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250 CHAPTER 11 ■ Socialism Meets Social Marketing

the Soviet public health system, where decades of massive entitlements, no longer
affordable, were almost instantly abandoned. Layered beneath this problem was a
Byzantine medical system and standards of practice that effectively encouraged the
use of abortion as the principal method of fertility regulation, resulting in an abor-
tion rate for the women of Kazakhstan that ranked among the highest in the world
(Henshaw, Singh, & Haas, 1999). By the year 2000, that rate had been cut roughly
in half (Westoff, 2000), and the social marketing effort that played an important
role in that reduction was being sustained on a solely commercial basis by a net-
work of private pharmacies.

K A ZAKH STAN: A C O U NTRY OVE RVI EW

Kazakhstan, largest of the Central Asian Republics and ninth largest country in the
world, is situated between Russian Siberia to the north and the Indian sub-continent
to the south. Populated by a mix of Mongol and Turkic nomadic tribes from the
thirteenth century, Kazakhstan was conquered by Russia in the eighteenth century
and became a Soviet Republic in 1936 (Central Intelligence Agency [CIA], 2009).
With the country’s annexation into the Soviet Union came the imposition of all the
Soviet systems, both for the good and the not-so-good. Among the “good” was ed-
ucation. Literacy was near 100% in Kazakhstan (CIA, 2009), and education was a
highly valued commodity. Among the “not-so-good” was the healthcare system.
While offering virtually universal free access to health care, Soviet medicine
evolved in a vacuum with little exposure to modern medical advances or standards-
of-practice outside the USSR. The state healthcare system was responsible for all
aspects of health services, including the determination of what drug regimens and
drugs would be available, as well as their procurement, manufacture, and distribu-
tion through a central government pharmacy, Farmatsyia (Krakoff, 1997).

A Dependence on Abortion

The confluence of questionable Soviet medical practice, misconceptions about
modern contraceptives, and a constricting supply of pharmaceuticals led to a de-
pendence on abortion as a woman’s top choice for fertility control (Popov, 1990).
At the time of the collapse of the Soviet Union and the achievement of independ-
ence by Kazakhstan, Kazakhstani women could expect to average 1.8 abortions
over their lifetime, and those living in the capital saw a rate of 3.1, close to double
the national average (USAID/Macro International, 1995).