Kyrgyzstan: The Persistence of Informal Networks and Payments in Negotiating Access to Quality Healthcare.

Valeriya Melnichuk, Graduate of the University of Cambridge Development Studies Program.

 Kyrgyz people have been making recourse to their informal networks (families, clans and tribes) for protection against social risks since the pre-Soviet period (McKee 2002, 17-18). The Soviet institutionalized social security system did not eradicate the practice of employing informal networks for accessing welfare services (Kuehnast 2004, 3). After the break-up of the Soviet Union, neither state nor market could provide and regulate welfare services in Kyrgyzstan because both the state (Marat 2006, 10) and the market were weak (Caparova and Bostan 2013, 99). People continued to use their personal networks to negotiate access to healthcare (Esengul 2012, 21). However, in the second half of the 1990s the government, urged by international donors, carried out a series of reforms to the mechanisms of healthcare system financing and service delivery aimed at extending coverage and ensuring universal access to health care (Ibraimova et al. 2011, 120-127). Nevertheless, the population still extensively relies on informal networks, personal connections and informal payments for negotiating access to quality healthcare (Esengul 2012, 21) despite the re-institutionalization of welfare services and increased presence of the state in healthcare provision. Informal networks and payments persist because of the state’s incapacity to provide equal price and quality care and because the values of doctors and patients have changed.

Background

Healthcare reforms in Kyrgyzstan were launched in 1996 (McKee 2002, 144). The reforms intended to preserve the system of state provided healthcare with its benefits of universal coverage and accessibility at the same time optimizing state healthcare spending (Ibraimova et al. 2011, 152). Financing and service delivery mechanisms were drastically changed. The Mandatory Health Insurance Fund (MHIF) was established, and co-payment for medical services was introduced (McKee 2002, 184). The Program of State Guarantees (PSG), which provides a legislative base for a minimum health services and medications benefit package for disadvantaged social groups, was developed and re-approved annually starting from 2001 (Meimanaliev 2005, 34). With regards to service delivery, the number of hospitals was reduced and the focus was shifted towards primary care (National Statistical Committee of the Kyrgyz Republic 2011). Now, the state remains actively involved in the regulation of the healthcare system and the arrangements for the universal equal access to healthcare are in place. However, due to the state’s incapacity and changing patients’ and doctors’ values informal networks and payments are still widely relied upon for negotiating access to quality care.

Since the state guarantees access to health care for all, it is important to define what is meant by quality care which is a focus of the article. Based on existing research and the interviews, conducted during the fieldwork, I compounded an approximate set of criteria by which people define quality care. Those include accessing better doctors; accessing better equipped medical institutions; circumventing general bureaucratic rules; receiving more attention translated into longer appointments, more extensive and frequent examinations and consultations along with friendlier and more helpful attitude of medical workers.

The interviews focused on maternal care since it is often a positive experience of encountering with healthcare system that patients are more willing to talk about. Moreover, maternal experience includes a wide range of contacts with healthcare system starting from the primary care institutions for general consultations and tests, extending to the secondary level for specialist-consultations and inpatient care for labor and after-birth care, and referral to tertiary level institutions for more complicated cases (caesarian section or after-birth complications).

I interviewed 15 women patients of different age with high and low income, living in urban and rural areas, 12 doctors working in the area of maternal health and a professional, who now works to promote patients’ right and teaches in the Medical Academy, but had been involved in the healthcare reforms.

Proposed Explanations for the Persistence of Informal Networks and Payments

Incomplete Implementation of the Reforms

State incapacity to provide universal quality healthcare is partly explained by its incomplete implementation of the reforms launched in 1996, which resulted in limited affordability of healthcare services. The MHIF, established in 1997 in cooperation with the Social Fund provide limited coverage (McKee, 2002, p. 202). The MHIF does not cover full care costs of insured patients, the state supplements this gap; however, both sources have low revenue levels and “out-of-pocket payments by patients continue to be the major source of revenue for healthcare system” (McKee, 2002, p. 202). Hence, most of the burden of paying for health services lies on patients, which considerably decreases affordability of care.

