This essay will describe the development of the health sector in Gorno-Badakhshan after the collapse of the Soviet Union. Economic, social and political aspects will be also briefly described, as they directly affect the topic.
Health care reform in the CIS countries, especially in the initial period, negatively affected the health status of the population. One of the main trends is a decrease in life expectancy and an increase in mortality. This situation has no precedent in world history: nowhere in developed countries has the state of health deteriorated so significantly during peacetime (Grigoryeva 2016). At the end of the first decade of the 21st century, these indicators improved slightly. However, mortality reduction rates vary by country (CIS Statistics 2012). It should be noted that for many CIS countries there is no complete data, Tajikistan is no exception, which complicates the comparative analysis. In 2014, almost all countries improved their indicators, but it is too early to talk about sustainable trends. In most CIS countries, privatization in health care has been undertaken. In the early 2000s in Tajikistan, private spending on health services exceeded 80%. However, by 2013, it fell quite significantly to 69.4% (WHO 2013).
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Today, it can be confidently stated that the health sector of Tajikistan and the GBAO, as a part of Tajikistan, is in crisis. From the whole Central Asia countries, Tajikistan allocates the smallest part (1,6%) on a health care system. Despite an era of economic leap during the Soviet Union, modern Tajikistan is by far the poorest European region. Since independence, Tajikistan has been faced with a severe economic downturn and a sharp increase in some communicable and non-communicable diseases. With the signing of the peace agreement in 1997, the situation began to change. There has been steady economic growth since 2000, and the poverty rate has declined from 73% in 2003 to 33% in 2014 (Khodjamurodov et al 2016:3)
After the collapse of the Soviet Union, Tajikistan was the only country that faced a civil war for 5 years. The health care system has suffered enormous damage due to conflicts that have affected infrastructure, reduced funding resulting in a lack of materials, leaving doctors to Russia, etc. Following the war, the state, with the support of NGOs, launched reforms in the health sector. Tajikistan has free access to the health sector, which they adopted from the Soviet Union. There are no insurance schemes and social benefits - financing comes directly from the budget. The state and local authorities finance the facilities with the state and local budgets, relying on public resources and taxes. The system is almost entirely public, except few branches like pharmacy and dentistry. Doctors are almost all civil servants. The private facilities were developing slowly (Kreuzmann 2016).
Tajikistan has undertaken health care reform, which after two decades has been seemed controversial. This reform became part of general structural changes and led to a change in the entire socio-economic system. Reform in Tajikistan, as in all CIS countries, has become a kind of experiment. So far, no country in the world has had the experience of moving from a centralized society to market mechanisms based management (Grigoryeva 2016).
Four main periods can be distinguished in the post-Soviet development of healthcare in Tajikistan:
The first period is the beginning of the 1990s. In 1991, the law on medical insurance in the Russian Federation was adopted in Russia. Interesting that the law was adopted even though the rest of the CIS countries, including Tajikistan, continued to use the USSR model. In other words, the unified healthcare system of the USSR lost the fundamental element, and could no longer function as a single mechanism. This unusual situation continued until the fall of 1991. After independence and the start of reforms in Tajikistan, health indicators fell sharply, and many indicators have still not reached the Soviet level (CIS Statistics 2012). For comparison, health care spending in 1960 was 18.4%, in 1980 - 14.7%, and in 1985 - 13.7%. (Statistical Yearbooks of the CMEA Member Countries for 1960-1985).
The second period begins in the late 1990s and early 2000s. Negative trends continued to worsen. The volume of medical care was significantly reduced, and its quality was deteriorating. As a result, the rights of citizens to affordable and free medical care were violated. Active commercialization of the healthcare sector begins. As a result of the healthcare restructuring, polyclinics and hospitals were closed, the number of sanatoriums and children's recreational facilities was sharply reduced. Health indicators continued to decline.
The third period is the beginning of 2000 to 2008. The Tajik government is forced to admit that economic and political changes have had serious negative consequences for the level of well-being of the population. Tajikistan tried to find further ways to develop health care, trying to solve at least three problems. First of all, the goal was set to receive additional financial resources for the healthcare system. Secondly, it was necessary to create extrabudgetary channels for the movement of these funds. And Finally, it was necessary to provide centralized control over the distribution and use of these funds.
The fourth period from 2008 to the present. These years have been the years of transition to the formulation of promising tasks and the formation of new health strategies. In Tajikistan, long-term strategic plans for health modernization have been developed. At the initial stage of health care reform, Tajikistan set the task of introducing market mechanisms. However, the Soviet model laid a very high level of social guarantees for the population and a rejection of these guarantees entails great social losses. Because of this, there was a mismatch between the goals and mechanisms for their achievement. This discrepancy exists today. In addition, it can be assumed that the mentality of the CIS countries is more likely to hush up problems rather than seek solutions. Thus, the picture of what is happening is distorted and it becomes harder to draw the right conclusions and develop appropriate action plans (Sinfield 2005:15-33) There is also a specific policy in the healthcare sector. Most often to solve a problem, the most low-cost option is chosen, the correctness of the decisions made is not obvious until practical implementation and none of the solutions to the problem guarantees the achievement of the expected result (Patton, Sqwicki 1983:1)
Significant changes have occurred in the availability of health services for the population. Tajikistan is trying to instill the principle of universal access to medical services, but the state is not really able to provide it. Access is becoming increasingly limited due to insufficient public resources allocated to medicine and healthcare. As a result, private practice is expanding, which is practically not regulated by the state and the network of medical institutions is significantly narrowing. It should be noted that for all the importance of the financial factor, many reasons for unsatisfactory results are associated with health policy and how it was implemented.
Talking about the restructuring of the health care system in the first decade of the 21st century, the number of doctors of all specialties decreased in Tajikistan. There is also a decrease in the number of nurses, and accordingly an increase in the load on one specialist. In the current decade, this trend is slowly changing. We are seeing an increase in the number of all specialties and the number of paramedical personnel.
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