PONARS Eurasia
  • About
    • Contact
    • Membership
      • All Members
      • Core Members
      • Collegium Members
      • Associate Members
      • About Membership
    • Ukraine Experts
    • Executive Committee
  • Policy Memos
    • List of Policy Memos
    • Submissions
  • Podcasts
  • Online Academy
  • Events
    • Past Events
  • Recommended
  • Ukraine Experts
Contacts

Address
1957 E St NW,
Washington, DC 20052

adminponars@gwu.edu
202.994.5915

NEWSLETTER
Facebook
Twitter
YouTube
Podcast
PONARS Eurasia
PONARS Eurasia
  • About
    • Contact
    • Membership
      • All Members
      • Core Members
      • Collegium Members
      • Associate Members
      • About Membership
    • Ukraine Experts
    • Executive Committee
  • Policy Memos
    • List of Policy Memos
    • Submissions
  • Podcasts
  • Online Academy
  • Events
    • Past Events
  • Recommended
  • Ukraine Experts
DIGITAL RESOURCES
digital resources

Bookstore 📚

Knowledge Hub

Course Syllabi

Point & Counterpoint

Policy Perspectives

RECOMMENDED
  • The Russia Program at GW (IERES)

    View
  • The Evolving Concerns of Russians after the Invasion | New Voices on Eurasia with Sasha de Vogel (March 9)

    View
  • PONARS Eurasia Spring Policy Conference (March 3)

    View
  • Ukrainathon 2023 (Feb. 24-25)

    View
  • How Putin has shrugged off unprecedented economic sanctions over Russia’s war in Ukraine – for now

    View
RSS PONARS Eurasia Podcast
  • The Putin-Xi Summit: What's New In Their Joint Communique ? February 23, 2022
    In this week’s PONARS Eurasia Podcast, Maria Lipman speaks with Russian China experts Vita Spivak and Alexander Gabuev about the February meeting between Vladimir Putin and Xi Jinping, and what it may tell us about where the Russian-Chinese relationship is headed.
  • Exploring the Russian Courts' Ruling to Liquidate the Memorial Society January 28, 2022
    In this week’s PONARS Eurasia Podcast, Maria Lipman chats with scholars Kelly Smith and Benjamin Nathans about the history, achievements, and impending shutdown of the Memorial Society, Russia's oldest and most venerable civic organization, and what its imminent liquidation portends for the Russian civil society.
  • Russia's 2021 census and the Kremlin's nationalities policy [Lipman Series 2021] December 9, 2021
    In this week’s PONARS Eurasia Podcast, Maria Lipman chats with social scientist Andrey Shcherbak about the quality of the data collected in the recent population census and the goals of Vladimir Putin's government's nationalities policy
  • Active citizens of any kind are under threat [Lipman Series 2021] November 5, 2021
    In this week’s PONARS Eurasia Podcast, Maria Lipman chats with Alexander Verkhovsky about the Kremlin's ever expanding toolkit against political and civic activists, journalists, and other dissidents.
  • Russia's Legislative Elections followup [Lipman Series 2021] October 4, 2021
    In this week’s PONARS Eurasia Podcast, Maria Lipman chats with Tanya Lokot and Nikolay Petrov about the results of Russia’s legislative elections and about what comes next.
  • Why Is the Kremlin Nervous? [Lipman Series 2021] September 14, 2021
    In this week’s PONARS Eurasia Podcast, Maria Lipman chats with Ben Noble and Nikolay Petrov about Russia’s September 17-19 legislative elections, repressive measures against electoral challengers, and whether to expect anything other than preordained results.
  • Vaccine Hesitancy in Russia, France, and the United States [Lipman Series 2021] August 31, 2021
    In this week's PONARS Eurasia Podcast episode, Maria Lipman chats with Denis Volkov, Naira Davlashyan, and Peter Slevin about why COVID-19 vaccination rates are still so low across the globe, comparing vaccine hesitant constituencies across Russia, France, and the United States.  
  • Is Russia Becoming More Soviet? [Lipman Series 2021] July 26, 2021
      In a new PONARS Eurasia Podcast episode, Maria Lipman chats with Maxim Trudolyubov about the current tightening of the Russian political sphere, asking whether or not it’s helpful to draw comparisons to the late Soviet period.
  • The Evolution of Russia's Political Regime [Lipman Series 2021] June 21, 2021
    In this week's episode of the PONARS Eurasia Podcast, Maria Lipman chats with Grigory Golosov and Henry Hale about the evolution of Russia's political regime, and what to expect in the lead-up to September's Duma elections.
  • Volodymyr Zelensky: Year Two [Lipman Series 2021] May 24, 2021
    In this week's episode of the PONARS Eurasia Podcast, Maria Lipman chats with Sergiy Kudelia and Georgiy Kasianov about Ukrainian President Zelensky's second year in office, and how he has handled the political turbulence of the past year.
  • Policy Memos | Аналитика

