Turkmenistan - Rationalizing the health sector

Report No. 14861-TM Turkmenistan Rationalizing the Health Sector januarv 1'), 1996 -Ih r!).ii '> 9w L (s 1-|)i\ i'.,;ii)[ [IL,T)Ia)(' xi(l Cnlrai, Asii (Ci.LJntrv DctFxirtm!'.'t iil Document of the World Bank  This report was written by Mr. M. Mills and Ms. T. Haque of the Human Resources Division, Europe and Central Asia Country Department 111. It is the result of a health sector review conducted in May, 1995, by a team led by Mr. M. Mills (Principal Economist) and comprising Messrs/Mesdames P. Cowley, T. Haque, Z. Oztek and V. Vargas. Substantial support was provided by staff from the Health Reform project funded by USAID and managed by Abt Associates. Background work was undertaken by Ms. S. O'Dougherty, and Messrs. M. Borowitz, A. Danilenko and E. Kutanov participated in part of the mission. The work was carried out under guidance of Mr. C. Michalopoulos (Senior Advisor), and the divisional responsibility of Mr. R. Liebenthal and the departmental responsibility of Mr. Y. Huang. The draft report was discussed with the Government in October, 1995, and was then revised.  ACRONYMS AND ABBREVIATIONS ARI Acute Respiratory Infection CBR Crude Birth Rate CDD Control of Diarrheal Diseases CDR Crude Death Rate COPD Chronic Obstructive Pulmonary Disease CRD Central District Hospital DALY Disability Adjusted Life Year (Lost) DAP Drugs Action Program DRG Diagnostic Related Group EPI Expanded Program on Immunization FAP Feldcher Accousteur Post FSU Former Soviet Union GNP Gross National Product IUD Intra-Uterine Device IMF International Monetary Fund MOEF Ministry of Economy and Finance MOHMI Ministry of Health and Medical Industries IHD Ischemic Heart Disease IMR Infant Mortality Rate MVA Motor Vehicle Accident PPP Purchasing Power Parity OECD Organization for Economic Cooperation and Development ORS Oral Rehydration Salts PHC Primary Health Care SES Sanitary Epidemiological Services STD Sexually Transmitted Disease SUB Rural District Hospital SVA Rural Outpatient Clinic TIKA Turkish International Cooperation Agency UNDP United Nations Development Program UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund WDR World Development Report WHO World Health Organization   CONTENTS EXECUTIVE SUMMARY . ............................................ i CHAPTER 1: THE HEALTH STATUS OF THE POPULATION .................... 1 Introduction ................................................. 1 Demographic Situation . .......................................... 2 The Pattern of Disease . .......................................... 3 Causes of Disease ............................................... 7 CHAPTER 2: THE HEALTH SYSTEM ................................... 10 Organization and Structure ....................................... 10 Management ................................................. 13 Hospitals .................................................. 14 Primary Care . ............................................... 18 Public Health . .............................................. 20 Staffing and Training . .......................................... 20 Pharmaceuticals, Equipment and Supplies .............................. 24 Financing .................................................. 25 Expenditures . ............................................... 28 Legal Framework . ............................................ 34 CHAPTER 3: STRATEGIES FOR THE FUTURE ............................. 35 Introduction ................................................. 35 Alternative Systems of Health Care Provision and Financing .................. 35 Design of a Minimum Package of Services ............................. 38 Delivering Health Care . ........................................ 44 A. Primary Care ............ ............................ 44 B. Public Health . ........................................ 48 C. Hospitals . .......................................... 49 D. Staffing and Training ................................... 50 E. Pharmaceuticals ........... ............................ 52 Financing Health Care . .......................................... 54 A. Refonms in Budgeting and Provider-Payment Systems ............... 55 B. Sources of Health Financing ............................... 58 Developing the Private Sector ..................................... 63 Planning for Change . .......................................... 66 CHAPTER 4: CONCLUSIONS AND RECOMMENDATIONS ..................... 67 Annex 1: Statistical Annex ............................................. 74 Annex 2: Mary Velayat Case Study ...................................... 80  List of Tables and Charts Table 1-1 An Overview of the Population (1993) ............................ 1 Table 1-2 The Burden cf Disease: Disability Adjusted Life Years Lost Attributable to Major Causes (1993) ....................................... 5 Table 1-3 The Disease Profile and Risk Factors ............................. 8 Table 2-1 The Distribution of All Health Facilities by Velayat (1994) .............. 15 Table 2-2 Utilization of MOH and Velayat Hospitals (1993-94) .................. 16 Table 2-3 Health Workers by Category (1993-94) .......................... 23 Table 2-4 Governmental Health Expenditures as Proportion of Total Government Spending and GNP, 1991-1995 ...................................... 26 Table 2-5 Health Expenditures by Item (1991-1995) ......................... 30 Table 2-6 Health Expenditures by Velayat and by Item, 1994 (Manat's 000s) ... ...... 32 Table 2-7 Health Expenditures by Type of Facility (1993-94) ................... 33 Table 3-1 Alternative Mixes of Health Financing and Health Care Delivery .... ...... 36 Table 3-2 Cost-effectiveness of Selected Interventions for High and Low Priority Diseases .40 Table 3-3 Categorization of Interventions Based on Cost-Effectiveness and Burden of Disease .42 Table 3-4 Total Cost of Extending Coverage of Selected Diseases by an Additional 50 percent . ............................................. 43 Table 3-5 Equipment Needs for Primary Health Care Activities by Type of Facility ..... 45 Table 3-6 Responsibilities and Knowledge/Skill Needs for Health Staff to Provide Cost- Effective Interventions for Priority Diseases ....................... 46 Table 3-7 Health Workers by Salary Grades (1994) ......................... 51 Table 3-8 Possible List of Pharmaceuticals for Basic Package of Health Care Services . .. 53 Table 3-9 Strengths and Weaknesses of Alternative Methods of Paying Health Providers .. 