Organisation mondiale de la santé (OMS) · Publications

Health care reform in Kyrgyzstan: “becoming a lion”

1 janvier 2000 Organisation mondiale de la santé

Le texte intégral est hébergé par l’organisation qui le publie. lawenc.com indexe les métadonnées et renvoie vers la source officielle.

Texte intégral

EUROPEAN HEALTH21 TARGET 15

AN INTEGRATED HEALTH SECTOR

By the year 2010, people in the Region should have much better access to family- and community-oriented primary health care, supported by a flexible and responsive

hospital system

(Adopted by the WHO Regional Committee for Europe at its forty-eighth session, Copenhagen, September 1998)

EUROPEAN HEALTH21 TARGET 20

MOBILIZING PARTNERS FOR HEALTH

By the year 2005, implementation of policies for health for all should engage individuals, groups and organizations throughout the public and private sectors,

and civil society, in alliances and partnerships for health

(Adopted by the WHO Regional Committee for Europe at its forty-eighth session, Copenhagen, September 1998)

EUROPEAN HEALTH21 TARGET 21

POLICIES AND STRATEGIES FOR HEALTH FOR ALL

By the year 2010, all Member States should have and be implementing policies for health for all at country, regional and local levels, supported by appropriate

institutional infrastructures, managerial processes and innovative leadership

(Adopted by the WHO Regional Committee for Europe at its forty-eighth session, Copenhagen, September 1998)

© World Health Organization – 2000 All rights in this document are reserved by the WHO Regional Office for Europe. The document may never- theless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. For the use of the WHO emblem, permission must be sought from the WHO Regional Office. Any translation should include the words: The translator of this document is responsible for the accuracy of the translation. The Regional Office would appreciate receiving three copies of any translation. Any views expressed by named authors are solely the responsibility of those authors.

This document was edited and typeset in Health Documentation Services WHO Regional Office for Europe, Copenhagen

EUR/00/5017691 Text editing: Mary Stewart Burgher

ISBN 92 890 1176 9

ABSTRACT

Many governments in the WHO European Region are reviewing their health care systems and the suitability of their existing approaches to financing, organizing and delivering health care services. A growing literature describes the experience of health care system reform, but it has paid more attention to the technical content of reform programmes than to strategies for managing change. This imbalance needs to be addressed if the gap between plans for reform and their implementation on the ground is to close. This document is intended to address this imbalance by describing and analysing the process of change in one country attempting to reform its health care system. In 1994 the Government of Kyrgyzstan decided to embark on a programme to reform the whole of its health sector, committing itself to a process of change with three main features: the development of a strategic vision of change on the basis of wide-ranging and participatory policy development; the development of individual and organizational capabilities; and active coordination of donor input. It is hoped that the description of the change process in the Kyrgyz health sector will contribute to the debate on what makes change happen in health systems.

Keywords

HEALTH CARE REFORM STRATEGIC PLANNING HEALTH SERVICES ADMINISTRATION NATIONAL HEALTH PROGRAMS – organization and administration DELIVERY OF HEALTH CARE – trends STAFF DEVELOPMENT INTERNATIONAL COOPERATION HEALTH POLICY KYRGYZSTAN

BECOMING A LION

Contents

List of figures and tables i List of boxes ii List of abbreviations and acronyms iii

CHAPTER 1 – INTRODUCTION PAGEREF _Toc450026512 4 CHAPTER 2 – THE NEED FOR REFORM OF THE KYRGYZ HEALTH CARE SYSTEM PAGEREF _Toc450026513 7 CHAPTER 3 – DEVELOPING AND SUSTAINING A STRATEGIC VISION FOR REFORM OF THE KYRGYZ HEALTH SECTOR PAGEREF _Toc450026514 15 CHAPTER 4 – BUILDING INSTITUTIONAL AND INDIVIDUAL CAPACITY PAGEREF _Toc450026515 28 CHAPTER 5 – INTERNATIONAL AGENCY COLLABORATION PAGEREF _Toc450026516 44 CHAPTER 6 CHAPTER SIX – POLITICS, COMMUNICATION AND THE PACE OF CHANGE PAGEREF _Toc450026517 58 CHAPTER 7 – CRITICAL SUCCESS FACTORS FOR SUSTAIN- ABLE CHANGE PAGEREF _Toc450026518 63

References 54

List of figures and tables

Figure 3.1 How the MANAS programme developed Table 4.1 Development of the Mandatory Health Insurance Fund Table 5.1 Comparing the MANAS health care reform with Sector Wide Approaches Table 5.2 World Bank and WHO inputs during project development List of boxes

Box 1.1 Overview of Kyrgyzstan PAGEREF _Toc450026298 5 Box 2.1 Critical Success Factors PAGEREF _Toc450026299 7 Box 3.1 A plan as a tool for developing a strategic vision of change PAGEREF _Toc450026300 15 Box 3.2 The importance of analysing the current situation during plan preparation PAGEREF _Toc450026301 19 Box 3.3 Debating options for change PAGEREF _Toc450026302 20

Contents

Page

Preface ............................................................................................ vii

Acknowledgements .......................................................................... ix

Introduction ..................................................................................... 1

1. The need for reform of the Kyrgyz health care system .................... 4

Introduction ................................................................................ 4 Main features of the health care system of the USSR ...................... 4 Pressures for health care reform after independence ........................ 6 Discussion ................................................................................... 9

2. Developing and sustaining a strategic vision for reform of the Kyrgyz health sector ........................................................... 10

Introduction ............................................................................... 10 Developing the Kyrgyz master plan for health care ........................ 10 Discussion .................................................................................. 19

3. Building institutional and individual capacity ............................... 24

Building institutional capacity ..................................................... 24 Developing individual capacity .................................................... 29 Discussion .................................................................................. 35

4. International agency collaboration ............................................... 37

Introduction ............................................................................... 37 International agency involvement in the Kyrgyz health sector .................................................................... 37 Sector-wide approaches ............................................................... 41 WHO-World Bank collaboration ................................................ 45

contents

5. Politics, communication and the pace of change ........................... 48

Understanding and managing the political arena ........................... 48 Developing and implementing a communication strategy for health sector reform ............................................................... 50 Maintaining an appropriate pace of change ................................... 51 Conclusion ................................................................................. 52

6. Critical success factors for sustainable change ................................ 53

Using critical success factors to monitor implementation .............. 53 Using critical success factors for research and evaluation ................. 55

References ....................................................................................... 56

5. Politics, communication and the pace of change ........................... 48

6. Critical success factors for sustainable change ................................ 53

Using critical success factors to monitor implementation .............. 53 Using critical success factors for research and evaluation ................. 55

References ....................................................................................... 56

BECOMING A LION

Contents

List of figures and tables i List of boxes ii List of abbreviations and acronyms iii

References 54

List of figures and tables

Preface

1994 – Kyrgyzstan was undergoing a period of transition following the dissolution of the USSR. The need to reform health care had already been recognized as part of the transition process. At that time many governments in the WHO European Region were reviewing their health care systems and the suitability of their existing approaches to financing, organizing and delivering health care services. The growing literature describing this experi- ence of health care system reform pays more attention to the technical content of reform programmes, which have provided valuable guidance on what to do. Within this body of literature, however, little attention has been paid to strategies for managing change, which can provide guidance on how to carry out reforms.

When the Government of Kyrgyzstan decided to embark on a programme to reform its whole health sector, a process was established, with the WHO Regional Office for Europe, that paved the way forward. At that point a commitment was made to a process of change with three main features:

• the development of a strategic vision of change on the basis of wide- ranging and participatory policy development;

• emphasis on the development of individual and organizational capabili- ties; and

• active coordination of donor input.

1999 – This process has allowed significant achievements and progress continues. The process has not been easy. It was stressful and sometimes painful for the people who coordinate the process and for those who are affected by the change. During this process, everyone involved learned a lot; all of us have learned to be more patient; all of us have learned to work together. Our experience of managing change offers a lot of lessons that should be shared, and I believe this WHO study of our experience in Kyrgyzstan will provide an objective view. A description of the change process in the Kyrgyz health sector may contribute to the debate on what makes change happen in health systems.

I would like to take this opportunity to extend our gratitude to WHO Regional Office for Europe for its invaluable and continuous support from the very beginning. Sincere thanks are also given to the United

preface

viiipreface

NationsDevelopment Programme (UNDP), the World Bank, the Asian Development Bank, Islamic Development Bank, the Danish International Development Agency (DANIDA), the German international cooperation agency (GTZ), the Swiss Development Agency, the British Know-How Fund, the Turkish International Cooperation Agency (TICA) and the United States Agency for International Development (USAID) for their assistance in reforming health care in Kyrgyzstan.

The Government of Kyrgyzstan is committed to continue to work to reform its health sector and believes that it will go ahead with this endeav- our with its international and bilateral partners.

