and economic development plan in areas selected by this body.

The Cabinet of Ministers might wish to formulate a policy and plan for
the creation of a supra-ministerial body, such as a National Social,
Health and Economic Development Board with senior representatives of the
major socioeconomic development-related ministries, that would be
authorized to formulate the proposal for a multi-sector integrated
development strategy and plan for Cabinet review and approval. Once
approved, the Cabinet or its designated coordinating body, if
authorized, would set out the necessary policies and reorganization
orders for implementation.

-   [The Ministry of Health and selected health-related ministries or
    other GOA bodies]{.underline} that would plan for their
    sector-specific programs aimed at improvements in the health and
    social status of Azerbaijanis, and improvements in the
    effectiveness, equity and efficiency of the sector, and explore the
    role that USAID might play in such a progressive undertaking.

The emphasis of such discussions might usefully emphasize the following
topics:

-   Important links between health, social, and economic development and
    the broader goal of sustainable human development;

-   A vision of the total health sector in a pluralistic setting,
    including the government health sector, the private health sector,
    and the PVO/NGO health sector, and the productive relationships they
    can have in meeting the public's health needs;

-   The changing role of government under a health reform initiative in
    which the role of government transitions from being a sole-source
    provider of health services to one of providing information,
    financial, standards and regulatory support, and of managing change
    and growth of the sector;

-   Development of new tools for both the private and the government
    health sectors. While the private sector financiers and providers
    develop new tools for supporting and providing private sector goods
    and services, the government sector could develop new tools, and
    strengthen their capacity to use them for managing fiscal tools, and
    the legal and administrative tools to foster the desired
    improvements. The government sector should also take the measures
    necessary to collect, analyze and provide accurate, valid, timely
    and reliable health data and information of importance to both
    providers and consumers in order to improve the whole system and its
    impact on health; and

-   High priority strategic issues, such as strengthening health
    resource management, establishing priorities and setting targets,
    listing essential drugs, decentralization of authority,
    rationalization of services, health care financing, privatization
    and the roles of private practitioners within the national health
    system.

#### 3. In consultation with the MOH, other donor agencies, the WB, PVO/NGOs, and others, conduct a joint strategic planning exercise that leads to the development of a comprehensive strategic plan for the health sector in Azerbaijan that clarifies the respective roles of the participating institutions and organizations.

The broad goals for the plan might include, for example:

-   To improve health status and consumer satisfaction by increasing the
    effectiveness and quality of health services;

-   To achieve greater equity by improving the access of
    underserved/vulnerable populations to quality health care; and

-   To obtain greater value for money (cost-effectiveness) from health
    spending, considering improvements in both the distribution of
    resources to priority activities (allocation efficiency) and the
    management of resources that have been allocated (technical
    efficiency).

#### 4. Develop USAID/Azerbaijan's health strategic framework from the comprehensive, coordinated strategic framework.

#### 5. Develop a procurement instrument (RFA/RFP) to implement activities outlined in the USAID/Azerbaijan strategic framework.

#### 6. Award agreement/contract to implementing partners and begin implementation.

#### 7. Consider hiring one (1) PSC and one (1) FSN to be assigned to USAID/Azerbaijan to manage and monitor implementation.

#### 8. Conduct periodic monitoring exercises with external consulting technical experts in order to monitor and facilitate implementation.

## conclusion: prospects for productive partnerships to advance synergistic social, health and microeconomic development for all azerbaijanis

Several bright stars are emerging on the development horizon in
Azerbaijan that helps define the context for planning USAID's social and
health development strategy and for engaging GOA and MOH leaders:

-   The WB and the GOA have signed a \$5.5 million Health Reform
    Project, which UNICEF will help manage, that aims to strengthen
    strategic and health reform capacities of MOH officials at central
    and district levels, strengthen primary health care services in five
    additional districts using a quasi-experimental design to enhance
    the potential for learning important lessons, strengthen the
    reporting system and further design and test a management
    information system (MIS) to better manage resources and services at
    the primary care level.

-   The WB has indicated interest to provide up to \$70-80 million in
    about two years in order to enable the MOH to implement a major PHC
    program in all districts of Azerbaijan, including the establishment
    of major diagnostic and treatment referral centers in every three to
    four districts.

-   The MOH has appointed an MIS Task Group and is in the process of
    adopting the ICD-10 (International Classification of Diseases),
    making appropriate changes to its health records and report formats,
    and developing diagnostic and treatment protocols for some priority
    diseases.

-   The Canadian International Development Agency (CIDA) has approved a
    \$3 million grant to enable the MOH to implement a national health
    information system.

-   The Italian energy company, Agip, has made a \$1 million grant to
    the MOH for malaria control.

-   The MOH, Ministry of Social Security, and Ministry of Justice are in
    the process of establishing the legal and regulatory arrangements
    for promotion and support of private medical practices and
    facilities.

USAID is now well positioned to engage GOA and MOH officials, given the
repeal of Section 907 and the warm reception that USAID received when
initiating preliminary discussions with the MOH during the team's visit.
MOH officials are clearly interested in continuing discussions with
USAID, although USAID may wish to confer with other bilateral and
international development assistance organizations in Baku -- and
possibly discuss elements of this report -- before entering into
substantive discussions with MOH and other GOA officials.

The presentation of the Executive Summary of this report to Minister
Insanov might usefully be done in the context of a meeting with the
Minister of Health so that the new perspectives, strategic approaches,
and recommendations presented in this report can be explained in general
terms before MOH officials study the Executive Summary more carefully.
When meeting with the MOH, USAID may wish to emphasize that the goal of
the social and health assessment team's recommendations, taken
collectively, is to create powerful synergistic social, health and
microeconomic development with sustainable benefits for all
Azerbaijanis, beginning with the most vulnerable population groups who
are currently at highest risk for unwanted disease, disability,
fertility, and premature death.

Implementation of these recommendations, especially in the context of
health policy and system reform, in partnership with USAID and other
major development assistance organizations could create powerful
synergies for faster and more sustainable social, health and
microeconomic development in Azerbaijan.

###### 

ANNEXES

A: Scope of Work 43

B: References and Principal Documents Reviewed by the Azerbaijan Social
and Health Assessment Team, February 2002 55

C: Key Consultations and Site Visits Conducted by the Azerbaijan Social
and Health Assessment Team, February 2002 61

D. Key Findings of the Reproductive Health Survey, Azerbaijan, 2001,
ADRA, MC, SCS, CDC, USAID, UUNFPA and UNHCR 67

####### ANNEX A

####### scope of Work 

####### scope of Work

**SOCIAL/HEALTH ASSESSMENT OF**

**REFUGEES/IDPS IN AZERBAIJAN**

######## 

######## Introduction

The Azerbaijan conflict with Armenia in 1988 has resulted in
approximately 850,000 refugees and IDPs residing in various districts in
the country. Since 1993, USAID has supported a range of programs
directed at assisting refugees/IDPs in Azerbaijan. Many of these have
been humanitarian efforts directed at procuring supplies and rebuilding
infrastructure. Due to US Government restrictions imposed by 907, work
is focused only on IDPs and refugees, although the overall status of the
country is generally poor. Within this framework, USAID Azerbaijan seeks
to complete a current social/health assessment of the IDP/refugee
situation in Azerbaijan, recognizing the diverse social, health, and
socio-political and economic situation.

