Most countries in the Former Soviet Union either have plans to reform or have already begun to reform their health system.  With people’s incomes and tax revenues falling, governments need to find new ways of financing health care.  Introducing health care treatment charges in an effort to balance the budget may mean that less people receive the treatment they need. Policy in this area should be closely linked to the individual's ability to pay.

At independence in 1991, Tajikistan was the poorest of all the Soviet Republics.  However, part of the Soviet legacy was almost universal literacy and a life expectancy of 70 years.  The health service was comprehensive and free, if inefficient. Since independence, the country has faced the economic upheaval of moving from a planned to a market economy, as well as civil war.  Spending on health care is now less than a tenth of its pre-independence level and there is little money for drugs and food, let alone maintaining or rebuilding facilities.  In 1999 over half of rural clinics did not have oral rehydration salts in stock and two-thirds were unable to monitor the growth of young children.

The UK's University of Southampton analysed the Tajikistan Living Standards Survey, a national household survey of 2 000 families carried out in May 1999, to discover how much people were currently paying for health care and whether poverty prevented people from seeking medical attention. Payments in cash or in kind are increasingly expected for consultations as doctors and nurses seek to survive on an income of less than US$ 5 per month.  These salaries, compared to the average salary of US$ 11 per month, are often paid several months in arrears. The study found that:

• The poor use the health system much less than the top 20 % ‘wealthy’ members of society - although more than 90 % of the population is living below the official poverty line
• The cost of consultations and treatment is preventing people from visiting the doctor for advice in the first place and, if money is found for a consultation, the patient often cannot afford the treatment recommended by the doctor
• Although exemptions are made on an informal basis, some families have to sell their possessions or go into debt to meet the costs of care.

The report suggests that the current system of informal payments should be made official.  However, care should be taken that the system does not become more unjust than at present. Policy-makers must be aware that if doctors’ salaries do not increase, then bribes will continue side-by-side with the new payments, making health care even more expensive.

Bribes from the poor are considerably lower than those from the wealthy at present.  Official charges must be linked to people’s ability to pay, for example the young, the elderly and the chronically sick, as well as the poor, could be exempt from paying for treatment.

Source(s):
‘Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan’, Social Science and Medicine 58: 247-258, by J. Falkingham, 2004
‘Inequality in utilisation of maternal health care in Tajikistan’, Studies in Family Planning 34 (1): 32-43, by J. Falkingham, 2003
'Understanding informal payments for health care: the example of Bulgaria', Health Policy 62 (3): 243-73, by D. Balabanova and M. McKee, 2002

Funded by: United Nations Development Programme (UNDP); World Bank

id21 Research Highlight: 19 July 2004

Further Information:
Jane Falkingham
Department of Social Statistics
University of Southampton
Southampton 
SO17 1BJ
UK

Tel: +44 23 8059 3846
Contact the contributor: j.c.falkington@soton.ac.uk

University of Southampton, UK

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