Turkmen Patients Pay for Privatisation

Sunday, 20 November, 2005

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IWPR Central Asia

Turkmenistan’s medical service has been plunged further into crisis after recent decrees caused funding problems, which are now being passed on to the republic’s patients.

The effects of a December 2004 decree - which effectively privatised the state medical system, removing the bulk of government support and making each hospital and clinic self-supporting – are now beginning to have an impact on the health service.

A series of charges are now being levied for routine check-ups and minor treatment that were once free of charge, or priced very low. As the average wage in Turkmenistan is around 40 US dollars a month, few people can afford this extra drain on their finances.

While specialists such as pediatricians and cardiologists are in constant demand and can hope to earn a decent salary, those with a general remit – such as surgeons, anaesthetists and nurses – have suffered an effective pay cut.

One nurse, who did not want to be named, said, “Before we became self-sufficient I received around 40 dollars a month. But after the new decree came into effect at the New Year, my pay packet shrank to ten dollars.

“They tell me to be happy with this money, and to be content that I even have a job in the first place.”

However, most polyclinics have since adapted their practices to ensure that enough extra money comes in for the staff’s salaries to be paid.

The head of one polyclinic in Ashgabat, who spoke on condition of anonymity, told IWPR that the new rules dictated that only some of the administrative personnel and family doctors receive their salaries from the state budget, and that all other workers must be paid from the clinic’s revenues.

“At the same time, the health ministry has given us a price list of services provided, and we are not able to raise these prices,” he said. “So to make ends meet, we have to literally force people to pay for a medical examination.”

Doctors who make house calls now lecture their patients that, in line with the Turkmen president’s new Saglik (Health) programme, all illnesses have to be diagnosed and treated as early as possible. To this end, a series of tests, X-rays and ultrasound scans – which all carry a price tag – are recommended.

Family doctor Aigul Jerenovna told IWPR that she has come under a lot of pressure from her polyclinic to persuade her patients to undertake expensive tests and scans.

“Each family doctor has been ordered to prescribe ‘paid’ treatment amounting to at least 180 dollars,” she said.

“But I know my district and my patients – I won’t be able to collect this much money from them. So someone in the polyclinic will not receive their salary, and I will feel guilty.”

The Turkmen medical service has been plunged into crisis after a series of presidential decrees fundamentally changed how the system operated.

All medical care was free under the Soviet Union, but independence in 1991 was followed by a series of financial cutbacks. While the initial post-Soviet period involved only small charges for treatment, observers say that these tariffs have increased as the quality of service has fallen.

In March 2004, President Saparmurat Niazov, who calls himself Turkmenbashi, announced the closure of all hospitals in the country apart from those situated in Ashgabat, where all medical specialists were transferred.

Unfortunately, not all staff were found employment in Ashgabat as, under Soviet-era legislation, only those registered in the capital are allowed to work there. The surplus were simply made redundant.

This has exacerbated Turkmenistan’s already high unemployment rates, which have already been boosted by Turkmenbashi’s decision to sack some 15,000 medical workers and replace them with conscript soldiers – effectively free labour.

These cuts have concerned the population in general, and analysts believe that this new emphasis on recommending expensive tests runs the risk of alienating patients even further.

Women who come to the capital’s polyclinics complain that are often required to have a series of costly tests that are seemingly unconnected with the problem for which they were seeking treatment.

One young Ashgabat mother who attended a clinic to inoculate her child – a free service - was first sent to the gynaecology department.

“Only after I produced a receipt to show that I had been given tests – and paid for them – was my son given the injection we came for!” she said angrily.

As a result, increasing numbers are turning to quack doctors, local mullahs and even elderly members of the community who offer folk remedies for a small fee.

This problem is particularly widespread in rural areas, where the ignorance of the population and the lack of qualified medical aid leave people no other choice.

While no official figures record the number of Turkmen who die after contracting serious illnesses that go undetected by quack doctors, analysts suspect that the numbers are high – and are only likely to grow.

Pensioner Mered-aga told IWPR that, as a result of the changes to the healthcare system, he had stopped going to the doctor.

“I'm better off going to the mullah and giving him a dollar,” he said. “He will read me a prayer, give me something to drink, and my illness will go away.”