As the COVID-19 virus spread in Eurasia in early 2020, Tajikistan’s President Emomali Rahmon and his government chose to deny the crisis for more than four months, then acknowledged on April 30th only a very limited presence of the virus, according to the official data, of 15 cases. This low figure was at odds with the numerous local testimonies about people with symptoms of COVID-19 and the difficulties they were having in accessing medical care due to the lack of infrastructure and equipment. In addition, there were reports of hospitals refusing to admit patients with symptoms of COVID-19 due to unofficial instructions from some government officials to lower the number of reported cases.
Tajikistan’s controversial management of the COVID-19 crisis goes well beyond the undeniable difficulty for any government to react to the unforeseen consequences of a pandemic. Rather, it is part of a deep and long-lasting crisis in the Tajikistani medical sector which has a variety of causes. First, the Tajikistani medical system has been weakened by the poor economic situation of the country, which undermined investment in the social welfare sector. Second, the lack of investment has also resulted from the kleptocratic and neo-patrimonial practices of the regime, where funding for the health sector has collided with protection of the economic and financial interests of the political elites and with securing the survival of the authoritarian political regime.
Government denial and censorship
Until April 30th 2020, the eve of the visit of the World Health Organization (WHO) to Tajikistan, the Government had systematically denied registering any coronavirus infections, and instead criticised journalists who were trying to disseminate information on this topic, accusing them of provoking panic among the population. After they recognised the presence of COVID-19, the political authorities, however, have continued to downplay the impact of the pandemic, registering only 52 deaths by the end of June 2020.[1] Finally, at the end of January 2021, the Government declared that the country was virus free. Since early January, the country’s coronavirus count has not changed, with, according to official statistics, 13,308 infections and 90 fatalities.[2]
The official statements and figures go against even official state data. According to an annual digest produced by the State Statistics Agency, more than 41,700 people died in Tajikistan in 2020, about 8,650 more than in 2019, amounting to a 26 per cent increase over the average number of deaths recorded annually between 2015 and 2019; at the same time, Dushanbe recorded a 38 per cent surge in deaths.[3]
This contrast has been further questioned by local testimonies, including from medical staff. Local doctors have reported about the difficulties of getting a reliable coronavirus diagnosis. Tajikistani medical services have not received the necessary equipment for widespread testing of the population, and hospitals have not received test kits to verify the diagnosis, making a reliable assessment of COVID-19 infections highly unlikely, as well as of COVID-19 deaths.[4]
Second, the Government has kept tight control over the circulation of information about the spread of the disease, including by censoring the media, by exerting pressure on the population through fines on people deemed guilty of spreading ‘fake news’ on the pandemic for things like questioning the official statistics, and by pressuring medical staff to discharge patients with COVID-19 symptoms, such as high fever, in order to reduce the statistics, especially prior to the visit of the WHO delegation.[5] These measures have sparked controversy among medical staff and resulted in resignations, for example of a hospital manager in the Sughd Regional Hospital in Khujand.[6] Some doctors, with condition of anonymity, have reported that patients who died from symptoms of COVID-19 were instead recorded as having died of pneumonia, tuberculosis or Swine flu, and hospitals refused to return the bodies of people who supposedly died of pneumonia to their families and they were instead buried by medical workers dressed in hazmat suits.[7]
The impact of a weakened healthcare system
The Government’s difficulty in managing the COVID-19 crisis resulted primarily from a long-standing crisis. Since independence, the Government claimed to have committed to rebuild and modernise the health system by means of several reforms and programmes and the construction of hospital infrastructure. The most recent ‘Programme of State Guarantees to Provide the Population With Medical and Sanitary Assistance for 2017-2019’ envisaged the construction of hospitals and health centers throughout the country.[8] The announced improvements contained in multiple programmes discussed in government-controlled state media, however, have contrasted considerably with the experience of patients with the healthcare system of the country, which has been weakened by the accumulation of infrastructural and political factors.
