*Data from the Ministry of Health and Medical Industry

The ratio of abortions per 1,000 livebirths is the highest for the five republics of Kazakstan, Kyrgyzstan, Tadjikistan, Uzebkistan and Turkmenistan at 272 in 1995. It has remained at this level over the period 1990 to 1995 and presumably reflects the low level of availability of family planning services.

There are difficulties in reconciling the reported figures for total fertility and abortion rates with the estimated contraceptive prevalence rate.

The abortion rate in Turkmenistan is lower than the rates in Kazakstan and Kyrgystan. The total abortion rate declined from 44 per 1000 women in 1987 to 40 in 1991. In recent years ‘mini-abortions’ done 3-4 weeks after missing menses, have replaced regular abortions, provided by the MCH Institute’s family planning department and FP units in district hospitals. Many Turkmen women it seems prefer abortions to IUDs as they fear and distrust IUD, and mini-abortions are easier to conceal from husbands and in-laws.

3.2.2.4 Maternal Nutrition

Overall levels of nutrition is of limited concern from the point of view of overall intake levels of protein and calories. However there are issues related more inappropriate consumption patterns rather than under-nutrition and deficiencies in certain micronutrients, in particular iron (UNICEFArea Office for Central Asian Republics and Kazakstan, 1997; World Bank 1996). Nutrition problems include unhealthy diets particularly the high consumption of fatty foods, which is probably related to the very high rates of ischaemic heart disease. Many women are anemic. In 1996 just under a half of pregnant women (47.4 percent see Akmuradova, Turaeva, Geldiev 1998) attending for antenatal care were anaemic. In certain areas of the country a majority of pregnant women are anaemic, for instance in Dashowuz around 75 percent of pregnant women have anaemia (UNICEF Area Office for Central Asian Republics and Kazakstan, 1997).

The percentage of babies born with low birth weight (weighing less 2,500 g) was five in 1993 suggesting that maternal nutrition during pregnancy in terms of calorie intake is good (Academy of Sciences of Turkmenistan and UNDP 1997).

3.2.2.5 Child Survival

Infant mortality remains the highest in the WHO European Region (37.1 per 1000 live births in 1997) (Table-14). Moreover, Turkmenistan uses the Soviet definition of a live birth, which leads to an underestimate of infant mortality by up to 25percent (UNICEF Area Office for Central Asian Republics and Kazakstan, 1997). Neonatal mortality is responsible for around a half of infant mortality, but in some provinces (for instance Dashowuz at 13 percent) is a far lower proportion. Stillbirths are responsible for about a half of perinatal mortality which at around 14 deaths per 1,000 live and stillbirths is relatively high. These relatively high absolute rates and the substantial proportions of perinatal deaths due to stillbirths and of infant mortality due to neonatal deaths, that many neonatal deaths are due to asphyxia and birth trauma, particularly given the high rate of institutional delivery, but low Caesarean section rate and that many births being attended by a pediatrician suggest there are major deficiencies in the quality of delivery and neonatal care.

Acute respiratory infections are the most common cause of mortality and morbidity among children and yet almost 75 percent of the population do not know the most important signs and without parental understanding of the severity of illness and the need to seek proper medical care they may not come for care. Diarrhoeal diseases are the second most common cause of mortality and morbidity in children and while almost a half of children with diarrhoea receive some ORT few receive it appropriate amounts (UNICEF Area Office for Central Asian Republics and Kazakstan and Ministry of Health Turkmenistan, 1995).

3.2.2.6 Breast feeding

Mothers usually breast-feed their babies in Turkmenistan and do so for longer than the minimum recommended period, however, only about half (54 percent) of the mothers do not supplement breast milk with other substances. The practise of exclusive breast-feeding varies greatly among provinces, ranging from 28 percent in Dashowuz to 81 percent in Ahal). Ninety four per cent of all children under the age of one have been breast fed at sometime and 94 percent are still breast fed at the age of one, but only 54 percent of infants under the age of four months are exclusively breast fed (UNICEF Area Office for Central Asian Republics and Kazakstan and Ministry of Health Turkmenistan, 1995).

3.2.2.7 Reproductive Tract Infections

STDs have shown an increase in the last few years and in 1995 there were 32.3 new cases reported per 100,000 population. This is a relatively low rate in comparison to Russia and Kazakstan, however reported new cases of syphilis were 7.2 times higher in 1996 than in 1992. Increasing numbers of congenital syphilis have been diagnosed, which indicates a breakdown in the previously reliable system for antenatal screening for syphilis during pregnancy. Rates of new reported cases of gonorrhoea have remained at relatively low levels (29.2 cases per 100,000 population in 1995).

Turkmenistan has a low prevalence of HIV/AIDS with only one registered HIV positive case as of 20 June 1998 (WHO, EURO, 1998). However, there is a risk that HIV/SAIDS will spread because of the increased number of risk groups such as drug users. The incidence of drug abuse is high and was 13.2 cases per 100,000 population in 1995. This had doubled over the previous five years.

It is said that the treatment methods of STDs are quite outdated and characterised by unnecessary hospitalisation and inefficient, high-cost treatment.

3.2.2.8 Domestic Violence and Abuse

There is no systematic information available on domestic violence and abuse, however anecdotally there are reports of increasing injuries resulting from disagreements within families. This is likely to be associated with the stresses placed on men and women associated with economic reform, increasing unemployment and alcohol abuse.

3.2.2.9 Breast and Cervical Cancer

Mortality rates for carcinomas of the female reproductive organs (breast and cervix) have remained virtually unchanged over the five years 1990 to 1995 (WHO/EURO 1996). Although mortality from cancer of the breast has increased from a standardised mortality ratio (SDR) of 11.9 per 100,000 women in 1990 to 13.3 in 1995, it remains at a much lower level than the average for countries of the WHO European Region with a standardised death rate (SDR) of 30. Mortality from carcinoma of the cervix at 5.1 (SDR in 1994) is far closer to the European average of 4.6 (WHO/EURO 1996).

3.2.2.10 Adolescent Health

There is limited information available on the reproductive health status and needs of adolescents or services for them. The age-specific fertility rate for adolescents aged 15 to 19 years has changed very little over the past 20 years and is low in comparison to other countries of the former Soviet Union. In 1996 there were 22 births per 1,000 of this age group and less than 10 percent of births in the country are to women aged less than 20 years (Akmuradova, Turaeva and Geldiev, 1998).

There is a well-established system of health and development assessments carried out principally through pre-school and school health services.

There are however certain suggestions that unprotected sexual activity among adolescents is increasing (see Djumakuliev, Kulieva 1998) with reports of increasing rates of sexually transmitted diseases in this age group (Nomnoeva 1997) and that about 2,400 of therapeutic abortions or one in fourteen of all abortions are among this age group (Kerimova 1997).

The maternal mortality rate in 1992 was 48 deaths per 100,000 live births (WB 1994) . Among the five CARK countries, Turkmenistan has the highest MMR, although it is steadily declining over the years. This is an issue of great concern specially in a country where over 90 percent of deliveries take place in hospitals or maternity houses, and women normally visit health facilities at least four times during pregnancy. About 60 percent of urban pregnant women, and 75 to 80 percent of rural women, are anaemic (WB 1994), caused by short intervals between gestations and poor nutrition. Hemorrhage, toxemia and sepsis together are responsible for more than 70 percent of maternal deaths (UNICEF 1997). According to the Ministry of Health the prevalence of iron deficiency anemia among pregnant and breast-feeding mothers is around 48 percent. This is expected to increase as the previous practice of providing iron and food supplements to anaemic pregnant women has been curtailed or stopped because of funds and drug shortages.

Short intervals between childbirth and frequent induced abortions as a method of family planning will seriously affect the health of women. HDR 1996 noted that more than half of children are born within 2 years of the previous child, of which 40 percent are born within 1.5 years.

Breast-feeding in Turkmenistan is a traditional practice but is on the decline. In 1984 75 percent of mothers breastfed their babies exclusively, in 1991 the figure had decreased to 49 percent. Over the past decades the average breastfeeding period has shortened considerably. Thirty years ago mothers reported breastfeeding for three years; now only 44 percent of rural and 14 percent of urban women still nurse their children for 6 months. While 45 percent of women in rural areas and 39 percent in urban areas say they rely on breastfeeding as a contraceptive method, a study conducted among 1034 women showed that 70 percent had insufficient volume of lactation, which can adversely affect the reliability of the contraceptive effect of breastfeeding. According to MOHMI data the failure rate among those who practiced ‘lactation contraception’ was high which is hardly surprising given the decline in exclusive breastfeeding practices. Breastfeeding women are an important target group for reliable and modern FP methods.

In the majority of CIS countries there is a significant increase in the incidence of STDs which is in danger of turning into epidemic proportions. In Turkmenistan STDs are on the increase, albeit at a slower pace than the other CIS countries. In 1996 the number of STDs was about 29 cases per 100,000 inhabitants compared to 4 cases in 1992 - an increase of more than 7 times. From MOHMI’s analysis of syphilis cases (December 1997) it was found that the highest number are from the age group 20-29 (51 percent) followed by the 30 - 39 age group (27 percent). The number of those under 14 years old infected with syphilis had increased five times, for 15- 17 years old, eight and a half times and for those 18 - 19 years old, more than twelve times. In another study among 242 patients infected with syphilis and ghonorrhea (MOHMI December 1997), it was found that among those infected, there were more married than single patients, their average age was 29 years with the youngest being 18 years old; and all the women reported having one sexual partner. These findings are of major concern not only because of the rapid spread of STDs but also that it is spreading among women and housewives and not just among high risk groups such as commercial sex workers and traders.

The same study also revealed that although 78 percent knew that condoms can prevent STDs, they did not use them; and 22 percent did not know how to prevent STDs. According to MOHMI data, out of 155 pregnant women about two- thirds are suffering from venereal diseases.

The Government has developed a health care reform programme, which was adopted by the President of Turkmenistan in July 1995. The “State Health Programme of the President (PHP)” outlines the principles of health care reform and also defines a policy direction. The PHP outlines as the main policy goal the achievement of an improvement in the health status of the population and sets out a series of principles for changes in the areas of health management, finance, primary health care, hospital services, pharmaceuticals, human resources, health care infrastructure, medical research and legislation.

Under the PHP a series of wide ranging reforms are anticipated all of which have implications for the organisation and management of reproductive health services.

• Improvement of Health Management

It is planned that the MOHMI will assume more of a policy-making function by reducing its role in the operational activities of health care institutions. Accordingly, the MOHMI, velayat health administrations and Ashgabat City Health Administration will be restructured in line with new roles and responsibilities. With the exception of Ashgabat and Turkmenibashy City Health Administrations, the city health administrations will be abolished. Reorganisation should result in greater autonomy for managers at health care institutions.

• Sustainable Health Care Financing

The share of GDP for health care is planned to increase to about 5.5 percent by the year 2000. Health services will be funded mainly from government revenues. Additional revenues for health services may be generated from health insurance, user charges for some services, income from licensing of imported drugs and foreign aid. In order to ensure that the preventive services are adequately financed, government expenditure on health care will primarily be allocated to preventive services and primary health care. Resources will be allocated initially to regions and then to health care providers, according to the number of inhabitants served.

• Effective Primary Health Care

Emphasis will be placed on the improvement of primary and preventive services rather than on curative care. This will be achieved by allocating resources to primary health care from hospital services. Preventive services will continue to be financed from government revenues. Primary health care will be further improved with the introduction of family physicians and nursing care at home. Every citizen will have easy physical access to quality services related to mother and child health, family health, and the treatment and prevention of the most prevalent diseases

• Efficient Hospital Services

Services currently provided on an in-patient basis will, as far as possible, be shifted to outpatient facilities.

• Well Co-ordinated Sanitary-Epidemiological Services

The sanitary epidemiological services will be reorganised and the emphasis placed on inter-sectoral co-ordination.

• Availability and Improved Management of Pharmaceuticals

A drug supply policy and a system which ensures the continuous availability of drugs to the whole population will be developed.

