This very interesting paper, based on data from four cross-sectional household surveys conducted in rural Tajikistan between 2005 and 2011, shows that household out-of-pocket expenditure on medicine has doubled over this six-year span. These surveys measured the same asset index, which included characteristics of the household’s dwelling, water, sanitation and meat consumption. The study population was PHC users (> 18 years) living in rural districts of Tajikistan (Danghara, Warzab, Shahr-i Naw and Regar [Tursunzada]). The results show statistically significant differences across the geographical regions of Tajikistan in out-of-pocket expenditure, as well as across the relative economic groups. Moreover, the authors analyse the impact of overall healthcare reform on household out-of-pocket expenditure which is mostly related to drugs/medicine. They stress that informal payments and interpersonal relationships were a part of the system, and nominally free services were combined in practice with various relational modalities, bribes, ‘gratitude payments’ and blat (‘connections’). That is why, in this post-Soviet context, health providers at the PHC level are filling the gap between their insufficient salaries and other inputs by direct payments (OFP) from patients. Authors underline that the health reforms that were implemented in Tajikistan during the 1990s had aimed to offer free primary care services, and to strengthen the role of family medicine, but did not meet the expected benefits and standards. They argue that the rationality of the healthcare sector and especially of the drug supply access needs to be addressed as well as the question of resource allocation and access to quality of care in the remote regions of Tajikistan and the other Central Asian States.


Sophie Hohmann, School of Advanced Studies for Social Sciences, Paris