57 Table 3-10 Alternative Additional Sources of Health Sector Financing .............. 62 Chart 1-1 Trends in Infant Mortality Rate, Crude Birth Rate and Crude Death Rate ... ... 2 Chart 1-2 Disability Adjusted Life Years Lost Attributable to Major Causes .... ....... 6 Chart 2-1 The Organizational Structure of the Health Services .................. 11 Chart 2-2 Structure of the Ministry of Health and Medical Industries .............. 12 Chart 2-3 Distribution of Beds by Velayat (1994) .......................... 15 Chart 2-4 Number of Medical Students by Specialty and Grade .................. 24 Chart 3-1 Proposed Structure for Reform of Health Financing and Expenditure System ... 56 Box 3-1 Changing Public-Private Roles in Health Service Provision and Financing ..... 65 Table Al-1 Trends in Infant Mortality, Crude Birth Rate and Crude Death Rate (1978-93) . 74 Table A1-2 The Distribution of Non-MOHMI and Non-Velayat Health Facilities and Services by Organization (1994) .................................... 74 Table Al- 3 Health Workers by Velayat (1994) ............................. 75 Table A1-4 Number of Students in the Medical School by Specialty and Grade (1995) ... . 76 Table Al-5 Norms of Bed Numbers per Doctor ............................. 77 Table A1-6 Norms of Drug Expenditures per Patient ......................... 77 Table A1-7 Health Investment Program by Facility (1994-95) .................... 78 Table A2-1 Health Facilities in Selected Etraps of Mary Velayat (1994) .... ......... 81 Table A2-2 Hospitals in Selected Etraps of Mary Velayat: Bed and Staff Implications of Possible Rationalization (1994) ............................... 84 Chart Al-i Distribution of Health Facilities by Velayat ........................ 75 Chart A1-2 Health Workers by Velayat (1994) ............................. 76  EXECUTIVE SUMMARY (i) Turkmenistan became independent from the Soviet Union in 1991. The country has abundant energy resources, primarily natural gas and oil, and is rich in other mineral resources. The Government is gradually moving the economy from a command to a market system. Per capita income in 1994 was estimated at about US$1,000. (ii) Health status. For a country of its income level, health indicators are not good, with an infant mortality rate higher than the average for lower-middle income countries. Compared to other countries of the Former Soviet Union (FSU), life expectancy is the lowest, the infant mortality rate (officially at 46/1,000) is the highest, maternal mortality is the fifth highest, fertility rates are relatively high, rates of cardiovascular diseases are extremely high and increasing, and respiratory, digestive and infectious and parasitic diseases are also among the highest. An analysis of the burden of disease, i.e., of disability-adjusted life years (DALYs) lost due to different diseases, indicates that the most important disease problems are, in order of importance, the following: ischemic heart disease, respiratory infections, perinatal conditions, diarrheal disease, cerebrovascular disease, motor vehicle accidents and chronic obstructive pulmonary disease. Respiratory infections, perinatal conditions and diarrheal disease are all directly related to the high level of infant mortality. (iii) There are several reasons for the poor health status of the population. First, family budget surveys of the late 1980's indicate that a significant proportion of the population is relatively poor (accurate estimates of incomes and income distribution are difficult to obtain, however, given the methodological problems associated with Soviet family budget surveys). Second, the country's population is gradually aging, and chronic diseases are becoming more important. Third, life style factors (especially smoking and alcohol consumption) account for a significant proportion of the morbidity and mortality. Fourth, while there is relatively little malnutrition, food consumption patterns tend to be inappropriate (with too much consumption of fatty foods in particular). Fifth, there is serious environmental degradation which has resulted in the contamination of drinking water supplies. Coupled with poor infrastructure, this contributes to water and sanitation related diseases, especially in rural areas. (iv) The health care system. The system of health services in Turkmenistan exhibits most of the features of the inherited Soviet structure. It is very extensive and service accessibility is relatively easy due to the large number of facilities. However, the system is inefficient and has insufficient impact on the country's health problems. The system is characterized by excessive numbers of inappropriately trained staff; very high reliance on hospital rather than primary services; medical care which is overly disease orientated and of generally poor quality; and an emphasis on specialist care with multiple tiers of referral and poor case management. (v) Policy making for the health sector is conducted within the Cabinet of Ministers, while the Ministry of Health and Medical Industries is responsible for the operation of the health services. In each of the country's five administrative "velayats", the Ministry of Health and Medical Industries is represented by the provincial governor, under whom there is a health department. Each velayat has a large number of health facilities, including general hospitals, children's hospitals, narcology hospitals, maternity hospitals and tuberculosis hospitals. Below the velayat level are 49 "etraps", and they also operate hospitals, outpatient clinics, polyclinic ambulatories and rural health posts. Decision making is highly centralized and bureaucratic, and use is still made of Soviet norms. A complex management information system exists, but it is very rigid and designed to send information upwards for centralized planning purposes rather than to assist in decision-making at the local level. i  (vi) A prominent feature of the health system is the over emphasis on the role of hospitals in health care. There are too many hospital facilities and too many beds; too many of the hospitals are specialist facilities; admission rates are too high (although occupancy rates are low); and lengths of stay inordinately long. Many hospitals are inappropriately located, badly constructed, and lack basic infrastructure. Shortages of basic equipment and drugs, and inappropriate training of staff further contribute to inefficiencies in the health care