• Sustainable Development of Human Resources

Human resources for health care will be subject to reform with regard to the quality and quantity of health care personnel.

• Improvement of Health Care Infrastructure

The quality of health services will be improved with the provision of appropriate medical and diagnostic equipment and a better infrastructure.

• Medical Research

Medical research will be directed towards applied research by focusing on social problems which have a bearing on health, the health status of the population taking demographic features into account, and the effects of industry and the environment on health.

• Legislation

New laws, decrees, orders or amendments to existing legislation will be introduced to provide increased health protection for the individual.

Following the adoption of the Presidential Health Programme, a need arose for the preparation of a comprehensive health plan for the implementation of the principles outlined in the PHP. In December 1995, the Lukman Health Project was initiated by the MOHMI with the assistance of UNDP, WHO/EURO and the Turkish International Co-operation Agency (TICA) to develop the National Health Plan. Part of this was the Lukman Health Project, the objectives of which were to prepare a comprehensive national health plan and improve institutional capacity. Primary responsibility for implementation of the Lukman Health Project rests with the MOHMI. The National Health Plan (NHP) of the Ministry of Health and Medical Industry (MOHMI) is based on the PHP and is expected to be approved by the cabinet in late 1998 (Ministry of Health and Medical Industry, Turkmenistan, 1998).

3.3.1 The National Health Plan

The National Health Plan (NHP) is based on the principles of the State Health Programme of the President and was completed in February 1998. Approval of the cabinet and President is awaited. The NHP aims to improve the health status of the people of Turkmenistan by ensuring health care reform in line with the Health For All principles which promotes:

• health gain in terms of improved health status resulting from interventions and increase in the measured health status of individuals and population groups, including length and quality of life;

• equity regarding the distribution of health gain with the emphasis on equal access for equal need, equal utilisation for equal need and equal quality of care for all;

• effectiveness, which implies achievement of the maximum total benefit from the resources available to a community (efficiency) and ensuring continuous improvement in quality of care with respect to the input of resources, the process of care and the outcome.

One of principles agreed in the “State Health Programme of the President (PHP)” was that Government spending on health will be directed towards those problems constituting the major health burden of the population. The strategies adopted to address these problems were decided whenever possible, to be of proven cost-effectiveness. This approach should improve allocative efficiency in health spending, giving greater improvements in people’s health for the money spent and these services will constitute a comprehensive package of priority health services.

The aim of defining a priority set of health services is to try to ensure that the entire population receives high-quality preventive and curative services to tackle the major health problems of the country. It was decided that priority services will continue to be provided free of charge to all citizens and will be funded by Government revenues.

3.3.2 Priority Health Targets

During the development of the NHP possible programmes and interventions were prioritised taking into account burden of disease and cost-effectiveness of interventions. As a group, three conditions – diarrhoeal diseases, acute respiratory infections and maternal and perinatal conditions – relate to the problems of mothers, infants and young children. This group accounts for almost a half (46.5 percent) of the total burden of disease. In addition other communicable diseases account for further significant portion of the burden of disease and analyses also indicated that in terms of health status women constitute a vulnerable group, especially during the fertile age, and that their health is directly related to child health.

Cost-effectiveness analyses undertaken by the World Bank in Turkmenistan suggest that several of the most cost-effective interventions are those directly related to reproductive health (Table-16). These include the mother-baby package, family planning and integrated management of child health. Although a detailed study has not been carried out, there were clear indications that clinic-based treatment of STDs, breast-feeding promotion and nutrition education are very cost-effective in Turkmenistan (World Bank 1996).

Therefore, by taking into account the epidemiological picture and cost-effectiveness of interventions, child health, women’s health and services for the prevention and treatment of STDs/HIV, were all accepted as among the top three highest priority areas for health services.

3.3.3 Health Service Organisation and Coverage of Services

3.3.3.1 The Current Situation

The health care system in Turkmenistan still exhibits most of the features of the system inherited from the Soviet period. The structure is extensive and service accessibility is relatively easy due to the large number of facilities. However, the system is inefficient and has insufficient impact on the current problems. The management of health services is undertaken mainly at two levels: the Ministry of Health and Medical Industry (MOHMI) and velayat health administrations (VHA). The etrap level services are administered by the chief physician of the central etrap hospital in addition to his (and it usually is a male health worker) responsibility as the head of the hospital. The management of the health system tends to be bureaucratic, hierarchical and centralised, with considerable emphasis given to the continued use of norms (or Prikaz) which originated in the Soviet period. Norms determine administrative decisions such as on the opening of new facilities, staffing levels, budgets and purchasing procedures, but also clinical management of patients. Although these norms are no longer followed so strictly as in the past, they still result in the health care system and patients being administered rather than managed.

The MOHMI is responsible for policymaking, but exercises no influence over the allocation of financial resources, which is made directly from the Ministry of Economy and Finance to the velayat administrations. Each velayat health administration reports to the haki, the head of the velayat and the MOHMI. It is not clear within these relationships where the responsibility for the health of the public actually lies. The current organisational structure of the MOHMI is a flat organisation with two deputy ministers. This organisational structure introduces less hierarchy. The deputy ministers are responsible for the activities for a number of departments, providing the opportunity for the departments to become more involved in the technical aspects of the work. As they have direct contact with the Minister, this also increases the contact of the Minister with the technical issues.

The VHA holds the administrative responsibility in the velayat. The chief physician of the central etrap hospital is also responsible for all services in the etrap, including the primary health care services, and is the budget holder for the health services in the etrap. Currently, this does not create much conflict of interest since the budgets are earmarked for facilities on the basis of line-item budgets. However, this may affect the expenditures in favour of hospitals as more autonomy is delegated in the future.

3.3.3.2 The Comprehensive Package of Priority Health Services

A key policy decision implicit in the Presidential Health Programme and articulated in the National Health Plan is that a core set of services will be guaranteed by the state. At both the hospital and primary levels certain services or items will be defined as high priority and the state will provide at both these levels a “comprehensive package of priority health services” of which reproductive health is a major component. At the primary care level this will be based on family physicians or general medical practitioners) and cover a package of services including, the mother and baby package, family planning and integrated management of the sick child. Hospitals will continue to play a crucial role in supporting the primary level, particularly with regard to maternal and child health, e.g. obstetrics and paediatrics (Ministry of Health and Medical Industry, Turkmenistan, 1998).

3.3.3.3 Organisation and Management of Health Services

Health services are mainly under the responsibility of the MOHMI. The MOHMI ensures the provision of health services through velayat health administrations (VHA) and health facilities. Political, economic, social and managerial changes in the country are compelling the health sector of Turkmenistan to review existing authority relationships and structures. The changes are aimed at stimulating improvements in service delivery and securing better use of resources according to needs. The health services in Turkmenistan will be restructured in a way that maintains accessibility for the population. In restructuring services, functions of the facilities will be the main focus rather than organisational structures. Therefore, the organisational settings are being defined to perform the required functions. The facilities will be restructured in order to ensure accessibility to the needed services and more efficient provision of these services. In the management of health services, the national health policies will provide guidelines for all health service managers and providers regardless of the level of decentralisation. However, it is generally accepted that it is crucial to define the responsibilities at each level and the magnitude of decentralisation. Central regulatory controls will be strengthened. The MOHMI will maintain functions as:

• the basic framework for health policy;

• strategic decisions on the development of health resources;

• regulations concerning public safety;

• monitoring, assessment and analysis of the health of the population and health care provision.

The VHAs will be responsible for strategic and operational planning at the velayat level, adaptation of national programmes, provision of services, financial management and information management.

The reforms introduce a special emphasis on primary health care and better utilisation of primary health care services. It is considered that many of the health problems of the population can be dealt with at the primary level. Furthermore, most of the strategies outlined for priority health targets are to be implemented at the primary health care level. Therefore, the main strategy will be the strengthening of primary health care by rationalising and rehabilitating the infrastructure, providing necessary supplies and upgrading staff.

At present the primary health care facilities in Turkmenistan are quite well distributed throughout the country and accessibility is high. In the rural areas, FAPs (Felsher-Midwife Points), SVAs (Rural Doctor’s Clinics) and SUBs (Rural Hospitals) are the main facilities involved in the provision of primary health care. The FAPs are the most peripheral outpatient health facilities and they are usually staffed with a felsher and a midwife, sometimes a felsher-midwife or a nurse. However, after the introduction of the family practice system, some felshers have started practising as family felshers in 1996. The felshers examine and treat minor diseases and prescribe certain drugs such as analgesics and antibiotics. The SVAs, the main medical service delivery points in rural areas, used to be staffed with a paediatrician, a general physician, an obstetrician and a dentist. Currently all paediatricians and general physicians in SVAs work as family physicians. The SUBs are small hospitals, typically with 25-30 beds. They provide a full range of outpatient services, which may be combined or separated from the in-patient services. Although they are organised as hospitals, they in fact serve as PHC units. During 1996 and 1997, some SUBs have been closed or upgraded to SVAs. Maternity Homes and Health Centres are usually located in the collective and state farms and are staffed by a midwife whose main responsibility is to conduct deliveries. Each has about 5-6 beds. Since 1996, their numbers have also been reduced.

In urban areas, polyclinics provide the outpatient facilities (Ashgabat, velayat and etrap centres). People are assigned to a family physician who has previously worked as a paediatrician, general physician or other specialist doctor. In addition to family physicians, several specialist doctors, including cardiologists, neurologists, gastroenterologists and surgeons, continue to work in the polyclinics. Polyclinics, FAPs, SVAs, SUBs and rural maternity homes are administratively managed by the head of the central etrap hospitals in the etraps, while in Ashgabat and Turkmenbashy cities and velayat centres, polyclinics are managed by their chief physicians. More sophisticated diagnostic tests for outpatients are done centrally by the Diagnostic Centre in Ashgabat.

Emergency services are delivered by separate emergency centres in Ashgabat City and the velayat centres, while in etraps they are managed by the central etrap hospitals.

3.3.3.4 Organisational Settings

It is planned that in the rural areas of Turkmenistan, “rural health houses” and “rural health centres” will provide primary health care services. Some of the SUBs which are located in remote areas will initially be retained and later closed or upgraded to rural health centres. The main primary health care facilities will be in the urban/city health centres. It is planned that the existing FAPs will be replaced by “rural health houses”. They will be the first contact points of primary health services at the rural level where a physician does not reside. The new name, rural health house (OSO), will reflect the new organisational understanding of integrated and comprehensive health services rather than staffing. A rural health house will typically serve a population of 300-2000.

Major activities of OSOs will be the provision of maternal care. This will include antenatal and postnatal follow up by a midwife during the six-week period following delivery. Most deliveries will continue to take place in maternity homes and etrap and velayat hospitals. In the short term, women who want to have intra-uterine device (IUD) inserted will be referred to the nearest health centre (rural or urban) or to the etrap hospitals. In the long term, the midwives working at the OSO will be trained in IUD insertion. IUD insertions will be carried out at the OSO where the midwives are certified. Rural Health Centre or OSMs will eventually replace the existing SVAs in the rural areas. Each OSM will have an obstetrician-gynaecologist who will be in charge of family planning services, including IUD insertions and in-service training of other health personnel, especially the midwives at the OSM and OSOs. Reproductive health care will be the major function of PHC.

Each pregnant woman will be followed up by the obstetrician-gynaecologist in co-operation with the family physician and midwife. Such follow-ups may take place at the health centre or at home.

As mentioned earlier, in consideration of the high infant and maternal mortality rates in Turkmenistan, all women will, in principle, give delivery in hospital. In case of home delivery, the obstetrician, family physician or a trained midwife should attend them.

The midwife at home will follow up mothers during the six weeks after delivery.

3.3.3.5 City Health Centre (Sheher Saglyk merkezi – SSM)

The existing “polyclinics” will be replaced by “city health centres”, reflecting that the focus is not just on curative issues but also on health. In general, they will run services similar to those provided by the rural health centres. They will be administratively attached to and logistically supported by the velayat health administration (in Ashgabat, the City health Administration). Each SSM will be assigned to a catchment area and be responsible for an urban population; of approximately 20,000.