Professor Tilek S. Meimanaliev Minister of Health Kyrgyzstan

BECOMING A LION

Contents

List of figures and tables i List of boxes ii List of abbreviations and acronyms iii

References 54

List of figures and tables

Acknowledgements

acknowledgements

Acknowledgement is due both to the people who have contributed to the development and implementation of MANAS Programme that this docu- ment describes and to the people who have contributed to the preparation of the document itself.

If the MANAS Programme has become a success story, it is the result of the persistent efforts of officials in Kyrgyzstan. The continuous commitment of President Akaev ensured the sustainability of the process. The leadership of Dr Kasiev, the State Secretary (former Minister of Health) provided strategic direction throughout the Programme. With his experience and vision, the late Dr Subanbaev played an important role in shaping the Programme at the start. The devoted hard work and determination of Professor T. Meimanaliev, the Minister of Health (former head of the MANAS team), and all MANAS team members made the process and the outcomes happen.

Assistance from international and bilateral agencies have significantly con- tributed to the process. The support of the following agencies is acknow- ledged: United Nations Development Fund (UNDP), the World Bank, the United Nations Children’s Fund (UNICEF), the British Know-How Fund, the Danish Development Agency (DANIDA), the German Techni- cal Cooperation Agency (GTZ), the Swiss Development Cooperation, the Turkish International Cooperation Agency (TICA) and the United States Agency for International Development (USAID).

For invaluable personal commitment and support beyond their institu- tional responsibilities, I extend especially sincere gratitude to Dr Jo E. Asvall, former WHO Regional Director for Europe; Mr Ercan Murat, former resident representative of UNDP in Kyrgyzstan; and Mr Umut Arik, former President of TICA.

Dr Gulin Gedik played a very special and unique role in the whole process. She was deeply involved in the process from the outset, and supported and facilitated it on site, working with national officials as resident adviser between 1994 and 1996. Since 1996, she has followed the progress of MANAS, monitored its implementation from the WHO Regional Office for Europe and generously contributed to the preparation of this document.

xaknowledgements

Ms Shelia O’Dougherty, Regional Director, Zdravreform programme, USAID, has provided strong support on site for the implementation of the MANAS Programme since 1997.

During the preparation of this document, the following people kindly contributed through interviews. For sharing their views and providing the insight of the process, thanks are extended to: Dr I. Abyldaev, Mr O. Adams, Professor I. Akylbekov, Dr F. Apfel, Dr J.E. Asvall, Ms M. Dhangaracheva, Ms D. Dinara Djoldosheva, Ms A. Fawcett-Henessy, Dr G. Gedik, Mr M. Goker, Ms G. Holmes, Ms C. Hoppy, Dr A. Ibrahimova, Dr A. Imanbaev, Dr. N. Kasiev, A. Koshmuratov, Dr K. Kultaeva, Mr J. Kutzin, Dr K. Mambetov, Professor T. Meimanaliev, Mr M. Mills, Professor Mirrahimov, Dr E. Mirrahimova, Mr E. Murat, Dr Niyazov, Ms S. O’Dougherty, Mr D. Pole, Dr G. Sadikova, Ms T. Saktanova, Dr A. Sargaldakova, Dr Z. Subanbaeva, Mr J. Wandel, Mr M. Wheeler.

Special gratitude is due to Ms Marian Craig for her significant contribu- tions to this document: visiting Kyrgyzstan, interviewing the people in- volved in the MANAS process, making literature searches, assisting in the conceptualization of the critical success factors and patiently developing the numerous drafts. This document could not have been completed without her efforts.

B. Serdar Savas Director, Programme Management WHO Regional Office for Europe

introductionintroduction

Introduction

Across Europe, countries are reforming their health care systems and a growing literature describes and analyses these changes. More attention has been paid to analysing the technical content of change strategies than the process of change; “the reform debate has paid little attention so far to the problems of implementation, and to strategies for managing change” (1).

This document describes the process of bringing about fundamental change in health care systems based on the experience of health care reform in Kyrgyzstan in central Asia (Box 0.1). It attempts to do this in a way that is understandable by and relevant to ministry of health staff, health profes- sionals and international agencies in other countries engaged in health sector reform. It is written in the belief that research on how to develop the individual and institutional capacity required to implement change lags far behind epidemiological, demographic, economic and health service re- search. An account of one country’s experience of managing the process of health sector reform, it is hoped, will partly redress this imbalance. While better information is always needed for allocation decisions in the health service, Cassels (2) shows that more research is needed to analyse the out- comes of different approaches to institutional change.

It is too early to judge how durable and effective the changes being imple- mented in the Kyrgyz health sector will prove to be. This document argues that a successful change process, which will result in substantial health gain and equity and efficiency improvements in a country lacking the internal capacity to plan and manage change, requires the following:

• the development of a strategic vision of change (which can be encapsu- lated in a master plan or another form);

• the creation and ongoing development of individual and institutional capacity, designed to upgrade human and organizational capabilities; and

• a supportive and, if possible, stable political environment.

To the extent that these requirements for successful change are being met in Kyrgyzstan, a process of reform has been established with the potential to improve the effectiveness, equity and efficiency of the country’s health care system. This document describes the requirements for change in more

2 introduct ion

detail, and spells out the Kyrgyz approach to developing a vision of change for its health sector, and creating the individual and institutional capacity to effect it.

Following the introduction, section 1 begins with an overview of the health care system inherited from the former USSR. Then follows an account of the external and internal pressures for reform on the Kyrgyz health care system after the country gained independence. Section 2 describes the proc- ess followed in Kyrgyzstan to develop a strategic vision of change, follow- ing the Government’s decision in early 1994 to develop a master plan for reform throughout the health sector. Section 3 looks at the development of institutional and individual capacity in the health sector. It makes the case for creating a permanent unit in charge of the change process, and looks at

Kyrgyzstan has a population of approximately 4.5 million; in 1989 52% were Kyrgyz, 22% Russian and 13% Uzbeks. Considerable migration has taken place since independence, as in other central Asian republics. The population is dispersed over an area of about 198 000 km2. The country is mountainous, with an average altitude of 2750 m. The Kyrgyz population is relatively young; 37.7% is under 15, and 5.3% is over 65. At the current birth rate of 24.3 per thousand, the population is expected to grow to 6.2 million by the year 2005. The Kyrgyz people are believed to have migrated from north-western Mongolia over 2000 years ago, occupying dispersed areas along the length of the Tien Shan mountain range. It was only at the beginning of this century that the country as it is known today started to take shape; it was part of the USSR from 1936 until 1991. Kyrgyzstan is divided into six regions (oblasts),

governed by oblast-level administrators (akeems) who are appointed by an elected president. Bishkek city, the capital, also has oblast status. The presidency is supported by a bicameral parliament in charge of legislative functions. Each oblast has several districts (rayons); there is a total of 42 rayons, headed by administrators appointed by the akeem. Beneath the rayons are village administrations. Seventeen cities are administered separately by city administrations. The economy is primarily agricultural and has suffered a decline in production in the period following independence. This decline has affected all sectors, including health. The speed and decline of the economic collapse have transformed the country’s prospects for the short and medium term. Both the share of public health expenditure in terms of gross domestic product (GDP), and allocations to health care from the state budget have recently fallen.

Box 0.1. Overview of Kyrgyzstan

3introduct ion

the evolution of three other institutions: the Mandatory Health Insurance Fund, the State Medical Academy and the Postgraduate Training Centre. An account of the development of capacity in individuals follows, and it is argued that, although the development literature urges that serious re- sources should be devoted to empowering local staff to implement change, in practice this case still needs to be made. Section 4 examines cooperation among international agencies. Many organizations have been and are active in the Kyrgyz health sector. Their involvement in health care reform is described, and whether this collaboration could be improved or intensified is examined. This section also looks briefly at how WHO and the World Bank could work together more effectively. Section 5 considers the politi- cal dimension of change management, and at how a communication strat- egy and management of the pace of change have helped those managing reform to understand different interest groups in the Kyrgyz health sector. The final section summarizes critical factors for successful, sustainable change in the Kyrgyz health care system.

The need for reform of the Kyrgyz health care system

INTRODUCTION

This section describes the pressures on the Kyrgyz health care system in the years following 1991, when Kyrgyzstan became independent. It provides the context for the analysis of the critical factors for success- fully implementing a sustainable process of change in the health sector (Box 1.1).

section 1

The section begins by describing the health care system under the USSR and goes on to identify the external and internal triggers for change in the Kyrgyz health care system.

MAIN FEATURES OF THE HEALTH CARE SYSTEM OF THE USSR

Some knowledge of the health care system of the former USSR is necessary to understand how health services are organized and financed in Kyrgyzstan. The brief account that follows is based on Savas & Gedik (3). In the former USSR, the whole population was entitled to most types of health services with very limited personal charges. Services were centrally planned and financed, and provided by the state. The system centred on the medical profession, with very little involvement of lay people. Health services were delivered from an intensive network of facilities accessible to most of the population. The corollary, however, was an inefficient system, with excess provision, and financing methods that encouraged inefficient use of re- sources. Despite these shortcomings, considerable improvements in popu- lation health status were achieved, including significant decreases in mor- bidity and mortality.

