Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine
ß The Author 2011; all rights reserved. Advance Access publication 24 May 2011
Health Policy and Planning 2012;27:281–287
doi:10.1093/heapol/czr040
Lessons from two decades of health reform
in Central Asia
B Rechel,1* M Ahmedov,2 B Akkazieva,3 A Katsaga,4 G Khodjamurodov5 and M McKee1
1
European Observatory on Health Systems and Policies, London School of Hygiene & Tropical Medicine, London, UK, 2Department of Health
Services, University of California, Los Angeles, USA, 3Health Policy Analysis Centre, Bishkek, Kyrgyzstan, 4Independent Health Policy
Consultant, Toronto, Canada, 5State Surveillance Centre for Medical Activities, Ministry of Health, Tajikistan
*Corresponding author. European Observatory on Health Systems and Policies, London School of Hygiene & Tropical Medicine, 15–17
Tavistock Place, London, WC1H 9SH, UK. Tel: 020 7612 7808. Fax: 020 7612 7812. E-mail: [email protected]
Accepted
18 February 2011
Since becoming independent at the break-up of the Soviet Union in 1991, the
countries of Central Asia have made profound changes to their health systems,
affecting organization and governance, financing and delivery of care. The
changes took place in a context of adversity, with major political transition,
economic recession, and, in the case of Tajikistan, civil war, and with varying
degrees of success. In this paper we review these experiences in this rarely
studied part of the world to identify what has worked. This includes effective
governance, the co-ordination of donor activities, linkage of health care
restructuring to new economic instruments, and the importance of pilot projects
as precursors to national implementation, as well as gathering support among
both health workers and the public.
Keywords
Health systems, health policy, health reform, Central Asia
KEY MESSAGES
This paper is one of the first that makes a comparative assessment of reforming health systems and policies in Central
Asia.
The countries of the region have undertaken profound changes to their health systems, affecting governance
arrangements, financing mechanisms and health care delivery.
Challenges of health system performance in the region include wide inequities in health resources and utilization,
financial barriers to access, inefficiency and poor quality of care.
We identify several factors facilitating successful health reforms in the region: effective governance, the co-ordination of
donor activities, linkage of health care restructuring to new economic instruments, the importance of pilot projects
as precursors to national implementation, and gathering support among both health workers and the public.
Introduction
Since achieving independence in 1991, the former Soviet
countries of Central Asia have undertaken profound changes
to their health systems, affecting governance arrangements,
financing mechanisms and health care delivery. Yet, in contrast
to other former Soviet countries such as Russia, Ukraine or the
Baltic States, they have received relatively little attention. There
are only few comparative studies (Rechel and McKee 2009),
281
most of which are now outdated (McKee et al. 1998). In this
article we review developments in health systems and policies
in Central Asia in the two decades since independence. The
experiences of these countries offer lessons for those undertaking health reforms in the region and in other low- and
middle-income countries in transition.
Although the countries of Central Asia differ in many
respects, most notably in terms of their socio-economic
282
HEALTH POLICY AND PLANNING
Table 1 Demographic and socio-economic indicators, 2008
Kazakhstan
Kyrgyzstan
Tajikistan
Turkmenistan
Uzbekistan
Population, total (in millions)
15.7
5.3
6.8
5.0
Population aged 0–14 years (%)
23.7
29.7
37.5
30.1
27.3
30.1
Rural population (% of total population)
42.1
63.7
73.5
51.4
63.2
GDP per capita (PPP, in constant international $)
10 458
2025
1761
6119
2455
Source: World Bank (2010).
Table 2 Health indicators, 2008 (or latest available year)
Kazakhstan
Kyrgyzstan
Tajikistan
Turkmenistan
Life expectancy (years)
66.4
67.4
66.7
64.8
Uzbekistan
67.8
Life expectancy males (years)
60.7
63.0
64.1
60.8
64.7
Life expectancy females (years)
72.5
72.0
69.5
69.0
71.0
Infant mortality (per 1000 live births)
26.9
33.3
54.1
43.1
33.7
Maternal mortality (per 100 000 live births)
140 (2005)
150 (2005)
170 (2005)
130 (2005)
24 (2005)
Source: World Bank (2010).
development (Table 1) but also Tajikistan’s experience of civil
war between 1992 and 1994 and Turkmenistan’s international
isolation, they have shared many of the same challenges in
reforming their health systems. These include the common
Soviet legacy, a marked economic decline in the first years of
transition, young populations and a large share of people living
in rural areas with poor infrastructure.