After independence, the Tajikistani regime had to respond to the economic and social crisis caused by the sudden loss of Soviet Union subsidies which had been an essential support to the local social welfare system, and by the civil war which significantly damaged the country’s economy. Despite some economic progress, in particular a notable increase in GDP and a decrease in poverty since the 2000s, some organisations have pointed out some root causes of the slow and limited improvement of the healthcare system, in particular low spending by the state on health at only $17 per capita.[9]
Due to the lack of investment, an overwhelming majority of medical facilities, which were built between the 1930s and late 1970s, have deteriorated significantly since the collapse of the Soviet Union. Despite government declarations to the contrary, many medical facilities still have outdated or dysfunctional equipment, lack medicines and a reliable supply of electricity, water, and heating, or a proper sewage system. The dilapidation of medical facilities and the disengagement of political authorities has led residents of some smaller cities and villagers to take repair or reconstruction into their own hands.[10]
Medical facilities in rural areas are in worse shape than those in more urban areas. Most rural hospitals are staffed with only one doctor, and other medical facilities are generally staffed with young, inexperienced nurses and lack basic medicine. Hence, many patients prefer to avoid the physicians and local health centers which are supposed to provide primary care and go instead to the larger city hospitals that are more specialised for secondary and tertiary care. This, however, leads to an overcrowding of these facilities, which themselves are insufficiently staffed and equipped, and negatively impacts the quality of their services.
In a mountainous and poor country, access to medical facilities can be difficult. Many Tajikistanis live tens of kilometers away from medical centers. This isolation, although not specific to Tajikistan, is made significantly worse by a faulty road system impacted by harsh winter climatic conditions, as well as by the deterioration of the public transport system since the fall of the USSR, resulting in few connections to cities.[11]
Access to hospitals in emergency situations is particularly critical. The ambulance fleet is old and insufficient, including in large cities. Private transport by unofficial taxis is therefore the essential means to reach medical centers, including in case of severe symptoms such as heart failure or stroke. Worryingly, a significant part of the population, 30 per cent of which live under the national poverty line, cannot afford a private taxi service.[12] This leads residents of regions such as the GBAO to rely on understaffed and underequipped local health centers even in serious health situations.[13]
Lack of preparedness and corruption in the Tajikistani administration
Difficulties in addressing issues related to the national healthcare system is certainly not specific to Tajikistan. Many countries around the world, including in Eurasia, have struggled to reform and improve their healthcare systems. However, Tajikistan’s difficulties have been exacerbated by the neo-patrimonial nature of its political regime, in which the political and economic elites are closely interconnected, and sometimes are even the same, and where part of the way the medical system is managed has been based less on prioritised health needs and more on corruption and enrichment schemes for the elites.
The well-documented misappropriation of the profits of the country’s scarce resources, especially those of the state aluminum company and biggest national export-earner Talco, by the President’s family and closest circles have gutted investment in social welfare, including in the health sector. As reported more than ten years ago by a former US ambassador, the “people of Tajikistan effectively subsidise Talco, by living without adequate health services, education or electricity”.[14] Since then, the President has strengthened his grip on the country’s resources and made Tajikistan essentially a family run state, resulting in further deterioration of the social welfare system.[15]
Second, the medical sector itself has been a source of income for the presidential family, which has also had an impact on its management and development. For example, the construction of some medical or hospital centers have resulted more from corruption than from a strategic healthcare objective. According to local doctors and several other testimonies, businessmen without experience in medical management have been authorised to open medical structures by paying bribes to the presidential family.[16] Moreover, the pharmaceutical sector is largely under the control of presidential family members. Two of the companies which dominate Tajikistan’s pharmaceutical market, Sifat Pharm and Orion-Pharm, are owned respectively by the President’s daughter, Parvina, and his son, Rustam Emomali.[17] This has enabled Rahmon’s family and close allies to limit competition in the pharmaceutical sector and sell drugs at inflated prices, including during the COVID-19 crisis when the price of medications for mild forms of the disease increased seven fold, making it a source of income for the Rahmon family while also increasing the difficulty for poor families to access medical treatment.[18]