system. (vii) In contrast, the primary level of the health system is under-utilized. Accessibility to services is good, but the quality of services is often deficient and there is considerable inefficiency. Staff in polyclinics typically need retraining and most polyclinics experience a serious lack of drugs, basic equipment and supplies. Recently there has been an important innovation with the pilot introduction of family doctors, who used to be pediatricians and therapists and who have been converted into multi- purpose doctors working in a defined geographical area. (viii) Turkmenistan inherited a well-functioning public health system from the FSU, the Sanitary Epidemiological Services (SES). The SES inspect and regulate food and water; control infections and parasitic diseases; provide preventive health services; and establish sanitation and health education. Their work, however, has been hampered by severe financial constraints. (ix) Turkmenistan has a large number of trained health workers, but there is a need for substantial rationalization of the skills and personnel mix, for impiovements in training and for a reduction in the overall number of staff (especially doctors). Compared to other sectors, the wages of health workers have traditionally been low, and salaries of health professionals are highly compressed. There are inadequate incentives to reward performance, and thus the status and morale of health professionals are low. (x) Before the break-up of the Soviet Union, there was a tradition of plentiful (indeed excessive) usage of pharmaceuticals. Now shortages of drugs are common due to the low budget for drugs, limited access to foreign exchange, irrational prescribing, lack of a comprehensive drug policy, and only minimal cost recovery. There are also significant shortages of equipment, supplies (particularly x-ray films) and diagnostic equipment. (xi) One of the fundamental reasons for the inefficiencies in the health care delivery systern is the system of budgeting (based on norms) and the resulting lack of incentives for efficiency. There is also inadequate coordination between the Ministry of Economy and Finance and the Ministry of Health and Medical Industries, and there is generally poor prioritization of spending. (xii) In recent years the health sector has suffered from a severe decline in the real value of health spending. The proportion of GNP now allocated to the sector is relatively low by international standards. (xiii) Besides funding by the Government, the health system does receive some financing from other sources. Fees can be charged for "non essential" services, but the extent of cost recovery is small. A new health law is now being prepared and it proposes some major changes in the legal framework for the financing and provision of health services. In particular, it provides for a private health sector to develop, and stipulates that the Ministry of Health and Medical Industries should have the authority to determine the scope of free services to be provided by the Government. (xiv) Strategies for the future. The entire health care delivery system needs to be restructured to avoid the danger of collapse. Health service rationalization should consist of strengthening the primary care level, consolidating the middle levels, and especially restructuring the overly dominant hospital ii  sector. So far, no overall reform plan has been developed. Recently, however, it has been agreed that the Ministry of Health and Medical Industries, supported by several external agencies, will carry out the development of a comprehensive reform plan for the sector. (xv) In the reform process, the government should focus its priority efforts on the most significant disease problems while taking into account the costs and effectiveness of different possible interventions. The major recommendations emerging from this sector review are sumnarized as follows: (a) Cost-effective interventions: Information on the burden of disease can be combined with the cost of interventions to treat or prevent diseases, in order to identify those interventions which are most cost-effective, i.e., where the greatest numbers of DALYs can be gained at the lowest cost (cost per DALY gained). Based on cost data collected by the mission, the following interventions are believed to be most cost-effective: (i) the integrated management of the sick child (ie. acute respiratory infections and diarrhea management focussed on under-five year old children); (ii) short course treatment for tuberculosis; (iii) simple hypertension treatment; (iv) smoking prevention program; (v) mother baby package (ie. a series of prenatal and delivery care recommended by the World Health Organization, highlighting the major complications of delivery including obstructed labor, pre-eclampsia and post-partum hemorrhage); (vi) hepatitis treatment; (vii) alcohol abuse prevention program; and (viii) family planning (ie. using an increased variety of methods rather than just IUDs which have a dominant role at present). The following interventions are also concluded to be very cost-effective, although an analysis was not done in detail for them: (i) the expanded program of immunization; (ii) clinic- based treatment of sexually transmitted diseases; (iii) breastfeeding promotion; (iv) the iodinization of salt; and (v) nutrition education. In addition, it is appropriate to include investments in potable water supply improvements, sanitation and hygiene education as cost-effective, given not only their health effects but also improvements in the quality of life. (b) Guaranteeing a basic minimum package of health services: It is likely that the bulk of health care will continue to be financed and probably also provided by the public sector for a number of years. In order to ensure the most effective and equitable use of scarce public resources, it is recommended that the government focuses on the financing and provision of a basic minimum, guaranteed package of health services. The basic package should be designed based on the analysis of the burden of disease and cost- effective interventions. This basic service package could be provided (initially by the public sector, but later by a combination of the public and private sectors) to everyone free of charge, (or, in order to encourage efficiency, with only minimal charges). Where the Government does provide health services beyond the basic package, significant cost recovery ought to be undertaken. (c) Strengthening