“Thank you, doctor. How much is it now?” – “Give thirty somoni, it will be enough.”
Such kind of dialogues are typical between patients and employees of Dushanbe Health Centers (as polyclinics in Tajikistan are now officially called). According to experts, this shows that corruption has taken deep roots in the field of healthcare in Tajikistan. The anti-corruption body, the General Prosecutor’s Office, and even the country’s Prime Minister are talking about this problem.
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Our investigation has shown that corruption has widely spread in the healthcare system, and primarily the ordinary citizens are its victims.
Corruption Without Fear and Beyond Reproach
The investigation showed that even strict control could not prevent corruption in this area in Dushanbe.
For investigation, the journalists went to the city’s Health Center No.1, about which Dushanbe residents most often complained.
This Center is located in the Firdawsi district of the capital. According to the administration of the institution, 326 employees work here, and up to 800 people visit it each day. We tried to find answers to two basic questions: 1. Where do the funds paid by patients go: to the budget of the Center or into the pocket of its employees? 2. What is a degree of employees’ involvement in corruption?
“Four Hundred Somoni in Two Hours”
On December 8, 2018, we came for examination to the ophthalmology office of Dushanbe Health Center No.1 as common patients, where two doctors received visitors. After the examination, the doctors told the journalist that they needed to undergo a short course of treatment.
The doctor wrote prescriptions for medicines, after which the journalist asked how much he should pay for the examination. The doctor replied, “as much as you want”.
The journalist said that he came here for the first time, and does not know how much he should pay, after which the doctor told the exact amount, “10 somoni”. The journalist paid and left the office without any questions, after which he went to see the ENT doctor (otolaryngologist). There was a big line here and the journalist had to wait for almost two hours.
During this time, two doctors of the department examined 15 people and the observation showed that one of them took money from visitors and put it in his pocket. People gave doctors from 15 to 25 somoni.
The price list was posted outside the office door, signed by the Director of the Center G.H.Amirova. The minimum amount for treatment was five somoni and the maximum – 40 somoni.
At an examination in the otolaryngologist’s office, the doctor examined the journalist’s throat with a tool called a spatula and rinsed it with some kind of liquid. The doctor told the journalist that he had a little cold and should take medicine. After that, he demanded the patient to pay 20 somoni.
We should note that in the price list, which was hung behind this doctor’s back, none of the treatment types cost this amount (20 somoni).
The journalist also noted that in two hours, none of the patients had been sent to the cashier for the payment.
Two weeks later, on December 21, 2018, the journalists visited the Health Center No.1 again. 10 somoni for the examination by the eye doctor was demanded again.
The journalist asked the doctors for a check for the insurance company. The doctors agreed, wrote down the name of the patient in a special notebook, issued a receipt for payment of 10 somoni to the cashier. Then, the doctors said that the receipt would need to be returned to them so that they could write down the numbers. Meanwhile, the eye doctors’ price list indicated prices for services from one to 11 somoni.
At the secondary examination, the ENT doctor did not take money from the journalist and, after a short examination, sent him for electrotherapy to another specialist, who demanded 30 somoni for a six-day course of treatment. One procedure took only one minute per day.
The journalist asked for a receipt again. In response, this specialist initially said that he would give it the next day, but then began to assure that the insurers would pay for all the diseases, but they would not pay for the diseases of the throat. “They won’t give insurance for the throat. Insurance has many nuances,” said this doctor.
Meanwhile, in contrast to the numerous queues standing at the doctors’ offices, there was almost no one at the cash desks. On December 8, 2018, beside a journalist, there was only one pregnant woman near the cashier office.
On December 21, 2018, the situation was similar, and the journalist asked the pregnant woman what was she paying for. In response, the woman said that she was paying for some expertise in order to get a medical certificate.
“Do You Want to Set Me Up?”
It should be noted that previously the journalists received information that a health certificate can be bought in the Center without any examination.
To study this issue, another journalist, whose goal was to obtain a health certificate known as “Form-86”, visited Center No.1. One of the nurses initially said that the Center would not give him this certificate if he lives in another, remote district. However, the nurse then suggested the journalist to follow her and took him to the doctor’s office.
The doctor asked the nurse “Is this person insider or stranger?” After the answer “Stranger”, the doctor suggested the journalist to visit the necessary doctors for examination. However, the journalist replied that the certificate is needed very urgently. The doctor, again mentioning that “the visitor is a stranger,” noted, “I don’t know who you are; do you want to set me up, by any chance?”