Third, management of the medical sector has been heavily impacted by President Rahmon’s efforts to secure his political regime and a potential dynastic transition to his son Rustam Emomali. To this end, Rahmon has combined authoritarianism and repression against opposition together with conveying an image of himself as the guardian of citizens’ welfare; he has also striven to counter portrayals of degradation in the social welfare system in local testimonies or in the limited opposition media. In this context, the rationale behind investing in medical facilities has been less a matter of improvement and balanced development than of political authorities laundering their reputations. This has been reflected in the repeated announcements of improvements in medical infrastructure which have not been implemented. For example, notwithstanding some achievements of the ‘Programme of State Guarantees to Provide the Population With Medical and Sanitary Assistance for 2017-2019’, information is vague concerning the location and opening dates for the planned 560 medical facilities.[19] Surprisingly, those facilities that were built have received very little press coverage in a country where achievements in the social welfare sector are usually widely celebrated by the state-controlled media. Actually, most new medical facilities reported on in the press in the last three years were not part of this programme, but instead the result of foreign aid coming inter alia from the Asian Development Bank, Islamic Development Bank, the Russian Federation, Japan, or the Turkish Cooperation and Coordination Agency (TIKA).
This is also demonstrated by the geographic concentration of new medical constructions, which are mainly in the capital, where they are more visible than in remote regions, and in Khatlon, Rahmon’s birthplace, where seven out of eight medical centers under the 2017-2019 programme were built. This focus on Khatlon is also part of the President’s strategy to secure the loyalism of the elites of this region, on whom he had heavily relied since the end of the civil war, but whose political unity has been undermined by dwindling money and resources.[20] Despite the legitimate importance of developing infrastructure in the capital or in Khatlon, the geographical concentration of limited funds has undermined the development of infrastructure in the provinces and even led residents of some towns or villages to build or repair medical centers with their own money, including on the basis of Hashar-collective labour as noted in Lolazor-2, a village in Vakhsh district in the region of Khatlon.[21]
COVID-19 versus regime security
Rahmon’s prioritisation of the security of his political regime at the expense of the health of the population has been clearly illustrated by the Government’s management of the COVID-19 crisis. Recognising a large scale spread of the virus on the Tajik territory, and consequently imposing a lockdown like most countries in the world, posed a significant economic and social risk likely to further threaten the legitimacy and security of the regime. It therefore happened only belatedly and in a limited way.
Tajikistan has been going through a social and financial crisis for several years. The extent of economic progress, growth of GDP and decrease in poverty that has been proclaimed by the Government has been widely disputed by independent observers.[22] Moreover, as described by the World Bank, Tajikistan’s economy remains vulnerable to external shocks.[23] While the remittances sent back by up to one million Tajikistani migrant workers in Russia had been an essential contribution to economy of the country and hence to the survival of the regime for at least the last 15 years, restricting the circulation and hence the migrations of Tajikistanis would have increased unemployment.
The weakening and even unavoidable bankruptcy of many of the small and medium-sized businesses with a lockdown of the country would have further impacted the local labour market, and hence increased the risk of social unrest. Moreover, this was likely to impact the rentier system of Rahmon and the elites. Small and medium-sized enterprises bear a large share of the tax burden in Tajikistan, and significantly reducing their activities would have cut down income for the state budget and might have made it more difficult for the Government to reduce the tax allowances granted to big companies controlled by Rahmon and regional political elites, and which constitute an essential rentier source.[24]
Finally, the intersection of the country’s health policy with the neo-patrimonial and authoritarian policies has been intensified by the timing of events. The COVID-19 crisis intersected with the 2020 presidential election, which was held in November and which OSCE observers found “took place within an environment tightly controlled by state authorities and characterized by long-standing restrictions on fundamental rights and freedoms… no genuine political alternative … (and) lacked credibility and transparency.” Even if President Rahmon has kept tight authoritarian control over the administrative machine and the electoral process to prevent the emergence of any opposition, the crisis resulting from the COVID-19 could have undermined his official narrative portraying himself as the guarantor of economic progress in the country and of the supposed well-being of the population.