the primary care system: The existing primary care system needs to be strengthened to ensure that the minimum package is widely available, that more cases may be treated on an outpatient rather than inpatient basis, and that the quality of such services is high. Most of the highest priority health problems can be addressed at the primary level, and there is considerable potential in the existing primary system because the basic infrastructure (of facilities and staff) already exists. Resources should be shifted from the currently emphasized hospital-based provision of services towards strengthening primary health care services. This shift in emphasis and resources will imply comprehensive investment in staff re-training (and re-assignment) and in making iii  available the basic pharmaceuticals, diagnostic and other equipment, and (in rural areas) transport necessary for appropriate referrals to hospitals. The recently initiated family doctor program is an important step in strengthening primary health care delivery. There are several outstanding issues, however, including the appropriate doctor/population ratios, the financial implications, and arrangements for training and retraining. (d) Rationalizing the hospital system and staffing: At the hospital level, substantial rationalization is needed in facilities, and in the levels and mix of staffing. Facilities need to be rationalized in order to (i) improve the cost-effectiveness of services which need to be carried out in hospitals, and (ii) allow resources to be shifted from hospitals to the primary sector. Treatment norms and protocols should be reviewed in order to reduce the current excessive utilization of hospital services. Rationalization of the hospital sector should incorporate the reduction of the total number of beds, amalgamation of some specialist hospital services with more general hospitals, reduction in lengths of stay, consolidation and strengthening of supervision of small rural hospitals, guidelines for new forms of outpatient treatment, and investments for the physical rehabilitation of the remaining hospital facilities. Rationalization is also needed in staffing patterns. The extent of specialization should be reduced, many existing training programs need to be improved, and new or reinforced programs are needed to strengthen delivery of some priority services. Difficult measures will need to be considered in order to rationalize, make more efficient and increase incentives for existing cadres of staff. Options include reducing new student intakes for training (thereby releasing existing training capacities for retraining activities); temporary early retirement schemes; testing staff competencies and subsequently retraining if appropriate, or making redundancies; salary decompression; and reductions in generous leave provisions. Identification and implementation of staffing and facility rationalization measures are necessary but politically sensitive. In order to mitigate negative social response to the measures, care will need to be exercised to involve major stakeholders, including providers and users, in the process of formulating an appropriate plan. (e) Rationalizing provider-payment and budgeting systems: It is clear that a "top- down" reform initiated by the government to increase efficiency through rationalization of facilities and staffing will need to be accompanied by "bottom-up" change induced by reforms in incentive and expenditure management systems. There is a need to move away from the system of budgeting based on physical capacity (such as the numbers of beds or doctors) and to introduce payment systems which create incentives for cost- effectiveness by rewarding productivity. In place of budgeting based on physical norms, there is need to introduce capitation systems of payment for primary care provision and, global or case-based budgets for hospitals. This should build on the recently introduced pilot scheme for 22 hospitals. Another necessary step to achieving reform in the service- provider incentive structure will be to consolidate funds and integrate budgets at the local (velayat) level to avoid the problems caused by the present fragmentation of the health system with different institutions supervised by different ministries. One option is to establish a semi-autonomous health care "fund" as the institutional mechanism for consolidating resources from the general budget, regional budgets, payroll taxes, and from any other sources into a central body, and then distributing them back to the velayat level to pay for both primary health care and hospital services. Whatever specific provider payment system is conceived, it is suggested that a pilot demonstration site be selected in order to monitor response by providers (specialists as well as generalists) and the impact on service utilization. iv  (f) Financing health reform: Various financing options to fund the health sector could be considered: these include payroll taxes, taxes on alcohol and/or tobacco, the introduction of fees on non-essential health services, and health insurance. The Government has already indicated that it is planning to introduce a voluntary four percent payroll contribution for health services, though details of this remain undefined. Taxes on alcohol and/or tobacco could supplement the general revenue budget and at the same time have a beneficial health impact by discouraging excessive consumption of commodities harmful to health. An increase in fees charged for services outside the basic, minimum guaranteed package, could also raise a modest amount of revenue for the sector. In most countries, user charges account for a small fraction of revenue, but may also have positive effects in reorienting demand. Although the proportion of the total budget allocated to health fell significantly in 1995 compared to the previous year, it is difficult to argue for an increased share for the sector as a comprehensive review of public expenditures has not been carried out. However, expenditure rationalization should release some funds in the form of savings, and the health system should be allowed to keep those savings in order to improve the quality of the health services. While the prospects for private financing are currently limited, international experience suggests that private voluntary insurance should have an increased role in the future in financing health services which are supplementary to the basic package. In time, if there