######## Background

Azerbaijan suffers from the same social and health problems as other NIS
countries but with heavy social and health burdens and more serious
infrastructure and systemic issues due to lingering internal conflicts.
USAID has assisted Azerbaijan to meet the critical challenges of
economic and democratic transition, and provided humanitarian assistance
to the most vulnerable groups of IDPs/refugees.

All U.S. Government-funded activities in Azerbaijan are subject to the
provisions of Section 907 of the FREEDOM Support Act (FSA). Section 907
states that, "United States assistance under this or any other Act may
not be provided to the Government of Azerbaijan until the President
determines, and so reports to Congress, that the Government of
Azerbaijan is taking demonstrable steps to cease all blockades and other
offensive uses of force against Armenia and Nagorno-Karabakh." In FY
1999, humanitarian assistance (including health) was exempted from 907.
Although the Act by the U.S. Congress has restricted the scope of
USAID's country assistance, USAID is making a substantial contribution
to Azerbaijan as evidenced by the U.S. position as the major bilateral
donor providing humanitarian assistance.

Economic trends worsened for everyone in Azerbaijan in the aftermath of
independence from the Soviet system. This decline was exacerbated by the
armed conflict over Nagorno-Karabakh that resulted in the displacement
of 650,000 people from their homes and the influx of additional 200,000
Azerbaijani refugees from neighboring countries. The maternal mortality
rate increased four-fold between 1990 and 1998 from 9.3 per 100,000 live
births to 41 per 100,000 live births (*Statistical Yearbook of
Azerbaijan 1999*). Unofficially, rates are quoted as 78-80 per 100,000
live births. The overall under-five mortality rate was 38 per 1000 in
1997, which is high compared with western standards of an average of 6
per 1,000. Morbidity and mortality rates appear to have ceased their
upward spiral; the infant mortality rate has been stable at 20 per 1000
live births since 1997, according to the State Statistical Committee.
This figure is considered unusually low due to Azerbaijan not using the
international standard for classifying live births.

The greatest causes of mortality in Azerbaijan are related to
cardiovascular disease and cancer. The incidence of malaria,
tuberculosis, and outbreaks of vaccine-preventable diseases is
widespread. There is virtually no published data available on the
mortality and morbidity arising from acute respiratory infections and
diarrheal diseases among children but these are thought to be among the
leading causes of child morbidity. Communicable diseases, anemia and
parasites also remain a major contributor to morbidity statistics.
Again, although there are no reliable statistics from the Ministry of
Health, surveys conducted by PVOs reported a high number of STIs.

######## Goals

*The goal of the Azerbaijan Rapid Social/Health Assessment is to set the
stage for future USAID participation in critical social/health areas.
This assessment supports part of its Strategic Objective 3.1: Reduced
Human Suffering in Conflict-Affected Areas. The primary focus of the
Assessment is to examine the present state of health and social well
being of IDPs/refugees living in Azerbaijan and to make recommendations
on future goals, particularly as it relates to transitioning from relief
to development.*

## The technical scope of the assessment should focus primarily on issues of nutrition, environment, housing and general health status of the idp/refugee population. the assessment will consider the general accomplishments of projects as related to goals, constraints, failures, and finally, possibilities for the future, particularly as related to transitional development activities. the assessment should focus on information comprising a broad spectrum of health and social situations of refugees/idp's in azerbaijan. usaid and us government activities should be included as well as other international and national donors programs.  {#the-technical-scope-of-the-assessment-should-focus-primarily-on-issues-of-nutrition-environment-housing-and-general-health-status-of-the-idprefugee-population.-the-assessment-will-consider-the-general-accomplishments-of-projects-as-related-to-goals-constraints-failures-and-finally-possibilities-for-the-future-particularly-as-related-to-transitional-development-activities.-the-assessment-should-focus-on-information-comprising-a-broad-spectrum-of-health-and-social-situations-of-refugeesidps-in-azerbaijan.-usaid-and-us-government-activities-should-be-included-as-well-as-other-international-and-national-donors-programs. .unnumbered}

######## Purpose and Objective

The objective of the assessment is to provide USAID/Azerbaijan with:

-   A synthesis of the social and health status of refugees/IDPs
    currently living in Azerbaijan;

-   Options and recommendations for a set of activities which are
    technically, economically, socially and politically sound;

-   Suggestions for future direction for USAID-funded activities in the
    social/health sector in Azerbaijan for the next three years.

-   In all of the above, consideration given to the existence of 907 or
    regarding transition and future directions without 907 restrictions.

The purpose of this activity is to assess the current health status of
refugees/IDPs residing in Azerbaijan past accomplishments and current
challenges; lessons learned; and to provide recommendations for future
direction of activities. The final written report will make specific
recommendations to strengthen health interventions in targeted areas
most in need of assistance.

# 

This social/health assessment will assist USAID/Azerbaijan in
determining the best direction for future activities, as integrated into
the greater country strategy. To the extent possible, the assessment
will be a summary and synthesis of information available and work
previously completed. The assessment team will examine the results of
current and previous projects in the targeted regions for successes and
failures. The team will assess projects based on their benefit without
regard to their current or past donor or benefactor. The intent of the
assessment is to amass ideas for future projects, not to evaluate the
status of current activities. While the assessment is not intended to be
exhaustive, it is expected to be complete enough to provide USAID with
adequate justification and rationale for selected directions and
recommendations. Once the assessment report is complete, it will be used
as the basis for discussions with the regional USAID mission toward the
development of health and social assistance strategies.

######## Assessment Strategy

1.  Assemble written information already gathered and perform key
    informant interviews to collect secondary information on the health
    of IDPs and refugees in Azerbaijan; including population
    distribution, demographic information, morbidity, health system
    availability, primary risk factors, and nutrition (especially
    micronutrient deficiencies).

2.  Define and characterize high-risk groups.

3.  Perform a vulnerability analysis that highlights groups most in need
    of assistance.

4.  Assess social indicators as they relate to the overall health and
    social status of IDPs/refugees with regard to employment/income,
    housing, and education.

######## Methodology

An external team of three MEDS consultants will plan the assessment
methodology with advice and agreement from USAID/Caucasus technical
staff. They will work in Baku for three weeks gathering and reviewing
relevant written materials and secondary data, interviewing key
informants, and analyzing and compiling information. The team will meet
with USAID/Caucasus several times throughout to seek information and
direction, provide updates on the assessment progress and present early
findings and recommendations.

In the field, the evaluation team will undertake the following specific
activities:

1.  [Meet with USAID/Caucasus staff.]{.underline} The team will hold two
    formal briefing meetings with USAID staff. On arrival, the team will
    meet with USAID staff to clarify Mission perspectives, activities
    and priorities of the assessment. The team will present a work plan
    for implementing the assessment. During the assessment, USAID staff
    will accompany the team on field visits, as necessary.

> A final briefing near the end of the TDY will be made at which time a
> verbal report will be submitted. The result of the meeting will be to
> summarize current conditions and recommend how to strengthen and
> improve future strategic approaches to treatment of the refugee/IDP
> population. Interim briefings, as appropriate, may be undertaken in
> Azerbaijan with Mission staff participating on the evaluation team.

