Turkmenistan Has Highest Child Mortality Rate in Central Asia

The mortality rate of children under five in Turkmenistan was 45.8 per 1,000 live births in 2018, a significant fall on 1990 but still much higher than its neighbors’. These and other classified statistics on maternal and child health and wellbeing are given in a recent Turkmen National Strategy for the Protection of Reproductive Health and the Health of Mothers, Newborns, Infants, and Adolescents for 2020-2030. The strategy covers current problems in maternal and child health, and sets out targets and ways to achieve them by 2030.

Turkmen.news has acquired a copy of the comprehensive document, which was sent to various ministries and departments in Turkmenistan. According to a source in one of the ministries, the draft strategy is at the discussion and finalization stage, in particular its section Specific Strategic Objectives and Key Actions, though the statistics included appear to be definitive. The document will soon be submitted for consideration by the cabinet of ministers but, according to the source, “sensitive” definitions have to be removed first, for example “socially vulnerable families and children,” and “poor households,” since there are none in Turkmenistan.

To make the information easily digestible, we are presenting here only the data on child health. The main theses have been broken down into subgroups.

Child health and wellbeing (0-9 years)

The mortality rate of children under five in Turkmenistan fell from 70 per 1,000 live births in 1990 to 45.8 in 2018, which is still very high. Deaths are more frequent among children from poor households, and rural families than urban families. A detailed breakdown is not given;

Turkmen.news note: According to UNICEF, the average under-five mortality rate worldwide, including Africa, in 2008 was 38.6. Of the Central Asian countries the lowest rate is in Kazakhstan – 9.9, then Kyrgyzstan (18.9), Uzbekistan (21.4), Tajikistan (34.8), and Turkmenistan (45.8).

Infant mortality fell from 70 per 1,000 live births in 1990 to 43 in 2016;

The proportion of mothers and newborns receiving postnatal care remains low – 39%. These services are substandard. The country has no services or provision for early intervention for children at risk of developmental difficulties;
At the country level 91% of children between the ages of 36 and 59 months developed in line with their age (statistics for 2016);
The percentage of children with suspected pneumonia who received antibiotics perorally (tablets or syrup) fell from 50.4% in 2006 to 34% in 2016. Some 13% of children with suspected pneumonia received intramuscular antibiotics in 2016. These figures are too low, as antibiotics are recommended for all children with suspected pneumonia. In 2016 the majority of children (71%) with a high temperature received paracetamol, 38% received ibuprofen, and 12% received other medicines;
Ninety-five per cent of children in their first two years received all the necessary injections. Vaccines are bought wholly with funds from the state budget;
Vitamin A deficiency – one of the most important causes of preventable child blindness, disease, and premature death. In 2011 one in two children between the ages of six and 59 months had Vitamin A deficiency, which influenced both morbidity and mortality. Some 7.2% of children suffered from a severe Vitamin A deficiency.
The level of unintentional injuries among children fell sharply over the past decade (from 13.9% in 2007 to 2.7% in 2017). The main causes of unintentional injury among children in 2017 were drowning (35%), the effects of smoke, fire or flames (9%); and road traffic accidents (7%);
Turkmenistan has the highest rates for exclusive breastfeeding, and the rates are increasing faster than in other countries of the region;

Adolescent and youth health (10-24)

Adolescents and young people between the ages of 10 and 24 make up 27% of the population of Turkmenistan;
Restricted access to reproductive health information and services and the lack of sex education in schools lead to early pregnancies and the spread of sexually transmitted diseases (STDs), including HIV;
According to research conducted in 2013 among secondary school pupils, only 38% of respondents had any understanding of how HIV is transmitted. The majority of adolescents are poorly informed about the symptoms of STDs and do not know where to go for testing, advice, and medical help. The majority of adolescents do not know where they can take a pregnancy test and receive health advice. Turkmenistan has practically no medical specialists trained to provide adolescents-friendly services;
On average 28 births are registered per 1,000 women between the ages of 15 and 19. This indicator is highest in Ahal region – 46 births per 1,000 women, while it is lowest in Balkan region – 10 births. The adolescent birth rate is 40% higher in rural areas (35 births per 1,000 women compared with 25 in urban areas);
There is a significant shortage of medical personnel trained in providing specialized services to adolescent boys. There is inadequate training in child and adolescent reproductive health. Overall, there is no system for long-term planning to bring about a sustainable improvement in adolescent reproductive health;
Research from 2015 to 2016 showed low involvement of fathers in bringing up children (15%).

