Now, Tajikistan, 27 February 1998 (RFE/RL) -- It is raining in the provincial town of Now in Leninabad Oblast in Tajikistan. But the medicine vendors outside the entrance of Now District Central Hospital stay in place behind their makeshift tables. Their only bow to the weather consists of sheets of plastic draped over their wares.
Officially, Tajikistan has regulations controlling pharmaceuticals and licensing those who deal in them. In practice, Tajikistan's pharmaceuticals industry has withered since the country declared independence from the Soviet Union in 1991.
The vendors at the hospital in Now aren't licensed or registered. The drugs they sell may come from neighboring China or Uzbekistan, and these medicines, too, are unregulated. Nobody interferes because patients at the hospital haven't any alternative. State hospitals can't supply free medicines as they did before. And state pharmacies offer only limited supplies.
Street sales of medicines are emerging as early signs of privatization in the medical sector. The haphazard pharmaceuticals market in Now has counterparts at most of Tajikistan's 187 rural hospitals. Outside the main entrance of each hospital, vendors stand behind tables in every season, under rain and snow or sunlight, exposing both themselves and their supplies to the weather.
When Tajikistan was a Soviet Republic, its constitution guaranteed free medical care to all citizens. Officially in 1995, the independent republic adopted a health-care-for-all policy. Officially, the government favors privatization of health care.
In practice -- although the medical sector has changed radically -- neither privatization nor state-provided health care has taken hold.
Not only must hospitalized patients themselves buy the medicines they need, their relatives must bring to the hospitals bedsheets and most of their food. During the winter, in all village and some district hospitals, patients' relatives must provide fuel to warm sickrooms. Patients at village hospitals must provide oil lamps or candles to light their rooms at night because electricity is limited.
Officially, medical treatment nominally is free throughout Tajikistan. But the Tajik state budget for 1996, the latest numbers available, provides the equivalent of 1.2 U.S. dollars a year per capita for health care. For the nation of nearly six million people, the official health care budget is about $7 million. Salaries for medical personnel in Tajikistan range from about a dollar a month for hospital cleaners to nine dollars for surgeons. Davron Azimov, a chief surgeon at Khojand District Central Hospital says his monthly salary, equivalent to $10, will pay for five kg of beef.
That's why a system of informal payments for doctors has became widespread in Tajikistan. And the system goes deeper. At the Dehmoy specialized dispensary for tuberculosis, relatives of patients say, the hospital cleaner cleans a room only when patients pay.
Although patients buy medicines, food and services, formal fees and medical sector privatization haven't developed. Ministries in the capital, Dushanbe, have yet to agree on the direction privatization would take or on regulations to guide it.
Some institutions are forging ahead on their own. At the Now hospital, Deputy Director Juraboy Azimov says the hospital has installed a private diagnostic room, and it plans to establish a family doctor service and a private emergency service.
Dr. Hamid Gulomov in Asht district has dared more. He is establishing a small private polyclinic in his village. He anticipates difficulties. In his words: "People are accustomed to the illusion of free medical treatment even though they pay for everything in state hospitals. Psychologically, they aren't yet ready for private doctors."
But, he says, there will be advantages for all. He says: "Being paid formally as private doctors, we will have greater responsibility as well as more opportunity. That will affect the work we do. Gradually, people will take notice."