They also share a similar pattern of disease (McKee et al.
1998), with very high rates of non-communicable disease
(the main cause of death), but also high rates of communicable
disease (in particular tuberculosis, but increasingly also
HIV/AIDS), and high maternal and infant mortality (Table 2).
Life expectancy, estimated to be between 64.8 and 67.8 years at
birth in the different countries of the region (World Bank
2010), is much lower than in Western Europe, where it stood at
80.4 years in 2007 (WHO 2010).
Methods
This paper draws on our work producing the Health Systems in
Transition (HiT) country profiles on Kazakhstan, Kyrgyzstan,
Tajikistan and Uzbekistan, led by the European Observatory on
Health Systems and Policies and prepared by national experts
and Observatory staff, in consultation with Ministries of Health,
as well as on our separate studies on health in Turkmenistan.
The HiT profiles are based on a common template designed
to ensure the comparable description of health systems
and policies (Rechel et al. 2010). We complemented the
information retrieved with a review of documents produced
by the governments in question and international agencies
(collected through our work in these countries over 15 years) as
well as an updated search of PubMed, using the search terms
‘‘Central Asia’’, ‘‘Kazakhstan’’, ‘‘Kyrgyzstan’’, ‘‘Tajikistan’’,
‘‘Turkmenistan’’ and ‘‘Uzbekistan’’, in combination with
‘‘health reform’’ and ‘‘health care reform’’. We have benefitted
from our ongoing links with each health ministry, with the
exception of Turkmenistan; its Ministry of Health not only
refused to provide information, but, as we have shown
previously, systematically manipulates health data (Rechel
et al. 2009a; Rechel et al. 2009b; MSF 2010).
Results
Timing
The countries of Central Asia have pursued different reform
trajectories. Most started to embark on wide-ranging reforms in
the second half of the 1990s, often assisted by external
agencies, such as the World Bank, WHO, USAID, DFID or the
Asian Development Bank. However, the pace varied, with
Kazakhstan only adopting a systematic approach after 2004
(Kulzhanov and Rechel 2007), while reforms in Tajikistan
were delayed by the civil war (Mirzoev et al. 2007). In
Turkmenistan, initial reforms were halted under the eccentric
president Niyazov and have not yet resumed under president
Berdimukhamedov who came to power in 2007 (Rechel et al.
2009b).
Organization and governance
Following independence, the national Ministries of Health
assumed responsibility for developing and implementing national health policies. They had inherited from the Soviet period
a health system that was divided into three administrative tiers:
republican (national), oblast (regional), and district (rayon) or
city, being funded from separate budgets. Each level carried out
core functions of health systems: the collection of revenues, the
pooling of funds, the purchase of health services and the
provision of care. Within each oblast, these functions were
implemented by each rayon government and also by the oblast
government. This organization of the health system resulted in
the duplication of functional responsibilities and overlapping
population coverage (Ibraimova et al. 2011). The system was
LESSONS FROM HEALTH REFORM IN CENTRAL ASIA
283
Table 3 Selected health financing data, 2007 (or latest available year)
Health expenditure per capita, PPP (constant 2005 international $)
Kazakhstan
Kyrgyzstan
Tajikistan
Turkmenistan
Uzbekistan
405
111
93
187 (2005)
114
Health expenditure, total as % of GDP
3.7
6.5
5.3
2.6
5.0
Health expenditure, public as % of total health expenditure
66.1
54.0
21.5
52.1
46.1
Source: World Bank (2010).
further fragmented by the existence of many specialized health
services (such as those for tuberculosis) being delivered
through separate vertical systems, while numerous bodies
(such as the Ministry of Internal Affairs, the Ministry of
Defence and large companies) traditionally ran their own
parallel health systems. The resulting fragmentation of health
financing and service provision was one of the major challenges
to reforming health systems (Kutzin et al. 2010; Ibraimova et al.
2011).
In the original model, primary care and basic community
(central rayon) hospitals were managed by city and rayon
authorities, general hospitals were managed by oblast health
authorities, and specialized hospitals and related institutions
were managed by the Ministry of Health. This model, with
management of primary and community care by the central
rayon hospital, has persisted in Kazakhstan, Tajikistan and
Uzbekistan, with the exception of a few localized pilot schemes,
confirming the subordination of primary care to secondary care
and constraining the scope for development of the former.
In these three countries, most official health financing is
raised and spent at sub-national (oblast and rayon) levels.
