In 2004 and 2005, Turkmenistan's first post-Soviet president, Saparmurat Niyazov, sacked 15,000 medical workers and closed down all regional hospitals in the country, calling them unnecessary luxuries. Anyone who needed medical treatment, he said, could just come to the capital, Ashgabat.
In a dramatic U-turn, Niyazov's successor, Gurbanguly Berdymukhammedov -- who came to power in late 2006 and is himself a dentist by profession -- has been investing tens of millions of dollars to improve and modernize the reclusive nation's beleaguered health-care sector.
The revamp included an annual Month of Health and Sports, which is currently under way in Turkmenistan and has thousands of people throughout the country taking long walks in parks and participating in compulsory physical fitness classes at their workplaces.
Besides such ambitious health initiatives, numerous hospitals, clinics, and wellness and sports palaces have also been built in Ashgabat, all equipped with modern medical technology.
According to media reports, Turkmenistan invested $56 million to build an ophthalmology complex in Ashgabat as well as another $47 million in a traumatology center in the same city -- to name just a few high-profile projects. Turkmen government websites are awash with photographs of impressive, multistory medical facilities that Berdymukhammedov's government has built in the Turkmen capital using the energy-rich country's natural-gas revenues.
The reality, many Turkmen complain, is far less impressive. Only the facade of the country's medical sector has changed, they say. While Berdymukhammedov has, indeed, reopened rural hospitals shuttered by Niyazov, little appears to have altered in the quality of the medical services provided there, according to doctors and patients interviewed by RFE/RL.
"Medical services in the Turkmen provinces still remain at the level of the 1970s," says a Turkmen doctor who identified herself as Maral Nedirova. Nedirova worked as a general practitioner in Turkmenistan's health sector for more than 20 years before leaving the country earlier this year. Her most recent stint was at Niyazov Hospital in Ashgabat.
"While Ashgabat hospitals are engulfed in stifling corruption, village hospitals face a severe shortage of the most basic medical equipment, such as sterile medical materials," Nedirova says.
Outhouses For Toilets
A tuberculosis hospital in Tagtabazar in Turkmenistan's southeastern Mary Province is a case in point. While the walls of its dilapidated building have recently been brightened with a new coat of paint, the hospital still lacks running water, a modern heating system, and modern toilets.
Patients are forced to use an outhouse and sleep in Soviet-era iron beds, while the furniture in the hospital's canteen consists of an old fridge, a bench, and a shabby table covered with a plastic tablecloth.
According to Nedirova, the situation is similar in rural hospitals across the country.
"They use outhouses instead of flush toilets," she says. "Many hospital buildings across the country haven't been renovated for years. There is a bad smell everywhere. The hygiene standards are very poor and rooms are cold. Patients routinely bring their own food. Patients pay for everything, but it's not clear where all the money goes. There are no central heating systems in rural hospitals and patients have to provide their own stoves during the winter."
Nedirova says those hospitals in Ashgabat that do have the latest high-tech equipment often don't have staff who have been properly trained to operate them.
Bahar, a medical student in the eastern city of Turkmenabat, in interning at the district hospital. She describes conditions there as "appalling."
"The hospital building is very old and all medical equipment and furniture is very old," she told RFE/RL's Turkmen Service. "Hospital rooms are small and cramped. There is a constant shortage of medicine."
Despite their shortcomings, village hospitals are the only places where many impoverished Turkmen citizens can see a doctor. Those who are ill and have the money travel to Ashgabat, but the cost of treatment in the capital's modern hospitals is beyond the reach of even middle-income Turkmen.
On paper, Turkmenistan's state-funded health insurance partly covers hospital treatment and medications in state medical facilities. In reality, however, patients tell RFE/RL that they end up paying for almost everything -- from hospital beds and food to medicines and surgeries.
"Bribery is a rule in Turkmen hospitals," says Nedirova, who did not want to reveal where she is currently living. "Patients have to pay cash to everyone -- from junior medical staff to the surgeons. This is in addition to what they formally pay to a hospital before being admitted there."
"In those marble-clad new medical centers in Ashgabat, doctors create completely unnecessary queues to make patients pay bribes for faster service," she adds. "For instance, to get an MRI [magnetic resonance imaging], patients have to wait two to three months if they don't pay."
According to media reports, hospitals officially charge around $8,500 for a typical cancer surgery, some of which is covered by state health insurance. But Nedirova says the real figure is usually much higher after factoring in the bribes paid to doctors and nurses.
For serious illnesses, patients have been known to sell their homes and cars or borrow money from relatives to raise the necessary funds.
Arzu, a 55-year-old housewife from western Balkan Province, requires hospital treatment every six months for a chronic kidney ailment. Arzu says her grown children are forced to foot her ever-increasing medical bills and the almost compulsory bribes.
She says she is considering giving up her treatment altogether because her family is no longer able to afford it.
At one time, well-to-do Turkmen used to travel to Turkey, Iran, or Russia to seek medical treatment. In recent years, however, Turkmen authorities have introduced complex, time-consuming paperwork for those seeking medical treatment abroad, in an apparent effort to discourage such travel.
Twenty-seven-year-old Ayna is suffering from breast cancer and claims that her condition dramatically worsened during the time she was awaiting proper treatment.
"I wasn't allowed to go to Iran for cancer surgery. Then I went to Turkey, pretending I was going on vacation," she says, adding, "The authorities think the world would find out about the real state of our country's health care if Turkmen kept traveling abroad for medical treatment."
By RFE/RL's Turkmen Service and Farangis Najibullah.