No Documents, No Doctor? No Longer

Jamila used to be one of tens of thousands of drug users, migrants, and others in Kyrgyzstan denied health care simply because she did not have a permanent address. Now, thanks to work by Asteria, an Open Society Foundations grantee, she and others are able to get health care without being excluded by the old, Soviet-era system.

Kyrgyzstan, like most former Soviet countries, requires a passport as proof of identity in order to access basic social goods, including health care, education, employment, and welfare. Having no passport means the inability to be formally employed or access essential health services. As in Soviet times, passports are still issued according to the obsolete system of propiska, or the formal registration of citizens based on their permanent address. This out-of-date system means that social services, like health care, are distributed only according to the number of people registered in a certain area. People living on the margins of society, like Jamila, are first to be excluded from these services. Without a permanent address—on top of the stigma attached to her status as a former inmate and a drug user—Jamila cannot access all the social and health benefits available under propiska.

While she was still in prison, a volunteer gave Jamila the phone number and address of Asteria, a harm reduction organization in Bishkek that also runs a small shelter for homeless women who use drugs. Most women who come to Asteria for harm reduction services, or who stay in its shelter, face the same issue: They have no passports or identity documents, and no address to register at in order to get propiska. According to Tatyana, Asteria’s social worker, the greatest challenge is to support women who are pregnant. Prenatal care is also denied to those without a passport, leaving women in anguish over the health of their future child. In fact, most of these women see a doctor for the first time once already in labor, having been brought to the emergency room by an ambulance.

Tired of having to see women left by the state without the most basic health services, Asteria started negotiations with Kyrgyzstan’s Ministry of Health and primary care providers in search of a solution. Countering bureaucratic arguments by the authorities with realistic solutions and the real-life stories of their clients told by the women themselves, Asteria managed to convince the Ministry that the situation needs to change. And finally, in June 2013, the Ministry of Health revised the current regulation to allow any organization in Kyrgyzstan that runs a shelter to register its clients with the local primary care provider, without the requirement of passport or propiska. This is good news for hundreds of people in crisis situations—migrants, victims of domestic violence, former inmates, LGBTI people, and people who use drugs—who will no longer have to use the emergency room as their only health care option.

Jamila, who now works as an outreach worker at Asteria, is expecting her first child this fall. While she still does not have a passport, she is looking forward to her first doctor appointment—literally, the first in her adult life. 

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We need to celebrate this breakthrough by Asteria, it tells us that those in humanitarian work have to as much as possible engage governments and other authorities in dialogue.Let us continue to sharpen our political strategies for the betterment of the lives of especially those socially excluded individuals and communities. We need to congratulate the Kyrgystan government for the reform in policies.

Sad situation. But, it happens in our good ole United States also. If the government is inconvenienced by access to certain documents, then government will try its best to hide the documents (plus, attempt to poison food or contaminate medicine), and the victim cannot (easily) get access to remedies or resolution without the said documents. Be it medicine, or criminal justice system, whatever....

Human nature is the same -- everywhere -- regardless of ethnicity, culture, religion, race, gender, ...


It is indeed the achievement! It would be interesting to see examples where if to paraphrase the title of the article doctors in regular health system would be accessible without documents.
In Lithuania, ID is needed in order to get health insurance and 'compulsory' government health insurance is the key in accessing basic services (alternatively of course you can always pay and access in private sector). for ID you need a residence address but these days it is easier than the soviet system. Anyway, I have little knowledge of good practices in other countries how they organize the system for those without health insurance (and if I understand well from the article above - do that in a way that no major obstacles for getting documents or residence address would be in place).

Thank you for your comment, Raminta! It is indeed a catch 22: understandably, government wants to see some form of ID to make sure it provides care to those who qualify (e.g. have low income and cannot afford private care), but for many the requirement of ID is the biggest barrier. In Kyrgyzstan, like in many other former Soviet countries, ID is tied to permanent residence address, and in our mobile world many people do not have it anymore. Add stigma attached to people who use drugs or have served prison term, and this bureaucratic barrier becomes insurmountable.

But this is not only a post-Soviet issue: recently a co-worker mentioned that in England undocumented migrant women, survivors of domestic violence, cannot access health care for lack of legal ID as well. It is so profoundly wrong when public health care is denied to those who need it most and do not have any other resources to turn to. Hopefully, we will see a positive change in Kyrgyzstan following this change!

Drug addicts who are ready to change seek a prefessional help. One needs to acknowledge and accept the problem he or she is faced with in order to change. There is a slight difference btwn addiction and drug or alcohol abuse. Again,drug and alcohol addicts use different defence mechanisms that prevents them to seek professional assistance. What is needed is psychotherapy and treatment from group of health professionals.

В Тюмени, Россия с правом получить медицинскую помощь ещё хуже.
1) Я имею паспорт РФ, имею гражданство РФ, имею регистрацию места проживания в Тюмени, имею Полюс обязательного медицинского страхования!
2)Я инвалид по вине репрессивной политики СССР!
3)Конституция РФ "гарантирует бесплатную медицину!
4) Россия издала ряд законодательных Актов о предоставлении медицинских услуг РФ в любых медучреждениях России по выбору больного!
Однако медицинские учреждения г. Тюмени отказывают мне в предоставлении квалифицированной медицинской помощи, игнорируя полюс ОМС грубо, с особым цинизмом требуют за визит (либо запись к врачу) крупную сумму денег.
5) Чтобы защитить свои права, я в письменной форме обратилась за разъяснениями к Главврачу Областной Клиники; в ответ получила невнятное разъяснение по поводу запрета Губернатора Тюмени предоставлять мне медицинские услуги согласно Закона РФ
5) Суд не принял к рассмотрению моего дела, так как я оспариваю коррупционные действия Главврача и Губернатора - суды России зависимы и подчиняются коррупционным чиновникам.

Sorry, but this same situation could arise in many Western European countries. Health care is a human right and should be given freely.

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