In Uzbekistan in 2005, for example, 87.7% of government
health expenditure came from local budgets (Ahmedov et al.
2007a). Given the considerable variation in revenue raising
potential among sub-national units, these systems are prone to
high levels of geographical inequality. Only two countries,
Kyrgyzstan and Kazakhstan, have introduced national pooling
systems (see below).
The private sector and professional associations do not yet
make a significant contribution to health policy making. So far,
the private sector is largely confined to pharmacies, dental care
and small diagnostic facilities.
Financing, pooling and payment
The countries have fared very differently following independence, largely due to the presence or absence of natural
resources, in particular oil and gas. Consequently, health
expenditure per capita varies considerably, from US$405 in
Kazakhstan to US$93 in Tajikistan (Table 3). However,
countries have made different choices about how much of the
available resources they spend on health, with Kyrgyzstan
spending 6.5% of its GDP on health in 2007, despite being one
of the poorer Central Asian countries, although it should be
noted that this expenditure includes state expenditure, private
expenditure and funding from external agencies.
Informal payments (in cash or in kind) as well as the use of
blat, or connections, was a ubiquitous, if rarely acknowledged,
feature of the Soviet health system, although care (except for
outpatient drugs) was formally free. While historical comparative data are unavailable, it is widely accepted that there has
been a marked increase in the importance of out-of-pocket
payments (including both formal co-payments and informal,
under-the-table payments), which have now become a
main source of health revenue. Private health expenditure
amounted to 78.5% of total health financing in Tajikistan in
2007 (Table 3). International development agencies have also
grown in importance, especially in Kyrgyzstan and Tajikistan,
contributing to 10% of health financing in the latter in 2007
(Khodjamurodov and Rechel 2010). However, donor co-ordination has become a problem and so far Kyrgyzstan is the only
country in the region that has adopted the framework of a
sector-wide approach.
Experience with health financing reform has been mixed.
Kazakhstan introduced a health insurance scheme nationwide
in 1996 (Ensor and Rittmann 1997), but discontinued it in 1998
(Rechel and McKee 2009). Kyrgyzstan introduced mandatory
health insurance in 1996, while Turkmenistan created a
nominal system in 2006. However, these schemes are all fairly
marginal in relation to total health expenditure, amounting
to 4.1% in Turkmenistan and 9.0% in Kyrgyzstan in 2006
(Rechel and McKee 2009). Voluntary (private) health insurance is almost non-existent, despite being encouraged in
Kazakhstan, where it covered about 5% of the population in
2005 (Kulzhanov and Rechel 2007).
The reforms in Kyrgyzstan meant that the newly created
Mandatory Health Insurance Fund became a single purchaser
of health services, with pooling of funds at the national level
(following initial pooling at oblast level) (Kutzin et al. 2009a;
Ibraimova et al. 2011), so abolishing the previous fragmented
budgetary structure (Kutzin et al. 2009a; Kutzin et al. 2010).
Geographical pooling of funds has also been introduced in
Kazakhstan, using general government revenues, initially with
oblast health authorities as single payers for both oblast and
rayon facilities within their borders (Kulzhanov and Rechel
2007). Since 2010 pooling of funds for hospital care has taken
place at the national level.
The challenge of funding systems guaranteeing universal
coverage (Preker et al. 2002) when faced with severely constrained resources has led all governments to introduce defined
benefit packages and official patient co-payments (Rechel and
McKee 2009). In Uzbekistan, a state-guaranteed basic benefit
package was adopted in 1996 (Ahmedov et al. 2007a; Ahmedov
et al. 2007b). In Kyrgyzstan, a state-guaranteed benefit package
was piloted in 2001 and rolled out nationwide in 2004
(Meimanaliev et al. 2005; Kutzin et al. 2009a). In Kazakhstan,
a basic benefit package existed between 1996 and 1998 as part
of the short-lived health insurance system; a new basic benefit
package was adopted in 2005 (Kulzhanov and Rechel 2007).
In Tajikistan, a basic benefit package, as well as formal
patient co-payments, were introduced nationwide in 2005,
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HEALTH POLICY AND PLANNING
but discontinued after only 2 months due to dissatisfaction
among both patients and staff. A revised benefit package was
introduced in 2007 on a pilot basis but had not been extended
by early 2010 (Rechel and Khodjamurodov 2010).
