A Hospital by the Vegetable Garden

by Mari Michener Oye:

“Nation’s Health is the Wealth of the State,” reads a banner on Tajikistan’s Ministry of Health website. The site features photographs of Emomali Rakhmon, the Central Asian country’s president, standing beside small children and nurses in trim white coats.

Yet in Tajikistan, the poorest country of the former Soviet Union, health often depends on wealth. Most doctors are employed by the state, but the government salaries they receive are pitifully inadequate: around $10 to $30 per month. To make a living, doctors charge their patients out-of-pocket, under-the-table fees for care. Sometimes these “tips” or “gifts” are reasonable. Sometimes they border on extortion.

“Doctors are not surviving on their salaries. They are like hunters, sitting and waiting for patients,” said a former surgeon who asked to remain anonymous in order to speak more freely. “In this country, you will be an honest doctor and you will die from hunger. Or you will be a crap doctor, and you will take bribes, and you will survive.”

Frustrated by the situation in Tajikistan, many doctors leave for Russia, Canada, or even neighboring Afghanistan, where the pay is better. Others take multiple jobs, or quit the profession entirely to drive buses, work on the family farm, or sell shoes in the bazaar. Yet their skills are badly needed in Tajikistan, where preventable diseases like diarrhea and respiratory infections are the leading killers of children under five.

With support from the World Health Organization, reform efforts are underway in a few pilot districts. Although health indicators in these areas are improving, change comes slowly—and it is hindered at every step by the insidious presence of corruption, whether in Tajikistan’s medical schools, hospitals, or higher levels of government.

The Anatomy of a Crisis

Ibn Sina university in Tajikistan’s capital, Dushanbe, is named for a tenth-century physician and philosopher famed for his studies of anatomy. Today, however, students there can pass anatomy class by handing in an exam book with crisp somoni notes between the pages. For an important test or a thesis, professors demand the equivalent of $500, as much as many Tajiks earn in a year.

“No one wants to study. Everyone wants to just pay for exams,” said Dalida Alieva, a third-year cosmetology student. “If the family is rich, then they can pay.” The problems at the medical school are symptomatic of a growing divide between Tajikistan’s Mercedes-driving elite class and the rest of the population, 60 percent of which lives below the poverty line.

“This is going to come back to haunt Tajikistan in a few years,” said Frank Johansen, a political officer working on anti-corruption initiatives with the Organization for Security and Co-operation in Europe (OSCE). “The families care about having the diploma on the wall, or they need it so their uncle can get them a government job. They don’t care about learning, about the education.”

The attitudes formed in medical school can set the stage for malpractice later on.

While working for the OSCE in northern Tajikistan, Johansen heard of one family whose newborn baby was placed in intensive care for three days. The hospital denied them permission to see their child and charged them for expensive procedures and medicines. On the third day a nurse pulled them aside and told them not to bother paying anymore. The baby had been stillborn.

Such stories, although shocking, are not rare.

“I saw it,” the former surgeon testified. “An Afghan migrant brought in his child, a girl, who had eaten something bad and was throwing up. The doctors kept this child for five days and charged a lot of money even though she was okay on the next day.”

While some doctors in Tajikistan cheat their patients, others end up subsidizing care for poor families, working for free when they know the patient cannot afford to pay.

Suraya Abdulhamidova, a soft-spoken woman in her forties, refused to take side payments while working as a government doctor. She was forced to work night shifts at multiple jobs in order to provide for her three children. “It’s not my way to take money from people,” Abdulhamidova said. Although she eventually quit her position as a state doctor to earn a higher wage at the U.S. Embassy health clinic, she still takes care of her neighbors for free. “There is a feeling that I am a Muslim, I have to help,” Abdulhamidova said. “It’s the traditional hospitality.”

In the village of Turoj-Bagh, an hour’s drive into the mountains west of Dushanbe, that traditional Tajik hospitality was on full display as Dr. Ilhom Garfurov and his wife, the village nurse, showed a monitoring team from the international NGO Mercy Corps around the hospital where they have worked for 25 years.

The hospital has a dirt floor and mud walls decorated with posters of President Rakhmon and health information flyers from UNICEF.  Young women with babies and toddlers in their arms wait to be seen in the daylily patch outside.  Dr. Garfurov is also responsible for the area around his village, and he travels miles by donkey or four-wheel-drive to make house calls. This is the kind of post most young graduates of the medical school hope to avoid.

“The government salary is nothing,” Garfurov said. “I serve because I am a patriot. The main income is from the garden.” He gestured toward the grape vines and apple trees growing on the steep slope in front of his house, just down the road from the little hospital.

Turoj-Bagh is lucky to have a doctor at all. In rural mountainous areas, the nearest hospital is often miles away. Snow-covered roads make travel difficult in winter. In 85 areas, Village Development Councils established with help from Mercy Corps have set up ambulance transport systems and pools of emergency funds for the community.

Other Mercy Corps programs focus on preventing malnutrition and waterborne diseases by training volunteers, who in turn pass on the information to friends and neighbors in twice-weekly seminars. Women are desperately eager for the information. “My son died three years ago from diarrhea and a fever,” said Oimhon Halimova, one of about 20 women learning how to mix oral rehydration salts at a Mercy Corps training seminar in the Rasht Valley. Halimova said she wished the seminars had been available three years ago, in time for her to treat her son.

Spare Change or Behavior Change?

While Mercy Corps focuses on educating the population and supporting local health workers, the government is slowly implementing a larger program of reform in eight target districts. The program, paid for entirely by international donors, aims to raise the quality of care, streamline payment, and eliminate bribes from the system.

“We are working hard to change the way health care is financed, to move from a system where hospitals are reimbursed on the basis of beds occupied to an evidence-based system which reimburses on the basis of actual diagnosis,” said Tracey Jacobson, U.S. ambassador to Tajikistan. “Also, we need to work to raise salaries for health care workers and to eliminate the mentality of ‘unofficial payments’ for medical services.”

Results so far have been mixed. In theory, patients in pilot areas pay for their care at a hospital cashier, with the price clearly posted and government subsidies available for orphans, veterans, and the elderly or chronically infirm. In practice, patients tell stories of paying the cashier for service at the posted rate, then also having to pay the doctor, the nurse, and the lab worker a little something on the side. Though some doctors have seen their salaries go up, others have not — and they still ask patients for extra money.

“We should maybe have calculated better about the salary of the doctor,” said Ilhom Bandaev, head of international affairs in the section of the Ministry of Health tasked with reform. “That is bad, because we know that if we do not improve the level of payment we do not have result,” he said. “We know about this problem.” With the current economic crisis, though, the Ministry of Health has no plans to raise doctors’ salaries or to expand the pilot programs to new districts next year.

The problem is partly one of resources and partly one of priorities. According to a 2008 International Crisis Group report, the government of Tajikistan spent a grand total of $75 million per year on health care in 2008. In contrast, the many-columned Presidential Palace of Nations in Dushanbe cost $300 million dollars to build, including $52 million for the furniture alone.

In comparison to these numbers, the fees charged by underpaid doctors seem insignificant. Many do not abuse the system, but until financial incentives for doctors line up with good medical practice, patients, especially the poor, will remain vulnerable.

Mari Michener Oye is a junior Political Science major in Timothy Dwight College. This summer she volunteered with Mercy Corps in Tajikistan. Her research for this article was supported by a Frank M. Patterson Grant in Political Science and by the Coca-Cola World Fund at Yale.