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Health in Turkmenistan

Bernd Rechel Inga Sikorskaya Martin McKee
29 July 2009

The West pays little attention to Turkmenistan, one of the most repressive and reclusive countries of the former Soviet Union. When it does, it is often for dubious reasons - like the bizarre personality cult around former President, Saparmurat Niyazov. In the absence of opposition parties or an independent media, the real situation in the country has been shrouded in mystery.  

Bernd Rechel is a researcher at the European Observatory on Health Systems and Policies, and lecturer at the London School of Hygiene & Tropical Medicine

Inga Sikorskaya is a Senior Editor at the Institute for War and Peace Reporting

Martin McKee is Professor of European Public Health at the London School of Hygiene & Tropical Medicine The effects of Niyazov's dictatorship on public health have been disastrous, however.   A report in The Lancet in 2004 drew attention to the worsening situation. In the following year, we undertook a comprehensive review of the situation. We found that while vast sums were being spent on high-profile projects that glorified Niyazov's regime (a gold-plated, revolving statue of the dictator, the largest mosque in Central Asia, a 40m-high pyramid and an ice palace whose construction was mercifully interrupted by his death), the health of the population had deteriorated markedly. Women's health, to take one indicator, was much worse than in any other part of the post-Soviet space, with female life expectancy estimated by the World Health Organization (WHO) to have fallen from 70 in 1990 to 66.9 in 2002.   

There was evidence too that the regime had withheld information about serious outbreaks of disease. Incredibly, they denied the existence of HIV/AIDS in the country. They were doing little to contain widespread trafficking and consumption of drugs (indeed, Niyazov's regime was suspected to have been actively involved in the drug trade), and the dictator had announced his intention of closing all hospitals outside the capital, Ashgabat.

Then Niyazov died suddenly in December 2006 and was succeeded by former Minister of Health, Gurbanguly Berdymukhammedov.  Has this change in leadership had positive consequences for the country's health sector?

We offered to conduct an independent assessment of the health system. The new government did not take up our offer. The only way we could gather information inside the country was to commission anonymous observers to submit reports in November and December 2008. We contacted the main United Nations (UN) agencies, bilateral donors and western embassies, and undertook a comprehensive search of relevant websites and databases.

Unreliable official data
However, the chief obstacle to assessing the health situation in Turkmenistan remains the paucity or unreliability of official data. Where data has been reported, it is often questionable. Take the figures on maternal mortality which were submitted to UNICEF's TransMONEE database. These indicated that maternal mortality had declined from 55.2 maternal deaths per 100 000 live births in 1989 to 4.3 in 2006 (UNICEF 2008). This is hardly credible, being lower than the ratio recorded in the Netherlands (WHO 2009).

WHO-graph.png

The official data on HIV/AIDS is equally suspect (Open Society Institute 2008; United Nations 2008). Turkmenistan reported only one new case to UNICEF between 1989 and 2006 (UNICEF 2008). Regional comparison makes it clear that the true figures are not being reported. (Figure 1) Figure 1    Reported HIV infections in 2006 <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4; mso-font-charset:0; mso-generic-font-family:swiss; mso-font-pitch:variable; mso-font-signature:-1610611985 1073750139 0 0 159 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin-top:6.0pt; margin-right:0cm; margin-bottom:0cm; margin-left:0cm; margin-bottom:.0001pt; text-align:justify; line-height:200%; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:Calibri; mso-ansi-language:EN-US; mso-fareast-language:EN-US;} @page Section1 {size:612.0pt 792.0pt; margin:72.0pt 90.0pt 72.0pt 90.0pt; mso-header-margin:36.0pt; mso-footer-margin:36.0pt; mso-paper-source:0;} div.Section1 {page:Section1;} --> Source: (WHO 2009) This calls into question all data reported by the Turkmen government. Trying to assess population health in Turkmenistan is like staring down a black hole. However, thanks to our other sources of information, we have been able to fill in some of the information gaps.

For ordinary Turkmen citizens, a major barrier to accessing health services seems to be widespread under-the-counter payments, a practice common throughout most of Eastern Europe and the former Soviet Union. For minor operations, such as appendicitis, even the poor in Turkmenistan are reportedly expected to pay at least USD 200, with higher payments for more complex procedures and richer patients.

Recent positive developments
However, we also found evidence of some positive developments under the new President. One of the most significant has been in the sphere of illicit drug use. Under President Niyazov, whose regime was said to be implicated in the trade, this problem was not even acknowledged. The situation seems to have improved greatly, though whether this commitment will translate into less drug trafficking and consumption remains to be seen.

The new leadership has also started building many new health facilities. At first they just built prestigious tertiary care facilities and hospitals in the capital (UNICEF 2008). But more recently they have started constructing new facilities in rural areas and new child and maternal health centres in all regional centres (Government of Turkmenistan 2008).

What's needed now
However, promising though these signs are, they have not been accompanied by much-needed reforms of the health system. Above all, effective organizational and regulatory structures need to be put in place and sustainable and adequate financing provided. Decision-making, budget allocations and spending patterns remain opaque (European Union 2007).

The shortage of health care workers remains a key barrier to improvement. Many are poorly trained. The education sector suffered tremendously under Niyazov - his decision not to recognize higher education degrees awarded abroad being only the starkest example of the  catastrophic war he waged against learning. The new President has increased the duration of higher education from two to five years. But it will take time to repair the damage done to the health and education sectors under Niyazov.

In short, despite some areas of improvement under the new President of Turkmenistan, the situation in the health sector overall is cause for concern. International agencies, such as the World Bank or the European Union, can play a key role in supporting positive trends and raising issues where substantial progress still needs to be made.

The paper is based on research funded by the Open Society Institute. The funding sources had no involvement in the research presented here.

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