Payment to providers was initially based on the Soviet model
of historical budgeting, in which line-item budgets with little
scope for virement (re-allocation) limited managerial autonomy. This approach is still used for paying hospitals in
Tajikistan, although capitation for primary health care was
introduced in 2008. Capitation-based payment for primary
health care is also used increasingly in Uzbekistan, Kazakhstan
and Kyrgyzstan. Hospitals in Kyrgyzstan are paid per case
according to clinical cost groups, a type of diagnosis-related
group (DRG). Kazakhstan also used an adaptation of DRGs but,
starting in 2010, this is being replaced with reimbursement of
actual expenditures.
Physical and human resources
The countries inherited Soviet-era health infrastructures that
were extensive but inefficient. The absence of opportunities to
migrate, coupled with controls on prices of basic goods, made it
possible to pay low wages and the health sector was a means of
ensuring full employment. Hospitals also fulfilled an important
social care role. Faced with declining government revenues,
each country has sought to reduce hospital capacity, although
not without difficulty (Ensor and Thompson 1999). Bed
numbers dropped substantially in the 1990s and now more
closely resemble the levels seen in Western Europe (Figure 1).
Levels of capital investment were low throughout the 1990s,
but Kazakhstan and Turkmenistan, both beneficiaries of
revenues from oil and gas, have embarked on major new
investments in infrastructure in recent years (Rechel et al.
2009a; MSF 2010).
In contrast to what has been seen in Western Europe, the
ratio of physicians per population has declined in most
countries of the region, except Kazakhstan (Figure 2). This
has had particularly adverse consequences for Kyrgyzstan and
Tajikistan, which have lost health workers to Russia and
Kazakhstan. However, national averages are misleading, with
physicians highly concentrated in urban areas (Ahmedov et al.
2007b; Kulzhanov and Rechel 2007). In Kazakhstan in 2008, for
example, the number of physicians per 100 000 population was
588 in urban areas but only 130, nearly five times fewer, in
rural areas. Kyrgyzstan and Kazakhstan have responded by
mandatory posting of state-funded medical graduates to rural
areas, but many health workers are able to evade this.
Turkmenistan requires separate consideration. The late president Niyazov virtually stopped higher education, so that only 6
nurses per 100 000 population graduated in 2007, compared
with the Central Asian average of 91 (Rechel et al. 2009a;
Rechel et al. 2009b).
The Soviet model of medical training, with specialization at
undergraduate level and physicians trained in very limited areas
(so a primary care facility might have a paediatrician, internist
and obstetrician, all operating at a very basic level) is gradually
giving way to a broader curriculum and the creation of family
medicine programmes (Ahmedov et al. 2007b; Parfitt 2009).
There are also efforts to upgrade nursing training (Parfitt and
Cornish 2007; Pirnazarova and Schlickau 2010). Kyrgyzstan has
made particularly good progress and 98% of doctors working
in primary care have retrained in family medicine (Hardison
et al. 2007). However, ‘specialists’ still receive higher incomes
than generalists (Ahmedov et al. 2007a) and there is a lack of
evidence on changes in the quality of medical education.
Another legacy of the Soviet era is the much lower wages
in the health sector than in other parts of the economy,
a situation exacerbated by the introduction of market economies. For example in Tajikistan in 2007, the average monthly
salary of physicians was US$17, as compared to a workforce
average of US$53 (Khodjamurodov and Rechel 2010), while in
Kazakhstan in 2004, the average salary in the health sector was
only half the national average for all sectors combined
(Kulzhanov and Rechel 2007). This is an obvious factor in the
persistence of widespread informal payments.
450
400
1400
1200
Kazakhstan
350
1000
Kazakhstan
Kyrgyzstan
Tajikistan
Kyrgyzstan
300
800
600
400
200
Tajikistan
Turkmenistan
Turkmenistan
250
Uzbekistan
Uzbekistan
EU members
before May 2004
0
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
Figure 1 Number of beds in acute care hospitals per 100 000
population Source: WHO (2010).
200
EU members
before May
2004
150
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
Figure 2 Number of physicians per 100 000 population
(2010).
Source: WHO
LESSONS FROM HEALTH REFORM IN CENTRAL ASIA
Provision of services
All countries in the region have embarked on primary health care
reforms. Models of health care provision differ in urban and rural
areas. In urban areas, primary and secondary care are delivered in
polyclinics/family medicine centres, with basic secondary care in
rayon hospitals, specialized secondary care in oblast or city
hospitals, and more complex care in national hospitals.