2.  [Review relevant documentation]{.underline}. The team will review
    relevant documents such as UN reports; work plans; operations
    research reports; assessments; progress and quarterly reports from
    groups working with IDPs/refugees in Azerbaijan. USAID/Caucasus will
    assist in providing relevant documents.

3.  [Meet with stakeholders in selected regions in
    Azerbaijan]{.underline}. The team will collect information through
    interviews, discussions or focus groups with key stakeholders, e.g.,
    participating agencies (UNHCR, WHO, MCI, IMC,) including USAID
    staff, community development members and health workers of District
    Health Stations.

4.  [Make site visits.]{.underline} The team will meet with
    social/health workers at selected social and health facilities and
    with community members and caretakers at outpatient clinics in areas
    serving significant numbers of refugees/IDPs. Team members should
    also interview clients at clinics and social service centers.

######## Audience

The primary audience for the assessment is USAID/Caucasus and
USAID/Washington. Portions of the report will also be disseminated and
shared in-group process meetings with international NGOs and by
distribution of the final report to relevant parties.

######## Team Preparation

1.  Prior to the team's departure for fieldwork, designated member(s)
    will collect health sector information in Washington, DC with
    assistance and guidance from USAID/Azerbaijan.

2.  Prior to field work, a designated team member will speak with
    representatives of USAID/Washington (desk officer, E&E, G/PHN), CDC,
    participants in the AIHA partnership program, the World Bank, other
    donors and PVOs, to obtain information regarding past projects and
    current activities in Azerbaijan.

3.  A two-day team-planning meeting will take place in Baku in order to
    clarify team roles and responsibilities, discuss the assessment
    scope of work, and formulate an assessment work plan, timeline, and
    methodology.

**Report**

### *The outcome of this assessment will be a final report. The team will be responsible for completion of the final report synthesizing findings and recommendations. The report should be concise, not exceeding 30 pages with appendices, as needed. The team leader will be responsible for completing the report on time and submitting it to the Mission. The final report should include the following sections:* {#the-outcome-of-this-assessment-will-be-a-final-report.-the-team-will-be-responsible-for-completion-of-the-final-report-synthesizing-findings-and-recommendations.-the-report-should-be-concise-not-exceeding-30-pages-with-appendices-as-needed.-the-team-leader-will-be-responsible-for-completing-the-report-on-time-and-submitting-it-to-the-mission.-the-final-report-should-include-the-following-sections .unnumbered}

### *Executive summary* {#executive-summary .unnumbered}

### *Background* {#background-2 .unnumbered}

### *Methodology*  {#methodology-1 .unnumbered}

### *Description of activities*  {#description-of-activities .unnumbered}

### *Summary of key issues*  {#summary-of-key-issues .unnumbered}

### *Conclusions* {#conclusions .unnumbered}

### *Recommendations* {#recommendations .unnumbered}

### *Annexes* {#annexes .unnumbered}

Suggested Annexes or sections woven into the report are listed below and
as Annexes to this scope of work:

1.  Socioeconomic and Political Context: (Briefly)

```{=html}
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```
A.  Key socioeconomic indices for the population (size, mortality,
    income, literacy),

B.  Political/security environment,

C.  Current public policies that affect the availability of and access
    to services in the public and private sectors,

D.  Key trends, official attitudes toward policy reform in the
    social/health sector,

E.  Household-level economics, including spending.

```{=html}
<!-- -->
```
2.  Social/Health System

```{=html}
<!-- -->
```
A.  Structure, range and quality of available **social** services
    (public and private),

B.  Public and private **health** services, as above, including a brief
    description of the availability and access to essential drugs and
    vaccines,

C.  Public access to services with specific reference to women, children
    and the elderly or other vulnerable parts of the population,

D.  Caliber of staff and equipment at service delivery facilities.

3\. Priority Social/Health Problems:

A.  Provide epidemiological profiles, which outline the major
    social/health problems with specific attention to women, children
    and the elderly,

B.  Note how key social issues impact health findings, i.e.,
    smoking-lung cancer, domestic violence-pregnancy,

C.  Describe the capacity of existing systems to respond to these
    priority problems.

```{=html}
<!-- -->
```
4.  USAID Assistance to date in the social/health sector

```{=html}
<!-- -->
```
A.  Summarize USAID assistance to date,

B.  Comment on the extent to which this assistance responds to priority
    concerns noted above,

C.  Other Donor and NGO Activities

```{=html}
<!-- -->
```
1)  Summarize other donor and NGO assistance

2)  Comment on the extent to which this assistance responds to priority
    concerns noted above.

```{=html}
<!-- -->
```
5.  Opportunities for USAID Involvement

```{=html}
<!-- -->
```
A.  Identify potential priority opportunities for USAID participation in
    health/social sector assistance,

B.  Identify USAID's comparative advantage in pursuing specific
    assistance opportunities.

C.  Identify constraints and issues that may affect USAID's responses to
    priority problems.