The extent to which the population have access and are exposed to mass media and other IEC and advocacy programmes and activities will have implications for future programmes. Data on TV and radio ownership and accessibility are not available but it seems that almost everyone in Turkmenistan owns a television set. The popularity of television is underscored by the findings of the UNDP Living Conditions Survey 1997 (LCS) whereby the majority of respondents (88 percent) cited TV as their main source of information, followed by radio (6 percent) and newspapers (2 percent). In fact 48 percent of respondents are willing to pay for cable or satellite television, whereas hardly 11 percent and 39 percent subscribe to magazines and newspapers respectively. Currently there are no private television stations and satelite television is not yet widely available, accounting for an estimated 10 percent of households, mainly in Ashgabat.

The Television and Radio Company of Turkmenistan (TRCT), is headed by a chairman with the rank of a State Minister. It seems that TRCT operates on a small budget and with outdated equipment. Staff expertise needs updating by modern technological and artisitc standards. Programmes are produced mostly in traditional formats: talks, round-table discussions, interviews and straightforward lectures. Producers and scripwriters have not heard of the entereducate format and seem to ‘prefer’ the didactic, pedagogical approach, saying that ‘their viewers prefer them’. In the abscence of an audience survey and competition from private or foreign media it is difficult to determine the accuracy of such a view. But with limited budget and staff expertise it is unlikely that an audience survey will be conducted in the near future.

Turkmen TV broadcasts from 7 in the morning till 12 midnight everyday on each of the two national channels in Turkmen language and one Russian channel from the Russian State Television; and a Turkish channel for 2-3 hours every evening. Three out the five Velayats have their own local branch station but transmission time is limited to 3-4 hours each day. The television programmes include news, entertainment, local culture and folklore, science and technology. Of particular relevance to population and health related aspects are the programmes ‘Saglig’ a television magazine programme addressed to women and youth; ‘Nisil’ and ‘Dayanch’ are youth programmes; ‘Dayhan’ and ‘Oba Dourmouchy’ are programmes targetted at the rural audience.

The national radio network produces a number of public interest programmes on a range of topics. The centrepiece is a daily two hour radio programme aired in three segments throughout the day (at 7 a.m, 2 pm and 6 p.m) and appears to be very popular. It deals with a variety of topics on public and social life including news, health, economic development, environmental issues, produced in various formats by a team of about 35 specialists. On health issues the Health Prevention and AIDs Control Centre has a weekly 30 minute slot in this programme. There are also other programmes particularly directed at youths, children, farmers and women. But these are intermittently produced due to resource and equipment constraints.

In a country with nearly 100 percent literacy, the written word is among the most cost-effective ways of disseminating information. One of the major outlets for the printed word in Turkmenistan are found in the numerous widely circulated daily and weekly newspapers and magazines targetted at the general public as well as particular segments such as women, youth and children. Newspapers and magazines are published in Turkmen and Russian and among the most important of these are: the national daily ‘Turkmenistan’ with a circulation of 60,000 in Turkmen and 20,000 in Russian; provincial newspapers in both languages; ‘Generation’ targetted at the youth; and the Voice of Turkmen a monthly magazine. Many of the publications regularly publish special editions or segments dedicated to the specific needs of a particular target group. For example ‘Turkmenistan’ publishes monthly a whole page on family life issues and another on youth; a weekly section on education; articles on health, science; and a daily section dedicated to farmers and rural development. After 1992, with the establishment of a Department of Journalism in the Turkmen State University, it was possible to train journalists locally; before that specialised training in journalism or communication could only be obtained in Moscow. The increase in printing costs has decreased access to books, magazines and newspapers, which in turn has triggered a decrease in publications.

All three mass media offer excellent opportunities for wider dissemination of reproductive health including family planning and gender issues, as well as shaping public opinion on them. At present the involvement of mass media, especially television, on health and family planning is poor (LCS 1997)

3.4.1 Knowledge and Attitudes towards Family Planning

The Government of Turkmenistan has historically endorsed a pronatalist position and still encourages large families (WB 1994). However over a 20 year period the total fertility rate has steadily declined: from 5.9 in 1969 - 70, 5.2 in 1979-80 and 4.2 in 1990 (Bureau of Census). Birth intervals are short, averaging less than 1.5 years.

From a study by MOHMI among 6000 respondents it was found that about 90 percent have positive attitudes towards family planning; although 20 percent were indifferent to any kind of FP services and another 29 percent are unaware of family planning practices. Among women with positive attitudes to FP, about a quarter preferred the IUD. Reasons for this preference had very little to do with cost or availability but more on provider bias and the confidential nature of this method especially to women who live with in-laws who prefer large families and are against family planning. The irregular supplies of hormonal and other contraceptive methods in the health system, could have influenced the choice of contraceptive method. According to MOHMI officials oral contraceptives are not popular because women tended to forget to take them regularly and are afraid of side-effects. It was also found that about 26 percent of women use ‘lactation contraceptive’ with high failure rate, since the practice of exclusive breastfeeding has declined considerably. Among those who had undergone abortion to terminate their pregnancies, about 19 percent refused to practice contraception because of disapproval either from their husbands or in-laws. It seems that the decision regarding the number of children is not made by the woman or dictated by her physical condition but by her husband and his parents. However in the absence of a national demographic and health survey it is difficult to determine the accuracy such findings.

3.4.2 Men’s Attitudes on Family Planning

Three major opinion groups, illustrative rather than representative, were found in a 1988 KAP study of 1008 urban Turkmen.

• The first group, composed of young men 15-25 years old with secondary education or higher, want families with 4-5 children and were eager for more information on reproduction, contraception and family life;

• The second group, consisting of married men 35 -39 years old with secondary and higher education with 1-3 children, had a negative view of childspacing and favoured having many children;

• The third group, composed of men over 50 years old with 5 or more children, had mixed feelings. Although they opposed child-spacing, they recognized that the quality of children is important when building a family.

The above findings reveal that among men the desire and even the practice of having more than 2 children is the norm. However the younger generation are more open-minded and with more intensive information campaigns the oldest generation can be influenced to change their attitudes. Studies have shown that men tended to be persuaded more by economic considerations when deciding on the number of children. The present economic hardships will be a major influence in men’s attitudes and practices on FP although with economic recovery the tendency to have large families will prevail.

It seems that 67 percent of men had never seen a condom (UNFPA Mission report 1992). Qualitative studies revealed that men associate condoms with illicit sex and as a means of preventing infection from STDs rather than for preventing pregnancy. The study also found women rarely practice family planning without their husbands’ consent or knowledge; and at times the in-laws’ decisions are a ‘more powerful influence than the husband’. (JHU/CCP 1997).

At the ICPD in 1994 there was a strong consensus concerning the need to mobilise additional domestic and external financial resources for national population programmes in support of sustainable development. To provide for universal access to free quality reproductive health services in Turkmenistan, UNFPA estimates annual resource requirements to be US$13.39 million in year 2000 and US$20 million in 2015 (UNFPA 1997).

In a low-growth scenario of macroeconomic hardship and fiscal stringency, overall and public expenditure has declined in Turkmenistan and particularly in the social sector including health. As a consequence, the quality and availability of health care services has decreased.

This section sets out to analyze trends in expenditure levels on health care, to identify major barriers to resource mobilisation for population and reproductive health programmes and to suggest strategies for future consideration.

From 1991 onwards indicate a sharp fall in GDP in real terms from 1991 to 1997 to less than half its 1991 value. Real output is projected to recover slightly in 1998, but GDP growth is still narrowly based on natural resource exports and economic activity of the public sector. In 1997, only 25 percent of GDP were attributable to the private sector (Falkingham 1998). Extremely high inflation (i.e. the change in consumer prices) has characterised the first half of the 1990s, however, since 1994, inflation (Table-17) has declined and is expected to be under control by the end of the decade.

*1998 figures are projections, 1997 figures are estimates.

Source: EBRD (1998) Transition Report Update, World Bank Key Indicators 1997/98

GNP per capita was estimated at US$ 1490 (PPP) in 1989 and has declined by 38 percent to US$ 920 in 1995. Since 1989, Turkmenistan has experienced a considerable increase in income inequality with Gini coefficients rising from 0.26 to 0.36 in 1994.

From 1992 to 1996, the current account balance has been positive, largely due to exports of oil, gas and cotton. The trade account surplus is declining with the trade with Russia, however, and the official external debt is rising steadily. Increased external debt and the persistent budget deficit effectively undermine the current account surplus (BRE/CIS 1998, World Bank 1994/97/98).

In summary, continued macroeconomic stabilisation is a prerequisite for sustained output growth, employment and income. Fiscal and monetary policies that promote both private and public saving, curb inflation and mobilise domestic resources need to be adopted. However, economic policies should also seek to restore social safety nets and the provision of basic social services.

Government expenditure is the main source of health care finance but with the share of private sector participation is anticipated to grow in the near future (MOHMI 1998). In 1996, government expenditure accounted for 91 percent of total health spending, with the state voluntary scheme (VHI) comprising around 6 percent. Private sector spending, e.g. out-of-pocket payments, constituted only 3 percent of total health expenditures.

From 1991 to 1993, domestic health expenditures declined by 72 percent from 5 percent of GDP to 1.4% (Table 18). In addition, in 1993 output fell by 19%. Since 1994, public health care spending has recovered and was 3.5 percent of GDP in 1996 (Falkingham 1998). In comparison, government expenditures on education were 3.3 percent of GDP in 1996. The increase in health spending from 1994 reflects in part the overall improvement in the economy but government expenditures on health are well below the 1991 level and with inflation still high the real value of domestic health expenditures is effectively reduced.

Source: MOHMI 1998

In a regional perspective, Turkmenistan allocates less of GDP to the health sector than do several of its Central Asian neighbours and considerably less than OECD countries, which spent an average of 8.4 percent of GDP in 1995.

External assistance to the social sector has been limited and declining and there is plenty of scope for increased donor funding to the population/reproductive health sector in particular.

Source: Global Population Assistance Report 1995 and 1996 UNFPA/NIDI database on resource flows or population activities

In addition, the levels of population assistance are very low by regional standards. Turkmenistan received substantially less external assistance to the population sector, including reproductive health, than any country in the region.

UNFPA assistance to Turkmenistan began in 1992, initially as emergency assistance in the procurement of contraceptives and related training. Contraceptives were procured in 1993 and 1994 and following a Sectoral Review Mission in 1992 a project was developed for “Family Planning and Related Training” for the period 1994 to 1996 (TUK/93/P01). In addition, UNFPA has supported the 1995 population census and will provide technical assistance for the 1999 census.

Besides UNFPA, there has been some external assistance in the health sector, including reproductive health. UNICEF has provided assistance totaling about US$ five million over five years in support of programmes for immunization and diarrhoeal disease control (see UNICEF Area Office for Central Asian Republics and Kazakstan, 1997).

WHO has been involved in executing the UNFPA project mainly with regard to training. WHO also provided assistance to the MOHMI as part of the EURO/WHO project for Central Asian Countries, Azerbaijan, and Kazakstan (i.e. the CARKA Project), which is concerned with ‘the improvement of mother and child health and family planning at the district level’. UNDP funded and initiated support for a programme to reorientate medical education and WHO provided technical support. These agencies together with the World Bank and TICA (Turkish International Cooperation Agency) for the ‘Lukman (doctor) Health Programme of Turkmenistan', which was developed in 1995 and is a crucial part of the Presidential Health Programme. The funds for supporting the Lukman Programme have amounted to about US$ 800,000 and have been provided by WHO, TICA and UNDP.

The World Bank carried out a sector review in 1996 (World Bank, 1996) and is negotiating a loan for the health reform programme. It is intended that the World Bank will provide a loan of US$ 10 million to test reform interventions in one pilot etrap (Tejen). The British Know How Fund (KHF) is funding four experts, who are advising the MOHMI on health reform.

