Dushanbe, 31 May 2012
Members of the press,
Ladies and gentlemen,
Allow me to begin by warmly thanking the Government for inviting me to Tajikistan and for facilitating a rich and interesting programme of meetings and visits. During my visit, I have met with Government officials, as well as representatives of international organizations and civil society. I have visited health facilities, specialized clinics for people suffering from tuberculosis (TB) and multi-drug resistant tuberculosis (MDR-TB), mental health facilities, and a prison hospital. Throughout my visit, I have been met with warm hospitality and courtesy. There has been a candid and frank exchange of views with senior Government officials. I take this opportunity to thank all those who have given me the benefit of their time and experience. I am grateful to the Government and relevant ministries for all their efforts in organizing and facilitating my mission.
You will find in this room a short document that explains my UN responsibilities as Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (the right to health). In brief, I am an independent expert who reports to, and advises, the UN Human Rights Council and UN General Assembly on the realization of the right to health. Although appointed by the Human Rights Council, I am not employed by United Nations and the position I hold is honorary. As an independent expert, I exercise my professional judgment in order to arrive at my conclusions and recommendations.
Today, I would like to confine myself to discussing some of my preliminary observations, which will be explored in more detail in the final report to be presented to the Human Rights Council in June 2013.
The objective of my mission was to understand, in the spirit of dialogue and co-operation, how Tajikistan has implemented and endeavours to implement the right to health. The focus of the mission was on three major issues that I find of particular importance in Tajikistan: health systems and financing, prevention and treatment of tuberculosis, and mental health.
I would first like to commend the Government of Tajikistan for its reduction of poverty in the country following the civil war, which engulfed it from 1992 until 1997. The Government should continue its efforts to reduce poverty in view of the high rates of malnutrition amongst children in the country, as well as concerns regarding food security and safety. The Government is also committed to improving health in the country. This is evident from its increasing expenditures on health. For example, from 2007 to 2012 the budget allocation for health increased by over 400% from 178 million TJS (37.3 million USD) in 2007 to 716 million TJS (152.3 million USD) in 2012. Government spending on health as a percentage of the GDP also doubled from 0.9% in 2001 to about 2% in 2012. I commend the Government for these advances.
Despite that, current Government expenditure on health is still too low. It is low by international standards and lower than the 2010 average in the former Soviet republics (5.9%). Only 6% of Tajikistan’s state budget is allocated to health expenditures, while the average for developing countries in Europe and Central Asia was approximately 10% in 2010. The Government itself has acknowledged that spending on health is too low. Increasing expenditure on health to meet international standards, including those regarding the right to health, should be of the utmost priority in order to realize the right to health of all the people of Tajikistan.
Regrettably, the primary health care system in Tajikistan remains underdeveloped and underfunded. This is especially acute in rural and mountainous areas where many people continue to lack access to basic health care services, especially during the winter months. This is a major concern, as up to 75% of the population of Tajikistan lives in rural areas. The lack of adequate primary health care also negatively impacts maternal and infant health and impedes access to basic immunization services for children.
The underdevelopment of the primary health care system is part of the legacy of the Semashko model health system inherited from the Soviet Union, which emphasised investment in highly specialized secondary and tertiary care institutions and funding on the basis of bed capacity, leading to excess capacity. I commend the Government for acknowledging this problem and embracing reforms. Among other things, it has begun to reduce excess capacity, including hospital beds, and to train and promote the use of family doctors in order to meet primary health care needs. However, investment continues to be predominantly in the specialized hospital institutions and, as a result, primary health care continues to suffer.
Out-of-pocket expenditures and informal payments have been prevalent throughout the health system in Tajikistan. Out-of-pocket expenditures account for up to 75% of total spending on health, a large percentage of which comprises expenditures on pharmaceuticals.
Even though many health services are legally required to be provided free of charge in public health facilities, in practice, informal payments for services are all pervasive. This is due in large part to the low salaries paid to doctors and other health care professionals: the average monthly salary for doctors is approximately 85 USD and 50 USD for nurses. Low salaries also contribute to low quality of health services, which in turn erodes the public’s confidence in the health system.
The Government has taken the following steps to address these problems.
I am pleased to note that the Government has increased salaries for doctors and other healthcare professionals by 30 to 40% each year since 2007. However, this is not enough, given that salaries were initially very low. Salaries for doctors and other health care professionals should be substantially increased in order to improve the quality of health services and reduce the prevalence of informal payments throughout the health system.
In order to increase financing for health, the Government has introduced two pilot programs: the Fee-for-Service program in 130 hospitals and the Basic Benefits Package in eight districts. The Fee-for-Service program allows health facilities to charge a fee set by the Ministry of Health for certain hospital services. The program has resulted in an increase in revenue for those participating institutions. This has also led to an increase in the salaries of doctors, partially curbing the ‘brain drain’, and has financed the purchase of advanced medical equipment in these hospitals. However, increased revenues under the program have been mostly in wealthy districts, particularly in Dushanbe. The vast majority of institutions have not benefitted. Moreover, the increases in doctors’ salaries have been inconsistent even within the institution. Forty per cent of all revenue from the Fee-for-Service program remains in the department in which it is collected. The departments that experience the greatest increases in revenue under the program are highly specialized or surgical units.
