ALMATY, Kazakhstan -- Less than two years ago, after a trip to a state medical clinic in Kazakhstan's largest city, Almaty, Gulnur Shayakhmetova was diagnosed with a cancerous tumor that would need extensive treatment.
Doubting the analysis, the 30-year-old went to a private clinic for a second opinion. Test results showed the initial diagnosis to be incorrect. While Shayakhmetova was relieved, she was also left fuming.
Thanks to an overhaul that entered into force in early 2020, working Kazakhs and their employers pay a mandatory payment worth up to 3 percent of their salaries in additional tax to cover them in the state's Compulsory Social Medical Insurance (MEMS) plan.
The new tax was supposed to increase and improve medical coverage provided by state medical institutions, as well as allow investment into a health sector that officials have acknowledged is underfunded.
Instead, Shayakhmetova and other Kazakhs find themselves paying twice: once for MEMS and once to go to another doctor when the care provided by MEMS fails to meet their needs.
"They created a malfunctioning system to launder money," Shayakhmetova told RFE/RL's Kazakh Service. "We supposedly have free medical care, but the equipment in the clinics is old and you wait in line for hours for tests."
Kazakh President Qasym-Zhomart Toqaev -- who oversaw the introduction of MEMS in the first year of his presidency -- has admitted that the results have thus far been disappointing.
Addressing lawmakers and officials on February 7 after appointing a new cabinet -- including a new health minister -- Toqaev pointed out that the health-care sector's budget had doubled since MEMS was first introduced. "However, there has not yet been a significant improvement in the quality and accessibility of medical care," he argued.
New Prime Minister Olzhas Bektenov reinforced that message in his first meeting with his cabinet later that week, noting that corruption and inefficiency within MEMS meant the policy needs "serious reconsideration" and "reformatting," while the health sector as a whole required "full digitization and transparency."
But so far there is no indication that Kazakh authorities are going to abandon MEMS.
To the contrary, draft amendments backed by the Health Ministry that may soon come to the legislature would increase mandatory payments covering medical care for Kazakhs earning over 850,000 tenges ($1,900), with the maximum allowable payments under the system rising by as much as five times.
And while that categorization limits blowback to those further from the breadline, the attempt to pump more money into a broken system is already generating plenty of anger.
No Likes, Many Dislikes
The period for public discussion of the draft law ended on February 7. On the government portal where it was posted for discussion, exactly zero registered users gave the law a Facebook-style "like," while more than 140 users gave it a thumbs down.
That the webpage has been viewed less than 8,000 times since it was posted on January 24 highlights the limited public engagement within the "public discussion" of laws in Kazakhstan. But the comments section bulged with hundreds of indignant remarks.
"I am categorically against [the amendments]. Our health-care [system] is not at the level to [justify] ripping off that kind of money from people," wrote one user, Aizhan Tazhinova, who related her experience of trying to get the electrocardiogram from a state clinic that was required to excuse her son from school sports.
"They said to my face, 'Go do it at any private one.' Whatever clinic you go to, you enter nine circles of hell. [The authorities] are just coming up with new ways of crawling into our pockets," she wrote.
Comments such as these were met with pasted responses from the Health Ministry to the effect that MEMS, while requiring improvements, was "fulfilling its main functions." The ministry also stressed that increased payments would only apply to 10 percent of the country's workforce, with the remainder unaffected by the proposed tax.
The decision to increase obligations for higher earners makes political sense -- and not just because MEMS is "socially oriented," in the government's words.
Kazakhstan's worst independence-era unrest two years ago -- the Bloody January events that left at least 238 people dead and the regime hanging by a thread -- began with a New Year's spike in the cost of liquefied petroleum gas.
Since then, the authorities have been cautious not to anger a cash-poor, inflation-weary population. When officials announced hikes in utility tariffs last year, they offset the measure with stipulations for financial assistance from provincial governments for the poorest residents.
Median monthly salaries in Kazakhstan hover around $560, while the minimum wage is less than $200 per month.
But the new legislation is clearly bad news for businesses, which typically bear the larger share of the burden in terms of covering their employees' payments into the Fund for Social Medical Insurance (EMSK).
One rebuttal to the amendments during the public-discussion period was posted by the Republican Association of Mining and Metallurgical Enterprises, a lobby group that includes some of the country's most powerful companies, where highly trained specialists are more likely to earn around or over the threshold envisaged in the amendments.
The association warned that the legislation would entail "a significant increase in the financial burden on employers, workers, and the self-employed population."
Underfunded Health Care
Kazakhstan's health-care woes do not begin and end with MEMS.
Successive economic crises in the decade prior to the scheme's introduction saw funding from the budget for the health-care sector sacrificed as other social spending -- such as handouts -- took precedence.
A report from the government's official English-language publication, the Astana Times, in 2019 -- as the government prepared to roll out a MEMS pilot project in Qaraghandy Province -- noted that the proportion of the state budget allocated to health care fell from over 12 percent to just 9 percent between 2010 and 2017.
Quoted in the same report, then-Health Minister Elzhan Birtanov said that MEMS would help bolster the low wages of medical workers, some of whom were either leaving the profession or seeking jobs abroad. "We have to understand that the biggest problem for us now is the lack of staff; we should at least try not to worsen it," he said.
Elzhan Birtanov was health minister at the time MEMS was introduced. He was later sentenced for corruption.
It was also acknowledged -- both by the government and the World Health Organization (WHO) -- that state medical facilities were offering less and less coverage, leading to a de facto rise in the number of treatments and services that citizens had to pay for out of their own pocket.
Even after MEMS, Kazakhstan's health funding is still only around 3.8 percent of GDP -- below the minimum 5 percent of GDP advocated by the WHO.
The main problem with MEMS, by many accounts, is that the new money going into health care is simply getting lost as medical institutions claim money from the EMSK for unnecessary services.
Almaty resident Zhibek Batyrova, speaking to RFE/RL's Kazakh Service, compared the system to an "organized mess."
"You can't go to a neurologist right away -- you first need to make an appointment with a general practitioner, get a referral, wait in line, then go to the right specialist, and so on, in a circle. As a result, treatment is delayed for weeks," she said.
Shortly after RFE/RL's Kazakh Service published its report on MEMS, the Health Ministry said the practice of requiring such referrals would end from the beginning of April -- one of several measures apparently aimed at decluttering patient care.
But there is also the problem of medical clinics claiming money for services they never offered in the first place.
According to EMSK, monitoring by the fund in 2022 revealed that these kinds of false claims cost the fund at least 400 million tenges in 2022 (nearly $900,000 at the time).
And this is very likely the tip of the iceberg, given that methods for detection often leave much to be desired.
In January of this year, the anti-corruption agency's branch in Abai Province reported that several hospitals in the province were suspected of misusing funds after investigators said they compared the number of beds in the hospitals to the number of patients and randomly called about 100 patients to check on the services they had received.