USAID has supported activities under a ‘Reproductive Health Services Expansion Program (RHSEP)’ which was developed in 1993 and aims to improve the health of women and children in five Central Asian countries. In Turkmenistan this has mainly concentrated on expanding reproductive health services with the aim of reducing the dependence on abortion for family planning. Other USAID Cooperating Agencies including AVSC and JHPIEGO have carried out activities under the RHSEP Project, mainly consisting of training in up-to-date contraceptive technology, infection control, counselling skills and clinical training. (Cromer C, Collins C, Seltzer J, Makhmudova S 1998).

4.2.5 The 20/20 Initiative

In 1994, the ICPD recommended the 20/20 initiative as a spending target and quantifiable goal for stable and adequate level of funding to meet the basic social needs of the poor. Subsequently, in 1995 at the World Summit for Social Development, there was strong national and international commitment to the 20/20 initiative. It requires the donor community to provide adequate aid flows to enable recipient governments to give high priority to the provision of basic social services by allocating at least 20 percent of government expenditures

To maximize expenditures for human development, UNDP in the Human Development Report has suggested four indicators should be closely monitored. They are:

• The public expenditure ratio - the percentage of national income that goes to public expenditure;

Of the four indicators, the human expenditure ratio is the overall figure intended to measure governments' efforts to improve the living conditions of people through direct budgetary action. It is the product of the other three ratios.

In Summary, negative economic growth and high inflation has adversely affected the mobilisation of resources for basic social services, including essential reproductive health care. In addition, income inequality has increased dramatically in just a few years and demand for equal access to basic social services is rising; The Government is running a persistent budget deficit with negative impact on the current account. Government expenditures as a percentage of GDP have declined sharply since 1991; Total domestic health expenditure as a percentage of GDP declined by 44 percent from 1991 to 1995. In 1996 expenditures showed sign of recovery. Lower public expenditures indicate both large cut backs in the public sector and increasing expenditures by the private health sector; Foreign aid to the social sector has declined in aggregate. Aid levels to the population sector have been low and declining throughout the decade.

The prospects for raising additional resources for the population and reproductive health areas in Turkmenistan depend on the Government's ability and commitment to economic stabilisation, including privatisation, and efficient tax collection. However, within overall expenditures for human development priorities, it is important to ensure that funds are used as productively as possible, both in terms of targeting of funds on cost-effective interventions, as well as cost efficiency of operations.

The National Health Plan (NHP) proposed by MOHMI reflects substantial efforts aimed at enhancing efficiency in the use of limited resources, to improve quality of services, to improve cost-effectiveness and to target the most vulnerable sections of the population. Resources are to be increasingly reallocated to primary health care particularly through the introduction of a package of essential services, including basic reproductive health care. However, a number of constraints continue to impede progress towards resource mobilization for effective reproductive health care.

At present, resource allocation to the health care system in Turkmenistan is based on a rigid central structure inherited from the Soviet era. More efficient use of resources through better targeting requires an information base to identify the areas and population groups in greatest need of support. Furthermore, human resource development needs to be improved to increase the cost efficiency and technical efficiency of the resources used.

Resource allocation to oblasts. The resource allocation mechanisms to the social sector rest on former Soviet budgetting procedures. In the Turkmen health sector budgetting decisions are based on normatively defined criteria related to infrastructure (e.g. number of hospital beds) and utilization (e.g. bed occupancy). The Ministry of Economics and Finance (MOEF) allocates resources to oblasts and velayats. Variations reflect supply and workload and not differences in the needs of the population or performance (health outcomes) (World Bank 1996).

In response to the current infrastructure-based resource allocation, the Ministry of Health and Medical Industry has proposed a population-based mechanism, which should allow for geographical variations in age/sex structures and morbidity of the population and thus correct for discrepancies in the burden of disease across oblasts and velayats. This formula would better reflect the Government's priorities of maternal and child health care.

To make needs-based allocation functional a few caveats should be considered. First, commitment and coordination across ministries is critical so as to avoid funds continuing to flow directly from MOEF to oblast administrations. Secondly, it is critical to improve the capacity of oblast health administrations and the MOHMI through training in financial management, health economics and communication skills.

Resource allocation within oblasts (Provider payments). The system of provider payment is an extension of the central allocation system. At the hospital level, managers calculate their resource requirements each year, which are then revised according to the resource availability at the velayat level. In general the system is inflexible in as much as hospitals are allocated budgets according to line items with no authorisation for virement.

The current payment mechanism contributes to inefficiency, e.g. occupancy levels used for budgetting are related to the length of stay. If two hospitals treat the same number of patients and one hospital reduces the number of bed days per patient in a given year to save money for medicines that hospital gets penalised with a reduced budget the following year.

Payment of primary health care of which a large amount is provided through hospitals suffers from the same inefficiencies and lack of incentives for increased effectiveness and quality in delivery.

As the Turkmen health sector suffers not only from under funding but from severe inefficiency, there is a case for mobilisation of resources through improvements in the cost efficiency with which services are delivered.

Rationalisation: A prominent feature of the health system is the overemphasis on the role of hospitals in health care, which in turn suffers from a number of shortages. Large savings can be made in the health sector when facilities or parts of facilities are closed. Operating costs are minimised by closing underused and poorly located or duplicative-sited units and amalgamating their functions into other units.

The hospital level is characterised by excessive number of doctors and hospitals, in part because of the infrastructure-based budgetting system. The high number of resource inputs is often exacerbated by emphasis on relatively expensive specialty-based inpatient care as against alternative primary cost-effective care. Rationalisation of services, and equipment and beds at the hospital level is critical to more effective use of resources (World Bank 1996).

A study undertaken in the Tejen district recommended bed closures and a reduction in the average length of stay via updating treatment protocols, moving dispensaries of STD and ophthalmology to acute hospital sites, and the closure of two SUBs. The estimated savings of the rationalisation lie between 4-7 percent of the total district health budget (Hensher 1997).

Integration at the primary care level: Turkmenistan is unlikely to have the resources to immediately implement the reproductive health package all at once. Instead, selected reproductive health services have been introduced at the functional level into the existing family planning and MCH programme.

Recent research indicates that integration of components of reproductive health services in existing programmes is affordable:

1. Incremental additional reproductive services add little to total costs because the bulk of expenditures is already incurred for staff and facilities which are the largest recurrent costs;
2. There are considerable cost savings from combining services where more than one item of service is addressed in one visit such as IUD check combined screening for RTI, and from the use of specially trained nurse-midwives instead of doctors; and
3. Underutilisation where total costs are allocated over a smaller number of outputs, hence the cost of adding reproductive health services will be low. The MOHMI expects utilization to generate considerable savings through a reduction in hospital admissions and a shift away from self-referrals. At present, these are bypassing the local rural health facilities in favour of polyclinics and hospital-based outpatient clinics at the district level (Mitchell et al. 1996, MOHMI 1998, Walker 1998, World Bank 1996).

The essential package of basic health services: Integration in the form of an essential package has proven to be the most feasible way of effective delivery of basic reproductive care. Provision of essential services is associated with large positive externalities and with several interventions characterised as (semi) public goods. Government provision of an essential package thus is likely to capture considerable benefits to the society at large.

Apart from 'social' benefits, there are large financial gains from concentrating government service delivery on a few selected essential health interventions of proven cost-effectiveness. Recent research and experience suggest that operating costs facilities offering essential care are low (Savas 1998).

As part of the ongoing reforms in the health sector, the MOHMI is proposing the implementation of a package of seven essential interventions of which the reproductive health interventions are the most cost-effective using disability-adjusted life year (DALY as a measure of health outcome (MOHMI 1998). The package is described in detail in chapter 3.

A potential problem with total government financing of an essential package is that indirectly can lead to subsidies to the wealthy, who can afford their own services. However, in taking into account equity in essential delivery, emphasis should be given to improved access rather implementing expensive targetting of the poorest segments of the population.

Drugs: Government budget problems have had a negative impact on provision of free drugs, which combined with falling incomes and large co-patient payments have made (essential) drugs increasingly unaffordable to providers and clients.

In addition, the quality of drugs is in question owing to decentralised procurement, parallel markets and insufficient government control and inspection. Consumers are unprotected and can buy drugs in the street without prescription and quality guarantee (Savas 1998, THDR 1996)

Supplementary to the strained government health budget, generation of additional domestic funding might be a feasible option in the medium and long term. This could both be in the form of public and private (voluntary) health insurance, imposition of user charges for selected services and privatisation of selected cost intensive operations, e.g. medical equipment production.

Health insurance: Health insurance schemes, either public or voluntary, has begun to be established in most CARAK countries. In Turkmenistan, the Government is currently raising additional income from insurance contributions under the State Voluntary Health Insurance Scheme (VHI) established in the beginning of 1996.

The VHI scheme is for wage earners, pensioners and students. Seventy-five percent of the population is currently covered by the scheme, either directly as contributors or as dependants. Contributions are set at 4% of gross annual income, with the self-employed paying 4% of the average wage nationally, a figure that has been fluctuating during the transition. In 1996, the VHI accounted for about 6% of total health spending. This share is anticipated to rise over the next ten or so years (MOHMI 1998).

As most health insurance schemes in Central Asia, the affordability and feasibility of the VHI are critical issues that need to be resolved before the scheme can be expected to be financially sustainable. Affordability of medical insurance is likely to be low to both employee and employer considering the cost-escalation of pharmaceuticals from increased demand. Also, the imposition of a payroll tax increases the cost of labour to employers, which may be inappropriate considering the general recession. Finally, workers and other groups under the scheme (either directly or indirectly) already pay a considerable proportion of their salaries for social security and may not want to contribute to an insurance scheme (World Bank 1996).

As regards the feasibility of collection, a payroll-based insurance scheme like the VHI is likely to be affected by the degree of industrialization and the presence of existing organisational structures. The financial sustainability of the VHI scheme is in question, as the agricultural sector is accounting for a large proportion of employment in Turkmenistan and the organisational structures are falling apart (World Bank 1996).

Fee-for-service: User fees have been introduced for selected services in Central Asia with the expectation of raising additional revenue for the public sector. In Turkmenistan, with the adoption of the State Health Programme of the President (PHP) in 1995, a number of user charges were introduced in addition to charges for outpatient prescriptions, in an attempt to raise revenue for the health sector. These charges tend to focus on a limited range of diagnostic procedures, dental care, and services such as acupuncture and massage. Fee-for-service represent about 3 percent of total health expenditure.

One of the central arguments for initiating user charges was that it would generate additional income to the public sector. In 1996, approximately US$ 350,000 was generated from user charges, which is only a small a small nominal amount of overall revenue (MOHMI 1998). Other arguments have to do also with increased incentives for quality and efficiency improvements on the part of the service provider.

Official user charges apply to all pharmaceuticals prescribed for outpatients unless one is covered under the VHI scheme. Also, charges are now applied to self-referred patients and for a variety of services. Prices for charged services are determined nationally by the MOHMI together with the MOEF.

In addition to official user charges, unofficial charges are becoming increasingly predominant in service delivery, although the actual magnitude is not known. Anecdotally, these are said to be substantial. A household survey from the Tejen district found that over 50% of people interviewed had made payments for medical care (Ladbury 1997). Unofficial fees thus seriously overburden already falling household incomes.

Privatisation. Across the Central Asia region, privatisation of loss-making public enterprises is likely to generate considerable cost-savings in the public sector. Privatisation also of the provision of health care has marked consequences on equity. Turkmenistan is yet to launch a comprehensive privatisation scheme. At present, private sector provision constitutes only a small fraction of total health expenditure.

If not carefully regulated, privatisation of pharmaceutical manufacturing is likely to have a significant impact on the availability and affordability of quality (essential) drugs. Unlike other Central Asian governments, Turkmenistan has not decentralised procurement, which puts it in a position to ensure quality to the clients.

