Kazakshstan Health Profile 2012

Trends in life expectancy in Kazakhstan are broadly similar to those observed in the CIS, although life expectancy in Kazakhstan has remained below the CIS average and the decline in life expectancy after 1991 was steeper. The dissolution of the Soviet Union was followed by a dramatic decline in life expectancy. In Kazakhstan, life expectancy dropped from 68.81 years in 1990 to 64.4 years in 1996, and then increased again to 65.89 in 2005 (WHO Regional Office for Europe 2007). However, despite the economic recovery, this still fell almost three years short of its 1990 level and was 13.74 years lower than the average life expectancy in the EU15, which was recorded at 79.63 years in 2004 (WHO Regional Office for Europe 2007). Kazakhstan also has one of the world’s largest gender gaps in life expectancy (IRIN 2007a). In 2005, according to official statistics, males could expect to live for 60.4 years, while official female life expectancy was 71.73 years (WHO Regional Office for Europe 2007).

Male life expectancy also experienced a much steeper fall than female life expectancy in the first half of the 1990s, from 63.9 years in 1990 to 58.93 years in 1996 (WHO Regional Office for Europe 2007). The largest proportionate increases in mortality have occurred among males of working age. Between 1987 and 1995, mortality rates more than doubled for men aged 30–44 and rose by more than 75% for men aged 45–54 (Becker & Urzhumova 2005). There are also substantial regional variations in life expectancy. The most prosperous areas (Almaty city and the capital Astana) have a substantial advantage in terms of life expectancy over other more depressed areas of the country (Becker & Urzhumova 2005). It should, however, be noted that actual life expectancy may be even lower than recorded in official statistics . The reason for this lies in the underreporting of infant mortality, which is described in more detail below. Estimates that take this  factor into account point to an actual life expectancy of 61 years in 2003, which is four years less than official statistics indicate (Rechel, Shapo et al. 2005). Disability-adjusted life expectancy (DALE) at birth was estimated at 52.6 years for males and 59.3 years for females in 2002 (WHO Regional Office for Europe 2007). The decrease in life expectancy in Kazakhstan in the 1990s is largely due to an increase in mortality from cardiovascular diseases, in particular among middle-aged males. The age-standardized mortality rate from ischaemic heart disease for males increased from 405 per 100 000 male population in 1989 to 611 per 100 000 in 1996, declining again to 525 in 2005 (compared to 118 in the EU15 in 2004) (WHO Regional Office for Europe 2007).

The age-standardized mortality rate for selected alcohol-related causes of death is also high and stood at 308 per 100 000 population in 2003, compared to 58 per 100 000 in the EU15 in 2004. Age-adjusted cancer mortality rates (at 173 per 100 000 in 2005) are comparable to those in the EU15, but significantly higher than the central Asian average of 107 per 100 000 population (WHO Regional Office for Europe 2007). There are, however, problems with the identification of causes of death (Ministry of Health 2004), which means that mortality-related statistics classified by cause of death have to be treated with some caution. Alcohol consumption, smoking, diets high in fats and low in antioxidants, and poor detection and treatment of hypertension are major contributing factors to the increase in cardiovascular mortality (McKee & Chenet 2002). According to a nationally representative survey with 2000 respondents conducted in 2001, 55.6% of men in Kazakhstan were heavy vodka drinkers (defined as consuming more than 100 g of vodka per sitting) and only 13.8% consumed fruits on a daily basis (Cockerham, Hinote et al. 2004). While market liberalization has resulted in increased availability of a large number of consumer items, its effects on public health have often been detrimental. A survey of 648 vendors in Almaty in 1999–2000 found that cigarettes, alcohol, sweets, coffee and tea were widely available, but that there was only limited availability of fruits, vegetables and whole grains (Yim, Humphries et al. 2003). Central Asia has also become one of the key targets for the international tobacco industry (Gilmore & McKee 2004).

The Living Conditions, Lifestyles and Health Study of eight countries in the former Soviet Union (Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, the Russian Federation  and Ukraine) found the highest smoking prevalence among males in Kazakhstan, where 65.3% of male and 9.3% of female respondents reported to be currently smoking (Pomerleau, Gilmore et al. 2004). However, according to three surveys conducted by the National Centre on Healthy Lifestyles in 1998, 2001 and 2004, the incidence of tobacco smoking among the general population decreased from 28% to 23% and smoking among health professionals decreased from 34% to 26%. Despite health education campaigns in schools, however, the surveys did not find evidence of reduced smoking rates among adolescents, with an incidence of 14% in 13–15 year-olds in 2004 (National Centre on Healthy Lifestyles, personal communication, 2006). Kazakhstan also has very high mortality rates due to external causes (accidents, injuries, poisonings and traumas) and an increase in external cause mortality contributed to the mortality crisis in the 1990s, in particular for non- Kazakh males of working age (Becker & Urzhumova 2005). Age-standardized mortality rates increased from 118 per 100 000 in 1991 to 161 in 2005, which was close to the CIS average (159), but considerably higher than the average for the central Asian republics and Kazakhstan (CARK) (81) and more than four times higher than the EU15 average (37 in 2004) (WHO Regional Office for Europe 2007). In 2005, external cause mortality in Kazakhstan was one of the highest in the WHO European Region, only surpassed by the Russian Federation and Belarus (WHO Regional Office for Europe 2007). A significant proportion of external cause mortality is due to suicide, in particular among males (49 per 100 000 male population in 2005) (WHO Regional Office for Europe 2007). Car accidents are another important cause of external cause mortality and the use of seat belts, although mandatory, is not strictly enforced. The age-standardized mortality rate for motor vehicle travel accidents among males was 20 per 100 000 in 2003, which compared to 13 per 100 000 in the EU15 in 2004 (WHO Regional Office for Europe 2007). Like other countries of eastern Europe and central Asia, Kazakhstan has recorded a significant increase in the incidence of diabetes in recent years. In Kazakhstan, the incidence rate increased from 35 per 100 000 population in 1995 to 116 per 100 000 in 2005, which is below the CIS average of 158 per 100 000, but above the CARK average of 60 per 100 000 (WHO Regional Office for Europe 2007).