are significant charges for non-essential and specialist services, and especially if the number of private service providers increases, then supplementary private voluntary health insurance may be expected to develop further. However, few countries rely mainly on private voluntary insurance, due to problems that result from selection bias. (g) Developing the private sector: International experience demonstrates that there are many possible combinations of public and private roles in the financing and provision of health services. Public financing does not necessarily imply public provision, and vice versa. In the Turkmen health sector, currently dominated by public financing and provision, the private sector (at present very small) should be encouraged to play a larger role in both the financing and provision of health care in order to improve the supply and mix of health services. This will require organizing appropriate training for private practitioners, strengthening cost and medical information systems, improving availability and accessibility to credit for private practitioners, and putting in place an appropriate regulatory and quality control system. Implementation of these measures may be a lengthy process since they are often linked to reforms in the broader economy (e.g. reform of the banking sector) and subject to political bargaining. The public-private mix may be seen as an evolving process. Initially it is deemed to be most feasible for the private sector to focus on the delivery and financing of services outside of the basic package. In the medium to long term, private providers could bid for and provide some basic services (with a compensation basis equivalent to that for public providers). Also in the longer term, private financing could extend to components of the basic package, while public financing could focus on components of the package where private financing may be inadequate (e.g. infectious diseases). v   CEAPTER 1: THE HEALTH STATUS OF THE POPULATION Introduction 1.1. Turkmenistan became a constituent republic of the Soviet Union in 1924, and became independent in 1991. The country has abundant natural resources, including gas, oil and cotton. Following the breakup of the Former Soviet Union (FSU), the economy declined about 5 percent in 1992, 10 percent in 1993, and 19 percent in 1994, when per capita income was estimated at about US$1,000. Although the Government continues to intervene considerably in the economy, it is now gradually moving from a command to a market system. The country's population is relatively small (4.4 million in 1993), and population density is generally low due to the country's large land area (488,000 square kilometers). For a country of its income level, health indicators in Turkmenistan are not good. For example, the official infant mortality rate (IBR) is 46/1,000, although this figure needs to be adjusted upwards by maybe 20 percent (to the mid-50s/1,000) for international comparative purposes. In contrast, the average for lower-middle income countries (40/1,000) is somewhat lower even than the official figure for the country. The level of infant mortality in Turkmenistan is also worse than in the neighboring Central Asian countries: in Kazakstan (per capita iiicome US$ 1,540), it is 28/1,000; in Uzbekistan (per capita income US$ 960), it is 32/1,000; and in the Kyrgyz Republic (per capita income US$ 830), it is also 32/1,000. The average infant mortality figure for the entire FSU (22/1,000) before its break-up was less than half of the rate in Turkmnenistan. Most of the infant mortality is due to acute respiratory infections (ARIs) and diarrhea, caused mainly by environmental and behavioral factors, and lack of appropriate and early treatment.' The overall crude death rate (at 8/1,000) is also believed to be rising slightly. 1.2. The Government is very concemed about the poor health conditions and status of the people; and in January 1995 the President announced the need for a fundamental reform of the health care system. The President made a major speech in July, 1995, on the problems of the health sector, and a new Presidential health reform program is now being planned. The World Bank was asked to assist in the process of reviewing the sector. Table 1-1 An Overview of the Population (1993) Population size 4.4 million Urban population 45 percent Dependency ratio 79/100 Birdi rate 33/1,000 Death rate 8/1,000 Rate of natural increase 2.5 percent Infant mortaliy rate 46/1,000 Life expectancy 66 years Total fertility rate (urban) 3.7 Total ferdlity rate (rural) 4.8 Contraceptive prevalence rate _ 20 percent Source: uoskomstat, 1994. Notes: The infant mortality figure needs to be adjusted upwards for international comparative purposes. 'Some national experts have argued that genetic factors due to a significant number of intra family marriages may also be pat of the explanation.  Demographic Situation 1.3. A census was conducted in 1991. Key population data are presented in Table 1-1. Another census was carried out in January 1995. The preliminary results suggest that the population was then about 4.406 million, of whom 11.9 percent lived in Ashgabat, 14.7 percent in Akhal Velayat, 7.9 percent in Balkan Velayat, 20.6 percent in Dashkhovuz Velayat, 20.9 percent in Lebap Velayat, and 22.9 percent in Mary Velayat. The detailed results of the 1995 census are still being analyzed. Chart 1-1. TIknds in Infant Mortality Rate, Crude Birth Rate, and Crude Death Rate 60 so l 140 30. S 20 ----- 10 1978 1979 1900 1981 1982 1903 1984 1905 1986 1987 1988 1989 1990 1991 1992 1993 1.4. The census data can be supplemented by official data from the Ministry of Health (see Chart 1-1). These show that: (a) The crude birth rate rose gradually from 1978 to 1987, and it then declined slightly to its present level (33/1,000). The four "velayats" ("oblasts" or regions) of Dashkhovuz (36/1,000), Mary (36/1,000), Akhal (35/1,000) and Lebap (35/1,000) have the highest rates, while the more urbanized and industrialized areas of Ashgabat (the capital) and Balkan have lower rates (respectively 22/1,000 and 26/1,000). (b) The crude death rate shows some unexpected movements in several years, but in general it declined from 1981 to 1990 after which it began to rise again. The rate increased sharply in 1992 and 1993, as it also did in Kazakstan and the Kyrgyz Republic. Ashgabat has a slightly higher death rate (8.2/1,000) than elsewhere in the country. (c) Despite fluctuations in the infant mortality rate (which are not surprising), the trend from the mid-1980's to a decade later was downwards: altogether it dropped by about 5/1,000 points. Compared to the official 1993 national figure of 46/1,000, infant mortality by administrative region ranged from 36/1,000 (in Balkan Velayat) to 51/1,000 (in Dashkhovuz Velayat). 