```{=html}
<!-- -->
```
6.  Conclusions and Recommendations

```{=html}
<!-- -->
```
A.  Suggest an integrated and strategic approach to the sector,

B.  Outline a draft framework, including possible objectives and
    results,

C.  Suggest a possible range of program activities,

D.  Identify critical areas needing further assessment.

######## Suggested Team Composition

The team will be comprised of individuals who can tolerate extremes of
temperature, long hours, and harsh travel conditions. Accommodations may
be quite primitive. Food, although plentiful, will not be varied. Team
members must be in good health and physical condition.

#### A. Core Team

1.  Team Leader -- Requires experience in crisis work as well as
    development projects.

> [Required LOE: 27 days]{.underline}, including one week in Washington
> for assignment briefings and preparation; three weeks field work, four
> days travel and nine days for report preparation.

2.  Public Health Specialist -- Requires prior international experience,
    preferably in the NIS assessing health and social conditions and
    development of appropriate/feasible donor responses to such
    problems. Must have excellent conceptual and drafting skills.
    [Required LOE: 23 days]{.underline} including one week in Washington
    for briefings and preparation for fieldwork with four days travel.

3.  Epidemiologist -- Requires prior experience in the assessment of
    health and social issues and in the examination, analysis and
    interpretation of epidemiological data to determine implications for
    program reform. [Required LOE: 23 days]{.underline} including three
    weeks field work; four days travel; and eight report preparation.

**B. Administrative/Logistical Support**

> A local organization must be chosen to provide support to the
> evaluation team including assistance in providing a physical work and
> meeting space, interview contacts and appointments, local travel
> arrangements, hotel accommodations and interpretation.

######## 

######## Level of effort

For the consultants hired by the project, the level of effort will be
approximately as follows:

Background Reading 2 days

Travel Days 4 days

Team Planning 2 days

Interviews/Discussions in Baku 4-6 days

Interviews/Discussions in the field 4-6 days

Analysis & Report Writing 4-6 days

Oral Presentation 1 day

Addressing USAID/NGO Partner Comments 2 days

Total number of working days: 23-27 days

######## Administrative and logistical arrangements

1\. Relationships. The team leader will report directly to the
Coordinator, USAID/Azerbaijan. The team leader will work closely with
the Regional Health Advisors and Regional Coordinators. As necessary,
the Regional Legal Advisor and Regional Executive Office, USAID/Tbilisi
will provide supplementary guidance.

2\. Completion of Deliverables. The contract will be considered
successfully completed when the team leader submits to USAID/Azerbaijan
the document described in the "Scope of Work". Two paper copies of the
final document shall be delivered to the Coordinator's office. In
addition, the team leader will submit an electronic copy of the entire
document in Word on a 3.5\" diskette.

3\. Office space and equipment. Because office space is limited, the
team will **not** be provided with temporary workspace at USAID Baku.
The team leader will be required to have a personal computer and should
arrange with the logistics coordinator for temporary workspace and other
assistance with the local administrative/logistical support providers,
as needed. No access to USAID Azerbaijan services, facilities, or staff
will be provided.

4\. Transport. Local transport and per diem will be reimbursed at the
USAID rate for Azerbaijan on a daily basis. Airline tickets will be
reimbursed on a cost basis, upon submission of official receipts.

5\. Work week. A six-day workweek is authorized, without a premium
payment.

######### ANNEXES

1.  **Objectives of assessment**

2.  **Data collection**

3.  **Data points**

4.  **Additional sector specific information**

5.  **Data analysis and interpretation**

6.  **Relevant reading materials**

7.  **Important contacts**

**Annex 1 -- Objectives of Assessment**

-   Effective collection and use of information for planning, monitoring
    and evaluation*.*

-   Social/Health seeking behavior of refugees/IDPs.

-   Existing knowledge and IEC materials.

-   Access to pharmaceutical outlets

-   Performance and skills of NGO trained workers in facilities attended
    primarily by refugees/IDPs

-   Community programs and delivery systems

-   Potential for financing mechanisms

-   Management information systems

-   Potential for community development

### *Annex 2 -- Data Collection* {#annex-2-data-collection .unnumbered}

The following sector specific data points will be collected as an
overall health and social system assessment. In this short duration
assessment, information from numerous sources will be obtained and
compiled. Only the targeted field data collection of primary data in a
few specific areas will be possible because of the short time available.

Annex 3 -- Data Points

Specific data points will be organized by sector. The following is a
non-inclusive list of data points to **consider**. This should be
adapted to USAID data needs for Azerbaijan.

[Demographic Evaluation:]{.underline}

Regional size and population

Number of families in household

Head of household and education

Number and location of refugees

Number and location of IDPs

Migrant populations

Ethnic composition of population and displaced

Movement and regional population stability

Age and sex stratification

Family unit and pertinent customs

[Health sector:]{.underline}

Crude mortality rate estimates

Deaths per month

Deaths in under 5 population per month

Vaccination (EPI) coverage and practices

Incidence of vaccine preventable diseases

Most common illnesses stratified by age group

Diarrheal illness over the prior two weeks

ARIs over the past two weeks

Source of health care for under 5

Access to pre-natal care

Trauma and injury

# 

# [Health Systems Analysis]{.underline}

Access to health care (curative and public health)

Health care access for vulnerable populations (pregnant women, children,
elderly, disabled)

Staffing of health facilities

Immunization status for under 5

Drug and equipment availability

Training programs

Level of NGO participation and coordination

# [Food and Nutrition]{.underline}

# Food delivery and access

Markets and pricing

Rates of PEM

Breast feeding for children \<2

Anthropometry (\<5 and \<12)

Micronutrient deficiency syndromes

Record keeping and nutritional surveillance capacity in local health
system

Current food aid programs and NGOs

Other possible measures include thyroid screening (exam) and hemoglobin
(lab)

### *Annex 4 Additional Sector Specific information* {#annex-4-additional-sector-specific-information .unnumbered}

[Environmental:]{.underline}

Geographical features and climate considerations

Shelter specifications and variations

####### Access to clothing and cleaning materials 

Vectors

[Water and sanitation]{.underline}:

Local water sources and quality

Sanitation practices and cultural issues

Variations in sanitation practices by groups and region

Water born disease prevalence

# [Logistics]{.underline}

Food and material transport

Supply availability

Availability of personal transport

**Annex 5 Data Analysis and Interpretation**

Data management will be accomplished by Epi Info 6.1 or similar
software. Anthropometric software will be used to calculate HFW and
Z-scoring.

### *Annex 6 Relevant Reading Materials* {#annex-6-relevant-reading-materials .unnumbered}

In 1996, the CDC and UNICEF (in collaboration with Relief International
