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Central Asia/Caucasus: Countries Battle To Reform Health Services

London, 30 October 1996 (RFE/RL) -- The World Health Organization (WHO) says the Central Asian and Caucasus countries face an uphill struggle as they seek to reform their Soviet-era health care systems to meet the needs of their populations.

All countries share problems similar to those elsewhere in the former Soviet Union: health care is fragmented, with parallel services, duplication of facilities, and inappropriate forms of treatment.

Management skills are lacking (because, historically, all decisions were taken in Moscow), doctors are slow to adapt to limited resources and reduce over-capacity (too many beds in hospitals); and all countries lack any tradition of community involvement in public services.

Doctors and nurses have the wrong skills or are badly trained, primary health care is poorly developed, and health systems still put too much emphasis on curative rather than preventive medicine.

Everywhere, the medical infrastructure -- hospital, clinics, child centers -- is decaying. Hospitals and patients cannot afford the high cost of imported drugs. Many health care services are nominally free but under-the-counter payments to physicians remain common.

The WHO's regional office for Europe in Copenhagen reaches these conclusions in four reports, entitled "Health Care Systems in Transition," that focus on Azerbaijan, Kyrgyzstan, Tajikistan and Turkmenistan. Reports on other countries in the region are to be issued at a later date.

The key problem faced by all four is lack of funds to restructure their health services to make them more responsive and efficient. Here are summaries of the situation in each country.


The problems faced by Tajikistan are "especially severe" because it is recovering only slowly from the bitter civil war that led to many deaths, a major population displacement, and destruction of facilities. In addition, there has been an exodus of trained medical staff.

The WHO report says services are poorly coordinated and remain badly placed to respond to major challenges, particularly rising levels of chronic disease and the poor health of mothers and children.

Tajikistan is one of the least developed former Soviet republics and the policy of monoculture and industrial specialization has left it especially vulnerable to the collapse of its traditional trading links.

Economic collapse has been exacerbated by the breakdown of systems for raising government revenue. All these factors have left the health system more dependent than its neighbors on foreign aid.

The WHO report says the system inherited from the Soviet Union, in which the Tajikistan Finance Ministry allocates funds directly to oblasts, gives the Health Ministry "few levers in which to implement reform."

The report says there has, as yet, been virtually no privatization of health care facilities or manufacturing of health related goods.

Official health care expenditure per capita is just 359 Tajik rubles ($1.2). Another problem is the remuneration of physicians: the average medical salary per month is $2.5, although surgeons are paid higher.

The WHO report says the civil war has meant that reform is much slower than in neighboring republics, but this has given Tajikistan an opportunity to learn from mistakes elsewhere. However it says plans to introduce a health care system based on insurance payments by individuals by 1999 is "extremely ambitious." The most recent estimate of annual per capita income, in 1994, is $350.


The greatest challenge facing Kyrgyzstan as it seeks to reform its health services is to manage the transition against a background of serious economic decline. The health care budget may now be only 10 to 15 percent of what it was in 1990 in real terms.

The WHO report says Kyrgyzstan faces problems because of an exodus of staff from the health sector since 1990 (10,000 doctors left in 1990-93); the deterioration of hospital buildings and other facilities; and because neither hospitals nor patients can afford to buy drugs.

Like other Central Asian countries, Kyrgyzstan has no factories for producing modern drugs and is dependent on imports.

As in other former Soviet republics, the WHO says, "the focus on numerical indicators of health care provision has created a legacy of over supply of hospitals and excessive specialization." Although the number of physicians is high, many perform tasks that would be the responsibility of nurses elsewhere. Wages are low and there are few support staff.

Central planning has "left little room for local managerial innovation, leading to inflexibility, waste and provision of inappropriate services."

The Kyrgyzstan government has an "ambitious" plan to move from the centrally-planned health care system to one based on health insurance with people making regular premium payments

But the WHO report says this plan "would be difficult to implement in any country" and there are questions about how feasible it can be in Kyrgyzstan because of its economic decline and "lack of many of the skills and infrastructure required to operate such a system."

The Health Ministry is not equipped adequately to carry out the health care reform process because of "its historical role as a conduit for policy developed in Moscow." The report says: "The experience of a pilot project to implement social insurance is not encouraging."


Turkmenistan is potentially in a much better position than other former Soviet republics because of its rich mineral and hydrocarbon reserves, although it has yet to realize much income from them.

But health indicators are worse than in many developing countries, the birth rate is decreasing, and life expectancy is falling.

Turkmenistan is suffering from the legacy of the Soviet system which gave priority to curative rather than preventive medicine. It also suffers from poor quality training in medical colleges and shortages of qualified nurses. Problems include difficulties with access to teaching material in the Turkmen language and low salaries (72 percent of national average) leading to an exodus of nurses from the profession.

The challenges facing its hospital services are excess capacity, high rates of hospitalization, long lengths of stay, low quality of service, poorly trained staff, and shortfalls of drugs and equipment.

The average length of hospital stay (15 days) is high compared to Western countries. One cause is non-functioning medical equipment.

Turkmenistan plans to tackle these problems by reducing the number of beds by up to 45 percent by the year 2,000; upgrading the infrastructure of hospitals; and retraining medical staff. However, like other countries in the region, it lacks management skills.

Some progress has been made. The first steps to implementing a social insurance scheme and modern primary care have been taken. But implementation of social insurance faces formidable obstacles, including the problem of collecting subscriptions from would-be patients.


Health reform in Azerbaijan has been held up by the war with Armenia, a refugee displacement of up to one million people, and an economic crisis which saw per capita income fall to $317 last year.

Budgetary allocations for health care spending per capita have fallen from $8 in 1993 to $6.30 this year. In a table of 13 newly-independent states, Azerbaijan's total spending on health as a percentage of GDP was the second lowest. (The Russian Federation was at the bottom.)

The WHO report says the health care system in Azerbaijan in the post-Soviet period has deteriorated considerably. Reasons include: lack of funds due to economic collapse, shortage of management skills, and failure to adapt to limited resources and reduce over-capacity. Other reasons are disruption of the former Soviet health network with its system of medical supplies; weakness in primary health care; and too many specialist doctors, not enough general practitioners

The WHO report notes that Azerbaijan has the benefit of major petrochemical reserves and, in the long-term, should have fewer financial problems than neighboring countries, thus making health care reform easier. But it still faces a difficult transition period.

The Health Ministry has introduced reforms in a pilot district, but faces a problem because of an absence of consensus about the most appropriate financing model for the health care system.

Once agreed, any reform program needs to address major challenges. They include a fear of innovation that pervades all levels of the management structure; absence of a legislative basis for reform; severe shortage of public funds, and the complete absence of any tradition of community involvement in public services.