HEALTH CARE MANAGERS EDUCATION AND TRAINING PROBLEMS IN THE REPUBLIC OF ARMENIA Tereza S. Khachatryan, Doct. of MS, Prof., Academician of AMS 1

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1 HEALTH CARE MANAGERS EDUCATION AND TRAINING PROBLEMS IN THE REPUBLIC OF ARMENIA Tereza S. Khachatryan, Doct. of MS, Prof., Academician of AMS 1 Abstract The objectives of study are to examine health care managers (HCM) education and training practices, problems and perspectives in the Republic of Armenia (RA). As a base for the settlement of the existing tasks mainly are used the primary materials of National Institute of Health (NIH) School of Health Care Management and Administration (SHCMA) the sole structure in the country having great experience of health care manager s education and training. It s shown the need in the improvement of HCM and health care policy makers education and training in regard to the socio-economic and Health Care reform as well as the urgency and importance of the preparation of that specialists until their appointment to the post of health care manager. The results of the survey revealed that under the absence of the diploma preparation system 53.8 percent of the health care managers of the Republic passed Health Care Management training after 10 years work, as manager and 31.5 percent during 5-10 years work. At the same time draws attention the reduction of the duration of the training courses to 1.5 month in recent years. It s substantiated that developing and implementing current health care reform strategy in RA requires a strengthening of management capacities. Decentralization also increases the need for greater number of well-educated and trained health policy makers. It s noted the main priority problems of HCM preparation and training with substantiation of the need to work out a new educational and training system as well as new educational standards and develop some innovative curriculums for the preparation of specialists in the field of Health Care Management and Organization. The contemporary circumstances for the activity of the Health Care system prompt such a training of Health Care Managers which virtually corresponds to the educational minimum of Health Care Management in foreign countries, i.e. the possession of means and instruments for the settlement of administrative, economic and financial problems at the level of medical institution. It is entirely necessary to work out and refine the legislative base, which will accord the preference for holding HCM and health policy making posts to respectively two year, and for acting managers at least six month professionally educationed, certificated and licenced specialists. One of the means for the improvement of the professional education must be the accreditation and licencation of HCM educational Institutions, which will entail to the clearness of their responsibilities and to their coordinated work. Chapter 1: Introduction The democratization and decentralization of Health Care Management in the current social conditions of the Republic of Armenia in regard to the Health Care reforms with the shift to market economy over the recent years some new specific problems for Health Care Managers were put in the forefront. This fact demands thorough professional knowledge and managerial skills. In the countries of former Soviet Union, including RA, there was no special basic education on Health Care Management, and practically the Medical Establishments were being managed by physicians, who were taking short-term post-diploma training in Health Care Management and Organization at the Chairs of Social Hygiene and Health Care Organization. Unfortunately, situation is the same by this time. 1 Dean and Head of chair, School of Health Care Management and Administration, NIH, MOH, Yerevan, Republic of Armenia 1

2 Maybe these approaches were acceptable in the previous years. In the past Soviet managing system of RA in terms of Planning Economy could be characterized as «top down», as for Health Care Managers they only performed functions within the frames of official government documents. As a point they had no problem to make the budget of their office themselves or perform some other economic or even legal or other activities. Currently situation is different; existence of any health care facility depends on health care managers' qualification to correctly manage the business. Thus, preparation and training of Health Care Managers as well as development of Requirements for the performance of Health Care Managers are among the priorities of the RA current government. We find it necessary that Health Care Management Education and Training should be in concord with the implemented socio-economic reforms and democratization of Armenian Society based on the principle that today the management turned out from the principles of socialist distribution, where no economic regulation was in place. Chapter 2: Objectives and scope of the study The objectives of the study are to examine HCM education and training practices, problems and perspectives in the RA Particular attention is given to Currant approaches to HCM education and training ; Conclusions for further development of preparing and training health care managers as well as health care policy makers. The only structure in the