Critical success factors are the limited number of areas in which satisfactory results will ensure successful performance for an individual, a department or an organization: the few

key areas where things must go right for an organization to flourish and for the managers’ goals to be attained. (Here the goals are defined in terms of objectives for health care reform.)

Box 1.1. Critical success factors

5t h e n e e d f o r r e f o r m

Organizational structures The central ministry of health in Moscow managed the health care system of the USSR, discharging the functions of planning, standard setting, con- sultation and general supervision. The academy of medical sciences super- vised a myriad of research institutes distributed across the country, includ- ing those under the health ministry. Each republic also had a health minis- try, whose structure and functions largely mirrored that of the central ministry in Moscow.

The basic organizational structure of the republics’ health care systems reflected the general administrative structure. Each republic was made up of oblasts (regions) with an oblast health administration, accountable both to the oblast administration and the republic’s health ministry. Below oblast level were rayons, whose health services were under the authority of the chief physician of the rayon hospital, who reported to the oblast heath adminis- tration.

Service delivery The extensive basic infrastructure of the health care system meant that access to primary care services was good. In rural areas, feldsher–midwife points were the most peripheral points of the health service. Rural polyclin- ics were the main delivery points for medical services in rural areas, and were usually staffed with four physicians (paediatricians, therapists, gynaecolo- gists and in some cases stomatologists). Small rural hospitals with 25–30 beds provided outpatient services and limited inpatient services. Maternity homes were located in collective and state farms, and staffed by midwives.

City polyclinics were the principal facilities for outpatient health care deliv- ery in urban areas, with different polyclinics for children and adults. They were typically staffed with various specialist physicians, including so-called narrow specialists such as cardiologists, neurologists, gastroenterologists, surgeons, otorhinolaryngologists and ophthalmologists. There were also some specialist outpatient facilities in urban areas, such as women’s consul- tation clinics. Hospitals were organized at the levels of rayon and oblast, and at the republic level for tertiary care. The specialist hospitals (dispensaries for tuberculosis, sexually transmitted diseases (STDs) and oncology) also provided outpatient and inpatient services at the oblast and republic levels.

Human resources for health The health care system trained vast numbers of health personnel, with the highest priority given to physicians. In this system physicians per- formed many functions more appropriate to other personnel. Physicians

6 sect ion 1

specialized very early in their training and graduated from medical insti- tutes as specialists.

Feldshers (with two and a half years of formal higher education) providing care in rural areas were authorized to prescribe only a limited number of drugs. Nurses (with two years of higher education) were expected only to assist physicians, and were underutilized. The training of all health person- nel emphasized curative health care.

Financing The health care system was financed by public revenue, with budget alloca- tions made on the basis of norms developed by the central health ministry. Funds, however, flowed directly through the ministries of finance and oblast administrations. The budget was based on 18 line items in accordance with the centrally established norms related to the number of beds and outpatient visits. The population had virtually free access to services, with the exception of some minor charges or “contributions” for, for example, outpatient drugs.

PRESSURES FOR HEALTH CARE REFORM AFTER INDEPENDENCE

After the dissolution of the USSR, public services in all of the newly independent states (NIS) faced a double challenge. Budgets were greatly reduced and services were free to change the ways in which they operated. The wide range of external and internal pressures on the health care system in Kyrgyzstan after independence in 1991 are described below.

External pressures on the health care system

1. Economic and social transition Since independence Kyrgyzstan has developed as a secular state and attempted to implement market reforms. It is among the NIS most adversely affected by this transition. This has had a significant negative impact on the health of the population. Poverty was widespread before independence, with a third of the population suffering a so-called socially unacceptable standard of living. The level of financing of broad social programmes inherited from the former system was not sustainable. To stabilize the economy after 1991, the Government allowed social ex- penditure to fall. In the case of health, expenditure fell from 3.7% of GDP to 2.4%, rising again to 3.6%. GDP as a whole declined dramati- cally, however; in 1995 it was at only 50% of its 1990 level (3). Taken

7t h e n e e d f o r r e f o r m

together this meant a very significant reduction in total real expenditure on health.

An increasing trade imbalance caused shortages of drugs and other consumables, and the real value of public-sector salaries fell. This coincided with a deterioration in the wellbeing of the population, especially with regard to health (4). This was partly due to the declining effectiveness of the delivery system for social services at a time of severe fiscal pressure. It also resulted from changes in underlying risk factors and other determinants of health status, including levels of poverty, the structure of the labour market and worsening diet and nutrition.

2. The collapse of central planning In the USSR, the central government planned a production and distribu- tion strategy for the whole country. Particular republics assumed certain tasks and responsibilities on behalf of the entire USSR, which meant that they intensified production capabilities in certain industries. After the dis- solution of the USSR and with it the distribution system, the NIS had to cope with any deficits in supply through external supply or internal pro- duction. These changes have affected the health sector in terms of goods (such as medical equipment, pharmaceuticals and vaccines) and services (such as highly specialized medical care, and medical and nursing educa- tion).

3. Change for the sake of change There was enthusiasm for change of any sort; anything different from the old system was good. Initially this enthusiasm blinded people to the prob- lems that would arise during the transition to a market economy. In the health sector in particular, change was quite simply equated with the intro- duction of health insurance, and the development of democracy was syn- onymous with privatization. Understanding of these concepts was weak, or even non-existent. Privatization was perceived as the method of financ- ing and organizing health services in western countries, so it was also seen as the best way forward.

4. Adoption of western approaches to health sector reform

In the early 1990s, increased NIS contact with the west coincided with a period of reform in western health care systems in which a perceived need to contain costs was one of the main catalysts for change. The strategies adopted to achieve this have included both demand-oriented and supply- oriented measures (1). Measures to influence demand levels have included cost sharing, opting out and no-claim bonuses (in which people who limit

8 sect ion 1

their use of the public health care system pay lower contributions to social insurance schemes). Containing costs by influencing the supply of health services has been attempted by introducing, for example, competition be- tween public providers, setting global expenditure ceilings for providers and controlling the cost of human resources and the supplies used to pro- vide health care. The effectiveness of these strategies in containing costs has varied. Nevertheless, to the extent that these represented the main strategies for change in the west at the time the NIS were achieving independence, they have been influential.

5. Influence of external agencies active in the health sector

Many external agencies were active in the Kyrgyz health sector in the years immediately before and following independence: for example, the World Bank, WHO, the United Nations Children’s Fund (UNICEF) and the United States Agency for International Development (USAID) and some other bilateral agencies. Each agency brought its own agenda and expertise, and some bilateral agencies in particular promoted their own systems or some features of them. (Section 4 is devoted to the issue of collaboration between international agencies.) At this stage, none of the agencies ap- proached the health sector as a whole.

Internal pressures for change

1. Deterioration in health status

The health status of the population deteriorated between 1990 and 1994. Infant mortality fluctuated, from 29.6% in 1991 to 31.95% in 1992/ 1993 to 29.4% in 1994. These fluctuations followed declining mortality during the 1980s; 45% of these deaths resulted from acute respiratory infections and 25% from diarrhoeal diseases. The crude mortality rate increased from 7 per 1000 in 1990 to 8.3 in 1994. The incidence of communicable diseases (tuberculosis and STDs) and vaccine-preventable diseases increased. Analysis of the causes of mortality, especially maternal and infant mortality, showed that many deaths were preventable. Further, the central Asian republics were experiencing an epidemiological transition. The causes of morbidity and mortality were characteristic of both develop- ing countries (high infant and maternal mortality and increasing rates of infectious disease) and of western industrialized countries (increasing car- diovascular diseases and cancer).

2. Inefficient service delivery The network of services was complex, resulting in duplication of services, with underprovision in some areas and overprovision in others. Although

9t h e n e e d f o r r e f o r m

many of the country’s health problems are best addressed by primary care services, secondary and tertiary services were overprovided. Almost 75% of the health budget was spent on hospital services, so admission rates and average lengths of stay were high. The major division between services was between republican (country-wide) institutions and the network of local facilities. While about 90% of the health budget was devoted to the latter, the Ministry of Health had direct managerial control only over the republi- can institutions (4). The physical delivery structure of the delivery system was poorly maintained.

3. Inadequate resources

The main sources of health care finance in 1994 were tax-based government health expenditure, official and unofficial out-of-pocket payments, debts and arrears and enterprise expenditures. As indicated above, both the ratio of public health expenditure to GDP and allocations to health from the total government budget declined in the early 1990s. While taxes contin- ued to be the main source of funding, some revenue was raised through official user charges, and unofficial out-of-pocket payments were rising significantly, placing a significant burden on household income. A study in 1994 showed that 86% of households made some payment for inpatient care and the total private payments for a single case exceeded total house- hold income in one in five cases (5). The geographical distribution of resources among oblasts was uneven, with no correlation between resource allocation and need.

