Kyrgyzstan Health Profile 2012

Social safety nets In a jealously defended clause of the constitution, Kyrgyzstan is defined as a socially oriented state with mandatory welfare state provisions for the vulnerable in society. There is a range of social safety nets provided to various target groups, such as maternity leave, elderly care and veteran benefits. The Bakiyev administration reintroduced a school lunch program for primary school children. However, all of these provisions are token and unable to realistically meet the greater needs of the country. A reduction in poverty levels has been slowly advancing with the support of external financial donors, yet on its own the government is unable to sustain programs to reduce poverty.

Equal opportunity in accessing various social services and to professional advancement is generally guaranteed all citizens. Gender equality is rated high in recent relevant World Bank development indicators; ethnic and religious groups are also generally guaranteed equality. There is still a degree of discrimination, such as at the highest levels of public service, where women or ethnic and religious minorities have fewer chances of advancement. Equal access to education is generally guaranteed, but can be hampered by corruption.

HEALTH & DEVELOPMENT
Comprehensive long-term reform of the health system is in progress. The Government of Kyrgyzstan aims to improve population health, reduce the financial burden of seeking care, and improve the quality of health care services. The reforms were initiated in 1996 with the “Manas National Health Care Reform Program” which outlined the vision of change for 10 years. In 2005, evaluations of the reforms identified substantial progress as well as continuing challenges and remaining tasks. The activities of the original Manas reforms are now being carried forward under the “Manas Taalimi National Health Reform Program” for 2006-2010. The new Program has been approved at the highest government level, and supported by the international community through a Sector-Wide Approach (SWAp). Both the first Manas reform plan and its successor focus on a set of comprehensive changes in the organization, financing and content of the health system.
Health financing reforms eliminated fragmentation which was inherent in the previously decentralized financing system. This was accomplished through the creation of regional purchasing pools (and from 2006, a single national pool) under the Mandatory Health Insurance Fund for allocation of resources using output-based strategic purchasing methods, a radical change from the previous input-based budgeting process based on allocations decided centrally. Simultaneously, and in part due to the change of incentives and the Law on Health Care which gave greater autonomy to providers, hospital downsizing occurred and led to savings on utilities and other fixed costs.

Primary care services have been reorganized in Family Group Practices (FGPs), which by 2004 had enrolled approximately 98.5% of the population. An outpatient drug benefit has been introduced to improve access to medicines for primary care management of conditions such as hypertension and to reduce unnecessary hospitalizations. Despite continuous increases in funding for primary health care, salaries for healthcare staff remain low and there is a shortage of personnel in remote areas.

Maternal mortality rate has increased soon after independence and remains at high level. Poverty is an important health determinant; infant mortality rates are 1.8 times higher in the 20% poorest households than in the wealthiest 20%.  A long tradition of childhood immunization with good coverage of the Expanded Programme on Immunizations (EPI) vaccines has been maintained. Leading morbidity causesa are respiratory (23.8% in 2007) and urogenital system diseases (12.8% in 2007).

Main causes of mortalitya are cardiovascular diseases (48.3% in 2007), injuries and poisoning (9.8% in 2007)respiratory diseases (9.4% in 2007), and cancers (7.9% in 2007). Tuberculosis remains an important disease, particularly in prisons (incidence rate over 40 times greater than in general population) where multidrug-resistant tuberculosis is a major problem. Syphilis and gonorrhoea increased until 1997 and decreased since 2000. HIV/AIDS incidence has increased, particularly in the southern part of the country along the opium/heroin trade routes. According to the United Nations Office for Drug Control and Crime Prevention 2001 survey, drug addicts totaled 2% of the total population, mainly males. Waterborne diseases are common due to widespread contamination of water sources.

Health care reform in Kyrgyzstan has taken place in the difficult context of political and economic transition and severe economic pressures. In 1996, the country, with the support of external donors, embarked on a comprehensive 10-year health sector reform programme, which has now entered its final phase. The country has managed to accomplish a number of the tasks that it had set itself in 1996 and has become a regional leader in health reform. A mandatory health insurance system has been introduced, followed by new provider payment methods and contract arrangements. The single payer system, which unites all previous achievements of health reform and serves as acatalyst for reform, has also been introduced. Primary care has been restructured
and strengthened.