Republic which has many years experience of conducting short term post-diploma training courses for the acting health care managers (since1988), as well as experience of preparation through two year residentura (since1997) is the Chair of Social Hygiene and Health Care Organization of the National Institute of Health of the Ministry of Health of the RA. On the base of that Chair taking into account the existence of relevantly specialized lecturers staff, educational programs and bases, Health Care organizers educational experience in that Chair by the decision of the Government of the Republic in 1999 was created and now acts NIH School of Health Care Management and Administration, in the framework of which with the mentioned Chair act also four chairs: Health Care Economics and Financing, Nursing Care Organization, Health Policy and Strategy, Planning and Management of Human Resources. The above mentioned is the reason of what, that as a base for the settlement of the tasks involved in this research have been used the primary materials of NIH SHCMA for preparation and training of health care managers in the RA (see also below chapter 3). The research includes the period of Chapter 3: Short overview of HCM educational structures in Armenia. Some correctives to the article of G.Selimyan and L.H.Danielyan 2. The analysis of Public Health Management and Policy Education and Training problems in the RA, implemented in the work of G.Selimyan and L.H.Danielyan (2004) demands introduction of some correctives in regard to HCM educational structures in the country, which seems us important for the solution of the tasks standing before us. First of all one must stress the principal differences between missions and goals of two acting still from Soviet times educational structures The Yerevan State Medical University and The National Institute of 2 Allan Rosenbaum, Juraj Nemec, Tolo Kenneth (2004). Health Care Delivery Systems: Opportunities for Public Management education in Central and Eastern Europe. NISPAcee,

3 Health (in the past the institute for post-diploma training of physicians). The goals of the University program are to provide future physicians for required general knowledge in Public Health, Health Care Administration and the statistical methods most frequently used in the health care, future physicians, who mainly must treat patients and completely aren t oriented to become health care managers. In accordance with this purpose the educational program is mainly represented by the enumerated courses of speciality. In fact, this education does not a graduate program in health management for people to be appointed as health managers. And in future, it is obligatory that, after they held the managerial position in Health Care as directors, deputy directors, chief doctors (heads), deputy chief doctors they attend 1.5 month courses that advance their qualifications in the field of Health Care Management and Organization in the National Institute of Health Care every five years. The mission of the National Institute of Health in the face of the above mentioned Chairs of SHCMA is the concerted postdiploma training and continuing education of the acting health care managers as well as the preparation Health Care professional managers through the two-year rezidenture. And this means compulsority to provide for profound managerial knowledge and skills in the field of the Health Care Management and Organization as well as in Population Health and Health Care policy, indispensable for a specialist in the work on managerial as well as on policy making positions. It is natural that the educational HCM programs and specialization of the teaching staff in NIH must be principially different from the educational program in the University (see below chapter 4). We consider completely justified such concretization of educational responsibilities for such a small Republic as Armenia (the population of the Republic constitutes totally 3.2 million) with small amount of administrative cadres in the sphere of Health Care. Deeply welcoming the creation of the Public Health Department in the American University of Armenia (AUA) in1991 in the help to republican structures in the preparation of the specialists of Public Health in postsoviet period we demand to introduce clearness into the matter of the third HCM educational structures appeared in the Republic recently uninamed SHCMA at AUA, which is now in the framework of the college of Health Sciences of the AUA (in the order of public respond to the numerous application to us, also in the number of international donor organizations, as well as by the reason, that attentive reader of the above mentioned article will observe certain error and misunderstanding of the authors in this matter). The authors write: The National Institute of Health is the leader in postgraduate training of health care administrators. In 1999, the School of Health Care Management and Administration moved from the National Institute of Health to the American University of Armenia. However the name also retained by the National Institute of Health. First of all not in1999, but through 1.5 years after creation of SHCMA. Secondly let us not agree with the proposition moved. Why? As moved is not whole NIH SHCMA with its departments and bases. But only again appointed and soon resigned his post manager with 2-3 new employees. Whole main teachers stuff up to now days works in NIH. Except of this by the decision of the Government of the Republic of Armenia SHCMA was created only in NIH. Chapter 4: Contemporary problems of management in the RA as a base for working out of educational problems. Overview of education. 