Inequalities in access to and financing of care in Tajikistan: the role of informal strategies and migration.

Summary The starting point of this thesis is the observation that in post-soviet health systems, informal payments to health professionals persist well beyond the post-socialist transition, despite successive waves of health system reform. At the same time, since the independence of the Republic of Tajikistan, a profound mistrust of certain health professionals has developed and the renunciation of care has increased, affecting vulnerable populations in particular. What role do the various informal remuneration practices play then? Are they a source of mistrust or a means of restoring trust? Are informal payments adjusted to the standard of living of patients or do they create inequalities between patients? According to the equity indicators mobilized, and contrary to popular belief, informal payments do not make it possible to make the system progressive and to guarantee access for all. In the face of these barriers to access to care, households implement different strategies: informal solidarity, debt, recourse to traditional medicine, mobilization of social capital, etc. We then study, more precisely, the extent to which migration, a massive phenomenon in Tajikistan, is part of these strategies and the extent to which remittances enable beneficiary households to improve their access to care.