DISCUSSION

This section has described the triggers for change in the Kyrgyz health care system: the factors that led to the decision to develop and implement a comprehensive programme for reform of the sector. A range of internal and external factors combined to create a situation in January 1994 in which the Ministry of Health responded favourably to WHO’s proposal of collabo- ration to develop a formal plan. In part this represented a continuation of activity that had begun in the late 1980s, at the end of which perestroika both created the opportunity for external agencies with an interest in the health sector to begin work in the region and to make proposals for change, and exposed Kyrgyz health professionals to other ways of doing things. What was new was the decision to look at the health sector as a whole, and to develop a mechanism, in the form of a master plan designed and coordi- nated by a national team, to facilitate the coordination of the activities of national and international agencies. The next section describes how this master plan was developed.

Developing and sustaining a strategic vision for reform of the Kyrgyz health sector

INTRODUCTION

In early 1994 the need for change in the Kyrgyz health care system was clear. Some believed the only problem was lack of funds; others saw the need for system-wide change. In both cases, however, the problem for the Govern- ment was what to change, and how to start on the path to reform. At this point, Kyrgyzstan sought the assistance of the WHO Regional Office for Europe, which urged the development of a strategic vision for reform of the health care system, encapsulated in a master plan. This would require the development and implementation of a strategy to create the individual and institutional capacity needed to implement change and manage a modern- ized health service. WHO also advised that all relevant parties be encour- aged to take part; successful implementation demanded wide involvement. Thus the MANAS Health Care Reform Programme was initiated.

This section describes the process of developing the master plan, and, in broad outline, its content, to show how the former has served the overall aim of developing and sustaining a strategic vision for change. It is based on the premise that a systematically developed strategic plan must underpin an effective strategy for fundamental change in a country’s health care system, and that the process of developing this plan will determine the effectiveness of the strategy. This section argues that the master plan for the health sector is a tool, not an end, that serves certain purposes; some of these are related to the process of development of the plan, and others are related to the existence of a comprehensive and sector-wide plan, as described in Box 2.1.

DEVELOPING THE KYRGYZ MASTER PLAN FOR HEALTH CARE

The development of the Kyrgyz master plan for health care is described in some detail here, to show the full extent of consultation and participation undertaken to develop a strategy and plan for reform of the sector.

The master plan was developed in three stages between February 1994 and June 1996:

section 2

11a s trateg ic v i s ion

1. situation analysis 2. development of policy options 3. preparation of the master plan based on the selected policy option.

In June 1996 implementation began. Fig. 2.1 shows the timetable for this process.

Before starting the situation analysis, a national MANAS team was estab- lished, consisting of members of the staff of the Ministry of Health and the oblast health administrations. Its role was to coordinate and act as the secretariat of the whole process of plan development. This ensured that team building began at this initial stage, as did training in the basic skills needed to plan and manage health care systems. The establishment and

The development of a master plan may serve as a useful tool for developing a strategic vision of change, depending on the process of development of the plan. If a participatory and transparent process is followed within an adequate time frame, and the necessary activities are simultaneously undertaken to prepare capacity to implement it, the following benefits will stem from the process of development:

– plan preparation enables all those involved to learn about and update their knowledge of the health sector, and contributes to capacity building; and

– preparation and continuing refinement of the plan provide a common forum for the management and coordination of inputs from all national and international agencies involved in the health sector, and they

ensure that the components of a programme of change are integrated in a comprehensive plan.

The master plan can serve as a facilitating tool in the implementation of health care reforms if commitment to reform exists at the national level. The following benefits stem from the existence of a plan:

– the plan provides direction and guidance for the innovations and operations of various institutions in the country;

– it provides a reference point against which progress may be measured;

– publicizing the plan creates a visible national agenda for health; and

– dissemination of the plan persuades people that the proposed changes are good by contrasting a vision of an improved future with the difficult present.

Box 2.1. A plan as a tool for developing a strategic vision of change

12 s ect ion 2

training of this team is described in more detail in the next section. The MANAS team was assisted by a Programme coordination secretariat from the WHO Regional Office for Europe.

Stage 1. Situation analysis (June – November 1994) Describing and analysing the current situation are the first steps in preparing a master plan. The importance of this stage lies in what it teaches health sector professionals about the sector and how it challenges their

Fig. 2.1. How the MANAS

13a s trateg ic v i s ion

assumptions, as well as in providing the basic analytical data required to prepare a plan for change (Box 2.2).

The national team carried out the Kyrgyz health situation analysis, with input from external agencies, over a period of six months. The team was assisted by consultants from the Turkish International Cooperation Agency (TICA), who helped its members to gather and analyse data on target population, health policy, organization and management, primary care,

S Programme developed

14 sect ion 2

human resources and health information systems. Other agencies working in the Kyrgyz health sector also provided useful information, as described in more detail in section 4.

Stage 2. Developing strategic policy options (December 1994 – April 1995) Stage 2 consisted of reviewing broad policies for development of the health sector, framing them in a way that would facilitate debate before agreeing the broad strategy for change, and then refining the strategy. This took place in the first half of 1995, although of course policy continues to be refined and modified as the plan is implemented.

The policy options were:

1. a preservation strategy that would maintain as far as possible the main features of the old system;

Some health development experts are sceptical about the value of formally assessing the current situation, arguing that the current constraints and challenges to the health system are well understood. This may be so in countries where some local capacity exists, or where work of this kind has already been done. Clearly an assessment must be made of the level and accuracy of existing knowledge of the current situation, in determining the resources required for this stage of master plan preparation. Nevertheless, a comprehensive situation analysis will ensure a systematic review and better understanding of the system. Even if a good understanding exists among more senior health professionals, less experienced staff will benefit, as will administrators and politicians not

directly concerned with the health sector. The analysis must be carried out principally by local staff, so that those who will be responsible for implementing the reform plan fully understand the situation.

In addition, reviewing the current situation in the health sector is the point at which the process of building the capacity required to sustain the process of change begins, an issue which is examined in greater depth in section 3. This means that external consultants must work with national staff to develop the skills and concepts needed to make a critical assessment of the performance and organization of the health care system. The review may take longer as a result, but this is time well spent if it is agreed to be a valuable contribution to capacity building.

Box 2.2. The importance of analysing the current situation during plan preparation

15a s trateg ic v i s ion

2. a prioritization strategy, in which continuity of structural features would be maintained with a concerted effort to realize efficiency and equity gains by redirecting resources;

3. a contract strategy, introducing structural change in the form of a separa- tion of health care provision and finance in a highly managed market; and

4. a laissez-faire strategy in which a free market would ensure efficient production of health services to meet consumer demand.

The document describing these options was distributed for information and feedback to all departments of the Ministry of Health, republican health institutions, oblast health administrations, other relevant ministries, and international and bilateral agencies. It was then discussed in several meetings of the collegia. (This is the decision-making body of the Ministry of Health, comprising the minister, deputy ministers and heads of some departments. It meets once a month.) The MANAS National Conference on Health Care Policies, held in Bishkek in February 1995, was the final step in discussing policy options. Three hundred Government officials participated, as well as representatives from bilateral and international agen- cies. Participants debated the proposed policy options, providing further information to the Kyrgyz Government for internal deliberations on the way forward. In April 1995, the Ministry of Health identified and an- nounced the main directions of the health care reform. A combination of the different options was agreed upon, with the prioritization strategy being chosen in the short term and the contracting strategy for the medium and long term (Box 2.3).

The preparation and discussion of options for change is a key stage in the creation of a strategic vision. This was particularly true for Kyrgyzstan, a country at an early stage (in 1994) of developing a democratic culture. The importance of developing the capacity that will enable this debate to take place cannot be overemphasized. The vigour with which options are debated,

and the extent of involvement of all relevant groups of the population (professional and lay, administrative and political) has a direct effect on the validity of the chosen option for development of the health care system. This choice must ultimately be made locally, and the external agencies involved must actively facilitate this local debate and choice.

Box 2.3. Debating options for change

16 sect ion 2

Stage 3. Preparation of the master plan based on the selected policy option (May 1995 – June 1996) The next stage was to discuss policy issues in the chosen strategy in sufficient detail to enable the master plan to be prepared in broad outline. To this end, the MANAS Workshop on Health Care Reform Strategies was held at Cholpan-Ata from 28 June to 1 July 1995. The 45 participants included deputy ministers, department directors from the Ministry of Health, repre- sentatives of republican institutions and oblasts, MANAS team members and representatives from international agencies.

The MANAS national team, with the assistance of the Programme coordi- nation secretariat and international consultants, then developed a detailed draft of the master plan for consultation. The draft plan was presented in the collegia, and distributed for comment within the Ministry of Health, republican institutions, the Ministry of Finance, the Social Fund, oblasts and to international and bilateral agencies. Workshops were held in Bishkek and Chui oblasts to discuss the detail of the plan, each involving 100–200 participants. Over a period of some eight to nine months, every opportu- nity was used to present the draft plan and receive comments on it (for example, the opening of a health facility and the celebration of Physicians’ Day). MANAS team members had individual discussions with every de- partment director in the Ministry of Health, directors of many republican institutions and oblast health directors.