To underline the need for reciprocal commitments by the Turkmen Government and the donor community, UNFPA has been advocating that at least 20 percent of total ODA be allocated either bilaterally or through multilateral agencies and NGOs in support of basic social services, including reproductive health. It is important that both the Government and donors engage in dialogue to strengthen existing partnerships and to build new alliances in order to improve programme implementation and the cost-effective use of available resources.

• Establishment of a coordinating mechanism under the Cabinet of Ministers for population and development in order to strengthen the linkages between various sectors such as health, education, women’s development, social welfare and other agencies.

• A longer term planning perspective ranging over 10 to 15 years would be necessary for demographic, economic and social policy formulation.

• Assisting the collection, analysis, report writing and dissemination activities for demographic data with adequate gender disaggregation. The National Institute on Statistics and Forecasting requires immediate assistance in human resource development and in utilisation of necessary computing equipment. Similarly, the Census Department would require technical, financial and equipment support.

• The monitoring system for population and development requires strengthening. The existing national capacity in this area is limited and therefore, donor support is very much required. An assessment of specific gaps in national potential for population and development planning would be required and training should be more focussed on these needs. Training of trainers is a particularly effective strategy in Turkmenistan because of language consideration.

• In the area of population research and training, support is urgently needed. Research efforts need to be funded in a way that helps utilisation of research findings for programme planning. Establishment of a population research and training centre is a priority.

• The use of mass media for increasing the awareness of healthy way of life, family planning and the role of family in primary health care will be essential. In this context, the involvement of NGOs and local community in programme planning and implementation would be required.

“by the year 2001 to have reduced maternal mortality by 30percent infant mortality by 10percent and perinatal and neonatal mortality by 10percent, and at the same time to have achieved substantial improvements in the health status of neonates, children, adolescents and women of reproductive age” .

Although the health services are physically within easy reach of the population, primary health care in Turkmenistan is not fully integrated and the relationships between PHC units and specialised services (such as STD control) are weak. The PHC units, especially the ones in rural areas, have very limited diagnostic facilities. The available equipment in these units is generally, old and out of date, and much of the equipment is not functioning properly. The physical and sanitary conditions of rural health institutions are very poor. Many of them do not have piped water systems or toilets in the buildings, including the maternity unit in the second largest city Mary. Besides having large numbers of health facilities (with 10.2 hospital beds per 1,000 population), Turkmenistan has also a large number of trained health workers (with 314 physicians, 674 nurses and 90 midwives per 100,000 population in 1995, see WHO/EURO 1996; WHO 1997). Twenty per cent of all physicians in Turkmenistan are involved in PHC. However, the types of physicians found in Turkmenistan are different from those found in many other countries. To a great extent they function as specialists and only perform a limited range of functions.

There is a serious lack of all types of medicines in Turkmenistan. There are no or only very limited supplies of drugs in FAPs, SVAs and SUBs. Patients have to buy their drugs, which are prescribed by the local physicians, from pharmacies in the towns. In most cases drugs are provided late or not at all. Irrational prescribing is common and generally medical and pharmacy professionals are not cost-conscious.

The National Health Plan argues that most of the high priority health problems in Turkmenistan can be addressed at the primary level. The basic infrastructure already exists, however, resources need to be shifted from the current emphasis on hospital-based provision of health services to strengthening primary health care services.

The proposed developmental strategies and principles for the provision of PHC in the country are:

• PHC services will be available, accessible and affordable to the population in the country;

• PHC services will be designed and provided in a way that is acceptable to the community;

• all PHC-related activities will be integrated at service level;

• the emphasis will be on preventive services and health promotion;

• services will be provided by a team, appropriate to the level and location, under the leadership of a family physician;

• each member of staff will have an appropriate and clear job description;

• the PHC units will be rehabilitated and strengthened through the acquisition of appropriate equipment;

• an effective referral system will be implemented and PHC institutions will be supported by secondary level institutions;

• PHC will be continuously supervised and assessed.

• the maternal mortality rate will be reduced to at least 50 per 100,000 live births;
• birth spacing will be increased to at least three years;
• the infant mortality rate will have been reduced by at least 25 percent;
• mortality caused by acute respiratory infections among children under the age of two will be reduced by 30 percent from 1996 levels;
• mortality caused by diarrhoeal diseases will be reduced by 30 percent from 1996 levels;
• vaccine coverage will be at least 95 percent.

5.2.1 Strategies to Improve the Health of Women and Children

Females make up just over a half (50.6 percent) of the population of Turkmenistan (1997). More than half of them (54.6 percent) lives in rural areas. The health of females in Turkmenistan is notably affected by social and biological factors, namely the high number of deliveries and short intervals between deliveries. Maternal mortality is relatively high, at 81.9 per 100 000 live births (1997). Haemorrhage was the most common cause of maternal death in 1996 at 26 percent of the total; complications of abortion, hypertensive disorders of pregnancy (especially eclampsia) and sepsis are other major causes of maternal mortality. Anaemia is extremely common with almost a half of pregnant women being either moderately or severely anaemic.

The health status of women is worst in Dashowuz velayat, which is the region bordering the Aral Sea and has the most unfavourable environmental conditions. Among females of fertile age living in Dashowuz velayat almost 98 percent, reported some illness in comparison to among 82 percent females of fertile age in the country as a whole. Another group with extremely low health status is women who have had more than five deliveries (grand multiparous women). This group has a high level of non-reproductive system pathology, as well as more frequent complications during pregnancy and delivery. The rate of anaemia among multiparous women is considerably higher than for other women (UNICEF Area Office for Central Asian Republics and Kazakstan 1997).

The health of infants is to a great extent affected by the health of the mother and complications arising during pregnancy and delivery. Moreover, birth spacing plays an important role in child health. Often, multiparous women have birth spacing of less than 1.7 years. This situation is paralleled by low use of contraceptives. The low prevalence of use of contraception (estimated at about 15 percent in 1995) in Turkmenistan is associated with the high birth rate and low birth spacing. IUD is the most popular mode of contraception (86 percent) of all contraceptive methods, followed by oral contraceptives (8 percent), injectables (5 percent) and condoms (just over 1 percent).

Since independence in 1991, there has been ambivalence about the desirability to restrain the growth of the population of the country. The Government has not been concerned per se about the size of the population of the country as it is felt that given the undoubted and relative abundance of natural resources, in time the country should be affluent. However the Government has given priority to measures to help attain ‘healthy mothers and children”.

This is as part of the “State Health Programme of the President” (PHP) approved by a Presidential Resolution in 1995 (No.2297) and which is closely connected to improving reproductive health. One of the priorities of the President’s “State Health Programme” is the development of a National Programme for Maternal and Child Health Protection, which includes family planning and improved nutrition. A draft of the programme has been prepared and is awaiting presidential approval.

It is planned that a series of measures should be taken directed at reducing the numbers of high risk and unwanted pregnancies, reducing the numbers of obstetric complications and reducing the case fatality rate in women with complications. The measures will include:

• ensuring that felshers, midwives, family nurses and physicians at all levels in the health system have the appropriate knowledge and skills to manage normal pregnancies and deliveries and to detect, manage and/or refer high risk cases and complications. All birth attendants, midwives, felshers and doctors will be aware of the need to refer cases of prolonged and obstructed labour to a higher level of care;

• all pregnant women will have access to basic maternity care, comprising quality antenatal care, clean and safe delivery and postpartum care;

• all pregnant women will have a minimum of four antenatal visits for prevention and early detection and management of complications;

• all pregnant women will be examined for anaemia as part of an antenatal check-up;

• services related to termination of pregnancy will be high quality, equitably distributed and accessible to those in need;

• availability of and accessibility to adequate family planning information and services will be ensured in order to reduce the number of high risk and unwanted pregnancies and to achieve a consequent reduction in maternal deaths;

• an optimal range of contraceptives will be available free of charge to meet the needs of the widest possible range of users;
• adolescent girls and boys will be educated on issues related to reproduction, human sexuality and the inadvisability of early marriage and pregnancy;

• a major IEC strategy will be developed, focussing on birthspacing and birth timing as important health measures for mother and child.

In this context, the following strategic recommendations are relevant:

• A demographic health and survey or similar type of survey would be required to generate reliable information on reproductive health status, use of RH services and attitudes to RH issues among men and women, the contraceptives prevalence and method mix.

• The contraceptive logistics systems including procurement, regulation of pharmaceuticals (including contraceptives), supply and distribution system would have to be improved.

• There is a need to extend choices of contraception to include for example, sub-dermal implants, female condom, emergency contraception, vasectomy and female sterilisation.

• Training of providers in the rationale use of contraceptives; including competency based training in clinical contraception (minilaporotomy, vasectomy, IUD insertions, etc.) and counselling skills.

• Revision of clinical ‘norms and standards’ (prikas) used for maternal health care, abortion care and management of reproductive tract infections.

• Systems to encourage the practise of ‘good quality reproductive health care’.

• Provision of regular scientific information to medical universities and medical practitioners to assist them in the practise of ‘evidence based reproductive health care’.

• IEC for demand creation for family planning services and on reasonable use of maternal health care and services for reproductive tract infections, including STDs and HIV.

5.3.1 IEC/Advocacy Strategies and Programmes

The Centre for Health Prevention and AIDS Control, MOHMI responsible for health education, is well-organized and staffed by active and dedicated personnel, and has the necessary support from the Ministry and government. Before independence it was a centrally controlled State organization called the ‘House of Health Propaganda’ and its mandate was to promote atheism and healthy life styles. Post-independence, it continues to promote healthy lifestyles through doctors and other medical personnel from health facilities and schools. Since April 1997 the Centre was amalgamated with the AIDS Control Centre.

Prevention through health education is clearly a government priority. A government decree has made it mandatory for every doctor to spend 4 hours a month on health propaganda. Among the aims of the Presidential State Programme of Turkmenistan ‘Health’ is to develop responsibility among the community for both individual and societal health through the education and public health system, mass media and other social institutions. For this purpose, the State Programme has planned an extensive ‘healthy lifestyle medical propaganda’ which would include the following:

• introduction of a mandatory course on healthy lifestyle in the school curriculum;

• introduction of ‘health for all’ into all mass information systems (newspapers, journals, periodicals, radio and television programmes);

• ban on advertising of harmful substances such as alcohol and tobacco;

• ban on smoking in public places; and

• mass distribution of popular and scientific publications, visuals and other information on healthy lifestyle.

The success of the healthy lifestyle campaign will be ensured through a multisectoral approach, integrating the activities of state public health organisations with that of education, culture, tourism, mass media and other social organisations and taking into consideration the demographic and traditional features of the country.

The Centre has in place an extensive infrastructure which has the potential to reach every village, health facility and school. There are centres in each of the 5 regions or Velayats, whose activities are coordinated by the National Centre.

Health education at the community level, including schools and industrial establishments , is carried out mainly by the family doctors. According to the Centre’s Director the family doctors are carrying out more than the mandatory 4 hours per month of health education; but without a systematic monitoring plan or the means to do it, the Centre has no way to determine if this is actually happening or to assess the quality of the health education activities. The importance of the family doctor as a source of reliable and credible information cannot be emphasized enough; according to LCS the family doctor is the main source of information on health. It is not clear what kind of support is provided by the Centre’s staff to these family doctors who have had no training in communication and education methods. Moreover the Centre’s staff themselves have little knowledge and expertise in communication planning and education methods and techniques.

The Centre has good working relationship with TV and radio. Thirty minute television programmes on health are aired three times a week, and once a week on radio, also for 30 minutes. These programmes are targetted mainly at women in the reproductive age group, pregnant women, housewives and adolescents. So far no audience survey has been conducted to obtain feedback on the programmes. Although there are TV and radio stations in 3 Velayats, production is centralised and undertaken jointly by the National Centre together with the central TV and radio stations.

