By the time Saidburkhan, a traditional healer from a small Uzbek town in the Ferghana Valley, arrived at work on a recent autumn day, his private clinic specializing in herbal medicine was packed. Three blocks away, a government-run hospital was empty – most doctors and nurses, under pressure from local authorities, were out in the cotton fields, fulfilling government harvest quotas.
If one believes official statistics, access to and the quality of healthcare in Uzbekistan has improved immensely over the past decade: Since 1999, child mortality is said to have decreased by 68 percent, and maternal mortality by 38 percent, according to official figures. In 2010, authorities announced plans to spend 13 percent of the national budget on healthcare, a significant increase. But if one actually talks to local doctors and health experts, you are apt to hear a very different story.
“Officials tend to include large infrastructure projects in healthcare spending [thus inflating the figures]. The reality is that government spending has been declining,” said a Tashkent-based epidemiologist and tuberculosis expert who spoke on condition of anonymity. Indeed, according to a 2007 report by the European Observatory on Health Systems and Policies, a World Health Organization affiliate, Tashkent’s healthcare spending fell from 5.5 percent of GDP in 1991 to 2.4 percent in 2005. The report also noted a decrease in life expectancy for both men and women in the same period.
The stagnant healthcare system’s effect on public health is obvious. Médecins Sans Frontières, the humanitarian aid agency, warns that less than 10 percent of the population has access to drug-resistant tuberculosis treatment even though “[t]he prevalence of drug-resistant tuberculosis in Uzbekistan is one of the highest in the world.” Few international aid agencies will speak publicly about Uzbekistan’s health woes, due to fear that doing so would provoke Tashkent into expelling whistle-blowing groups from the county.
Independent health experts believe a public health crisis is brewing. HIV infections are skyrocketing, while outbreaks of typhoid, dysentery, cholera and other infectious diseases are becoming more frequent, especially in the countryside, opposition media reports say. Nationwide, with a diet less nutritious than it was a generation ago, the number of iodine deficiency-related illnesses is also growing.
By law, Uzbek citizens are entitled to free healthcare. But in reality, most are forced to pay to get even basic care. “When my wife was diagnosed with cancer, it was devastating for the whole family,” said Abdullajon, an Andijan resident and father of three who declined to provide his full name, fearing government retribution. “We have already spent all our savings: 3 million sums [$1,700] for treatment. I don’t know how we are going to cover other costs.”
Officials routinely “misreport key healthcare indicators, such as child and maternal mortality, and the incidence of infectious diseases,” according to a report published by the International Crisis Group in February, so as not to “be seen as failing in their responsibility to the people.”
“Drugs are overpriced by at least 20 percent, because the government shuts out competitive bids. In reality, only acute emergency care is free,” the report added.
Local anecdotal evidence supports the grim assertions contained in the report. “I recently went to the hospital and I was shocked to see that even basic things – such as disposable needles, anesthetics, and antibiotics – are in short supply. This was not the case during Soviet times,” said a retired doctor from Andijan, who linked poor service with low pay. The average monthly salary for a doctor is around $150, she said. A nurse makes about $80 per month.
Since Uzbekistan gained independence in 1991, international organizations, including the World Bank and USAID, have attempted to promote health-care reform in the Central Asian nation. But insiders complain many of their initiatives have failed because of the government’s habit of adopting decrees without consulting local doctors. Widespread bureaucracy and corruption also thwart attempted improvements. Thus few experts believe a $93 million World Bank loan, signed in September and designed to reform access to rural healthcare, will be meaningful.
“The main beneficiaries are consistently dissatisfied with the healthcare system. Reforms are meaningless,” said the epidemiologist.
Another part of the problem is the Uzbek government’s penchant for secrecy, as well as its desire to maintain a chokehold on news and information inside the country. In 2010, HIV activist Maxim Popov was sentenced to seven years in jail for “corrupting minors” through the distribution of pamphlets about safe sex. He was released after a year, but the case sent a message to his colleagues, and to donors supporting his activities: there is little appetite for substantive healthcare reform.
At present, many observers of the Uzbek healthcare sector believe the government is attempting to keep doctors and nurses from leaving the country, either to stem the exodus of skilled medical personnel, or to quarantine information about the sorry state of Uzbekistan’s healthcare system, perhaps both. Without explanation, in March 2010 the Ministry of Health adopted a decree requiring medical workers to apply for ministry permission before traveling abroad – on top of obtaining an exit visa that all citizens require. Authorities are additionally trying to hush reports that women are being forcibly sterilized.
In this situation, it’s no real surprise that many Uzbeks seek alternatives. An increasing number of women in rural areas are giving birth at home, or in private clinics, sometimes because they fear doctors will trick them into undergoing a sterilization procedure. Among the wealthy, medical tourism is on the rise, with patients traveling to Kazakhstan, Russia, India and Thailand in search of medical services. The number of clinics operated by traditional healers such as Saidburkhan has also quietly mushroomed.
“Unless the government starts to view healthcare as a top priority, little will change. Unfortunately, the current official approach does more to weaken the sector than fix it,” said the epidemiologist from Tashkent.