Health care in central Asia - WHO/Europe - World Health Organization

239 Pages·2001·0.75 MB·English

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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, LondonSchool
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
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Open University Press
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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
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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, Tajikistan, 1999 51
Table 4.7 Percentage of persons ill in the 4 weeks before the
survey, reporting all required drugs obtained and, if
not, the reasons for not obtaining them, Kyrgyzstan,
1993–96 52
Table 4.8 Medication use in the 2 weeks before the survey
in Tajikistan, by household economic status 53
Table 4.9 Mean (median) value of out-of-pocket payments
for consultations and associated medications by
quintile, Tajikistan, 1999 54
List of figures and tables ix
Table 8.1 Public spending on health as a percentage of GDP 95
Table 8.2 State budget health spending per person, in US
dollars, 1998 97
Table 9.1 Basis of norms used to compute expenditure on
line items 109
Table 9.2 Main types of provider payments 116
Table 10.1 Numbers of physicians and nurses, physical persons,
per cent change 129
Table 10.2 Physicians: full-time equivalent (FTE)
persons compared to physical persons (PP) 133
Table 10.3 Real wages for total workforce (base year = 100) 136
Table 12.1 Acute care beds per 100,000 population in the central
Asian republics, 1991–98 158
Table 12.2 Total number of hospitals in the central Asian
republics, 1991–98 159
Table 12.3 Acute care hospitals per 100,000 population in the
central Asian republics, 1991–98 159
Table 14.1 Policy changes, in selected areas, in the central
Asian republics 184