Impact on the population
The logic of prioritising policy at the expense of health, combined with authoritarianism, impacts the health of the Tajikistani population. By first refusing to recognise and then minimising the COVID-19 crisis, as well as preventing a lockdown, the Tajik Government has bet on the development of herd immunity, as have bet some other countries, such as Sweden, thereby hoping to reduce the economic and political risks brought by the health crisis. The Swedish strategy, however, has been criticised.[25] Moreover, unlike the well-developed Swedish healthcare system, the Tajikistani health system is weak and has been unable to address the epidemic; the Government’s assertion disseminated in the state media that the country had the necessary capacity to respond to the crisis has been contradicted by the testimonies of hospital workers from several different regions who have spoken out about the severe shortage of personal-protection equipment (PPE) for medics as well as other supplies, including those for treating patients.
In addition, the lack of acknowledgement of the crisis slowed down dissemination of guidelines, instructions and treatment related to COVID-19. Temporary guidelines for the prevention, diagnosis and treatment of the infection were approved by Minister of Health Olimzod only on April 13th. Hence, doctors did not receive protocols for the diagnosis and treatment of the disease until at least four months after the outbreak of the virus. Although international aid has since contributed to improving the situation, the initial denial of the crisis led to a significant and risky lack of equipment, as reported in the southern district of Muminobod, where only one ventilator was been made available, at the main hospital, for a region of more than 72,000 inhabitants.[26]
Moreover, the Government’s denial of the continued spread of the virus in the country led part of the population to not take seriously the risks of the disease or the necessary precautions to prevent its spread. This is likely to have been worsened by the WHO’s endorsement on April 20th 2020 of Rahmon’s narrative that no case of COVID-19 had been identified in the country, despite local testimonies, which was subsequently widely circulated in the controlled state media.[27]
Finally, the COVID-19 crisis has exacerbated the difficulties the population already had in accessing medicine due to the underdeveloped and overly expensive pharmaceutical sector, as well as the control of the pharmaceutical market by the elites and the presidential family. Despite repeated official statements that there would be free medical services, including by Minister of Health Jamoliddin Abdullozoda in February 2021, patients have been charged around $200 USD for treatment of mild illnesses, and $400-700 for treatment of severe illnesses, including COVID-19. In 2020, nearly two-thirds of health expenditures came from out-of-pocket spending.[28] The high cost of drugs and medical treatment has made it inaccessible for a part of the population whose average salary is $150 USD.[29] Larger and poorer families were particularly affected, resulting in increased debt to finance treatment. Overall, the crisis has further highlighted a significant disparity between wealthy elites who have access to the few well-equipped hospitals and the majority of the population.
Conclusion
While lack of proper healthcare has become one of the main grievances of the population towards the regime, the policy conducted by the Government has raised many questions and has been further illustrated by the management of the COVID-19 crisis. President Rahmon’s initial denial and then underestimation of coronavirus infections despite a growing number of suspicious deaths is likely to have further eroded people’s trust in the regime.[30] While most of the rest of the world faced the crisis and sounded warnings about the spread of the disease, and despite the WHO’s March 16th recommendations about the need to avoid mass gatherings, President Rahmon continued large celebrations and events during the electoral campaign to promote his regime and his son Emomali, such as the pompous Navruz celebrations, the Tulip Festival, and others.
Despite the Government’s propaganda efforts and suppression of information, much of the population nevertheless is aware of the problems and contrasts the current failing health system with the free and relatively effective system it had been accustomed to under the Soviet regime. This has left many Tajikistani citizens dissatisfied with their current situation. While healthcare experts and economists have demonstrated an inextricable link between poor health, poverty, and under-development, Tajikistan’s emphasis on regime security and kleptocratic interests over healthcare is likely to have long-term negative impacts on this sector and on the country’s development.[31]
Despite the complexity of providing assistance to authoritarian and corrupt regimes, international donors could make a real difference, even taking into account that many today have only modest investment capacities, including through targeted, smaller assistance programmes that contribute to the development of local medical structures, especially outside the capital; by improving access to health facilities, including by helping to develop emergency transport services such as ambulances; by supporting the development of civil society organisations which contribute to accountability in the medical sector but whose activities are currently restricted; and by raising visibility about the state of the medical sector in Tajikistan internationally.
