If the health-care debate in the United States seems complicated, then try looking at what’s going on in Kazakhstan.
During the Soviet era, almost everyone worked for the government. But following the collapse of Communism in 1991, opportunities for private-sector employment arose across the former Soviet republics. Dariga Chukmaitova, a doctoral candidate at Claremont Graduate University's School of Politics and Economics, is taking measure of how the public-to-private transition is going by examining Kazakhstan’s health-care sector. She presented some of her findings earlier in November at a seminar at George Washington University’s Institute for European, Russian and Eurasian Studies.
It would seem that making the jump is not so easy for many medical professionals in Kazakhstan. Drawing upon a survey conducted this spring of approximately 1,000 practicing physicians working in both the public and private health care sectors from nine Kazakhstani regions, Chukmaitova analyzed the individual incentives physicians have for switching sectors, and their perceptions of perceived risks.
Chukmaitova noted that “little is still known about the dynamics of sector-switching behavior, or the characteristics of people who are switching sectors, particularly in transitional economies.”
When it comes to the health-care sector, the switch from public to private sector in Kazakhstan is fraught with risk. And many Kazakhstani citizens are wary of risk, due in large part to the Soviet legacy, which discouraged individual initiative. In transition economies, like Kazakhstan’s, legal and public institutions are apt to be inefficient and corrupt, while the employment sphere can be marked by political instability and socio-economic tensions due to high inflation and unemployment. In addition, public-sector employees in transition countries usually receive much lower wages than their private-sector counterparts. But, public-sector health-care workers have substantial opportunities to augment their state salaries through informal payments (i.e. bribes) from patients.
Chukmaitova found that sector switching became more common when investment in public health care decreased, when reforms amplified uncertainty about the future of public-sector health care, and when public-sector salaries and benefits declined. Not surprisingly, individuals with a greater propensity to accept risk were also more open to switching job sectors.
In the survey, respondents complained about excessive paperwork and government regulations, inadequate salaries, and being blamed (with potential legal ramifications) for providing low quality care. They also expressed dissatisfaction that their compensation and other rewards were unrelated to their educational experience and other qualifications.
According to Chukmaitova, Kazakhstan’s health care workers also complained “that there are too many reforms that are being implemented, [and that] they are being implemented in a top-down approach, physicians are not being consulted or asked for their opinion in terms of whether there is need for another reform.”
“There is no ownership or engagement coming from the physicians so they have no idea what is happening and they are not feeling comfortable with all these reforms the ministry is implementing,” Chukmaitova added.
The researcher voiced the belief that, “as the number of reforms increases, the perception of uncertainty within the sector increases as well.” Concern about upheaval in the state sector thus acts as an incentive for health-care professionals to make a move into the private sector.
Based on her findings, Chukmaitova recommended that the Kazakhstani government “increase [state-sector] physicians’ salaries, at least to make it similar to what is received by physicians in the private sector.” The government should also “protect physician rights” better to shield them from improper malpractice lawsuits.
Another clear lesson for the government, Chukmaitova said, was “to ask physicians’ for their opinions or recommendations” before initiating yet another public health-care sector reform.
Richard Weitz is a senior fellow at the Hudson Institute in Washington, DC.