A UNFPA funded project on IEC, Population Policy and Advocacy Support to Reproductive Health/Family Planning Programme in Turkmenistan, started implementation in May 1997. An innovative feature of this project is the training and capacity building of selected NGOs involved in women and youth activities, to undertake RH advocacy and IEC activities. Twenty- two NGOs were trained on reproductive health issues, project development and management. Subsequently 14 submitted project proposals out of which 6 were selected for UNFPA funding support. The project will also build the capacity of the Ministry of Education to develop a family life education curriculum and develop teaching materials on sexual and reproductive health which will be incorporated in the syllabus of class 9 students who are mainly 16-17 years old. A third aspect of the project is to support the health education efforts of the Health Prevention and AIDS Control Centre through the development of IEC materials for the electronic and printed media and for clinic and service delivery points; and training Velayat level service providers on health education and counselling skills. The project’s activities on improving public knowledge and awareness on safe and effective modern contraceptives, were designed to complement another UNFPA funded project TUK/96/PO2 ‘Improving Reproductive Health Services and Access to Family Planning in Turkmenistan’. In reality coordination between the two projects will need to be strengthened. Three research activities initiated under this project will provide useful insights on teenagers and their parents’ reproductive health behaviour and on the quality of RH services. One is a KAP survey of 2500 teenagers and their parents to identify the major determinants of RH behaviour, including their knowledge and attitudes on specific RH issues. The second is a baseline survey focussing on access and exposure to the mass media among a representative sample of 2000 households. Third is a qualitative research on the quality of IEC and counselling during RH service provision to assess the frequency, intensity and level of unmet needs for information and counselling. Results of the research are expected by the end of 1998.

5.3.2 Adolescent Reproductive Health

The population of Turkmenistan is very young as 48 percent is below 18 years old. LCS found that 40 percent of the survey population were children younger than 16 years old.

A KAP study on reproductive health was conducted in early 1998 on over 2500 teenagers between the ages of 14-19 years old and their parents. Preliminary results have yielded some very interesting findings and will be extremely useful when developing adolescent reproductive health strategies and programmes. Among them are:

• Knowledge on contraceptive methods is highest (83 percent) among 18 year olds and lowest (24 percent)for 14 year olds. There is no difference in the number of boys and girls (59 percent) who do not know about contraceptives. Television and friends are the main sources of information on contraceptives. The majority of boys (73 percent) know about condoms; for girls many (41 percent) know about IUD, than any other method.

• About 47 percent of teenagers know about STDs. Among them 60 percent know that using condoms can protect against STD infection. More boys ( 58 percent) than girls (46 percent) know of this. Main sources of information on STDs are parents, friends and doctors. Teachers and printed materials were the least quoted sources.

• Regarding gynaecological (preventive) examinations, 42 percent of the girls had positive attitudes towards it, a substantial number (36 percent) were embarassed to undergo such an examination while 11 percent were afraid of their parents. On the other hand many parents, especially in Ashgabat were agreeable to have such examinations conducted on their daughters.

• A significant number of parents (45 percent) were not against abortion. Interestingly, 82 percent of parents want their children to know more about the after effects of abortion.

Although still in an embryonic stage , the school system with technical assistance and funding support from UNFPA had developed a curriculum intended to improve the sexual and reproductive health knowledge of students in the ninth grade. As a pilot activity, in early 1999 sixteen year old students from 10 schools (8 in Ashgabat and 2 in Ahal Velayat) will be introduced to a comprehensive family life education (FLE) curriculum comprising of the study of the anatomy and physiology of the reproductive organs, sexuality and reproductive health issues, contraceptives, marriage and family relationships, personal and negotiation skills. Gradually this curriculum will be introduced to students in the same grade in all 1917 schools in Turkmenistan. The lack of teachers trained in the subject and educational materials could hamper the rapid development and expansion of this programme to all schools.

There are as yet no immediate plans to introduce this FLE programme to other grades and the decision will naturally depend not only on the success of the pilot programme but on the response of parents, community and religious leaders. The school authorities are aware of the necessity to inform and educate parents and community/religious leaders of the importance of such a programme to pre-empt any negative reactions from them.

A number of NGOs have supported out-of-school activities for youths such as Women’s Organisation of Turkmenistan, Youth League of Turkmenistan, Gengeshi (on religious affairs), and National Organisation of Red Cross. They have sponsored drawing competitions for children and young people on ‘My family and my World’ ‘For Healthy Life’ and sports activities.

Strategic advocacy actions are needed to gain the support of national and local leaders on many issues: improvements in women’s health and economic status, NGO status as equal social partners with the government, family planning and reproductive health issues, including male responsibility and participation and adolescent reproductive health. In a newly independent country where the legislative agenda is being formulated, revised or modified, this is an opportune time to build alliances and advocacy support at all levels of the legislative and judicial authority, and among regional, district and local councils; to put on the agenda of policy makers reproductive health and gender issues; and to institutionalise the political commitment and programmes aimed at improving gender roles and equity.

It is important to make a conscious effort to improve women’s economic and health status. Slow economic reform recovery and increasing unemployment, especially for women has made it more and more necessary for women to engage in income generating activities. In some cases they are the major, if not the primary income earner in their families. It is harder for them to obtain loans because they are often discriminated against by banks and moneylenders. In many cases self employment is their only means of survival because of lack of education or skills relevant to a market economy.

4. Improving male attitudes on reproductive health

Men must adopt a more responsible attitude and behaviour towards reproductive health and ‘male’ friendly strategies must be developed to achieve this. This would include: providing reproductive health messages through male outreach workers, community and religious leaders and the mass media; and organisations frequented by men. Improving interspousal communication is another important aspect of ensuring that both women and men practice safe sexual practices.

The capacity of NGOs as sources of information on reproductive health and gender issues should be strengthened. Women NGOs should be encouraged to become strong advocates for reproductive health rights and improving the status of women, from the grassroots to the highest levels. They should be exposed to opportunities for experience and information exchange, to social communication methods, effective ways of working with the media and to successful projects in other countries.

The media particularly radio and TV should be extensively used to disseminate information for advocacy purposes. The skills of radio and TV producers should be upgraded to improve programming standards on reproductive health and gender issues. In collaboration with the Centre for Health Prevention and AIDs Control, the possibility of establishing listener and viewer groups to discuss the TV and radio programmes with a trained health worker should be explored. Audience surveys should be initiated to determine needs and to obtain feedback on the programmes.

Communication strategies should include mechanisms for using relevant data, such as community-based research on local attitudes and practices. Where important data is lacking, communication research and planning should take the initiative to collect data in a participatory manner. These same methods could be used to improve the professional skills of health workers including health education personnel, family doctors and felshers on communication and education techniques, interpersonal communication and counselling..

Clients need information on most aspects of reproductive health. To that end it is recommended that client information materials are developed and distributed through rural health centres, local NGOs and the local community councils. Other ways to reach clients are: Training of peer counsellors in how to encourage community councils and communities to hold education and information sessions; and continued training and education of service providers to help them as providers of information, counselling and contraceptive services to clients.

The present mode of health care provision is unlikely to be sustainable. There is an urgent need for Government and donor action if the persistent decline in health spending and efficiency in health care are to be arrested.

In view of the continuing difficulties with the national economy, significant increases in government revenue are unlikely in the medium term. Strategies for increasing domestic allocations to reproductive health necessarily should emphasise gains from improved efficiency in management and cost-effectiveness in delivery.

To increase financial sustainability, UNFPA recommends quantifiable spending targets, as they (i) help ensure that budgetary allocations for human development priorities are not cut disproportionately in times of budgetary constraint, and (ii) signal to the donor community a firm commitment to social development, which should in turn encourage donor support. The '20/20' is an advocacy tool for mobilizing resources for reproductive health, including family planning and sexual health, in the 1990s. It involves both Government and donor commitment and action.

Consistent with the principles of the State Health Programme of the President, it is likely that the following actions will improve the possibility of providing efficient reproductive health services.

• Reorganising health financing:

Allocation to oblasts: To develop an allocation formula that reflects the health care needs of the population and the performance of services. Along the lines of the NHP, a formula based on age, sex and morbidity (e.g. standardized mortality) would help ensure that resources go to where they are most needed and thus improve the overall cost-efficiency of the health care system. Allocation of velayat-level budgets should reflect population size, using appropriate weights rather than infrastructure. Transition should be gradual for the affected regions to accommodate the changes, whether increased or reduced allocations, and thus not hamper services;

Allocation within oblasts: There is a need to develop a provider-payment mechanism that stimulates delivery of outpatient and quality services as well as performance at the primary care level. Central to the NHP is the strengthening of the primary level. It proposes a host of comprehensive changes partly to direct more resources towards the PHC sector and partly to continue to develop the network of family physicians but with revised payment systems including changes to introduce patient choice.

At the hospital level, there is a need to introduce global budgets in all oblast hospitals and selected pilot state hospitals in order to increase incentives for better targetted quality services. The new payment system should be simple to avoid unnecessary administrative costs and to be integrated with existing structures. It should, however, be sufficiently sophisticated to take into account the main complexities of providing care at a given level of the system. At each level it is important to complement changes with the development of appropriate institutional and human resource capacities.

• Minimising costs:

Rationalisation. To continue reducing the number of unused and unprofitable facilities at both the primary and hospital level based on careful evaluation of selected services, equipment and beds in oblast and central hospitals. It is important that the potential social impact is taken into account through careful examination in order not to hamper service delivery and overall quality of the health system. Furthermore, the alternatives for rationalised services should be examined. If a facility is closed, it should be defined where to the functions are going to be transferred. The infrastructure for shifting functions to the primary level should be ensured;

Integration. To integrate reproductive and family planning services at the primary care level as a central component of an essential package of health services provided by the Government. The selection of basic services for the essential package should be subject to careful needs assessment and proven cost-effectiveness.

Privatisation. Privatisation may lead to a two-tier system of differing qualities and distribution, and thus damage the access of vulnerable groups to health care.

If privatisation is to deliver greater efficiency, a set of complementary policies is necessary. Regulation is necessary, including the establishment of national standards for personnel and institutions, especially to avoid undesirable economies of scale. Development of a contracting framework will be necessary for purchasers and providers of services. To develop the private sector, purchasing power should be secured whether purchasers are public, private insurance organisations or individuals.

• Private sector participation:

Cost recovery. User fees might be initiated for selected non-priority health services at the primary and hospital level. It is critical that fees apply to services not covered by the package of essential services. Identification and implementation of services should be transparent and simple and price setting should be based on estimates of income and price elasticities from individual oblasts in order to ensure equity in delivery;

Health insurance. Consideration might be given to revision of the VHI scheme, which is already in place, in order to ensure affordability and the feasibility of its implementation and collection. If additional (true) voluntary insurance schemes are to be provided for, the Government must ensure insurance of high-risk groups and those most in need (e.g. through ear-marked subsidies);

Mixed modes of service delivery. To explore feasible combinations of public and private (for-profit or NGO) sector financing and delivery. It is important that the Government finds partners in the private and non-governmental sectors to supplement provision and delivery of basic social services to the population.

• There is a need to raise additional amounts of foreign assistance for the social sector in general and health in particular. Efforts should go to attracting grant assistance rather than loan-based assistance and to work towards better coordination of donor financing;

• Duplication of efforts and imperfect information across the donor community should be minimised in order to best utilise existing and future commitments in the population and reproductive health sector;

• The donor community should work towards reduced programme costs (and increased effectiveness in delivery) through increased programme efficiency. This could be done partly through improved monitoring (and evaluation) of programmes (including greater use of operations research).

To work towards greater accessibility and availability of government expenditures by programmes and by budget sub-heads. This would not only improve transparency about actual expenditure but allow for better and more realistic budgetary analysis and meaningful monitoring of public spending

UNFPA assistance to Turkmenistan began in 1992, initially as emergency assistance in the procurement of contraceptives and related training. Contraceptives were procured in 1993 and 1994 and following a Sectoral Review Mission in 1992 a project was developed for “Family Planning and Related Training” in Turkmenistan for the period 1994 to 1996 (TUK/93/P01).

