The last time I talked about my work as a Peace Corps Volunteer in Kyrgyzstan, I talked about networks and capacity development. This time, I wanted to talk about another integral component of development work: context. Issues in development – gender-based violence, ethnic conflict, food insecurity, oppression of civil society – don’t emerge suddenly in vacuums of space and time. They are heralds of the cultural, historical, economic, ecological, social, and political constructs in which they exist. Like anything, development problems – and development solutions – are products of their environment and history, and to really understand creating impact, one needs to understand the underlying causes and context of development problems.
In its simplest definition, the work that I do is on healthcare reform. I’m working to make the institutions and organizations providing health promotion and health education in Kyrgyzstan more efficient, more effective, and more responsive to the needs of the communities in which they work. The project I am working on now is attempting to decentralize planning of health interventions, empowering local ownership of health promotion work. But how did the work that these institutions do become established? Why is planning around health promotion activities happening at the center, and not in the community? Where do you start to address systemic limitations to the healthcare program in Kyrgyzstan?
Start with understanding the Soviet healthcare system.
Largely established in the 1920s, Soviets guaranteed healthcare for all citizens as a constitutional right and operated their healthcare as a branch of the federal government. According to Diane Rowland and Alexandre Telyukov, by the time the USSR fell in the 1990s, Soviet citizens lagged behind Americans in life expectancy, prevention of non-communicable diseases, maternal and infant mortality rates, and spending on healthcare. Just before the fall of the Soviet Union, the USSR contributed only 3.4% of its GNP on healthcare spending (as compared to America’s 11.4% of its GNP)*. Rowland and Telyukov prescribe the repetitive failure of the Soviet system to address the needs of its people as rooted in its flawed design. They describe it here:
“The Soviet Health Ministry in Moscow controls healthcare facilities, medical education training, personnel, and financial resources throughout the Soviet Union… [It] exerts power in several ways. First, it controls resources through a five-year plan as well as annual plans that set total healthcare expenditures and allocate them between operations, capital, and investment funds for specific categories of medical providers. These funds are then allocated by the central ministry to each of the fifteen Soviet republics. Second, the ministry establishes the number, type, and geographical residence of health personnel through its control of training curricula, medical facilities, and medical graduates’ assignments. Third, as the monopsonistic buyer of medical supplies and equipment, it controls the quantity and quality of medical equipment, drugs, and other supplies in the Soviet Union and from abroad. Finally, the ministry funds biomedical research through the Soviet Academy of Medical Sciences and controls epidemiologic surveillance and monitoring.”*
Below this centralized Health Ministry were the Health Ministries of the Soviet Union’s 15 republics, all localized duplicates of the Moscow-based institution. Tasked with the planning and control of their Republic’s healthcare, they were limited by the budgets and annual plans of the Moscow Health Ministry. On the regional level, there were health boards incorporated into the local Sovet (representative local government), ideally designed to manage implementation of health plans at the local level. In theory, these local boards were channels to the planners of local realities and health needs, but often failed to act as the people’s voice in any planning activity.
This top-down structure left local areas inept at responding to local health needs or providing appropriate primary care to its citizens. Structured like a pyramid, the overall system was both resistant to changing needs or realities. Often, Republics furthest from Moscow would suffer most in budget shortages and the politicization of administration posts. Central Asian republics, like Kyrgyzstan, who were mostly nomadic, were given limited means and less authority in providing care to its citizens.
In the Soviet healthcare system, primary care facilities were built to match the community’s size – hospitals in large cities, medical centers and poly-clinics in small cities, and rural clinics, often only equipped with a feldsher (an equivalent of an American Nurse Practitioner), at the village level. The people favor hospitals, often with long and unnecessary admission periods, whether from actual experience with unqualified or underequipped local care points or the imagined belief that hospital care is the only good and qualified care. Distances between clients and primary care access are often excessive, and patients often choose to only admit themselves to hospitals after their illness or malady are far past treatment. And, when the majority of your population is rural, nomadic, and hard to reach – like most of the populations in Kyrgyzstan – accessibility to healthcare is even more diminished.