Tajikistan and Uzbekistan have sought to simplify primary
health care delivery in rural areas. In Tajikistan, the formerly
multi-layered provision of primary health care in rural areas is
being transformed into a two-tiered system, with Health
Houses as the gatekeepers to rural health centres (formerly
rural physician clinics or rural hospitals) (Khodjamurodov and
Rechel 2010). Similarly, in Uzbekistan, primary health care in
rural areas has been switched to rural physician points and
outpatient clinics of central rayon hospitals (Ahmedov et al.
2007b). In Kyrgyzstan, Family Group Practices, Family
Medicine Centres and General Practice Centres provide most
primary health services, but the traditional feldsher-midwifery
posts have been retained in small villages and remote areas
with populations of 500–2000 people. Despite these efforts,
there continues to be an overreliance on hospitals for conditions
that could be treated in primary care (Ibraimova et al. 2011).
Co-ordination of different levels of care remains a major
challenge, given the fragmentation of health systems
(Ahmedov et al. 2007a; Kulzhanov and Rechel 2007).
The public health system is also fragmented, with multiple vertical systems, including the traditional sanitaryepidemiological (san-epid) services, HIV/AIDS and tuberculosis
services, programmes to improve nutrition and, increasingly,
centres for the promotion of healthy lifestyles.
Health system performance
Although rigorous evaluations of the effects of reforms on
health system performance are generally lacking, it is possible
to identify key areas of concern for health systems in the
region. One is the persistence of wide inequalities. In all five
countries, money, health workers and facilities vary geographically, especially between urban and rural areas, with consequent marked disparities in access and utilization (Thompson
et al. 2003). In Kazakhstan in 2001, health expenditure varied
by a factor of 4.2 between the richest and poorest oblasts,
narrowing to 2.1 times in 2008. These are the inevitable
consequence of localized financing structures, so an obvious
response is to pool resources nationally, as is being done in
Kyrgyzstan and, to some extent, in Kazakhstan (Ibraimova et al.
2011). A further factor is physical geography. The mountainous
terrain of Kyrgyzstan and Tajikistan results in major challenges
in providing services to particularly remote rural areas, while
Uzbekistan, Kazakhstan and Turkmenistan have large expanses
of bleak and sparsely inhabited territory, with little transport
infrastructure.
There are also financial barriers to access. The decline of
government expenditure on health, with the accompanying
widespread reliance on out-of-pocket expenditure (both formal
and informal) has major implications for the accessibility of
health services to poorer groups of the population, as has been
shown in Kazakhstan (Ensor and Savelyeva 1998; Danilovich
2010), Tajikistan (Cashin 2004a; Cashin 2004b; Falkingham
285
2004; Habibov and Fan 2008; Tediosi et al. 2008; Fan and
Habibov 2009; Habibov 2009), and Turkmenistan (Rechel and
McKee 2005; Rechel et al. 2009a; MSF 2010). In Kyrgyzstan,
however, the introduction of a single payer system, an
expanded state-guaranteed benefit package, the introduction
of formal co-payments and patient information campaigns have
improved financial protection and reduced informal payments
(Kutzin et al. 2009b; Falkingham et al. 2010). According to
successive rounds of the Kyrgyz Integrated Household Surveys
between 2000 and 2006, the proportion of the population that
reported that they needed health care but did not seek it
because it was too expensive or too far away has fallen
significantly, from 11.2% in 2000 to 3.1% in 2006 (Ibraimova
et al. 2011). The share of hospitalized patients making informal
payments to medical personnel declined from 70% in 2001 to
52% in 2006, partly due to better awareness about patient rights
(Ibraimova et al. 2011).
Inefficiency remains another problematic issue. The continued
reliance on inpatient care, partly to address social needs of patients, is one reason why the health systems are so inefficient, a
situation exacerbated by the fragmented nature of services and
the lack of linkages, creating gaps and duplication (Kulzhanov
and Rechel 2007). Integrated primary care, based on family
medicine, could address this, creating a gatekeeping and
navigating role, but investment here, while increasing, remains
inadequate.
The final challenge is how to improve quality of care. There
is considerable over-diagnosis and use of ineffective remedies
(Duke et al. 2006). The reasons are many, including lack of
investment in facilities and technologies, insufficient supply of
pharmaceuticals, poor training of health workers, absence
of systems for quality improvement (Khodjamurodov and
Rechel 2010; Ibraimova et al. 2011), the paucity of locally
generated evidence, and inadequate access to the international
literature (Guindon et al. 2010). There have been many attempts
to improve quality and establish evidence-based practice, with
success in a number of pilot projects (Nugmanova et al. 2008),
but they have been difficult to scale up in the presence
of entrenched Soviet-era concepts of evidence (McKee 2007)
and outdated training curricula (Asadov and Aripov 2009).