The PSG was introduced during the reforms as a part of an overall plan to ensure universal coverage and affordability of healthcare. According to the Program, pregnant women, registered at the medical institution they are assigned to, are eligible for free medical services related to their pregnancy. However, doctors often prescribe tests done in private laboratories which cost money or tell patients that there is an official fee for the service, but the receipts are never given for these ‘official’ fees (interviews). The state has limited capacity to monitor such extraction of money. Therefore, patients often prefer to employ their informal networks to negotiate a better price and avoid paying for unnecessary tests or have them done in a public laboratory which is cheaper.

The second dimension of incomplete implementation of the reforms is many citizens’ ignorance of procedures after more than ten years from the moment of their introduction.  Many citizens do not know what they are entitled to, what services they have to pay for and how much and where they can go in case their rights are violated (Ibraimova, et al., 2011a, p. 39; Orozaliev, S. n.d.). This results in informational asymmetries and decreased affordability. Thus, the patients do not make use of reformed healthcare system.

Also, the lack of legal knowledge makes patients more vulnerable in situations when medical staff is not well-aware of the procedures or takes advantage of the patient’s ignorance to charge him/her more. This partly leads to a problem of wide-spread informal out-of-pocket payments for services which otherwise are free (Falkhingam, 2010, p 3-4.). The usage of personal networks in the case of informal payments may decrease the amount of money requested by the doctor or the doctor may not ask for any unofficial payment or gift; however, the usage of networks, according to the interviews, often obliges the patients to present a gift at the end of treatment as “gratitude”. Incomplete insurance coverage, limited benefits provided by the PSG and impediments caused by informational asymmetries complicate access to affordable medical care. In this context, patients have more incentives to resort to their personal relationships to scale down the prices or avoid paying additional informal payments.

Medical Institutions’ Organization and Structure

In addition to limited affordability of medical care, urban medical institutions’ structure and organization create disincentives for patients to seek medical assistance without making recourse to their personal networks. First, the quality of medical services varies in different public medical institutions. Some providers are better equipped and staffed, consequently, are able to provide better quality services, while others encounter such problems as lack of medical staff (International Crisis Group 2011, p. 5; Meimanaliev 2005, p. 71) or lack of high-qualified staff (Meimanaliev 2005, p. 102). There is no guarantee of quality when a patient chooses to go to a random public medical institution. Hence, such organization of the sector where there are better and worse healthcare providers incentivizes patients to employ informal networks for negotiating easier access to institutions perceived to be better ones.

The second barrier related to medical institutions’ organization and management is the incomprehensive system of appointments. There is no single waiting list or computerized system of signing up for an appointment. A patient has to go to a medical institution and wait in line to see a medical specialist and perhaps has to do so for several days (Kiber Demokrat 2013). Logically, waiting lines for better doctors at better institutions will be longer than those for less qualified doctors in less reputable medical institutions. Consequently, some people may not be able to receive needed services if they do not employ their personal connections to facilitate the process of obtaining an appointment with a specific doctor. The absence of an effective appointments management system produces more disincentives for patients to turn to public medical institutions without prior recourse to informal networks. Hence, employing informal relationships enhances chances of signing up for an appointment with a better doctor in a better hospital for a better price.

Exercising Voice or Exit

Health services provision is mainly monopolized by the state. First, patients do not have possibilities to exercise their voice effectively. The system of filing a complaint in case of malpractice, request of illegal payments by medical workers or other patients’ rights violations is complicated, cumbersome and ineffective. There does not seem to be one body which deals with the complaints filed by unsatisfied patients. The numerous mechanisms listed by the authors include referring to the Ministry of Healthcare public reception room, meeting with the Minister, deputy-Minister and other officials within the Ministry of Healthcare, writing letters to the Ministry or other associated public bodies, publishing in mass media, or calling hotline administered by the Ministry and the MHIF (Ibraimova et al. 2011a, pp. 34-36).