and MSF-Holland) conducted a health and nutritional assessment of
Azerbaijan.

USAID Azerbaijan Strategic Plan, 2001-2003, May 2000.

Azerbaijan Nutrition Survey, supported by USAID, WHO & UNICEF, April
1996.

IMC Two Part Baseline Survey on Primary Health Care and Population
Health Needs and Utilization of Health Care Services, August 2000.

**Annex 7 Important Contacts**

American International Health Alliance (AIHA)---Jeyhoun

International Medical Corps (IMC)

World Bank

UNICEF

UNHCR

UNDP

####### ANNEX B

####### References and Principal Documents Reviewed by the Azerbaijan Social and Health Assessment Team, February 2002 

####### References and Principal Documents Reviewed by the Azerbaijan Social and Health Assessment Team, February 2002

Azerbaijan Republic, 2001. **National Reproductive Health Strategy,
Azerbaijan Republic (2001-2005)**. Baku, Azerbaijan

Blanden, C., Powell, C., Lattu, K., Eltom, A.A., and Holmes, P., 1998.
**Final Report, Caucasus Health Sector Assessment, October 1998**,
USAID/ENI.DGSR Technical Assistance Project, Arlington, Va.

Branca, F., Burkhodler, B., Harnel, M., Parvanta, I., and Robertson, A.,
1996. **Health and Nutrition Survey of Internally Displaced and Resident
Population of Azerbaijan -- April 1996**. USAID, WHO, and UNICEF, Baku,
Azerbaijan.

Braveman P., 1997. **Monitoring Equity in Health: A Policy-oriented
Approach in Low- and Middle-Income Countries**. Division of Analysis,
Research, and Assessment, WHO.

Buchholz, U., 1999. **Cluster Survey on the Knowledge, Attitudes,
Practices and Behavior of Azeri Women Regarding Childhood Immunizations
and Reproductive Health in Four Districts in the Northwest of
Azerbaijan, 1999**. Medecins-Sans Frontieres -- Holland (MSF- Holland),
Baku, Azerbaijan.

CARE, 1994. **Azerbaijan: A Food and Nutrition Security Rapid
Assessment**.

CHF International and International Medical Corps, 2001**. Babi Hospital
Complex Grand Opening Ceremony, November 14, 2001.** CHF International
and IMC, Baku, Azerbaijan.

CHF. Social Inventory Assessment, 2001. CHF-Azerbaijan., Baku,
Azerbaijan.

CHF-Azerbaijan, 2001**. Social Inventory Assessment 2001**,
CHF-Azerbaijan, Baku, Azerbaijan.

Gotsadze, G., 2000. **Technical Report: Population Health Needs and
Health Service Utilization in Southern Azerbaijan, International Medical
Corps, Community Based Primary Health Care Development Program.**
International Medical Corps and Curatio International Foundation, Baku,
Azerbaijan.

Gotsadze, G., 2000. **Technical Report: Primary Health Care Network
Survey for Southern Azerbaijan**. International Medical Corps and
Curatio International Foundation, Baku, Azerbaijan.

[]{.mark}

International Committee of the Red Cross, 2001, **Tuberculosis Control
Project Inside the Penitentiary System of the Republic of Azerbaijan**,
ICRC, Baku, Azerbaijan.

International Federation of Red Cross and Red Crescent Societies,
1999**. Azerbaijan, Assessment Mission Report, Internally Displace
Persons Living in the Southern Camps and Surrounding Areas (13 October
to 19 November).** IFRC, Geneva, Switzerland.

Leenan H. **Equality and Equity in Health Care, 1985**. WHO/Neuffield
Centre for Health Service Studies Meeting, 22-26 July 1985.

Mathias, I., 1998. **Trans Caucasus Donor Assessment: A review of Donor
activity in four areas of health reform in Georgia, Armenia and
Azerbaijan.** Canadian Society for International Health (CSIH), Ottawa,
Canada.

Medecins Du Monde -- Greece, 1998, **Programme for Emergency Repletion
of Iodine in Youth Population in the Republic of Azerbaijan**.
MDM-Greece, Baku, Azerbaijan.

Ministry of Health Azerbaijan Republic, United Nations Population Fund
and the World Health Organization, 2001. **National Reproductive Health
Strategy, Azerbaijan Republic (2001-2005).** MOH, UNFPA, WHO, Baku,
Azerbaijan.

Ministry of Health Azerbaijan Republic 2002**. Health Statistics of
Azerbaijan Republic, as seen at
[www.mednet.az](http://www.mednet.az/).**

Norman, C. Feiden, R. and Thompson, C., 1999. **Report of an evaluation
of the PHC revitalization project in Azerbaijan, Final Report December
1999**. London School of Hygiene & Tropical Medicine, Baku, Azerbaijan.

Qulieyeva, D.P. and Huseynov, S.A., 1999. **Primary Health Care
revitalization in Azerbaijan**. Croat. Med. J. 1999, June, 40(2):210-15.

**Serbanescu, F., Morris, L., Rahimova, S., and Flowers, L, 2002.
Women's Reproductive Health Survey, 2001. Preliminary Report.**
Adventist Development and Relief Agency, Mercy Corp, State Committee of
Statistics, and Centers for Disease Control and Prevention, USA, Baku ,
Azerbaijan and Atlanta, Georgia, USA.

State Committee for Statistics, 2001. **Statistical Yearbook for
Azerbijan**. Azerbaijan Republic, Baku Azerbaijan.

Toole, M.J. and Waldman, R.J., 1997. **The Public Health Aspects of
Complex Emergencies and Refugee Situations.** Annu. Rev. Public Health.
18:283-312.

UNAIDS, 20001. **Situation Analysis and Response of the UN Theme Group
on HIV/AIDS in Azerbaijan.** UNAIDS, Baku, Azerbaijan.

United Nations Children's Fund (UNICEF), 2000. **Azerbaijan Multiple
Indicator Cluster Survey 2000.** UNICEF, Baku, Azerbaijan.

United Nations Children's Fund (UNICEF), 1999. **Government of
Azerbaijan---UNICEF Programme of Cooperation, Master Plan of Operations,
2000-2004**. UNICEF, Baku, Azerbaijan.

United Nations Children's Fund (UNICEF), 1999**. Report of an Evaluation
of the PHC Revitalization Project in Azerbaijan.** London School of
Hygiene & Tropical Medicine, Department of Public Health and Policy,
Health Services Research Unit. Baku, Azerbaijan.

United Nations Children's Fund, 1999. **Children and Women in
Azerbaijan: A Situation Analysis.** UNICEF, Baku, Azerbaijan.

United Nations Development Programme, 1997, **Azerbaijan Human
Development Report, 1997**, UNDP, Baku, Azerbaijan.

United Nations Development Programme, United Nations High Commissioner
for Refugees and United Nations Development Fund for Women, 1998.
**Report Sub-Regional Conference Women's Rights are Human Rights: Women
in Conflict, May 18-20, 1998**,. UNDP, UNHCR, and UNIFEM, Baku,
Azerbaijan.

United Nations Development Programme, 1999, **Azerbaijan Human
Development Report**, 1999, UNDP, Baku, Azerbaijan.

United Nations High Commission for Refugees, 2000. **UNHCR Global Report
2000**, Azerbaijan, pp. 351-356.

United Nations Population Fund and Government of Azerbaijan Republic,
2002. **Report of the UNFPA Annual Review Meeting, December 11-12,
2001**. UNFPA, Baku Azerbaijan.

United Nations Population Fund, 1999. **Azerbaijan: Country Population
Assessment.** UNFPA, Baku Azerbaijan.

United Nations Statistics Division Web page, **Azerbaijan Statistics**
as seen at <http://www.un.org/depts/unsd>.

United Nations, 2002. **Azerbaijan: Country Information**.
<http://www.un-az.org/couinf.htm>

United States Agency for International Development, 2000. **Strategic
Plan 2001-2003,** Azerbaijan, USAID/Caucasus.

United States Agency for International Development, 2001. **Azerbaijan,
Regional Overview, Azerbaijan Overview**,
[**http://www.usaid.gov/country/ee/az/**](http://www.usaid.gov/country/ee/az/).

United States Agency for International Development, 2001.
**USAID/Caucasus- Azerbaijan, Results Review and Resource Report (R4)**,
USAID, Baku, Azerbaijan.

United States Agency for International Development, 2002. **Azerbaijan:
Activity Data Sheet**, as seen at
[**http://www.usaid.gov/country/ee/az/112-031.html**](http://www.usaid.gov/country/ee/az/112-031.html).

Whitehead M. **The Concepts and Principles of Equity and Health**. WHO
Regional Office for Europe, Copenhagen, 1990.

[]{.mark}

World Bank, 1997. **Azerbaijan Poverty Assessment Report No. 15601-AZ**.

World Bank, 2001. **World Development Indicators**. As seen at
