Kyrgyzstan: Contemplating reform of the mental healthcare system

Daniel Sershen: 11/14/07

The first of a two-part series

Dr. Esenaman Beshkempirov charged down the hallway of a women's ward in Kyrgyzstan's main psychiatric hospital, barely offering a glimpse into the rooms. The scene – broken floors, narrow beds and patients ambling in a haze, or sleeping off their morning medication – hardly served as an advertisement for the curative powers of Kyrgyzstan's mental healthcare system.

Beshkempirov, deputy director of the Republican Mental Health Center in the capital, Bishkek, lingered longer in a rehabilitated wing. He and the doctor on duty pointed proudly to the freshly painted walls, new floor and ceiling, and smaller rooms, offering patients greater privacy.

Also the Ministry of Health's chief psychiatrist, Beshkempirov, blamed poor funding for the dilapidated state of the system. He explained that the collapse of the Soviet Union, which relied heavily on huge mental hospitals for both political persecution and medical care, had left each new country with massive infrastructure but tiny budgets.

"The big hospitals stopped getting funding," he said, "and the patients and workers suffered first and foremost... In such poor conditions, [how] could we fix the system?"

But according to Burul Makenbayeva, Executive Director of the nongovernmental group Mental Health and Society, the system should not be fixed so much as dismantled. Diagnoses as varied as schizophrenia, learning disability and even epilepsy often result in the same treatment: imposed hospitalization at a distance from family and friends. [Makenbayeva is a board member of the Soros Foundation-Kyrgyzstan, and her group has received support from its partner, the Open Society Institute. EurasiaNet operates under OSI's auspices].

"Hospitals should be a short-term solution – there should be other links in the chain," Makenbayeva said. She noted that World Health Organization standards, to which Kyrgyzstan has committed, call for a mixed approach of short-term hospitalization, outpatient care, and house calls by mental health professionals. In addition, she said, patients should be given better access to information about their treatment.

Like Beshkempirov, Makenbayeva highlighted financing as a key problem, although she criticized not the volume of funds but their distribution. She said that the budgets of Kyrgyzstan's three major mental health hospitals were determined exclusively by the number of patients on the books.

"There is no connection whatsoever between quality of care and financing, which means that there's no incentive to cure people. The incentive is to keep them there," Makenbayeva said.

Keneshbek Usenov, who treats about 60 walk-in patients as the head of Bishkek's main mental health clinic, said that the hospital system often did more damage than good. "Centralized treatment doesn't lead to any result," he said. "If these [outpatients] were treated there, they would be invalids," Usenov added. His project incorporates a social rehabilitation center supported by Mental Health and Society.

Watchdog groups say that the flaws in Kyrgyzstan's mental health structure lead not only to poor treatment, but also violations of basic rights. The Youth Human Rights Group has conducted several rounds of monitoring of various aspects of Kyrgyzstan's treatment system since 2000. Nazgul Turdubekova, a monitoring coordinator with the group, described conditions in the hospitals as "equal to torture." While researching a 2004 report on conditions in the hospital at Chym-Korgon, "we uncovered [evidence of] sexual violence and economic exploitation," she said. Turdubekova added that some patients had been abused, while others were put to work growing and processing food that the hospital itself then purchased.

She said such "corruption" extended to other aspects of the system in Kyrgyzstan, from the skimming of construction funds to psychiatrists' taking bribes to institutionalize troublesome family members. Materials made available by the group said that such diagnoses could be obtained from local doctors for as little as 250 som (just over seven dollars). Turdubekova described one woman patient whose grandmother had had her admitted to a psychiatric hospital because she sneaked out to the dance club too often.

Beshkempirov acknowledged that the system required serious reform, but said it was moving in the right direction. He described a plan of his to gradually transform Kyrgyzstan's monolithic hospital-based model into a dispersed network of primary care centers, regional hospitals, and downsized central institutions. If approved by the government, he said, the strategy would eventually bring Kyrgyzstan into line with world standards.

International experience "shows that you do not need to close [big] hospitals immediately – that first you need to open small hospitals and only then let the big ones shrink," Beshkempirov said. "We don't want to make a revolution."

Editor's Note: Daniel Sershen is a freelance journalist based in Bishkek.

Posted November 14, 2007 © Eurasianet