Sebastien Peyrouse, PhD, is a research professor at the Central Asia Program in the Institute for European, Russian and Eurasian Studies (George Washington University). His main areas of expertise are political systems in Central Asia, economic and social issues, Islam and religious minorities, and Central Asia’s geopolitical positioning toward China, Russia, India and South Asia. He has authored or co-authored several books on Central Asia such as Turkmenistan. Strategies of Power, Dilemmas of Development (Armonk: M. E. Sharpe) and published many articles, including in Europe Asia Studies, Nationalities Papers, China Perspectives, Religion, State & Society, Journal of Church and State.
Image by Ninara under (CC).
[1] RFE/RL Investigation Finds, Tajikistan’s Official Coronavirus Stats Don’t Reflect Reality, RFE/RL, June 2020, https://www.rferl.org/a/tajikistan-official-coronavirus-stats-don-t-reflect-reality-rfe-rl-investigation-finds/30692651.html
[2] RFE/RL, Tajik Mosques Reopen as Government Claims No New Coronavirus Cases, February 2021, https://www.rferl.org/a/tajik-mosques-reopen-as-government-claims-no-new-coronavirus-cases/31080795.html
[3] Eurasianet, Tajikistan’s excess mortality data belie COVID-19 denialism, February 2021, https://eurasianet.org/tajikistans-excess-mortality-data-belie-covid-19-denialism
[4] RFE/RL Investigation Finds, Tajikistan’s Official Coronavirus Stats Don’t Reflect Reality, RFE/RL, June 2020, https://www.rferl.org/a/tajikistan-official-coronavirus-stats-don-t-reflect-reality-rfe-rl-investigation-finds/30692651.html
[5] Tajikistan’s excess mortality data belie COVID-19 denialism.
[6] Farangis Najibullah, As Coronavirus Infections Go From Zero To Hundreds In Days, Tajikistan’s Hospitals Can’t Keep Up, RFE/RL, May 2020, https://www.rferl.org/a/overcrowded-hospitals-in-tajikistan-as-coronavirus-infections-go-from-zero-to-hundreds-in-days/30597899.html
[7] Radio Ozodi, Zhertvy COVID -19 v Tadzhikistane. Rassledovanie June 2020, https://rus.ozodi.org/a/30690777.html; RFE/RL Investigation Finds, Tajikistan’s Official Coronavirus Stats Don’t Reflect Reality, RFE/RL, June 2020, https://www.rferl.org/a/tajikistan-official-coronavirus-stats-don-t-reflect-reality-rfe-rl-investigation-finds/30692651.html
[8] Sebastien Peyrouse, The Alarming State of the Healthcare System in Tajikistan, IPHR, July 2020, https://www.iphronline.org/new-report-the-alarming-state-of-the-healthcare-system-in-tajikistan.html
[9] See the World Bank website: https://www.worldbank.org/en/country/tajikistan/overview
[10] Eelco Jacobs and Claudia Baez Camargo, Local health governance in Tajikistan: accountability and power relations at the district level, International Journal for Equity in Health, 19, 30 (2020).
[11] Hursand Hurramov, “V bol’nicu za 40 km”. Zhiteli tadzhikskih glubinok ne imejut dostupa k medicine, Radio Ozodi, June 2019, https://rus.ozodi.org/a/29976795.html
[12] Sam Bhutia, How economic growth in Tajikistan and Kyrgyzstan masks the plight of their poorest, Eurasianet, December 2019, https://eurasianet.org/how-economic-growth-in-tajikistan-and-kyrgyzstan-masks-the-plight-of-their-poorest
[13] Eelco Jacobs and Claudia Baez Camargo, Local health governance in Tajikistan: accountability and power relations at the district level, International Journal for Equity in Health, 19, 30 (2020).