After this extensive round of consultation the master plan was revised and completed. On 10 June 1996 the MANAS Health Care Reform Pro- gramme (1996–2006) was adopted by the Government. Box 2.4 presents highlights of the Programme.

Implementation of the master plan (June 1996 onwards) Implementation began after the adoption of the master plan. It is taking place in phases and involves pilot testing. It began in Bishkek city, Chui oblast and Issyk-Kul oblast, with a focus on strengthening primary care, and is gradually being extended to the other oblasts. Implementation has re- quired the development of some new institutions, such as the Mandatory Health Insurance Fund, the Family Group Practice Association, the Hospi- tal Association and the Health Management Training Centre. A great deal of effort is going into training staff, especially primary care personnel, to ensure their adaptation to the restructured system.

The implementation process is coordinated by the Reform Coordination and Implementation Department of the Ministry of Health, which was

17a s trateg ic v i s ion

Principles All health services in Kyrgyzstan are to be provided according to the following basic principles:

1. improvement in health status; 2. equity in health, aiming to reduce

and eliminate differences in health indicators in different regions and between urban and rural areas, and to guarantee access to existing facilities;

3. increased effectiveness of service provision; and

4. protection of patients’ rights.

Strategies A strategy of prioritization is being pursued in the short term, in which the main features of the existing system are preserved. Public ownership of the provider system and taxes as the principle source of funding will continue. The aim is to rationalize the existing network of health facilities, hospital beds and staff to reduce excess capacity. The plan is initially to consolidate facilities at three levels: republican institutions, specialty hospitals, and rural hospitals and outpatient facilities. Savings generated by this process are being redirected to the priority areas of strengthening primary health care (PHC), particularly mother and child health, and controlling communicable diseases.

Financing The main sources of funding continue to be general taxes with some additional

Box 2.4. Highlights of the MANAS Health Care Reform Programme1

resources raised through user charges, earmarked taxes on tobacco and alcohol, and the transfer of social fund revenues used for resort treatment and sick leaves. Health insurance is being gradually introduced as an additional source of funding. A more equitable resource allocation mechanism is to be used to distribute funds to oblasts. A formula has been developed for this based on three indicators:

– oblast population weighted for age and sex according to an index of volume of need

– standardized mortality ratios for each oblast as a proxy for morbidity

– proportion of the oblast population living at high altitude as a proxy for socioeconomic conditions.

The expenditure management system at facility level is to be moved away from itemized budgeting based on the norms and payment systems of the former USSR. Incentives to improve cost–effectiveness are to be introduced. Capitation-based payments will be used to pay PHC providers, and hospitals are to receive global budgets giving them more autonomy. In the long term it is planned to introduce a purchaser– provider split, with contracting between the health fund and providers.

PHC A major objective of the MANAS Programme is strengthening PHC; in

18 s ect ion 2

formed by the MANAS team members. The Department supports the establishment of new institutions and plays an important role in maintain- ing the flow of information about developments and plans to the Govern- ment, health professionals, public and donor agencies. It also involves many national institutions and donor agencies.

As part of the ongoing monitoring and evaluation of reform implementa- tion, a WHO mission visited Kyrgyzstan at six-month intervals (in April and November 1997 and April and November 1998). The missions

Box 2.4. (contd)

the future, it will play the main role in service provision. Existing facilities are being rationalized and upgraded. PHC will be provided from feldsher–midwife points and PHC centres in rural areas, and by PHC groups in urban areas. PHC centres will supervise feldsher– midwife points. PHC will be provided by teams consisting of family physicians, feldshers, nurses and midwives, and staff will be trained to improve the quality of care.

Hospital services Hospital services are being rationalized, and service cost– effectiveness improved through better management, revision of treatment protocols and staff training. Hospitals will have autonomous status. Executive, management and auditing boards will be introduced.

Human resources New estimates of needs for human resources will be made and the supply

of trained personnel adjusted accordingly. Recruitment, career development, job descriptions, performance evaluation, monitoring and supervision, reimbursement and incentives will all be addressed to improve human resource management.

In medical education, general practitioners are being trained and the faculties of therapy and paediatrics have been merged. Some physicians are being trained as family physicians through short-term courses.

Information systems The health information system is being enhanced to ensure the collection, processing and analysis of data and information for decision-makers at all levels. Health indicators are being revised to comply with national standards and meet national needs. Information technology requirements are being estimated in the light of the redesigned information system.

1 This box presents highlights of the MANAS Programme, more or less as presented in a WHO document (6). It is based on the content of the master plan adopted in 1996. Strategies have developed and changed since then.

19a s trateg ic v i s ion

reviewed each component of the master plan, and selected one topic for detailed assessment. During each mission a workshop was held, to which all organizations involved in the reform process were invited. Participation in these workshops was extensive, with very high level participation, includ- ing the President and Prime Minister. Each mission report made recom- mendations based on the conclusions reached about the progress and direc- tion of the reform process, and the implementation of the recommenda- tions was reviewed in subsequent missions.

DISCUSSION

It has been argued that the MANAS Programme is a rather general set of proposals that do not provide sufficiently specific guidance for external agencies wishing to invest in the health sector. This view overlooks the value of the process of development of the plan, a process whose function is to create the local capacity to implement change. Further, without this sector- wide blueprint for change, there would be no vehicle for the coordination of the input of national and international agencies. The master plan func- tions as a map indicating areas requiring investment. For example, the

Organizational structure and management Establishing the Department of Reform Coordination and Implementation has strengthened the policy-making, coordination and supervisory role of the Ministry of Health. The original MANAS team has formed the core of this Department.

Some reorganization of the structure of the Ministry of Health has taken place during the last few years. This has consisted of merging some departments (such as the Department of Sanitary–Epidemiological Management with the Republican Sanitary–Epidemiological Service) and establishing some new structures (such

Box 2.5. Implementation of the MANAS Programme – selected highlights

as the Department of Pharmaceuticals, the Department of Non-budgetary Activities, and the Licensing and Accreditation Committee).

The mandatory health insurance system, which was to have been introduced in the long term in the original master plan, was implemented in 1997 as a result of political pressure. It involves a multipayer system at the country and oblast levels. A move towards a single-payer system, however, has been initiated with the development of the concept of jointly used systems. This involves the merging of some Ministry of Health and Mandatory Health Insurance Fund (MHIF) functions (such as the running of

20 sect ion 2

Box 2.5. (contd)

systems for provider payment, accounting, quality assurance and clinical information), to avoid former duplication of information systems.

MHIF was established as an independent entity under the Government, but was brought under the jurisdiction of the Ministry of Health in 1998 to ensure uniform policy in health reform implementation. A new position of deputy minister responsible for health reforms was established in 1999 and further internal restructuring and reallocation of responsibilities within the Ministry of Health continues.

Some new professional associations have been established since independence. The Family Group Practice and Hospital associations are among the main stakeholders in health reform and are actively involved in the implementation process for PHC and hospital services. The Nursing Association is playing a significant role in nursing reforms.

An advisory board (known as the Coordination Commission) was established under the Government in 1997, and includes representatives of the Ministry of Health, MHIF, the Ministry of Finance, the Social Fund, and other relevant Government agencies. Employers and associations representing providers and consumers are also represented. The Commission

provides policy advice, options and recommendations to decision-making bodies such as the Government, the Ministry of Health and MHIF.

Health care finance A database on health sector expenditures and health personnel is under development. A needs-based resource allocation mechanism weighted for different factors is to be introduced in regions in the medium term. Its preparation work includes examination of programme budgeting.

Government health expenditures have been pooled at the city level in Bishkek with further introduction of case-based payment to hospitals and capitation payment to family group practices (FGPs) from budget (public) resources.

Capitated payment from budget funds to PHC providers was tested in the Issyk-Kul demonstration project in 1998 and these payments have been extended to Bishkek. MHIF has made capitated payments to contracted FGPs since 1998. MHIF introduced case- based hospital payment in 1997 and this experience is rolling out to hospital payment from budget funds in pilot regions.

Health care delivery system Strengthening PHC is a key priority in the reform process. After creating multiprofile polyclinics, the next step in restructuring PHC was to establish

21a s trateg ic v i s ion

Box 2.5. (contd)

FGPs. Their locations have been determined and basic medical equipment procured. Enrolment of the population with FGPs has begun in pilot regions and free choice of PHC provider has been introduced.

The number of hospital beds has been reduced by 20% since 1991. Rationalization plans have been prepared at the national, oblast and district level. The number of rural hospitals closed or transformed into outpatient facilities is limited and varies between oblasts. No changes have taken place to rationalize republican institutions or merge specialized with general hospitals. Rationalization of hospital services has been constrained by retaining a hospital financing system based on number of beds. The increase in STD and tuberculosis incidence continues. The issue of reinvestment of savings remains to be resolved.

