With its health care system lagging behind other sectors of the economy, the government of Kazakhstan recently attempted to reverse its deterioration by turning over health care financing reform to local authorities. Top government officials hope decentralization will prevent a collapse of health care. Following the 1991 demise of the Soviet Union, Kazakhstan, like the rest of the former Soviet Republics, lost the government subsidies that supported health care. Now, most of the Central Asian states seek to build a system that curtails Soviet excesses, but still maintains free health care for the uninsured and impoverished.

The region's once vast public health system could be counted among the major accomplishments of the Soviet Union. The ratio of doctors and nurses to population was among the highest in the world. State-provided housing, improved nutrition and other social services helped double life expectancies between the 1917 October revolution and 1970. Many diseases -- including diphtheria, smallpox, cholera, tuberculosis, polio, whooping cough and tetanus -- were virtually eradicated.

The Soviet collapse, however, prompted a drastic decline in health care. The newly independent states were confronted with the task of supporting a health care system no longer capable of meeting the needs of its citizens. Health-related problems in Central Asia are perhaps more acute than the rest of the NIS due to higher levels of poverty, a significant drop in expenditures, and a slow approach to health care reform.

Current health indicators reflect the deplorable state of health care in Central Asia. Adult life expectancy plummeted from 63.3 per thousand in 1991 to 59.7 in 1995, and UNICEF reports that life expectancy at birth is five years less than in Eastern Europe and 11 years less than in Western Europe. The primary causes of death are related to the resurgence of many previously contained diseases, among them typhoid, flu, diphtheria and drug resistant tuberculosis. Also problematic are cardiovascular disease, alcohol abuse, maternal and childhood illnesses, and violence.

Some place blame for poor health care at the highest political levels. In Kazakhstan, the press has criticized President Nursultan Nazarbaev for allocating insufficient funds for health care. The World Bank reports that oil rich Kazakhstan's financing for health care has failed to adjust to falling incomes. The proportion of Kazakhstan's gross domestic product devoted to health care has declined from 6 percent in the 1980s to 1.5 percent today.

"First, health care was the responsibility of a committee, then a ministry, and now reduced to an agency," said Dr. Muhtar Aliev, Director of Kazakhstan's Scientific Surgery Center for the National Academy of Sciences. Aliev blames bureaucratic indecision for the slow pace of health care reform. Family clinics, often with no electricity, inadequate equipment and poorly trained doctors, are unable to plan due to the numerous shifts in policy.

Corruption is also playing an increasing role in Central Asian public health care systems. Informal cash payments to doctors for pharmaceuticals, surgery and other treatments that the state or insurers do not cover have become the norm. These under-the-table payments have reduced access to the health care system for thousands who cannot afford them. Referred to as "envelope payments" for physicians, or "contributions" to hospitals, this form of bribery is said to distort health care, delay reforms and discourage investment or support by international lenders.

More Central Asians are currently living in poverty than was the case a decade ago. Links between poverty and health are especially evident in rural areas, where the entire labor force is dependent upon a single, industrial enterprise. Such firms are often stuggling, if not bankrupt. The unemployed in one-company towns are notorious for high crime rates and self-destructive behavior, especially among young people. In Central Kazakhstan, for example, the city of Temirtu has become a site of a major break out of HIV/AIDS, mostly among IV drug users.

Maternal and infant-mortality rates in all of Central Asia are high by international standards. However, official figures in Turkmenistan, which boasts the region's highest maternal and infant mortality rate, show a recent decrease from its high of 130 deaths per thousand in 1992 to 99.5 in 1995.

As Tajikistan, the poorest and least developed country in Central Asia, copes with civil war and its aftermath, and a host of natural disasters, 85 percent of its population lives in poverty. Per capita health care expenditures – shockingly low at less than $1 USD per person – cannot possibly assure adequate care. Official state health indicators show increased transmission of water-borne and communicable diseases, and elevated mortality and morbidity rates. It is unlikely that current levels of mortality and morbidity due to water-borne, parasitic and vaccine-preventable diseases will be reduced to their pre-war figures any time soon.

Perhaps less publicized are the largely untreated illnesses caused by environmental factors. Thousands of people have abandoned the former nuclear test sites close to Semipalatinsk (near the Russian-Kazakh border), and some 250,000 fled ecological disaster near the Aral Sea in northern Uzbekistan and western Kazakhstan.

The disappearance of the Aral Sea has degraded the health of the surrounding population along with the environment. The Aral has lost about 75 percent of its water volume and up to half its surface area over the past thirty years. The dried seabed, caused by three decades of diversion of water resources to irrigate cotton production has created some 35,000 square kilometers of highly salinated and toxic tundra. Salt storms now commonly blow through an area that once produced 23,000 tons of fish annually. Five million Uzbeks and Kazakhs continue to live in this toxic environment that has caused a dramatic rise in respiratory diseases and birth defects. With the economy and health care structures in a state of disarray, the region is unable to deal effectively with this disaster.

Across Central Asia, hospital and ambulatory care rates are falling. The sick now self-refer to specialists in order to bypass frequently ill trained family doctors, if they can afford it. Many unable to pay for health care increasingly use herbs and home remedies remembered from pre-Soviet days. But more often, Central Asians go without medical attention at all. "We do not want health care to become a distant memory," said Isakova Ainagul, director of Family Group Practices in Kyrgyzstan. However, the efforts of Family Group Practices and other service providers are not enough to combat this escalating problem.

Part II of this series will examine how the most vulnerable segments of Central Asian society cope with the collapse of the health care system.