[14] Alexander A. Cooley and John Heathershaw. 2017. Dictators Without Borders: Power and Money in Central Asia. New Heaven and London: Yale University Press.
[15] John Heathershaw and Parviz Mullojonov, Elite Bargains and Political Deals Project: Tajikistan Case Study, Stabilization Unit, February 2018.
[16] Ariana, M. Dzhonmahmadov: Tadzhikskaia еkonomika – jeto semeinoe predpriiatie docherei Е.Rahmona, July 2012, https://ariana.su/?S=0.1207241307
[17] Elena Korotkova, Emomali Rahmona obvinjajut v nazhive na epidemii koronavirusa v Tadzhikistane, News Asia, June 2020, http://www.news-asia.ru/view/13889; Eurasianet, Tajikistan: Coronavirus panic puts sufferers of other illnesses in grave danger, May 2020, https://eurasianet.org/tajikistan-coronavirus-panic-puts-sufferers-of-other-illnesses-in-grave-danger
[18] RFE/RL, In Tajikistan, COVID-19 Patients, Families Scoff at Pledge Of ‘Free Treatment’, February 2021, https://www.rferl.org/a/tajikistan-covid-19-coronavirus-free-treatment-scam-big-bills/31112946.html
[19] TAJ News, S nachala goda v Tadzhikistane postroili 7 medpunktov, December 2018, http://news.taj.su/?p=24897
[20] Lawrence Markowitz, Tajikistan: authoritarian reaction in a postwar state, Democratization, vol. 19, no. 1, 2012, pp. 98-119.
[21] Cabar Asia, Tajikistan: Rural Residents Complain About Poor Conditions of the Healthcare Centers, October 8, 2020, https://cabar.asia/en/tajikistan-rural-residents-complain-about-poor-conditions-of-the-healthcare-centers-photoreport
[22] Cabar Asia, The great discrepancy of Tajikistan: the rhetoric of poverty and the practice of state festivities, January 2021, https://cabar.asia/en/the-great-discrepancy-of-tajikistan-the-rhetoric-of-poverty-and-the-practice-of-state-festivities
[23] See the World Bank website: https://www.worldbank.org/en/country/tajikistan/overview
[24] Azia Plus, Koronavirus v Tadzhikistane est’. Tak schitaet tadzhikskij politolog i ob’’jasnjaet, pochemu molchat vlasti, April 2020, https://asiaplustj.info/ru/news/opinion/20200416/koronavirus-v-tadzhikistane-est-tak-schitaet-tadzhikskii-politolog-i-obyasnyaet-pochemu-molchat-vlasti
[25] Kelly Bjorklund, Andrew Ewing The Swedish COVID-19 Response Is a Disaster. It Shouldn’t Be a Model for the Rest of the World, Time, October 2020, https://time.com/5899432/sweden-coronovirus-disaster/
[26] Farangis Najibullah As Coronavirus Infections Go From Zero To Hundreds In Days, Tajikistan’s Hospitals Can’t Keep Up.
[27] Koronavirus v Tadzhikistane est’. Tak schitaet tadzhikskij politolog i ob’’jasnjaet, pochemu molchat vlasti.
[28] See the World Bank, Project Information Document, March 2020, http://documents1.worldbank.org/curated/en/274761585067722387/pdf/Project-Information-Document-Tajikistan-Emergency-COVID-19-Project-P173765.pdf
[29] Elena Korotkova, Еmomali Rahmona obvinjajut v nazhive na jepidemii koronavirusa v Tadzhikistane, Asia News, June 2020, http://www.news-asia.ru/view/13889; In Tajikistan, COVID-19 Patients, Families Scoff At Pledge Of ‘Free Treatment’
[30] Tajikistan’s excess mortality data belie COVID-19 denialism.
[31] J W Lynch, G D Smith, G A Kaplan and J S House, Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions, BMJ, vol. 320, April 2000.