4.1 The current HCM system and problems in RA. Health Care Management system in RA is represented by three hierarchical levels in accordance with the administrative division of the territory of the Republic: base (community), regional (marz) and national. The base level covers rural and urban administrative districts. At the marz level there are health agencies, which are responsible for introduction at the marz level, the national Health Care policy. 3

4 However there is yet a need in more concretization and differentiation of managerial functions between various levels of the Health Care management, which seems us important for constituting professionalpositional demands and educational programs according to the various levels of management. Ministry of Health Care of the Republic, which formerly totally managed the Health Care system with all its aspects of organization of medical-prophylactic aid to the population, science, education and materialtechnical supply, medicine security, construction and restore of medical institutions etc., now has drastically decreased in size leaving for itself mainly functions of Population Health and Health Care Policy, formulation Health Care reforms and overseeing their implementation. Many managerial functions have been transferred to the lower hierarchical levels of management, as well as immediately to the medical institutions. Decentralization of the management inherent for the Health Care reforms in recent years not only for Armenia, but also for all of the Central and Eastern European countries (CEE) and the Newly Independent States (NIS), who have started to adopt the market economy model after 1989, has entailed to the situation in which Health Care managers implement new functions, demanding from them the possession of new management technologies such as financial, personnel, planning, economic etc. For the financing of the medical aid has been created a special structure the State Health Agency. The incipient aim of the creation of this structure was seemingly the division of the functions of medical aid implementation and the payment for that aid, the creation of a financiating body (in type of insuring organizations) implementing the role of the mediator for between those, who supply medical aid, and patients. However this structure now is found in the framework of the Health Care Ministry of the Republic. And as a matter of fact, in spite of the many years of discussion and promises of the government (since 1990) about the introduction of Compulsory Medical Insurance of the citizen of the Republic, still hasn t been adopted a corresponding Law and hence, there is not any introduction of insuring principles for the medical aid implementation. The Health Care System in Armenia has been developed unstably in recant years, which creates some difficulties for managers of Health Care. So, in 1995 all the health care establishments received status of state enterprise, and in according with The Law of RA about state enterprise, and entrepreneurial activity drastically increased the managerial autonomy of their managers, particularly they received the right: To adopt, affirm, change and cancel establishing documents of enterprise, to define internal order for activity of enterprise, authorities, rights and responsibilities of managers and other officials of enterprises ; To plan autonomously their activity, to define volume, prices of being implemented works and services, their providers and consumers of production ; To define internal organizational structure of enterprise, system of management of departments ; To form autonomously their fiscal resources ; To attract employees signing, with them job treaties, to define their wages ; To allot workers opportunity of participation in profits of enterprise etc. In 1997 decentralization of the Health Care Management received another course of development of events: all the health care establishments were reconstituted as non-commercial state joint stock companies following the passage of the 1996 Law on Joint Stock Companies. Recent health care reforms in Armenia are the optimization of the health care delivery system, privatization reform orienting various actors to market forces and competition to improve allocation decisions and, the introduction of Medical Obligatory Insurance. 4