However, there are some encouraging examples; in Kyrgyzstan,
involving local communities and NGOs in the development and
implementation of quality improvement programmes has
proven to be very effective (Ibraimova et al. 2011).
Discussion
As this review of experience in the first two decades of
independence has shown, the countries of Central Asia face
many challenges that defy easy solutions. These include a
difficult economic and political context, lack of resources
and capacity, Soviet legacies, and the complex interplay
between national and local authorities. Nevertheless, a
number of important lessons emerge from health reform that
are of relevance beyond the region.
The first is the importance of political leadership, governance
and continuity. Countries that demonstrated a consistent
commitment to comprehensive reforms (such as Kyrgyzstan)
fared better than those that followed a more erratic approach
(such as Kazakhstan). Continuity was facilitated by
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HEALTH POLICY AND PLANNING
incorporation of capacity building into reform programmes, as
in Kyrgyzstan, with its Health Policy Analysis Project that has
now been transformed into the Health Policy Analysis Centre.
The Centre has provided a range of reports and surveys on the
reform process which fed back into health policy-making. In
other countries, such as Tajikistan, a lack of local
capacity-building has been identified as one of the factors
impeding reforms (Rechel and Khodjamurodov 2010).
The co-ordination of donor activities has been another
challenge (Rechel and Khodjamurodov 2010). So far, only
Kyrgyzstan has adopted a sector-wide approach, which has
helped to increase aid effectiveness and avoid fragmentation. A
more general problem is that, given the lack of local capacity,
health reforms in the region are largely driven by international
agencies. This risks making reforms unsustainable, once external support is withdrawn or redirected, and underlines the need
for local capacity-building.
Third, the pooling of health funds and the use of single payer
mechanisms have been necessary to address regional and
sectoral inequalities. The countries inherited a fragmented
budgetary system from the Soviet period that was divided
into three administrative tiers (republican, oblast and rayon or
city), and the pooling of health funds at the national level
allowed them to overcome this fragmentation and use resources
more efficiently and equitably.
The fourth is the sequencing of health reforms and the
combination of health care restructuring with new economic
instruments (Kutzin et al. 2010). While in Kyrgyzstan the
introduction of a state-guaranteed benefit package and patient
co-payments was embedded in a wider reform of health care
financing and delivery (Meimanaliev et al. 2005), in Tajikistan
the new scheme was not accompanied by new mechanisms
of health financing or an emphasis on primary health care.
This meant that although most services under the basic benefit
package were to be delivered at primary care level, the budget
was still directed at the operating costs of hospitals (Ministry of
Health et al. 2004).
Fifth, experience in Central Asia highlights the importance of
piloting reform elements before rolling them out nationwide, a
conclusion that has also been reached in other countries of
Central and Eastern Europe and the former Soviet Union (World
Bank 2003). An example is the failed introduction of the benefit
package in Tajikistan, versus the more step-wise introduction
elsewhere, such as in Kyrgyzstan, which allowed consensus to be
built on reforms and for their refinement where necessary.
Finally, the involvement of the general population and of health
workers has been an element of successful reforms in some
countries of Central Asia and was missing in reform attempts that
failed. This might not be surprising in many countries, but is so in
the political context of Central Asia, which is generally
characterized by the strong role of the executive and the powers
vested in the presidency. It seems that even in less permissive
political environments, health reforms depend on the buy-in of
health workers and the general population.
Acknowledgements
Special thanks go to all those who contributed to the Health
Systems in Transition profiles. We would like to thank in
particular the author teams on Central Asia, including Ravshan
Azimov, Vasila Alimova, Bolot Elebesov, Aibek Ibraimov,
Ainura Ibraimova, Maksut Kulzhanov, Elina Manzhieva and
Adilet-Sultan Meimanaliev. Thanks are also due to external
reviewers and the valuable contributions of Ministries of
Health. We are also very grateful to Inga Sikorskaya for her
contributions on Turkmenistan.
Funding
The work of BR on Central Asia was supported by the European
Observatory on Health Systems and Policies. The Health
Systems in Transition profiles are financed by the European
Observatory on Health Systems and Policies, while our studies
on Turkmenistan were financed by the Open Society Institute,
New York. The funding bodies had no involvement in the
findings presented here.
Conflict of interest
The authors declare that they have no competing interests.
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