On July 21, 2018, in an address to doctors, President Gurbanguly Berdymukhamedov boasted that Turkmenistan had “strengthened its place in the world as a powerful state with highly developed medicine.” He claimed that people from neighboring states and beyond could even come to get treatment in the country’s hospitals. Since 2007, health and the medical system have been propagandized as essential components of Berdymukhamedov’s narrative on nation-building. The supposed success of the country’s health care system has been touted as an emblem of national pride and promoted by numerous slogans such as “The health of the nation—the wealth of the homeland!” The Turkmen president’s praise and narrative, however, dramatically contrast with the population’s daily experience receiving care. They are confronted with a system that is still widely reliant on the legacy of Soviet healthcare, that has received little governmental investment (except in a few white elephant projects), and that is often disconnected from meeting the many basic needs of the population.
This memo first discusses how the Turkmen president has made use of the health care system as an instrument to promote his regime’s authoritarianism and survival, often to the detriment of the population’s wellbeing. Second, although this approach is common to several authoritarian regimes, the combination of Turkmenistan’s extreme authoritarianism with its ubiquitous cult of the president’s personality, together with the unprecedented current economic crisis, are likely to more seriously damage the health care system and to challenge the country’s development in the longer term. In conclusion, the memo raises the international community’s Cornelian dilemma concerning its possible responses to this situation, with on the one hand, whether to engage with an extremely authoritarian and corrupt country at the risk of becoming complicit with the regime’s policy and sustainability or, on the other hand, to boycott it, at the risk of seeing the population increasingly threatened and the future of the country further challenged.
Health as Nation-Branding
When former President Saparmurat Niyazov died in 2006, Turkmenistan’s healthcare system was considered to have been one of the most negatively impacted in the Eurasian space by the collapse of the Soviet Union and by poor management under an autocratic political power. In the mid-2000s, life expectancy in Turkmenistan was 62.7 years, at least six years lower than most other post-Soviet states, and 17 years lower than in Western European states. In response to this critical and widely known situation, new president Berdymukhamedov publicly committed to reforming this sector. He announced tens of millions of dollars of investments to build new medical structures throughout the country and to reopen provincial hospitals closed by his predecessor. He increased medical training by restoring PhD programs that Niyazov closed and restored the number of practitioners that had been dramatically reduced when 15,000 of them were sacked by Niyazov in 2004.
A former dentist, Berdymukhamedov has set himself further apart from his predecessor through his recurrent narrative on the country’s medical sector, which he claims is reaching the peak of modernity and performance under his regime. His descriptions seek to make the health sector a core feature of the Turkmen nation and people. For more than ten years, Turkmen media and websites have regularly praised the inauguration of new hospitals and clinics as having state-of-the-art equipment and highly qualified staff. They are supposed to serve as demonstrations of the country’s access to international methods and standards, amid claims that it is recognized as such within and beyond its borders.
This inextricable link between health and nation-building routinely intrudes into the daily life of Turkmenistanis, who are henceforth expected to maintain an exemplary healthy life-style. Smoking has been banned from the street and is only allowed in restaurants and private places. In continuation of Soviet ideology, sport has been raised to the rank of a national symbol. Through the construction of numerous, gigantic and expensive facilities, such as stadiums and ice rinks, sport has also become ubiquitous in the lifestyle of Turkmenistanis, from school children to the presidential entourage, no matter whether they are sporty or not. Thousands of people throughout the country are for instance pressured to participate in compulsory physical fitness classes at their workplaces. Berdymukhamedov has even compelled his ministers to join sports classes, often led by himself and recorded to be broadcast later on television. The cult of sport and its corollary, a healthy nation and president, are supposed to foster, with the help of media propaganda, Turkmenistani national pride.
Window Dressings in the Healthcare System
The reality tells a different story. Reports from the few NGOs and international organizations still working with Turkmenistan, as well as from private Turkmen citizens, depict a significantly different image of the healthcare system, akin to the faux marble and gold façades that adorn the most visible parts of the country and hide the poverty and hardship suffered by the population. Berdymukhamedov’s reforms have been criticized as being essentially cosmetic and confined to a few specific practices, such as cancer or eye surgery, in the capital.