[http://www.worldbank.org](http://www.worldbank.org/)

World Bank, 2001**. Project Appraisal Document on a Proposed Learning
and Innovation Credit in the Amount of SDR4.0 Million (Equivalent to
US\$5 Million) to The Azerbaijan Republic for a Health Project, May 16,
2001, Report No: 21956-AZ.** World Bank, Baku, Azerbaijan.

World Health Organization, 1996**. Health and Nutrition Survey of
Internally Displaced and Resident Population of Azerbaijan -- April
1996**. WHO, Baku, Azerbaijan.

World Health Organization, 1997. **Final Report of Meeting on
Policy-oriented Monitoring of Equity in Health and Health Care. 29
September -- 3 October 1997.** WHO, Geneva, Switzerland.

World Health Organization, 2001. **The World Health Report 2000, Health
Systems: Improving Performance, WHO/WHR/00.1**. WHO, Geneva,
Switzerland.

World Health Report 2000: **Health Systems -- Improving Performance**.
WHO, Geneva, Switzerland

World Health Organization, 2000. **Health For All Database**. WHO,
Geneva, Switzerland.

[]{.mark}

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### ANNEX c

#### Key Consultations and Site Visits Conducted by the Azerbaijan Social and Health Assessment Team, February 2002 

#### Key Consultations and Site Visits Conducted by the Azerbaijan Social and Health Assessment Team, February 2002

February 6, 2002 USAID/Washington:

Paul Holmes, Mary Jo Lazear, and Tim Clary

February 12, 2002 USAID Mission, Baku, Azerbaijan:

Mr. Bill McKinney, Country Coordinator

Mr. Khalid Hasan Khan, Humanitarian Assistance Specialist

Ms. Catherine Fischer, Regional Health Specialist

Ms. Gulnara Rahimova, Project Management Specialist/Humanitarian Sector

February 12, 2002 DRH/CDC in Baku, Azerbaijan:

Dr. Leo Morris, Chief, Behavioral Epidemiology & Demographics Research
Branch, and Dr. Florina Serbanescu

February 13, 2002 UNICEF, Baku, Azerbaijan:

Mr. Nazim Agazade, Project Officer and Acting Representative

Dr. Dinara Kulieva and Dr. Shahin Huseynov, Health Officers

February 14, 2002 MOH, Baku, Azerbaijan:

Minister Ali Insanov, First Minister of Health, Ministry of Health

Professor Alexander Umnyashkin, Adviser to the Minister of Health

February 14, 2002 UNHCR, Baku, Azerbaijan:

Ms. Nailya Velikhanova, Senior Field Clerk

February 14, 2002 UNFPA, Baku, Azerbaijan:

Mr. Ramiz Alekperov, Program Officer, and Ms. Jamilya Kerimova

February 15, 2002 AIHA, Baku, Azerbaijan:

Mr. Jeyhoun Mamedov, Program Coordinator

February 15, 2002 ICRC, Baku, Azerbaijan

Dr. Fuad Mirzayev, Head of Medical Program

February 15, 2002 Save the Children Federation, Baku, Azerbaijan:

Mr. Michael C. Halbert, EO Program Manager and Technical Advisor

Kishor N. Sharma, Program Manager, Integrated Community Development

February 15, 2002 Mercy Corps, Baku, Azerbaijan:

Mr. William R. Holbrook, Chief of Party

Ms. Mary Hennigan, Health Program Manager

February 16, 2002 World Bank Resident Mission, Baku, Azerbaijan:

Mr. Rasul Bagirov, Operations Officer, HD

February 18, 2002 Shamakhi District Health Department:

Dr. Bahtiyar Abbasov, Head Doctor, and team

February 18, 2002 Goychay District Health Department:

Dr. Shabon Osmanov, Head Doctor, and team

February 18, 2002 IDP camp in Barda, Yevlakh

Dr. Kubra Hanum, local ambulatory doctor, and the local IDP government
representatives

February 18, 2002 Akhtachi Village:

Dr. Ikram, Head Doctor of Akhtachi Village Hospital

February 18, 2002 Sabirabad District Health Department:

Dr. Rahil Musayev, Head Doctor, and team

February 18, 2002 Saatly District Health Department:

Dr. Adil Mursalov, Head Doctor, and team

February 18, 2002 IDP camp at Bahramtapa

Dr. Bahman Shukurov, DAC Head Doctor

February 19, 2002 Shaki District Health Department and Regional
Hospital:

Dr. Mahil Gafarov, Head Doctor, and team

February 19, 2002 Gabala District Health Department, Hospital,
Mirzabaliyev Village DAC:

Dr. Sabir Bayramov, Head Doctor and team, local ambulatory doctor,
Village Executive Committee and Municipal Council representatives

February 19, 2002 Masally District Health Department and Hospital:

Dr. Rasim Azizov, Head Doctor, and team

February 19, 2002 Sigdash Village DAC:

Dr. Yusif, DAC Head Doctor

February 19, 2002 Salyan District Health Department and Hospital:

Dr. Ibragim Guliyev, Head Doctor, and team

February 20, 2002 CHF, Baku, Azerbaijan:

Mr. Christopher Siliski, Country Director

February 21, 2002 Khizi District Health Department and Hospital:

Dr. Behdash Nabiyev, Head Doctor, and team

February 21, 2002 Gusar District private health care facility:

Dr. Malik Kerimov, Head Doctor, and team

February 21, 2002 Sumqayit Hospital and Dr. Karlen Abbasov, Head Doctor

Republican (Mirkasimov) Hospital and Hospital Director

February 22, 2002 ADRA, Baku, Azerbaijan:

Mr. Conrad Vine, Nakhichivan Health Development Program Director (and
Micro Credit Projects Director) and Ms. Jenni Sequeira, Nakhichivan
Health Development Program Director (and Health Projects Director)

February 23, 2002 National NGO, "Family and Society", Baku, Azerbaijan:

> Dr. Faiza Aliyeva, President, and Director of the Republican Center
> for Family Planning

February 25, 2002 IMC, Baku, Azerbaijan (and multiple interactions
during Feb. 10-26):

Mr. Adam Sirois, Country Director

Dr. Natalia Valeeva, Primary Health Care Officer

Mr. Hamidzade Fuad, Office Manager/Logistics

Mr. Ibrahimov Fuad, Field Coordinator

Ms. Adele Gafurova, Administration

Mr. Rasim Hagverdiyev, Driver

February 26, 2002 USAID Mission, Baku, Azerbaijan:

Mr. Bill McKinney, Country Coordinator

Mr. Khalid Hasan Khan, Humanitarian Assistance Specialist

Ms. Catherine Fischer, Regional Health Specialist

Ms. Gulnara Rahimova, Project Management Specialist/Humanitarian Sector

February 26, 2002 MOH, Baku, Azerbaijan: Professor Alexander Umnyashkin,
Adviser to the Minister of Health

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### 

####### ANNEX d

#### Key Findings of the Reproductive Health Survey, Azerbaijan, 2001, ADRA, MC, SCS, CDC, USAID, UNFPA and UNHCR 

#### Key Findings of the Reproductive Health Survey, Azerbaijan, 2001, ADRA, MC, SCS, CDC, USAID, UNFPA and UNHCR

### Fertility and Pregnancy Experience {#fertility-and-pregnancy-experience .unnumbered}

#### Fertility Levels and Patterns

-   The total fertility rate for the three years preceding the survey
    was 2.1 births per woman, slightly above the replacement level. This
    is about 20 percent higher than the fertility rate of the other
    Caucasus region countries, Georgia and Armenia, but substantially
    lower than the central Asian republics, excepting Kazakhstan.

-   Similar to other countries of the region, Azeri women initiate and
    complete childbearing in an early age. The highest fertility levels
    are among 20-24 year old and 25-29 year old women, accounting for 36
    percent and 32 percent respectively, of the TFR.

-   Fertility amongst adolescent women (44 births per 1,000 women aged
    15-19) is the fourth highest, contributing 11 percent of the TFR.

-   Women aged 35-39 and 40-44 make minimal contributions to total
    fertility rates account for only 5 percent and 2 percent
    respectively of all fertility.

-   Out-of-wedlock births are rare and unmarried women contribute very
    little to overall fertility (less than 5 percent of births were
    out-of-wedlock).

-   Fertility among women living in urban areas, including Baku, was on
    average almost 30 percent less than among rural women in the
    three-year period preceding the survey. By region, women living in
    the Central areas and in Baku had the lowest level of fertility (1.8
    and 1.9 births per woman).

-   Fertility rates were comparable among the IDP and non-IDP women.

