Mens sana in corpore sano – stories about the Kyrgyz health care system

Everyone is talking about health care these days. The US government was shut down due to trouble with the Tea Party Republicans about the health reform “Obamacare”. Okay, it’s basically two different things – the US household and Obamacare – but you see: one can link anything to health (or anything else that suits the Conservatives)…

Anyway, recently random American people were asked about their preferences regarding the health care system and didn’t know that there is no difference between the affordable health care act and its nickname “Obamacare”. See the video here. Still, I guess we shouldn’t be too ready to make fun of them (like we Europeans often are), because, I, being asked about the health care system in my country, probably couldn’t explain how it works in detail either. And if we don’t know about our own country, what then about other countries we have been to due to globalization?

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Abandoned health care. A surgery room in an old hospital in Beelitz, not far from Berlin. (pic by Grabthar – flickr)

Recently, I’ve had the unwanted opportunity to get in touch with the Kyrgyz health care system and made some research about it additionally. Of course my experiences (in italic) are not to represent the system but only picture the tiny impression I could get during one week of coping with labs, doctors, nurses and pharmacists of the Kyrgyz Republic. So here’s what I learned:

My odyssee or: how specialization can drive you crazy!

1st day
When I first went to the clinic because I had ongoing pain, they almost immediately sent me away. I should go to the laboratory to do some testing, they told me. They gave me a somewhat worrying first estimation of my disease but said I had to double-check. I was given a card with all the available laboratories in Kyrgyzstan – a whole lot.

2nd day
I checked out the nearest one to my flat the next day and they checked me. Unfortunately not as quick as I had hoped. Instead of doing the testing right away, they told me to come back the next day. For another test, I should come back after two days – because the specialist was not available before that date. Thus, I was sent away again.

3rd day:
The next day I came back, proudly carrying my urine in the box they had sold me before. I handed it in and discussed quite a long time to do another test that they did not want to let me do at first. I was sent away again.

4th day:
On the next day I waited two hours in front of the specialists’ cabinet, which brought me some pleasant acquaintances but also significant delay for work. During the examination, I got slightly worried due to the specialist’s questions as she had some worrying results (completely different from the ones I had obtained the day before and those I had from my first visit at the clinic) that she would not specify but told me to go to the doctor for a clear statement, because: – she was just a specialist. I was sent home…

5th day:
On the next day, I went to the doctor to get some clear statements. I had printed out the results that the lab had uploaded to their website (only accessible with a personal password of course). Since the pain had gotten worse again, I had called my embassy to get a hint on good clinics. Arriving at this good clinic they told me to come back the next month, which I kindly rejected.

Luckily, with the help of a Kyrgyz friend of mine I got an appointment with another doctor that same day. He told me that I had to wait for the whole laboratory result as some spots were still missing. Else, apparently I had done the urine sample wrong and should hand it in again. I was almost already sent away again, insisted on a short check-up to be clear about the worrying assumptions the analysts had made before and:
– received the worst pain I had ever had in this part of my body until that day. Instead of the usual gynecology chair, I was sitting on a relic from the 60s (actually nice retro style) and he did not touch me but examined my body with a giant something that looked like barbecue tongs. Although the whole corridor which was full of people waiting for their appointment could hear my pain, a clear analysis kept missing and I kept hobbling all the way back to the taxi.

The Kyrgyz Health System – roots, reforms and flaws

As can be seen from the statement of the analyst, the difficulties I experienced in my efforts to get a clear answer or diagnosis, were largely due to a high degree of specialization and a lack of a general analysis. To better understand where this comes from, I looked up the roots of the system – like most of the time in Kyrgyzstan you have to deal with Soviet heritage:

With the Soviet Union a new remarkable health care system was brought to Central Asia, which, in its first years served as “a model for developing countries and other socialist states” (Rowland/Telyukov 1991). Health care was declared a constitutional right and provided for free, completely sponsored by the state. During Soviet Union the system was highly centralized with the Ministry of Health in Moscow controling every aspect (facilities, personal, financial resources, etc.) of the following hierarchical steps of the system (Health MInistry of the Kyrgyz Republic, Oblast Health Department, Health Department of the Rayon or City). The system’s primary aim was to provide free health care and it largely succeeded. Also, between 1923 and 1970 expeditions in remote areas with the help of Soviet authorities helped to achieve a decline in infectious diseases. The centralized Soviet system had some weaknesses, like a focus on curative hospital care rather than preventive primary health care. Still,

“considering the starting point, the Soviet health system made tangible progress in providing universal access to basic health services, with significant improvements in health service utilization and coverage, as well as health outcomes!”

With the economic crisis during the 80s and 90s this system with high public spending was no longer applicable. Already before the break-down of the Soviet Union, during Perestroika, new private clinics and laboratories had opened up. After the Soviet Union ceased to exist, public spending became even more restricted due to investment regulations by IMF and Worldbank. Officially, with the introduction of private institutions, a good mixture of competition, freedom of choice and free social services was envisaged. According to OECD, though, none of these ideas has worked out, leaving Kyrgyzstan with a huge number of more or less specialized health providers, numerous hospitals – and a complex, overly bureaucratic health care system.

To date, one of the most frequently mentioned, problematic aspects of the system is the limited access to medicine and drugs, old technology and outdated equipment, which I experienced during my second visit at the clinic. Also, as far as I know, there is no patient record system. Although you often have lots of doctors in one building, you mostly have to see different specialists for different health aspects, who will do the same testing over and over again. Therefore the idea of testing in laboratory with printable results to bring with is, I think, a good way to avoid this over-testing. Still you have to change places all the time for examinations, lab testing and purchase of drugs. Because of the missing technology or equipment the clinics cannot do all of it themselves.

The first goal of a free and effective health care system is difficult to maintain as public spending is low. In my view, the system remains relatively cheap but contrariwise to the Soviet system everything seems to be privatized by now, so that you pay small fees for everything (consultation, diagnosis, laboratory tests, medicine). Still, it has to be mentioned that, heeding local advices, I only went to private clinics, which are said to be better than the public ones – and with less bribe-paying frequency, by the way another big problem in the Kyrgyz system and a heritage of the Soviet one:

The dramatic decline in government revenue and expenditure that followed the break-up of the USSR led to a dramatic growth of informal out-of-pocket payments in almost all countries of the former USSR, with resulting inequities in accessing health care.

(Ibraimova et.al. 2011)

Since the mid 2000s there have been other reforms of the health system, previewing a combination of general services and services for people under health insurance, better integration and participation of regional institutions to avoid hierarchical bureaucracy, improvement of primary health and quality of services and lots of other incentives and improvement strategies, which you can find assessed by WHO here.

The end of the story

To sum up my personal experience: apart from the extremely long time it took me to gather all my results, I have to say that the laboratory did a really good job, as they analyzed every single aspect of the testing I gave them, which, a German doctor told me later, they never do that thoroughly in Germany. Also the medicine I bought at the pharmacy was immediately available and worked at least part-time (although I was stunned and am not entirely sure that antibiotics should be available without prescription). From my point of view the lack of a overall assessment by one professional who knows your health background remains a problem, which I hope the reform programs will resolve sooner or later. A lot of the problems I experienced were certainly also due to my ignorance about the particular structure of the system, which always let me in some kind of insecurity about what could, would or should happen next. It was really interesting to see how health systems differ from each other and what you are just used to – nevertheless, I’m glad it’s over now and I hope I do not have to draw on any health care system again any time soon.

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