Turkmenistan continues to operate a healthcare system based on an outdated infrastructure inherited from Soviet times, and has failed to invest in updating it. Reports describe how urgent needs in many areas have been largely forgotten or delayed. Basic medical care remains very weak, particularly in rural areas where provincial hospitals lack sterilized equipment, drugs, and the most basic equipment. In addition, the number of trained personnel is far too low. In many hospitals, nurses conduct all phases of patient treatment, including prescribing drugs. Even where it exists, modern equipment is rarely used because of a lack of competent personnel to handle it and to interpret the results. Moreover, patients are charged for all services, from hospital beds and food to medicine and surgeries. Corruption is pervasive. According to reports, despite the weakness of primary healthcare, Turkmen hospitals are increasingly avoided by the population, who see them as part of an incompetent system.
Health as a Political or Socioeconomic Tool
By making healthcare (and healthiness) a pillar of nation-building, supported by robust propaganda touting its supposed successes, Berdymukhamedov is using the sector to promote his own political legitimacy, which was weak at the time he took the presidency. Through political discourse touting changes and progress made under his regime in, among others, the healthcare system, he has sought to use his public commitment to this sector to distance himself from one of his predecessor’s most unpopular policies. In the second half of the 2000s, the new president’s buoyant statements raised hopes both within the population and among foreign observers that standard of living would rise.
Second, and related, Berdymukhamedov made social welfare an instrument for regime survival. In Turkmenistan, health strategies and spending have been shaped less by the country’s budget capacity and economic resources than by their use as a tool to prevent political and social protest. By insisting on the so-called universality and excellence of the health system while at the same time making these benefits contingent on citizens’ support, Berdymukhamedov, like other authoritarian rulers, manipulates the loyalty of citizens, even in the absence of economic prosperity. In short, Turkmenistanis fear that they will not receive healthcare care benefits if they participate in any political activism against officialdom. This particularly resonates in post-Soviet states where populations are accustomed to having universal healthcare of some sort.
Finally, Berdymukhamedov has sought to prevent the emergence of local or foreign civil society actors addressing the health system’s shortcomings, which would undermine his government’s propaganda about its progress and delegitimize the president and his policies. Almost all foreign NGOs working in the medical sector were kicked out of the country in the 2000s. Others, like Doctors Without Borders, left voluntarily, citing unacceptable working conditions. Restrictions on any group not strictly controlled by the state have not stopped since then; the only Turkish clinic, the Central Hospital in Ashgabat, was closed in April 2017. Although no official reasons for the closure of this hospital were reported, the Ministry of Health might have been displeased with its popularity and so compelled people to use only the services of local clinics controlled by the president's family.
The Heavy Impact of Turkmenistani Autocratic System
The failure of the healthcare system along with its authoritarian management is neither unprecedented nor specific to Turkmenistan. This is first and foremost a replicate of the Stalinist era in which threats to the political system, more than economic considerations, guided healthcare policy, even when decisions were economically inefficient. Besides, many authoritarian states in the post-Soviet space, for example neighboring Uzbekistan, as well as in other regions such as Tunisia under former President Ben Ali, used social welfare to pressure the population against engaging in political contestation. Turkmenistan has, however, set itself further apart through the combination of 1) a healthcare system built as an essential element of the government’s nation-building narrative, 2) unchallenged authoritarianism marked by pervasive personality worship, and 3) an unprecedented socio-economic crisis since 2014. Such a combination is likely to continue to have a negative impact on the health of the population and the development of the country over the longer term.
For a closer look, first, Berdymukhamedov has made health an essential component of his cult of personality. Through his professional background, and by publicly visiting new hospital facilities or having himself photographed while performing surgery, he presents himself as the healer of the nation and thereby implies an overlap between his person and the Turkmenistani nation. In this context, the decision-making power of the Health Ministry has remained weak. As in many other sectors, Berdymukhamedov takes the overwhelming majority of the decisions and “potemkinizes” further the state by increasing the gap between a system such as the one depicted in propaganda and the real life difficulties faced by the population
Second, since independence, the Turkmenistani government has tampered with medical statistics, such as infant and maternal mortality rates, and concealed data on infectious and contagious diseases, particularly HIV, tuberculosis, measles, cholera, and hepatitis, the true scope of which could cast doubt on the alleged success of the healthcare system. Doctors and testing laboratories are reportedly pressured not to diagnose tuberculosis above a prescribed threshold, resulting in a number of sick persons denied access to hospitals and treatment. In such settings, the task of the Ministry of Health has often consisted more of controlling doctors and patients than supporting the former and treating the latter. Officials have required doctors working in provinces not to disclose HIV infections (since 2015, the Ministry of Health has been required to keep records of HIV-infected patients). All persons diagnosed with HIV must undergo compulsory treatment in Ashgabat for a period of 2 months and are then prevented from leaving Turkmen territory. These types of policies contribute to driving serious diseases underground and prevent reliable assessment of the real healthcare situation in the country.