The piloted Basic Benefits Package is intended to provide free access to primary healthcare services for all and free hospital services for certain groups, including the poor, while others pay a formal co-payment. Funding for free primary health care under the program is supposed to be provided in large part by the Government from a specific budget allocation. However, in reality, funding for the Basic Benefits Package has relied almost exclusively on co-payments for hospital services, because it has not been subject to specific budget allocations. This is problematic because co-payments are meant to be used to improve the quality of health services through the increase in doctors’ salaries and the enhancement of the material and technical capacity of health facilities. The program is also underutilized because of low public awareness and has thus been ineffective in increasing access to primary healthcare services for the poor.
Both the Fees-for-Services and the Basic Benefit Package programs have failed to reduce out-of-pocket expenditures, including informal payments. The programs have also failed to substantially increase access to hospital services for the poor. The poor and other population groups are supposed to be exempt from fees under both programs. However, in order to obtain free services, the poor must produce a certificate acquired from a local commission. I have heard reports that the poor are unable to obtain such certificates for diverse reasons. The Fee-for-Service program is also expanding to include more health facilities and, in some instances, fees are being charged for primary healthcare services. This may impede access to primary healthcare services for the poor in those facilities that have implemented fees for such services.
In 2011, pursuant to the National Health Sector Strategy for 2010-2020, an inter-agency technical working group on health financing reached an agreement to implement a pilot program in 2013 involving the pooling of health funds at the region (oblast) level in Sughd oblast. Under the pilot, primary health care in each district (rayon) would be funded from the oblast pool on a per capita basis through local taxes supplemented with national tax revenues in order to ensure equity across districts. Funds for primary health care would be allocated to the Basic Benefits Package providing a much-needed funding source for this program. National tax revenues from the oblast pool would be allocated to hospital facilities on a case-based payment, rather than the hospital-bed based method used now. The program is stalled because of diverse concerns amongst various stakeholders. These concerns need to be urgently resolved and the overlapping functions of the Fee-for-Service program and the Basic Benefits Package must be reconciled. I call upon the Government to urgently develop a progressively funded, comprehensive healthcare package based on pre-payments rather than fees at the point of service in order to ensure universal access to health care for all.
Low-quality healthcare services remain a key concern throughout Tajikistan, resulting in a lack of public trust in the health system and the medical profession generally. Many healthcare workers are poorly trained and qualified professionals often choose to work abroad in order to earn more income and work under better conditions, which contributes to high turn-over rates throughout the medical profession. The quality of medical education in the country needs to be significantly improved and standards need to be developed to ensure uniform qualifications across the sector. Reforms must also address corruption within educational institutions to ensure medical degrees conferred based solely on competence.
Dear members of the press,
The Government has acknowledged that tuberculosis (TB) is a serious challenge for Tajikistan and has implemented substantial measures toward addressing the problem in the country. I would like to commend the Government for these efforts. The DOTS treatment program has been implemented since 2002 and a comprehensive National TB Program was introduced in 2009. However, the rate of TB prevalence in Tajikistan is very high, at 382 per 100,000, and Tajikistan remains a high burden MDR-TB country, with 19.6% of all new TB cases having MDR-TB and only 20% of all MDR-TB cases are currently receiving treatment. There is also significant number of repeat TB cases. HIV/TB co-infection is also a major concern and is already making it difficult to lower the death rate from TB. The problem of TB in prisons is even more acute than in the general population, partly due to the lack of trained healthcare personnel. Efforts to control the spread of TB in prisons are often inadequate, as evidenced by the number of prisoners who contract TB while in prison.
A number of factors contribute to the high prevalence of TB and MDR-TB in Tajikistan. Inadequate public awareness, less than comprehensive detection, and incomplete collection of health information at the primary healthcare level remain major problems. The underdevelopment of the primary healthcare system, inadequate training of primary healthcare workers in TB prevention and detection and the lack of health care workers in remote areas are fuelling the epidemic. High turn-over of healthcare workers exacerbates the problem. Interrupted access to medicines for poor and physically isolated populations in the DOTS programme is also an issue, especially for migrant workers who leave Tajikistan prior to completing first-line treatment.