5 The whole stated shows that the developing and implementing currant health care reforms created an entirely new environment for health care managers. This demands from them to implement functions, which were not distinctive in soviet times such as financial analysis and management, managerial accounting, strategic management, marketing, information system management. With the privatization of the delivery of health services and the use of market-based instruments to finance health care, the need in health care managers is evident. Evaluation, assessment and planning skills as well as logistics, crisis management and public relations skills are likely to be in increasing demand. Skills and knowledge are essential for the successful implementation of reforms. Decentralization also increased the need in greater numbers of well-educated and trained health care policy makers. Besides, Armenia faces problems in the health sector similar to those faced by other NIS countries. Armenia has a shortage of personnel with knowledge and technical skills in health administration, policy and planning. So, most of the current problems in the health care system relate to its management. Management responsibilities have given individuals who lack the necessary education and experience to manage personnel and operate in an environment of limited financial resources. The Republic of Armenia has already paid a significant price for this situation through reform failures, indexes of which can be the following negative results of implemented reforms failures decline of universality and availability of medical aid, lost of prophylactic directness of health care, social insecurity of medical employees etc. 4.2 Overview of HCM Education and Training Practices in NIH MOH RA ( ) In the table 1 is adducted the duration of HCM training courses from to now. Table 1: The duration and the character of HCM training programs suggested to the managers of the RA Program character Till 1990 From 1990 to 1995 From 1995 to 1998 Since 1998 till now Specialization 4 5 months none none none General training 3 months 1,5 2 months 1 month 1,5 month Subject Training 1,5 2 months none 10 days none Information courses days none none none The data, which are presented in the table 1, show that in spite of the fact, that in recent years the improvement of HCM professional preparation has become more emphasized need the duration of training courses has been reduced. If until 1990 for health care managers the education by the order shown in the table was considered compulsory with 4-5 months duration for being specialized, 3 months for general training by the RA Ministry of Health Care decision of 1995 duration of the training courses was reduced to 1 month, and since 1998 it has become 1.5 month (7 weeks, 242 educational hours). In 1996 for the first time in the Republic Nurse Managers also began to pass HCM training courses-1 month (5 weeks, 180 hours), and in 2001 with two week programs also physicians passing specialization and courses in NIH in the sphere of Family Medicine and Family Stomatology. The data presented in the figure, show that since 1994 has been observed a growth of the number of the health care managers participated in training courses. 5

6 Figure: Number of the HCM Trainees (NIH, from 1988 to 2004) Health Care Managers Nurse Managers Family Doctors Residents Others (economists, statistics, etc.) This circumstance is explained by 2 reasons, one of, which is the growth of personal concern of health care managers to acquire professional knowledge and skills, connected with the enlargement of their functional responsibilities. It is important to note that the implementation of the health care reforms in HCM practice work, without their preliminary education rose a general alarm and panic in the Republic in HCM circle. About it had noted also Chernicov (2000) by the results of the researches made by him in Russia. And the second, in the system has begun to be realized HCM licencation with this two stages; the first stage computer check up knowledge with professional tests, made up by NIH SHCMA teaching staff, which are including all the parts of the speciality, certainly demanding presence of professional deep knowledge HCM and the second stage oral examination by professional staff made by Ministry of Health Care. For getting licence it became compulsory demand the presence of the certificate testifying the participation in training courses beforehand in the Chair of Social Hygiene and Health Care Organization of NIH (and since 1999 in NIH SHCMA). This circumstance testifies that the development and implementation of accreditation and licencation or some other mechanisms for all levels of management in the Republic by the direction of creating impulses for possession of profession today must be observed HCM education and training improvement one of the most important instruments (see the abruptly diminution of the numbers of trainees in recent years presented in the figure, when by the decision of Ministry of Health Care had been stopped the process of licencation for the specialists of health care sphere also for health care managers). At the same time getting data testify that more then 80 percent of managers of the Republic had a presence in training courses passing in NIH 3 and more times testify that overwhelming majority of health care managers of the Republic it consider importance the professional education in the sphere of the health care management and organization. As preset the results of systematically researches made by us in the framework of HCM s which had parted that courses, their majority (98.9%) note the severe unsatisfactory of the duration of the courses for getting professional education. 6

