Dr. Damira Saaliva, director of the central hospital in Kyrgyzstan's Issyk-Kul province, is not daunted by the precipitous decline in health care services throughout Central Asia. Saaliva is one of a handful of doctors striving to reform the old Soviet system – shifting the emphasis from the urbanized hospital sector to more of a rural-oriented primary care system.

Saaliva's most important task currently is to promote decentralization of health care delivery. Under the old Soviet-style system policies and budgets were developed in Moscow then handed down to the state capitals. Saaliva is critical of the old system, describing it as "inflexible." But like many reform-minded physicians in the region, Saaliva does not want to relinquish the legacy that provided universal care to all Soviet citizens. "We don't want to lose the good aspects of that system," she said.

Poorly equipped and dilapidated hospitals and clinics are now the norm in Central Asia. In addition, doctors lack training in the latest diagnostic and treatment methods. According to Dr. Damira Saaliva's colleague in Almaty, Dr. Daulet Berkov Laushin, "the problem is that government officials have far too little interest in health care policy, don't provide sufficient funds or attention to health care; and offer a reform program that is insufficient for those who cannot afford its costs."

At present, health care reform efforts are relatively small in scope, and financed largely by private initiatives. The goal of the of the primary financiers of reform, the World Bank, USAID and the Asian Development Bank, is to downsize the hospital sector and shift resources to an improved primary care system. But, USAID officer Kathryn Stratos notes, "urban hospitals, rather than family clinics, continue to consume more than 70 percent of the regions' health care budgets." Stratos likens the health delivery system to an inverted pyramid. "The hospital sector at the top is overdeveloped; and the primary health care sector, which should serve as a broad point of entry to health care, is underdeveloped, underfinanced and underutilized."

Dr. Serik Ibraev, First Assistant Director of Kyrgyzstan's Agency for Health, formerly a ministry, said the goal of inverting the pyramid could, in part, be accomplished by shifting resources from the extensive network of hospitals to the family clinics. Government-sponsored reforms would allow for evidence-based medicine, retraining of specialists and upgrading the skills of general practitioners to allow for expanded treatment in the family clinics.

Most of the region's family clinics are small centers with a few rooms and one, two or three staff with limited capabilities. Beyond immunization, virtually all care is referred to specialists at polyclinics or hospital. Doctors periodically visit the family clinics from the nearest polyclinic or hospital. The facilities that typically serve several thousand people often lack even the most rudimentary equipment and medicines. Many have no running water, power or sanitation.

There are several pilot programs that are attempting to invert the pyramid. These few Family Practice Group clinics -- located primarily in Kazakhstan, Krygyzstan and Uzbekistan -- offer maternal and child health care, modernized equipment, drug therapies and physicians who specialize in family medicine. Patients express far greater confidence in the donor-financed practices than the decaying outposts that they prefer to bypass.

There are also privatized family group practices, such as the Kazakh-owned InterTeach, operating in Kazakhstan, Krygyzstan, Uzbekistan and Mongolia. Such providers boast better trained physicians, equipment and perishables than the legacy of the state-run systems, but they are largely beyond the reach of the rural poor. One InterTeach physician, Dr. Lubov Nikolaeva Slivkina, said she left the polyclinic system for the private company because it offered her "better training, better opportunities to practice medicine and better pay." The small company's revenues from international corporations operating in the region, in part, subsidizes the costs for the InterTeach family clinics. But the costs for its health care remain out of reach for most.

According to Dr. Yerkin Durumbetov, Deputy Chair of Kazakhstan's Health Care Agency, reform requires both long- and short-term strategies. Short-term clinical education programs have increased the skills of family practitioners. But for both political and economic reasons, many of the region's governments have resisted pressures to fully implement reforms designed to produce a fully operative community-based health care system. According to Durumbetov, "in reality, health care reform depends upon a sustained recovery of the region's economies."

Oil riches could be the engine for reform in the social sphere, including the development of a new health care system. Within 15 years, the Oil and Gas Journal estimates that Kazakhstan could be producing as much oil as Kuwait – as much as 655 million barrels a year. With such potential, some of the region's health care specialists, such as Dr. Muhtar Aliev, Director of Kazakhstan's Scientific Surgery Center for the National Academy of Sciences, believe the state should allocate a larger share of resources drawn from oil revenues to benefit the health of its citizenry.

Durumbetov expressed concern that the well-being of the Kazakh people is at risk should the health care system continue to deteriorate. What we need, he said, is "more money, more clinics, more training, more everything." He paused. "What we want is for our people to believe that we can deliver health care."