In response, the journalist said that he would leave if the doctors could not give him a certificate. After that, the doctor stopped him, “Okay, I’m going to say that you are my relative and I will take a certificate.”
Five minutes later, she returned with a certificate, which she wrapped in paper and warned the journalist to put it in a bag so that it was not visible on the cameras. At the request of this doctor, the journalist paid 80 somoni for help.
One of the employees of the Center on condition of anonymity said that it was impossible to receive the signatures and seals of six doctors in five minutes. The doctor explained that some of his colleagues put signatures and seals in advance and then only enter the name of the right person in the certificate.
According to journalists’ observations, a similar problem exists in other medical centers in the country.
The Head of Health Center No.1, which is located in the Firdawsi district, Gulhumor Amirova categorically rejected the violations mentioned above, in particular, self-willed collection of money from patients and the business of issuing medical certificates.
In an interview with journalists, Amirova said that all visitors first pay to the cashier office to receive paid services and only then go to the doctor’s office. Amirova emphasized that ENT doctors do not take any money from patients.
At the same time, the Head of the Center stressed that during every meeting she tells her subordinates about the impermissibility of corruption.
According to Amirova, medical certificates or, as they called, “Forms-38” come to them from the Ministry of Health and these documents are kept only by her deputies.
Amirova stressed that the Center employees cannot issue these certificates without money paid to the cashier and examination of relevant doctors. On the contrary, Gulhumor Amirova blamed the patients for giving money to doctors sometimes and demanding prompt certificates issue.
Meanwhile, in the medical certificate under the number AA0068116, which the journalist received in the Center, seven seals were put: of Health Center No.1, a surgeon, a psychiatrist, an ophthalmologist, an ENT doctor, and a seal for sick leaves and certificates. However, the corner with the initials of the Health Center’s Head, which was at the end of the certificate, was empty. Near it, the signature of B.K. was put.
“It Is Free, but Pay Money Anyway”
The problems of corruption in medical institutions of Tajikistan are not limited to issuing false certificates. There are also frequent cases when doctors require patients to pay even for free types of treatment. In particular, some pregnant women told journalist that, contrary to the law, they were demanded to pay for an examination, which should be free of charge in state medical institutions. Otherwise, the doctors refused to examine them.
Zarnigor Khojaeva, Dushanbe resident, who brought the pregnant daughter-in-law to the Health Center No.1, says that they did not have enough money for the examination, and the doctor told them that he would not pass the results of blood tests to his colleague until he received full amount of money.
“How can I not pay them? I paid 25 somoni, and was told that it should be 30. Due to a shortage of five somoni, I was told that they would not give blood tests to a doctor. No matter how much I begged them, they still said that they would not give me the tests until I bring these five somoni,” said Khojaeva.
According to her, she was not given any receipt for 25 somoni that she paid.
Another woman with whom journalists spoke at Health Center No.1 said that doctors extort money even for measuring the weight and height of pregnant women.
In this regard, one of the doctors of this Center on condition of anonymity told journalists that some pregnant women do not come for check-ups due to extortion of money by doctors.
“Family doctors repeatedly visit the pregnant women’ homes and urge them to come for a free examination every month. However, these women do not go for examination saying that doctors demand money, when they do not have money. Doctors take money even for measuring the weight of pregnant women. And for the money they take from pregnant women, they do not issue receipts at all,” said anonymous source.
Pregnant women are not the only group that has to pay for the provision of supposedly free services.
Recently, reports of extortion by doctors during the provision of first aid often appear in the media.
Even the Founder of Peace and National Unity – Leader of the Nation, President of the Republic of Tajikistan, Emomali Rahmon, in his message to Majlisi Oli (The Supreme Assembly, Tajikistan’s parliament) on December 26, 2018, mentioned this problem and demanded that all types of first aid should be provided free of charge.
The Faraj newspaper writes that after the President’s criticism, the Ministry of Health Care and Social Protection of Population took the issue of free first aid under strict control. In this regard, a source at the Health Center No.1 reported that its Head, Gulhumor Amirova did not take any measures to remedy the situation even after talking to journalists.
Lawyers say that Tajik legislation prohibits doctors from taking money from patients.
