Paying out of the pocket: how state funded healthcare services are budgeted

– Are you beneficiary of the state funded health services?
– I don’t really know; how do I check?

We had this short conversation at one of the medical centers as we were preparing one of my relatives for a surgery. The costs of the surgery were the double of the average salary in Armenia [editor’s note: as of April 2022, the average monthly salary in Armenia was equal to AMD 217 000].

A poster on the announcement board in the medical center would prompt the 8003 hot line number of the Ministry of Heath, which we called.

In response to our inquiry, the operator on the line read out loud the list of social groups, who are beneficiaries of the state funded health services, including political prisoners, family members of military servicemen, some of those who are below a certain social line, and some others.

The list seemed a long one, unlike the patience of the operator.

“You would definitely know, if you were a beneficiary,” the operator said.

We took it for granted, for we were running out of time. We paid for the surgery out of own pocket. The medical procedure went successfully.

We fell short of taking the advantage of getting state funding for the sought health service, yet, we will share about the mechanism of operation of the state funded health services, the groups it is intended for and the ways it is distributed.

Growing regularly, the state funding is never enough to cover the actual demand

The expenses steered to covering the state funded healthcare services grow consistently year by year.

That’s a fact. The budgetary means steered to state funded healthcare services equaled to AMD 66,524 billion in 2017; in 2021 the expenses exceeded AMD 107,194 billion, growing by more than 60%. Yet, the fact is, the funding never proves enough, and the proof of it follows shortly.


The infographics show that the funds allotted for state financed services have been near equal in 2017 and 2018; the funding for 2018 has been less against the budget in 2017. In 2019 the financing was increased by over AMD 18 billion.

The next major leap in the amount of sums allotted from the state budget for health services was registered two years later, in 2021, in the post-COVID and post-war year, which, probably, is conditioned by the need to overcome the consequences of the pandemic and the war, treatment of injured soldiers, and for other expenses.

As to allotments for a wide range of health services, the budgetary means directed for this purpose to specialized services as a rule grow on yearly basis, with only few exceptions, when the allotment size decreases.

And yet, every fifth citizen of Armenia refrains from getting medical treatment on the grounds of the lack of financial means. According to the draft concept for introduction of comprehensive health insurance system in Armenia,

about 20,1% of the country’s population refuses to see a doctor at the primary health services provider institutions for financial reasons.

But is there an available comprehensive data on beneficiaries of the state funded health services? The Armenian legislation defines groups of people, who are eligible for free state funded health and medical services.

The RA government decision on the free and privileged medical help and services guaranteed by the state (N 318-N, 4 March 2004) says the population of the country is provided in-hospital medical help and services of the following types:

  • reanimation procedures
  • medical help services related to tuberculosis,
  • medical help services related to mental and narcological diseases,
  • medical help services related to intestinal and other infectious diseases, HIV/AIDS,
  • medical help services to persons of military conscription age,
  • obstetric services,
  • medical help services to children under 18,
  • hemodialysis services.

Now let’s suppose that you are well aware of your eligibility to get medical services by state funding. And, yet, you may be surprised to learn that, despite submitting all the required documents proving your eligibility, the clinic you visit has run out of the funding. And that is totally possible.

However, the website of the Ministry of Health,, gives you opportunity to find out how much funds are still available under state financing program for each medical center. As of mid-June, there were medical centers that had already used the state funds allotted for the whole year.

For example:

  • Only AMD 1800 were remaining from about AMD 8 mln intended for out-of-hospital and hard-to-reach diagnostics in the Yerevan-based medical center “Slavmed”;
  • Only AMD 7800 were remaining from about AMD 12 mln intended for first aid medical services in the Jermuk Health Center in Vayots Dzor; and so on.

It seems the demand for a certain type of service has been so high in the mentioned medical centers that the funds intended for that service for 12 months have depleted in less than six months. That is, the medical centers have received the funding for the whole year, yet, have spent it on services way before the end of the year.

In such case the same services may be rendered to patients in medical centers, where the funds are still remaining. And yet this raises another set of questions: what if you prefer a doctor in a certain medical center, or a center that is closest to your home?

The answer is still the same: you either choose another medical center, or pay out of own pocket.

The website says there are 40 types of services rendered through state funding. The financing of each such service is distributed across months, and in the case of most of those services there are still remaining funds, which means that the funds allotted for the upcoming months are not spend yet.