7 However at the same time it is considered not realistic today s managers more long-term absence from the workplace under the existing hard, financial insufficient and demanding the greatest responsibility from HCM conditions. This circumstance made extremely urgent the passing of the courses in the place, also organization of the correspondence courses, as more productive educational technology in existing conditions. The analysis of trainee s staff by their holding post is presented in the table 2. Presenting data testify that majority part of trainees constitute the managers of the hospitals and ambulatory-polyclinic establishments. The date of the training Table 2: Health Care manager trainees staff by their holding posts Top managers Hospital Manager or deputy manager Rural medical ambulatory Ambulatorypolyclinic establishment Hygienicantiepidemic center Health resort establishment Total Tables 3 and 4 present the distribution of the trainees dependent on the circumstance in what period they have passed retraining after being appointed in the post as well as their age index. Table 3: The index of the trainees after assumption in the post The date of General Has been trained after assumption the post the training number of trainees In the first 3 years During 3-5 years During 5-10 years After 10 and more years Total (31,5%) 556(53,8%) Table 4: The age index of trainees The date of The age (by years) Training Till Over Total (39,3%) 567(54,8%) 7

8 As the data of the table 3 and 4 show the overwhelming majority of the trainees percent constitute those who have lot of work experience (5-10; more then 10 years) and 50 and more years old people (54.8%). We think that this circumstance witnesses that in the country the managing style of health care managers is formed basically by the method of trials and mistakes. As according to the legislation existing in the Republic the managers post holder at the same time has the right to work also as a physician managers pass training courses also in the sphere of the clinic speciality chosen by them. The research shows that trainees by their clinic profession about which informs table 5, basically are therapeutists, surgeons, pediatricians, obstetricians, dentists and sanitary physicians. Let s note that this enumerated specialists, except of therapeutists and surgeons, manage mainly the medical establishments corresponding to their clinical speciality (for example, dentist a dental ambulatory). Table 5: Health Care Manager trainees index according to their clinical speciality The date of Professional data training Therapy Pediatrics Obstetrics Surgery Stomatology Sanitary Etc Total Connected with the changes in the Republic in recent years HCM education in National Institute of Health has been perfected by Creating of new chairs, increasing of the quantity of being teached themes and also lecturers staff ; Completing the SHCMA staff composition with medical and non medical professional members (full-time and also part-time staff) from the different organizations, such as Ministry of Health, State Health Agency, Trade Union of Medical Workers etc ; Improving the quality of the staff through short-term and long-term training, including Ph.D. and Doctoral degrees ; Creating of the innovative educational programs, such as Economic bases of Population Health Reproduction Under Market Conditions by the financial help of Soros Foundation (table 6) ; Founding NGO- Armenian Health Care Managers Association (AHCMA) in the ruling body of which by the managers of the Republic have been elected 3 lecturers from NIH SHCMA ; Restoring of the learning resources center of the Social Hygiene and Health Care Organization Chair of the NIH, which periodically is completed with professional literature. Besides it by the financial help of Soros Foundation and a grant from the Bureau of Educational and Cultural Affaires of the US Department of State by lecturers staff have been made up textbooks 3 in Russian and in national language, situational tests of all modules of educational programs, different 3 T.S.Khacahatryan, M.K.Lepyan, T.Z.Tonoyan, L.V.Andreasyan (2002). Health Care Management, Financing and Economics Under Market Conditions, Yerevan. T.Z.Tonoyan, M.K.Lepyan, G.K.Aroutunyan (2004). Health Care Economics, Yerevan. 8

9 educational methodical manuals, have been implemented translations of professional literature (from English into Armenian) in the frame of the partnership program Armenia-Canada (see below) etc. Table 6: Main modules and themes of innovative educational program Economic Base of Population Health Reproduction under Market Conditions. # The name of the module # 1. Public health status and Health Care under the new economical conditions 2. Medical aid quality of management 3. Theoretical Fundamentals of Health Care Management 4 Social-Psychological Aspects of Management 5. Problems of Health Care Economics under Market Conditions 6. Systems of Health Care Financing and Methods of Resource Distribution 7. Fundamentals of Pricing 8. Financial Management in Financial Mechanism Structure Theme 1.1 Public Health as a System forming Factors and Efficiency Criterion in Health Care Reform. 1.2.Social and Economic Conditionality of the Population Health Status. Economical Fundamentals of Reproduction. 1.3.Organizational Systems of Medical Care Delivery to the Population 1.4. Health Care Systems Reform in Foreign Countries 1.5. Organization of Medical Care to the RA Population 2.1 Character of medical aid quality. 2.2 The problems of Standardization. 