Nutrition

In 2016, 3.2% of children under the age of five in Turkmenistan were of low weight, while 0.7% were classified as seriously underweight, compared to 9.2% and 2.6% respectively in 2006. Five per cent of children were stunted or too short for their age, while 4.2% were wasted or too thin for their height in 2016, compared with 18.9% or 7.2% in 2006;
Six per cent of children below the age of five were obese or overweight for their age in 2016, compared with 4.5% in 2006. The percentage of overweight children increases with age, reaching 11.5% among seven-year-olds at the national level (equally among girls and boys), and 19.1% in Ashgabat. Four per cent of boys and girls in that age group are underweight;
One of the results of poor nutrition is anemia, which is considered a serious problem in Turkmenistan. However, the country has no data on anemia in relation to food consumption and the calorific value of food consumed, so the exact causes of the high indicators for anemia in Turkmenistan are not given.

Critical points and recommendations

On health care funding

Low state expenditure on health care (just 1.1% of GDP);
The country has a high level of informal payments for medical services. In 2015, personal out-of-pocket expenditure on health care constituted 71% of all current expenditure. This deprives poor households of access to health services;
A highly centralized budget process with ineffective spending on reproductive, maternal, neonatal, child, and adolescent health (RMNCAH); a separate cost item should be introduced to the overall budget for RMNCAH;
Funding should be reallocated to the provision of care, personnel training, provision of main medicines and medical equipment with an emphasis on primary (outpatient) care;
Draw up a basic package of free RMNCAH services, including before and during pregnancy, childbirth, and in the post-natal and neonatal periods, and for children (0-15), and adolescents;
Draw up a needs assessment for medical personnel, medical equipment, and materials at all levels of care and service provision.

Human resources

A shortage of qualified medical personnel, including pediatricians, specialists in early child development and early RMNCAH intervention at all levels, especially at the level of primary health care;
The total number of pediatricians increased slightly from 315 in 2007 to 349 in 2016, while in the same period the number of doctors in general practice increased from 13,000 to 13,800. In addition to the small number of pediatricians, there is a noticeable imbalance in their distribution at the different health care levels with no pediatricians at all in primary care (the first level) and a concentration of them at the second level, i.e. only for inpatient care.
The figures for nurses, midwives, and doctors per 1,000 people remained low in 2016 in comparison with other countries in the region;
A shortage of qualified medical personnel trained in modern approaches to and methods of emergency obstetric care;
The health care system has a shortage of qualified staff in collecting and analyzing data, especially at the local level. Data management is poor because of deficiencies in infrastructure and outdated methods, with local data often entered on paper, then processed on computer. The distribution and use of data is also limited, including important information on the results of health care measures and final outcomes;
There is no national plan for the development of health care personnel;
Post- and pre-degree study programs (in universities and colleges) do not meet modern standards;
Outdated training programs on RMNCAH at both pre- and post-degree levels for medical students, interns, obstetricians and gynecologists, neonatologists, pediatricians, family doctors, midwives and nurses;
A lack of stimulus and motivation for graduates to work in primary health care, especially in remote areas.

Concerning the management of the health care system

A lack of skill and coordination in making RMNCAH interventions;
Weak coordination structures, including intra-sectional responses to RMNCAH problems at the national, regional, and district levels;
The ineffective introduction of legislation and policies to support the expansion of basic vital interventions;
Limited national potential in devising technical standards, protocols, syllabuses, and other normative documentation;
The poor application of guidelines, protocols and standards;
A low level of implementation of current protocols and guidelines;
Since 2017 the Ministry of Health has taken full responsibility for the provision of contraceptives in the country. However, there are deficiencies in the reliable supply of these products, including problems in the distribution system to medical establishments and a lack of expertise amongst health workers in determining the necessary quantity, forecasting and management of medical products;
Turkmenistan’s current national index of essential medicines has not been updated since 2011.

The provision of sanitary and hygienic conditions in schools, including suitable water supplies and sanitation, constitutes a separate point in the recommendations.