N:\EC\COM\HDS\IDP\DOCSTORE\DOCSTORE\Docs for PDF filing\Obs\Health care in central Asia.doc Health care in central Asia European Observatory on Health Care Systems Series Series Editors Josep Figueras is Head of the Secretariat and Research Director of the European Observa- tory on Health Care Systems and Head of the European Centre for Health Policy, World Health Organization Regional Office for Europe. Martin McKee is a research director of the European Observatory on Health Care Systems and Professor of European Public Health at the London School of Hygiene & Tropical Medicine as well as a co-director of the School’s European Centre on Health of Societies in Transition. Elias Mossialos is Research Director of the European Observatory on Health Care Systems and Bnan Abel-Smith Reader in Health Policy, Department of Social Policy, London School of Economics and Political Science and Co-Director of LSE Health and Social Care. Richard B. Saltman is Research Director of the European Observatory on Health Care Systems and Professor of Health Policy and Management at the Rollins School of Public Health, Emory University in Atlanta, Georgia The series The volumes in this series focus on key issues for health policy-making in Europe. Each study explores the conceptual background, outcomes and lessons learned about the dev- elopment of more equitable, more efficient and more effective health systems in Europe. With this focus, the series seeks to contribute to the evolution of a more evidence-based approach to policy formulation in the health sector. These studies will be important to all those involved in formulating or evaluating national health care policies and, in particular, will be of use to health policy-makers and advisers, who are under increasing pressure to rationalize the structure and funding of their health systems. Academics and students in the field of health policy will also find this series valuable in seeking to understand better the complex choices that con- front the health systems of Europe. Current and forthcoming titles Martin McKee and Judith Healy (eds): Hospitals in a Changing Europe Martin McKee, Judith Healy and Jane Falkingham (eds): Health Care in Central Asia Elias Mossialos, Anna Dixon, Josep Figueras and Joe Kutzin (eds): Funding Health Care: Options for Europe Richard B. Saltman, Reinhard Busse and Elias Mossialos (eds): Regulating Entrepreneurial Behaviour in European Health Care Systems The European Observatory on Health Care Systems is a unique project that builds on the commitment of all its partners to improving health care systems: • World Health Organization Regional Office for Europe • Government of Greece • Government of Norway • Government of Spain • European Investment Bank • Open Society Institute • World Bank • London School of Economics and Political Science • London School of Hygiene & Tropical Medicine The Observatory supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of the dynamics of health care systems in Europe. European Observatory on Health Care Systems Series Edited by Josep Figueras, Martin McKee, Elias Mossialos and Richard B. Saltman Health care in central Asia Edited by Martin McKee, Judith Healy and Jane Falkingham Open University Press Buckingham · Philadelphia Open University Press Celtic Court 22 Ballmoor Buckingham MK18 1XW email: [email protected] world wide web: www.openup.co.uk and 325 Chestnut Street Philadelphia, PA 19106, USA First Published 2002 Copyright © World Health Organization 2002 The views expressed in this publication are those of the editors and contributors and do not necessarily represent the decisions or the stated policy of the participating organizations of the European Observatory on Health Care Systems. All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the copyright holder or a licence from the Copyright Licensing Agency Limited. Details of such licences (for reprographic reproduction) may be obtained from the Copyright Licensing Agency Ltd of 90 Tottenham Court Road, London, W1P 0LP. A catalogue record of this book is available from the British Library ISBN 0 335 20926 2 (pb) 0 335 20927 0 (hb) Library of Congress Cataloging-in-Publication Data Health care in central Asia / edited by Martin McKee, Judith Healy, Jane Falkingham. p. cm. — (European Observatory on Health Care Systems series) Includes bibliographical references and index. ISBN 0-335-20927-0 (hb) — ISBN 0-335-20926-2 (pb) 1. Medical care—Asia, Central. 2. Medical policy—Asia, Central. 3. Health care reform—Asia, Central. 