2.3 The control of medical aid quality Introduction to Management 3.2. Management Procedure 3.3 Management Decision-Making Process 3.4. Control in Management Decision Realization 4.1. Leader 4.2. Organizational Climate and Organizational Culture 4.3 Organizational Behavior 5.1. Present Problems of Health Care Economics 5.2. Medical Services Market and its Features 5.3. Medical Services Marketing 6.1. Systems of Health Care Financing Under Market Conditions 6.2. New Approaches to Per Capita Principle of Financing 6.3. Financial Resources of a Medical Institution 6.4. Distribution Mechanism of Financial Resources to Institutions. 7.1 General Problems of Making a Price 7.2 Principles of Medical Service Pricing 7.3 Expendable Principle of Pricing 8.1 Financial Mechanism of a Medical Institution 8.2 Economical Standards and Norms in Health Care 8.3 Management Accounting under New Conditions 8.4 Economical Evaluation of the Activity and Analysis of Financial Stability of Medical Institutions 8.5 Strategic Planning in Health Care 8.6 Efficiency in Health Care System 9. Health Care Tax System 9.1 Taxes and Charges 9.2 State tax control on the tax legislation observance For improvement HCM education and training in NIH SHCMA has a decisive importance the partnership program of Health care Management Training in Armenia of the Center for International Management Studies of the McGill University of Canada and NIH SHCMA. The main objectives of this program are as follows: To increase the capability and capacity of the SHCMA and its faculty to provide education and training for Armenian health care administrators to effectively meet the needs and demands of the MOH health care reforms as well as to establish a reproductive model that will permit health care management training in the other Caucasus countries. In the framework of this program has appeared possibilities for teaching staff as 9

10 well as students to have access to Internet and computer-based information and learning resources, has been implemented work for advancing of educational methodologies including two-week workshops in Montreal (for trainers- 6 teachers of NIH SHCMA) and in Yerevan (for 50 acting Health Care managers and HCM residents), case preparation and presentation, as well as site visits to key health facilities in Montreal and in Yerevan. So, the above mentioned has contributed in somewhat improvement of HCM education and training in Armenia, however work for further development of preparing and training health care managers as well as health care policy makers must be continued. And this first of all for the purpose to create a new HCM educational and training system corresponding to international standards. As a matter of fact in present conditions health care managers activities in Armenia are almost the same as in foreign countries. The advancing of the educational part demands special attention of the Population s Health and Health Care Policy. The decentralization of management entailed to the fact there, that health policy skills are needed also at the level of marzes-regional offices need to find specialists knowledgeable in designing and implementing regional health policies and able to deal with the many acute organizational problems (e.g. emergency services organization, reduction of the number of beds etc). SHCMA needs in partnership to support development of the teaching staff in the analytic work to the policy analysis; partnership activity to develop some innovative curriculums, creation of new corresponding educational standard for longer preparation (at least 6 month s internal-correspondence cycle of training) of acting Health Care Managers, working out professional positional demands and educational programs for different levels of management as well as for different directions of health care reform such as the implementation of corresponding lecturers staff, educational bases and educational materials, case presentation, situational tests, more active collaboration with international organizations (in 2004 NIH became a member of NISPAcee). Conclusions In recent years connected with the introduction of new conditions of management in Health Care system the transition of health care from a system providing branch resources to the new models of development, with the introduction of market mechanisms and new technologies, creation of such a Health Care system, which will maximally provide for the implementation of guarantied medical aid to the population under insufficient financial conditions has become an extreme necessity. HCM education and training today is a very important problem for various health officials from members of the commission of Health Care of the Parliament to the Ministry of Health and State Health Agency as well as Health service administration/management positions, including the Directors and Deputy Directors of Medical Establishments, nursing managers, and heads of departments and units. We think that the main priority problems of Health Care Managers education and training in the Armenia are the following: The development of economic thinking is very important taking into account financial analysis and validity of investments in the process of addressing any problem at the health care institution ; Attracting more attention specifically to the managerial economics in the delivery of health care services ; Strategic Planning ; Financial Management ; Health Insurance ; Social Psychology parallel to the implementation of market economy ; 10