At the roundtable on the health insurance system organized by the “Journalists for the Future” NGO in late April, Ara Sinanyan, expert of the standing committee for healthcare at the National Assembly, confirmed that the state funding gets depleted in a number of medical centers by mid-year. “The reason may be the poor planning,” the expert said.

Indistinctness about insurance

And yet, there is a significant number of people who do not use the option, because of incompliance to any of the described social groups eligible for the state funded services, and are forced to pay out of own pockets, when facing the need to undergo an expensive surgery.

This mechanism of payment is called as is: an out-of-pocket payment.

The lion’s share of all health related services in Armenia are actually out-of-pocket payments. And though the budgets allotted by the state for health services grow year by year, the amounts paid out of pocket for healthcare services grow, too.

The most up-to-date complete information is available in the National Healthcare Аccounts 2018 report.

Presumably, this problem can be potentially solved through introducing health insurance. The idea is to safeguard people from unexpected health related expenses through regular payments to insurance companies of a certain portion of their income, in order to have the companies pay for the healthcare services, when such necessity arises.

The incumbent government of Armenia had developed the first draft of the comprehensive health insurance strategy back in 2019. The second draft is currently under development.

The government’s action plan for 2021-2026 envisions exact dates when the concept on comprehensive health insurance is anticipated to be passed, along with respective legislation, as well as the timeframes of establishing a special fund intended for accumulation of the means of insurance, and other related functions. Most of the set deadlines have long been exceeded.

The initiative is currently getting funding. Last February Minister of Health Anahit Avanesyan told the “Sputnik Armenia” news agency that according to the ministry’s estimates employed citizens of Armenia will pay approximately 3% of their income, with their employers paying a portion equal to another 3% of employees’ income.

At the roundtable on the health insurance system organized by the “Journalists for the Future”, Paylak Tadevosyan, chairman of the Taxpayers’ Rights Protection NGO, insisted that introduction of a comprehensive health insurance will come at a price for the working part of the population, implying increased taxes and imposing heavier burden on employers.

“This system is unacceptable to me also from the perspective of social justice, because it seems an employed citizen is going to pay for those who are jobless,” says Tadevosyan.

In an interview to Radio Free Europe/Radio Liberty, Minister of Finance Tigran Khachatryan underlined that the draft state budget for 2023 envisions some AMD 130 to 140 billion on healthcare expenses, whereas the Ministry of Health anticipates some AMD 350 billion to be spent within the next year.
This in fact points to disagreements inside the government in regard to such a dramatic increase on financing the healthcare sphere.

At the moment, the statements of representatives of the state agencies, seem contradicting when it comes to the introduction of health insurance. Specifically, this refers to the incumbent and the former ministers of health, Anahit Avanesyan and Arsen Torosyan.

Torosyan says he believes a step back is needed in order to go the evolutionary and not the revolutionary way of introducing comprehensive health insurance system increasing the portion of state budget envisioned for the healthcare expenses from other taxes.

Avanesyan disagrees with this viewpoint. The minister says the gradual increase in expenses cannot be a comprehensive solution.

Violetta Zopunyan, head of the “Center for Rights Development” NGO points to problems, which may potentially pop when the system is rolled out.

“We deal with lots of those patients, who are eligible for state funded services, but in fact are unable to entertain their right for that. And now, as we hear everybody needs the right and will be using those packages, we have the fears people will face quite a different situation. I am afraid that even those rare [editor’s note: vulnerable groups] who have an opportunity to get those services to some degree owing to the decision 318-N, will be left out in case the insurance system is introduced,” Zopunyan says.

She recalls the introduction of the Armed system: “It was deployed in 2017 and was intended to move from paper-based documentation to electronic circulation of documents in the sphere of healthcare. Yet, even today, the search for patient charts [widely known as anketa] at the policlinics is there.”

The expert at the National Assembly points practical situations need to be studied in more than one direction before the system is introduced.

“The state increases the funding of the healthcare system every year, extends the list of medical services covered by state. But there are problems, such as the queues for those services, which were to a certain degree generated by the situation with the COVID and the war. And the problem is not solved yet.

Imagine the queues that will be, when the comprehensive insurance gets deployed,” the expert believes.
Sinanyan adds that introduction of the system is unacceptable unless the problems get solved; otherwise, he predicts both a stressful situation and a crisis of services.

Text and visualization By Garik Harutyunyan

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First Published: 10/11/2022