The Government is committed to the anti-TB programme. However, the stigmatization of individuals living with TB and living with HIV/TB co-infection is a serious concern. Stigmatization prevents people from getting tested for TB and discourages affected individuals from seeking treatment. This significantly impedes TB prevention efforts. Stigmatization is rooted in low public awareness about the TB prevention and transmission. In order to address this, the Government should increase its efforts to raise public awareness and reduce stigmatization through mass, social and other media. I was pleased to learn that in some instances the Government has involved individuals who recovered from TB in such campaigns. I would like to emphasize that the participation of affected communities is central to the realization of the right to health and is necessary to ensure sustainable and effective prevention and control of TB in Tajikistan. I was pleased to learn that other stakeholders, civil society and religious leaders, have also been involved in the advocacy efforts. I therefore urge the Government to facilitate robust participation of individuals living with TB and other stakeholders, in all aspects of its prevention and control efforts, including policy making, prevention, advocacy, and monitoring and evaluation.
During my visit, I also assessed the realization of the right to health for persons living with mental illness. Despite the fact that the burden of mental illness in Tajikistan is similar to that in other post-conflict countries, Tajikistan lacks a comprehensive national plan addressing mental health. I was pleased to learn that the Government is now considering adopting the National Mental Health Policy/Strategy. I am however concerned about the low funding for mental health in Tajikistan. The Government currently allocates only about 1.5% of the health expenditure to mental health, half of which goes to mental hospitals. Unfortunately, international donor funding is generally not available for mental health. This indicates a very low prioritization of mental health in the country. I urge the Government to substantially increase funding for mental health as a matter of priority.
Regrettably, mental health services in Tajikistan are of low quality and treatments are not evidence-based and often ineffective. There is also a lack of qualified mental healthcare workers in the country. This is particularly acute in rural and remote areas. Primary healthcare workers are not trained to diagnose or treat mental illness and thus many mental illnesses such as depression go undetected at the primary healthcare level. This deficit, along with the lack of psychological services, high levels of domestic violence and other concerns, also contributes to the alarmingly high rates of suicide amongst women and young people in Tajikistan. In addition, persons living with mental illness suffer from a lack of access to, and availability of, appropriate psychiatric medicines. I am also very concerned with the poor conditions in mental health facilities, which often include a lack of basic sanitation and hygiene, and substandard infrastructure.
The stigmatization and discrimination of persons living with mental illness is a significant concern. Among other things, stigma is generated and perpetuated in Tajikistan by the registration of persons who receive treatment in mental health facilities. Registration information is shared with employers, educational institutions and other state agencies and, in some cases, results in discrimination in access to employment and education. The right to be free from discrimination based on one’s health status is a core component of the right to health. I therefore urge the Government to review the registration system with a view to assessing its impact on the availability and accessibility of other services and facilities for persons living with mental illness.
The mental health system in Tajikistan has relied too heavily on the institutionalization of persons suffering from mental illness, including children. I am pleased to note that the Government has begun reducing the number of hospital beds and emphasizing outpatient treatment in line with other health sector reforms. However, community-based treatment is currently not available in the country. Such treatment allows persons living with mental illness to remain in their communities while receiving treatment. It also involves the participation of the community in their treatment and rehabilitation. Community-based treatment is also more cost-effective than inpatient treatment and hospitalization. Moreover, community-based treatment will contribute significantly to the reduction of the stigmatization of mental illness in Tajikistan. I call upon the Government to take steps towards community-based treatment for persons living with mental illness in line with international standards and to ensure that those persons receive appropriate mental health care, medication and community support.
During my visits, I learned that patients are admitted to mental health facilities and receive treatment without their explicit and informed consent, though required by law. In these facilities, the consent of relatives of those living with mental illness is all too often accepted as a substitute for the consent of the patients themselves. Under the right to health, the informed consent of all who possess legal capacity must be obtained prior to the administration of medical treatment. Adult persons, including those living with mental illness, are presumed to possess legal capacity and thus have the right to consent to, refuse, or choose an alternative medical intervention. The right to informed consent is fundamental to individual autonomy, self-determination and human dignity.
The health system in Tajikistan also suffers from a lack of remedies, including compensation, for misdiagnosis and medical malpractice. This lacuna further erodes the public’s trust in the health system and medical profession. During my visit, I met with a number of individuals with serious grievances related to misdiagnosis and gross medical negligence. In each case, the relevant authorities had not adequately investigated their complaints and those persons lacked access to compensation under the law for their losses. The Office of the Ombudsman has an important role in addressing these concerns. However, to date it lacks sufficient capacity and has not adequately fulfilled its mandate in this regard. According to the right to health, individuals must have access to appropriate remedies for violations of their right to health, including for medical negligence. I urge the Government to take concrete steps to ensure victims of misdiagnosis and medical malpractice have access to appropriate remedies at law, including compensation for physical and emotional damages.
Dear members of the press,
I am very grateful to the Government of Tajikistan for inviting me to visit, enabling me to deepen my understanding of the right to health in the country. The Government’s invitation – and much of what I have learnt during my visit – confirms that it is taking the issues related to the enjoyment of the right to health seriously. I would like to use this opportunity to encourage the Government to extend a standing invitation to all special procedures mandate holders, to afford others the same opportunity I have had.