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Tajik Government Pledges to End Maternity Clinic Crisis

The health ministry has promised radical reforms to birthing hospitals, where bribes and poor service are the rule.
By IWPR Central Asia
When most western women go to hospital to give birth, they take it for granted that the doctors and nurses will take care of them. They might give them chocolates or flowers if they feel they have been especially well treated, but it goes no further than that.



But when the daughter of a Dushanbe schoolteacher recently gave birth in a rural hospital in Tajikistan, the medical staff not only demanded a cash bribe, but virtually held the woman hostage until her family paid up.



“When she was due to be discharged from hospital, three members of the medical personnel came up to my daughter smiling and saying, ‘Congratulations on having a son,’” the teacher, who did not want to be named, told IWPR.



“Then they added, ‘You owe us money and until your husband pays us, we won’t let you go.’ At first, we thought it was just a joke. But they weren’t joking, so my son-in-law took 100 somoni [30 US dollars] out of his pocket and gave it to them. Relatives told us that we got off cheap.”



The teacher’s story might sound like an aberration. But her account is far from unusual in Tajikistan. Sanovbar Ahmedova and Lilia Chernova, both residents of Dushanbe, told IPWR they had had almost identical experiences.



The women said that when it came to getting discharged from maternity clinics in the city, the medical staff mentioned their low salaries and demanded remuneration for their work.



“We had to pay everyone – both those who did have something to do with us and those who didn’t,” said Chernova. “They all lined up, the nurses and the auxiliaries. It was terrible!”



Officially, Tajikistan still provides free healthcare, but in practice, the system has been collapsing for years. The cash-strapped government is unable to pay much in the way of salaries to health workers, leaving it up to doctors and nurses to extract the money they want – or need – from patients.



Sherkhon Salimov, director of the State Agency for Financial Control and Fighting Corruption, recently brought attention to a case involving Zebo Tosheva, an obstetrician and gynaecologist from the City Medical Centre’s maternity department.



A member of his agency caught Tosheva demanding 300 US dollars from a patient in order to carry out an operation that should have been available for free.



After the woman told her husband, he went to the anti-corruption agency and protested. Tosheva was subsequently caught red-handed by agency staff while soliciting another bribe.



Sheer poverty fuels the culture of corruption in Tajikistan’s health service. The country is among the poorest states in the former Soviet Union, and average salaries are only about 45 dollars a month.



This is reflected in poor health care. Tajikistan has high levels of maternal mortality, and the worst rate of infant mortality in Central Asia.



On average, 44 mothers die in childbirth or immediately afterwards for every 100,000 live births, while 16 of every thousand children die within the first ten months of life, a figure that rises to 21 in 1,000 within the first five years.



Most deaths occur in rural areas and in health care institutions that lack blood products, anesthetics and other basic medical items. Because of the lack of funding, women attending the majority of maternity hospitals have to bring everything they need themselves, including bed sheets and nappies. They also have to pay for such basic items as cotton wool, syringes and bandages.



To address the virtual collapse of free healthcare, the government is phasing in a system of fixed payments for the state health service. However, at this point mother-and-child care remain free.



In response to increased complaints about the poor conditions in maternity hospitals, and the stated aim of cutting maternal and infant mortality rates, the health ministry has drawn up new regulations for these institutions.



The head of the ministry’s department for mother-and-child care and reproductive health, Shamsiddin Kurbanov, announced last year that the regulations would provide for separate rooms for each mother-to-be, fully provided with changing tables, nappies, blankets, baby wear and other items.



The new services are to be provided first in a pilot project in the town of Shahrinau, 20 kilometres from the capital. The project will be funded by international donors, but ultimately the aim is to get families to pay for these services to make the service self-financing.



While the reforms sound excellent on paper, few believe they will ever be put into practice on a wide scale. For now, such conditions are a distant dream for the majority of pregnant women in Tajikistan, many of whom never make it to a hospital at all.



The head gynaecologist at the ministry of health, Gulbahor Ashurova, said a high percentage of women still deliver babies at home, especially in rural areas where 70 per cent of the population still lives. This is another major reason for the country’s high mortality rate, she said.



Far from decreasing, the death rate among Tajikistan’s mothers is currently stable or rising. This year, an increase in the mortality rate of birthing mothers was recorded in Khatlon region in the south of the country, for example. There were ten deaths per 100,000 women in this region in 2006, and 11 per 100,000 within the first ten months of 2007.



Dr Barno Mirzoeva, head doctor for children’s health and obstetrics for the Rudaki district, 17 kilometers from Dushanbe, told IWPR a typical case involved a young woman who died at a local midwife’s house after the midwife failed to stop her bleeding.



“It is sad, but in the first ten months of 2007 we had three deaths of women in childbirth,” the doctor said. “The third died on our table because she arrived too late. The police held her car up at a checkpoint for one and a half hours, and as a result, we were unable to save her or the child.”



Like most experts, Dr Mirzoeva blames the crisis in maternity care on the lack of qualified personnel, low salaries among doctors and nurses and the generally defective finances of most health care institutions.



“Junior staff in hospital receive only 55 somoni [15 dollars] per month. Tell me what you can buy for that money today, when a sack of flour costs 107-110 somoni, a kilo of meat 15 somoni, and a kilo of [cooking] oil nine somoni?” she asked.



Staff were also overloaded, she said, noting that hospital personnel often have to assist in the birth of ten children in a day.



Ashurova says the low salaries have led to an exodus of qualified doctors, particularly obstetricians and gynecologists who head for Russia and Kazakhstan.



Hospital managers say the medical graduates they get for maternity care are not up to scratch.



“There are lots of students who have internships in our hospitals but after graduation only two or three of them come to the maternity clinics,” she said. “The majority leave for other countries in the Commonwealth of Independent States, and usually low pay is the reason.”



Experts say attempts to systematise maternity provision will be ineffective without implementing comprehensive reform of the health sector in general.



“It is gratifying that Tajikistan is trying to follow World Health Organisation recommendations when it comes to effective obstetric techniques, but making them a reality will take substantial resources,” warned Sobirjon Kurbanov, a representative of the United Nations children’s agency UNICEF.



Those resources are in short supply. Health does not appear to be number one priority for the authorities, judging by the percentage of money assigned to this area – under 4.5 per cent of a modest total budget for 2008.



Jumaboy Sanginov, who sits on parliament’s committee for social, family, health and environment issues, says it is time to wake up.



“As long as there is no real support from government, and there aren’t the right resources, goals will not be achieved and the impetus for reform will subside,” he said.



Salimakhon Vahobzade is a correspondent for Narodnaya Gazeta and Lola Olimova is IWPR’s Tajikistan editor.

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