New Broom Sweeps Kazak Health Sector

Monday, 21 February, 2005

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Karim Tanaev

The Kazak health ministry has launched what seems like a laudable effort to stamp out widespread corruption in the hospital system, where patients often have to pay for services that should be free.

But some doctors are warning the drive could go too far, and make it impossible for hospital staff to charge patients when they purchase extra medicines that the chronically underfunded state sector has failed to deliver.

The measures were announced by recently-appointed minister Erbolat Dosaev when he presented a wide-ranging five-year reform programme at a meeting with health sector employees in Karaganda on June 29.

“I am in favour of legalising the shadow economy that exists in the health sector,” said Dosaev, saying that healthcare was dogged by the problem of illicit payments.

The health minister picked out three areas which needed to change: the common practice of presenting gifts to hospital staff, the illegal sale of medicine, and fraudulent accounting for legitimate charges.

He explained that after spending three months in his post, he had discovered that close to 90 per cent of the money that the state should be earning when doctors charge for certain services disappears into the shadow economy.

Since independence, Kazakstan’s health service has begun charging for some services, for example when a patient seeks treatment without having been referred by his or her doctor. Basic services continue to be free, as in the old Soviet Union.

Sometimes a doctor will strike a deal with the patient, accepting – and pocketing - a sum lower than the official fee the hospital would have taken, on condition there is no paper trail.

Another abuse of the system is where a doctor refers non-paying patients to his own chargeable hours, so that when they come back they have to pay, but benefit by jumping the queue for treatment. According to Dosaev, “Some of them have got into the habit of sitting in one and the same building, but spending the morning working for the state while working to line their own pockets in the afternoon.”

Dosaev’s initiative has been welcomed as a way of diverting money from the grey economy back into the cash-starved state sector.

“The main task set by Dosaev - who has a background in finance - is the requirement that funds should go where they’re supposed to go. That’s very difficult to control,” political analyst Sanat Kushkumbaev told IWPR.

One area that has sparked some controversy is the practice where patients pay for medicine and supplies that should be free.

Medics interviewed by IWPR say that such payments were only to reimburse hospital staff when they had to go out and buy items that government funding had failed to provide. They insist that this is not corruption, just a way of filling the gap left by underfunding.

The head doctor at a hospital in the capital Astana, who asked not to be named, said, “The funds that the government budget allocates do not cover the costs of providing free healthcare as it stands.”

Aigul, who manages a unit at another Astana hospital, warned that cracking down on the practice was likely to harm rather than improve healthcare provision.

“We lack many drugs, even simple bandages. How is a doctor supposed to get them?” she said. “I can’t cancel an operation simply because there isn’t any novocaine. Of course I go to the pharmacy and buy it with my own money. And yes, the patient’s relatives will repay the money to me. Is that wrong, do you think?”

For Aigul, with experience running an overstretched hospital unit, the health ministry’s campaign seems to undermine the work of professionals who are just trying to do their job.

“It looks like they want to extinguish doctors as a profession.... If I use my own money to buy medicine to save a patient’s life, am I breaking the law?” she asked.

Some patients agree, and are grateful for the money doctors spend on extra supplies

“I had a serious car accident and spent a long time in intensive care,” recalled Oleg, a 20-year old Astana resident who got out of hospital a month ago. “When I recovered, they told me the amount of drugs used in the operation that they had bought themselves… Of course I gave the doctors money for the drugs. I checked how much they cost in the hospital pharmacy and paid back all the money.”

Sometimes, though, patients complain that they are overcharged by doctors. Almaty resident Arman thinks the health minister has the right idea, after seeing what happened when his brother was hospitalised.

“You can imagine what a state we were in, with our brother in critical condition in intensive care – and here were the doctors one after another asking for money for the drugs that would be used,” he said. “Later on I checked the prices, and found we had been cheated up to three times the original price.”

Another grey area that minister Dosaev wants to clean up is the giving of gifts.

Sometimes it is an unsolicited gesture of gratitude, but at other times it amounts to a bribe, although such gifts are not usually substantial –a box of chocolates, bottle of wine or some perfume.

Dosaev made it clear that he is not totally against the practice, but he wants to regulate it for the sake of transparency. “If a patient gives a doctor something by way of thanking him for the good treatment he’s received, then why not? But why do it clandestinely? Let’s make it open.”

It is not clear how the minister plans to keep tabs on a practice that has become a tradition. “I am a medical worker myself,” said Lyudmila, a paediatrician. “But when I was in hospital a year ago, I too gave the doctors money. I know there is a shortage of medical supplies. I also presented nurses with chocolates and gave the doctor who did the operation a bottle of perfume. It’s just an expression of gratitude.”

The new health minister does not look as though he will be deterred by custom and practice in his drive to increase efficiency.

At a press conference on June 16, he said, “We want to turn illegal money into legal money. We won’t be able to do it in 2004 or 2005, but in 2007 it should be possible.”

Karim Tanaev is the pseudonym for a journalist in Astana.