2  The Pattern of Disease 1.5. There is a lack of accurate statistics and reports which describe the true health status of the people. Disease surveillance and management information systems do exist, but communications between the regions and the capital are poor. There is concern about the accuracy of statistics due partly to historic practices and partly to the budgeting system which is still reliant on norms (as discussed later). 1.6. Using available, reported data, at the end of 1992, the World Health Organization (WHO) identified the following major areas of concern in the health profile of the population: (a) life expectancy was the lowest among the countries of the FSU; (b) infant mortality was the highest among the FSU countries; (c) maternal mortality was the fifth highest among those countries; (d) fertility rates were particularly high, with breastfeeding on the decline; (e) rates of adult cardiovascular diseases (especially ischemic heart disease) were extremely high and increasing; (f) respiratory, digestive and infectious and parasitic diseases were among the highest of the FSU countries; and (g) the rate of tuberculosis was increasing.2 1.7. More recent reported data are available to update the picture of the disease profile, and these confirm that the health of the population is indeed of considerable concern: (a) Mortality. The major causes of death, as reported, are diseases of the circulatory system, diseases of the respiratory system, infectious and parasitic diseases, accidents, injuries and poisonings, and malignant neoplasms. Patterns of mortality vary between urban and rural areas and between regions of the country, with the Dashkhovuz Velayat having among the highest mortality rates from infectious and parasitic diseases. (b) Infant and Child Health. About 38 percent of infant deaths are due to diseases of the respiratory system; and of these, about 50 percent are due to bacterial pneumonia, which is a particular problem in the winter3. About 24 percent of infant deaths are due to infectious and parasitic diseases; and of these, about 75 percent are due to intestinal infections. Diarrheal diseases (leading to dehydration) are a major problem, especially in the summer months. Due to lack of supplies of vaccines, there is a real danger of an increase in immunizable diseases. (c) Maternal Health. The maternal mortality rate was about 105/100,000 in 1993, and most of the deaths are due to problems of quality of care in maternity homes. Maternal anemia is clearly a problem, although the extent of it may be over-reported, and it is probably due to the poor nutritional status of women, short birth intervals and frequent abortions. Abortions (at about 33/100 births in 1994, according to the official figures) are relatively common, though less so than in the Russian Federation (which then had 195/100 births). In 1991 about 160,000 (20 percent of women in the 15-45 age group) practiced some form of family planning, with about 130,000 using intra-uterine devices. (d) Morbidity. Among children, the main causes of morbidity are diseases of the respiratory system (44 percent), followed by infectious and parasitic diseases. Among 2WHO: Highlights on Health in Turkmenistan". 3The incidence of measles is relatively low, and only about two or three percent of ARI deaths are believed to be measles- related. The proportion of low birth rate babies does not appear to be very high. 3  adults, ischemic heart disease is a major problem; respiratory diseases account for about one quarter of reported morbidity; and diseases of the digestive system account for about 13 percent. Other important health problems in the country are tuberculosis and hepatitis.4 1.8. It is possible to consider the relative importance of the different disease problems by calculating the years o f potential life lost by cause of death. Such an analysis was carried out by the United States Bureau of the Census in 1992, but again mostly using the reported data. This showed that males in Turkmenistan annually lose a total of about 32,000 years of potential life per 100,000, with circulatory conditions causing the greatest loss at 27 percent, respiratory conditions another 23 percent, injuries 12 percent and neoplasms 10 percent. For females, the loss is about 29,000 years of potential life, with circulatory conditions causing 30 percent, respiratory conditions 24 percent, neoplasms 11 percent, and injuries 6 percent. 1.9. In order to explore further the burden of disease in the country, a more detailed analysis was carried out by the sector review team using the official 1993 data and also additional information provided by national experts for each of the major disease categories. The analysis also took into account the extent of disability caused by different diseases. The analysis was be done in terms of disability adjusted life years lost (DALYs). The results are shown in Table 1-2 and Chart 1-2. Numbers of DALYs lost are estimated based on the methodology developed by the World Bank's "Development Report 1993: Investing in Health". A disability-adjusted life year (DALY) is a unit used to measure both the burden of disease and the effectiveness of health interventions, as indicated by reductions in the disease burden. It is calculated as the present value of the future years of disability-free life that are lost as the result of premature deaths or cases of disability occurring in a particular year. While it should be admitted that the DALY methodology is not free from important underlying assumptions and value judgements, and that it does not itself identify underlying risk factors etc., it is felt that it is the best methodology available for comparing the relative burden of different diseases. 