#### Induced Abortions Levels and Patterns

-   The total induced abortion rate (TIAR) was 1.5 times higher than the
    TFR during the three years prior to the survey (3.2 vs. 2.1).

-   The age pattern of abortions is concentrated at 25-29 years of age
    (177 induced abortions per 1,000 women) and 30-34 years of age (176
    per 1,000), accounting for 50 percent of TIAR.

-   The abortion rates were equally high and varied little by background
    characteristics, with the exception among internally displaced women
    who reported substantially higher rates. IDP women reported the
    highest TIAR (4.7 abortions per woman) and all the age-specific
    abortion rates among these women were higher than among non-IDP
    women.

-   57 percent of women reported their last pregnancy as unintended and
    the majority of them (84 percent) reported it was unwanted rather
    than mistimed.

-   The preference among women for small families is reflected not only
    in the declining fertility levels and high abortion rates, but also
    in their stated desires to not have more children. Among women in
    union, over two thirds of respondents (69 percent) reported that
    they do not want to have more children.

### Contraceptive Knowledge and Use {#contraceptive-knowledge-and-use .unnumbered}

#### Contraceptive Awareness and Knowledge of Use

-   Azeri women have a relatively high level of family planning
    awareness, contrasting with their low prevalence of modern
    contraceptive use; 87 percent had heard about at least one
    contraceptive method. The level of overall awareness of either
    modern or traditional methods was slightly higher among urban than
    rural women.

-   Overall, no modern method was recognized as very effective by a
    majority of women, partly because substantial numbers of women
    lacked awareness of modern methods.

#### Current Contraceptive Prevalence

-   About half (55 percent) of women currently in legal or formal unions
    were currently using a method of contraception but only 12 percent
    used modern methods.

-   Modern contraceptive use was twice as high in urban areas as in
    rural areas (29 percent vs. 13 percent); it was higher in Baku (35
    percent) than in any other region, among 25-44 year olds than among
    young adults, and among those with at least one living child than
    among childless couples.

-   By far the most prevalent method in use among women in union was
    withdrawal (41 percent), which accounts for 73 percent of
    contraceptive prevalence. IUDs, which were used by 6 percent of
    women in union, and condoms (3 percent) were the next most used
    methods and accounted for 78 percent of modern methods.
    Contraceptive sterilization, despite an overwhelming desire by most
    women to have no more children, was used by only 1 percent of women
    currently in union; the pill was also used by only 1 percent of
    women in union.

#### Sources of Contraceptive Services

-   The public medical sector is in general the largest source of
    contraception (54 percent). Hospitals with gynecologic wards and
    maternity wards supplied 27 percent of women currently in union with
    their current method of contraception.

-   Women's consultation clinics supplied 21 percent of women, whereas
    polyclinics and village hospitals and dispensaries supplied only 5
    percent of women.

-   Commercial sales, particularly through pharmacies, are the second
    largest source of contraceptive supplies (35 percent).

-   IDP and refugee women were less likely to obtain contraceptive
    supplies in public hospitals and clinics (43 percent vs. 54-59
    percent) and more likely to receive a method from a health clinic
    operated by NGOs.

#### Reasons for Not Using Contraception

-   The most common reasons for not currently using contraception were
    related to pregnancy (40 percent), lack of current sexual activity
    (19 percent) and female fecundity impairment and the presence of
    pelvic inflammatory disease (15 percent).

-   Reasons for not using a method did not vary much between IDP/R and
    non-IDP/R women but differed sharply by age group. Younger women in
    union were more likely to be either pregnant or in the postpartum
    period (52 percent) or were seeking to become pregnant (24 percent),
    whereas women aged 35-44 years were likely to not be able to get
    pregnant.

#### Unmet Need for Contraception

-   About one of three women (38 percent) had a potential demand for
    contraception -- defined as the sum of current contraceptive use
    (met need) and the additional contraceptive use that would be
    required to eliminate the risk of unwanted or mistimed births --
    including 7 percent of current users of modern methods, 25 percent
    of current users of traditional methods, and 7 percent of non-users
    at risk for unintended pregnancy.

-   According to the most recent census data, this translates into an
    estimate of 775,000 women aged 15-44 years with a potential for
    family planning services.

#### Communication with Family Planning Providers

-   Two of three women were advised by a health care provider to use the
    current or last modern method (65 percent by a physician and 2
    percent by a nurse or a midwife.

-   One in four women started using her last method at the partner's
    suggestion (22 percent) or at her own counsel (4 percent) by passing
    any potential medical advice.

-   In 4 percent of cases the choice of method was made at the
    suggestion of a pharmacist and in the remaining cases, the choice
    was suggested by a friend (three percent) or a relative (one
    percent).

### Pregnancy, Delivery and Breastfeeding {#pregnancy-delivery-and-breastfeeding .unnumbered}

#### Prenatal Care

-   Of the 3,430 births reported since January 1996, about two thirds of
    women (70 percent) had received some prenatal care, of those, almost
    two thirds (64 percent) had received their first prenatal care visit
    in the first trimester.

-   Approximately one in five of all women had the first visit during
    the 2^nd^ trimester and 6 percent during the third trimester.

-   Rural women, residents of the South region, those who did not
    complete secondary education or had a low social economic status
    (SES) and women who had already had two or more births, were more
    likely not have any prenatal care.

-   Only 6 percent of births within the past five years had received
    adequate or adequate plus care while 81 percent had received
    inadequate prenatal care.

-   The principal source of prenatal care was a women's consultation
    clinic (46 percent). The second source of most prenatal visits was a
    maternity (36 percent) or village hospital (13 percent). Rural
    dispensaries and private clinics provided prenatal care for 2
    percent and 1 percent respectively of pregnant women.

-   3 percent of women received prenatal care at home.

#### Intrapartum Care

-   Most deliveries in the past five years took place in maternities (56
    percent) or village hospitals with inpatient obstetrical care (17
    percent).

-   One in four births, however, was delivered outside medical
    facilities and less than on percent were delivered in private
    clinics.

-   Home deliveries were relatively high among rural residents (36
    percent), those living in the Central, South, and South-West regions
    (35 percent, 36 percent and 39 percent), those with low levels of
    education or SES (39 percent and 36 percent respectively), IDP/R
    women and non-IDPs living in conflict areas (41 percent and 35
    percent), those with four or more other births (42 percent) and
    those with no prenatal care (48 percent).