In 1997, UNFPA and the Government, covering population assistance for 1996 and 1997 signed three projects:

• “Equipment and Contraceptive Support for the Reproductive Health facilities in UNFPA Project Sites in Turkmenistan” (TUK/96/P01) for the amount of US$ 553,000;

• “Improving Reproductive Health Services and Access to Family Planning in Turkmenistan” (TUK/96/P02) for US$ 563,519; and

• “IEC, Population Policy and Advocacy Support to the National Programme of Reproductive Health Services and Access to Family Planning in Turkmenistan” (TUK/96/P03) for US$ 592,600.

The first of these projects had the objectives of strengthening the existing reproductive health services including those for maternal and child health. The project inputs consisted almost entirely of medical equipment for six reproductive health clinics and other maternal and child health clinics, the procurement of contraceptives including condoms, oral hormonal contraceptives and IUDs. The Government executed this project.

The second project was executed jointly by UNFPA, the Government and WHO. It had the objectives of strengthening national capacity for formulating and implementing reproductive health care. The project focussed assistance on establishing a reproductive health resource centre in each velayat and Ashgabat.

The third project aimed to strengthen national capacity in the formulation of IEC and advocacy strategies; and there by improve access to about 30 percent of the rural population and 50 percent of the urban population. Project inputs included expert technical assistance, equipment for developing IEC and advocacy interventions and training of nationals in modern techniques.

In addition, UNFPA has supported the 1995 population census and will provide technical assistance for the 1999 census.

So far, there has been some other external assistance in the health sector, including reproductive health. UNICEF has provided assistance totalling about US$ five million over five years in support of programmes for immunisation and diarrhoeal disease control. Technical assistance has been provided by UNICEF in identifying interventions aimed at reducing maternal and perinatal mortality in Dashowuz, which has some of the worst statistics in the country (see UNICEF Area Office for Central Asian Republics and Kazakstan, 1997).

WHO has been involved in executing the UNFPA project (TUK/96/P02) mainly with regard to training. WHO has also provided assistance to the MOHMI as part of the EURO/WHO project for Central Asian Countries, Azerbaijan, and Kazakstan (the CARKA Project), which is concerned with ‘the improvement of mother and child health and family planning at the district level’. This has principally consisted of seminars on neonatal care, breastfeeding, obstetric and nursery care, high-risk deliveries, and family planning in pilot etraps. UNDP has funded and initiated support for a programme to reorientate medical education. WHO has also been involved in providing technical support, together with the World Bank and TICA (Turkish International Cooperation Agency) for the ‘Lukman (doctor) Health Programme of Turkmenistan', which was developed in 1995 and is a crucial part of the Presidential Health Programme. The funds for supporting the Lukman Programme have amounted to about US$ 800,000 and have been provided by WHO, TICA and UNDP.

The World Bank carried out a sector review in 1996 (World Bank, 1996) and is negotiating a loan for the health reform programme. These negotiations have been somewhat drawn out due to differences on the proportion of the loan to be devoted to technical assistance and fellowships. Much of the preparatory work for the programme has been supported from a US$ 500,000 loan from the Japanese Government. It is intended that the World Bank will provide a loan of US$ 10 million to test reform interventions in one pilot etrap (Tejen). The set of interventions to be tested will include activities to: 1) consolidate and rehabilitate health services; 2) improve the management and effectiveness of clinical and emergency services; and 3) improve the management and efficiency of health services including the development of a new provider-payment mechanism. The pilot project will also assist the MOHMI to evaluate the feasibility and impact of specific reforms and to determine what aspects of the pilot programme might possibly be replicated. Concerns have been raised about how realistic the reform package will be given that it is only dealing with one etrap and the resources needed to replicate it to all other 47 etraps are likely to be considerable (Cromer C, Collins C, Seltzer J, Makhmudova S 1998).

The British Know How Fund (KHF) is funding four experts, who are advising the MOHMI on health reform.

USAID has supported activities under a ‘Reproductive Health Services Expansion Program (RHSEP)’ which was developed in 1993 and aims to improve the health of women and children in five Central Asian countries (Kazakstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan). In Turkmenistan this has mainly concentrated on expanding reproductive health services with the aim of reducing the dependence on abortion for family planning. Other USAID Cooperating Agencies including AVSC and JHPIEGO have carried out activities under the RHSEP Project. These have mainly consisted of training in up-to-date contraceptive technology, infection control, counselling skills and clinical training. Other US Government funded activities in Turkmenistan which are relevant to reproductive health include some of the upto 100 Peace Corps volunteers who are working in rural areas as part of a community health educator programme (Cromer C, Collins C, Seltzer J, Makhmudova S 1998).

In the next cycle of programme assistance in Turkmenistan, UNFPA will adopt a programme approach that links component projects closely to each other to produce an overall effect at the subprogramme level and then at the country programme level. There is a fair amount of commonality in the experiences of the CIS countries during the Soviet days. The nature of issues they face are also somewhat similar in the three thrust areas of UNFPA, namely reproductive health services, population-development strategies and advocacy efforts, with gender concerns cross-cutting all areas. Hence there is a case for certain components to be implemented from the regional office in Tashkent, for administrative expediency and more importantly avoid duplication of similar efforts in each country, particularly in the case of activities which lend themselves to be handled regionally more effectively and efficiently.

One such area is the overall policy review on population and development with respect to support for concerns on population size and distribution, allocation of resources for the social sector which has implications to family size decisions, population mobility and environmental concerns. For example, emigration is one of the key demographic realities in the country but there is a relative dearth of reliable information on volume and composition of migrants, the reasons for migration and how public policy can address this issue. The data collection system is not without problems and there could be double counting at the borders. Similarly, the statistics on births and deaths based on the registration system has to be reviewed along with with the system of how these data are used for public policy. This area would require external assistance in Turkmenistan.

The second area needing external support relates to demographic data, research and training. There is very limited expertise available in the country at present, but the need is significant. The demographic research and training should be programme relevant. Capacity for this work should be developed in the National Institute of Statistics and in some other agencies as well, including universities. External assistance would be required to encourage research at the university level and among other educational and training agencies. As mentioned earlier in this report, data analysis capacity, both with respect to technical aspects and data processing equipment is very limited and would require immediate external assistance. This includes the census operations planned for the year 2000.

Donor co-ordination is an important area in Turkmenistan and the concept of United Nations Development Assistance Framework (UNDAF) has significant relevance in the present development context. The UNDP Resident Co-ordinator and UNFPA Representative has a key role in this context.

UNFPA’s mandate in Turkmenistan should emphasis advocacy for ICPD goals, improved reproductive health for women and men, promoting women’s empowerment, gender equity and equality and a consensus on population and development goals and strategies. Advocacy and other developmental work (such as information, curriculum preparation for population education, staff training, systems development etc.) could have a national focus, but other specific support would have to take an area approach and focus on certain selected regions of the country, mainly de to limitation of funds. One such area could be building technical and managerial capacity in the context of decentralisation and increasing responsibility to local governments.

In the population and Development sector, external assistance would be needed on the following:

• Establishment of a coordinating mechanism under the Cabinet of Ministers for population and development in order to strengthen the linkages between various sectors such as health, education, women’s development, social welfare and other agencies.

• A longer term planning perspective ranging over 10 to 15 years would be necessary for demographic, economic and social policy formulation.

• Assisting the collection, analysis, report writing and dissemination activities for demographic data with adequate gender disaggregation. The National Institute on Statistics and Forecasting requires immediate assistance in human resource development and in utilisation of necessary computing equipment. Similarly, the Census Department would require technical, financial and equipment support.

• The monitoring system for population and development requires strengthening. The existing national capacity in this area is limited and therefore, donor support is very much required. An assessment of specific gaps in national potential for population and development planning would be required and training should be more focussed on these needs. Training of trainers is a particularly effective strategy in Turkmenistan because of language consideration.

• In the area of population research and training, support is urgently needed. Research efforts need to be funded in a way that helps utilisation of research findings for programme planning. Establishment of a population research and training centre is a priority.

• The use of mass media for increasing the awareness of healthy way of life, family planning and the role of family in primary health care will be essential. In this context, the involvement of NGOs and local community in programme planning and implementation would be required.

Specifically, areas indicated under Chapter-5 need external assistance which are:

• Information on reproductive health status, use of RH services and attitudes to RH issues through a representative sample survey of the population in the fertile age group, including contraceptive prevalence and method mix; such as a ‘Demographic and Health Survey” and smaller scale operational research or descriptive studies are needed.

• The contraceptive logistics systems including procurement, regulation of pharmaceuticals (including contraceptives), supply and distribution system.

• Extension of choices of contraception to include for example, sub-dermal implants, female condom, emergency contraception, vasectomy and female sterilisation.

• Training of providers in the rationale use of contraceptives; including competency based training in clinical contraception (minilaporotomy, vasectomy, IUD insertions, etc.) and counselling skills.

• Revision of clinical ‘norms and standards’ (prikas) used for maternal health care, abortion care and management of reproductive tract infections.

• Systems to encourage the practise of ‘good quality reproductive health care’.

• Provision of regular scientific information to medical universities and medical practitioners to assist them in the practise of ‘evidence based reproductive health care’.

• IEC for demand creation for family planning services and on reasonable use of maternal health care and services for reproductive tract infections, including STDs and HIV.

The constitution of Turkmenistan guarantees women equal opportunities in education, training, employment, salary and promotions and equal rights in public and cultural spheres. The level of literacy among women is also universal, as for men. However, female workers seem to operate in non-competitive and under-priviledged employment situations. It has been repoeted that in cases of job displacement, women with children below 18 years are usually displaced first. As for the health of women, short birth intervals and frequent induced abortions will seriously affect their reproductive health status.

NGOs are a new phenomenon in Turkmenistan. It is mandatory for NGOs to be registered but many are not due to the slow and cumbersome process, and thus operate as “NGOs without a legal status”. In the past due to lack of donor support NGOs have been forced to rely on their own income-generating activities. Two notable examples are the Women’s Union named after Gurbansoltan-Edje (WU) and Youth Organisation of Turkmenistan (YOT). Both NGOs are the two leading civil organisations in the country, with extensive infrastructure and government support and branches in all five Velayats and in each etrap.

The lack of a strong legal framework has been identified as the main obstacle to NGO development in Turkmenistan especially of a clearly defined applicable registration mechanism. In December 1997 the first Conference on Civil Society was organized jointly by UNDP and Counterpart Consortium. Twenty-eight NGOs from all Turkmenistan attended and “it marked an important beginning in helping to clarify the institutional and legal status of NGOs” (USAID 1998). There are other constraints that have hampered NGO development: NGOs lack experience, exposure to NGOs in other countries and expertise other than welfare assistance. Over time these constraints can be overcome provided they are given recognition as the third sector in Turkmenistan and the necessary support to enhance their technical capabilities. With the move towards privatization and the reduced role of the state, NGOs’ role to supplement government’s efforts in development will become increasingly crucial.

In the above context, strategic recommendation for advocacy would include:

Strategic recommendations in advocacy sector include:

• Improving the status of women
• Developing capacity of NGOs
• Extensive use of mass media for advocacy on RH and gender
• Communication research and planning
• Providing adequate information and counselling to clients.

In a regional perspective, Turkmenistan allocates less of GDP to the health sector than do several of its Central Asian neighbours and considerably less than OECD countries, which spent an average of 8.4 percent of GDP in 1995. External assistance to the social sector has been limited and declining and there is plenty of scope for increased donor funding to the population/reproductive health sector in particular. The National Health Plan (NHP) proposed by MOHMI reflects substantial efforts aimed at enhancing efficiency in the use of limited resources, to improve quality of services, to improve cost-effectiveness and to target the most vulnerable sections of the population. Resources are to be increasingly reallocated to primary health care particularly through the introduction of a package of essential services, including basic reproductive health care.