Healthcare, overall, was not a Soviet priority, and its institutions were consistently under budgeted and undervalued. Budgets determined by a five-year plan in Moscow focused on inputs and outputs – constantly increasing numbers of hospital beds and quotas of planned procedures without investing in human capital or infrastructure. In the 1980s, up to 25% of Soviet hospitals lacked basic necessities like running hot water, sanitation tools, modern surgical equipment, or qualified, committed, well-paid staff. Medical staff, employees of the federal government, were assigned to fill doctors positions, but were paid so poorly many demanded bribes from patients to do their jobs. The Soviet System faced a rapid, planned increase of care without the funding, infrastructure, or personnel to support it.
Health promotion in this Soviet Structure is limited or non-existent, often focusing exclusively on communicable diseases like typhoid or tuberculosis. While Soviets valued health in their people – the “New Soviet Man,” in addition to being educated and selfless in his commitment to furthering the goals of the Marxist revolution, was healthy, strong, and physically capable – basic things like nutrition, physical exercise, and mitigating risky behavior were not broad parts of the Soviet health program. It was, however, advanced in providing information on female sexuality and reproductive health to the “New Soviet Woman,” although rural women were more limited in the information and services they received, often only counseling reproductive health as a form of political pronatalism. People are not empowered to make choices about their own health, and commonly feel that they have no control over their own health outcomes. What will be will be, and there is little one can do to stop it.
You can imagine, as a new nation-state formed from a former Soviet Republic, the legacy of health care left behind by the dissolving Soviet Union. An entire generation brought up malnourished and uneducated about personal health and non-communicable disease, dependent on doctors and health policy makers from other Republics for healthcare and health promotion decisions. Struggling economically as rapid changes ensue, still attempting to guarantee health care to every citizen. In its young life, Kyrgyzstan has attempted to move away from the Soviet System, heavily investing in healthcare reform.
Focusing on improving access and quality of care and localized planning, these reforms are now in their third iteration, but there are still persistent reminders of the former system. Primary care still follows the population-based structure, with increasing size of clinics and their capacity based on population size. Doctors, nurses, and feldshers are still underpaid, still resistant to rural placements, and still accepting bribes for standard care. The Kyrgyzstani people still favor extended hospital stays instead of basic treatment in their community, often long after when treatment would be simple and accessible. Preventative care is novel, and basic understanding of health, recognizing disease, or mitigating risky behavior is still new to Kyrgyzstan. Rural communities, for a variety of economic, cultural, and social reasons self-medicate, using inexpensive alcohol to treat flu, depression, pain, headaches, or terminal disease. Advances in treatment of infectious disease are limited by lack of funds, innovation, or modern treatment programs. The progressive reproductive health programs are curtailed by a public shift towards conservatism, offering little knowledge to young people about the development of their bodies, pregnancy, sexuality, or disease. Health promotion is still limited, but is growing every year through the Community Action for Health networks of Health Promotion Units and Village Health Committees.
Kyrgyzstan’s health system is progressing, but it still is trapped by the remnants of Soviet control. The healthcare reforms of this country were meant to move away from Soviet healthcare, but that kind of progress takes time and money and political power and commitment. There are fundamental changes that are slowly, painstakingly taking place in Kyrgyzstani communities, but change continues to be a long time coming. Even Russian healthcare reform is failing to escape the Soviet legacy. Kyrgyzstan’s choice to invest in empowering local capacity to act on health issues, disease, and education, however, moves away from the centralized model, and encourages individuals to take control of their health. The health promotion system is new, growing, and flawed, but at least it is growing in the right direction.
My work here is to help address the functionality of the health promotion system, improve its capacity to work, to provide education on health and wellness and disease. My organizations, the Republican Centre for Health Promotion and the Association of Village Health Committees of Kyrgyzstan, are tasked with empowering communities to act on their own for the improvement of health. Understanding the long road of progress as context for changes in healthcare and health promotion is only a part of that.