Institute for War and Peace Reporting | Giving Voice, Driving Change

Tajiks To Pay For Doctors

Free healthcare is being replaced by paid services in Tajikistan, and patients worry the new system will be no better than the old.
By Zebo Tajibaeva

Tajiks will begin paying for healthcare next month under a massive overhaul that the government insists will improve access to medical services, but which patients fear will make a trip to the doctor less affordable than ever.

The scheme has already been piloted in two districts, but from August 1, doctors everywhere will charge a health ministry-approved price for each procedure they perform. About 20 per cent of the cost will be financed by the state, with the rest to be paid by the patient.

Certain categories will be exempt from paying including the disabled, orphans; children under five, pregnant women with diabetes, people suffering from asthma, cancer or tuberculosis, the mentally ill and serving soldiers.

Second World War veterans are among just 5,000 of Tajikistan’s 500,000 pensioners who will have to pay - a hardship in a country where monthly pensions are about eight US dollars.

Average monthly wages are around 20 dollars, and according to the World Bank, about 64 per cent of the population lives below the poverty line.

At the moment, medical care is supposed to be free in Tajikistan but the system is badly underfunded, and in reality a complex system of bribes exists, meaning patients usually have to pay up before receiving treatment.

Oktam Bobokhojaev, one of the architects of the new programme, believes the new system will replace corrupt practices with a fair system. “The price list for medical services approved by the health ministry will be significantly lower than the illegal rates which have been established by medical personnel themselves,” he told IWPR.

“Almost all the costs of diagnosis and treatment have long been paid for by the patients themselves. This state programme will make it possible to regulate the relationship between medical personnel and patients.”

Bobokhojaev said payment offices will be set up at all polyclinics and hospitals and will issue receipts, ensuring the new system is transparent.

“On the basis of the receipt issued, the patient can demand that money be returned in cases of low-quality service, including incorrect diagnosis,” he said.

Some Tajiks worry, however, that the system of bribes is so deeply ingrained that they will simply end up paying twice for medical services once the new scheme is in place.

“The programme won’t work,” said housewife Rajabul Ravshanova. “We will have to pay both the cash desk and the doctor…. We will be even more out of pocket than we were before this programme was introduced.”

The government promises that 40 per cent of the money raised will go towards increasing doctors’ salaries, currently about eight dollars a month. The remaining funds will be allocated for buying medication, equipment and repairing buildings.

Doctors are sceptical that they’ll see any of the money or that the quality of care will improve.

Anna Fedorova, an anaesthesiologist of 40 years, said she takes bribes from patients in order to pay her superiors, and she doubts that will change.

“Just for signing a permit to carry out an operation, the head doctor demands 10 dollars from us. And the attitude of medical employees to patients will significantly worsen, because the doctors will not get anything from them personally - everything will go to the cash desk.”

Fedorova said in the southern Dangara district, one of the areas where the project was piloted, unscrupulous medical staff were recommending expensive procedures in order to raise their takings.

“According to the price list, services for an ordinary birth are charged at only one dollar, and it is impossible to ask more from the patient. Doctors have all begun to prescribe Caesarean sections, which cost a lot more,” she said.

None of the medical workers interviewed by IWPR had heard of the new system, only weeks before it is due to be implemented.

Accountant Alisher Nozimov worries what will happen when doctors catch on that their income is linked to the amount of money raised.

“They will discover new illnesses each time,” Nozimov said. “If in the past doctors set the price too high, you could simply argue with them and complain to someone, but now you’ll just have to put up with it or not go to the doctor at all.”

International donors including the World Bank, the Asian Development Bank, UNICEF and USAID helped fund the pilots in Dangara and Varzob, near Dushanbe, which they see as an important first step in reforming the Tajik health care system and improving access for the most vulnerable.

In neighbouring Kyrgyzstan, a similar programme has been introduced gradually over a five-year period and the foreign experts warn that the Tajik authorities could encounter problems as the new system is introduced countrywide.

Bobokhojaev, however, remains hopeful that the programme will succeed despite the difficulties ahead, citing Dangara and Varzob where calls to professional doctors increased while home births decreased.

Zebo Tajibaeva is an IWPR contributor in Tajikistan.