The Health of the Nation—the Wealth of the Homeland! Turkmenistan’s Potemkin Healthcare System

  • February 13, 2019
  • Sebastien Peyrouse

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.[1] 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.[2] Even where it exists, modern equipment is rarely used because of a lack of competent personnel to handle it and to interpret the results.[3] 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.[4] 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.

[PDF]

Homepage image credit/license.


[1] 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.

[2] Special thanks to Diana and Yulia Serebryannik at the organization “Rights and Freedoms of Turkmenistan Citizens” for their insights and information.

[3] Based on the author’s interviews with Turkmenistani non-governmental activists.

[4] This was further confirmed through several author’s interviews with Turkmenistani activists.

Memo #: 574
Series: 2
PDF: Pepm574_Peyrouse_Feb2019.pdf
Related Topics
  • 2019
  • Peyrouse
  • Turkmenistan
Previous Article
  • Commentary | Комментарии
  • Point & Counterpoint

Abortion in Russia: How Has the Situation Changed Since the Soviet Era?

  • February 12, 2019
  • PONARS Eurasia
View
Next Article
  • Recommended | Рекомендуем

Haran: Now we see what kind of a strategic partner Russia can be if it invaded Crimea and brought war to Donbas

  • February 13, 2019
  • PONARS Eurasia
View
You May Also Like
View
  • Policy Memos | Аналитика

Exodus: Russian Repression and Social “Movement”

  • Laura Henry, Valerie Sperling and Lisa Sundstrom
  • March 24, 2023
View
  • Policy Memos | Аналитика

The Ukrainian Resistance Movement in the Occupied Territories

  • Yuriy Matsiyevsky
  • March 20, 2023
View
  • Policy Memos | Аналитика

Using Russian Prisoners to Fight in Ukraine: Legal or Illegal?

  • Alexander N. Sukharenko
  • March 14, 2023
View
  • Policy Memos | Аналитика

Ramzan Kadyrov’s Gamble in Ukraine: Keeping Chechnya Under Control While Competing for Federal Power

  • Jean-François Ratelle
  • March 13, 2023
View
  • Policy Memos | Аналитика

The Risk of Protest Won’t Stop Election Manipulation: Implications for Democracy Assistance

  • Cole Harvey
  • March 6, 2023
View
  • Policy Memos | Аналитика

Ukraine’s Current Counterintelligence Capabilities

  • Eli C. Kaul
  • March 1, 2023
View
  • Policy Memos | Аналитика

The Evolving Concerns of Russians After the Invasion of Ukraine: Evaluating Appeals to the Presidential Administration

  • Sasha de Vogel
  • February 27, 2023
View
  • Policy Memos | Аналитика

Russia’s Invasion of Ukraine and Weaponization of the “Humanitarian Space”

  • Lance Davies
  • February 24, 2023
PONARS Eurasia
  • About
  • Membership
  • Policy Memos
  • Recommended
  • Events
Powered by narva.io

Permissions & Citation Guidelines

Input your search keywords and press Enter.