11 Human rights and Law in the newly independent Armenia. The implementation of the enumerated priority problems is very important for the preparation of managing personal capable to work under contemporary, new circumstances, which is the guarantee of the success in Health Care reforms being implemented in the post soviet era. At the same time it is impossible not to mark the existence of some obstacles for the implementation of what has been stated, such us, for example doctor s uninterestedness to possess the profession until the engagement of Health Care Manager post, as the criteria about the necessary knowledge and practical capacities to which must correspond the person until the engagement of Health Care Manager post don t exist in the country; insufficient productiveness of the training every 5 years with 1,5 month duration after the engagement of the post and so on. It is entirely necessary the development and improvement of legislative bases, which will give Health Care Management and Health Policy making posts contemporary two-year and for acting managers if only had been got six-year special education, certificated and licenced specialists. The presence of such a legislative field will favour firstly of becoming a specialist then take a post favouring also for future development of professional education, as in present the specialists which had graduated from the HCM residentura loosing their rights to work as a clinicists, have no preference after the HCM residenture to get work by their profession first of all than another physician. One of the ways of improvement of the professional education will be the accreditation and licencation of HCM educational establishments, which will bring lucidity of their responsibilities and coordinated work. The contemporary circumstances for the activity of the Health Care system prompt such a training of Health Care Managers which virtually corresponds to the educational minimum of Health Care Management in foreign countries i.e. the possession of means and instruments for the settlement of administrative, economic and financial problems at the level of medical institution. So, It is very important to create a new educational and training system, as well as new educational standards and develop some innovative curriculums for the preparation the specialists in the field of Health Care Management and Organization. References Association of Schools of Public Health in the European Region (ASPHER). Association of University Programs in Health Administration (AUPHA). Chernikov I.G. (2000). The research of social-psychological peculiarities of HCM work (by the example of managers of the country polyclinic departments) In J. Health Care Economics, 1, Dumanyan D.H., Khachatryan T.S. (1998). The problems of preparation of managing cadres in RA. In Scientific Works and Notes. Jubilee scientific Conference committed to 35 years of NIH, Yerevan, Hovhannisyan, Samvel G., Ellie Tragakes, Suszy Lessof, Hrair Aslanian, and Ararat Mkrtchyan (2001) Health Care Systems in Transition, Report of Armenia. European Observatory on Health Care Systems. Khachatryan T.S. (2002). The problems of preparation and training of health care managers under the new conditions : Proceedings of the First National Medical Congress of Armenian, Yerevan, T.S.Khachatryan (2003) About Problem of Preparing the Personal for Health Care System Managerial Positions. In J. Arokhchapautoun, Yerevan, N1, 6-7. Korvetsky O.D., Lytvak A.I. (1999) Up-grading Training of Health Managers is the Important Element of Health System Reforming. In.: Actual Issues of Public Administration. Edition No.2. 11

12 Kucharenko, V.Z. and Minerova O.A. (2002). Important questions of advancing the quality of education at the departments of public health administration. In J. Public Health Management in Moscow, No.12. Lindenbriten, A.L., Shepin V.O. and T.I. Rastorguev (2003). Role of medical education for public health managers, In J. Problems of Social Hygiene, Public Health Management and History of Medicine, No.3. Ministry of Health, Republic of Armenia (1999). Statute of the Ministry of Health of Armenia, Yerevan. National Association of Schools of Public Affairs and Administration. Roberts, J.L. (1995). Training for Public Health Support for Countries of Central and Eastern Europe (CCEE), in Scientific Foundations for a Public Health Policy in Europe. Rosenbaum Allan, Memec Juraj, Tolo Kenneth (2004) Health Care Delivery Systems: Opportunities for Public Management education in Central and Eastern Europe. NISPAcee. Saltman R.B., Fisgejras Dj. (2000). The reforms of Health Care system in Europe. Analys of present strategies. Translation from English. M., Medicine. Schneider P., Khachatryan T., Budagowa K. (2003). Development of HC management in Armenia. Processing of the first Int.Med.Congress in Armenia. July 1-3,Yerevan, 50. Ter-Grigoryan A.A. (2004), Some aspects of system reform of health care financing of Republic of Armenia. In J. Health Care Economics, 7 (85), World Health Organization (2000). The Health Care Systems. Copenhagen: WHO Regional Office for Europe. 12