#### Poor Birth Outcomes

-   Of all births during the 1996-2001 period, 21.2 per 1,000 were
    stillbirths.

-   The stillbirth rate was higher among women living in urban areas
    than in rural areas (26 vs. 17 per 1,000), among residents of the
    West and Central regions (38 and 31 per 1,000), among women aged
    35-44 years, among women with postsecondary education, and among
    those with three or more previous births.

-   The incidence of low birth weight was 12 percent. Higher rates were
    reported by rural women, women in the Southwest, South, and Central
    regions (18 percent, 15 percent, and 14 percent respectively), women
    with low education (16 percent) or low SES (16 percent), IDP and
    non-IDP women living in conflict areas (16 percent), women with at
    least three prior births, women with no prenatal care (17 percent)
    and those delivered at home (18 percent).

-   The incidence of prematurity (birth before 37 weeks of gestation)
    was 5.7 percent.

#### Breastfeeding

-   The majority of babies (95 percent) born during 1996-2001 were
    breastfed at least for short periods of time.

-   Of infants who were breast fed, only 2 percent began breastfeeding
    during the first hour after birth. The majority of children began
    breastfeeding between 1 hour and the completion of the first day (49
    percent) or during the second day of life (26 percent).

-   The mean duration of any breastfeeding was 11.6 months. For most of
    this time, however, breastfeeding was only partial.

-   The mean duration of exclusive breastfeeding was 0.4 months and with
    the exception of the women residing in the Central region, did not
    vary greatly by maternal characteristics.

-   Very few children were exclusively breastfed for the length of time
    recommended by the WHO (WHO recommends that all children under four
    months of age should be exclusively breastfed).

#### Prevalence of Routine Gynecologic Visits

-   Only about one in two (57 percent) sexually experienced women had
    ever been examined by a gynecologist during a routine exam and only
    22 percent were examined in the previous 12 months.

-   15 percent of women had undergone an exam within the past three
    years and 21 percent more than three years ago.

-   Rural residents, women living in the South and West, younger women,
    women with lower education, and those not currently employed, were
    more likely to have never received preventive gynecologic exams.

#### Breast Self-Exam

-   Less than one of three (30 percent) sexually experienced women of
    childbearing age has ever heard about breast self-exam and only one
    of ten (10 percent) has ever performed this procedure.

-   Awareness of breast self-exam is higher among urban than rural
    residents (37 percent vs. 21 percent) among women residing in Baku
    (49 percent), increased with age and education level, was higher
    among women currently employed, and among those who underwent
    routine gynecological exams.

#### Pelvic Inflammatory Disease (PID)

-   Overall, 27 percent of all women and 42 percent of ever-married
    women reported PID.

-   Those most likely to report PID were women who ever had a routine
    gynecologic exam (64 percent).

#### Other Health Conditions

-   One in six women reported that she had been told by the doctor that
    she had high blood pressure; 14 percent reported urinary tract
    infections; 2 percent had been diagnosed with Hepatitis B, and a few
    women had been told that they have Diabetes.

### Knowledge and Experience of Sexually Transmitted Diseases {#knowledge-and-experience-of-sexually-transmitted-diseases .unnumbered}

#### Knowledge of AIDS and other STDs

-   A high percentage (75 percent of women have heard of HIV/AIDS but
    significantly fewer women have heard of syphilis (41 percent) and
    gonorrhea (35 percent).

-   Only 12 percent of women have heard of trichomonas, 85 have heard of
    Chlamydia, 7 percent were aware if bacterial vaginosis, 6 percent
    and 5 percent, respectively, knew that genital warts and genital
    herpes were transmitted sexually.

-   Although three fourth of women were aware of HIV/AIDS, only one in
    six (16 percent) said that she knew where HIV test are provided,
    including 3 percent who have been tested for HIV/AIDS.

-   Only 28 percent of the women who had heard of HIV knew that the
    disease could be present with no symptoms.

#### Self-Reported STD Testing and Diagnostic

-   According to the women's responses, the most often diagnosed STDs
    were yeast infection and trichomoniasis. Overall, five percent and
    one percent, respectively, of all women aged 15-44 reports having
    had a yeast infection and trichomoniasis infection.

-   Women living in Baku (12 percent and 3 percent), women with
    university education (12 percent and 3 percent), and women with two
    or more lifetime sexual partners (22 percent and 9 percent) were
    more likely to report positive testing, probably due to differences
    in health seeking behaviors and access to health services.

-   A history of other STDs was very seldom reported; only 0.3 percent
    of women have been diagnosed with chlamydia, 0.2 percent with
    gonorrhea, and 0.1 percent with genital herpes, or bacterial
    vaginosis.

-   When interpreting results one should be cognizant that laboratory
    resources in Azerbaijan are quite limited and, for STDs, without
    testing there is no diagnosis. Only 19 percent of sexually
    experienced women have ever been tested for STDs.

#### Self-Reported STD Symptoms

-   Almost one in three sexually experienced women reported abnormal
    vaginal discharge and 2 percent reported "sores, warts, or ulcers in
    the genital area".

-   Reports of vaginal discharge and sores were higher among women who
    have ever been tested for or diagnosed with a STD, suggesting that
    STD symptoms were severe enough to seek medical attention.

-   Among women who have recently experienced vaginal discharge, 78
    percent reported also low abdominal pain, 51 percent reported
    vaginal itching, 41 percent reported pain during sexual intercourse,
    and 37 percent reported painful urination.

[^1]: "Children and Women in Azerbaijan: A Situation Analysis," UNICEF,
    1999.

[^2]: World Bank, 1997.

[^3]: United Nations Development Program (UNDP), 1999.

[^4]: Center for Disease Control (CDC), 2002.

[^5]: World Bank (WB), 2001.

[^6]: UNDP, 1999.

[^7]: United Nations Development Program (UNDP), 1999.

[^8]: *Ibid*.

[^9]: United Nations Children's Fund (UNICEF), 1999.

[^10]: RHS Azerbaijan 2000; Azerbaijan MICS, UNICEF, 2000.

    ^11^ WHO, HFA Database, 2000

[^11]: ^12^ Azerbaijan MICS, UNICEF, 2000.

[^12]:

[^13]: "Health and Nutrition Survey of IDPs and Residents," USAID,
    UNICEF, WHO, 1996.

[^14]: "Master Plan of Operations 2000-2004," UNICEF, 1999

[^15]: UNICEF, 2000.

[^16]: UNAIDS, 2001.

[^17]: "World Health Report (Rapprot sur la Santé dans le Monde) (WHR),
    2000.

[^18]: Health for All (HFA) Database, WHO, 2000.

[^19]: WB Poverty Assessment, 1997.

[^20]: Reproductive Health Survey (RHS), 2000; Health and Nutrition
    Survey, 1996; "Population Health Needs and Health Service
    Utilization," International Medical Corps (IMC), 2000.

[^21]: "Azerbaijan Human Development Report," UNDP, 1997.

[^22]: RHS, 2000.

[^23]: HFA Database, 2000.

[^24]: UNFPA, 1999.

[^25]: Azerbaijan Multi-Indicator Cluster Survey (MICS), UNICEF, 2000).

[^26]: Postner, SF, et. al., 2001.

[^27]: Braveman, "Monitoring Equity in Health," WHO, 1997.

[^28]: Leenan, "Equality and Equity in Health Care," 1985.

[^29]: Whitehead, "The Concepts and Principles of Equity in Health,"
    WHO/EURO, 1990.

[^30]: WHO, Geneva, 1997.