Turkmenistan Health Profile 2012

The Turkmenistan health care system is mainly funded from national government revenues. Until 1991, there was only one source of finance: the central budget. A voluntary medical insurance scheme was introduced in 1996. This contributed about 7% of total health expenditures in 1997. The state budget is still the main source of funding (about 90%). State revenues are mainly derived from natural resources and taxation. Taxes are collected nationally and locally. National taxes (such as income tax, valueadded tax, excise duty and the natural resource taxes) are collected by the central government, and the revenue is distributed to velayat governments and the Ashgabat municipality. In addition, the local authorities levy their own taxes (as defined in Article 13 of the Law of Local Government of Turkmenistan). In addition to the budgeted allocation, the President may allocate extra monies to the health sector, usually for pharmaceuticals and medical equipment particularly in tertiary level institutions The state budget is considering other means of obtaining finance for health care. Discussions have included introduction of statutory health care insurance and the extension of user charges.

Turkmenistan has been in transition from a centrally planned to a market economy since independence in 1991. These years have seen problems that have had a negative impact on the health status of the population. Economic difficulties, partly as a result of shrinking export markets and nonpayment by debtor nations, have taken their toll upon the population. There is great health need, particularly amongst children, women and in the more rural  parts of the country. Turkmenistan seems to exhibit the health problems both of developed and developing countries. In order better to align the health care system to the needs of the population, a series of changes to the health care system have been set in motion. Turkmenistan has opted for a cautious approach to health care reform, in line with its policy on broader economic and social change. Health sector reform policy has been formulated in the context of the epidemiological situation and the available resources, in collaboration with both national and international agencies. As a result, the presidential state health programme was announced in 1995 and was further elaborated in the plan for the realization of the presidential state health programme in 1999. The stated aims of the reform process are the decentralisation of the health care system, enhancement of service efficiency, and a shift in balance from specialist and hospital oriented services to primary health care and preventative services. Greater public involvement and local managerial flexibility are also envisaged. Turkmenistan still faces many challenges in adapting its health system better to serve the needs of its people. Reform plans have been difficult to implement The culture remains one of administration rather than management. Whilst
there are educational programmes to enhance management skills, it is unclear if there is the will to make the transition away from centrally-governed systems. Information and information systems remain geared to governance from the centre, and provide little information to managers in the field, further inhibiting local decision-making.

Turkmenistan has introduced additional sources of funds for the health care system through voluntary medical insurance and user fees. The system of finance allocation, however, wherein the Ministry of Economy and Finance allocates funds directly to the regional (velayat) governments militates against effective supervision by the Ministry of Health and Medical Industry. Were general health funding allocated and distributed by the ministry, this might encourage more effective and efficient use of resources. It would also potentially strengthen accountability and constrain diversion of funds at velayat level between health and other budgets.
The continued reliance upon normative indicators to determine service configurations and resource allocation does not reflect the health needs of the population. More attention needs to be paid to the quality of care provided. There is a need to address perverse incentives to service rationalization, ensure quality enhancement and end the legacy of overprovision and over-reliance on specialist services. Planning and resource allocation processes need to be better aligned with population health needs. In the wake of reorganization and rationalization, health services remain fragmented, with parallel systems and duplication of facilities. Primary care is central to the development of health services in Turkmenistan. The expansion of family medicine and the reconfiguration of primary care services are important strategies. It is unclear, however, the degree to which these changes are substantive and not merely alterations in nomenclature. The use of financial incentives to encourage clinicians into family medicine may also serve to strengthen the status of primary care within the service. Current target payment structures may act as a perverse incentive to clinicians working in districts with the greatest need, thus compounding health inequalities. Secondary care inherits a number of challenges from prior systems. Budget allocation systems still militate against reductions in inappropriate hospitalization. The reduction in the numbers of small specialist hospitals has removed some of the excess capacity. Hospitals now can issue contracts of employment, hich gives them more flexibility in the size and skill mix of their workforce. Other key issues in hospital services include out-dated clinical methods, and dilapidated infrastructure. Over the past two years, the economy has shown some encouraging signs. In the longer term, the extensive hydrocarbon reserves in Turkmenistan could yield a more prosperous economic future. The challenge for a population health policy is to ensure that any increase in wealth for Turkmenistan translates into an increase in health for all its citizens.