Nevertheless, more remains to be done. The restructuring of health care delivery needs to be continued, with an emphasis on the hospital sector and the san-epid service. It is also necessary to develop the concept of quality assurance. Activities to stop the spread of communicable diseases, in particular tuberculosis, malaria, and HIV/AIDS, must be continued and strengthened, and the population should be encouraged to take greater responsibility with regard to its own health. Although life expectancy has improved again in recent years, it is still lower than it was in 1991, and infant and maternal mortality continue to be very high.

The government has acknowledged the threat to equity in the availability of health care services that resulted from a breakdown of the Soviet system of free health care for all. It has developed a State Benefits Package and an essential drugs list. In spite of these reforms, about half of health financing comes from private out-of-pocket payments, many of them unofficial underthe-table payments. Although informal payments have to some extent been replaced by official co-payments through the introduction of the single payer system, people with lower incomes continue to face difficulties in accessing health care and drugs. While Kyrgyzstan has a lower share of out-of-pocket
spending than many other CIS countries for which good evidence exists, the need for patients to pay for their care remains a serious burden. The high levels of patient spending are related to the low levels of government spending and the overall fragility of the Kyrgyz economy. Significant increases in public spending are therefore unlikely in the near future.

Despite restructuring plans, there has been no change in the share of government allocations to hospitals. In the single payer scheme, new financing  mechanisms for secondary and tertiary care institutions have been introduced in most health facilities, based on outputs rather than the capacity norms of the Soviet era. The rationalization of the hospital sector, however, has so far been limited to a reduction of bed numbers and on-site rationalizations. To achieve more substantial gains in the use of the country’s limited resources, it will be crucial to overcome the resistance to hospital closures, including the closure of republican facilities. This will allow a shift of resources to preventive interventions in the areas of noncommunicable diseases and the promotion of healthier lifestyles.

There has been some progress in the reform of medical education. Training and retraining programmes in family medicine have been set up, a school of health management established and curricula of the State Medical Academy  revised. What is lacking so far is a comprehensive system of human resources management. At present, human resources are very unevenly distributed, with an oversupply in northern and urban areas of the country and a lack in southern and rural parts. The salaries of health care workers are still low, even though they have improved under the single payer system. The successes of the Kyrgyz health reform process to date have been achieved through domestic political support, the effective coordination of donors’ efforts, continuity in health reform management and a step-by-step approach, linking pilot projects to national health reform. It will be necessary to ensure the continued support of all stakeholders for the implementation of further reforms. The country is facing the challenge of achieving a good performance in the health sector in the context of a difficult macroeconomic and political situation.

The MANAS Health Care Reform Programme will finish in 2006, and the Ministry of Health is currently developing its continuation. The new MANAS Programme will address the institutionalization of reforms, the integration of vertical programmes into the general health care system and the development of intersectoral strategies of health promotion.

• Strong Government ownership of the health reform agenda and formal commitment to gradually increasing the funding of the sector over the next five years
• Institutionalization of health policy analysis and training in the new Ministry of Health (MOH) Centre for Health  Systems Development
• Pooling of funds at the national level provides newopportunities for improving equality of resource allocation and reducing the financial burden of care for the poor
• Establishment of professional associations for professional development and increasing quality of care
• Development of Community Action for Health, to empower communities to control social determinants of
health
• Good childhood immunization programmes.
• Low income and high indebtedness of the country lead to low levels of resource mobilization for health care
• High out-of-pocket share in health spending undermines financial protection objectives and places a
disproportionate burden on poor households
• Quality of care is uneven, and outdated practice patterns of medicine remain, particularly in the area of drug prescription and use
• Limited human resource (HR) capacity at different levels; low healthcare staff salaries, no HR development plan, high medical education costs and inflexible training programmes for nurses
• Difficulty in attracting qualified health care personnel to remote rural areas
• Rapidly increasing drug prices limit access to medicines
• Outdated physical infrastructure for health care.