Health information systems New clinical information and financial systems are being developed and implemented in pilot regions. The health information system is linked to financial systems, which may contribute to data quality improvement. Health indicators are to be revised to meet international standards.

Pharmaceuticals management Short- and medium-term activities in the pharmaceutical sector have

concentrated on ensuring the appropriate structural organization and the provision of essential drugs. They include enforcement of a drug law, establishment and further strengthening of a drug regulatory administration and support to drug information services. An essential drugs list was developed and implemented in 1996 and revised in 1998.

A licensing and accreditation process for health facilities was developed and implemented in 1997, through which health facilities must pass to be eligible for contracting with MHIF.

Human resources development Medical education and retraining are shifting from the training of specialists to training general practitioners. Nursing education has been extended to three years with a new curriculum. Continuing intensive short-term retraining programmes in family medicine are provided to physicians and nurses in FGPs.

In 1997 a health care management training centre was established jointly by the Medical Academy and Kyrgyz International University. Training programmes are under development. There are training programmes for economists, chief physicians, and health information system specialists on management, new provider payment methods and new clinical information systems.

22 sect ion 2

master plan process highlighted the need for a hospital rationalization plan and led the British Know-How Fund to support work in this area. In addition, publicizing the plan helps to keep health high on the Kyrgyz national agenda.

The implementation of such a comprehensive plan is a challenge for any country, not least Kyrgyzstan, given the lack of resources. The implementa- tion of the master plan relies heavily on external funding, so the involve- ment of donor agencies from the beginning of the process has been crucial for implementation. The Government has been determined that donors should work within the framework of the MANAS master plan. The coordination capacity developed in the MANAS team, which became the locus for this function in the Ministry of Health, has ensured the complementarity of donor inputs.

Implementing health care reform where resources are constrained involves careful identification of priorities. A large proportion of health system resources pay fixed costs (for personnel and buildings), and in Kyrgyzstan these need to be rationalized. Other ministries, such as the Ministry of Finance, must therefore be involved, to make the relevant changes in budg- eting and resource allocation mechanisms. Hence intersectoral involve- ment is crucial and a master plan helps to guide this. This requires a persist- ent follow up of the issues, conveying messages to other sectors and per- suading them to cooperate; at this stage, leadership becomes extremely important. A few dedicated individuals on the MANAS team played a significant role in Kyrgyzstan.

A notable aspect of the Kyrgyz health care reform process is that it is reasonably well integrated. Naturally, there have been some unplanned developments, such as the early establishment of mandatory health insur- ance. Discussion continues about how best to administer the system and, indeed, the appropriateness of health insurance as a financing mechanism in Kyrgyzstan. Nevertheless, the development of MHIF has served two im- portant functions: providing invaluable experience in institutional devel- opment for a group of health sector professionals who hitherto had been fairly passive actors in a system designed in and run from elsewhere; and driving other changes. There have been improvements in the nature and quality of information supplied by hospitals about their caseload, and in procedures in hospitals seeking accreditation for financing by MHIF.

Change is rarely painless. The strategic vision encapsulated in a master plan helps to persuade people that proposed changes are for the better and worth

23a s trateg ic v i s ion

the trouble. It can do this by contrasting a vision of the improved future with the difficult present. The prospects for and the proposed pace of change presented in the plan must be realistic. A delicate balance must be struck between holding out the prospect of sufficient change soon enough, and being realistic about the time required to implement complex and sometimes controversial change. This latter issue is discussed further in section 5. The challenge for Ministry of Health reformers is “to strike a careful balance between taking on the do-able, whilst not disappointing the often ambitious expectations of the public and their political supporters.” (2).

Critical success factors for developing a strategic vision for sustainable change To conclude this discussion about developing a sustainable change strategy, the following critical success factors need to be in place for progress to be made in this area:

• a systematically developed strategic vision encapsulated in a sector-wide master plan

• development and ownership of the plan by nationals, with assistance from external agencies

• participatory and transparent process • commitment to the plan by high-level government and all organiza-

tions involved • participation of several individuals who have a vision of change and are

unconstrained by conventional approaches: “bright stars in the firma- ment”.

Building institutional and individual capacity

This section in based on the premise that a key requirement for implement- ing and maintaining a process of fundamental change in a health care system is to develop institutional and individual capacity. This is widely recog- nized, but descriptions in the literature of how to do this are rare.

Samuel Paul’s four dimensions of capacity building provide a useful start- ing point for describing and assessing the Kyrgyz experience of capacity building (7). The first dimension concerns human and institutional capa- bilities. Trained personnel are effectively utilized only in appropriate organi- zational or institutional settings. As well as training people in specific tech- nical skills, it is necessary to create the capability to manage the institutional mechanisms and arrangements that enable organizations to function. The dichotomy between planning and implementation is Paul’s second dimen- sion: “Planning capabilities focus on analytical skills, breadth and depth of sectoral understanding and interdisciplinary collaboration, while imple- mentation capabilities focus much more on organizational action, incen- tives, teamwork and results” (7). Thirdly, a capacity-building strategy must distinguish between the skills needed at the micro and macro levels. Imple- mentation and management capabilities are more relevant at the micro level, and policy and planning capabilities, at the macro level. The fourth dimension distinguishes cognitive and practical skills. Education and train- ing to transfer knowledge and develop analytical skills build cognitive capabilities, while the ability to apply and adapt these depends on opportu- nities to put them into practice. This applies equally to individual and institutional capabilities.

BUILDING INSTITUTIONAL CAPACITY

Kyrgyzstan can now claim considerable experience in institutional develop- ment in its health sector. This section describes this experience in some detail for three different organizations: the MANAS team, which is in charge of the health care reform process, the State Medical Academy and MHIF. The first and the last represent completely new developments for the country; the State Medical Academy existed before independence but is substantially changing the way it functions. These institutions did not

section 3

develop in a vacuum; the development of each has both caused change in other parts of the sector, and benefited from the evolution of the sector as a whole.

Creating the institutional capacity for managing change – establishing the MANAS team The importance of developing the institutional capacity required to man- age a process of change was recognized at the outset of the MANAS process. By July 1994 a team had been established for this purpose in the Ministry of Health, headed by a programme coordinator and including 25 central-level professionals, and seven regional-level professionals, one from each oblast. They all worked full time on the Programme. Additionally, two profes- sionals from each region worked for the team part time, and people were recruited to provide administrative support to the unit. The first task for this team was to prepare the situation analysis as described in section 2. Box 3.1 explains why a change management team is needed.

At the outset the MANAS team was divided into groups addressing health care financing, PHC, hospital services, pharmaceuticals, human resources, health information systems and physical infrastructure. Each group con- tained experienced health professionals and younger people. In addition, recruitment policy aimed to maintain gender balance, and to try to achieve a reasonable geographical spread, in terms of people’s places of birth and upbringing. Allegiances based on geography are very strong in central Asia. A team with overrepresentation of one or two regions would be unlikely to work effectively.

Remuneration was another key issue in the establishment of the change management team. In 1994 Kyrgyzstan was in the early stages of establish- ing a market economy, and demand for skilled labour considerably out- stripped its availability. People with a reasonable command of English and basic computer skills could expect to earn US $ 300–400 per month in the private sector, in contrast to the US $ 15–25 then earned on average by physicians. Despite initial resistance from some organizations, it was agreed that some donor funds could be used to cover monthly salaries of between US $ 100–150 for members of the MANAS team (Box 3.2). This amounted to a total of some US $ 50 000 in 1994 and 1995, less than 5% of the total cost of the MANAS Programme.

Though the MANAS team was established as a project team at the outset, it has highlighted the need for a locus for policy development and coordina- tion of the implementation process. The team has demonstrated its

25bu i l d i n g i n s t i t u t i o n a l a n d i n d i v i d ua l c a pac i t y

26 sect ion 3

Given the scale and complexity of a sector-wide programme of reform, there is a good argument for creating a permanent team for managing the process of change, staffed with individuals working full time on change management issues. Its members share a common and clear objective and are not distracted by routine operational health service management issues.

The existence of a team focused on reform efforts is of itself important. Its creation provides a clear focal point for reform efforts, enabling coordination of the reform process across the sector, and a recognized locus for policy development.

Implementing fundamental change in the health sector is a long-term process and plans require constant revision, underlining the need for a permanent team. The team manages relations between the decision-makers and those who are expected to implement the new strategies, the organizational context in which change can occur and the psychological environment. The team also contains the institutional memory of the reform process.

People appointed to such a team are removed from routine tasks to work full time on developing policy and planning implementation. Appointment to the team by a process of competitive entry

Box 3.1. The argument for creating a permanent team for managing change

should ensure that the reform process is being led by a talented and committed group who will benefit from training. Capacity-building efforts may initially focus on the team, but should rapidly move beyond, to a wider circle of health professionals. The unit is an important source of career development opportunities for such people, and as such it plays an important role in capacity building.