1.10. The analysis of the burden of disease shows that the disease ranking is (a) ischemic heart disease (IHD), (b) respiratory infections, (c) perinatal conditions, and (d) diarrheal disease. Each of these diseases accounts for more than 10 percent of the total examined DALYs in the entire group of diseases: specifically they accounted for 19 percent, 18 percent, 15 percent and 13 percent respectively. In total these four diseases, therefore, account for about 65 percent (roughly two thirds) of the total burden of disease. After these diseases, next of importance are (e) cerebrovascular disease (9 percent of the total DALYs), (f) motor vehicle accidents (4 percent) and (g) chronic obstructive pulmonary disease (COPD). Although ischemic heart disease is a chronic disease and by itself accounts for the highest burden of disease, the next three priority diseases all relate to problems of infants and young children. The epidemiological picture is, therefore, somewhat mixed, but it is clear that there is a need to give significant priority to addressing the causes of the still-high rate of infant mortality. 4For example, about one third of women in Dashkhovuz Velayat have had hepatitis. 4  Table 1-2 The Burden of Disease: Disability Adjusted Life Years Lost Attributable to Major Calues (1993) || Number DALYs Lost % Total Ranin 1. Communicable, Maternal & Periatal A. Infectious and Parasitic Tuberculosis 13,672 3.0% 8 Diarrheal Disease 58,493 12.7% 4 Hepatitis 7,566 1.7% 12 B. Respiratory Infections 80,501 17.5% 2 C. Maternal 5,290 1.2% 15 D. Perinatal 69,522 15.1% 3 11. Noncommunicable A. Malignant Neoplasm Esophagus 6,708 1.5% 13 Stomach 4,281 0.9% 16 Lung 3,495 0.8% 18 B. Diabetes 8,082 1.8% 11 C. Neuro-Psychiatric Psychosis 3,377 0.7% 19 Drug Dependency 2,681 0.6% 20 Alcoholism 12,748 2.8% 9 D. Cardiovascular Ischemic Heart Disease (IHD) 87,848 19.1% 1 Cerebrovascular 39,843 8.7% S Rheumatic 3,995 0.9% 17 E. Respiratory Chronic Obstructive Pulmonary Disease (COPD) 16,251 3.5% 7 Asthma 1,049 0.2% 21 F. Digestive GastritisfUlcer 5,394 1.2% 14 G. Urinary Tract 8,176 1.8% 10 Ill. Injuries A. Unintentional Motor Vehicle Accidents (MVAs) 19,983 4.4% 6 TOTAL: 458,955 100.0% Source: Data obtained from the Ministry of Health and Medical Industries and national experts. Mission estimates. 5  Chart 1-2. Disability Adjusted Life Years Lost Attributable to Major Causes (1993) Tuberculosis 13672 Diarrheal Disease 58493 Hepatbis _ 7566 Respiratory Infections 80501 Matemal 5290 Perinatal 69522 Esophagus 6708 Stomach 4281 Lung 3495 Diabetes 8082 Psychosis 3377 DrugDependancy 2681 Alchoholism 12748 87848 Ischemic Heart Disease Cerebrovascular 39843 Rheumatic 3995 Chronic Obstructive Pulmonary 16251 Disease Asthma 1049 GastrilsAUcer 5394 Urinary Tract 8176 Motor Vehicle Accidents 19983 0 10000 20000 30000 40000 50000 60000 700(0 80000 90000 Number of Disability Adjusted Life Years Lost Attributable to Major Causes (1993) 6  Causes of Disease 1. he . 11. .... .f the.. .....pu..t.. is ..r...e . p : ac or the 1 989 family bu s y p ta ~ ofid pcw.~ the poplaiows he belu~ow i.. the .. ..i.e..of.Rubles e fmil mebe permoth.Tettlfriity ra~Ii tyes itheavia counrys re~elativey high,g at i abou 4.Only abu 20 percnto wmen in the reroucie aenvgroupc tare prcicing foamily planin (motwnly using IUD);and ther isarther lowk rateof breas-fedn (wthe only about one third of mothr dingi excluivel, nd abutoe theirdnt doing itsw atr eall).e The ontr'pplationl his grtadualy iaging fmand chonic diseasesu. are t alrad ofsm motnei the overallh~t burde o dses. 1. .11. Aimpos tnat of the onty sepopulaton i is reatvlysoor:e aordingstl fatortes98 famlydn budkige anurvey,co79upercen of tloolhe poultonrasten belo theun oforcialot1 poertyelin of Rubes7 pxmier fAmLYs mntembaterfoante5 percmnt.ehettal feprtilityr ragrete inste countryireaivuely high,iatcabot4.Oly abou 20 rolm percenprtofrwme inftetos raeprodcieage geroupta are prcticin fl-hamlyh esphaelannin (mslyusicnges IHD; and therebisoavathelr lowsrate. Alofo brat-edngs(withon onl abou onher third,o monthiuers doin iatexcalusively,ata and about onl-ealthir;o dsoinageitat all) stoahe counterys;n populaton-isycgraduall agingo adrhrnirdse.e are3 alreadyni of some imotne cnteoverall burde morefro diea e. pito iwo nprpit 1.12.mpt An impoernsthant padr-ntrofthdisease riio profiles isnloduolf-sye fnhactors inldingtsmkcluing pandclal the consumption of alcholuTe fomernt may faccoun fords abou 10in pericientoyth Texaie DurtoalY malndurthedlte fsore aofther seperent. son partcuar ciarteos contributes significantly to the ifn otlt problems ofrsiatorya infectiois;blevdb matenal epen-ntaltb an chidnil-halth esphagleal andh lung can0ers;n IHD aomnd cuferebgromascoma diease. Aloholt consumtio, one thue othierc hand, contribtes tof mateareal,cpe-atalan 1.13. Nuteriadsnttion iseofasom concern,s buamre fromvthent epcalyinto view ofra iapropri5Abote 7pcnsmtion pathern thban poundrnurtion.adaot5 Nutritint pobltem incalud poulainhealth dipets (rincuingwae patiuplarly bth consupto of thsaeunduies ameountsaofnattdy foods)a and iodinerdeficiecy. Thelnutritiona mAlnourised (soamen of themwtrsppisi severelysadwocnrbt costrignifianty toath infan mortsaliy probem.cl Mpatrnaclanemi choisnelieved byuimany. exprt tohe absigniefican pipdwtroblsem, wtupeto80plerenot tof womrente suffaern fromr someh degree ofeit. choeve,ihctuaicdec and batrooiatnadnrseverityofitg warer unler.uhu 1.e 14.tr Wate andhl sanitaiatewion relaed-isese aromte prvaet,o felspeciall psinie en the ruara. bouget 78opecernt ofltheourba poplaio anebot50prent of theh ruraio poplaio have pipreueiecn edr drinin wothatero suples,ibut menyi oflthesea watern suppies are cnDskontzVeamiate byt chemical andw baterological pacollutandts.helt Adeqates tfchlrenipartiua.Adtlesoalsesment of the watersple s vrl c nanttonstandb itackiof inechtessarya charemcanls thee coundutry is highl ontamdeignateda witheruan-of feltrometfrtaato the cottnfils,w th y peTicies beinglthae nwbeinggs analyzed, and they should add considerably to existing knowledge about water, sanitation and related health conditions there. .... .... . ..... .... .. .... .7  Table 1-3 The Disease Profile and Risk Factors Cigarette Alcohol Excess 1 Nutrition | Hygiene 1 Water & | Smoking | Consumption Fertility | | | Sanitation I. Communicable, Maternal & Perinatal A. Infectious and Parasitic Tuberculosis X Diarrheal Diseases X X X Hepatitis X X B. Respiratory Infections X X X C. Maternal X X X D. Perinatal X X X X X H. Noncommunicable A. Malignant Neoplasm Oesophagus X X Stomach X Lung X B. Diabetes X C. Neuro-Psychiatric Psychosis Drug Dependency Alcoholism X D. Cardiovascular Ischemic Heart Disease X X Cerebrovascular X Rheumatic E. Respiratory Chronic Obstructive Pulmonary Disease X F. Digestive Gastritis/Ulcer X X G. Urinary Tract _ _ Im. Injuries A. Unintentional Motor Vehicle Accidents Ith Msion estimate. Source: Data obtaied fom the Mistry o ea an natona experts. 