Zafar Rasulov, a lawyer of the non-governmental organization “World of Law”, says that according to the law, doctors under no circumstances have the right to accept cash from patients or their relatives. According to Rasulov, money for treatment must be paid to the cash desk of the medical institution, and a receipt must be issued to the patient.
“The practice of collecting money from patients by medical employees is illegal, and this is nothing more than corruption. Payment to the cashier office and receipts also provides an opportunity for a patient dissatisfied with treatment to apply to the relevant authorities and present a receipt as evidence,” says the lawyer.
“Agency: Random Staff Cleared the Way for Corruption”
Law enforcement agencies have repeatedly criticized the health sector for widespread corruption.
For example, in June of last year, officials of the Agency for State Financial Control and Combating Corruption said that in 2018, this sector was the most corrupt in the country.
At one of the sessions of the Ministry of Health, the Agency’s employees expressed the opinion that this tendency is most likely because random people become workers of the healthcare sector, Radio Ozodi reports.
Currently, doctors are hired through the central office of the Ministry of Health Care and Social Protection of Population. Thus, doctors are recruited with the consent of the Ministry, on the basis of requests from hospitals or health centers.
Recently, the Prosecutor General’s Office of the Republic of Tajikistan also announced the discovery of a multiple facts of violation of medical and sanitary services provision procedures in public medical institutions; most of them were violations of the citizens’ rights to receive treatment.
Moreover, the Prime Minister of Tajikistan, Kokhir Rasulzoda, on December 19, 2018 at a meeting of the National Council for Combatting Corruption, criticized the leaders of the health sector and gave instructions on the elimination of conditions that contribute to corruption, reports Sputnik information agency.
“The Turnover of the Unofficial Market in the Health Sector Exceeds 3 Billion Somoni”
According to experts, “sticking plaster” solutions will not have an effect in this area if the roots of corruption are not eliminated.
Abdukhalil Kholikzoda, a healthcare worker in Dushanbe, says that there is only one way out – the introduction of a health insurance system, which can make it possible to streamline the financing of the sphere and increase doctors’ income.
According to Kholikzoda, the financial roots of corruption will be destroyed if these funds can be pulled out from the shadows.
Medical insurance is a form of health insurance that covers part of the expenses caused by an insured event, doctor’s consultation, or other expenses for medical services through regular joint investment in a general fund. Insurance of the unemployed, pensioners and children is paid by the state. As experts emphasize, only insurance companies pay for the patients’ treatment, that is, doctors do not take money from patients.
The problems of corruption in the field of health care in Tajikistan are not limited to extortion by doctors or business of providing various certificates, such as “Form-86”.
Sociologists say that this sphere is very important and widely used by people, so the energy of citizens need to be used to eliminate corruption. In their opinion, first of all, it is necessary to destroy some social habits that force people to pay doctors, thus clearing the way for corruption.
Muzaffar Olimov, a Tajik sociologist and director of the Sharq Analytical Center, believes that the problem is that citizens do not know enough of their legal rights. Olimov adds that many citizens prefer to give a bribe in order to be served better.
In his opinion, the people’s contribution to the fight against corruption can be significant only when citizens understand that their compellations give results and their problems are solved.
Most of the surveyed Dushanbe residents said that they pay doctors. According to respondents, sometimes this happens by the doctors’ request, sometimes by the own will of the citizens.
One of the respondents said that after examination he would surely “tip” the doctor, even if the latter does not ask for it.
However, there were those who said that doctors do not treat those citizens who do not pay them.
“My child was dying in my arms; nobody in the hospital was examining him. One doctor said that it was not his disease; another said that it was not his patient. Until we brought 800 somoni, nobody examined him,” one of the respondents said.
The Criminal Code of Tajikistan provides criminal sanctions for bribery, receiving a bribe and provoking a bribe (articles 319, 320 and 321 of the Criminal Code of the Republic of Tajikistan). Depending on the severity of the crime, the sanctions include fines or even imprisonment.
During the investigation, journalists concluded that to solve the corruption problem, it is necessary to ensure transparency in the sphere, so that all funds are collected in the budget of medical institutions. By these funds, it would be possible to establish a fair wage for doctors, so that they do not get involved in corruption.
In short, both the doctor and the patient should not talk about money, but only about treatment.
This article was prepared as part of the Giving Voice, Driving Change – from the Borderland to the Steppes Project implemented with the financial support of the Foreign Ministry of Norway. The opinions expressed in the article do not necessarily reflect the position of the editorial team or a donor.