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| Baiterek Tower in Astana, Kazakhstan's capital since 1997 |
Kazakhstan has been ruled by the authoritarian Nursultan Nazarbayev since he was first elected President in 1991. He has since faced persistent allegations of corruption and human rights abuses. Nonetheless, he seems to enjoy popularity, partly because the country has been spared the sort of civil strife seen in neighbouring states such as Kyrgyzstan. At the viewing platform of the 97-metre high Baiterek Tower in Astana, Kazakhs flock to have their photograph taken as they make a wish with their hands pressed into a 2 kg lump of gold impressed with the President's handprint.
Of the 17 million citizens, some 63% are ethnic Kazakhs, about 23% are ethnic Russians, and the rest are made up of a multitude of groups including Ukrainians, Uzbeks, Chechens, and Uighurs.
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There is also a legacy of environmental disaster. Starting in the 1940s, the Soviet Union did more than 400 nuclear weapons tests in the steppe region of north eastern Kazakhstan, where some 200 000 Kazakhs were exposed to large doses of radiation, leading to an increase in cancers and other diseases.
Pollution also plagues the region around the Aral Sea, which was the fourth largest lake in the world before Soviet irrigation projects almost drained it. In rural areas of the vast, landlocked state—Kazakhstan is larger than western Europe and is the ninth largest country in the world—people have to boil water for drinking.
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“The country has undergone many changes but whether they've been successful or not is another matter”, says a Kazakh doctor, who left the country in the 1990s but who wished to remain anonymous because he travels back regularly. “I wasn't happy working there because there was a lot of turmoil and then they decided to extract and sell all the oil”, he tells The Lancet. “It's not a merit-based culture, it's connection-based. People are tense because they fear for their jobs and decisions are made top-down. And when it comes to the government's attempts to bring democracy, frankly, for me, the word has been devalued.”
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“Many doctors have more than one job or see patients privately because salaries are low. All health-care workers are salaried, they don't get a fee for service, and salaries are one of the things that the government is looking at”, he says. “In other areas, the government has been pouring money into health care to the extent that sometimes the Ministry of Health has trouble spending it.”
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The health-care system is still dominated by a system of specialisation. Building trust in a system whereby a primary care physician oversees a patient's health is proving a challenge, says a western health specialist who has been helping to implement change in the country and who also wanted to remain anonymous. “Physicians and midwives can face time in jail or fines if something goes wrong with a patient even if it isn't their fault. So they can be very fearful and laws have yet to be changed”, she tells The Lancet.
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A strong desire to reform the health-care system was evident across the government and population, says Vujnovic. “The people wish to move forward and in the Ministry of Health, civil service, and in the WHO office, people come in to work extra hours every Saturday”, she says. “I mean it in the best possible way when I say that they move with the speed of an arrow and it is good to be the wind which supports its flight.”
The Lancet, Volume 383, Issue 9936, Pages 2197 - 2198, 28 June 2014
doi:10.1016/S0140-6736(14)61069-2
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