By Jeni Klugman, George Schieber, Timothy E. Heleniak
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Additional resources for A survey of health reform in Central Asia, Volumes 23-344
In Central Asia, in particular, health outcomes were good relative to per capita income (see Table 1 above). On the other hand, the systems tended to be underfunded by Western standards (as social sectors were given low priority in the state planning process), but were also inefficient and provided low quality care. 16 The disruptions associated with the breakup of the Soviet Union, described above, exacerbated these problems. As a result, the melange of problems in the health care financing and delivery systems in all the Central Asian countries include: declining health status of the population due to environmental risk factors and socio-economic trends which have drastically increased mortality from heart disease, violence, injuries, and suicides; public health programs for health promotion, disease prevention, family planning, adult health, occupational health, and environmental health being poorly structured or entirely absent; chronic underfunding (as an "unproductive" service sector) relative to Western countries; a rigid 18 category budgeting system for paying polyclinics, physicians, and hospitals which provides few incentives for economic efficiency and tends to encourage inpatient over outpatient treatment as well as care at the highest, most expensive, levels of the system; too many physicians, too many specialists, too many hospital beds, excessive utilization of services, particularly inpatient care, by the population; poorly trained primary care physicians, limited inpatient and outpatient diagnostic capacity, obsolete and poor condition of the capital stock; outdated treatment norms that promote ineffective medical practice (see Box 1), inefficient facility configurations, and staffing norms that restrict facility managers from making rational staffing decisions; lack of modern quality assurance systems; inefficient and outmoded production, procurement, distribution and management systems for pharmaceuticals; outmoded lists of essential drugs; and coverage/reimbursement policies which encourage individuals to be hospitalized to receive free drugs; little or no consumer choice; 16 For an extensive overview of the old Soviet system as well as the reform experiences of Russia see D.
Income growth and its distribution (as measured, for example, by the incidence of poverty) are probably the most important determinants in the long run. Recent reversals in this area may therefore be expected to have adverse repercussions. Maintaining education achievements, especially of women, is also important. And of course health programs play a critical role, in particular through the development of cost-effective interventions, health promotion, and improvements in water and sanitation. The goals of health sector reform can be stated in fairly non-controversial terms: that is, to improve the health status of the population, assure equity and access, improve efficiency, improve clinical effectiveness, and assure quality and consumer satisfaction.
The improvements in Uzbekistan have been attributed to a comprehensive program aimed at women of child bearing age that was launched in 1991, special preventive and treatment centers in hospitals and polyclinics, and the promotion of birth spacing, although it is suggested that these initiatives may be too recent to have had such striking results. Data on perinatal mortality, especially time series data, is difficult to interpret. Nonetheless, it does appear that perinatal mortality is high because relatively few births (less than 5 percent) involved access to significant obstetric care, such as cesarean section.
A survey of health reform in Central Asia, Volumes 23-344 by Jeni Klugman, George Schieber, Timothy E. Heleniak