Third, Berdymukhamedov’s extreme restriction of civil society sets Turkmenistan even further apart from many other authoritarian states. As demonstrated by Erica J. Johnson in her University of Washington dissertation, in many authoritarian regimes, the co-optation of NGOs and other civil society actors, despite the negative impact this might imply on their activities and performance, does not necessarily make them irrelevant to improving a specific sector. In Turkmenistan, however, the lack of data, the multiple patient accessibility obstacles, and the lack of implementation of international protocols, have thwarted related NGO activities.
Finally, the economic crisis that has been building since 2014 has exacerbated the situation. The fall of hydrocarbon prices in 2015, on which most of Turkmenistan's economy relied, significantly weakened the “post-Soviet welfare authoritarianism” that the government had hitherto strived to perpetuate. Berdymukhamedov has lowered or stopped many subsidies, particularly on drugs, a sensitive topic in a state that was already experiencing a serious deficiency in this sector. In 2017, the price of many medicines rose by some 50 percent.
The government has also responded to the economic crisis by increasing scrutiny and pressure on the population that may reveal, unintentionally, the dire situation of the country’s healthcare system. Well-to-do Turkmen used to travel to Turkey, Iran, or Russia to seek medical treatment. In recent years, authorities have, however, discouraged such travel by introducing complex paperwork necessities for those seeking medical treatment abroad. Several reports confirmed that individuals attempting to travel to Iran were stopped at the border when medical records were found on them.
The Cornelian Dilemma of Foreign Engagement with Authoritarian States
In conclusion, Berdymukhamedov’s decade-long policy of using the healthcare system to promote nation-building and regime legitimacy has fragile prospects. Despite the government’s propaganda, much of the population is aware of the problems and contrasts the current failing health system with the free and relatively effective one it had been accustomed to under the Soviet regime. This contrast feeds a nostalgia for the Soviet welfare system and leaves many Turkmenistanis dissatisfied with their current situation. This will have long-term negative impacts on this sector and on the country’s development. After all, healthcare experts and economists have demonstrated an inextricable link between poor health, poverty, and under-development.
This raises the issue of the efficacy of foreign actors’ engagement with authoritarian states. Turkmenistan has so far been reluctant to receive foreign assistance. As Johnson indicated, while poor countries are likely to rely on foreign aid, higher income countries do not need assistance and have more room to manage their own healthcare systems without external pressure. With a 2017 GDP per capita of $7,350, Turkmenistan is not considered a low-income country. However, the ongoing economic crisis appears to be leading the government to become more open to assistance from the international community (based on my interviews with representatives of Western governments). In 2018, several sources reported a relatively unprecedented openness of Turkmen officials to discussions with foreign actors, suggesting opportunities—albeit limited—to cooperate.
It should be noted that several studies in authoritarian countries, for example in Africa, have shown how leaders have used foreign assistance to escape local pressures; they have relied on long-term foreign assistance to put off implementation of reforms, including to improve healthcare systems. Hence, foreign actors’ engagement can have the unintended consequence of sustaining corruption, authoritarianism, and regime survival. Moreover, in the case of Turkmenistan, as the case of Doctors without Borders has shown, foreign organizations that are compelled to use questionable government statistics risk becoming accomplices of the government by unintentionally validating data and thereby perpetuating inefficient and even dangerous medical policies.
Sebastien Peyrouse is Research Professor at the Institute for European, Russian and Eurasian Studies at George Washington University.
 See: Bernd Rechel and Martin McKee, “Human Rights and Health in Turkmenistan,” European Centre on Health of Societies in Transition, 2005; Bernd Rechel and Martin McKee, “The Effects of Dictatorship on Health: The Case of Turkmenistan,” BMC Medicine, 2007.
 Special thanks to Diana and Yulia Serebryannik at the organization “Rights and Freedoms of Turkmenistan Citizens” for their insights and information.
 Based on the author’s interviews with Turkmenistani non-governmental activists.
 This was further confirmed through several author’s interviews with Turkmenistani activists.