The Republic of Turkmenistan became independent from the former Soviet Union by referendum in October 1991 followed by parliamentary adoption of the decision. In December 1995, the UN General Assembly accorded Turkmenistan the status of a neutral country. Since independence, several far reaching reforms are being implemented in the country to build a democratic society and implement effective market reforms. Turkmenistan is a vast land area (488.1 thousand sq. kms.), but about 80 percent of the territory is made up of sand deserts. The country is headed by the President, the People’s Council is the supreme body under the constitution and the Medjlis is the legislative body. There are five regions in the country, called the velayats, which are further divided into etraps. Khakims are the local representatives of the government and the system of local self governance works through Gengeshy, whose members are elected through a direct and secret vote, and oversee the functions of Archins at the local level.

The transition to market economy in Turkmenistan is taking place in phases, first in the production sector and services, followed by the trade and social sectors. Economic restructuring required strengthening capacity for cotton processing and enhancing industrial base for processing the rich mineral resources. The instability and lack of growth in the industrial sector has been due to decline in production in the energy sector owing to the insolvency of Turkmen gas consumers and also due to dependency on imports. Yet, excluding the gas sector, the industrial production has been impressive. State programmes such as “Ten Years of Stability”, “1000 days”, “Grain” etc. have contributed to improving economic situation in recent years.

Presently, the industrialization process concentrates on fuel-energy complex and agro-industrial production focussing on textiles and food processing. In this scenario the question of skilled work force required for this purpose needs to be addressed on priority. At the same time, the state has to adopt a number of legislative, economic and organizational measures, together with a reliable system of financial support for unemployed workers. There is a crucial role for public policy in ensuring that the much needed industrialization is achieved with adequate environmental protection, that the employment generation and employment guarantee schemes are effectively implemented. In the current stage of development in Turkmenistan, issues of population and development relate to the ecological considerations in addition to emigration, employment, privatisation, gender equity and equality, imbalances in regional growth, issues relating to social cohesion, quality of reproductive health services, reforms in the health delivery system etc. These are covered at some length in this report.

Turkmenistan ranks 103 out of 175 countries on the human development index. Literacy rate is universal, with very little difference between men and women and access to health services is excellent. The birth rate and the TFR have shown significant declines in recent years, but the infant mortality and maternal mortality.

Population policy formulation in Turkmenistan is influenced by a pro-natalist sentiment that appears stronger than in other CIS countries. Population policy was seen (a) as a mechanism or an approach to improve the quality of life for children by better spacing of births and (b) to adjust the social and economic conditions to the growing population. Rural population growth is aimed to be supported by sufficient creation of jobs. Population policy considerations were on the national agenda in the past, but no concrete actions emerged.

While the Ministry of Health is taking a leadership role in improving access to family planning for birth spacing, others at the decision making and level and at the service delivery level remain conservative, largely due to cultural and religious reasons. Yet family planning is accepted under medical reasons and the Ministry is positioning child spacing as a means of improving maternal and child health.

Though an explicitly stated population policy does not exist in Turkmenistan, the President’s State Health Programme gives a broad policy direction to health care reforms. In fact the main activities in the restructuring health care system started in 1994 and later incorporated in the President’s programme. The main policy goal of the State programme is to improve the health status of the population through improved health management, finance, primary health care, hospital services, pharmaceuticals, human resource development, improved health care infrastructure, medical research and legislation. Under this policy, a key strategy is for the Ministry of Health and Medical Industry to take on more policy-making function by reducing its role in the operational activities of health care institutions.

Traditionally, large families with many children was regarded as the felt need of married couples. A distinctive feature however is that majority of births are to young parents. But the recent decline in birth rate, despite early marriage and parenthood is partly due to socio-economic economic factors and to the relatively increased access to family planning.

Significant regional difference in population growth rates is a feature that government recognizes well. Migration plays a significant role in these growth rates. The net out-migration rate, the volume and composition of emigrants is a matter of concern due to its impact on staff training and meeting the demand for skilled workers and managers. Principal imbalances in the present period and for the future are the high rates of growth of labour force, insufficient development of human resources through professional training and the concentration of most unemployed and under employed labour in rural areas and smaller towns. The transition to market economy requires formulation and activation of a human resources development strategy which includes training and educational programmes for re-orientation labour force.

Due to the age structure effects, the number of people entering the labour force is approximately four times higher than the number leaving. The large territorial separation of the population aggravates the problem of employment in all velayats. The most unfavorable is in Balkan velayat where only 60 percent of labour force is employed in 1994.

After reviewing the population research and training situation, population data collection system and national capacity in this area, the following suggestion have been made:

• Establishment of a coordinating mechanism under the Cabinet of Ministers for population and development in order to strengthen the linkages between various sectors such as health, education, women’s development, social welfare and other agencies.

• A longer term planning perspective ranging over 10 to 15 years would be necessary for demographic, economic and social policy formulation.

• Assisting the collection, analysis, report writing and dissemination activities for demographic data with adequate gender disaggregation. The National Institute on Statistics and Forecasting requires immediate assistance in human resource development and in utilisation of necessary computing equipment. Similarly, the Census Department would require technical, financial and equipment support.

• The monitoring system for population and development requires strengthening. The existing national capacity in this area is limited and therefore, donor support is very much required. An assessment of specific gaps in national potential for population and development planning would be required and training should be more focussed on these needs. Training of trainers is a particularly effective strategy in Turkmenistan because of language consideration.

• In the area of population research and training, support is urgently needed. Research efforts need to be funded in a way that helps utilisation of research findings for programme planning. Establishment of a population research and training centre is a priority.

• The use of mass media for increasing the awareness of healthy way of life, family planning and the role of family in primary health care will be essential. In this context, the involvement of NGOs and local community in programme planning and implementation would be required.

The health care system in Turkmenistan still exhibits most of the features of the system inherited from the Soviet period. The structure is extensive and service accessibility is relatively easy due to the large number of facilities. However, the system is inefficient and has insufficient impact on the current problems. The management of health services is undertaken mainly at two levels: the Ministry of Health and Medical Industry (MOHMI) and velayat health administrations (VHA). The etrap level services are administered by the chief physician of the central etrap hospital in addition to his (and it usually is a male health worker) responsibility as the head of the hospital. The management of the health system tends to be bureaucratic, hierarchical and centralised, with considerable emphasis given to the continued use of norms (or Prikaz) which originated in the Soviet period. Norms determine administrative decisions such as on the opening of new facilities, staffing levels, budgets and purchasing procedures, but also clinical management of patients. Although these norms are no longer followed so strictly as in the past, they still result in the health care system and patients being administered rather than managed.

The MOHMI is responsible for policymaking, but exercises no influence over the allocation of financial resources, which is made directly from the Ministry of Economy and Finance to the velayat administrations. Each velayat health administration reports to the haki, the head of the velayat and the MOHMI.

The VHA holds the administrative responsibility in the velayat. The chief physician of the central etrap hospital is also responsible for all services in the etrap, including the primary health care services, and is the budget holder for the health services in the etrap. Currently, this does not create much conflict of interest since the budgets are earmarked for facilities on the basis of line-item budgets.

The reforms introduce a special emphasis on primary health care and better utilisation of primary health care services. It is considered that many of the health problems of the population can be dealt with at the primary level. Furthermore, most of the strategies outlined for priority health targets are to be implemented at the primary health care level. Therefore, the main strategy will be the strengthening of primary health care by rationalising and rehabilitating the infrastructure, providing necessary supplies and upgrading staff.

Although the health services are physically within easy reach of the population, primary health care in Turkmenistan is not fully integrated and the relationships between PHC units and specialised services (such as STD control) are weak. The PHC units, especially the ones in rural areas, have very limited diagnostic facilities.

There is a serious lack of all types of medicines in Turkmenistan. There are no or only very limited supplies of drugs in FAPs, SVAs and SUBs. Patients have to buy their drugs, which are prescribed by the local physicians, from pharmacies in the towns. In most cases drugs are provided late or not at all. Irrational prescribing is common and generally medical and pharmacy professionals are not cost-conscious.

After reviewing the reproductive health situation in the country with respect to all elements of RH as defined in ICPD-POA, the following strategic recommendations are made:

• A demographic health and survey or similar type of survey would be required to generate reliable information on reproductive health status, use of RH services and attitudes to RH issues among men and women, the contraceptives prevalence and method mix.

• The contraceptive logistics systems including procurement, regulation of pharmaceuticals (including contraceptives), supply and distribution system would have to be improved.

• There is a need to extend choices of contraception to include for example, sub-dermal implants, female condom, emergency contraception, vasectomy and female sterilisation.

• Training of providers in the rationale use of contraceptives; including competency based training in clinical contraception (minilaporotomy, vasectomy, IUD insertions, etc.) and counselling skills.

• Revision of clinical ‘norms and standards’ (prikas) used for maternal health care, abortion care and management of reproductive tract infections.

• Systems to encourage the practise of ‘good quality reproductive health care’.

• Provision of regular scientific information to medical universities and medical practitioners to assist them in the practise of ‘evidence based reproductive health care’.

• IEC for demand creation for family planning services and on reasonable use of maternal health care and services for reproductive tract infections, including STDs and HIV.

Though the gender situation is largely acceptable, women face a number of problems. In some cases they are the major, if not the primary income earner in their families. It is harder for them to obtain loans and in many cases self employment is their only means of survival because of lack of education or skills relevant to a market economy. Men must adopt a more responsible attitude and behaviour if women’s reproductive health is to improve and this includes better interspousal communication on sexual and reproductive health and practicing safe sexual practices.

The capacity of NGOs as sources of information on reproductive health and gender issues should be strengthened. Women NGOs should be encouraged to become strong advocates for reproductive health rights and improving the status of women, from the grassroots to the highest levels. They should be exposed to opportunities for experience and information exchange, to social communication methods, effective ways of working with the media and to successful projects in other countries.

The media particularly radio and TV should be extensively used to disseminate information for advocacy purposes. The skills of radio and TV producers should be upgraded to improve programming standards on reproductive health and gender issues. In collaboration with the Centre for Health Prevention and AIDS Control, the possibility of establishing listener and viewer groups to discuss the TV and radio programmes with a trained health worker should be explored. Audience surveys should be initiated to determine needs and to obtain feedback on the programmes.

In this context, communication strategies should include mechanisms for using relevant data, such as community-based research on local attitudes and practices. Where important data is lacking, communication research and planning should take the initiative to collect data in a participatory manner. These same methods could be used to improve the professional skills of health workers including health education personnel, family doctors and felshers on communication and education techniques, interpersonal communication and counselling..

Clients need information on most aspects of reproductive health. To that end it is recommended that client information materials are developed and distributed through rural health centres, local NGOs and the local community councils. Other ways to reach clients are: Training of peer counsellors in how to encourage community councils and communities to hold education and information sessions; and continued training and education of service providers to help them as providers of information and contraception to clients.

Government expenditure is the main source of health care finance but with the share of private sector participation is anticipated to grow in the near future (MOHMI 1998). In 1996, government expenditure accounted for 91 percent of total health spending, with the state voluntary scheme (VHI) comprising around 6 percent. Private sector spending, e.g. out-of-pocket payments, constituted only 3 percent of total health expenditures.

In a regional perspective, Turkmenistan allocates less of GDP to the health sector than do several of its Central Asian neighbours and considerably less than OECD countries, which spent an average of 8.4 percent of GDP in 1995. External assistance to the social sector has been limited and declining and there is plenty of scope for increased donor funding to the population/reproductive health sector in particular. The National Health Plan (NHP) proposed by MOHMI reflects substantial efforts aimed at enhancing efficiency in the use of limited resources, to improve quality of services, to improve cost-effectiveness and to target the most vulnerable sections of the population. Resources are to be increasingly reallocated to primary health care particularly through the introduction of a package of essential services, including basic reproductive health care.

As the Turkmen health sector suffers not only from under funding but from severe inefficiency, there is a case for mobilisation of resources through improvements in the cost efficiency with which services are delivered. In order to reorganize health financing, allocation system to oblast and within oblast has to be revised. In order to minimize cost, rationalizing of the health care delivery system, including integration of services, cost recovery and NGO/private sector participation would be required. The external donor community could help the government reduce programme costs and increase efficiency.

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