Nevertheless, the creation of a permanent change management team is associated with certain risks. The team may be perceived as an elite group whose members receive preferential treatment, and may therefore encounter resistance in dealings with other health professionals. It may be difficult to extend capacity building beyond the change management unit; indeed, there may be disincentives to do this. The medical profession may have a monopoly on positions on the team, particularly if it is perceived to have elite status. In fact, a mix of professions is needed. The team may concentrate most of its activity on one well resourced project, thereby losing sight of its responsibility for motivating change across the sector. Taken together, these risks do not outweigh the benefits of establishing such a team, but they should be anticipated when developing the capacity-building strategy.

27bu i l d i n g i n s t i t u t i o n a l a n d i n d i v i d ua l c a pac i t y

capacity to take on such a responsibility permanently; it became the Re- form Coordination and Implementation Department in the Ministry of Health on 5 January 1996 and as such has assumed a permanent and institutionalized form. It is responsible for coordination of the implemen- tation process, further technical development, information dissemination and coordination of donor inputs to the health sector. It has had to work hard to overcome problems of communication with other departments in the Ministry, where a certain amount of resentment and fear of change has had to be tackled. Transparency has been a key tactic in dealing with this,

There is a continuing debate about the appropriateness of using donor funds to enhance salaries of civil service counterparts in development projects. This should be seen as a legitimate cost of managing such projects, and is essential for maintaining continuity of employment, for the following reasons.

First, local counterparts should be paid a secure income that will support a reasonable standard of living. Extreme differentials between overseas consultants’ and local counterparts’ salaries are psychologically damaging and counterproductive. The MANAS team were paid the rough equivalent of the per diem of an overseas consultant. Clearly parity of income with international consultants would be inappropriate, where counterpart staff are less experienced and less highly trained. Nevertheless, taking purchasing power parity into account, a salary of US $ 100–150 is about 25 times less than an

Box 3.2. Remuneration of change management teams

international consultant earning US $ 10 000.

Second, it is necessary to supplement incomes to prevent high turnover in a rapidly changing labour market with extreme shortages of skilled labour. Continuity is vital in a unit in charge of a wide-ranging and ambitious programme of reform, where the work is, in a sense, experimental and far from routine.

If recruitment is based on a carefully designed system of competitive entry, the calibre of staff recruited to work in the change implementation unit will help to ensure that the short-term costs of supplementing public servant incomes will be repaid in terms of long- term productivity gains. If salaries, even when supplemented, are still well below levels paid in the private sector, this will help to ensure that people working in the change implementation unit are motivated not by earnings alone but also by a professional and personal commitment to the reform process.

28 sect ion 3

and great efforts have been made to encourage wide participation in techni- cal work.

Development of the State Medical Academy and Postgraduate Training Centre Many elements of Kyrgyz health care reform require new competences for human resources and, therefore, substantial change in the basic and post- graduate medical curricula. The State Medical Academy and the Postgradu- ate Training Centre are both changing the way they work to make these changes happen.

The development of the State Medical Academy owes much to the vision and energy of one person, its current Rector, who has been in post since 1996. He has been instrumental in updating the content of the medical curriculum and in introducing a programme for training family physicians. A new faculty for higher education of nurses has been established, and a health management training centre, in a joint initiative with the Kyrgyz International University. The Rector has introduced modern teaching meth- ods and the technology needed for this, and has used existing legislation to impose a retirement age of 65 on faculty members. Thus, the Rector has astutely appreciated the need for fundamental change in medical education to meet the requirements of a modernizing health service, and has exploited the opportunities for change that the MANAS reform process has pro- vided.

The Director of the Postgraduate Training Centre has developed retraining programmes for family physicians and family nurses. This ensures that the immediate needs of the reformed system are met, and that the institution benefited from resources available under the World Bank health sector reform project.

The development of these institutions is a good example of synergistic development between an institution and the wider sector. It may be argued that the MANAS reform movement has contributed to the development of the cultural environment needed for institutional modernization, and has also been instrumental in providing the practical tools needed.

MHIF The development of MHIF provides an instructive example of creating and developing a financing institution in a country exploring new ways of funding its health care system in the context of a sector-wide reform pro- gramme. Although the basic aim behind the creation of a mandatory health

29bu i l d i n g i n s t i t u t i o n a l a n d i n d i v i d ua l c a pac i t y

insurance system has been criticized, essentially because of the erroneous belief that new resources for health can be made available in this way, it has nevertheless provided invaluable experience of institutional development. The development of MHIF has required changes in the wider health sector, and it has been responsible for driving change beyond this institution, as described below.

In 1992 the Government enacted three basic laws related to health care reform, one of which was the Medical Insurance Law. This decreed that compulsory health insurance would be levied on employers for employees and on the state for Government employees, pensioners, the unemployed and students. Health offices at oblast level would administer the system. The original timetable for preparation and pilot testing of MHIF, as envis- aged in the master plan, was to extend over a period of five years, from 1998 to 2002. In the event political pressures prompted an earlier start and it was established in February 1997. This was gradually followed by the oblast health insurance funds. Table 3.1 summarizes the complex evolution of MHIF from this point.

DEVELOPING INDIVIDUAL CAPACITY

The process of developing capacity in people working in the Kyrgyz health sector has involved a mixture of training in specific skills, and a softer process in which opportunities have been exploited to build team spirit, leadership skills and the like. The kinds of skills required for developing and implementing a health care reform programme are described briefly in the introduction to this section. Individual members of the MANAS team received four kinds of training.

1. Training in English was provided for two years, and training in basic computer skills (word processing, spreadsheet analysis and presentation software) for eight months, throughout 1994 and 1995.

2. Structured short courses lasting 2–5 days were provided on manage- ment skills (basic management skills, project management, planning methods – LFA (Logical Framework Approach) and PERT (Planning, Evaluation and Review Technique) and on technical subjects (health and health care policy development, strategic planning for health informa- tion systems, development of health indicators, the Danish health care system, hospital management, human resources management and hu- man resources planning).

3. Seminars were given on an ad hoc basis when overseas experts were visiting Kyrgyzstan, on a range of topics. These included sources of

30 sect ion 3

Date Event Problems Wider health care encountered/ system and solutions institutional proposed development

implications

June 1996 MANAS Programme adopted

October MANAS Programme 1996

December Presidential edict on Following a trend in the Data requirements may 1996 health insurance signed, former USSR, proposal drive improvements in

Government resolution was based on erroneous health information system. adopted, thereby belief that new resources establishing MHIF can be made available this

way. Fait accompli, so opportunities were exploited for institutional development.

February Oblast health insurance This creates demand for 1997 funds established health finance and health

information people at oblast level.

January 2% tax on salary fund of Administrative Brings social fund tax on 1997 employers introduced difficulties delay actual employers to 39% of their

as contribution to MHIF collection to July 1997. salary fund. Amount of revenue to be raised in this way too small to provide meaningful insurance coverage for employees.

Early 1997 WHO recommends pooling Without this, a two-tier If Ministry of Health is in MHIF contributions with benefit system will overall charge of jointly general tax revenues to develop. used collection and cover costs of guaranteed payment system, could benefit package for help build more effective entire population strategic resource

management by Ministry

Table 3.1. Development of MHIF

31bu i l d i n g i n s t i t u t i o n a l a n d i n d i v i d ua l c a pac i t y

April 1997 Agreement is signed There is no legally binding The introduction of jointly keeping the separate agreement concerning the used systems prevents identity of MHIF and the jointly used systems and additional administrative Ministry of Health with there is a risk of failure in costs to system and different sources of funds, coordinated work. duplication. It allows the but they will work together implementation of a single to define and implement health policy. joint systems and jointly used system

Late 1997 Start of MHIF contact with Determination of the This allows the testing of hospitals for case-based reimbursement rates for some new methods of reimbursement cases is difficult, as is provider payment.

following up how the funds Further, some autonomy are used at the facility level. has been given to hospital

management in financial resource management.

Mid-1998 Start of MHIF payment As PHC providers, FGP This also serves as a of PHC providers formation is in progress and transition to per capita

the contracting partners payment to PHC are not standardized. The providers. The small additional payment for the amount of additional insured population could funds provides the cause cream skimming. opportunity to meet some

needs of FGPs and promotes joint decision- making among the PHC team.

End 1999 Establishment of MHIF as a The risk arose that MHIF This is a concrete move semi-autonomous body of would act as a sole towards single-payer the Ministry of Health insurance system. MHIF model rather than a

and the Ministry of Health two-tier system could have implemented different policies.

Date Event Problems Wider health care encountered/ system and solutions institutional proposed development

implications

Table 3.1. (contd)

32 sect ion 3

funds for health care, resource allocation, provider payment methods, United Kingdom health financing, national drug policies and STD and tuberculosis control.