Since the country’s independence, Kazakhstan has embarked on a number of major health care reforms. It has revised health care financing,  introduced new provider payment methods, carried out some initial rationalization of its network of health care facilities, started strengthening primary health care, and introduced the safe motherhood approach, the DOTS treatment strategy for TB, and healthy lifestyle activities, as well as other priority programmes. After 1991, the country faced a number of challenges. Kazakhstan inherited from the Soviet Union a health system based on outdated norms and practices, delivered through an oversized network of publicly-owned facilities with an overemphasis on inpatient care and managed through direct control rather than regulation or contracting and with few incentives for efficiency or quality. A key challenge after independence was the drop in health care funding from public sources. In 2002, public allocations to the health sector amounted to only 1.93% of GDP. As in much of the rest of the former Soviet Union, population health indicators showed a dramatic decline in the early 1990s. Life expectancy in Kazakhstan has still not reached its 1991 level, adult and infant mortality remain high, and communicable diseases such as TB are raging. As in other countries of the region, the rapid spread of HIV/AIDS presents another major challenge.

The Kazakh health system has so far been unable to respond effectively to these population health challenges. Several inequities have emerged during the 1990s, associated with the fiscal crisis. As the government health budget shrank, people increasingly had to pay for health services and pharmaceuticals, which disadvantaged those on subsistence income. Rural areas have suffered more than urban areas from health budget cuts and hospital closures. Continuing variations in health status and in health resource allocations across oblasts remain a key issue. Until 2002, health reforms were often inconsistent, lacked a clear evidence base and the allocation of appropriate resources. They remained at the conceptual stage and had little impact on the health of the population. One of the reasons for this was the lack of leadership and continuity, which seems to have been greater than in other central Asian countries. In Kazakhstan, there were frequent changes of leaders, priorities and the organizational set-up of the Ministry of Health, with the dissolution of the Ministry of Health between 1997 and 2002. Another serious problem was the existence of uncoordinated reform activities at local and national levels. Some effective pilot projects were running far ahead of the policy agenda at the time. In order to achieve more sustained reforms, it is necessary to strengthen health care management and the capacity of the Ministry of Health.

With the economic boom of recent years, and the decision of the Government to use some of the country’s oil revenue for the social sector, an opportunity for large-scale reforms of Kazakhstan’s health sector has arisen. In 2004, the Government adopted the National Programme of Health Care Reform and Development for 2005–2010. The programme is comprehensive, sets ambitious goals and suggests a sensible reform path. Since 2002, budgetary allocations to the health sector have increased significantly both in absolute figures and as a share of GDP, and the national reform programme envisages gradually increasing budgetary allocations to 4% of GDP by 2010.
However, increased financial allocation to the health sector does not automatically solve all of Kazakhstan’s health system challenges. Substantial changes are required in the organization, management and provision of health services. The inpatient sector continues to consume the majority of health funding and more attention will therefore have to be devoted in the future to the development of the primary care sector. There is also a continued reliance on specialized services, such as those for maternal and child health, as evidenced by the recent completion of a new maternal and child health hospital in Astana. The parallel health systems operated by some ministries or the railways continue to operate and their existence is not addressed by the current health reform programme.

Overall, there appears to be the need to integrate services for the provision of modern medical care and evidence-based medicine that allows for multidisciplinary teamwork and avoids duplication. Intersectoral coordination is vital as an interim measure to manage this process. Overall, increased emphasis needs to be placed on the quality and efficiency of services. A system of monitoring and evaluation, which is in the early stages of development, as well as the establishment or revision of clinical practice guidelines, could play an important role in achieving these aims.

Health care workers will play a paramount role in any reforms. The current reforms envisage an overhaul of the training of health care professionals and the introduction of financing mechanisms that encourage health professionals to perform well. Too often, health is still considered as a nonproductive sphere, and it will be important to overcome this traditional misperception to ensure sustained investment in the health sector. The involvement of professional associations in health policy-making could substantially enhance the effectiveness and sustainability of reforms. Kazakhstan has ambitious goals for the future. With rapid economic growth fuelled by the oil revenue, the country has embarked on a comprehensive national health reform programme, but it is still too early to assess its effectiveness. Now that the second stage of the programme is just about to begin, health policymakers need to carefully assess the successes and failures of its first stage, in order to feed this information into the second stage of reforms.