8  foreign exchange with which to buy the chemicals). High water tables, high soil permeability, and generally inadequate wastewater and sanitation systems exacerbate the pollution of the drinking water supplies. 1.15. Approximately 45 percent of the urban population and only about 1 percent of the rural population have sanitation connected to a public sewage system. About 75 percent of urban sewage is untreated and existing sewage plants need major rehabilitation. Most homes outside of the larger towns, as well as most public facilities (including rural health clinics, schools and markets) have, at best, only rudimentary, poorly maiained and unhygienic outdoor pit latrines. Many public facilities have no sanitation facilities at all, and sanitation receives little attention particularly in rural areas (where no sanitation inspections are conducted and where there is no government agency responsible for sanitation). The inadequate facilities, together with poor sanitation and hygiene practices, contribute to the high rate of diarrheal diseases (accounting for about 13 percent of the DALYs) and hepatitis (accountin for another 2 percent of the DALYs) 9  CHAPTER 2: THE HEALTH SYSTEM The.g, ..,alth care lystem in i~m*~stsa s:i Xl.bXt n Xd * X ', R',S.g ............. , f i S o R ' S S E E E . E E 'S 2~~~~~~~~~~~~~~~~~~~~....... ERR' : . w ..~~.. a .' eR_.............................................. R : 'T~ ~~~~~~~~~~~~~~A . .... . . '.9'ES.R.., Organization and Structure 2.1. The organizational structure of the health system, as inherited from he-fore the country's independence, is shown in Chart 2-1. The main legislative body is the Mejlis (Parliamt:nt) which consists of 50 seats. There is also a specific Turkmen institution called the Halk Maslahaty (People's Council) which is the ultimate representative body and which meets once a year. The Cabinet of Ministers is responsible for formulating government policies and is headed by the President. There is a Deputy Head of Government responsible for the social sectors, including the Health Department. The Head of that Department coordinates with the Ministry of Health and Medical Industries. Until recently, the Cabinet of Ministers also coordinated with the other public organizations and departments with responsibilities for some health services or activities (such as the Railways, the Ministry of Internal Affairs, Civil Aviation, Defence, the National Security Committee and medical institutes). Of the latter, the Ministry of Internal Affairs has the most health facilities, with 16 hospitals, in contrast to the eight hospitals run by the Railways. 2.2. The departmental structure of the Ministry of Health and Medical Industries (MOHMI) is shown in Chart 2-2. The Minister of Health and Medical Industries, like the members of the Cabinet of Ministers, is a Government employee, and he is assisted by six deputy ministers. These deputy Ministers are respectively responsible for (i) the treatment and prevention of disease; (ii) maternal and child health; (iii) medicine production and supply; (iv) health training facilities and science; (v) sanitary and epidemiological activities; and (vi) new technologies and medical equipment. Responsibility for planning and administration is with the Minister himself. This structure of the MOHMI was introduced in mid-1995, and appears to be a significant improvement on the previous structure. Under the new arrangements, it appears that the MOHMI will also have responsibility for all public organizations and departments with health services and activities, as mentioned above. 2.3. Medical research is the responsibility of the Academy of Medical Sciences. Within it are five separate institutes responsible for oncology, tuberculosis, maternal and child health, physical therapy, and venereal and skin diseases respectively. Under the new arrangements, the Academy will report to the MOHMI. The President has also recently announced the establishment of a High Council for Science and Technology. 10  Chart 2-1 The Organizational Structure of the Health Services Halk Maslahali (PeoplesPrsdnMeis(alnwt Comeil) l ~~~~~~Acadcmy Of Medical S&icnces Centnl Level C _ . m S~~~~~~~~~~~~~~~cientific and Productional Health Services Of Other Departmnent Of Health Association (Stomatology) Sectors Services ~z Institute Of Medicine Turkrnenderrnan (Drug Producing Company) Central Epidemniological Central Medical Institutions Station Ministry of Health * Central Diagnostic Center * Niyazof Hospital * Pirapov Hospital I Anti-plague Station * Tbc. Institute AnipageStin Skin and Venereal Diseases Institute * Psychiatry Institute Velayat Level (and Ashgab.t City) Hakim (Goveror) |Department Of Health Care | Sanitary and |Cenitral Spcaie K [ id-level D eeatnelt of De Iparmr t of| Epidemi olgcal Velayat Hospital s School | Mdcal Heafth | Station Hospital S Supples Education | Etrap Level Sanitary and [Etrap Hospital (CRB) Etrap Polyclinic Epidemiological l Station Level |Rural y ician RuralDtrict | Feldcher-[lidwifery | Health Center |OR Collective Farm LAmbulato,y (SVA) t Hospital (SUB) | | post (FAP) | | | | lMatemity Horne Source: The Ministry of Health and Medical Industries Note: This orpnizational structure continued untilmid-1995. Howvever, changes are now beingmade for all public organizations with health activities to report to the Ministry of Health and Medical Industries (which was fomierly the Ministry of Health).  3 ,E E I4g 03E~~~~~~~~~~~~~~~~~ ex~~~~~i  2.4. In each of the country's five velayats (and also in Ashgabat), the MOHMI is represented by the hakim (the provincial governor), under whom there is a health department. Each of these has a velayat medical director, several deputies and other personnel. For technical matters, the head of the velayat health department reports to the MOHMI; but for administrative and (most importantly) financial matters, he reports to the hakim. Each velayat has a large number of health facilities, including general hospitak, children's hospitals, narcology hospitals (for alcohol and drug treatment), maternity hospitals and tuborculosis hospitals. Below the velayat level are the "etraps" ("rayons" or districts). There are 46 etraps away from the capital city, plus three more in Ashgabat itself, and they operate hospitals, outpatient clinics, polyclinic ambulatories and rural feldcher accousteur posts (FAPs). Management Wo~~ - Wa~~~~~ o~wiioiiae i h Gltpro