4. Opportunities were exploited to ensure that MANAS team members participated in international fora. Thus, they have participated in inter- national meetings, particularly through the Central Asian Republics’ Network for Health Care Reforms (CARNET) cycles (Some informa- tion on these cycles is provided in Box 3.3). People have been sent on structured training courses abroad, and members of the MANAS team and other personnel have participated in study tours abroad. (These study tours have provided valuable learning opportunities. Neverthe- less, the host institutions and participants must prepare thoroughly in advance, if their full benefits are to be realized and their substantial cost fully justified.)

In addition to the more or less planned and structured training described above, on-the-job learning has been the main feature of capacity building. Development of the master plan has served as a useful tool for ensuring a broad understanding of the health care system and developing the capacity to coordinate the implementation process. In a situation of considerable resource constraint it has been necessary to focus some training opportuni- ties on certain people who have shown particular commitment to and enthusiasm for the reform process, including the determination to acquire certain general and technical skills.

After considerable investment in individual capacity building, it is critical to provide satisfactory job opportunities, to utilize this capacity for further development. The members of the MANAS team, who were involved in the development of the master plan, are now contributing to its implemen- tation. The team is growing gradually and is affected by some staff turnover.

Eleven members of the original MANAS team take part in the coordina- tion and further development of the reform process in the Department; one of them is the head of the newly established Hospital Association. Three team members head departments in the Ministry of Health and another three are managers in MHIF at both republican and oblast levels. One team member assumed the responsibility of national tuberculosis coordinator and working on changing clinical practices. Eight team members work in various oblast health administrations and eight more work as the directors of various health facilities. Only three members of the team returned to clinical practice. Three others are working in various posts. All team members continue to work in the public sector, except five who moved to the private sector.

33bu i l d i n g i n s t i t u t i o n a l a n d i n d i v i d ua l c a pac i t y

Thus, 27% of the team members still have a coordination role; 33% of them play an active role in implementation at the Ministry of Health, oblast health administration and MHIF; 20% are realizing changes at the facility

CARNET is a programme of the WHO Regional Office for Europe. Its participants include representatives from Azerbaijan, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan, and WHO staff and consultants. The programme is a tool:

– for ensuring the exchange of information and experience among the central Asian republics and other countries of the WHO European Region; and

– for providing technical support on issues related to health care reforms.

CARNET’s objectives are to help members orient health care reforms towards health gain, to promote equity of access to health care, to ensure the sustainability of health care service provision and to improve the quality of care. The programme is financed by the WHO Regional Office for Europe, with donations from international and bilateral agencies for specific meetings.

CARNET is run in developmental cycles, each focusing on a specific topic. Each cycle starts with the identification of a relevant health care reform topic by policy-makers in the

Box 3.3. CARNET

CARNET countries and WHO Regional Office. A theoretical framework and country-specific background papers are then prepared. A 3–4 day meeting follows, attended by national policy- makers and experts, and WHO staff and consultants. Experiences in the CARNET countries and the wider European Region are compared and policy directions are developed. Dissemination of country papers and meeting proceedings is arranged.

To date CARNET cycles have addressed the following topics:

– making resource allocation effective (Tashkent, 1994);

– balancing the public–private mix (Tashkent, 1995);

– MANAS: participatory policy development (Bishkek, 1996);

– moving from specialist care to general practice (United Kingdom, 1997);

– reforming medical education (Barcelona, 1997);

– improving hospital management: towards more efficient hospital services (Istanbul, 1998);

– bridging care and prevention: sanitary epidemiological services (underway); and

– lifestyle and PHC (underway).

34 sect ion 3

Professor Tilek Meimanaliev is a cardiologist. He was appointed programme coordinator for the MANAS Programme, the head of the national team when it was established in 1994. From the outset he took the development of English language skills very seriously. He has participated in all the training programmes organized for the MANAS team. Naturally, as Programme Coordinator, he has taken part in many international meetings, and joined several study tours. These have included each of the CARNET meetings; the WHO Conference on European Health Care Reforms held in Llubljana, Slovenia in June 1996; countrywide integrated noncommunicable disease intervention (CINDI) programme meetings in Barcelona, Lithuania and the Russian Federation; study tours to Denmark, Germany, Hungary, Slovakia, Turkey, the United Kingdom and the USA; and USAID meetings on health care reforms in the NIS. He is the key person leading and coordinating the reform activities and is now the Minister of Health.

Dr Ainura Ibrahimova is a physician who knew some English when she joined MANAS in 1994, and now speaks it to a high standard. She has participated in all the MANAS training programmes. She attended a three-month course on health care financing for participants from countries of central and eastern Europe (CCEE) and the NIS at the University of York in 1995, and has been on study tours to WHO headquarters in Geneva, and to Germany. At the outset she worked on

Box 3.4. Career development in the MANAS Team

human resource issues within the MANAS team. She has been appointed as Deputy Director of MHIF, and has travelled to other countries in central Asia to explain the emerging Kyrgyz model of health insurance. She has played the key role in the establishment and development of MHIF and ensured that this complements other reform activities. She is now the deputy minister.

Dr Acelle Sargaldakova is a physician who joined the MANAS team in 1994. She had some knowledge of English when she was recruited, and, like all the members of the team described here, took the development of her language and technical skills very seriously. She has participated in all the MANAS training programmes, and this enabled her to study for and obtain a Masters degree in public health based on one year’s study at the Braun School of Public Health and Community Medicine at the Hebrew University in Israel. She was the first person to obtain such a degree in any of the central Asian republics, and at the time of writing is still the only person with such a qualification in Kyrgyzstan. She was later awarded a three-month fellowship at the European Observatory for Health Systems Analysis based at the London School of Hygiene and Tropical Medicine. She is now working on monitoring and evaluation in the Reform Coordination and Implementation Department and is working with WHO as an advisor to other central Asian countries engaged in health care reform.

level. As seen, about 80% of the team initial team are dispersed at various positions all over the country, and work to make the planned reforms happen. This critical mass disseminates the new working style and team spirit through the sector.

DISCUSSION

What can be learned from the Kyrgyz experience of capacity building? It may be useful here to draw on Samuel Paul’s identification of several strate- gic issues that should be taken into account in developing individual and institutional capacity in the health sector (7). First, to what extent have needs for capacity building been assessed in Kyrgyzstan? Ideally, the reform process should have included a systematic assessment of the requirements, attitudes, preparedness and incentives of potential users of capacity early on. To the extent that there has been a structured or planned approach to capacity building in the Kyrgyz health sector, this has been based on allocat- ing responsibility to MANAS team members based on technical areas within the master plan, such as human resources or information system development. Training was then provided in these areas, in Kyrgyzstan or abroad, as resources permitted.

Second, what were the barriers to building capacity in Kyrgyzstan? Obstacles have included the view held by some politicians who consider that human capacity in the health sector is adequate and that resources are better spent on physical infrastructure. The lack of an agreed capacity-building policy among donors constitutes another barrier to development. The corollary is inadequate financial resources for training.

Third, problems have not yet emerged in terms of using newly acquired skills; identified demand for trained personnel still outstrips supply. The institutionalization of the MANAS team in the Ministry of Health may help to maintain demand for new capacity, but this raises the question of whether capacity building for health sector reform should be confined to the Government and its agencies (Box 3.5).

Critical success factors for sustainable development of institutional and individual capacity The following factors are suggested to be critical to the successful and sustainable development of the institutional and individual capacity needed to reform and manage a modernized health service:

• a full-time and permanent change management team is in place;

35bu i l d i n g i n s t i t u t i o n a l a n d i n d i v i d ua l c a pac i t y

• a capacity-building strategy recognizes the synergy between individual and organizational development;

• there is a well resourced sustainable training infrastructure and political support for investment in training; and

• an effective performance evaluation system is in place, based on good understanding of incentives for individual and organizational perform- ance.

The development literature recognizes the importance of capacity building, but reality still belies rhetoric. Some senior officials in the Kyrgyz health sector consider that too much has been spent on training under MANAS. Trained people and organizations that function effectively are less visible than newly constructed clinics and hospitals, high technology and drugs. As such, they are less attractive to the public, whom politicians wish to convince of their efforts to improve the health care system.

This is an old problem that affects health care reformers in all countries, but, where resources for development are extremely limited, the case for using resources for capacity building has to be argued all the more strongly. International agencies should help to make this case, and direct appropriate resources to this activity. To a certain extent, they have more freedom to do

Box 3.5. Establishing support for capacity building

this than nationals, who need to demonstrate more tangible outputs from health sector investment for political reasons. In addition, an environment should be created in which investment procedures are transparent and rigorously audited, to prevent opportunities for personal gain from investment in physical infrastructure.

Opportunities for capacity building arising from the use of technical assistance should be exploited to the full. A World Bank memorandum on a joint country assistance strategy for Kyrgyzstan refers to “a somewhat limited recognition of the need for and acceptance of foreign technical assistance” (8). Technical training of counterpart staff should be a standard element of all consultancy input, and technical assistance work plans should allow for this. This would also help to reduce

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 1 janvier 2000

Source Organisation mondiale de la santé