4. Medicine—Asia, Central. I. McKee, Martin. II. Healy, Judith. III. Falkingham, Jane. IV. Series. RA395.A783 H43 2002 362.1′0958—dc21 2001036105 Typeset by Graphicraft Limited, Hong Kong Printed in Great Britain by Biddles Limited, Guildford and Kings Lynn Contents List of figures and tables vii List of contributors x Series editors’ introduction xii Foreword xiv Acknowledgements xv part one Context 1 one Health care systems in the central Asian republics: an introduction 3 Martin McKee, Judith Healy and Jane Falkingham two History and politics in central Asia: change and continuity 12 Shirin Akiner three Macroeconomic pressures 31 Richard Pomfret four Poverty, affordability and access to health care 42 Jane Falkingham five Patterns of health 57 Martin McKee and Laurent Chenet six The Soviet legacy: the past as prologue 67 Mark G. Field vi Health care in central Asia part two Health systems and services 77 seven The reform process 79 Serdar Savas, Gülin Gedik and Marian Craig eight Health system funding 92 Joe Kutzin and Cheryl Cashin nine Allocating resources and paying providers 108 Tim Ensor and Jack Langenbrunner ten The health care workforce 125 Judith Healy eleven Modernizing primary health care 141 Gülin Gedik, Zafer Oztek and Antony Lewis twelve Rationalizing hospital services 151 Johannes Vang and Steve Hajioff thirteen Restructuring public health services 165 Ian MacArthur and Elena Shevkun fourteen Health care systems in transition 179 Judith Healy, Jane Falkingham and Martin McKee part three The countries 195 fifteen Profiles of country health care systems 197 Kazakhstan – Maksut Kulzhanov and Judith Healy 197 Kyrgyzstan – Acelle Sargaldakova, Judith Healy, Joe Kutzin and Gülin Gedik 201 Tajikistan – Rahmin Rahminov, Gülin Gedik and Judith Healy 204 Turkmenistan – Chary Mamedkuliev, Elena Shevkun and Steve Hajioff 207 Uzbekistan – Farkhad A. Ilkhamov, Elke Jakubowski and Steve Hajioff 210 Index 214 List of figures and tables Figure 1.1 Map of central Asia 10 Figure 4.1 Cumulative change in real GDP in central Asia, 1989–2000 43 Figure 4.2 Composition of the poor by age group in four central Asian republics 46 Figure 5.1 Life expectancy at birth, in years, for central Asian men 58 Figure 5.2 Life expectancy at birth, in years, for central Asian women 59 Figure 8.1 Health system funding sources and contribution mechanisms 93 Figure 8.2 Health as a percentage of total state budget spending 94 Figure 8.3 Trends in real health spending from public sources (index: 1999 = 100) 96 Figure 8.4 Trends in real per person public spending on health (index: 1995 = 100) 98 Figure 8.5 Trends in real per person public spending on health (index: 1995 = 100) 99 Figure 10.1 Number of physicians per 100,000 population in regions of Europe 128 Figure 10.2 Number of physicians per 100,000 population in central Asian republics 129 Figure 10.3 Numbers of physicians graduated per 100,000 population in central Asian republics 130 viii Health care in central Asia Figure 10.4 Number of nurses per 100,000 population in central Asian republics 131 Figure 12.1 Average lengths of stay (days) in acute hospitals in the central Asian republics, 1991–98 156 Figure 12.2 Admissions to acute care beds per 100 population in the central Asian republics, 1991–98 157 Figure 12.3 Acute care beds per 100,000 population in the central Asian republics, 1991–98 158 Figure 14.1 Human development index, world rank order, for the central Asian republics, 1990–98 182 Figure 14.2 Number of hospital beds per 100,000 population in the central Asian republics, 1980–98 189 Figure 15.1 Map of Kazakhstan 198 Figure 15.2 Map of Kyrgyzstan 201 Figure 15.3 Map of Tajikistan 205 Figure 15.4 Map of Turkmenistan 207 Figure 15.5 Map of Uzbekistan 210 Table 3.1 Initial conditions: republics of the former Soviet Union, 1989–90 32 Table 3.2 Economic performance indicators in central Asia, 1989, 1993, 1996 and 1999 34 Table 3.3 General government spending and balance in the central Asian republics (as per cent of GDP), 1990–99 36 Table 3.4 Social spending (as per cent of GDP) for the central Asian republics, 1991–96 37 Table 4.1 Absolute poverty rates in central Asia and other selected countries of the Former Soviet Union 45 Table 4.2 Relative poverty risks for households with selected characteristics within the central Asian republics 47 Table 4.3 Human development indicators in central Asia, 1991 and 1998 48 Table 4.4 Changes in school enrolment rates (per cent of the relevant age group) in central Asia, 1989 and 1998 48 Table 4.5 Reasons for non-use of medical services by area of residence, Kyrgyzstan, 1996 51 Table 4.6 Reasons for not seeking medical assistance by economic status of the household,