Complaining to the Ministry is ineffective because a patient is lost or confused by numerous bureaucratic procedures, referrals from one official to another or waiting lines to see an official. Also, widespread corruption in state bodies impedes effective communication between the population and the Ministry. Moreover, the Ministry of Healthcare is the provider of the services and the overseeing agency. Consequently, it is often biased in favour of medical institutions and doctors. Another suggested option is to refer to the head of the medical institution where the rights were violated or to file a court case against the doctor (Ibraimova et al. 2011a, pp. 39-42). Due to several factors the medical institution may not be interested in considering the complaint impartially, in particular, because of spoilt reputation and corruption, in addition to the high importance of personal and informal connections between the doctors. Filing a court case is an option; however, corruption within the system of justice, patients’ ignorance of laws and costly services of lawyers (Orozaliev, S.) prevent patients from effective use of their right to go to the court in case of their rights’ violation. Therefore, exercising voice becomes difficult, confusing and time-consuming with possibility of being ineffective in the end.

Furthermore, when a patient is not satisfied with service provision in a public medical institution and has no means of filing an effective complaint there are few opportunities to exit. The alternative to public healthcare is private healthcare. However, market in Kyrgyz healthcare is not well-developed. First, private providers offer limited amount of specialized services: ophthalmology, dental care, narcology, gynaecology etc. (Ibraimova et. al 2011a, p. 25; Meimanaliev 2005, pp. 51-53); so certain services are provided by state institutions only (complicated surgeries, oncological treatment etc.). Besides, the prices of private health services are often prohibitive especially for poorer patients (Meimanaliev 2005, p. 53). Consequently, patients cannot choose private healthcare as an alternative to public. Therefore, not being able to complain or exit, the patients are forced to find their ways around imperfections of the public system.

Cultural Aspects

Based on the information derived from the interviews, several cultural aspects that might contribute to the persistence of informal networks and payment in healthcare can be suggested. First, it is distrust in public healthcare institutions that is caused by institutional incapacity and worsened qualification of doctors. However, most respondents mentioned higher trust in services which they have paid for. Private health care, therefore, is trusted simply due to the fact that it is paid for. However, analysis of medical institutions’ personnel and to an extent technical base, as well as interviews with medical professionals show that public medical institutions are often better equipped and better qualified to perform more complicated medical procedures. Moreover, all the respondents who confirmed making informal payments in public healthcare institutions noted their increased trust after they had made the payment. They also mentioned that such increased trust is based solely on the expectation that if “you paid, you must be served better” (Nazik, February 2014). Hence, this phenomenon of trust into paid institutions and belief that money can necessarily buy better service should be studied further for comprehensive results on its effects on the persistence of informal payments in negotiating access to quality care.

Another aspect, discovered during the fieldwork, is the changing values held by doctors. Specifically, the doctors still believe that it is their duty to save people’s lives and health, but they no longer see patients as those in need of help only, they start perceiving patients as clients in the market economy. Possibly, due to the lack of financing for the institutions and low salaries of doctors in the first years of reforms, when doctors needed informal payments for their institutions and families to survive, the perception of market rule in the public healthcare was engraved in their minds. Furthermore, socialist ideology of everyone being equal is gone and doctors want to make decent living. “I have studied for 10 years to become a doctor and I love my profession, I love helping people. But I want to be able to feed my family with the money I earn” (Burul, February 2014). The topic brought up by the interviewed doctors was the comparison of doctors’ salaries in the West (mostly, the US) and in the post-Soviet Union (Kyrgyzstan in particular). Capitalist value of money entered the social welfare area. Older doctors want to make money from their profession; whereas, medical graduates prefer going into business or take up other jobs instead of treating people.

Conclusion

            The use of informal networks and payments persists due to the state incapacity to ensure equal access and quality of healthcare and the changed values of doctors and patients. The use of informal networks remained high after the reforms and informal payments became more relevant in public healthcare in the mid-1990s during the period of economic liberalization and arrival of capitalist values.

The current informal arrangements in the healthcare system are convenient for the wealthier patients; however, the poor patients are excluded. This has a negative effect on the country’s human development, jeopardizes productivity and, therefore, economic development. Hence, further policy research and implications should concentrate not only on unofficial payments demanded by doctors but should take into account the important role of informal networks in the system overall.

 

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