Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)

COMPENDIUM OF THE ROADMAP FOR HEALTH AND WELL-BEING IN CENTRAL ASIA (2022–2025)

COMPENDIUM OF THE ROADMAP FOR HEALTH AND WELL-BEING IN CENTRAL ASIA (2022–2025) ABSTRACT This compendium is a  supplementary document for the Roadmap for Health and Well-being in Central Asia (2022–2025) (hereinafter, Roadmap), which scopes the following Central Asian countries (CACs): Republic of Kazakhstan, Kyrgyz Republic, Republic of Tajikistan, Turkmenistan, and Republic of Uzbekistan. The Roadmap builds on the individual health and well-being goals and priorities of CACs through the lens of the European Programme of Work (2020–2025) – “United Action for Better Health” (EPW) and identifies shared priorities and potential synergistic actions across the subregion. The Roadmap also aligns efforts and fosters cooperation with regional, subregional, and country partners to implement political, investment and technical objectives that deliver on the core priorities of the EPW. This compendium is comprised of two sections. The first section contains two supporting tables for the Roadmap, which outline: 1) the gaps in health and well-being between CACs and the European Union and WHO European Region and 2) priority actions for health, well-being, and sustainable development at the country-level in Central Asia. The second section contains five country briefs, which were completed to identify and centre the health, well-being, and sustainable development priorities of CACs in the Roadmap’s development. Each brief is independently presented to facilitate easy access to relevant country information. Document number: WHO/EURO:2022-5904-45669-65599 © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0  IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. All photos: © WHO Designed by: Pointer Creative Contents Abbreviations ................................................................................................................. iv Supporting tables for the Roadmap: Identifying the priorities and gaps in health and well- being in Central Asia........................................................................................................1 1.1. Assessing the gaps in health and well-being in Central Asia and between the European Union (EU) and WHO European Region .................................................................... 2 1.2. Health and well-being priorities in Central Asia ............................................................................. 6 Country briefs: Identifying and centring the health and well-being priorities of CACs .....11 2.1. Introducing the country briefs ...................................................................................................... 12 2.2. Republic of Kazakhstan ............................................................................................................... 13 2.2.1. Health, well-being, and sustainable development progress in Kazakhstan ....................................................................... 13 2.2.2. Lessons learned from the COVID-19 pandemic .................................................................................................................. 17 2.2.3. Closing the Health Gap: aligning Kazakhstan’s priorities with the EPW ............................................................................ 18 References ........................................................................................................................................................................................... 24 2.3. Kyrgyz Republic ........................................................................................................................... 25 2.3.1. Health, well-being and sustainable development progress in Kyrgyzstan ......................................................................... 25 2.3.2. Lessons learned from the COVID-19 pandemic .................................................................................................................. 31 2.3.3. Closing the Health Gap: aligning Kyrgyzstan’s priorities with the EPW.............................................................................. 32 References ........................................................................................................................................................................................... 41 2.4. Republic of Tajikistan ................................................................................................................... 43 2.4.1. Health, well-being and sustainable development progress in Tajikistan ........................................................................... 43 2.4.2. Lessons learned from the COVID-19 pandemic .................................................................................................................. 47 2.4.3. Closing the Health Gap: aligning Tajikistan’s priorities with the EPW ................................................................................ 48 References ........................................................................................................................................................................................... 57 2.5. Turkmenistan ............................................................................................................................... 59 2.5.1. Health, well-being, and sustainable development progress in Turkmenistan ................................................................... 59 2.5.2. Lessons learned from the COVID-19 pandemic .................................................................................................................. 64 2.5.3. Closing the Health Gap: aligning Turkmenistan’s priorities with the EPW ......................................................................... 65 References ........................................................................................................................................................................................... 73 2.6. Republic of Uzbekistan ................................................................................................................ 75 2.6.1. Health, well-being and sustainable development progress in Uzbekistan......................................................................... 75 2.6.2. Lessons learned from the COVID-19 pandemic .................................................................................................................. 80 2.6.3. Closing the Health Gap: aligning Uzbekistan’s priorities with the EPW ............................................................................. 81 References ........................................................................................................................................................................................... 91 Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)iv Abbreviations 2025 Concept Concept on Health Sector Reform of the Republic of Uzbekistan (2019–2025) ADP Additional Drug Package AMR Antimicrobial resistance ART Antiretroviral therapy BCA Biennial collaborative agreement BCI Behavioural and cultural insights BoP Balance of Payments CACs Central Asian Countries: the Republic of Kazakhstan, the Kyrgyz Republic, the Republic of Tajikistan, Turkmenistan and the Republic of Uzbekistan CAREC Central Asian Regional Environmental Centre CF TJK Government of Tajikistan and United Nations Sustainable Development Cooperation Framework (2023–2026) CF TKM Sustainable Development Cooperation Framework between the Government of Turkmenistan and the United Nations 2021–2025 CF UZB United Nations Sustainable Development Cooperation Framework 2021–2025 for Uzbekistan COVID-19 Coronavirus disease 2019 CPRP Country Preparedness and Response Plan CST Caregiver Skills Training programme DALYs Disability-adjusted life years DTP3 Three doses of diphtheria tetanus toxoid and pertussis vaccine EPW European Programme of Work (2020–2025) – “United Action for Better Health in Europe” EU European Union GAP Stronger Collaboration, Better Health: The Global Action Plan for Healthy Lives and Well-being for All GBV Gender-based violence GDP Gross domestic product GPW 13 Thirteenth General Programme of Work 2019–2023 HDI Human Development Index Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) v Health 2030 Program of the Kyrgyz Republic Government on Public Health Protection and Health Care System Development for 2019–2030 “Healthy Person – Prosperous Country” HEPI Health Emergency Protection Index HiAP Health-in-All-Policies HMIS Health management information system HPOP Healthier populations HRH Human resources for health HWF Health workforce ICT Information and communications technology IHR International Health Regulations (2005) ILO International Labour Organisation IPC Infection prevention and control ISEF Integrated Socioeconomic Response Framework LGBTQIA+ Lesbian, gay, bisexual, transgender, queer, intersex, asexual and more MHIF Mandatory Health Insurance Fund mhGAP Mental Health Gap Action Programme MoH Ministry of Health MoHMI Ministry of Health and Medical Industry MoHSPP Ministry of Health and Social Protection of the Population Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)vi NCDs Noncommunicable diseases NHS 2030 Strategy on the Healthcare of the Population of the Republic of Tajikistan up to 2030 PIP Pandemic Influenza Preparedness PHC Primary health care PPE Personal protective equipment PPP Purchasing power parity SDG Sustainable Development Goal SGBP State-guaranteed benefit package SHP State Health Programme of the President of Turkmenistan (2021–2025) SPECA United Nation’s Special Programme for Central Asia Regional Cooperation SRMNCAH Sexual, reproductive, maternal, new-born, child and adolescent health STI Sexually transmitted infection TB Tuberculosis UHC Universal health coverage UN United Nations UNDAF United Nations Development Assistance Framework US$ United States dollar WASH Water, sanitation and hygiene Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Supporting tables for the Roadmap: Identifying the priorities and gaps in health and well-being in Central Asia 1 Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)2 1.1. Assessing the gaps in health and well-being in Central Asia and between the European Union (EU) and WHO European Region Select indicators have been compiled to represent the health, well-being and sustainable development statuses of Central Asia, the EU and the WHO European Region (Table 1). This data is intended to be used for population-based comparison to assess the gaps in health and well-being among Central Asia and the EU and WHO European Region. Data from United Nation (UN) and WHO sources were preferred; however, other sources were used if their data were either more recent or unavailable in UN or WHO databases. Table 1. Assessing the gaps in health and well-being in Central Asia and between the EU and WHO European Region. Indicatora,b Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Uzbekistan EUc WHO European Region Total population (millions) (2020) (1) 18.75 6.59 9.54 6.03 34.23 447.79 918.8 (2018) Population growth (annual %) (2020) (1) +1.3 +2.1 +2.3 +1.5 +1.9 +0.1 N/Ad Population aged 65 and above (% of total population) (2020) (1) 7.90 4.73 3.18 4.77 4.79 21 N/A GDP (current US$, millions) (2020) (1) 169 835.43 7 735.98 8 194.15 45 231.43 57 707.19 15 192 652.40e N/A GDP per capita (PPP current international $) (2020) (1) 26 728.50 4 965.00 3 858.40 16 195.50 (2019) 7 378.30 44 491.30 N/A GDP annual growth rate (%) (2020) (1) -2.6 -8.6 +4.5 +6.3 +1.6 -6.2 N/A Foreign direct investment, net (BoP, current US$, thousands) (2020) (1) -5 905 368.70 -336 659.80 -36 199.83 N/A -1 723 945.22 N/A N/A Unemployment rate (% of total labour force) (modelled ILO estimate) (2020) (1) 6.0 7.9 7.5 4.4 6.0 7.4 6.8 (2019) Human Development Index (2019) (2) 0.825 0.697 0.668 0.715 0.720 0.87(2015) (3) 0.83(2015) (3) Poverty headcount ratio at country poverty lines (% of population) (2019) (1) 4.3 (2018) 20.1 26.3 N/A 14.1 (2013) N/A N/A Public spending on health (% of GDP) (2018) (3) 1.78 2.80 1.96 1.20 2.02 5.9 4.87 Public spending on health (% general government expenditure) (2018) (3) 9.10 8.39 6.14 8.71 7.87 13.8 12.48 Out-of-pocket payments (% of current health expenditure) (2018) (3) 33.47 52.44 68.42 76.34 60.34 21.6 29.82 a All data are provided to two decimal places, except where the data source lacked that degree of specificity. b Dates and references for each row of data are provided in parentheses in the Indicator column, unless specified next to the data point. c When possible, EU27 data was used instead of EU28 data. d N/A indicates the data is not available. e Total value. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) 3 Indicatora,b Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Uzbekistan EUc WHO European Region Population with household spending on health greater than 10% of total household budget (%) (3) 2.56 (2015) 3.47 (2016) 17.73 (2009) N/A 6.66 (2003) N/A N/A Life expectancy at birth, female (years) (2019) (4) 77.61 77.31 71.55 72.97 75.21 83.82 (1) 81.29 Life expectancy at birth, male (years) (2019) (4) 69.98 70.75 67.58 66.48 70.76 78.45 (1) 75.09 Infant mortality rate (2019) (per 1000 live births) (5) 9.30 16.36 29.60 36.32 15.57 3.32 (1) 7.00 Under-five mortality rate (per 1000 live births) (2019) (5) 9.10 16.21 29.63 36.26 14.96 3.95 (1) 8.00 Maternal mortality ratio (per 100 000 live births) (2017) (5) 10.00 60.00 17.00 7.00 29.00 6.00 (1) 13.00 Standardized death rate for all causes per 100 000 population (2015) (6) 1042 1044 941 (2005) 1073 (2013) 955 (2014) 561 718 Total hospital beds per 100 000 population (2013) (6) 671.77 451.24 475.62 736.29 399.38 638.16 566.62 Physicians (health professionals) per 100 000 (2014) (6) 327 185 171 229 245 351 322 UHC Service Coverage Index (2017) (7) 76.0 70.0 68.0 70.0 73.0 N/A N/A Health Emergencies Protection Index (2019) (7) 90.0 71.5 79.7 84.0 77.5 N/A N/A IHR capacity and health emergency preparedness (2019) (7) 82.0 47.0 62.0 69.0 57.0 N/A 75.0 Vaccine coverage of at-risk groups for epidemic or pandemic prone diseases (%) (2018) (7) 98.5 94.0 97.0 99.0 97.0 N/A 93.4 Proportion of the target population with access to DTP3 (2019) (7) 97.0 95.0 97.0 99.0 96.0 N/A 95.0 Cause of death, by NCDs (% of total) (2019) (1) 86.68 81.59 73.19 72.30 85.18 89.82 N/A Cause of death, by communicable diseases and maternal, prenatal and nutrition conditions (% of total) (2019) (1) 5.13 10.44 19.49 21.95 8.21 5.55 N/A Table 1. contd. a All data are provided to two decimal places, except where the data source lacked that degree of specificity. b Dates and references for each row of data are provided in parentheses in the Indicator column, unless specified next to the data point. c When possible, EU27 data was used instead of EU28 data. d N/A indicates the data is not available. e Total value. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)4 Indicatora,b Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Uzbekistan EUc WHO European Region Percentage of DALYs attributable to NCDs (2019) (8) 75.64 70.98 64.07 73.66 70.16 87.55 83.79 Percentage of DALYs attributable to communicable diseases (2019) (8) 9.82 17.23 26.57 18.11 19.03 4.04 6.15 Probability (%) of dying between age 30 and exact age 70 from any of cardiovascular disease, cancer, diabetes, or chronic respiratory disease (2019) (4) 22.42 20.34 28.33 27.70 25.30 N/A 16.32 Alcohol, total per capita (15+) consumption (in litres of pure alcohol) (2019) (4) 4.8 6.3 3.3 4.9 2.6 N/A 9.5 Prevalence of tobacco use in adults aged 15+ (age-standardized) (2018) (7) 24.4 27.9 N/A N/A 12.3 N/A 26.32 Mortality rate attributed to exposure to unsafe WASH services (per 100 000 population) (2016) (4) 0.38 0.78 2.70 3.98 0.44 N/A 0.30 Age-standardized mortality rate attributed to household and ambient air pollution (per 100 000 population) (2016) (4) 62.68 110.70 129.30 79.30 81.14 N/A 30.00 Proportion of people living with HIV receiving ART (2019) (7) 52.0 40.0 51.0 N/A 58.0 N/A 58.0 Suicide mortality rate, age-standardized (deaths per 100 000 population) (2019) (4) 18.05 8.28 5.32 6.07 8.28 N/A 10.50 Notes. ART: Antiretroviral therapy; BoP: Balance of Payments; DTP3: Three doses of diphtheria tetanus toxoid and pertussis vaccine; DALY: Disability-adjusted life year; EU: European Union; GDP: Gross domestic product; IHR: International Health Regulations (2005); ILO: International Labour Organisation; NCDs: noncommunicable diseases; PPP: Purchasing Power Parity; US$: United States Dollar; UHC: Universal health coverage; WASH: water, sanitation and hygiene. a All data are provided to two decimal places, except where the data source lacked that degree of specificity. b Dates and references for each row of data are provided in parentheses in the Indicator column, unless specified next to the data point. c When possible, EU27 data was used instead of EU28 data. d N/A indicates the data is not available. e Total value. Table 1. contd. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) 5 References1 1 All online references were accessed on 11 April 2022. 1. World Bank Open Data [online database]. Washington, D.C.: The World Bank; 2022 (https://data.worldbank.org/). 2. Human Development Reports: Latest Human Development Index Rankings [website]. New York: United Nations Development Program; 2022 (http://hdr.undp.org/en/content/ latest-human-development-index-ranking). 3. Global Health Expenditure Database [online database]. Geneva: World Health Organization; 2022 (https://apps.who. int/nha/database/Select/Indicators/en). 4. World Health Data Platform: The Global Health Observatory [online database]. Geneva: World Health Organization; 2022 (https://www.who.int/data/gho/data/indicators). 5. Maternal, Newborn, Child and Adolescent Health and Ageing: Data portal [online database]. Geneva: World Health Organization; 2022 (https://www.who.int/data/maternal- newborn-child-adolescent-ageing/indicator-explorer-new/ mca). 6. European Health Information Gateway [online database]. Copenhagen: WHO Regional Office for Europe; 2022 (https:// gateway.euro.who.int/en/). 7. Triple Billion Targets Dashboard [website]. Geneva: World Health Organization; 2022 (https://portal.who.int/triplebillions/ PowerBIDashboards/Countries). 8. Global Burden of Disease Compare Data Visualization [online database]. Seattle: Institute for Health Metrics and Evaluation, University of Washington; 2022 (https://vizhub.healthdata. org/gbd-compare/). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)6 1.2. Health and well-being priorities in Central Asia After the country briefs (Section 2) were completed, a  summary of health and well-being priorities across CACs was compiled (Table 2). As shown, this analysis revealed a high degree of overlap among the priorities of CACs. Alongside the country briefs, this summary was used to identify areas for united subregional action and to formulate the Roadmap’s High Impact Action Areas and Reform Initiatives. Table 2. Summary of individual CACs’ health and well-being priorities considered under the auspices of the European Programme of Work (2020–2025) – “United Action for Better Health in Europe” (EPW)’s core priorities and flagship initiatives. EPW Core Priorities and Flagship Initiatives National health and well-being priorities Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Uzbekistan M ov in g to w ar ds U H C • Improve availability, quality, and effectiveness of health care • Strengthen PHC • Improve HRH • Reduce burden of NCDs • Combat communicable diseases, especially TB and HIV • Reduce financial hardship • Improve maternal, adolescent and child health • Strengthen national laboratory capacity • Improve the quality and coverage of PHC services, especially in rural areas • Improve health governance • Incorporate prevention, early detection of diseases and case management in PHC • Improve coordination between PHC and secondary and tertiary institutions • Improve the enrolment and coverage of mandatory health insurance programme • Improve HRH • Reduce burden of NCDs • Reduce burden of communicable diseases, especially drug-resistant TB, HIV and viral hepatitis • Reduce financial hardship • Improve the procurement of medicines and medical supplies and expand the ADP • Increase spending afforded to the SGBP • Improve maternal, adolescent and child health • Expand access to sexual and reproductive health services • Improve WASH services and access • Improve access, quality and effectiveness of health care • Improve health governance • Strengthen PHC • Improve HRH • Reduce burden of NCDs • Reduce burden of communicable diseases, especially TB, HIV, viral hepatitis and STIs • Reduce financial hardship • Improve maternal, adolescent and child health • Expand access to sexual and reproductive health services and rights • Improve quality and affordability of health care • Improve health governance • Strengthen PHC • Expand access to disease prevention, screening, monitoring, and treatment • Improve HRH • Reduce burden of NCDs • Reduce burden of communicable diseases, especially TB, HIV, viral hepatitis and STIs • Reduce financial hardship and improve sustainable health- care financing • Improve the procurement of medicines and medical supplies and further develop the pharmaceutical industry • Strengthen the material and technical base of health care • Protect the health of citizens across the entire life course • Improve maternal, adolescent and child health • Expand access to sexual and reproductive health services • Promote healthy lifestyles and nutrition • Improve access, quality and effectiveness of health care • Improve health governance • Improve long-term care for people who are elderly or who have disabilities or specialized mental health needs • Strengthen PHC • Improve HRH • Reduce burden of NCDs • Reduce burden of communicable diseases, especially drug-resistant TB, HIV and viral hepatitis • Reduce financial hardship • Improve the procurement of medicines and medical supplies and further develop the pharmaceutical industry • Expand compulsory medical insurance • Improve maternal, adolescent and child health • Expand access to sexual and reproductive health services and rights Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) 7 EPW Core Priorities and Flagship Initiatives National health and well-being priorities Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Uzbekistan M en ta l H ea lth C oa lit io n • Implement mhGAP and CST • Integrate mental health in PHC • Integrate mental health in PHC • Reduce fragmentation of mental health service systems • Improve interoperability of psychological services across other governmental bodies and sectors • Improve the implementation of the State programme on protecting the population’s health (2018–2030) • Integrate mental health in PHC • Deinstitutionalize services and adopt community-oriented approaches • Target the mental health of children and adolescents • Integrate mental health in PHC • Implement the National Programme for the Protection of the Mental Health of the Population of Turkmenistan (2018–2022) • Improve access to mental health care, especially for people who require specialized services • Improve mechanisms for mental health screening, detection and treatment • Further consider BCI that inform mental health care needs and care-seeking patterns • Integrate mental health in PHC and increase capacity of HWF to provide mental health interventions • Extend coverage of mental health services by publicly funded insurance • Invest in evidence- based, cost-effective clinical and population-based mental health interventions • Establish and strengthen monitoring and surveillance systems to estimate prevalence of mental health conditions and outcomes • Reduce the stigma associated with seeking mental health care • Implement mhGAP and CST Em po w er m en t t hr ou gh D ig ita l H ea lth • Support the formulation of a long-term national Digital Health strategy • Enhance continuity of care through interoperability of digital services and processes • Strengthen the maintenance of essential health services by improving and integrating digital health information systems • Develop an electronic health system • Provide unified and centralized data processing, information security, real-time access to information systems and assessments of cost-effectiveness • Integrate the health information system across other governmental sectors • Properly manage the health information system • Address the shortage of resources in the eHealth centre • Strengthen health data, governance, architecture and standards • Enhance connectivity to digital services and improve ICT infrastructure • Strengthen PHC by improving and integrating the management of information and digital health systems • Implement the inter- departmental plan to develop Turkmen- istan’s health informa- tion system • Develop a health-care telecommunications plan • Train and equip health-care profes- sionals to transition to digital health platforms • Develop advanced e-health management technologies • Improve infrastruc- ture for telemedi- cine and telehealth services, especially in rural areas • Develop and imple- ment plans for the creation of national electronic health re- cords and laboratory information systems • Implement an e-health system and introduce integrated health information systems and databases • Use ICTs to monitor the performance of medical organizations • Develop telemedicine to exchange information between medical organizations and provide rural medical and educational services Table 2. contd. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)8 EPW Core Priorities and Flagship Initiatives National health and well-being priorities Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Uzbekistan Pr ot ec tin g ag ai ns t h ea lth e m er ge nc ie s • Strengthen IPC • Increase availability and domestic manufacturing of medicines and medical supplies and improve joint procurement • Strengthen IHR capacities • Improve maintenance of essential services during health crises • Improve the training of health workforce for emergencies • Develop an advanced system of epidemiological forecasting and response • Improve intersectoral collaboration using One Health approaches • Strengthen IPC methods • Strengthen IHR capacities and strengthen national legislation, policy and financing related to IHR • Enhance emergency preparedness • Improve maintenance of essential services during health crises • Strengthen biosafety and biosecurity and the availability of HRH • Create a unified and effective system of sanitary and epidemiological surveillance • Improve national capacity for early detection, response and rapid reaction, including by optimizing laboratory quality and capacities • Combat declining vaccination rates for vaccine-preventable infections • Address drug- resistant TB • Address the HIV epidemic before it becomes generalized and eliminate vertical transmission • Strengthen IPC methods • Increase availability and domestic manufacturing of medicines and medical supplies and improve joint procurement • Strengthen IHR capacities • Improve maintenance of essential services during health crises • Improve the training of health workforce for emergencies • Create a unified and effective system of sanitary and epidemiological surveillance • Improve national capacity for early detection, response and rapid reaction, including laboratory capacity • Enhance cross- border data collection and collaboration, especially for migrants and refugees • Strengthen IPC • Strengthen IHR capacities and compliance • Improve maintenance of essential services during health crises • Improve the training of health workforce for emergencies • Improve national capacity for early detection, response, and rapid reaction, including laboratory capacity and surveillance • Strengthen One Health approaches, including on zoonotic disease surveillance • Implement the National Plan for the adaptation of the health of the population of Turkmenistan to climate change and its adverse impacts for 2020–2025 • Improve WASH services and expand access to WASH facilities in health- care settings • Improve sanitary quarantine points at all air, transport and railway border crossings and build new sanitary quarantine points • Maintain polio eradication and malaria, measles and rubella elimination • Strengthen IPC methods • Strengthen IHR capacities • Improve maintenance of essential services during health crises • Improve the training of health workforce for emergencies • Create a unified and effective system of sanitary and epidemiological surveillance • Improve national capacity for early detection, response and rapid reaction, including laboratory capacity • Improve the monitoring, control and distribution of PPE for medical staff • Enhance cross- border data collection and collaboration, especially for disaster risk reduction and for migrants and refugees • Address drug- resistant TB Table 2. contd. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) 9 EPW Core Priorities and Flagship Initiatives National health and well-being priorities Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Uzbekistan Pr om ot in g he al th a nd w el l-b ei ng • Address common risk factors for NCDs • Respond to unmet care needs of ageing population • Combat AMR • Address environmental and climate change issues • Improve road safety • Address common risk factors for NCDs, including by increasing taxation on products that are risk factors for NCDs • Address the social determinants of health • Improve capacities to combat AMR • Tackle obesity and low physical activity • Address environmental and climate change issues, especially air pollution • Improve road safety • Address common risk factors for NCDs • Combat AMR • Expand access to WASH facilities in health-care settings and increase the public’s access to safe water supply and sanitation systems • Combat the climate crisis • Address transboundary health issues, especially for migrants and their families • Improve road safety and support local living environments with the HiAP approach • Improve health-care services for people with disabilities • Combat food insecurity • Address common risk factors for NCDs • Combat AMR • Establish a tobacco- free country by 2025 • Combat alcoholism • Combat obesity and promote physical activity and good nutrition • Address environmental and climate change issues, especially air pollution • Improve road safety with HiAP approaches • Improve health-care services for people with disabilities • Reduce the burden of food insecurity • Protect land, air and water resources • Improve access to clean drinking water • Equip industrial enterprises with environmentally safe technologies • Address common risk factors for NCDs • Combat AMR • Tackle obesity and low physical activity • Address environmental and climate change issues, especially air pollution • Improve road safety and support local living environments with HiAP approaches • Improve health-care services for people with disabilities • Reduce the burden of food insecurity Eu ro pe an Im m un iz at io n Ag en da 2 03 0 • Increase vaccine confidence and acceptance • Implement the European Immunization Agenda 2030 • Improve access to routine vaccination, especially for people living in remote communities and for children of internal migrants in large urban areas • Increase vaccine confidence and acceptance • Implement the European Immunization Agenda 2030 • Increase vaccine confidence and acceptance • Implement the European Immunization Agenda 2030 • Sustain high levels of vaccine coverage • Increase vaccine confidence and acceptance • Implement the European Immunization Agenda 2030 • Improve capacity of PHC to administer vaccines • Increase vaccine confidence and acceptance • Expand the “zero dose” programme • Implement the European Immunization Agenda 2030 Table 2. contd. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)10 EPW Core Priorities and Flagship Initiatives National health and well-being priorities Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Uzbekistan H ea lth ie r B eh av io ur s • Increase percentage of people engaging in healthy behaviours and physical activity • Increase social spending on protecting vulnerable groups from poverty, social exclusion, and poor health outcomes • Reduce mortality associated with behavioural risk factors • Combat discrimination experienced by marginalized groups, especially the LGBTQIA+ community, migrants, people with HIV or TB and victims of GBV • Increase social spending on protecting vulnerable groups from poverty, social exclusion and poor health outcomes • Build BCI capacity • Increase percentage of people engaging in healthy lifestyles and physical activity • Increase social spending on protecting vulnerable groups from poverty, social exclusion and poor health outcomes • Build BCI capacity • Promote healthy choices and lifestyles, especially for nutrition • Combat discrimination experienced by marginalized groups • Increase social spending on protecting vulnerable groups from poverty, social exclusion and poor health outcomes • Build BCI capacity • Reduce mortality associated with behavioural risk factors • Promote healthy choices and lifestyles, especially for nutrition • Combat discrimination experienced by marginalized groups • Increase social spending on protecting vulnerable groups from poverty, social exclusion and poor health outcomes • Build BCI capacity Notes. Please see Section 2 of the Roadmap’s Compendium for more extensive information on each CACs’ health and well-being priorities. ADP: Additional Drug Package; AMR: Antimicrobial Resistance; BCI: Behavioural and cultural insights; CST: Caregiver Skills Training programme; EPW: European Programme of Work (2020–2025) – “United Action for Better Health in Europe”; GBV: Gender-based violence; HiAP: Health-in-All-Policies; HRH: Human resources for health; HWF: health workforce; ICT: information and communications technology; IHR: International Health Regulations (2005); IPC: Infection prevention and control; LGBTQIA+: Lesbian, gay, bisexual, transgender, queer, intersex, asexual and more; mhGAP: Mental Health Gap Action Programme; NCDs: Noncommunicable diseases; PHC: Primary health care; PPE: Personal protective equipment; SGBP: State- guaranteed benefit package; STI: Sexually transmitted infection; TB: Tuberculosis; WASH: Water, sanitation and hygiene. Table 2. contd. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Country briefs: Identifying and centring the health and well-being priorities of CACs 2 Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)12 2.1. Introducing the country briefs This section contains five country briefs that identify the health, well-being, and sustainable development priorities of CACs. As a  testament to multilateralism, the Roadmap is a  subregional policy for Central Asia that has been constructed using a bottom-up approach. The Roadmap’s development process began by assessing and centring the individual priorities of CACs. Then, it identified shared priorities for cooperative subregional action. Therefore, these country briefs are at the core of the Roadmap’s foundation. They have been and will continue to be used to develop and implement the Roadmap’s High Impact Action Areas and Reform Initiatives. Each brief contains an overview of its respective country’s progress and trajectories in health, well-being and sustainable development, lessons learned from the ongoing COVID-19 pandemic and an outline of national health, well-being and sustainable development priorities organized under the auspices of the Sustainable Development Goals (SDGs) (1) and the European Programme of Work (2020–2025) – “United Action for Better Health” (EPW) (2). More specifically, priorities are outlined in relation to selected targets of SDG 3, to ensure healthy lives and promote well-being for all at all ages, and across the three core priorities of the EPW, which include: 1) moving towards universal health coverage; 2) protecting against health emergencies; and 3) promoting health and well-being. The WHO Regional Office for Europe is committed to supporting health, well-being, and sustainable development in CACs. Every two years, this commitment is renewed with CACs’ Ministries of Health through the cooperative development of a biennial collaborative agreement (BCA) that defines both parties’ engagement as they work towards achieving each country’s health and well-being priorities (3-8). These briefs, as well as the entire Roadmap for Health and Well-being in Central Asia (2022–2025) package, should be understood as being fully complementary to the individual health and well-being priorities of CACs and their BCAs until 2025. Therefore, in addition to these country briefs, each CAC’s BCAs can be referenced for additional information regarding their health and well-being priorities in the specific context of the European Programme of Work, 2020–2025, “United Action for Better Health” (EPW). For further information regarding each country’s health, well-being, and sustainable development priorities, please consult the references used to assemble each brief. For all numerical references in Section 2, please refer to the end of each country brief. Each brief is independently presented to facilitate easy access to relevant country information. References 1. The 17 Sustainable Development Goals [website]. New York: United Nations Department of Economic and Social Affairs: Sustainable Development; 2022 (https://sdgs.un.org/goals). 2. European Programme of Work (2020–2025)  – “United Action for Better Health in Europe”. Copenhagen: WHO Regional Office for Europe; 2020 (https://apps.who.int/iris/ handle/10665/339209). 3. Biennial Collaborative Agreement between the Ministry of Healthcare of the Republic of Kazakhstan and the Regional Office for Europe of the World Health Organization 2022/2023 [DRAFT]. Copenhagen: WHO Regional Office for Europe; 2022. 4. Biennial Collaborative Agreement between the Ministry of Health of the Republic of Kazakhstan and the Regional Office for Europe of the World Health Organization 2020/2021 [signed 2019]. Copenhagen: WHO Regional Office for Europe; 2019. 5. Biennial Collaborative Agreement between the Ministry of Health and Social Protection of the Population of the Republic of Tajikistan and the Regional Office for Europe of the World Health Organization 2022/2023 [DRAFT]. Copenhagen: WHO Regional Office for Europe; 2022. 6. Biennial Collaborative Agreement between the Ministry of Health of the Republic of Uzbekistan and the Regional Office for Europe of the World Health Organization 2022/2023 [DRAFT]. Copenhagen: WHO Regional Office for Europe; 2022. 7. Biennial Collaborative Agreement between the Ministry of Health of the Kyrgyz Republic and the Regional Office for Europe of the World Health Organization 2022/2023 [DRAFT]. Copenhagen: WHO Regional Office for Europe; 2022. 8. Biennial Collaborative Agreement between the Ministry of Health and Medical Industry of Turkmenistan and the Regional Office for Europe of the World Health Organization 2022/2023 [DRAFT]. Copenhagen: WHO Regional Office for Europe; 2022. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Kazakhstan Country Brief 13 2.2. Republic of Kazakhstan This country brief outlines the Republic of Kazakhstan’s priorities for improving their population’s health and well- being from 2022–2025. These priorities have informed the development of the Roadmap and its action areas and reform initiatives. This brief is not intended to be exhaustive or prescriptive. Rather, it intends to highlight key issues and areas where Kazakhstan may benefit from and contribute to united action for better health and well-being in Central Asia. The brief identifies a compiled list of Kazakhstan’s national health and well-being priorities (Table 2) that will inform the development and implementation of the Roadmap for Health and Well-being in Central Asia. 2.2.1. Health, well-being, and sustainable development progress in Kazakhstan Kazakhstan is an upper middle-income country whose gross domestic product (GDP) has multiplied nine and a half times since 2000, growing from approximately 18 billion US dollars (US$) in 2000 to 171 billion US$ in 2020 (1). Between 2017–2019, Kazakhstan’s annual GDP growth rate averaged 4.2% per year. However, this rate fell to -2.5% in 2020 as a consequence of the COVID-19 pandemic. Kazakhstan’s unemployment rate was 4.9% of the total labour force, on average, between 2017–2020 (1). Kazakhstan’s economic vulnerability to external shocks poses a  challenge to sustainable development. Current issues include economic diversification and competitiveness, membership in global and regional international economic institutions, and relations with neighbouring states and foreign powers (2). Kazakhstan participates in the Commonwealth of Independent States. It seeks to reinforce its leadership position in structuring Central Asia’s future geopolitical landscape. As such, it signed the founding treaty of the Eurasian Economic Union with Eurasian integration, which is increasingly a priority area for diplomacy. With a total population of approximately 18.8 million, Kazakhstan has one of the lowest population densities in the world at 6.9 people per square kilometre of land area (1). However, between 2017–2020, Kazakhstan’s population grew on average by 1.3% annually. This steady increase can be attributed to the country’s relatively high birth and fertility rates, as well as a substantial increase in immigration from other Central Asian countries (2). The population of Kazakhstan is relatively young; 29.1% of the population were aged less than 15 years in 2020, which is more than twice the European Union (EU)’s percentage of 14.1% (1). Despite this, Kazakhstan’s population is ageing. The percentage of the population aged 65 years and older has steadily increased from 6.8% to 7.9% between 2015–2020. For reference, 7.9% is still less than half of the EU’s percentage of 20.8% for the same metric (1). In Kazakhstan, the incidence of poverty has decreased due to strong legislative and fiscal reform efforts, a strengthened public management and business climate and the expansion of resources for improved social services and infrastructure to sustain growth. Social modernization, equity and efficient management of social funds remain strategic goals alongside facilitating a green economy transition (2). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)14 According to the 2020 Human Development Index (HDI), Kazakhstan ranks 51st out of 189 countries and territories, which places it in the category of countries with high human development (3). Kazakhstan’s HDI increased from 0.764 to 0.825 between 2010–2019. This represents an average HDI growth of 0.61% per year, which is below Europe and Central Asia’s average growth of 0.76% per year during the same period. For reference, Europe and Central Asia’s combined HDI increased from 0.735 to 0.791 between 2010–2019 (3). Embedded in Kazakhstan’s improved HDI is their steady increase in life expectancy over the past decade. Between 2010–2019, life expectancy increased from 73.39 to 77.61 years (+4.22 years) for females and from 63.58 to 69.98 years (+6.40 years) for males (4). However, these figures are still significantly below the WHO European Region’s average of 81.29 for females and 75.09 for males (4). Building back better and leaving no one behind will be imperative to sustain the progress on health, well-being, and sustainable development that Kazakhstan was making prior to the coronavirus disease 2019 (COVID-19) pandemic. Although the focus during the first half of 2021 was directed towards strengthening health systems for combating COVID-19, WHO sustained its contribution in Kazakhstan to raising awareness on noncommunicable diseases (NCDs), mother and child care, and the health promoting schools’ initiative. Moreover, WHO has focused on case management, infection prevention and control (IPC), risk communication and community engagement, and the maintenance of safe and accessible health services throughout the COVID-19 response in Kazakhstan (5). Additionally, the WHO Regional Office for Europe has been supporting Kazakhstan’s Ministry of Health (MoH) with technical expertise, capacity building, logistics for medical supplies and equipment and other public health issues with special emphasis on strengthening health system delivery and governance. During the first half of 2021, WHO worked closely with the Government and health system stakeholders to implement policies and plans that would accelerate the achievement of the Sustainable Development Goals (SDGs) in Kazakhstan by mobilizing 1.8 million US$ for its activities (5). Prior commitments made by the Government include the national development strategy “Kazakhstan 2030”, the Strategic Development Plan of Kazakhstan until 2025 and the National Plan of the President of Kazakhstan entitled 100 Concrete Steps to Implement Five Institutional Reforms. These policies demonstrate how the Government is committed to achieving the SDGs. In fact, 79.9% of the SDGs are reflected in existing strategic documents and programmes, implying that they can be achieved if these strategic documents and programmes are properly implemented (6, 7). Notably, the Government has created a  high-level institutional mechanism to oversee their implementation. The nationalization process of the SDGs is under way, along with the work of tracking indicators and monitoring successful mechanisms. The multifaceted agenda of SDGs is well-suited for the challenges of Kazakhstan, and it is likely to assist the country in reaching its own development goals (6). 2.2.1.1 Looking forward: the health, well-being, and sustainable development trajectory Looking forward, the Government of Kazakhstan will focus its policy development on the achievement of the Kazakhstan 2050 strategy. The 2050 strategy is a cross-sectoral, all-of-Government policy that employs a Health- in-All-Policies approach. Within it, a key focus area is developing new principles of social policy, ranging from social safety nets to individual responsibility. Priority areas include to: 1) ensure the quality and availability of health services; 2) guarantee diagnostics and treatment of the broadest range of diseases; 3) establish preventive medicine as the key tool in the prevention of diseases; 4) introduce new approaches to promoting the health of children under 16 with a full range of health services; 5) dramatically improve the system of medical education; and 6) establish fitness and sports as a special focus of the Government. In 2021, the Government of the Republic of Kazakhstan approved the National Project, High-quality and affordable healthcare for every citizen  – Healthy Nation, for the implementation period 2021–2025 (8). The Project is an implementation arm of the 2050 strategy, and it is a high-level document that involves multiple ministries and agencies across sectors into the national health agenda. The National Project identifies expected economic and social effects. Economically, Kazakhstan wants to increase private investments into the health-care system from 121.5 to 783.3 billion Kazakhstani Tenge (approximately 285 million to 1.84 billion US$) between 2020–2025. Additionally, the country wants to create approximately 13 000 permanent jobs and increase domestic pharmaceutical production from 17% to 50% in the same timeframe. Socially, the National Project outlines five strategic indicators. Between 2020–2025, Kazakhstan aims to (8): • increase life expectancy from 71.37 to 75.00 years • reduce infant mortality to 7.2 deaths per 1000 live births Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Kazakhstan Country Brief 15 • reduce maternal mortality to 10.0 deaths per 100 000 live births • increase citizens’ satisfaction with health services from 53.3% to 80.00% and • increase the amount of investment into health-care equity by 372.2% compared to 2019. To achieve these goals, the National Project centres on four focus areas. These include to (8): • improve the availability, quality and effectiveness of health care • develop an advanced system of epidemiological forecasting and response » expand domestic capacity to produce high-quality, affordable medicines and medical products • increase the percentage of people engaging in healthy behaviours and promote sports for all. The National Project outlines several tasks per focus area to support the achievement of Kazakhstan’s health and well-being goals (Table 3). Table 3. The tasks associated with each focus area of Kazakhstan’s National Project. Focus area Task 1. Availability and quality of health care 1.1. Provide for wide coverage of the population with health services. 1.2. Ensure the health of pregnant women and children. 1.3. Reinforce the capacity of HRH. 2. Development of an advanced system of epidemiological forecasting and response. 2.1. Transition to an advanced model of epidemiological surveillance of communicable diseases. 2.2. Scale up access to advanced and high-precision laboratory testing. 3. Affordable, locally produced drugs and medical products. 3.1. Build the research and HRH capacity of the pharmaceutical and medical industries. 3.2. Promote the domestic manufacturing of drugs and medical products. 4. Increase the percentage of people engaging in healthy behaviours and promote sports for all. 4.1. Promote healthy decision-making. 4.2. Create an enabling environment for physical exercises and sports for all population categories and groups and improve availability of sports infrastructure. Notes. For more information regarding the national indicators associated with each task, please refer to the National Project (8). Finally, Kazakhstan’s 2022–2023 biennial collaborative agreement (BCA) honours all pre-existing international and national strategic frameworks for health and well-being that Kazakhstan has committed to between 2022–2023, including those referenced in this country brief. Notably, these include the Thirteenth General Programme of Work 2019–2023 (GPW), EPW, SDGs, 2050 strategy and the 2021–2025 National Project. A  thorough analysis of Kazakhstan’s progress achieving the outcomes of its 2020–2021 BCA was documented in the 2021 mid-year activity report provided by Kazakhstan’s WHO Country Office (5, 6). 2.2.1.2. SDG 3 progress: Ensure healthy lives and promote well-being for all at all ages SDG 3 aims to ensure healthy lives and promote well-being for all at all ages. In 2021, a  thorough analysis of Kazakhstan’s progress achieving SDG 3 revealed areas where health and well-being have been advanced and where challenges remain (9). These trends are summarized in Table 4. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)16 Table 4. Selected targets and indicators to track Kazakhstan’s progress on SDG 3. SDG 3 Targeta Statusb Description Indicator(s) 3.1 Target achieved By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births. • 3.1.1: Maternal mortality ratio: Decreased from 61.0 to 10.0 per 100 000 live births from 2000–2017. 3.2 Target achieved By 2030, end preventable deaths of new-borns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-five mortality to at least as low as 25 per 1000 live births. • 3.2.1: Children under-five mortality rate: Decreased from 42.2 to 10.5 deaths per 1000 live births from 2000–2019. • 3.2.2: Neonatal mortality rate: Decreased from 22.7 to 4.7 deaths per 1000 live births from 2000–2019. 3.3 Significant challenges remain By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases. • 3.3.1: New HIV infections: Increased from 0.04 to 0.20 new infections per 1000 uninfected population 2000–2019. • 3.3.2: Tuberculosis incidence: Decreased from 171 to 68 incidence per 100 000 population from 2000–2019. 3.4 Major challenges remain By 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being. • 3.4.1: Risk of dying between the ages of 30 and 70 from one of four main NCDs (cardiovascular disease, cancer, diabetes, or chronic respiratory disease): Decreased from 41.5% to 22.4% from 2000–2019. • 3.4.2: Suicide mortality rate: Decreased from 38.7 to 17.6 deaths per 1000 population from 2000–2019. 3.5 Challenges remain Strengthen the prevention and treatment of substance abuse. • 3.5.2: Alcohol consumption per capita among population aged 15 years and older: Decreased from 8.2 to 5.0 litres of pure alcohol from 2000–2019. 3.6 Significant challenges remain By 2020, halve the number of global deaths and injuries from road traffic accidents. • 3.6.1: Death rate due to road traffic injuries: Decreased from 14.2 to 12.7 deaths per 100 000 population from 2000–2019. 3.7 Challenges remain By 2030, ensure universal access to sexual and reproductive health-care services. • 3.7.1: Proportion of women of reproductive age with their needs met for family planning with modern methods: Decreased from 79.1% to 73.2% from 2011–2018. • 3.7.2: Adolescent birth rate: Decreased from 33.0 to 23.2 per 1000 women aged 15–19 years from 2000–2019. 3.8 Challenges remain Achieve UHC, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. • 3.8.1: Service coverage indexc: Increased from 39.0 to 76.0 from 2000–2019. 3.9 Challenges remain By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination. • 3.9.1: Age-standardized mortality rate attributed to household air pollution: 11.0 deaths per 100 000 population in 2016. • 3.9.1: Age-standardized mortality rate attributed to ambient air pollution: 53.0 deaths per 1000 population in 2016. • 3.9.2: Mortality rate attributed to unsafe water, unsafe sanitation and lack of hygiene: 0.4 deaths per 1000 population in 2016. • 3.9.3: Mortality rate attributed to unintentional poisonings: Decreased from 5.4 to 1.9 deaths per 1000 population from 2000–2019. 3.a Challenges remain Strengthen the implementation of the WHO Framework Convention on Tobacco Control. • 3.a.1: Age-standardized prevalence of current tobacco use among persons aged 15 years and older: Decreased from 33.2% to 24.4% from 2000–2018. Notes. NCDs: noncommunicable diseases; SDGs: Sustainable Development Goals; UHC: Universal health coverage. a For brevity, some SDG 3 targets and indicators were excluded when the health issues they addressed were not relatively high priorities or needs in Kazakhstan’s context (for example, tropical diseases) or if there was no data available for their indicators. b The status assigned to each target was determined by an analysis in the Sustainable Development Report (9), which was authored by the Sustainable Development Solutions Network. All data used to create the Sustainable Development Report are based on Sachs et al. (2022)’s publication. The indicators selected for this table represent some of the many indicators that were considered when these statuses were assigned. c There are significant limitations associated with this measure of service coverage. Source: Adapted from (9, 10). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Kazakhstan Country Brief 17 2.2.2. Lessons learned from the COVID-19 pandemic The COVID-19 pandemic made 2020 and 2021 challenging years in Kazakhstan: GDP was reduced and progress was either stalled or partially rescinded on numerous health, well-being and sustainable development goals. This is especially true for Kazakhstan’s progress towards advancing health equity, as the COVID-19 pandemic disproportionately affected its most vulnerable populations (11). The socioeconomic risk to households was heightened due to low coverage and the inadequacy of existing social protection transfers. Kazakhstan has expanded its social protection coverage to more vulnerable groups throughout the pandemic. Despite this, coverage was low and highly restrictive prior to the pandemic, so the expansion fails to meet all current needs (11). Additionally, the COVID-19 pandemic’s negative consequences on health equity in Kazakhstan have been exacerbated by the country not joining the COVAX programme; a worldwide initiative co-directed by WHO and aimed at equitable access to COVID-19 vaccines. As mentioned above, significant gaps have emerged in Kazakhstan’s social protection systems during the COVID-19 crisis, especially in the coverage of working-age populations and those in the informal sector. Social protection systems in Central Asia should develop a policy mix of tax incentives, income support and social services that will attract more people into the formal workplace and render labour markets more inclusive and jobs more resilient (11). Essential services were disrupted during the COVID-19 pandemic, such as the monitoring and evaluation of chronic conditions, due to Kazakhstan lacking sufficient supplies to protect health-care personnel and patients (12). A key lesson learned from the COVID-19 pandemic related to health emergency preparedness is that Kazakhstan must prioritize improving its health system’s capacity to provide immediate access to the medical supplies, protective equipment and digital infrastructure required to maintain essential services and protect health-care personnel and patients. Notably, Kazakhstan’s MoH has continued implementing the health system transformation process it outlines in the National Project while mounting a whole-of-government response to the COVID-19 pandemic. Consequently, the COVID-19 pandemic has had a significant impact on the health system. It adversely affected human resources for health (HRH) and hindered service delivery for many diseases (2). Recognizing this, the Government scaled up its overall emergency response to control the outbreak and begin efforts to build back better by expanding primary health care (PHC) services, poverty reduction efforts and targeted health-care programmes and strategies, as well as steadily increasing health-care funding. Kazakhstan has modelled several successes in improving the COVID-19 response, namely in the areas of: surveillance; outbreak forecasting; digital solutions for public health and social measures; utilization of scientific evidence in health policy-making and clinical care; operationalization of international guidance for strengthening IPC and community engagement; and improving vaccine uptake by the population (2). Through the National Project, the Government is invested in sustaining its gains in health system development during the COVID-19 pandemic. These gains, alongside the lessons learned from the challenges and obstacles Kazakhstan has faced, will be used as the foundation for wider health reforms. The COVID-19 pandemic identified the need to further strengthen PHC, develop public health capacities, address specific technical aspects aimed at improving the safety of care, combat antimicrobial resistance (AMR) and employ intersectoral approaches for emergency preparedness and response (2). Due to the country’s size and low population density, access to health-care services remains challenging, especially in rural and remote areas. This issue also highlights the need for improved methods of joint procurement for medicines and medical supplies across Kazakhstan. For example, it was estimated that only 46% of Kazakhstan’s population had been fully vaccinated for COVID-19 by 01 January 2022. This figure is 13% points less than the WHO European Region’s average of 59% for the same metric (13). This trend demonstrates the importance of strengthening governance and administration mechanisms across Kazakhstan’s health and social systems to reduce bureaucratic burden and increase resilience, collaboration and the adaptability of national systems to shocks and challenges. Additional factors that affect vaccine uptake, beyond availability, should be considered, including scepticism and poor care-seeking behaviours. Overall, these considerations also show how enhancing the quality of health care and education and strengthening social protection, with a particular focus on the most vulnerable, can help prepare for future health emergencies and reduce their negative impact on public health and the health system. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)18 2.2.3. Closing the Health Gap: aligning Kazakhstan’s priorities with the EPW Kazakhstan’s current national health priorities and gaps are discussed below in context of the EPW’s framework. 2.2.3.1. Core Priority 1: Moving towards UHC Moving towards UHC is a  high priority for Kazakhstan. WHO identifies the following areas of work as its highest priorities to address in Kazakhstan (5): strengthening public health; strengthening a  people-centred health system; maternal, child and adolescent health; HIV prevention and care; tuberculosis (TB) prevention and control; noncommunicable diseases; One Health and anti-microbial resistance; road safety and violence and injury prevention; and the Sustainable Development Goals. Progress towards UHC is monitored in two dimensions: the coverage of essential health services and financial hardship. Each is overviewed below in the context of Kazakhstan. Coverage of essential health services In 2019, 238 100 more people in Kazakhstan (1.2% of the population) were covered by essential health services than in 2018. By 2023, this number is projected to be 886 400 more people (4.6% of the population) (14). Coverage of essential health services is defined as the average coverage of the 14 SDG 3.8.1 tracer interventions. Of these 14 indicators, positive progress is projected for nine of them in Kazakhstan by 2023 (Table 5). Table 5. Projected percentage point changes in normalized valuesa across the 14 SDG 3.8.1 tracer interventions for service coverageb from 2018–2023 in Kazakhstan. Service Coverage Indicator 2018 value (%) Projected 2023 value (%) Projected change (%) Basic sanitation 97.9 98.2 +0.3 Care seeking for pneumonia for children under 5 80.4 81.6 +1.3 DTP3 immunization 98.0 96.4 -1.6 Health worker density 72.8 83.0 +10.2 Hospital bed density 100.0 100.0 0.0 IHR core capacity index 71.0 92.2 +21.2 ITN use N/Ac N/A N/A Mean fasting blood glucose 60.8 56.5 -4.3 Need met for family planning 73.9 74.9 +1.0 Non-elevated blood pressure 45.8 46.0 +0.2 People living with HIV receiving ART 49.2 71.6 +22.4 TB cases treated 100.0 98.5 -1.5 Tobacco non-use 75.6 77.5 +1.9 Women who received antenatal care visits 4+ times 93.5 94.2 +0.7 Notes. ART: Antiretroviral therapy; DTP3: Three doses of diphtheria tetanus toxoid and pertussis vaccine; IHR: International Health Regulations (2005); ITN use: Insecticide-treated bed net use among people at-risk of malaria; TB: Tuberculosis. a Some indicators in this chart have been transformed to have values between 0 and 100 (0 worst–100 best). Further information regarding the indicators can be found at (14). b There are significant limitations associated with this method of measuring service coverage. c N/A indicates the data is not available. Source: Adapted from (14). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Kazakhstan Country Brief 19 The key public health problem in Kazakhstan is the burden of NCDs. In 2019, the percentages of deaths and disability- adjusted life-years attributable to NCDs in Kazakhstan were 86.68% (1) and 75.64% (15), respectively. A  more systematic, high quality health information system that enables surveillance of risk factors and overall burden of diseases, improves the monitoring of service delivery for NCDs, progresses sustainable health financing policies, and enhances the assessment of providers’ performance is needed to improve the health system and tackle Kazakhstan’s burden of NCDs. Therefore, Kazakhstan is committed to achieving a  PHC system that is accessible, equitable, integrated, and community-oriented and includes support for NCD screening and prevention (2). Developing an integrated, patient- centred package of care and social protection will also help increase capacity for Kazakhstan to manage HIV, TB, and hepatitis, as well as improve mental health care through forging progress on the WHO Mental Health Gap Action Programme Guidelines (mhGAP). Other institutional challenges affecting progress include the uneven quality and coverage of the health system, including public and private systems, leading to regional differences in health access, utilization, and outcomes. To overcome these challenges and achieve these goals, Kazakhstan would benefit from subregional cooperation to strengthen the government’s capacity to monitor and evaluate access and utilization of essential services and to develop an evaluation mechanism for best practices. Financial hardship Ensuring everyone can access high-quality health services without facing financial hardship is a key target of the EPW and SDGs. At the governmental level, the percentage of GDP spent on health in 2018 in Kazakhstan was only 1.78%, which is significantly lower than the WHO European Region’s average of 4.87% (16). At the patient level, the percentage of health expenditure covered by out-of-pocket payments in 2018 in Kazakhstan was 33.47%, which is approximately 3.5 percentage points higher than the WHO European Region’s average of 29.82% for the same metric (16). In order to increase funding in health care, a Mandatory Social Health Insurance was introduced in January 2020 (17). The insurance aims to increase the availability and quality of medical care, reduce the level of informal payments and out-of-pocket expenses and minimize the financial risks related to catastrophic medical expenditures (5, 17). On its growth trajectory, Kazakhstan oriented its economic policies to an inclusive economy, including allocating resources to poverty reduction and social protection. Before 2015, Kazakhstan had achieved most of its Millennium Development Goals, including those related to poverty reduction, access to primary education, and improvement in children’s and maternal health. To reduce inequality, Kazakhstan aims to raise the income levels of the bottom 40% of the population, from 22.8% to 27% of the total income of the population by 2025 (7). For more information on Kazakhstan’s priorities to improve health-care affordability and to reduce financial hardship, please see Kazakhstan’s National Project (8). Flagship Initiative 1: The Mental Health Coalition Kazakhstan has identified several priority action areas to improve the country’s mental health care. A key priority will be to promote and support the implementation of WHO tools and guidelines on mental health at the PHC level, including mhGAP and the Caregivers Skills Training for families raising children with disabilities and developmental delays. Supporting the integration of mental health services into PHC functions will involve raising awareness, reducing stigma, targeting at-risk groups and improving disease management, treatment and rehabilitation. The COVID-19 pandemic demonstrated the need for measures to be taken to ensure the availability of additional mental health interventions during times of health emergencies (2). Flagship Initiative 2: Empowerment through Digital Health Kazakhstan has several priorities for enhancing connectivity to digital services in health care within the next decade. Initiatives intend to strengthen health systems by introducing further digital integration at all levels of health care. The vision for this enhanced strategy is to support not only clinical-level continuity of care, but also population health management functions via digital health needs and applications that have become especially important in Kazakhstan’s management of the COVID-19 pandemic (17). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)20 Prime among these initiatives are ongoing efforts to improve the level of internet access and basic digital literacy of all age levels in the population. Additionally, increased coverage of high-speed internet services in all regions of Kazakhstan will support the development of interoperability among digital health applications and systems, and help build capacity for a digitally enhanced health workforce and system (17). A detailed analysis of the effectiveness of digital health in Kazakhstan can be found in the country’s most recent progress report on SDG 3 (17). By taking steps to stimulate the advancement of strong digital health systems, Kazakhstan will be able to improve PHC by providing integrated, enhanced and more reliable data on patients and SDG 3 indicators, strengthening access to health-care services in remote communities, increasing quality health care by empowering patients through access to personal health-care data and information on health services and education. Kazakhstan will be able to achieve the WHO indicators for health and health-related SDGs by following recommendations that seek to enhance PHC and establish sustainable financing of health with a focus on digital health. The country will succeed by ensuring close engagement with people, institutions and initiatives that are focused on fulfilling the SDGs’ drive to improve “people, planet, partnership, peace and prosperity” in a manner that is inclusive and leaves no one behind (5). Kazakhstan would benefit from technical and financial support from WHO and subregional cooperation to advance digital health. 2.2.3.2. Core Priority 2: Protecting against health emergencies In 2019, Kazakhstan better protected 2.04 million more people (10.5% of the population) from health emergencies than in 2018. By 2023, this number is projected to reach 5.19 million people (26.7% of the population). In 2019, Kazakhstan scored 90.0% within the Health Emergency Protection Index (HEPI). HEPI is calculated based on three sub-indicators: 1) preparedness; 2) prevention; and 3) detection and response (14). Preparedness In 2020, Kazakhstan scored 81.0% in the preparedness sub-indicator. This sub-indicator assesses emergency preparedness by averaging the scores of all 13 International Health Regulation (2005) (IHR) core capacities at the country level, which are reported through the States Parties Annual Report (SPAR) tool (14). Prevention In 2019, Kazakhstan scored 98.0% in the prevention sub-indicator. This sub-indicator assesses efforts to prevent health emergencies through routine and targeted vaccine campaign efforts. It includes vaccination coverage for five major infectious diseases: measles, polio, meningococcal meningitis A, yellow fever, and cholera (14). Detection and response In 2021, Kazakhstan scored 93.3% in the detection and response sub-indicator. This sub-indicator assesses the appropriateness of a country’s reaction to an event of potential public health concern. It averages the time from a public health event’s start to detection, notification and response to provide an overall measure of timeliness (14). In order to address existing problems and reach the WHO goals for IHR, Kazakhstan has created and ratified a roadmap for the realization of IHR capacities (17) and included the respective actions in the National Project. Additionally, significant efforts have been made to respond to the spread of COVID-19 while maintaining essential health services. Three key areas for improvement include strengthening IPC measures, enhancing surveillance systems, and promoting a One Health approach to animal, human and environmental health management. Based on the lessons learned during the COVID-19 pandemic response, Kazakhstan is committed to strengthening IPC in the health-care sector and across communities. Consequently, the Government has demonstrated its commitment to sustaining the improvement of IPC throughout the recovery from the COVID-19 pandemic and building robust, sustainable solutions. Kazakhstan’s MoH is currently developing a national IPC programme, based on assessments conducted by WHO before and after the COVID-19 pandemic response. The programme includes reshaping the current technical working group on IPC (comprised of experts who participate voluntarily) into a formal IPC committee, which will include IPC practitioners from internationally accredited health-care facilities with robust IPC programmes to facilitate in-country sharing of best practices. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Kazakhstan Country Brief 21 A national surveillance system is a vital component of early detection and rapid response and mitigation measures. Development of the existing surveillance capacities require the amalgamation of the existing practices with contemporary surveillance methods. Implementation of the electronic surveillance system and its integration with the existing health information systems is urgently required to ensure rapid detection of health threats (17). One such health threat that needs better monitoring in Kazakhstan is AMR, which is an especially prominent issue in the country for multiple reasons. Kazakhstan’s geographical location has given rise to intensive farming and agricultural industries that exacerbate AMR. Additionally, the current state of IPC activities further worsens AMR, causing premature death, morbidity, and disability. To improve antimicrobial stewardship and control of disease outbreaks, capacity building approaches and strategies between human, agricultural and animal health services need to be better aligned across the country. Prevention activities require a special focus on antibiotic prescription, regulation of sales rights, and robust national and health facility programmes (17). Kazakhstan is committed to addressing AMR, through strengthened surveillance systems, increased laboratory capacity, IPC, awareness raising and evidence-based policies and practices (2). The WHO Regional Office for Europe can support Kazakhstan’s MoH to develop its response activities to acute emergencies by effectively utilizing all-hazard, whole-of-government approaches. This broadly involves progressing the technical assistance to response planning and coordination, surveillance and monitoring, laboratory capacity, IPC, case management and medical countermeasures, effective risk communication and community engagement, efficient supply chain management, mental health interventions (including mhGAP) and supporting the maintenance of the essential health services during emergencies (2). 2.2.3.3. Core Priority 3: Promoting health and well-being In 2019, 424 500 more people in Kazakhstan (2.2% of the population) enjoyed better health and well-being than in 2018. By 2023, that number is projected to reach 1.50 million more people (7.7% of the population) (14). The healthier populations (HPOP) index uses 16 outcome indicators related to social, environmental, and behavioural risks to assess the number of people whose lives have become healthier. In Kazakhstan, eight of the 16 indicators are projected to improve between 2018 and 2023 (Table 6). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)22 Table 6. Projected changes in the normalized valuesa of the 16 indicators of the HPOP index from 2018–2023 in Kazakhstan. HPOP Indicator 2018 value (%) Projected 2023 value (%) Projected change (%) Access to safely managed drinking water sources 91.1 96.7 +5.6 Access to safely managed sanitation services 90.4 89.5 -0.9 Adults not obese 78.3 76.0 -2.3 Ambient air quality 82.3 82.1 -0.2 Best practice policy implemented for healthy fats production 85.7 85.7 0.0 Children under 5 developmentally on track N/A N/A N/A Children (aged 5–19) not obese 93.4 92.3 -1.1 Children under 5 not overweight 90.8 92.0 +1.2 Children under 5 not stunted 92.4 94.4 +2.0 Children under 5 not wasted 97.4 98.0 +0.6 Primary reliance on clean household fuels 97.4 98.6 +1.2 Reduced alcohol use 80.0 80.0 0.0 Reduced child (aged 1–17) violence N/A N/A N/A Reduced partner violence N/A N/A N/A Reduced road traffic mortality 95.6 97.1 +1.5 Reduced suicide attempts 98.1 98.7 +0.6 Tobacco non-use 76.2 78.2 +2.0 Notes. HPOP: healthier populations. a Some indicators in this chart have been transformed to have values between 0 and 100 (0 worst–100 best). b N/A indicates the data is not available Further information regarding the indicators can be found at (14). Source: Adapted from (14). To address the social determinants of health across the life course, Kazakhstan is committed to coordinating with UN agencies to propose and implement interventions for social protection and health improvement for people, especially women and children, who face health inequities (2). Promoting health and well-being will require Kazakhstan to address the consequences of its persistently high burden of NCDs, with an intensive focus on the prevention of common risk factors, especially in relation to Kazakhstan’s high smoking prevalence of 24.4% in adults aged 15 years or older (14). While Kazakhstan has made progress in this regard, significant work remains to fully implement the WHO Framework Convention of Tobacco Control. Furthermore, reducing the high burden of NCDs will require a sustained increase in investment to strengthen the monitoring, treatment, evaluation, and prevention at the PHC level. It will also require additional supporting efforts, such as initiatives for nutrition and physical activity, alcohol and tobacco use, obesity and overweight prevention. Kazakhstan would benefit from subregional cooperation intended to promote an intersectoral approach to halt and reverse childhood obesity and diminish salt consumption through policy advocacy, developing and enforcing laws (such as taxation), front-end packaging labelling and health promotion in schools (2). Environmental health challenges and extreme weather events are also significant concerns in Kazakhstan. For example, the mortality rate attributed to household and ambient air pollution was high in 2016 at 62.68 per 100 000 population (18). In Kazakhstan, the economic, social, and environmental challenges are intrinsically interlinked. Kazakhstan is prone to various natural hazards, in particular floods, earthquakes, extreme temperature and glacier melting, which all lead Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Kazakhstan Country Brief 23 to disasters resulting in human and economic losses. Extreme temperatures and droughts have already caused significant economic losses, and their impact is likely to increase with the effects of climate change. Current national disaster risk reduction management plans remain mostly reactive and usually do not sufficiently consider risk reduction, prevention, and risk transfer measures. Environmental and climate change issues may result in decreasing water availability and quality, as well as the need to adapt agricultural practices. Given that 42.1% of Kazakhstan’s population resides in rural areas, the impact of climate change on health and well-being might acquire a  social dimension. For example, the rural population significantly relies on using solid biomass and coal for cooking and heating homes, which are major sources of household air pollution. Women and children face significant health and safety risks from household air pollution, including from carrying heavy fuel loads and from the lack of lighting. While women’s health is disproportionately harmed by the effects of non-renewable energy, women are largely absent as workers and engineers in the industries that produce modern sources of renewable energy. This observation demonstrates the importance of improving the representation of women in renewable energy development, which could help tackle the disproportionate harm of unclean fuel sources on their health and well-being (7). Flagship Initiative 3: The European Immunization Agenda 2030 Coverage for immunizations has increased since 2000 and the national immunization schedule ensures full immunization coverage of the population. In 2018, vaccine coverage of at-risk groups for epidemic or pandemic prone diseases was 98.5% in Kazakhstan (14). Similarly, the proportion of the target population with access to three doses of diphtheria tetanus toxoid and pertussis vaccine immunization was 97.0% in 2019 (14). A review of WHO and the United Nations Children’s Emergency Fund estimates of immunization coverage from the 2019 revision for Kazakhstan reveals worsening rates compared to the past five-year trend in Bacillus Calmette–Guérin vaccination and in 1-year-olds having received three doses of pneumococcal conjugate vaccine. Similarly, further decreases are expected moving forward across the board on many vaccine preventable diseases as immunization rates have decreased around the world due to shelter-in-place measures and other public health and social measures that have been instituted in the interests of controlling the spread of COVID-19 (14). Therefore, Kazakhstan is committed to implementing the European Immunization Agenda 2030, as well as facilitating an equitable COVID-19 vaccination campaign. The WHO Regional Office for Europe is well-suited to support these efforts, especially by convening subregional cooperation across Central Asia through Roadmap development and implementation (2). Through these initiatives, it will also be important to develop strategies that address vaccine acceptance and scepticism. Flagship Initiative 4: Healthier Behaviours: incorporating behavioural and cultural insights Safeguarding and, where possible, increasing social spending in areas such as health, social and child protection and education is a priority to protect Kazakhstan’s most vulnerable groups from poverty and social exclusion. This requires improved planning, budgeting, allocation and monitoring of public finances and increasing the effectiveness and efficiency of social spending, including better targeting of and outreach to the most vulnerable groups. There is also a need to explore alternative, innovative funding sources and to prioritize spending on areas that maximize return on investments (for example, early childhood development). This aligns with the EPW’s intent to develop an investment case for developing a knowledge and evidence base in this area of work. As an example, gender inequality, sexual and gender-based violence, lack of access to services and commodities due to cultural norms and homophobia in Kazakhstan represent serious obstacles to achieving the targets set out in the SDGs and the 2016–2021 Strategy of the Joint United Nations Programme on HIV/AIDS. The human rights of the Lesbian, gay, bisexual, transgender, queer, intersex, asexual and more (LGBTQIA+) community in Kazakhstan are limited. The Kazakh LGBTQIA+ community faces social and legal challenges, violence, and discrimination (19). Limited coverage of key structural interventions, including high quality, comprehensive sexuality education, age of consent for medical services, gender-based violence prevention and responses are part of the bigger picture (7). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)24 References2 2 All online references were accessed on 05 April 2022. 1. World Bank Open Data [online database]. Washington, D.C.: The World Bank; 2022 (https://data.worldbank.org/). 2. Biennial Collaborative Agreement between the Ministry of Healthcare of the Republic of Kazakhstan and the Regional Office for Europe of the World Health Organization 2022/2023 [DRAFT]. Copenhagen: WHO Regional Office for Europe; 2022. 3. Human Development Reports: Latest Human Development Index Rankings [website]. New York: United Nations Development Program; 2022 (http://hdr.undp.org/en/content/ latest-human-development-index-ranking). 4. European Health Information Gateway [online database]. Copenhagen: WHO Regional Office for Europe; 2022 (https:// gateway.euro.who.int/en/). 5. WHO Country Office, Kazakhstan: mid-year activity report. Copenhagen: WHO Regional Office for Europe; 2021 (https:// apps.who.int/iris/handle/10665/349205). 6. Biennial Collaborative Agreement between the Ministry of Health of the Republic of Kazakhstan and the Regional Office for Europe of the World Health Organization 2020/2021 [signed 2019]. Copenhagen: WHO Regional Office for Europe; 2019. 7. UN Sustainable Development Cooperation Framework 2021- 2025. Nur-Sultan: United Nations Kazakhstan; 2020 (https:// kazakhstan.un.org/en/89567-un-sustainable-development- cooperation-framework-2021-2025). 8. Decree of the Government of the Republic of Kazakhstan “On approval of the National Project ‘High-quality and affordable healthcare for every citizen  – Healthy Nation’”. Nur-Sultan: Government of the Republic of Kazakhstan; 2021 (https:// adilet.zan.kz/rus/docs/P2100000725#z10). 9. Sustainable Development Report 2021: The Decade of Action for the Sustainable Development Goals. Country Profiles. New York: Sustainable Development Solutions Network; 2021 (https://dashboards.sdgindex.org/). 10. SDG Indicators Database [online database]. New York: United Nations Department of Economic and Social Affairs; 2022 (https://unstats.un.org/sdgs/UNSDG/IndDatabasePage). 11. COVID-19 and Central Asia: Socio-economic impats and key policy considerations for recovery. New York: United Nations Development Programme; 2020 (https://www. eurasia.undp.org/content/rbec/en/home/library/sustainable- development/covid19-and-central-asia.html). 12. COVID-19 Health System Response Monitor (HSRM) [website]. Brussels: European Observatory on Health Systems and Policies; 2022 (https://eurohealthobservatory.who.int/ monitors/hsrm/overview). 13. COVID-19 Projections [website]. Seattle: Institute for Health Metrics and Evaluation, University of Washington; 2022 (https:// covid19.healthdata.org/european-region?view=social - distancing&tab=trend). 14. Triple Billion Targets Dashboard [website]. Geneva: World Health Organization; 2022 (https://portal.who.int/ triplebillions/PowerBIDashboards/Countries). 15. Global Burden of Disease Compare Data Visualization [online database]. Seattle: Institute for Health Metrics and Evaluation, University of Washington; 2022 (https://vizhub.healthdata. org/gbd-compare/). 16. Global Health Expenditure Database [online database]. Geneva: World Health Organization; 2022 (https://apps.who. int/nha/database/Select/Indicators/en). 17. Towards a  Healthier Kazakhstan: Progress on Sustainable Development Goal 3 and Digital Health in Kazakhstan. Copenhagen: WHO Regional Office for Europe; 2021. 18. World Health Data Platform: The Global Health Observatory [online database]. Geneva: World Health Organization; 2022 (https://www.who.int/data/gho/data/indicators). 19. UN Common Country Analysis Kazakhstan. Nur-Sultan: United Nations Population Fund Kazakhstan; 2019 (https:// www.unfpa.org/sites/default/files/board-documents/cpe_0. pdf). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Kyrgyz Republic Country Brief 25 2.3. Kyrgyz Republic This country brief outlines the Kyrgyz Republic’s priorities for improving their population’s health and well-being from 2022–2025. These priorities have informed the development of the Roadmap and its action areas and reform initiatives. This brief is not intended to be exhaustive or prescriptive. Rather, it intends to highlight key issues and areas where Kyrgyzstan may benefit from and contribute to united action for better health and well-being in Central Asia. The brief identifies a compiled list of Kyrgyzstan’s national health and well-being priorities (Table 2) that will inform the development and implementation of the Roadmap for Health and Well-being in Central Asia. 2.3.1. Health, well-being and sustainable development progress in Kyrgyzstan Kyrgyzstan is a  lower middle-income country whose gross domestic product (GDP) has multiplied five and a half times since 2000, growing from approximately 1.4 to 7.7 billion United State dollars (US$) between 2000–2020 (1). Between 2017–2019, Kyrgyzstan’s annual GDP growth rate averaged 4.4% per year. However, this rate fell to -8.6% in 2020 and GDP significantly dropped from 8.9 to 7.7 billion US$ between 2019–2020 due to the coronavirus disease 2019 (COVID-19) pandemic. Correspondingly, Kyrgyzstan’s unemployment rate was, on average, 6.9% of the total labour force between 2017–2019, but this figure increased to 8.7% in 2020 due to the pandemic (1). The percentage of people in poverty at national poverty lines was 20.1% in 2019 (1), which is a figure that also likely worsened in 2020 (2). Kyrgyzstan has a population of approximately 6.6 million people (1). Between 2017–2020, Kyrgyzstan’s population grew, on average, by 2.0% each year (1). The population is young: the percentage of Kyrgyzstan’s population aged less than 15 years was 32.6% in 2020, which is more than twice the European Union (EU)’s average of 14.1% (1). In contrast, the percentage of Kyrgyzstan’s population aged 65 years or older was 4.7% in 2020, which is more than four times smaller than the EU’s percentage of 20.8% for the same metric (1). Despite this, Kyrgyzstan’s population is slightly ageing. Between 2015–2020, the percentage of the population aged 65 years or older grew from 4.3% to the 4.7% it is now (1). According to the 2020 Human Development Index (HDI), Kyrgyzstan ranks 120th out of 189 countries and territories and it is categorized as a country with medium human development (3). Kyrgyzstan’s HDI increased from 0.662 to 0.697 between 2010–2019. This represents an average HDI growth of 0.35% per year, which is approximately half of Europe and Central Asia’s average growth of 0.76% per year during the same period. For reference, Europe and Central Asia’s average HDI increased from 0.735 to 0.791 between 2010–2019 (3). Embedded in Kyrgyzstan’s improved HDI is their increase in life expectancy over the past decade. Between 2010–2019, life expectancy increased from 73.29 to 77.31 years (+4.02 years) for females and from 65.20 to 70.75 years (+5.55 years) for males (4). However, these figures are still significantly below the WHO European Region’s average of 81.29 years for females and 75.09 years for males (4). Kyrgyzstan’s current State health programme, the Program of the Kyrgyz Republic Government on Public Health Protection and Health Care System Development for 2019–2030 “Healthy Person – Prosperous Country” (hereinafter, Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)26 Health 2030), was approved in 2018, and it is a continuation and acceleration of Kyrgyzstan’s ambitious health reform agenda from 1996 (5). The country has been recognized for its efforts to undertake sweeping reforms of its public health system. One of the most important early reforms was the introduction of a purchaser–provider split and the establishment of a single payer system for health services alongside a State-guaranteed benefit package (SGBP) (6). The SGBP sought to provide essential PHC services for all and free or reduced cost hospital services for certain groups of people while defining citizens’ rights to free care. The responsibility for purchasing health services was consolidated under the Mandatory Health Insurance Fund (MHIF), while the authority for health policy development and oversight was granted to Kyrgyzstan’s Ministry of Health (MoH) (6). Since 2006, the pooling of funds has been carried out at the national level (instead of the oblast level), which has allowed a more equitable distribution of the SGBP and the accompanying Additional Drug Package (ADP) (6). These early efforts also aimed to reorient the health-care system from providing costly, disease-oriented health care to providing less-expensive, prevention-oriented care within PHC. The family medicine model was introduced through the creation of the Family Medicine Institute and the establishment of a nationwide network of family doctors and group practices. Today, these service points and structures serve as the backbone of the PHC system (6). Development assistance for health has consistently supported reform and strengthening of Kyrgyzstan’s PHC system (6). However, despite progress in the early 2000s, Kyrgyzstan now faces a loss of trust in PHC driven by low levels of political and financial investment. This was exacerbated during the COVID-19 pandemic, when people bypassed the PHC system in favour of seeking direct hospital care because the PHC system was unprepared to address their needs. Progressively lower levels of funding for the health sector contribute to weakened PHC services and, subsequently, people’s disdain with them (6). Building back better from the COVID-19 pandemic will require a sustained investment in PHC to accelerate progress on health, well-being and sustainable development in Kyrgyzstan. Additionally, ensuring that no one is left behind will be critical for Kyrgyzstan to overcome the crisis and move forward with its development priorities and the Sustainable Development Goals (SDGs). Kyrgyzstan has a wealth of health, well-being and sustainable development progress related policies, programmes and reports to enable this progression, which are introduced in this brief and summarized in Table 7 for orientation. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Kyrgyz Republic Country Brief 27 Table 7. Overview of current policies, programmes and reports relevant to the context of health, well-being and sustainable development progress in Kyrgyzstan. Title Description Timeframe Keywords National Development Strategy for the Kyrgyz Republic 2018–2040 (7) National development strategy 2018–2040 Sustainable development, SDGs, national development, multi-sector strategy (education, finance, health, etc.) United Nations Development Assistance Framework for the Kyrgyz Republic (2018–2022) (8) UN framework 2018–2022 Development assistance, sustainable development, SDGs, multi-sector strategy (education, finance, health, etc.) Primary Health Care Quality Improvement Program for the Kyrgyz Republic (9) National programme 2019–2024 PHC, quality improvement, service delivery Program of the Kyrgyz Republic Government on Public Health Protection and Health Care System Development for 2019–2030 “Healthy Person – Prosperous Country” (5) National programme 2019–2030 PHC, public health reform, health system development Towards a healthier Kyrgyz Republic (10) WHO report 2020 GAP, SDG 3, national strategic policy review, intersectoral collaboration, public health reform Health financing in Kyrgyzstan: obstacles and opportunities in the response to COVID-19 (11) WHO report 2021–onward COVID-19, response and recovery, health financing Report on recommendations for the reform of public health services in Kyrgyzstan (12) WHO report 2021–2030 PHC, public health reform United Nations COVID-19 Socioeconomic Response Framework for the Kyrgyz Republic (13) UN framework 2021–onward COVID-19, response and recovery, socioeconomic, economy Biennial Collaborative Agreement between the Ministry of Health of the Kyrgyz Republic and the Regional Office for Europe of the World Health Organization 2022/2023 (6) BCA between WHO and Ministry of Health of the Kyrgyz Republic 2022–2023 EPW, UHC, health emergencies, health and well-being, PHC, public health reform Executive summary: Final evaluation of the United Nations Development Assistance Framework for the Kyrgyz Republic (2018–-2022) (14) UN Resident Coordinator report 2022 Development assistance, sustainable development, SDGs, multi-sector strategy (education, finance, health, etc.) Notes. BCA: Biennial collaborative agreement; EPW: European Programme of Work (2020–2025) – “United Action for Better Health in Europe”; GAP: Stronger Collaboration, Better Health: The Global Action Plan for Healthy Lives and Well-being for All; PHC: Primary health care; SDG: Sustainable Development Goal; UHC: Universal health coverage. 2.3.1.1. Looking forward: the health, well-being and sustainable development trajectory of Kyrgyzstan In Kyrgyzstan, the health sector is widely recognized as a leader in terms of aligning national priorities with SDG goals and adapting SDG indicators to the national context. Kyrgyzstan’s health sector achieves this by integrating SDG goals and indicators into Health 2030 and following an intersectoral, whole-of-government approach to policy development and implementation. In 2018, Kyrgyzstan launched several important strategies, including the new National Development Strategy for the Kyrgyz Republic 2018–2040 (7) and the abovementioned Health 2030. The SDG 3 targets and the nutrition-related components of SDG 2, in particular, are well integrated within Health 2030, which details Kyrgyzstan’s health priorities and provides strategic directions for implementing health initiatives. Health 2030 also articulates the policy framework and operational plan for advancing health and well-being within the context of the national framework for sustainable development. It also serves as the basis for subsequent development and revisions of programmes in other health priority areas, such as tuberculosis (TB), HIV, sexual and reproductive health, mental health and perinatal care (5). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)28 Health 2030 has identified eight main principles for its development and implementation (5): 1. health is the human right and the fundamental value for well-being of individuals, families, society, and the state; 2. ensured access to services and universal health coverage (UHC) for all, irrespective of age, gender, and place of residence; 3. ensured state responsibility and guarantees of obtaining good-quality and safe medical care and public health services; 4. more responsibility of citizens for their health (including health promotion, preserving health and not causing harm to others); 5. protection of patients’ rights; 6. reduced inequalities in health and access to health services; 7. accountability of the health system to people and society; 8. improved responsibility of the government for the creation of a health favourable environment. In line with its main principles, Health 2030 has identified ten priority areas for health and well-being progress (Table 8). Table 8. Priority areas of Health 2030 in Kyrgyzstan. Category of reform Priority area Care-specific reforms 1 Public health 2 Development of the PHC system 3 Improvement and rationalization of the hospital system 4 Development of the ambulance service Cross-cutting reforms 5 Laboratory services 6 Drugs and medical devices 7 Health-care governance 8 HRH 9 Development of Electronic Health 10 Development of the Financing System Notes. HRH: Human resources for health; PHC: Primary health care. Adapted from (5). Relevantly, Kyrgyzstan recently reached the final year of its implementation period for the United Nations Development Assistance Framework (UNDAF) for the Kyrgyz Republic (2018–2022) (8). Outcome 4 of the UNDAF was directly related to health: “By 2022, social protection, health and education systems are more effective and inclusive, and provide quality services.” The outcome sought to support the Government to achieve Health 2030 and improve the quality and availability of social protection, health and education services, as well as cash transfer programmes. More specifically, efforts to achieve this outcome included to (8): • strengthen access to and quality of health-care systems, promote healthy lifestyles, health education, and protect mothers and children and victims of human trafficking; • increase preschool education coverage, strengthen the education financing system, school meal provision, and include children and young people with disabilities in high-quality education services; and • protect the social rights of children, especially during their early years, prevent family separation and reduce the child poverty rate, gap and severity. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Kyrgyz Republic Country Brief 29 To monitor progress on achieving this Outcome, the UNDAF identified 11 targets for 2022, including three targets explicitly related to health: the percentage of households with catastrophic health expenditure; the percentage of women of reproductive age (15–49) who have their need for family planning satisfied with modern methods; and the proportion of new-borns who have a postnatal care visit within two days of discharge from health facilities (8). Many of the UNDAF’s targets were not achieved. Therefore, the United Nations Resident Coordinator Office in the Kyrgyz Republic recently issued a final UNDAF evaluation that included recommendations for how these targets can be achieved moving forward (14). Relevant recommendations include to (14): • strengthen inter-agency coordination and cooperation infrastructure; • strengthen joint planning and implementation; • step up resource mobilization; and • step up engagement with the Government, civil society and the private sector; Ultimately, Kyrgyzstan participating in the development and implementation of the Roadmap for Health and Well- being in Central Asia will directly heed the advice of the UNDAF evaluation’s recommendations, as well as help the country progress towards achieving the goals of Health 2030. Finally, Kyrgyzstan’s draft 2022–2023 biennial collaborative agreement (BCA) is still being negotiated (6). However, it will honour all pre-existing international and national strategic frameworks for health and well-being that Kyrgyzstan has committed to between 2022–2023, including those referenced in this brief. Notably, these include the Thirteenth General Programme of Work 2019–2023 (GPW), EPW, SDGs and Health 2030. 2.3.1.2. SDG 3 progress: Ensure healthy lives and promote well-being for all at all ages SDG 3 aims to ensure healthy lives and promote well-being for all at all ages. In 2020, a progress report that provided an overview of the status of health and well-being in Kyrgyzstan related to realization of the health-related SDG targets was published by the WHO Regional Office for Europe. The report was based on a review of national strategic policy and programme documents; a trend and status analysis of more than 60 indicators related to SDG 3; and interviews with national health experts (10). To view its results, please visit the 2020 report. In 2021, a  thorough analysis of Kyrgyzstan’s progress achieving SDG 3 revealed areas where health and well-being have been advanced and where challenges remain (15). These trends are summarized in Table 9. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)30 Table 9. Selected targets and indicators to track Kyrgyzstan’s progress on SDG 3. SDG 3 Targeta Statusb Description Indicator(s) 3.1 Target achieved By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births. • 3.1.1: Maternal mortality ratio: Decreased from 79.0 to 60.0 per 100 000 live births from 2000–2017. 3.2 Challenges remain By 2030, end preventable deaths of new- borns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-five mortality to at least as low as 25 per 1000 live births. • 3.2.1: Children under-five mortality rate: Decreased from 49.7 to 18.3 deaths per 1000 live births from 2000–2019. • 3.2.2: Neonatal mortality rate: Decreased from 20.5 to 12.3 deaths per 1000 live births from 2000–2019. 3.3 Major challenges remain By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases. • 3.3.1: New HIV infections: Increased from 0.03 to 0.14 new infections per 1000 uninfected population 2000–2019. • 3.3.2: Tuberculosis incidence: Decreased from 145 to 110 incidence per 100 000 population from 2000–2019. 3.4 Significant challenges remain By 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being. • 3.4.1: Risk of dying between the ages of 30 and 70 from one of four main NCDs (cardiovascular disease, cancer, diabetes, or chronic respiratory disease): Decreased from 33.5% to 20.3% from 2000–2019. • 3.4.2: Suicide mortality rate: Decreased from 14.8 to 7.4 deaths per 1000 population from 2000–2019. 3.5 Challenges remain Strengthen the prevention and treatment of substance abuse. • 3.5.2: Alcohol consumption per capita among population aged 15 years and older: Decreased from 5.5 to 4.9 litres of pure alcohol from 2000–2019. 3.6 Significant challenges remain By 2020, halve the number of global deaths and injuries from road traffic accidents. • 3.6.1: Death rate due to road traffic injuries: Increased from 12.4 to 12.7 deaths per 100 000 population from 2000–2019. 3.7 Challenges remain By 2030, ensure universal access to sexual and reproductive health-care services. • 3.7.1: Proportion of women of reproductive age with their needs met for family planning with modern methods: N/A. • 3.7.2: Adolescent birth rate: Increased from 34.7 to 37.7 per 1000 women aged 15–19 years from 2000–2019. 3.8 Challenges remain Achieve UHC, including financial risk protection, access to quality essential health- care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. • 3.8.1: Service coverage indexc: Increased from 52.0 to 70.0 from 2000–2019. 3.9 Significant challenges remain By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination. • 3.9.1: Age-standardized mortality rate attributed to household air pollution: 43.0 deaths per 100 000 population in 2016. • 3.9.1: Age-standardized mortality rate attributed to ambient air pollution: 74.0 deaths per 1000 population in 2016. • 3.9.2: Mortality rate attributed to unsafe water, unsafe sanitation and lack of hygiene: 0.8 deaths per 1000 population in 2016. • 3.9.3: Mortality rate attributed to unintentional poisonings: Decreased from 2.8 to 0.9 deaths per 1000 population from 2000–2019. 3.a Challenges remain Strengthen the implementation of the WHO Framework Convention on Tobacco Control. • 3.a.1: Age-standardized prevalence of current tobacco use among persons aged 15 years and older: Decreased from 31.7% to 27.9% from 2000–2018. Notes. N/A indicates the data is not available. NCDs: noncommunicable diseases; SDGs: Sustainable Development Goals; UHC: Universal health coverage. a For brevity, some SDG 3 targets and indicators were excluded when the health issues they addressed were not relatively high priorities or needs in Kyrgyzstan’s context (for example, tropical diseases) or if there was no data available for their indicators. b The status assigned to each target was determined by an analysis in the Sustainable Development Report (15), which was authored by the Sustainable Development Solutions Network. All data used to create the Sustainable Development Report are based on Sachs et al. (2022)’s publication. The indicators selected for this table represent some of the many indicators that were considered when these statuses were assigned. c There are significant limitations associated with this measure of service coverage. Source: Adapted from (15, 16). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Kyrgyz Republic Country Brief 31 2.3.2. Lessons learned from the COVID-19 pandemic The COVID-19 crisis has re-emphasized the absolute necessity for strong, adequately funded health systems at primary, secondary and tertiary levels in Kyrgyzstan that can respond quickly and equitably to emergencies while ensuring financial protection for all (11). Kyrgyzstan has taken important decisions to increase public funding for the health system response to the COVID-19 pandemic, including increased donor support for the scaling-up and delivery of population-based and individual services (11). Sustained investment in PHC is key to improving people’s attitudes towards the PHC system and delivering pandemic preparedness and response while ensuring continuity of essential services (11). In 2021, the WHO Regional Office for Europe collaborated with the WHO Country Office in Kyrgyzstan to produce a report on the obstacles and opportunities of health financing in Kyrgyzstan during the COVID-19 pandemic (11). The report provided a summary of lessons learned and recommendations for future action. The recommendations include to (11): • increase funding to secure an adequate overall level of public funding for population based and individual health services; • improve alignment of financing streams to address current challenges posed by the channelling of donor funding in parallel to MHIF contracts; • implement more efficient rules in public financial management to ensure health funding allocations are reliable, timely, flexible and strategic; • improve the MHIF coverage policy to ensure all people have access to essential care without experiencing financial hardship; • increase funding for PHC services to reflect the increased functions of PHC in tackling pandemics while securing continuity of other essential services; • mobilize resources to PHC settings to enable them to attract services from secondary and tertiary levels and meet the need for screening, testing and treating mild and moderate cases at the PHC level, allowing other essential services to be maintained; • complement increased funding with increased capacity-building for PHC health workers and safe working conditions for front-line workers, including the provision of personal protective equipment; • adequately fund the gatekeeping function of PHC for COVID-19 and essential services; • focus the design of the expansion of the SGBP on priority services and ensure that it reflects the burden of disease, including equity-related indicators, and incorporates the following criteria: 1) cost-effectiveness; 2) priority being given to people who experience greater hardship (for example, migrant workers and rural populations); and 3) financial risk protection; • expand the basis of registration in the informal sectors of the economy to allow undocumented people to benefit from the SBGP; • strengthen the capacity of the MHIF to improve its efficiency as a strategic purchaser; and • simplify public procurement systems and custom clearance procedures for medicines and health technologies. Additionally, in 2021, the United Nations COVID-19 Socioeconomic Response Framework for the Kyrgyz Republic was published with five pillars of response (13): 1. Health First: Protecting health services and systems during the crisis a. Including to expand surge capacity; support public information campaigns; assist infection prevention and control (IPC); restore essential health services; ensure equitable outcomes 2. Protecting People: Social protection and basic services 3. Economic Recovery: Protecting jobs, enterprises and informal sector workers 4. Macroeconomic response and multilateral collaboration 5. Social cohesion and community resilience. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)32 Finally, the framework explicitly recognises vulnerable groups that must be reached to ensure no one is left behind in COVID-19 response and recovery. Please consult the Response Framework for more information regarding the other areas of support it outlines (13). 2.3.3. Closing the Health Gap: aligning Kyrgyzstan’s priorities with the EPW Kyrgyzstan’s current national health priorities and gaps are discussed below in context of the EPW’s framework. 2.3.3.1. Core Priority 1: Moving towards UHC Moving towards UHC is a high priority for Kyrgyzstan. A primary focus in Kyrgyzstan for achieving UHC is improving the PHC system. Health 2030 outlines four key objectives related to this (5): 1. create an efficient model of PHC that includes prevention, early detection of diseases and case management (e.g. the home visiting programme for young children); 2. improve coordination of referrals between PHC and secondary and tertiary health-care institutions; 3. improve the quality and coverage of PHC services that result in improved health outcomes and equitable access to care for the entire population; and 4. strengthen staff capacity to deliver PHC services. To support the PHC strengthening outlined by Health 2030, the Primary Health Care Quality Improvement Program for the Kyrgyz Republic (2019–2024) has been launched to build and strengthen foundations for sustainable systemwide quality improvement and improve health outcomes, service quality, reduce inequities in health outcomes and improve financial protection. The Program aims to (9): • integrate sustainable quality improvement mechanisms into service delivery to establish and strengthen systems for quality care reporting and monitoring; • strengthen strategic purchasing for quality services and improve coverage for select priority conditions; • establish a national-level structure and mechanism for coordinated efforts to improve quality of care in the country through strengthened health sector stewardship and governance for quality improvement. Additionally, in 2021, the WHO Regional Office for Europe published the Report on recommendations for the reform of public health services in Kyrgyzstan (12). Currently, this reform focuses on the following six functions and related priority services until 2030: 1. surveillance and assessment of the health and well-being of the population, public health protection and the provision of a safe environment; 2. monitoring of and response to health hazards and emergency situations; 3. health protection, including environmental, occupational and food safety; 4. health promotion, including actions to address social determinants and reduce health inequalities; 5. disease prevention, including early detection of illnesses; and 6. assurance of strategic leadership for health and well-being. The specific reform initiatives to enhance these six functions, along with their justification, can be found in the Report (12). Progress towards UHC is monitored in two dimensions: the coverage of essential health services and financial hardship. Each is covered further in the context of Kyrgyzstan below. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Kyrgyz Republic Country Brief 33 Coverage of essential health services In 2019, 37 200 fewer people in Kyrgyzstan (0.5% of the population) were covered by essential health services than in 2018. In contrast, 77 200 more people (1.1% of the population) are projected to be covered by 2023 (17). Coverage of essential health services is defined as the average coverage of the 14 SDG 3.8.1 tracer interventions. Of these 14 indicators, positive progress is projected for eight of them in Kyrgyzstan by 2023 (Table 10). Table 10. Projected percentage point changes in normalized valuesa across the 14 SDG 3.8.1 tracer interventions for service coverageb from 2018–2023 in Kyrgyzstan. Service Coverage Indicator 2018 value (%) Projected 2023 value (%) Projected change (%) Basic sanitation 96.7 97.5 +0.8 Care seeking for pneumonia for children under 5 58.5 59.0 +1.1 DTP3 immunization 94.0 94.4 +0.4 Health worker density 52.7 61.8 +9.1 Hospital bed density 100.0 100.0 0.0 IHR core capacity index 57.0 42.4 -14.6 ITN use N/A N/A N/A Mean fasting blood glucose 80.7 76.4 -4.3 Need met for family planning 64.7 66.9 +2.2 Non-elevated blood pressure 46.7 46.4 -0.3 People living with HIV receiving ART 39.0 49.8 +10.8 TB cases treated 87.0 87.0 0.0 Tobacco non-use 72.1 72.9 +0.8 Women who received antenatal care visits 4+ times 93.1 94.1 +1.0 Notes. ART: Antiretroviral therapy; DTP3: Three doses of diphtheria tetanus toxoid and pertussis vaccine; IHR: International Health Regulations (2005); ITN use: Insecticide-treated bed net use among people at-risk of malaria; TB: Tuberculosis. a Some indicators in this chart have been transformed to have values between 0 and 100 (0 worst–100 best). Further information regarding the indicators can be found at (17). b There are significant limitations associated with this method of measuring service coverage. c N/A indicates the data is not available. Source: Adapted from (17). The population of Kyrgyzstan is entitled to basic essential health services, including emergency, primary and inpatient care. However, the package of services covered is very limited: inpatient care requires co-payments, and the Additional Drug Package covers just 50% of the so-called basic price of a specified list of medicines in PHC (18). The difference between 50% of the basic price and the retail price has to be paid out-of-pocket by patients. Furthermore, there are major gaps in population coverage, with 34.5% of the population enrolled with family doctors in 2018 not covered by the mandatory health insurance scheme (18). Additionally, despite the number of PHC facilities, some geographical barriers persist, exacerbated by physician shortages in rural areas. Even urban areas have gaps in coverage, with internal migrants facing particular challenges. Therefore, integrating and improving services for particularly vulnerable populations and conditions has been a priority (18). Despite the developments outlined in Table 10, there are many health areas in Kyrgyzstan that continue to warrant concern. Maternal mortality, neonatal mortality and family planning remain pressing challenges, and the reproductive rights of women appear to be under threat, especially among the rural population and younger women. Children in life-threatening situations lack access to quality integrated services at the primary and secondary levels of the health system. HIV infection is still growing in the country, affecting more women and young people. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)34 Communicable diseases and noncommunicable diseases (NCDs) are both significant public health burdens in Kyrgyzstan. In 2019, 10.44% of deaths in Kyrgyzstan were caused by communicable diseases and maternal, prenatal and nutrition conditions (1), and 17.23% of disability-adjusted life years (DALYs) were attributable to communicable diseases (19). In comparison, the EU’s averages for these two metrics in 2019 were 5.55% and 4.04%, respectively. Meanwhile, the percentages of deaths and DALYs attributable to NCDs in Kyrgyzstan in 2019 were 81.59% (1) and 70.98% (19), respectively. In comparison, the EU’s averages for these two metrics in 2019 were 89.82% and 87.55%, respectively. The main risk factors of disability include mental health disorders, accidents, reduced incomes, high household expenditures and NCDs, especially NCD risk factors such as tobacco use, poor nutrition and limited physical activity. Altogether, these risk factors have contributed to surging health-care costs and increased demands for social care and welfare support. Unfortunately, interventions on NCD risk factors are not achieving their expected results. Effective NCD risk reduction interventions require whole-of-government and whole-of-society approaches. Therefore, to improve the success of interventions in Kyrgyzstan, there is a  need to strengthen coordination and accountability for inter- and intra-sectoral responses, including for action at the local level (8). Kyrgyzstan faces significant obstacles in adequately sustaining the numbers, equitable distribution and training of its health workforce. These include shortages in more remote and rural areas; deficits in continuous education and the accreditation of skills of health-care workers; and low salaries that often lead to international migration of young doctors. Between 2020–2021, WHO and the Working for Health programme (20) provided technical support to implement national health workforce strategies, accelerate progress towards averting the global health workforce shortfall and achieve a sustainable global health workforce. The programme focused on three priority directions: 1) enhanced intersectoral commitment, social dialogue and policy dialogue for health and social workforce investments and action; 2) strengthened health and social workforce data and evidence to inform national strategies; and 3) strengthened capacity to develop and implement national health workforce strategies (20). Continuing the efforts of the Working for Health programme to improve human resources for health (HRH) remains a high priority for Kyrgyzstan and in this regard Health 2030 outlines initiatives to (5): • improve the HRH management system in health care on the basis of interdepartmental and intersectoral interaction; • increase the availability of medical personnel in remote regions, with focus on providing family doctors, public health and emergency medical aid staff; • complete the process of reforming the system of higher medical education; • promote the development of scientific research in the field of health for the scientific substantiation of policies and practices; • reform nursing education in accordance with new requirements and needs of health care; • improve the mechanisms for regulating the professional activity of health workers through the involvement of professional medical associations and continuous professional development. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Kyrgyz Republic Country Brief 35 Relatedly, to improve health-care governance, Health 2030 calls to strengthen the mechanisms for intersectoral cooperation and integration of public health issues into activity of the State, local authorities and development programmes; improve the accountable governance system over health care to improve access to high-quality, effective health services; and modernize the planning mechanisms and organization of health service provision based on the population’s needs (5). Financial hardship There are significant, oftentimes insurmountable, barriers to access health services for vulnerable groups in Kyrgyzstan. Health services continue to be costly for communities and patients: for example, out-of-pocket payments include official and informal co-payments for services and medicines. The current service delivery network is fragmented and inefficient, and it does not respond to the population’s needs. It also requires significant investment, modernization and innovation, starting with the PHC system. In addition, as stated above, the availability of nurses and doctors has become limited over recent years, especially in remote areas. Considering these factors, taking action to improve UHC and reduce financial hardship in Kyrgyzstan will help the country achieve many of the health-related SDGs (8). Ensuring everyone can access high-quality health services without facing financial hardship is a key target of the EPW, SDGs and Health 2030. At the governmental level, the percentage of gross domestic product (GDP) spent on health in Kyrgyzstan in 2018 was only 2.80%, which is significantly lower than the WHO European Region’s average of 4.87% (21). At the patient level, the percentage of health expenditure covered by out-of-pocket payments in 2018 in Kyrgyzstan was 52.44%, which is almost twice the WHO European Region’s average of 29.82% for the same metric (21). To combat financial hardship associated with health-care spending in Kyrgyzstan, Health 2030 identifies three key objectives to develop the health financing system, including to (5): 1. improve the efficiency of public financial management in the health sector 2. develop the strategic purchasing of health services and 3. increase the coverage of mandatory health insurance and provide financial protection to the population. Health 2030 also identifies five priorities related to the procurement of medicines and medical supplies. These include to (5): 1. improve the regulation and management of drug circulation and medical products; 2. establish the regulation for pricing of essential drugs and medical devices, in order to reduce the out-of-pocket expenditures for drugs; 3. improve the efficiency of public selection, procurement and use of drugs and medical devices, and improve drug management in health-care organizations; 4. improve the practices of prescribing of drugs by health workers and reduce the irrational use of drugs by the population, as well as the use of medical devices; 5. improve the mechanisms of drug benefit programmes regarding the population needs-driven selection of drugs. While public spending on health and State funding for health have increased, the funds currently available are insufficient to cover the cost of delivering the SGBP (6). The persistent funding gap is related to the rising costs associated with meeting the state obligations under the SGBP, which have outpaced increases in the contributions of the budgetary, co-payment and MHIF contributions intended to cover the cost of health services. There has been a steady expansion in the number of categories of people who are entitled to receive preferential services under the SGBP. At the same time, enforcement of payroll contributions to the MHIF remains problematic. This problem is exacerbated by the large number of citizens who have migrated outside the country for employment and do not contribute to the MHIF system (6). Consequently, the Government and WHO are working to improve health-care spending and case-based payments and strengthen the institutional capacity of the Single Payer System and budgeting process. For example, the PHC payment system is the focus of joint efforts of WHO and joint financiers supporting the PHC Quality Improvement Program introduced above (9). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)36 Additional factors contributing to the rising costs of health care in Kyrgyzstan include the rising price of medicines in an unregulated drug market and inefficiencies in the health-care delivery system, such as unjustified hospitalization and overprescribing practices (6). Fortunately, health authorities have already begun to address the rising cost of medicines. In 2017, three new laws on the regulation of medicines and health technologies were implemented. In 2018, new legislation was introduced to establish a regulatory framework, which will contribute to making medicines and medical devices more affordable and meet the requirements of accession to the Eurasian Economic Union and its common market (6). For the first time, these laws allow the Government to regulate the prices of medicines and medical devices. These changes were complemented by the revision of the national essential medicines list in 2018 and an initiative to update pricing, with a focus on medicines addressing areas of high disease burden (6). Flagship Initiative 1: The Mental Health Coalition In Kyrgyzstan, service systems for delivery of mental health services are highly fragmented and are not patient centred. There are parallel mental health systems in the health-care, social protection and educational institutions, as well as the State Penitentiary Service under the Government of the Kyrgyz Republic and the Ministry of Internal Affairs. Each of these systems is funded and accountable to their respective departments without coordination or a holistic vision of individual needs for mental health services. Institutional linkages between the government mental health service systems and non-profit-making organizational providers are generally limited and depend on the availability of funds rather than being based on identified priorities and the needs of individuals and their families requiring mental health services (10). Guidelines and standardized practices related to the provision of psychological services are not well defined. Linkages are poorly regulated between psychiatric services under the MoH and other state bodies and local self-government; health care, education, social protection and child protection agencies; and psychosocial services at the local level (10). In 2017, a new model for provision of comprehensive health-care services, including mental health, was piloted in a number of districts and coordinated through family medicine centres. A multidisciplinary team including psychiatrists, psychologists, social workers and nurses provide comprehensive services to people with severe mental disorders. This approach reduced the frequency of hospitalizations in the target group by almost 44% (10). Based on this pilot, a new State programme on protecting the population’s mental health (2018–2030) was developed with the goals of strengthening mental well-being, preventing mental disorders, providing affordable medical care, accelerating recovery, respecting human rights and reducing the mortality, morbidity and disability of people with mental disorders. The programme is being implemented under the framework of Health 2030; however, according to experts, more than 80% of the activities planned for 2018 were not implemented through lack of effective management of the programme by the State bodies (10). Flagship Initiative 2: Empowerment through Digital Health Kyrgyzstan recognizes the opportunities of digital technologies to promote health and social change and strengthen service provider accountability that supports human-centred development and leaves no one behind. Therefore, Kyrgyzstan is specifically calling for the development of electronic health systems. Health 2030 outlines efforts to (5): • form a health information system that can provide unified and centralized data processing, information security, access to information systems in real time and assessments of cost-effectiveness; • ensure the integration and interaction of a unified health information system with the information systems of other sectors; and • ensure proper management of the information systems in electronic health. Developing electronic health services, such as telemedicine and telehealth, and integrating them into the PHC system can help expand UHC in Kyrgyzstan. It can also help reduce the stress on the health system in future health emergencies by facilitating the maintenance of essential services for chronic conditions, mental health, maternal health, and beyond. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Kyrgyz Republic Country Brief 37 Therefore, digital health is a strategic priority for Kyrgyzstan’s MoH (6). WHO will continue to support the strengthening of national governance of digital health and building capacity for the implementation of the digital health agenda. This includes the continuation of technical assistance to the MoH in strengthening health data governance, architecture and standards, as well as addressing the chronic shortage of resources in its eHealth Centre; a centre within the MoH dedicated to organizing an intersectoral system based on modern computer technologies to form a unified health information system (22). Concrete areas for technical support include leveraging resources of the eHealth centre to support increasing linkage to Kyrgyzstan’s Tunduk interoperability platform, which is a cross-sectoral information system that allows state and municipal agencies to exchange data necessary to render services to citizens and organizations in the electronic form (23). 2.3.3.2. Core Priority 2: Protecting against health emergencies In 2019, Kyrgyzstan protected 546 000 fewer people (8.0% of the population) from health emergencies than in 2018. By 2023, this number is projected to reach 903 500 fewer people (13.2% of the population). In 2019, Kyrgyzstan scored 71.5% within the Health Emergency Protection Index (HEPI). HEPI is calculated based on three sub-indicators: 1) preparedness; 2) prevention; and 3) detection and response (17). Preparedness In 2020, Kyrgyzstan scored 52.0% in the preparedness sub-indicator. This sub-indicator assesses emergency preparedness by averaging the scores of all 13 International Health Regulations (2005) (IHR) core capacities at the country level, which are reported through the States Parties Annual Report tool (17). Prevention In 2019, Kyrgyzstan scored 96.0% in the prevention sub-indicator. This sub-indicator assesses efforts to prevent health emergencies through routine and targeted vaccine campaign efforts. It includes vaccination coverage for five major infectious diseases: measles, polio, meningococcal meningitis A, yellow fever, and cholera (17). Detection and response In 2021, Kyrgyzstan scored 100.0% in the detection and response sub-indicator. This sub-indicator assesses the appropriateness of a country’s reaction to an event of potential public health concern. It averages the time from a public health event’s start to detection, notification and response to provide an overall measure of timeliness (17). Kyrgyzstan is highly exposed to natural hazards and has experienced conflicts and political instability in its recent history. It has been designated as one of the WHO Health Emergencies (WHE) Programme’s priority countries and the MoH sees emergency preparedness as a high priority, having adopted a multi-hazard national emergency response plan for 2017–2021 (18). Furthermore, a total of 38 communicable and parasitic diseases are currently under epidemiological surveillance in Kyrgyzstan and continue to be a relevant source of illness in the country (12). Epidemiological surveillance is carried out for identified cases, morbidity is registered in real time and an electronic database is used. Hyperendemicity of viral hepatitis (A, B, C, D and E), brucellosis, echinococcosis and alveococcosis persists (12). The country has natural foci of infections such as anthrax, plague, arbovirus, and other quarantinable and especially dangerous infections. Only 45% of anthrax foci have been fenced off so far, and the locations of other foci have been lost, including as a result of mudslides and earthquakes (12). In recent decades, vaccine-preventable infections have begun to reoccur in Kyrgyzstan (12). Against the backdrop of the global epidemiological situation for measles and a decline in population immunity, measles morbidity increased between December 2017 and December 2018. The main reason for this trend is the refusal of parents to have their children vaccinated (12). Religious beliefs and doubts about the safety of immunization accounted for most of the reasons for refusal. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)38 TB morbidity and mortality are gradually declining in the country, but despite notable progress over the past decade, it remains an issue in Kyrgyzstan and the number of cases of multidrug-resistant and extensively drug-resistant TB continue to grow. Kyrgyzstan is among the top 30 countries in the world in terms of high burden of multidrug-resistant TB, and one of the 18 high-priority countries for TB in the European Region (12). Additionally, the HIV epidemic continues to grow in the country and threatens to become generalized (12). Currently, the infection spreads mainly through sexual intercourse, and it is spreading beyond populations most at-risk of transmission to also affect the general population. This is evidenced by the high rate of detection of HIV-infected women, where the growth rate of new cases is currently reported to be three times higher than men in the general population (12). A significant portion of these new cases are detected as a result of mandatory testing in pregnancy, and measures taken to prevent children from becoming infected with HIV by their mothers have reduced the vertical route of transmission. These, along with other activities, have allowed Kyrgyzstan to begin preparations for obtaining a WHO certificate on the elimination of vertical transmission of HIV. There have been numerous tailored simulation exercises, at central and oblast level, to test responses to key high-risk hazards, in particular floods, earthquakes, mass casualty events and foodborne disease outbreaks in cities (18). More recently, Kyrgyzstan has used WHO tools to mount operational simulation exercises to understand core capacities and emergency preparedness at points of entry with a view to better preventing and responding to public health risks, including COVID-19 (18). According to Kyrgyzstan’s self-assessment on the implementation of the IHR in 2019, the country scored low on selected core capacities that would allow it to respond to a  pandemic, compared to the WHO European Region average (18). Capacity scores were seen as particularly low in terms of human resources (20% versus 71% in the WHO European Region) and capacity at points of entry (30% compared with 60%) (18). This aligned with the findings of the 2016 Joint External Evaluation of the IHR core capacities which identified the following areas to be strengthened (18): • national legislation, policy and financing related to IHR • biosafety and biosecurity • availability of HRH and • capacities to combat antimicrobial resistance. Kyrgyzstan recognizes the need to improve the country’s laboratory services and capacities. Therefore, Health 2030 calls to optimize the network of laboratories and health organizations towards a more rational geographical location and efficient functioning; and the mechanisms for regulating and controlling the quality of the health system, including public health service laboratories (5). 2.3.3.3. Core Priority 3: Promoting health and well-being In 2019, 61 900 more people in Kyrgyzstan (0.9% of the population) enjoyed better health and well-being than in 2018. By 2023, that number is projected to reach 306 800 more people (4.5% of the population) (17). The healthier populations (HPOP) index uses 16 outcome indicators related to social, environmental, and behavioural risks to assess the number of people whose lives have become healthier. In Kyrgyzstan, eight of the 16 indicators are projected to improve between 2018 and 2023 (Table 11). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Kyrgyz Republic Country Brief 39 Table 11. Projected changes in the normalized valuesa of the 16 indicators of the HPOP index from 2018–2023 in Kyrgyzstan. HPOP Indicator 2018 value (%) Projected 2023 value (%) Projected change (%) Access to safely managed drinking water sources 69.1 72.4 +3.3 Access to safely managed sanitation services N/A N/A N/A Adults not obese 84.4 82.4 -2.0 Ambient air quality 76.9 77.9 +1.0 Best practice policy implemented for healthy fats production 85.7 85.7 0.0 Children under 5 developmentally on track N/A N/A N/A Children (aged 5–19) not obese 96.2 95.4 -0.8 Children under 5 not overweight 94.1 94.9 +0.8 Children under 5 not stunted 87.9 90.1 +2.2 Children under 5 not wasted 98.0 97.6 -0.4 Primary reliance on clean household fuels 76.6 76.7 +0.1 Reduced alcohol use 80.6 80.6 0.0 Reduced child (aged 1–17) violence N/A N/A N/A Reduced partner violence N/A N/A N/A Reduced road traffic mortality 97.7 98.4 +0.7 Reduced suicide attempts 99.2 99.4 +0.2 Tobacco non-use 72.9 73.6 +0.7 Notes. HPOP: healthier populations. a Some indicators in this chart have been transformed to have values between 0 and 100 (0 worst–100 best). b N/A indicates the data is not available Further information regarding the indicators can be found at (17). Source: Adapted from (17). The WHO Country Office in Kyrgyzstan supports the population’s health and well-being through the promotion of multisectoral actions to address the risk factors for NCDs, the promotion of healthy settings and Health in All Policies approaches and by helping to address the social determinants of health (18). For example, WHO has supported numerous efforts of national health authorities to promote tobacco-free environments (18). The country has improved its monitoring and surveillance of NCD risk factors. In collaboration with WHO, a STEPwise Approach to NCD Risk Factor Surveillance survey was undertaken, together with a gender analysis of survey data. Moreover, Kyrgyzstan has joined the WHO European Childhood Obesity Surveillance Initiative to measure trends in overweight and obesity among primary school-aged children. Kyrgyzstan is now also employing the Global Youth Tobacco Survey to monitor tobacco use among the youth and to guide the implementation and evaluation of tobacco prevention and control programmes. Additionally, in 2019, Kyrgyzstan became a member of the Health Behaviour in School-Aged Children research network, which collects data every 4 years on the health and well-being, social determinants and health behaviours of 11-, 13- and 15-year-old children (18). Air pollution remains a significant risk factor in Kyrgyzstan, and environmental health challenges and extreme weather events are also significant concerns. For example, the age-standardized mortality rate attributed to household and ambient air pollution was high in 2016 at 110.70 per 100 000 population, which is almost four times greater than the WHO European Region’s average for this metric of 30.0 per 100 000 population (4). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)40 Considering the above, Kyrgyzstan’s draft BCA for 2022–2023 has identified several priorities to promote health and well-being, including to (6): • support multisectoral collaboration and actions to create enabling environments for early childhood development, whole school approaches and addressing social determinants of health across the life course; • support intersectoral collaboration on NCDs; • strengthen capacity of PHC to prevent, diagnose and manage NCDs; • increase the capacity of national experts on the taxation of products that are risk factors for NCDs; and • promote policy environments that enable people to make healthy choices. Flagship Initiative 3: The European Immunization Agenda 2030 In 2018, vaccine coverage of at-risk groups for epidemic or pandemic prone diseases was 94.0% in Kyrgyzstan, which is below the WHO’s recommendation of 95.0% (17). The proportion of the target population with access to three doses of diphtheria tetanus toxoid and pertussis vaccine immunization was 95.0% in 2019 (17). Access to routine vaccinations has been disrupted during the COVID-19 pandemic. With technical assistance from the WHO Country Office, Kyrgyzstan established mobile immunization teams to improve access to immunization services during the pandemic for people living in remote communities and for children of internal migrants in large urban areas. This helped fill gaps in immunization coverage in all regions of the country, but efforts must be sustained and expanded further (18). Kyrgyzstan is committed to implementing the European Immunization Agenda 2030, as well as facilitating an equitable COVID-19 vaccination campaign. The WHO Regional Office for Europe is well-suited to support these efforts, especially by convening subregional cooperation across Central Asia through Roadmap development and implementation. Through these initiatives, it will also be important to develop strategies that address vaccine acceptance and scepticism. Flagship Initiative 4: Healthier Behaviours: incorporating behavioural and cultural insights Safeguarding and, where possible, increasing social spending in areas such as health, social and child protection and education is a priority to protect Kyrgyzstan’s most vulnerable groups from poverty and social exclusion. This requires improved planning, budgeting, allocation and monitoring of public finances and increasing the effectiveness and efficiency of social spending, including better targeting of and outreach to the most vulnerable groups. There is also a need to explore alternative, innovative funding sources and to prioritize spending on areas that maximize return on investments (for example, early childhood development). This aligns with the EPW’s intent to develop an investment case for developing a knowledge and evidence base in this flagship’s area of work. Notably, a population at extreme risk in Kyrgyzstan is the lesbian, gay, bisexual, transgender, queer, intersex, asexual and more (LGBTQIA+) community. The LGBTQIA+ community, as well as people living with HIV, are among the most vulnerable groups in all of the Kyrgyz social system due to high stigma, discrimination and intolerance (24). LGBTQIA+ people do not have equal access to quality education because there are insufficient, or a complete lack of, measures to protect and promote their rights in educational institutions. LGBTQIA+ women face exacerbated consequences of gender inequality in economic, social and political domains (24). Likewise, people with, or assumed to have, TB also experience high levels of stigma and discrimination In Kyrgyzstan, from health workers, community members and, sometimes, extended family. In addition, gender norms and practices and gender-based violence (GBV) present a  significant barrier to TB services. Relatedly, a  significant portion of domestic violence victims prefer not contact law enforcement and other bodies for the protection of their rights. Hence, a significant proportion of crime is not reported. This is largely due to the mistrust of victims in the justice system, the incompetence of law enforcement and judicial officials and their refusal to perceive GBV as a serious crime, negative societal attitudes towards victims and social shaming of women and girls. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Kyrgyz Republic Country Brief 41 References3 3 All online references were accessed on 05 April 2022. 1. World Bank Open Data [online database]. Washington, D.C.: The World Bank; 2022 (https://data.worldbank.org/). 2. Poverty and Shared Prosperity 2020: Reversals of Fortune. Washington, D.C.: World Bank; 2020 ( ht tps : //o p e nk nowle dge .wo r ldbank .o rg / b i ts t ream / handle/10986/34496/9781464816024.pdf). 3. Human Development Reports: Latest Human Development Index Rankings [website]. New York: United Nations Development Program; 2022 (http://hdr.undp.org/en/content/ latest-human-development-index-ranking). 4. World Health Data Platform: The Global Health Observatory [online database]. Geneva: World Health Organization; 2022 (https://www.who.int/data/gho/data/indicators). 5. The Program of the Kyrgyz Republic Government on Public Health Protection and Health Care System Development for 2019-2030 “Healthy Person – Prosperous Country”. Bishkek: Kyrgyz Republic Government; 2018 (http://zdrav2030.med. kg/index.php/en/2-uncategorised/23-the-program-of-the- kyrgyz-republic-government-on-public-health-protection- and-health -care -system-development-for-2019 -2030 - healthy-person-prosperous-country). 6. Biennial Collaborative Agreement between the Ministry of Health of the Kyrgyz Republic and the Regional Office for Europe of the World Health Organization 2022/2023 [DRAFT]. Copenhagen: WHO Regional Office for Europe; 2022. 7. National Development Strategy of the Kyrgyz Republic for 2018-2040. Bishkek: Kyrgyz Republic Government; 2018 (http://zdrav2030.med.kg/images/myFile/2019/np/National_ Development_Strategy_of_KR_2018-2040_final_ENG.DOCX). 8. United Nations Development Assistance Framework for the Kyrgyz Republic (2018-2022). Bishkek: United Nations Kyrgyz Republic; 2018 (https://unsdg.un.org/un-in-action/kyrgyz- republic). 9. Primary Health Care Quality Improvement Program in Kyrgyzstan (2019-2024). Washington, D.C.: The World Bank; 2019 (https://projects.worldbank.org/en/projects-operations/ project-detail/P167598?lang=en). 10. Towards a  healthier Kyrgyz Republic. Progress Report 2020 on Health and Sustainable Development. Copenhagen: WHO Regional Office for Europe; 2020 (https://apps.who.int/iris/ handle/10665/338569). 11. Health financing in Kyrgyzstan: obstacles and opportunities in the response to COVID-19. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/ handle/10665/343014). 12. Report on recommendations for the reform of public health services in Kyrgyzstan. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/ handle/10665/340701). 13. United Nations COVID-19 Socioeconomic Response Framework for the Kyrgyz Republic. Bishkek: United Nations Kyrgyz Republic; 2021 (https://kyrgyzstan.un.org/index. php/en/125389-united-nations-covid-19-socioeconomic- response-framework-kyrgyz-republic). 14. Executive summary: Final evaluation of the United Nations Development Assistance Framework for the Kyrgyz Republic (2018-2022). Bishkek: United Nations Kyrgyz Republic; 2022 (https://kyrgyzstan.un.org/en/172268-executive-summary- final-evaluation-united-nations-development-assistance- framework-undaf). 15. Sustainable Development Report 2021: The Decade of Action for the Sustainable Development Goals. Country Profiles. New York: Sustainable Development Solutions Network; 2021 (https://dashboards.sdgindex.org/). 16. SDG Indicators Database [online database]. New York: United Nations Department of Economic and Social Affairs; 2022 (https://unstats.un.org/sdgs/UNSDG/IndDatabasePage). 17. Triple Billion Targets Dashboard [website]. Geneva: World Health Organization; 2022 (https://portal.who.int/ triplebillions/PowerBIDashboards/Countries). 18. Health systems in action: Kyrgyzstan. Copenhagen: European Observatory on Health Systems and Policies, WHO Europe; 2021 (https://eurohealthobservatory.who.int/publications/i/ health-systems-in-action-kyrgyzstan). 19. Global Burden of Disease Compare Data Visualization [online database]. Seattle: Institute for Health Metrics and Evaluation, University of Washington; 2022 (https://vizhub.healthdata. org/gbd-compare/). 20. Working for Health reports and policy [website]. Geneva: World Health Organization; 2021 (https://working4health.org/ resources-publications-tools/). 21. Global Health Expenditure Database [online database]. Geneva: World Health Organization; 2022 (https://apps.who. int/nha/database/Select/Indicators/en). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)42 22. ОСНОВНЫЕ ЦЕЛИ ЦЕНТРА ЭЛЕКТРОННОГО ЗДРАВООХРАНЕНИЯ [Main Objectives of the Electronic Health Centre] [website]. Бишкек [Bishkek]: Министерство здравоохранения Кыргызской Республики [Ministry of Health of the Kyrgyz Republic]; 2022 (http://cez.med. kg / % d 0 % b 4% d 0 % b 5 % d1% 8 f % d1% 8 2 % d 0 % b 5 % d 0 % bb%d1%8c%d0%bd%d0%be%d1%81%d1%82%d1%8c/) [in Russian]. 23. Electronic Interoperability System “Tunduk”: The State Enterprise “Electronic Interoperability Center”. Bishkek: State Committee of Information Technologies and Communications of the Kyrgyz Republic; 2019 (https://kg.tunduk.gov.kg/wp- content/uploads/2019/03/%D0%B0%D0%BD%D0%B3%D0% BB-%D0%91%D1%80%D0%BE%D1%88%D1%8E%D1%80%D0 %B0.pdf). 24. United Nations Common Country Analysis (CCA) for the Kyrgyz Republic. Bishkek: United Nations Kyrgyz Republic; 2021 (https://kyrgyzstan.un.org/en/166597-united-nations- common-country-analysis-cca-kyrgyz-republic). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Tajikistan Country Brief 43 2.4. Republic of Tajikistan This country brief outlines the Republic of Tajikistan’s priorities for improving their population’s health and well-being from 2022–2025. These priorities have informed the development of the Roadmap and its action areas and reform initiatives. This brief is not intended to be exhaustive or prescriptive. Rather, it intends to highlight key issues and areas where Tajikistan may benefit from and contribute to united action for better health and well-being in Central Asia. The brief identifies a compiled list of Tajikistan’s national health and well-being priorities (Table 2) that will inform the development and implementation of the Roadmap for Health and Well-being in Central Asia. 2.4.1. Health, well-being and sustainable development progress in Tajikistan Tajikistan is a lower middle-income country whose lower levels of economic prosperity, high exposure to environmental hazards and vast socioeconomic disparities make Tajikistan vulnerable to internal and external shocks (1). Despite this, the percentage of people vulnerable to multidimensional poverty in Tajikistan decreased from 83% to 31% between 2000–2015 (2). This feat has put Tajikistan on the list of countries with the highest rates of poverty reduction in the last 15 years (3). Tajikistan’s poverty reduction efforts have been bolstered by their considerable economic growth. Tajikistan’s gross domestic product (GDP) has multiplied nine and a half times since 2000, growing from approximately 0.86 to 8.2 billion United State dollars between 2000–2020 (4). Between 2017–2019, Tajikistan’s annual GDP growth rate averaged 7.4% per year. However, this rate fell to 4.5% in 2020 as a consequence of the coronavirus disease 2019 (COVID-19) pandemic. Correspondingly, Tajikistan’s unemployment rate was, on average, 7.0% of the total labour force between 2017–2019, but this figure increased to 7.6% in 2020 due to the pandemic (4). Given Tajikistan’s persistent unemployment rate, the impressive aggregate economic growth has not translated to better job opportunities in the domestic market or significant increases in household income. In fact, a  large percentage of Tajikistan’s economic growth has been driven by domestic consumption fuelled by remittances, which account for nearly one-third of the country’s GDP (1). There are additional employment disparities in the country linked to sex, age, and skills. The COVID-19 pandemic has demonstrated the precariousness of jobs and the vulnerability of Tajikistan’s economy, with outmigration for employment as a major coping strategy (1). Despite this outmigration, the country is still experiencing rapid population growth. Between 2017–2020, Tajikistan’s population grew, on average, by 2.4% each year and stands currently at approximately 9.5 million people (4). The population is very young: the percentage of the population aged less than 15 years was 37.3% in 2020, which is more than two and a half times greater than the European Union (EU)’s percentage of 14.1% (4). In contrast, the percentage of Tajikistan’s population aged 65 years or older was 3.2% in 2020, which is six and a half times smaller than the EU’s percentage of 20.8% for the same metric (4). Despite this, Tajikistan’s population is slightly ageing. Between 2015–2020, the percentage of the population aged 65 years or older grew from 2.9% to 3.2% (4). A rapidly growing population will have a major strain on the economy, public goods and services, food supplies and the availability of future jobs (1). Nevertheless, an increase in Tajikistan’s population and labour force can generate opportunities for economic growth. For health and well-being, it is important to consider that nearly three-quarters of Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)44 Tajikistan’s population lives in rural areas (1). Most of the land is mountainous, and people who live in remote regions are especially difficult to reach during the winter (5). According to the 2020 Human Development Index (HDI), Tajikistan ranks 125th out of 189 countries and territories and it is categorized as a country with medium human development (6). Tajikistan’s HDI increased from 0.638 to 0.668 between 2010–2019. This represents an average HDI growth of 0.30% per year, which is less than half of Europe and Central Asia’s average growth of 0.76% per year during the same period. For reference, Europe and Central Asia’s average HDI increased from 0.735 to 0.791 between 2010–2019 (6). Embedded in Tajikistan’s improved HDI is their steady increase in life expectancy over the past decade. Between 2010–2019, life expectancy increased from 70.19 to 71.55 years (+1.36 years) for females and from 66.04 to 67.58 years (+1.54 years) for males (7). However, these figures are still significantly below the WHO European Region’s average of 81.29 years for females and 75.09 years for males (7). Building back better and leaving no one behind after the COVID-19 pandemic will be imperative to sustain the progress on health, well-being and sustainable development that Tajikistan was making prior to the pandemic. This is especially true for the progress being made on poverty reduction, which is especially vulnerable to redaction from the pandemic (8). At the national level, the pandemic has exposed universal weaknesses in health-care procurement, capacity, delivery and resilience, and has highlighted the need to strengthen primary health care (PHC), emergency preparedness and response mechanisms, and data systems to help address health inequities and ensure universal access to new health technologies (1). 2.4.1.1. Looking forward: the health, well-being and sustainable development trajectory of Tajikistan In 2021, the Government of the Republic of Tajikistan and its Ministry of Health and Social Protection of the Population of the Republic of Tajikistan (MoHSPP) approved the Strategy on the Healthcare of the Population of the Republic of Tajikistan up to 2030 (hereinafter, the NHS 2030) (9). The NHS 2030 has the overall goal of providing every citizen of Tajikistan with accessible and quality health care. To achieve this goal, the NHS 2030 has two strategic directions: 1) effective governance, sustainable financing, workforce provision and development of information technologies; and 2) accessible, affordable, and quality health and social services. To achieve these strategic directions, the NHS 2030 identifies six strategic objectives, including to (9): 1. effectively manage the health-care system 2. strengthen PHC delivery systems to achieve universal health coverage (UHC) 3. modernize and improve health-care service delivery systems 4. ensure appropriate and sustainable health-care financing 5. provide the health-care system with qualified and motivated human resources and 6. develop modern management information systems and digitalize health-care and social protection systems. Tajikistan’s strategic directions and objectives are rooted in four main principles (9): 1. reduce health inequalities and inequities: Tajikistan’s population experiences inequalities in their access to health-care services due to geographic variability and the differentiated economic capacities of administrative units in the country. Mechanisms to support this include to: » progress towards UHC and expand access to necessary quality health-care services without financial challenges; » enable lifelong approaches within the fields of health and social welfare; » protect the population from impoverishing health-care expenditures by pooling financial resources and mobilizing resources from outside health-related sectors, partners and systems; and » increase the efficiency and effectiveness of the spending of financial resources to improve the health-care sector’s return on investment. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Tajikistan Country Brief 45 2. strengthen evidence-based and informed decision-making; 3. ensure equitable access to high-quality health services by promoting a people-centred health-care system that utilizes a multisectoral approach to address the key determinants of health inequities; and 4. guarantee social integration and equal access to health-care services for all without any form of discrimination or social isolation based on their gender, age, location, profession, income, poverty status, race, ethnicity, religion, nationality or social category of their citizenship. For more information regarding the specific actions that Tajikistan will adopt to achieve the strategic directions and objectives outlined above, in line with their guiding principles, please see the NHS 2030 (9). In addition to the NHS 2030, Tajikistan has also identified its country-level priorities through its collaboration in the development of the Government of Tajikistan and United Nations Sustainable Development Cooperation Framework (2023–2026) (hereinafter, the CF TJK) (10). In the CF TJK, Tajikistan identifies four outcomes related to their intended sustainable development progress by 2026. The first outcome, entitled “inclusive human development”, is especially related to health. Within the first outcome, Tajikistan identifies six, health-related conditions of success for inclusive human development by 2026, which include to (10): 1. strengthen social protection systems and mechanisms to increase the coverage, quality and adequacy of social protection benefits and services and to increase inclusion of vulnerable groups; 2. introduce new capabilities for education systems to increase access to quality and inclusive life-long-learning and skills for employability and resilience; 3. ensure the health system is able to offer universal access to quality, affordable, risk-informed and integrated health and early childhood development services; 4. strengthen governance, planning, delivery and monitoring of equitable, safe, affordable and risk-informed water, sanitation and hygiene (WASH) services; 5. enhance institutional capacities to provide food security and access to nutrition services to vulnerable groups and households and encourage the widespread adoption of healthy behaviours; and 6. increase community and civil society organizations’ engagement in risk-informed policy-making and service delivery. For more information regarding the aforementioned conditions of success and specific actions that Tajikistan will adopt to achieve them, please see the CF TJK (10). Overall, Tajikistan’s gaps in the quality and coverage of its essential health and social services, especially in under- served rural areas and for vulnerable groups, are the highest priorities to address in the NHS 2030 and the CF TJK. The country is highly vulnerable to external economic shocks and the COVID-19 pandemic has highlighted structural vulnerabilities and widening inequalities, which undermine prospects to achieve the NHS 2030 goals and Sustainable Development Goals (SDGs) for a growing, diversifying economy and a thriving, productive society. The provision of adequately financed and high quality, inclusive services in the areas of education, health care, social protection, and WASH are central for Tajikistan to achieve these goals. Food security and malnutrition are major concerns that bridge economic and social policies and programmes. Cooperation strategies and results should incorporate the direct and indirect (more upstream) connections between higher quality, more inclusive and better financed social services and greener, more sustainable economic growth (the CF TJK’s second priority). Doing so will strengthen a virtuous cycle in which a healthy, more resilient population can better support, and benefit from, a shift to a more diversified, knowledge-based economy creating decent, formal sector jobs. More effective social services and spending will also better protect vulnerable groups and isolated rural communities. Expanding access to quality social services and economic opportunities and inclusion will reduce polarization and pressures for outmigration (10). Finally, Tajikistan’s draft 2022–2023 biennial collaborative agreement (BCA) is still being negotiated (1). However, it will honour all pre-existing international and national strategic frameworks for health and well-being that Tajikistan has committed to between 2022–2023, including those referenced in this brief. Notably, these include the Thirteenth General Programme of Work 2019–2023 (GPW), EPW, SDGs, NHS 2030 and CF TJK. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)46 2.4.1.2. SDG 3 progress: Ensure healthy lives and promote well-being for all at all ages SDG 3 aims to ensure healthy lives and promote well-being for all at all ages. In 2021, a thorough analysis of Tajikistan’s progress achieving SDG 3 revealed areas where health and well-being have been advanced and where challenges remain (11). These trends are summarized in Table 12. Table 12. Selected targets and indicators to track Tajikistan’s progress on SDG 3. SDG 3 Targeta Statusb Description Indicator(s) 3.1 Target achieved By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births. • 3.1.1: Maternal mortality ratio: Decreased from 53.0 to 17.0 per 100 000 live births from 2000–2017. 3.2 Challenges remain By 2030, end preventable deaths of new-borns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-five mortality to at least as low as 25 per 1000 live births. • 3.2.1: Children under-five mortality rate: Decreased from 83.6 to 33.8 deaths per 1000 live births from 2000–2019. • 3.2.2: Neonatal mortality rate: Decreased from 28.4 to 15.0 deaths per 1000 live births from 2000–2019. 3.3 Major challenges remain By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases. • 3.3.1: New HIV infections: Increased from 0.00 to 0.17 new infection per 1000 uninfected population 2000–2019. • 3.3.2: Tuberculosis incidence: Decreased from 219 to 83 incidence per 100 000 population from 2000–2019. 3.4 Major challenges remain By 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being. • 3.4.1: Risk of dying between the ages of 30 and 70 from one of four main NCDs (cardiovascular disease, cancer, diabetes, or chronic respiratory disease): Increased from 28.2% to 28.3% from 2000–2019. • 3.4.2: Suicide mortality rate: Increased from 3.8 to 4.3 deaths per 1000 population from 2000–2019. 3.5 Challenges remain Strengthen the prevention and treatment of substance abuse. • 3.5.2: Alcohol consumption per capita among population aged 15 years and older: Increased from 0.8 to 0.9 litres of pure alcohol from 2000–2019. 3.6 Significant challenges remain By 2020, halve the number of global deaths and injuries from road traffic accidents. • 3.6.1: Death rate due to road traffic injuries: Decreased from 19.5 to 15.7 deaths per 100 000 population from 2000–2019. 3.7 Major challenges remain By 2030, ensure universal access to sexual and reproductive health-care services. • 3.7.1: Proportion of women of reproductive age with their needs met for family planning with modern methods: Increased from 50.9% to 52.1% from 2012–2017. • 3.7.2: Adolescent birth rate: Increased from 37.3 to 54.3 per 1000 women aged 15–19 years from 2000–2016. 3.8 Significant challenges remain Achieve UHC, including financial risk protection, access to quality essential health- care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. • 3.8.1: Service coverage indexc: Increased from 41.0 to 66.0 from 2000–2019. 3.9 Significant challenges remain By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination. • 3.9.1: Age-standardized mortality rate attributed to household air pollution: 45.0 deaths per 100 000 population in 2016. • 3.9.1: Age-standardized mortality rate attributed to ambient air pollution: 94.0 deaths per 1000 population in 2016. • 3.9.2: Mortality rate attributed to unsafe water, unsafe sanitation and lack of hygiene: 2.7 deaths per 1000 population in 2016. • 3.9.3: Mortality rate attributed to unintentional poisonings: Decreased from 1.9 to 0.4 deaths per 1000 population from 2000–2019. Notes. NCDs: noncommunicable diseases; SDGs: Sustainable Development Goals; UHC: Universal health coverage. a For brevity, some SDG 3 targets and indicators were excluded when the health issues they addressed were not relatively high priorities or needs in Tajikistan’s context (for example, tropical diseases) or if there was no data available for their indicators. b The status assigned to each target was determined by an analysis in the Sustainable Development Report (11), which was authored by the Sustainable Development Solutions Network. All data used to create the Sustainable Development Report are based on Sachs et al. (2022)’s publication. The indicators selected for this table represent some of the many indicators that were considered when these statuses were assigned. c There are significant limitations associated with this measure of service coverage. Source: Adapted from (11, 12). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Tajikistan Country Brief 47 2.4.2. Lessons learned from the COVID-19 pandemic In 2020, Tajikistan’s UN Country Team, led by the United Nations Development Programme and supported by the United Nations Resident Coordinator’s Office came together to articulate its immediate support to the Government of Tajikistan to assist vulnerable people in an Integrated Socioeconomic Response Framework (ISEF) (13). Tajikistan’s ISEF is anchored to the Prime Minister’s Action Plan to combat the spread of COVID-19 and is linked to the Tajikistan COVID-19 Country Preparedness and Response Plan and the Ministry of Economic Development and Trade’s economic plan. The ISEF has five strategic pillars that are underpinned by building back better, leaving no one behind and achieving the SDGs (Table 13). Table 13. The strategic pillars, and their respective focus areas, of Tajikistan’s ISEF. Strategic pillar Focus areas 1 Health first • Maintain health preparedness and response • Ensure the continuity and safety of health services • Build a resilient health system for the future 2 Protecting people • Food security and nutrition among households • Continuance of education and learning • Social protection for vulnerable groups 3 Macroeconomic response • Macroeconomic stability • Fiscal spending for development and the SDGs • Trade and cross-border cooperation 4 Economic recovery • Protecting jobs • Support for small and medium enterprises • Restore production supply chains 5 Social cohesion • Strengthen social capital • Engage in social dialogue • Build community resilience Notes. SDGs: sustainable development goals. For more information regarding the tasks and indicators associated with each strategic pillar focus area, please refer to (13). Throughout the COVID-19 pandemic, Tajikistan has had a  limited supply of test kits, reagents, consumables and essential medicines (13). During times of rapid increases in infections, Tajikistan’s health–care infrastructure has been easily overwhelmed while operating at full capacity. There is also concern of progressing antimicrobial resistance (AMR) in Tajikistan through the inappropriate use of antibiotics during the pandemic (13). The COVID-19 pandemic has highlighted the need for improved health governance and human resources for health (HRH) in Tajikistan. There are only 4.8 hospital beds and 1.7 physicians for every 1000 people in Tajikistan (14) and the lack of personal protective equipment seriously hinders the ability of medical workers to provide essential services. Disrupted supply chains and breakdown in transport links make it difficult to procure diagnostics and other essential medicines, as well as recruit technical expertise from outside. As the health system focuses on managing COVID-19, the disproportional distribution of health workers in urban versus rural areas fosters an additional workload and inefficient resource expenditure for medical personnel in their provision of emergency and non-emergency care to rural populations. Consequently, Tajikistan has struggled to maintain essential health services, especially in rural areas. Community engagement throughout the COVID-19 pandemic has also been inadequate in Tajikistan (13). Maintaining the trust of the population in the public health system’s ability to control infection is key to ensure widespread health- seeking behaviour and adherence to public health advice. Public health messages explaining the risks and prevention of COVID-19 have not been actively used to raise awareness in the population. Consequently, parents have been hesitant to bring in their children for vaccination due to concerns regarding vaccine safety and the potential exposure to COVID-19 infection (13). Moreover, many sexual and reproductive health and antenatal services have seen a decline in use based on the higher risk of exposure to COVID-19 of women who access such services, due in part to the lack of protective equipment and inadequate adherence to clinical protocols. This decline is likely to contribute to: 1) a rise in maternal and new-born mortality, based on reduced screening for preeclampsia, foetal heart rate and growth monitoring and access to vaccines; 2) a further increase in the unmet need for family planning, which can potentially increase unwanted pregnancies and lead to rises in unsafe abortions; and 3) a rise in sexually transmitted infections, including HIV (13). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)48 In this regard, the COVID-19 pandemic has threatened the most marginalized segments of Tajikistan (13). An overburdened health-care system and growing disruptions in medical supply chains can have a devastating effect on HIV prevention and treatment, especially among vulnerable populations who face societal stigma and discrimination. Young people with HIV, who experience a disproportionate burden of the global HIV epidemic, are at greater risk of COVID-19 due to weak immune systems and dependency on a regular supply of antiretroviral medication and other services, which may not be prioritized (13). Moreover, Tajikistan is vulnerable to all the four dimensions of food security: availability, access, utilization and stability (13). Approximately one-third of households are moderately or severely food insecure, and nearly 1 in 10 face severe food insecurity in Tajikistan (15). Food insecurity in Tajikistan varies by geography and seasons, with people living in rural and remote areas being significantly more insecure than people in urban areas. Considering the existing vulnerabilities of food insecurity and nutrition, the COVID-19 pandemic is a  major threat to the nutritional status and overall well-being of Tajik people. For example, disrupted trade and supply chains have negatively affected the availability and price of food. Exacerbated food insecurity, onset by the COVID-19 pandemic, underscores how many households in Tajikistan are vulnerable to social and economic shocks. Overall, these considerations also show how enhancing the quality of health care and education and strengthening social protection, with a particular focus on the most vulnerable, can help prepare for future health emergencies and reduce their negative impact on public health and the health system (13). 2.4.3. Closing the Health Gap: aligning Tajikistan’s priorities with the EPW Tajikistan’s current national health priorities and gaps are discussed below in context of the EPW’s framework. 2.4.3.1. Core Priority 1: Moving towards UHC Moving towards UHC is a high priority for Tajikistan. Under the auspices of the NHS 2030’s two strategic directions, Tajikistan has identified several methods for achieving their goals related to expanding UHC (9): • Strategic direction I » improve health governance » improve sustainable financing » ensure the sustainable development of HRH » improve the management of information and digital health systems. • Strategic direction II » improve the access and quality of all health-care services; » improve the access, quality and responsiveness of PHC; » improve the health of mothers, new-borns, children and adolescents and expand access to sexual and reproductive health services and rights; » reduce the burden of infectious diseases; » improve the prevention and managements of noncommunicable diseases (NCDs) and disabilities; » improve aspects related to the supply of medicines and pharmaceutical activities; » improve public health care and healthy lifestyle services; » improve emergency preparedness and response to public health emergencies. Progress towards UHC is monitored in two dimensions: the coverage of essential health services and financial hardship. Each is overviewed below in the context of Tajikistan. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Tajikistan Country Brief 49 Coverage of essential health services In 2019, 99 600 more people in Tajikistan (1.0% of the population) were covered by essential health services than in 2018. By 2023, this number is projected to be 491 800 more people (4.8% of the population) (16). Coverage of essential health services is defined as the average coverage of the 14 SDG 3.8.1 tracer interventions. Of these 14 indicators, positive progress is projected for eight of them in Tajikistan by 2023 (Table 14). Table 14. Projected percentage point changes in normalized valuesa across the 14 SDG 3.8.1 tracer interventions for service coverageb from 2018–2023 in Tajikistan. Service Coverage Indicator 2018 value (%) Projected 2023 value (%) Projected change (%) Basic sanitation 97.3 98.3 +1.0 Care seeking for pneumonia for children under 5 69.0 72.6 +3.6 DTP3 immunization 96.0 96.3 +0.3 Health worker density 44.3 63.3 +19.0 Hospital bed density 100.0 100.0 0.0 IHR core capacity index 58.0 76.4 +18.4 ITN use N/A N/A N/A Mean fasting blood glucose 71.3 64.6 -6.7 Need met for family planning 52.7 56.0 +3.3 Non-elevated blood pressure 47.3 46.2 -1.1 People living with HIV receiving ART 47.5 68.0 +20.5 TB cases treated 75.1 74.4 -0.7 Tobacco non-use 74.4 76.3 +1.9 Women who received antenatal care visits 4+ times 60.3 60.3 0.0 Notes. ART: Antiretroviral therapy; DTP3: Three doses of diphtheria tetanus toxoid and pertussis vaccine; IHR: International Health Regulations (2005); ITN use: Insecticide-treated bed net use among people at-risk of malaria; TB: Tuberculosis. a Some indicators in this chart have been transformed to have values between 0 and 100 (0 worst–100 best). Further information regarding the indicators can be found at (16). b There are significant limitations associated with this method of measuring service coverage. c N/A indicates the data is not available. Source: Adapted from (16). Communicable diseases and NCDs are significant public health burdens in Tajikistan. In 2019, 19.49% of deaths in Tajikistan were caused by communicable diseases and maternal, prenatal and nutrition conditions (4), and 26.57% of disability-adjusted life years (DALYs) were attributable to communicable diseases (17). In comparison, the European Union’s averages for these two metrics in 2019 were 5.55% and 4.04%, respectively. Tajikistan’s NHS 2030 focuses on reducing mortality and morbidity attributable to infectious diseases, primarily HIV, Tuberculosis (TB), viral hepatitis and sexually transmitted infections (STIs) (9). Improvements regarding the prevention and management of infectious diseases are incorporated in all strategic directions of Tajikistan’s NHS 2030 – starting from improved access to water and sanitation and epidemiological surveillance to improvements in the quality of health-care services. For more information regarding the specific initiatives designed to combat HIV, TB, viral hepatitis and STIs in Tajikistan, please see the NHS 2030 (9). The percentages of deaths and DALYs attributable to NCDs in Tajikistan in 2019 were 86.68% (4) and 75.64% (18), respectively. A  more systematic, high quality health information system that improves the monitoring of service delivery for NCDs, progresses sustainable health financing policies, and enhances the assessment of providers’ performance is needed to improve the health system and tackle Tajikistan’s burden of NCDs (9). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)50 Therefore, Tajikistan is committed to achieving a PHC system that is accessible, equitable, integrated, and community- oriented and includes support for NCD screening and prevention. Tajikistan’s NHS 2030 has identified five broad categories of actions to improve the PHC system, including to (9): 1. improve the access, quality and responsiveness of PHC services; 2. increase the quality and competencies of PHC services; 3. develop information systems to improve the process and management of the PHC system; 4. enhance the integration and development of essential service PHC facilities, including palliative care, emergency medical care and vertical service delivery structures; and 5. engage communities in health issues and build partnerships between communities, healthy lifestyle centres and PHC facilities. It is also a key priority for Tajikistan to improve the health of mothers, new-borns, children and adolescents, as well as expand access to sexual and reproductive health services and rights. In 2021, an assessment was conducted on the progress of sexual, reproductive, maternal, new-born, child and adolescent health (SRMNCAH) in the context of UHC in Tajikistan (19). The primary findings of the report were to suggest the following policy priority recommendations (19): • strengthen governance for SRMNCAH • improve service delivery and strengthen evidence-based practice • adjust health financing to improve support for SRMNCAH • reduce out-of-pocket expenditure on essential medicines and health products for SRMNCAH and • strengthen HRH for provision of SRMNCAH services. In order to improve HRH, Tajikistan’s NHS 2030 outlines actions to improve strategic planning, training and education processes and employment conditions of HRH, and to support the development of science, modern technologies and innovations in the field of medicines (9). Additionally, Tajikistan’s draft 2022–2023 BCA calls for support in developing national health workforce strategies based on previous health workforce assessments and health labour market analyses (1). Financial hardship Ensuring everyone can access high-quality health services without facing financial hardship is a key target of the EPW and SDGs. At the governmental level, the percentage of gross domestic product (GDP) spent on health in 2018 Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Tajikistan Country Brief 51 in Tajikistan was only 1.96%, which is significantly lower than the WHO European Region’s average of 4.87% (20). To achieve the NHS 2030 and UHC targets and to strengthen the health system response to COVID-19, the Government of Tajikistan plans to increase public health spending to more than 4.0% of GDP (16). At the patient level, the percentage of health expenditure covered by out-of-pocket payments in 2018 in Tajikistan was 68.42%, which is more than twice the WHO European Region’s average of 29.82% for the same metric (20). To reduce the number of people suffering financial hardship from health spending, Tajikistan’s NHS 2030 identifies the key priority of improving aspects related to the supply of medicines and pharmaceutical activities. Medicines are the main driver of out-of-pocket spending, therefore, improving access to essential medicines and medical supplies is required. To achieve this goal, the NHS 2030 calls for providing equitable physical and economic access to essential medicines to the population, as well as strengthening the State’s control in the field of the circulation of medicines to prevent counterfeit and unregistered medicines from being in the pharmaceutical market (9). In Tajikistan’s draft 2022–2023 BCA, they have also called for developing a comprehensive health financing policy to support large scale UHC reforms and strengthening national regulatory capacity of the pharmaceutical industry (1). Flagship Initiative 1: The Mental Health Coalition Tajikistan is experiencing a  growing burden of mental illness (9). Despite more patients needing treatment, little has been changed in the public provision of mental health services. Those in need of intensive treatments are placed in large public institutions with demolished infrastructure and poor services, which fall short from meeting acceptable quality standards and treatment approaches and basic human rights (9). However, Tajikistan is committed to changing this trend, especially by expanding mental health-care services to mothers, children and adolescents. Young people in Tajikistan have a variety of health concerns: mental health, depression, obesity, violence, stigma and discrimination, suicide, unwanted pregnancies and growing problems with STIs/HIV. A recent survey revealed that 79.0% of adolescents miss classes due to health issues, and that social media is negatively affecting their mental well-being (16). The country, and especially its young people, have suffered from the independence process, the civil war, poverty and vulnerability. Trauma can become intergenerational and the 21 Youth Friendly Health Departments that provide medical care and psychological support to children, adolescents and youth can only meet a third of the national demand (16). Therefore, improved mental health care is greatly needed across Tajikistan, and the country would benefit from subregional cooperation to facilitate progress in this field. Flagship Initiative 2: Empowerment through Digital Health Tajikistan’s NHS 2030 specifically calls for the improvement of management information systems and digital health (9). Of the goals and objectives identified, the actions prioritized to achieve these goals include to adjust legal and regulatory frameworks for health management information systems and digital health development; and to strengthen the country’s information and communications technology infrastructure, especially of the MoHSPP, to ensure the entire population can access digital health services. Improved digital solutions and management in Tajikistan will support more effective sectoral reform in human development by promoting more transparent and evidence-based leadership and decision making (21). Currently, Tajikistan’s information system cannot produce and disseminate what is needed for this. By promoting the development of telemedicine, e-learning and text-messages campaigns, health services can be made available to the most remote and vulnerable populations. However, there is a need to develop strong health policy frameworks that better support planned and existing e-governance policies. Improved digital connectivity and skills need to be supported to achieve improved access to health and social services through digital solutions. Existing health management information systems need to be further improved. All e-government systems will need to adhere to stringent data protection and privacy requirements which align with international standards and best practices (21). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)52 2.4.3.2. Core Priority 2: Protecting against health emergencies In 2019, Tajikistan better protected 457 300 more people (4.5% of the population) from health emergencies than in 2018. By 2023, this number is projected to reach 2.50 million people (24.6% of the population). In 2019, Tajikistan scored 79.7% within the Health Emergency Protection Index (HEPI). HEPI is calculated based on three sub-indicators: 1) preparedness; 2) prevention; and 3) detection and response (17). Preparedness In 2019, Tajikistan scored 62.0% in the preparedness sub-indicator. This sub-indicator assesses emergency preparedness by averaging the scores of all 13 International Health Regulations (2005) (IHR) core capacities at the country level, which are reported through the States Parties Annual Report tool (17). Prevention In 2019, Tajikistan scored 97.5% in the prevention sub-indicator. This sub-indicator assesses efforts to prevent health emergencies through routine and targeted vaccine campaign efforts. It includes vaccination coverage for five major infectious diseases: measles, polio, meningococcal meningitis A, yellow fever, and cholera (17). Detection and response In 2021, Tajikistan scored 100.0% in the detection and response sub-indicator. This sub-indicator assesses the appropriateness of a country’s reaction to an event of potential public health concern. It averages the time from a public health event’s start to detection, notification and response to provide an overall measure of timeliness (17). Tajikistan understands that protecting the population from public health-care emergencies and ensuring rapid and adequate responses are imperatives of the health-care system and responsibilities of national health-care authorities. Public health-care emergencies have many forms, including outbreaks of infectious, life-threatening diseases, climate change emergencies and natural disasters due to environmental hazards. Tajikistan’s international commitments on the management of public health-care emergencies, including the IHR, are aimed at facilitating the prevention and management of public health-care risks related to the international transmission of diseases (9). To achieve Tajikistan’s goals related to better protecting their citizens from future health emergencies, the NHS 2030 calls to (9): • create a unified and effective system of sanitary and epidemiological surveillance; • improve surveillance and infection prevention and control (IPC) methods; • improve national capacity for early detection, response and rapid reaction, including laboratory capacity; • enhance monitoring and surveillance of behavioural risks, nutrition and environmental factors, including the social determinants of health, and collect data for evidence-based decision making; and • enhance intersectoral collaboration and implementation of all IHR strategies. Additionally, Tajikistan’s draft 2022–2023 BCA aspires to (1): • enhance country preparedness by strengthening the capacity of policy-makers and managers at all levels of the health system by looking at policies, legislation and the development of Standard Operational Procedures, such as for the maintenance of essential health services in emergency settings; • enhance cross-border data collection and collaboration with neighbouring countries for migrants and refugees; and • enhance vigilance for highly-threatening pathogens and influenza and maintain influenza surveillance. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Tajikistan Country Brief 53 2.4.3.3. Core Priority 3: Promoting health and well-being In 2019, 206 700 more people in Tajikistan (2.0% of the population) enjoyed better health and well-being than in 2018. By 2023, that number is projected to reach 819 900 more people (8.1% of the population) (17). The healthier populations (HPOP) index uses 16 outcome indicators related to social, environmental, and behavioural risks to assess the number of people whose lives have become healthier. In Tajikistan, eight of the 16 indicators are projected to improve between 2018 and 2023 (Table 15). Table 15. Projected changes in the normalized valuesa of the 16 indicators of the HPOP index from 2018–2023 in Tajikistan. HPOP Indicator 2018 value (%) Projected 2023 value (%) Projected change (%) Access to safely managed drinking water sources 48.1 49.0 +0.9 Access to safely managed sanitation services N/A N/A N/A Adults not obese 87.2 85.4 -1.8 Ambient air quality 66.7 69.3 +2.6 Best practice policy implemented for healthy fats production 85.7 85.7 0.0 Children under 5 developmentally on track N/A N/A N/A Children (aged 5–19) not obese 97.1 96.4 -0.7 Children under 5 not overweight 96.3 97.1 +0.8 Children under 5 not stunted 83.0 87.5 +4.5 Children under 5 not wasted 94.5 95.0 +0.5 Primary reliance on clean household fuels 80.9 85.8 +4.9 Reduced alcohol use 96.5 96.5 0.0 Reduced child (aged 1–17) violence N/A N/A N/A Reduced partner violence N/A N/A N/A Reduced road traffic mortality 97.5 98.1 +0.6 Reduced suicide attempts 99.6 99.6 0.0 Tobacco non-use N/A N/A N/A Notes. HPOP: healthier populations. a Some indicators in this chart have been transformed to have values between 0 and 100 (0 worst–100 best). b N/A indicates the data is not available Further information regarding the indicators can be found at (17). Source: Adapted from (17). Promoting health and well-being will require Tajikistan to prioritize prevention and address the risk factors propelling its high burden of NCDs. The NHS 2030 is highly focused on preventing and addressing the four common risk factors related to lifestyle and behaviour: tobacco use, harmful use of alcohol, inadequate physical activity and unhealthy diet. While Tajikistan has made progress in implementing its anti-smoking campaign (9), significant work remains to fully implement the WHO Framework Convention of Tobacco Control. In regards to the harmful use of alcohol, Tajikistan was one of the “first-movers” of countries who implemented the WHO Global Strategy to Reduce the Harmful Use of Alcohol and the WHO European Action Plan to Reduce the Harmful Use of Alcohol 2012–2020 (22). By doing so, Tajikistan adopted the WHO’s three best-buy interventions in reducing the alcohol-attributable burden to: 1) increase taxes on alcoholic beverages; 2) enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising; and 3) enact and enforce restrictions on the physical availability of retailed alcohol. Progress here should be sustained and broadened. Finally, reducing Tajikistan’s persistently high burden of NCDs will require a sustained increase in investment to strengthen monitoring, treatment, evaluation and prevention at the PHC level. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)54 In May 2018, Tajikistan adopted the National Action Plan on Control of Antimicrobial Resistance, which stipulates actions to be implemented in corresponding sectors, including human health, animal health and environment to ensure coordinated and comprehensive approaches to address the issue of AMR (9). To broadly improve public health care and healthy lifestyle services, the NHS 2030 calls to (9): • improve and consolidate information about health and the health status of the country by improving the supervision of public health-care services; • ensure the sustainability and efficiency of the National Program of Immunoprevention; • strengthen the leadership and advocacy role of the MoHSPP for improving WASH and health-care waste management at health facilities, both within the public sector and beyond; • introduce the most effective mechanisms to ensure safety and acceptability of water supply and sanitation systems; • contain emerging AMR through public health measures; • ensure coordination and response to transboundary health issues, especially that of migrants and their families; and • engage communities on health promotion and healthy lifestyle issues in the framework of introducing and implementing the Guidelines on Partnership with Communities on Health Issues. Environmental health challenges and extreme weather events are also significant concerns. For example, the age-standardized mortality rate attributed to household and ambient air pollution in Tajikistan was high at 129.30 per 100 000 population in 2016, which is more than four times greater than the WHO European Region’s average for this metric of 30.0 per 100 000 population (7). A  large proportion of Tajikistan’s population still lives without access to WASH facilities, particularly in rural areas. This exposes them to higher risk of infectious diseases – often gastrointestinal infections, which are a particularly high risk for the health of children. Furthermore, increasing levels of air pollution, particularly in the cities, contribute to increased incidence of acute and chronic respiratory illness and allergies (21). The degradation of soil is a  further environmental factor, having an impact on health through poorer growth of crops and poorer nutritional quality of crops. Tajikistan’s vulnerability to climate change further threatens its food insecurity. More frequent droughts, floods and landslides have reduced agricultural productivity, increased losses and damaged farming livelihoods. Small agricultural plots limit household production and income, while climate change, manifested in rainfall variability and increasing temperatures, compounded by limited livelihood diversification, hampers smallholder productivity and incomes (16). Sustainable economic growth and the health and wellness of the population are at risk from the degradation of water, air, forests and agricultural land, and accelerated biodiversity loss. Tajikistan is disaster-prone and climate change is expected to cause an increase in the magnitude and frequency of climate-related hazards such as flooding and drought. This further threatens agricultural productivity and food security and undermines resilience. Sustainable management of the country’s natural resources will depend upon: policy and regulatory change and capacity development for climate change adaptation and mitigation; more efficient use of ecosystem resources – especially water; effective disaster risk management; and increased community readiness to respond to disasters and emergencies. This requires coordination mechanisms for ‘horizontal’ policy design and implementation, focused on the inter-actions between environment, energy, agriculture and livelihoods, especially for rural communities and vulnerable groups (10). Overall, insufficient resources are being deployed for climate change adaptation and emergency response. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Tajikistan Country Brief 55 People with disabilities, especially children, are among the most marginalized in Tajikistan. People with disabilities in Tajikistan face the challenges of (16): • gaps in laws and policy frameworks compared with Tajikistan’s international commitments that enable discrimination; • limited quality and accessibility of rehabilitation services and the availability of trained health-care workers, including for early diagnosis and care for children, particularly in rural areas; • inconsistent application of quality standards and adequate monitoring of disability and rehabilitation services; and • gaps in coordination and referral mechanisms among service providers and more secure, long-term funding. Another population segment needing attention are migrants (14). During different stages of their journey, migrants may face conditions that can pose risks to their physical, mental and social well-being. More effort is needed to address the health of migrants by developing strong cross-border mechanisms to promote better access to health services. Additionally, early detection and treatment mechanisms for STIs, HIV, TB and other communicable diseases should be agreed on between migrants’ counties of origin and recipient countries (14). Another major challenge in Tajikistan with serious consequences for public health, is safe drinking water and hygiene. Access to drinking water and sanitation is essential for general health and well-being. Currently, WASH facilities in hospitals and PHC centres are areas for concern. Many health-care facilities, especially in rural areas, lack proper water and sanitation, which can become a source of or exacerbate disease (14). Flagship Initiative 3: The European Immunization Agenda 2030 In 2018, vaccine coverage of at-risk groups for epidemic or pandemic prone diseases was 97.0% in Tajikistan, as was the proportion of the target population with access to three doses of diphtheria tetanus toxoid and pertussis vaccine immunization in 2019 (17). However, to combat the rise of STIs and viral hepatitis as previously discussed, Tajikistan is committed to implementing the European Immunization Agenda 2030, as well as facilitating an equitable COVID-19 vaccination campaign. The WHO Regional Office for Europe is well-suited to support these efforts, especially by convening subregional cooperation across Central Asia through Roadmap development and implementation (1). Through these initiatives, it will also be important to develop strategies that address vaccine acceptance and scepticism. Flagship Initiative 4: Healthier Behaviours: incorporating behavioural and cultural insights Safeguarding and, where possible, increasing social spending in areas such as health, social and child protection and education is a priority to protect Tajikistan’s most vulnerable groups from poverty and social exclusion. This requires improved planning, budgeting, allocation and monitoring of public finances and increasing the effectiveness and efficiency of social spending, including better targeting of and outreach to the most vulnerable groups. There is also a need to explore alternative, innovative funding sources and to prioritize spending on areas that maximize return on investments (for example, early childhood development). This aligns with the EPW’s intent to develop an investment case for developing a knowledge and evidence base in this area of work. Additionally, Tajikistan’s draft 2022–2023 BCA calls for behavioural and cultural insights (BCI) capacity building among national health authorities through training and participation in summer schools and the establishment of national BCI units or teams. As an example of an area where BCI-informed policy-making is needed, stigma and gender discrimination contribute to the spread of HIV and hinder access to adequate testing and treatment services (16). Criminal code article 125 Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)56 on intentional HIV transmission in Tajikistan has been used to persecute persons with HIV. HIV-related stigma worsens pre-existing social inequities based on race, class, gender, and sexual orientation. Women and girls often have less information about HIV and fewer resources to take preventive measures. They face challenges to the negotiation of safer sex, because of unequal power dynamics with men. Widespread sexual violence exacerbates the risk of HIV transmission. In addition, women with HIV are often exposed to various forms of domestic violence. Furthermore, women and their children generally assume a disproportionate burden of care for others who are sick from or dying of AIDS, regardless of their own HIV status. This leads to the reduction of educational and employment prospects. Local governments and health organizations only recently started to acknowledge the need to prevent HIV transmission among sex workers. Sex work is illegal and police raids against sex workers are required by law. Sex workers are detained, fined, and undergo compulsory testing for HIV and syphilis. Additionally, voluntary sex between adult men in the country is not illegal, however, it is culturally not accepted. There are no systemic data of violence against men who have sex with men, but this group often keep their sexual orientation hidden as they are commonly subjected to physical and psychological violence (16). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Tajikistan Country Brief 57 References4 4 All online references were accessed on 05 April 2022. 1. Biennial Collaborative Agreement between the Ministry of Health and Social Protection of the Population of the Republic of Tajikistan and the Regional Office for Europe of the World Health Organization 2022/2023 [DRAFT]. Copenhagen: WHO Regional Office for Europe; 2022. 2. Beyond income, beyond averages, beyond today: inequalities in human development in the 21st century. New York: United Nations Development Programme; 2019 (http://hdr.undp.org/ sites/default/files/hdr2019.pdf). 3. Voluntary National Review: Improving Living Standards through Mainstreaming of Sustainable Development Goals into the National Development Policy in Tajikistan. Dushanbe: UN Country Team Tajikistan; 2017 (https:// s u s t a i n a b l e d e v e l o p m e n t . u n . o r g / m e m b e r s t a t e s / taj ik is tan# :~: tex t=In%202017%2C %20Taj ik is tan%20 initiated%20preparation,Level%20Political%20Forum%20 (HLPF).&text=The%20theme%20of%20the%20VNR,of%2- 0living%20standards%20in%20Tajikistan.). 4. World Bank Open Data [online database]. Washington, D.C.: The World Bank; 2022 (https://data.worldbank.org/). 5. Khodjamurodov G, Sodiqova D, Akkazieva B, Rechel B. Tajikistan: health system review. Health Systems in Transition. 2016;18(1):1-114. 6. Human Development Reports: Latest Human Development Index Rankings [website]. New York: United Nations Development Program; 2022 (http://hdr.undp.org/en/content/ latest-human-development-index-ranking). 7. World Health Data Platform: The Global Health Observatory [online database]. Geneva: World Health Organization; 2022 (https://www.who.int/data/gho/data/indicators). 8. Poverty and Shared Prosperity 2020: Reversals of Fortune. Washington, D.C.: World Bank; 2020 ( ht tps : //o p e nk nowle dge .wo r ldbank .o rg / b i ts t ream / handle/10986/34496/9781464816024.pdf). 9. Strategy on the Healthcare of the Population of the Republic of Tajikistan up to 2030. Dushanbe: Government of the Republic of Tajikistan; 2021 (https://medt.tj/en/strategy-and- programes/nds2030). 10. The Government of Tajikistan and United Nations Sustainable Development Cooperation Framework (2023-2026). Dushanbe: Government of Tajikistan and United Nations; 2022 (https://unsdg.un.org/sites/default/files/2022-06/Tajikistan_ Cooperation_Framework_2023-2027_0.pdf). 11. Sustainable Development Report 2021: The Decade of Action for the Sustainable Development Goals. Country Profiles. New York: Sustainable Development Solutions Network; 2021 (https://dashboards.sdgindex.org/). 12. Sachs JD, Lafortune G, Kroll C, Fuller G, Woelm F. Sustainable Development Report 2022  - From Crisis to Sustainable Development: the SDGs as a  Roadmap to 2030 and Beyond. Cambridge: Cambridge University Press, 2022. (https://s3.amazonaws.com/sustainabledevelopment. report/2022/2022-sustainable-development-report.pdf). DOI: 10.1017/9781009210058. 13. SDG Indicators Database [online database]. New York: United Nations Department of Economic and Social Affairs; 2022 (https://unstats.un.org/sdgs/UNSDG/IndDatabasePage). 14. Integrated Socio-Economic Response Framework to COVID-19 for Tajikistan. Dushanbe: UN Country Team Tajikistan; 2020 (https://unsdg.un.org/resources/integrated-socio-economic- response-framework-covid-19-tajikistan). 15. European Health Information Gateway [online database]. Copenhagen: WHO Regional Office for Europe; 2022 (https:// gateway.euro.who.int/en/). 16. Common Country Analysis Tajikistan [DRAFT]. Dushanbe: UN Country Team Tajikistan; 2022. 17. Triple Billion Targets Dashboard [website]. Geneva: World Health Organization; 2022 (https://portal.who.int/ triplebillions/PowerBIDashboards/Countries). 18. Global Burden of Disease Compare Data Visualization [online database]. Seattle: Institute for Health Metrics and Evaluation, University of Washington; 2022 (https://vizhub.healthdata. org/gbd-compare/). 19. Assessment of sexual, reproductive, maternal, new-born, child and adolescent health in the context of universal health coverage in Tajikistan. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/ handle/10665/341975). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)58 20. Global Health Expenditure Database [online database]. Geneva: World Health Organization; 2022 (https://apps.who. int/nha/database/Select/Indicators/en). 21. Health Sector Tajikistan Policy Note [DRAFT]. Dushanbe: European External Action Service, Delegation of the European Union to Tajikistan; 2021. 22. Implementing alcohol policies in the Commonwealth of Independent States: a  workshop of “First Mover” countries. Copenhagen: WHO Regional Office for Europe; 2020 (https:// apps.who.int/iris/handle/10665/335946). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Turkmenistan Country Brief 59 2.5. Turkmenistan This country brief outlines Turkmenistan’s priorities for improving their population’s health and well-being from 2022– 2025. These priorities have informed the development of the Roadmap and its action areas and reform initiatives. This brief is not intended to be exhaustive or prescriptive. Rather, it intends to highlight key issues and areas where Turkmenistan may benefit from and contribute to united action for better health and well-being in Central Asia. The brief identifies a compiled list of Turkmenistan’s national health and well-being priorities (Table 2) that will inform the development and implementation of the Roadmap for Health and Well-being in Central Asia. 2.5.1. Health, well-being, and sustainable development progress in Turkmenistan Turkmenistan is an upper middle-income country whose gross domestic product (GDP) has multiplied over fifteen times since 2000, growing from approximately 2.9 to 45.2 billion United State dollar (US$) between 2000–2019 (1). Turkmenistan’s GDP did drop from 43.5 to 35.8 billion US$ between 2014–2015, but it has been steadily rising since then and between 2015–2019, Turkmenistan’s annual GDP growth rate averaged 6.3% per year. However, this rate slightly fell to 5.9% in 2020 as a consequence of the coronavirus disease 2019 (COVID-19) pandemic (2). Correspondingly, Turkmenistan’s unemployment rate was, on average, 4.2% of the total labour force between 2017–2019, but this figure increased to 5.0% in 2020 due to the pandemic (1). Turkmenistan lacks an official national poverty line; therefore, national poverty estimates cannot be collected. However, according to State Statistics Committee data, absolute poverty was eliminated in 2000 (2). Despite this, the country faces significant challenges in achieving major health related targets, namely neonatal mortality, under-5 mortality and mortality from suicides. High shares of out-of-pocket expenditure on health care in Turkmenistan contribute to pushing households and individuals into poverty, and limited access to data does not allow the tracking of those who might be left behind. Regardless of the stated progress on poverty reduction, progress has been uneven across regions and groups of the population, and the disparities could widen going forward, making it challenging to achieve the sustainable development goals (SDGs) (2). Turkmenistan has a population of approximately 6.0 million people (1). Between 2017–2020, Turkmenistan’s population grew, on average, by 1.6% each year (1). The population is young: the percentage of Turkmenistan’s population aged less than 15 years was 30.8% in 2020, which is around twice the European Union (EU)’s average of 14.1% (1). In contrast, the percentage of Turkmenistan’s population aged 65 years or older was 4.8% in 2020, which is more than four times smaller than the EU’s percentage of 20.8% for the same metric (1). Despite this, Turkmenistan’s population is slightly ageing. Between 2015–2020, the percentage of the population aged 65 years or older consistently grew from 4.1% to the 4.8% it is now (1). According to the 2020 Human Development Index (HDI), Turkmenistan ranks 111th out of 189 countries and territories and it is categorized as a country with high human development (3). Turkmenistan’s HDI increased from 0.666 to 0.715 between 2010–2019. This represents an average HDI growth of 0.49% per year, which is approximately two-thirds of Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)60 Europe and CA’s average growth of 0.76% per year during the same period. For reference, Europe and CA’s average HDI increased from 0.735 to 0.791 between 2010–2019 (3). Embedded in Turkmenistan’s improved HDI is their consistent increase in life expectancy over the past decade. Between 2010–2019, life expectancy increased from 71.09 to 72.97 years (+1.88 years) for females and from 63.62 to 66.48 years (+2.86 years) for males (4). However, these figures are still significantly below the WHO European Region’s average of 81.29 years for females and 75.09 years for males (4). Building back better and leaving no one behind after the COVID-19 pandemic will be imperative to sustain the progress on health, well-being, and sustainable development that Turkmenistan was making prior to the pandemic. This is especially true for the progress the country was making on poverty reduction, which is especially vulnerable to redaction from the pandemic (5). Ensuring that no one is left behind will therefore be critical for Turkmenistan to overcome the crisis and move forward with its development priorities, including the SDGs. 2.5.1.1. Looking forward: the health, well-being, and sustainable development trajectory in Turkmenistan Turkmenistan was one of the first countries to start consultations on the national adaptation of the SDGs, and on 20 September 2016 adopted all 17 SDGs and 148 targets to be implemented in the country until 2030 (6). The implementation of the SDGs followed a three-step process adopted by United Nations (UN) agencies and Turkmenistan to: 1) define the SDGs applicable to Turkmenistan; 2) integrate the SDGs selected by the country into national strategies, programmes and development plans; and 3) create a measurement system to assess progress in implementing the SDGs (6). The Ministry of Finance and Economy was appointed as the coordinator for monitoring progress in SDG implementation and the State Statistics Committee of Turkmenistan as responsible for the methodology, creation and maintenance of the SDG database. A comprehensive list of all national laws and regulations related to SDG 3 can be found in Turkmenistan’s 2020 SDG 3 progress report (6). In accordance, Turkmenistan’s Ministry of Health and Medical Industry (MoHMI) developed a State Health Programme of the President of Turkmenistan (2021–2025) (hereinafter, the SHP) and a subsequent Action Plan to guide progress towards achieving the health-related targets of SDGs 2– 6 and 13 (7). The main objectives of the SHP are to (7): • create a  unified system for prevention, improve health system management and foster multisectoral interdepartmental cooperation in public health protection; • improve public health protection and disease prevention; • increase the ability of the population to fight communicable diseases and noncommunicable diseases (NCDs); • modernize water, sanitation and hygiene (WASH) services and disease control; • implement cost-effective health-care projects on early diagnosis of diseases and their treatment, as well as achieve active participation of patients in their effective treatment; • improve the provision of medical care to the population; • improve the principle of family medicine; • further develop the pharmaceutical industry to improve the provision of high-quality, safe medicines and medical supplies, replace imported products on the domestic market and significantly increase export opportunities; • improve the material and technical supply of the health-care system; • develop digital medicine and e-health systems, as well as improve health statistics; • expand sustainable financing schemes for the health-care system and improve the health-care economy; • improve the state voluntary health insurance offered to citizens of Turkmenistan; • strengthen the contributions of the private sector to the health-care system; • improve the training of medical workers and continually improve their qualifications; • develop the fields of medical science and research; and • improve legislation related to the field of health care. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Turkmenistan Country Brief 61 Turkmenistan’s MoHMI has also developed an Action Plan that details 80 activities, and their responsible agencies, to guide the implementation efforts of the SHP. The Action Plan includes plans for the development of national health programmes for 2021–2025 related to communicable diseases, NCDs, maternal and child health, digital health systems, HIV, and tuberculosis (TB). With the support of the WHO Regional Office for Europe, a comprehensive analysis has been carried out and a report prepared covering Turkmenistan’s progress towards achieving SDG 3 and the health-related targets within other SDGs, such as education and gender (6). Based on this analysis, three of the accelerators outlined in the Global Action Plan for Health and Well-being were considered as priorities: primary health care (PHC), health financing and data systems (8). Supporting the development of a sustainable health workforce that can provide quality health services in the future was considered a further important area of investment (8). Considering the findings of the SDG progress report in 2020 (6), Turkmenistan’s UN Country Team finalized the Sustainable Development Cooperation Framework between the Government of Turkmenistan and the United Nations 2021–2025 (hereinafter, the CF TKM) (9). The CF TKM outlines three strategic priorities and five expected outcomes of cooperation. The third strategic priority, “Quality, inclusive and affordable health, education, and social protection”, contains the health-related Outcome 4: “The population of Turkmenistan enjoys higher quality and inclusive health and social protection services.” The UN Development System will help Turkmenistan achieve this outcome through efforts to (9): • strengthen the Government of Turkmenistan’s capacities to analyse spending patterns and planned outcomes of the national health and social protection programmes and identify areas for improvement, risks of exclusion, and to assure universal health coverage (UHC); • enhance capacities of the key health and social protection stakeholders to implement results-based budgeting, improve the efficiency of health and social protection spending and work with the Government of Turkmenistan to strengthen the governance of the health and social protection systems; • develop the capacities of health professionals and social workers to deliver quality and inclusive services and strengthen training and supervisory systems to ensure much stronger and more accountable delivery of quality services; • strengthen the management of NCDs and reduced NCD-related mortality through the implementation of evidence-based national guidelines, protocols, and standards, using a primary care approach; • provide assistance to the relevant government entities to address the recommendations from the human rights treaty bodies and mechanisms to strengthen social protection measures for women, children, persons with disabilities and other vulnerable groups, ensure unhindered access to all social services, and expand access to quality health-care services, including reproductive health and psycho-social counselling, particularly in rural areas; • work with the Government of Turkmenistan to improve statistics and data for better targeting and management of health and social protection programmes and spending; and • partner with civil society and community groups to improve people’s (especially vulnerable groups’) knowledge and access, to information about family planning, pregnancy, nutrition, caring practices for themselves, their children and dependents, healthy lifestyles, and the prevention of diseases. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)62 Additionally, the CF TKM specifies eight health-related indicators, including baseline measures and targets, to track the achievement of Outcome 4. These indicators cover measures from the percentage of Turkmenistan’s GDP allocated towards health to the rate of TB cases per 100 000 population. For more information regarding these specific indicators and targets, please see the CF TKM (9). Finally, Turkmenistan’s 2022–2023 biennial collaborative agreement is still being negotiated (10). However, it will honour all pre-existing international and national strategic frameworks for health and well-being that Turkmenistan has committed to between 2022–2023, including those referenced in this brief. Notably, these include the Thirteenth General Programme of Work 2019–2023 (GPW), EPW, SDGs, SHP and CF TKM. Notably, in 2021, the WHO Country Office in Turkmenistan identified seven priority pillars for cooperation between WHO and Turkmenistan (11): 1) communicable diseases; 2) health systems; 3) NCDs; 4) preparedness, surveillance and response to public health emergencies; 5) influence of environmental factors and mitigation of the effects of climate change on health; 6) promotion of health lifestyles; and 7) capacity building at the PHC level. 2.5.1.2. SDG 3 progress: Ensure healthy lives and promote well-being for all at all ages SDG 3 aims to ensure healthy lives and promote well-being for all at all ages. In 2021, a  thorough analysis of Turkmenistan’s progress achieving SDG 3 revealed areas where health and well-being have been advanced and where challenges remain (12). These trends are summarized in Table 16. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Turkmenistan Country Brief 63 Table 16. Selected targets and indicators to track Turkmenistan’s progress on SDG 3. SDG 3 Targeta Statusb Description Indicator(s) 3.1 Target achieved By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births. • 3.1.1: Maternal mortality ratio: Decreased from 29.0 to 7.0 per 100 000 live births from 2000–2017. 3.2 Major challenges remain By 2030, end preventable deaths of new-borns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-five mortality to at least as low as 25 per 1000 live births. • 3.2.1: Children under-five mortality rate: Decreased from 69.8 to 42.0 deaths per 1000 live births from 2000–2019. • 3.2.2: Neonatal mortality rate: Decreased from 29.7 to 23.6 deaths per 1000 live births from 2000–2019. 3.3 Significant challenges remain By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases. • 3.3.2: Tuberculosis incidence: Decreased from 85 to 45 incidence per 100 000 population from 2000–2019 (13). 3.4 Major challenges remain By 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being. • 3.4.1: Risk of dying between the ages of 30 and 70 from one of four main NCDs (cardiovascular disease, cancer, diabetes, or chronic respiratory disease): Decreased from 37.3% to 27.7% from 2000–2019. • 3.4.2: Suicide mortality rate: Decreased from 12.5 to 5.7 deaths per 1000 population from 2000–2019. 3.5 Challenges remain Strengthen the prevention and treatment of substance abuse. • 3.5.2: Alcohol consumption per capita among population aged 15 years and older: Increased from 2.6 to 3.1 litres of pure alcohol from 2000–2019. 3.6 Significant challenges remain By 2020, halve the number of global deaths and injuries from road traffic accidents. • 3.6.1: Death rate due to road traffic injuries: Decreased from 16.1 to 13.5 deaths per 100 000 population from 2000–2019. 3.7 Target achieved By 2030, ensure universal access to sexual and reproductive health-care services. • 3.7.1: Proportion of women of reproductive age with their needs met for family planning with modern methods: Increased from 67.5% to 79.6% from 2000– 2019. • 3.7.2: Adolescent birth rate: Decreased from 26.1 to 22.0 per 1000 women aged 15–19 years from 2000–2017. 3.8 Challenges remain Achieve UHC, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. • 3.8.1: Service coverage indexc: Increased from 54.0 to 73.0 from 2000–2019. Notes. NCDs: noncommunicable diseases; SDGs: Sustainable Development Goals; UHC: Universal health coverage. a For brevity, some SDG 3 targets and indicators were excluded when the health issues they addressed were not relatively high priorities or needs in Turkmenistan’s context (for example, tropical diseases) or if there was no data available for their indicators. b The status assigned to each target was determined by an analysis carried out by the Sustainable Development Report (12), which was authored by the Sustainable Development Solutions Network. All data used to create the Sustainable Development Report are based on Sachs et al. (2022)’s publication (14). The indicators selected for this table represent some of the many indicators that were considered when these assessments were made. c There are significant limitations associated with this measure of service coverage. Source: Adapted from (12, 15). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)64 2.5.2. Lessons learned from the COVID-19 pandemic Turkmenistan has not reported any cases of COVID-19 in the country to WHO, nor has it communicated information on their epidemiological situation (2). Despite this, Turkmenistan remains committed to implementing its Preparedness and Response Plan for Acute Infectious Disease/Country Preparedness and Response Plan (CPRP), which was developed in Turkmenistan with extensive support of WHO. The priority areas of the CRPR, updated in 2021, include: leadership, coordination, planning and monitoring; risk communication and community engagement; surveillance, case investigation and contact tracing; travel, trade and points of entry; diagnostics and testing; infection prevention and control (IPC); case management and therapeutics; operational support and logistics; essential health systems and services; vaccination; and research, innovation and evidence (2). In the framework of the EU and WHO Regional Office for Europe’s Central Asia COVID-19 Crisis Response Programme, the Government of Turkmenistan focused on improving the readiness of health-care facilities; scaling up laboratory capacity and testing strategies; the capacity building of health-care workers in IPC, contact tracing and case management; the development of vaccines, vaccine deployment and planning; and the delivery of personal protective equipment (PPE) and testing kits for laboratories. Consequently, support was provided for the development of the laboratory strategy for Turkmenistan. Existing gaps were identified and the quality of work in regional laboratories was improved through regular mentor evaluation visits. In July 2020, a joint mission to review and strengthen preparedness for and response to the COVID-19 pandemic was conducted between the WHO Regional Office for Europe and Turkmenistan’s health authorities (16). A second WHO mission was conducted in November 2021. The 2020 review detailed lessons learned from the COVID-19 pandemic in Turkmenistan. These lessons included to (16): • strengthen local production capacity for PPE, consumables and disinfectants; • report any unusual or unexpected occurrence of disease or death in compliance with the International Health Regulations (2005) (IHR) to WHO, especially in the case of COVID-19, and facilitate greater access to resources from international stakeholders; • ensure financial resources and human resources for health (HRH) for critical public health functions and the health-care system to reach full response capacity level; • reinforce strategic planning and critical public communication on public health and social measures; • review the care system for the COVID-19 pandemic and future health emergencies across all levels of the health system to ensure that all patients receive safe care, essential services continue, and IPC is implemented from the community to the hospitals, including in the regions and provinces outside Ashgabat, the country’s capital; and • improve the communication of regular and accurate health advice, information on risks and details of what protective measures are introduced and their intended duration by extending and strengthening risk communications and community engagement channels, such as social and digital media, nongovernmental organizations and community and religious leaders. Additionally, the report noted a  need for strengthened surveillance systems in Turkmenistan. Four areas where surveillance systems need improvement include: 1) surveillance operations; 2) data management; 3) data analysis and reporting; and 4) case and contact investigation (16). Similarly, more extensive recommendations were made regarding the improvement of the following areas in Turkmenistan: 1) national laboratory systems; 2) IPC; 3) case management; and 4) supply chains and logistics (16). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Turkmenistan Country Brief 65 2.5.3. Closing the Health Gap: aligning Turkmenistan’s priorities with the EPW Turkmenistan’s current national health priorities and gaps are discussed below in context of the EPW’s framework. 2.5.3.1. Core Priority 1: Moving towards UHC Moving towards UHC is a high priority for Turkmenistan. To achieve UHC, the SHP outlines eight priority areas of the health-care system (7): 1) prevention and PHC; 2) multisectoral interdepartmental cooperation; 3) sustainable health- care financing; 4) organization of health services according to international standards, based on modern requirements; 5) continuing to develop and reform the health-care system based on the achievements of Turkmenistan’s world- leading medical science and education; 6) strengthening the material and technical base of health care; 7) providing high-quality and affordable medical services; and 8) providing advanced training for medical workers and the teachers and professors of the State Medical University of Turkmenistan, including by supporting their professional development through education and training abroad. Progress towards UHC is monitored in two dimensions: the coverage of essential health services and financial hardship. Each is covered further in the context of Turkmenistan below. Coverage of essential health services In 2019, 16  700 more people in Turkmenistan (0.2% of the population) were covered by essential health services than in 2018. By 2023, this number is projected to be 47 300 more people (0.8% of the population) (17). Coverage of essential health services is defined as the average coverage of the 14 SDG 3.8.1 tracer interventions. Of these 14 indicators, positive progress is projected for seven of them in Turkmenistan by 2023 (Table 17). Table 17. Projected percentage point changes in normalized valuesa across the 14 SDG 3.8.1 tracer interventions for service coverageb from 2018–2023 in Turkmenistan. Service Coverage Indicator 2018 value (%) Projected 2023 value (%) Projected change (%) Basic sanitation 98.9 99.5 +0.6 Care seeking for pneumonia for children under 5 65.8 70.4 +4.6 DTP3 immunization 99.0 98.8 -0.2 Health worker density 43.0 41.7 -1.3 Hospital bed density 100.0 100.0 0.0 IHR core capacity index 67.0 68.7 +1.7 ITN use N/A N/A N/A Mean fasting blood glucose 37.1 22.8 -14.3 Need met for family planning 75.3 76.4 +1.1 Non-elevated blood pressure 49.7 50.5 +0.8 People living with HIV receiving ART 53.2 66.4 +13.2 TB cases treated 80.0 80.0 0.0 Tobacco non-use 74.4 76.3 +1.9 Women who received antenatal care visits 4+ times 97.6 97.3 -0.3 Notes. ART: Antiretroviral therapy; DTP3: Three doses of diphtheria tetanus toxoid and pertussis vaccine; IHR: International Health Regulations (2005); ITN use: Insecticide-treated bed net use among people at-risk of malaria; TB: Tuberculosis. a Some indicators in this chart have been transformed to have values between 0 and 100 (0 worst–100 best). Further information regarding the indicators can be found at (17). b There are significant limitations associated with this method of measuring service coverage. c N/A indicates the data is not available. Source: Adapted from (17). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)66 Communicable diseases and NCDs are significant public health burdens in Turkmenistan. In 2019, 21.95% of deaths in Turkmenistan were caused by communicable diseases and maternal, prenatal and nutrition conditions (1), and 18.11% of disability-adjusted life years (DALYs) were attributable to communicable diseases (18). In comparison, the EU’s averages for these two metrics in 2019 were 5.55% and 4.04%, respectively. The percentages of deaths and DALYs attributable to NCDs in Turkmenistan in 2019 were 72.30 (1) and 73.66% (18), respectively. In comparison, the EU’s averages for these two metrics in 2019 were 89.82% and 87.55%, respectively. A more systematic, high quality health information system that improves the monitoring of service delivery for NCDs, progresses sustainable health financing policies, and enhances the assessment of providers’ performance is needed to improve the health system and tackle Turkmenistan’s burden of NCDs. Therefore, Turkmenistan is committed to achieving a PHC system that is accessible, equitable, integrated, community-oriented and includes support for screening and prevention. To do so, the SHP outlines a vision for expanding health promotion, disease prevention and the use of traditional and non- traditional medical practices. Screening, as well as voluntary medical and preventive measures, will be carried out to protect human health and promote the prevention, diagnosis and effective treatment of diseases (7). Improving Turkmenistan’s PHC system will require improvements in the country’s health governance and HRH. The SHP outlines specific reforms to the PHC system particularly to make medicines and services more affordable and accessible, to better organize PHC personnel and to improve the interaction of family medicine with in-patient or specialized care services. Relatedly, the SHP also introduces initiatives to improve the education of health-care personnel and advance the fields of medical research and development in Turkmenistan (7). The SHP also introduces a range of programmes aimed at protecting the health of Turkmen citizens at all stages of their lives and outlines specific health promotion activities that target various demographics, across chapters dedicated each to: maternal, child and adolescent health; nutrition and physical activity for adolescents; sexual and reproductive health services; adult health, especially in relation to addressing NCDs and occupational work hazards; the health of men; and the health of people who are elderly. Throughout, the SHP calls for increased PHC integration with specialized care to expand access to the prevention, screening, monitoring and treatment of disease (7). In 2020, the Government of Turkmenistan and the United Nations Children’ Fund finalized their joint Country Programme of Cooperation (19). In it, they detail five priority areas of work: 1) governance for children; 2) social and child protection; 3) COVID-19 prevention and response; 4) child health, nutrition and early childhood development; and 5) quality, inclusive education. The priorities and commitments detailed in the Country Programme of Cooperation are complementary to the efforts of the SHP and the health-related SDG targets (19). Financial hardship Ensuring everyone can access high-quality health services without facing financial hardship is a key target of the EPW and SDGs. At the governmental level, the percentage of GDP spent on health in 2018 in Turkmenistan was only 1.20%, which is significantly lower than the WHO European Region’s average of 4.87% (20). As outlined in the CF TKM, the Government of Turkmenistan aims to increase public health spending to 5.0% of GDP by 2025 (9). At the patient level, the percentage of health expenditure covered by out-of-pocket payments in 2018 in Turkmenistan was 76.34%, which is more than two and a half times greater than the WHO European Region’s average of 29.82% for the same metric (20). In contrast, only 4.9% of costs are estimated to be covered by Turkmenistan’s voluntary health insurance (2). These high out-of-pocket expenditures, coupled with additional health expenditures and rising price trends caused by the COVID-19 pandemic, affect vulnerable groups the most (2). This is likely to force vulnerable groups, including people with disabilities, low-income households, lonely elderly, women, and other marginalized groups, to shift to lower-priced, often lower-nutrient dense foods accompanied by a  reduced engagement in overall health-seeking behaviours. Together, these factors compound and severely negatively affect the health statuses of these groups (2). According to the Multiple Indicator Cluster Surveys 2019, voluntary health insurance coverage is also disproportionately low among women, rural communities, and households in the poorest income quintiles (2). A more in-depth analysis of Turkmenistan’s health budget is needed with a view to increasing general budget health expenditures to ensure quality health services for all. The SHP identifies an array of objectives and initiatives to reduce the financial hardship experienced from health- care spending in Turkmenistan (7). The priority actions are to: improve the state voluntary medical insurance of citizens of Turkmenistan; develop the pharmaceutical industry and strengthen the provision of medicines; strengthen the material and technical base of health care; and to develop sustainable financing of the health-care system and improve the health-care economy (7). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Turkmenistan Country Brief 67 Flagship Initiative 1: The Mental Health Coalition Turkmenistan is committed to finalizing the implementation of the National Programme for 2018–2022 on the Protection of the Mental Health of the Population of Turkmenistan. The lessons learned from this Programme can be used to inform the development of future mental health care initiatives in Turkmenistan (7). Future work will need to continue improving access to mental health care, especially for people who require specialized services, as well as mechanisms for screening, detection and treatment. Additionally, the 2020 progress report on Turkmenistan’s achievement of SDG 3 revealed that it is a  high priority to continue integrating mental health care into the PHC system (6). Behavioural and cultural insights that inform mental health care needs and care-seeking patterns in Turkmenistan will also need to be further considered. For example, the pressure to remain emotionally resilient often prevents men from seeking help when they experience anxiety, depression and other mental-health issues (2). Additionally, the COVID-19 pandemic and its subsequent economic hardships have likely been detrimental for the mental well-being of youth. Therefore, focused and more in-depth studies are needed to understand the impact of the pandemic on youth and develop mental health programmes accordingly (2). Flagship Initiative 2: Empowerment through Digital Health A chapter of the SHP is dedicated to developing the digital medicine system and improving health statistics in Turkmenistan. Consequently, the MoHMI has identified a considerable list of priority actions to support Turkmenistan’s goals of progressing its digital health technologies and telemedicine capacities. These efforts include to: • implement the interdepartmental plan to coordinate the development of the health information system; • develop a health-care telecommunications plan; • expand the use of Internet resources and cellular communications; • strengthen the structure of the health information and statistical system by expanding the capabilities of information and computer technologies; • develop advanced e-health management methods; • improve the established procedures of the relevant legislation on electronic health care; • improve the professional skills of medical workers using modern methods and tools, including modern simulation (virtual or imaginary) communication systems (online); • implement successful health-care informatization projects in practice; • improve the information and analytical system of health care (clinical and other health registers); and • develop and implement plans for the creation of electronic libraries, national electronic health records, laboratory information systems and video image production systems. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)68 Lockdowns and travel restrictions introduced in response to the COVID-19 pandemic in Turkmenistan have aggravated the need for development of digital health services (2). Telemedicine technologies could potentially help address the unmet health needs of women, children and particularly for rural populations and those with transportation and childcare barriers. Therefore, UN agencies and the MoHMI have engaged in dialogue on the introduction of telehealth services. However, limitations are in place in terms of infrastructure for making telehealth services available. For instance, most facilities at the PHC level do not have cable Internet provided by the Government. Consequently, doctors often pay for internet services on their smartphones (2). Further, obstetrician–gynaecologists and family practitioners who practice telehealth have limited capacity to use online platforms to ensure quality of care and patient safety. Measures need to be taken to ensure that remote areas are well equipped to respond to the challenges and that practitioners have enhanced digital skills. It is also important to provide the population, via the internet, access to information on medical services, prices, and benefits offered by every institution in Turkmenistan that provides health services. Every large institution, specifically, should have its own website with all relevant information about its structure and services. Improvements in this regard will require the re-orientation of financial plans and budgets, as well as the development of digital solutions, capacities and skills at national and local levels to enforce and expedite the implementation of the National Digital Health Strategy (2019–2025) (2). 2.5.3.2. Core Priority 2: Protecting against health emergencies In 2019, Turkmenistan better protected 125 700 more people (2.0% of the population) from health emergencies than in 2018. By 2023, this number is projected to reduce to only 118 300 more people (26.7% of the population) being better protected than in 2018. In 2019, Turkmenistan scored 84.0% within the Health Emergency Protection Index (HEPI). HEPI is calculated based on three sub-indicators: 1) preparedness; 2) prevention; and 3) detection and response (17). Preparedness In 2020, Turkmenistan scored 68.0% in the preparedness sub-indicator. This sub-indicator assesses emergency preparedness by averaging the scores of all 13 IHR core capacities at the country level, which are reported through the States Parties Annual Report tool (17). A comprehensive analysis of Turkmenistan’s compliance with the IHR can be found at (6). Prevention In 2019, Turkmenistan scored 99.0% in the prevention sub-indicator. This sub-indicator assesses efforts to prevent health emergencies through routine and targeted vaccine campaign efforts. It includes vaccination coverage for five major infectious diseases: measles, polio, meningococcal meningitis A, yellow fever, and cholera (17). Detection and response No information is available in Turkmenistan for the detection and response sub-indicator. Moving forward, Turkmenistan’s capacity should be developed to track this indicator. This sub-indicator assesses the appropriateness of a country’s reaction to an event of potential public health concern. It averages the time from a public health event’s start to detection, notification and response to provide an overall measure of timeliness (17). The SHP calls for improving the preparedness of the health system for emergency situations; the prevention of harmful effects on health from environmental hazards and other risk factors; and strengthening of sanitation measures and the fight against the spread of diseases (7). To achieve these goals, the SHP outlines a list of priority actions. These include to: • continually monitor the state of natural and artificial environments; • strengthen epidemiological surveillance, immediate response measures and appropriate regulatory legal acts in accordance with recognized norms of international law; Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Turkmenistan Country Brief 69 • improve the capabilities of the national laboratories for emergency preparedness, early detection and timely response; • improve WASH services and expand access to WASH facilities in health-care settings, • improve IHR capacities and compliance; • fight against obesity and injury by ensuring a safe environment, proper physical activity and healthy nutrition; • improve the prevention of diseases caused by chemical, biological and physical environment influences; • mitigate the harmful effects of climate change on health emergency preparedness; • maintain polio eradication, malaria, measles and rubella elimination; • improve the prevention, detection and treatment of HIV, TB, viral hepatitis, and sexually transmitted infections; and • improve sanitary quarantine points at all air, transport and railway border crossings and build new buildings for sanitary quarantine points, which will be equipped with modern technologies. Additionally, in 2021, Turkmenistan’s Acute Communicable Disease Preparedness and Response Plan was revised to reflect the progress of activities undertaken by the Government of Turkmenistan in cooperation with UN agencies and in accordance with the latest updated WHO Strategic Plan for Preparedness and Response to COVID-19 (10). The WHO strategic plan was designed to provide support to the government on the public health response to COVID-19 at the national and subnational levels. In the implementation of this plan, significant work was done to strengthen the country’s capacity in the field of preparedness and response to emergencies (10). The work this plan initiated should be continued moving forward. 2.5.3.3. Core Priority 3: Promoting health and well-being In 2019, 56 700 more people in Turkmenistan (0.9% of the population) enjoyed better health and well-being than in 2018. By 2023, that number is projected to reach 199 800 more people (3.2% of the population) (17). The healthier populations (HPOP) index uses 16 outcome indicators related to social, environmental, and behavioural risks to assess the number of people whose lives have become healthier. In Turkmenistan, seven of the 16 indicators are projected to improve between 2018 and 2023 (Table 18). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)70 Table 18. Projected changes in the normalized valuesa of the 16 indicators of the HPOP index from 2018–2023 in Turkmenistan. HPOP Indicator 2018 value (%) Projected 2023 value (%) Projected change (%) Access to safely managed drinking water sources 94.8 97.8 +3.0 Access to safely managed sanitation services N/A N/A N/A Adults not obese 82.1 79.6 -2.5 Ambient air quality 82.7 84.2 +1.5 Best practice policy implemented for healthy fats production 85.7 85.7 0.0 Children under 5 developmentally on track N/A N/A N/A Children (aged 5–19) not obese 95.3 94.4 -0.9 Children under 5 not overweight 96.1 96.6 +0.5 Children under 5 not stunted 91.5 93.8 +2.3 Children under 5 not wasted 95.9 96.0 +0.1 Primary reliance on clean household fuels 99.8 99.6 -0.2 Reduced alcohol use 87.7 87.7 0.0 Reduced child (aged 1–17) violence N/A N/A N/A Reduced partner violence N/A N/A N/A Reduced road traffic mortality 96.6 97.2 +0.6 Reduced suicide attempts 99.4 99.5 +0.1 Tobacco non-use N/A N/A N/A Notes. HPOP: healthier populations. a Some indicators in this chart have been transformed to have values between 0 and 100 (0 worst–100 best). b N/A indicates the data is not available Further information regarding the indicators can be found at (17). Source: Adapted from (17). Several initiatives are documented within the SHP that promote health and well-being. These initiatives include to (7): • promote health and prevent NCDs, at the population level, especially by targeting high-risk groups; • reduce the incidence of high blood pressure, high cholesterol, and obesity by promoting physical education, sports and healthy nutrition; • promote health literacy and education among young people; • create comfortable conditions for life, work, the environment, culture, economy, physical education, and sports to guarantee citizens’ right to their health; • improve the provision of pure drinking water, healthy nutrition and clean, non-polluted environments; • strengthen the implementation of WASH services and environmental standards in workplaces, homes and settlements to prevent cardiovascular, oncological, eye, hearing and communicable diseases; • ensure citizens’ ability to exercise regularly, including by providing opportunities for walking and cycling in urban planning; • fulfil the tasks set out in the National Plan for Healthy Nutrition of the Population of Turkmenistan (2020–2025); • conduct studies in partnership with the WHO Childhood Obesity Surveillance Initiative; Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Turkmenistan Country Brief 71 • transform Turkmenistan into a  tobacco-free country by 2025 by preventing tobacco advertising, informing citizens of the harmful effects of tobacco products, increasing taxes on tobacco products and fully implementing the WHO Framework Convention of Tobacco Control; • implement government measures to combat substance abuse disorders; • combat alcoholism by campaigning and raising awareness, strictly regulating the retail sale of alcoholic beverages, preventing drunk driving and strengthening diagnostic, consultative and rehabilitative medical procedures; • reduce mortality caused by road accidents by raising awareness and implementing measures to prevent injuries and disabilities; and • implement comprehensive measures to prevent disabilities resulting from disease, work or personal injury. Regarding the harmful use of alcohol, Turkmenistan was one of the “first-mover” countries who implemented the WHO Global Strategy to Reduce the Harmful Use of Alcohol and the WHO European Action Plan to Reduce the Harmful Use of Alcohol 2012–2020 (21). By doing so, Turkmenistan adopted WHO’s three best-buy interventions in reducing the alcohol-attributable burden, including to: 1) increase taxes on alcoholic beverages; 2) enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising; and 3) enact and enforce restrictions on the physical availability of retailed alcohol. Moving forward, Turkmenistan should seek to expand the ability of the PHC system to provide screening and brief interventions for alcohol abuse disorders. Health authorities will also prioritize the implementation of the National Programme for the Prevention of Harmful Effects of Alcohol in Turkmenistan for 2018–2024 (6). Air pollution is a significant risk factor in Turkmenistan, and environmental health challenges and extreme weather events are also significant concerns. The age-standardized mortality rate attributed to household and ambient air pollution in Turkmenistan was high in 2016 at 79.30 deaths per 100 000 population, which is more than twice the WHO European Region’s average for this metric of 30.0 per 100 000 population (4). The SHP addresses health and environmental safety by calling for initiatives to (7): • implement comprehensive measures to protect land, air and water resources; • equip industrial enterprises with the most advanced and environmentally safe technologies in the world; • strictly monitor the use of chemicals in the cultivation of agricultural crops and promote the use of biological and agrotechnical methods that are safe for human and environmental health; • ensure the sanitary provision of clean drinking water to the population; and • employ technologies and advanced research techniques to identify and prevent toxic substances from entering food production, and ensure food safety. The WHO Regional Office for Europe will assist and support the MoHMI to initiate and implement joint initiatives on an integrated approach aimed at ensuring a holistic approach to tackling threats to animal, human and plant health as well as their shared environment. This support includes the implementation of collaborative One Health activities in areas such as food safety, zoonoses, laboratory services, environment and health, and antimicrobial resistance (AMR) (10). Turkmenistan is one of the WHO Regional Office for Europe’s priority countries for the implementation of the Partnership Contribution within the Pandemic Influenza Preparedness (PIP) framework. With support from the PIP framework, the country has strengthened national capacities for laboratory and epidemiological surveillance of influenza and acute respiratory infections, and the WHO Regional Office for Europe will continue to provide support in this area. For example, with support from the WHO Regional Office for Europe, the MoHMI developed the Strategic Plan on Strengthening Control Measures for Viral Hepatitis in Turkmenistan for the Period of 2019–2030. Additionally, in 2016, Turkmenistan joined the Better Labs for Better Health initiative, which also seeks to strengthen the capacity of the laboratory service in the health sector. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)72 Regarding the influence of environmental factors, a National Plan for the adaptation of the health of the population of Turkmenistan to climate change and its adverse impacts for 2020–2025 was recently developed in cooperation with WHO. Additionally, Turkmenistan has initiated work on developing a Heat health action plan, and, in collaboration with WHO, they have also initiated a UN Water Global Analysis and Assessment of Sanitation and Drinking-Water country survey for the 2021–2022 period. Ultimately, this will lead to conducting a survey of WASH availability in health-care facilities. Finally, Turkmenistan is committed to preventing the emergence and spread of drug-resistant microorganisms. Combatting AMR is a high priority for Turkmenistan that the country plans to tackle through the National Strategy and Action Plan to Combat Antimicrobial Resistance Preparations for the Period 2017–2025, which includes initiatives to improve surveillance and laboratory capacity (6). An additional method Turkmenistan will employ to combat AMR will be to implement measures for the safe processing of medical waste (7). Flagship Initiative 3: The European Immunization Agenda 2030 Immunization is mandatory for all children and is provided free of charge (6). Therefore, In 2018, vaccine coverage of at-risk groups for epidemic or pandemic prone diseases was 99.0% in Turkmenistan (17). The proportion of the target population with access to three doses of diphtheria tetanus toxoid and pertussis vaccine immunization was also 99.0% in 2019 (17). Additionally, an immunization programme for boys and girls aged 9 years using 2 doses of a quadrivalent human papillomavirus (HPV) vaccine has been in place since 2016. The approach has been successful, resulting in a high coverage of over 95.0% (6). According to the WHO Joint External Evaluation conducted in 2016, immunization is a priority for Turkmenistan (6). The national vaccination programme includes vaccines against 14 vaccine preventable infections (hepatitis B, polio, TB, measles, rubella, mumps, diphtheria, Haemophilia influenzae type b, pertussis, tetanus, HPV, rotavirus, hepatitis A and pneumococcal infection). Therefore, Turkmenistan is committed to implementing the European Immunization Agenda 2030, as well as facilitating an equitable COVID-19 vaccination campaign. The WHO Regional Office for Europe is well-suited to support these efforts, especially by convening subregional cooperation across Central Asia through Roadmap development and implementation. Through these initiatives, it will also be important to develop strategies that address vaccine acceptance and scepticism. Flagship Initiative 4: Healthier Behaviours: incorporating behavioural and cultural insights (BCIs) Safeguarding and, where possible, increasing social spending in areas such as health, social and child protection and education is a priority to protect Turkmenistan’s most vulnerable groups from poverty and social exclusion. This requires improved planning, budgeting, allocation and monitoring of public finances and increasing the effectiveness and efficiency of social spending, including better targeting of and outreach to the most vulnerable groups. There is also a need to explore alternative, innovative funding sources and to prioritize spending on areas that maximize return on investments (for example, early childhood development). This aligns with the EPW’s intent to develop an investment case for developing a knowledge and evidence base in this flagship’s area of work. As an example of an area where BCI-informed policy-making is needed, ongoing difficulties and, in some cases, prejudices against people living with HIV/AIDS persist in Turkmenistan. A National Centre for Prevention of HIV/AIDS exists, but the official incidence of HIV in the country is reportedly zero. A  focus group discussion conducted for Turkmenistan’s 2021 Common Country Analysis found that there is considerable stigma directed at those living with HIV and that the lack of community-based services, staffed by professionals, is a factor contributing to the invisibility and the lack of support for this community. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Turkmenistan Country Brief 73 References5 5 All online references were accessed on 05 April 2022. 1. World Bank Open Data [online database]. Washington, D.C.: The World Bank; 2022 (https://data.worldbank.org/). 2. Turkmenistan Common Country Analysis. Ashgabat: United Nations Turkmenistan; 2021 (https://minio.dev. devqube.io/uninfo-production-main/56128eda-175f-4eda- 9f67-5c43d2950dc7_CCA_Update_2021_TKM_FINAL_2_ Dec_2021.pdf). 3. Human Development Reports: Latest Human Development Index Rankings [website]. New York: United Nations Development Program; 2022 (http://hdr.undp.org/en/content/ latest-human-development-index-ranking). 4. World Health Data Platform: The Global Health Observatory [online database]. Geneva: World Health Organization; 2022 (https://www.who.int/data/gho/data/indicators). 5. Poverty and Shared Prosperity 2020: Reversals of Fortune. Washington, D.C.: World Bank; 2020 ( ht tps : //o p e nk nowle dge .wo r ldbank .o rg / b i ts t ream / handle/10986/34496/9781464816024.pdf). 6. Health and sustainable development: achieving Sustainable Development Goal 3 on health and well-being and other health related SDG targets in Turkmenistan. Progress report. Copenhagen: WHO Regional Office for Europe; 2020 (https:// apps.who.int/iris/handle/10665/338442). 7. State Health Programme of the President of Turkmenistan (2021-2025). Ashgabat: President of Turkmenistan; 2021. 8. The Global Action Plan in Turkmenistan: coming together for healthy lives and well-being (2020). Copenhagen: WHO Regional Office for Europe; 2020 (https://www.who.int/ europe/publications/m/item/the-global-action-plan-in- turkmenistan-coming-together-for-healthy-lives-and-well- being). 9. Sustainable Development Cooperation Framework between the Government of Turkmenistan and United Nations 2021- 2025. Ashgabat: United Nations Turkmenistan; 2021 (https:// turkmenistan.un.org/en/138515-sustainable-development- cooperation-framework-between-government-turkmenistan- and-united). 10. Biennial Collaborative Agreement between the Ministry of Health and Medical Industry of Turkmenistan and the Regional Office for Europe of the World Health Organization 2022/2023 [DRAFT]. Copenhagen: WHO Regional Office for Europe; 2022. 11. United Nations in Turkmenistan [website]. Ashgabat: United Nations Turkmenistan; 2021 (https://turkmenistan.un.org/ en/151992-united-nations-turkmenistan). 12. Sustainable Development Report 2021: The Decade of Action for the Sustainable Development Goals. Country Profiles. New York: Sustainable Development Solutions Network; 2021 (https://dashboards.sdgindex.org/). 13. WHO Report 2002 Global Tuberculosis Control. Geneva: World Health Organization; 2002 (https://apps.who.int/iris/ handle/10665/63835). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)74 14. Sachs JD, Lafortune G, Kroll C, Fuller G, Woelm F. Sustainable Development Report 2022  - From Crisis to Sustainable Development: the SDGs as a  Roadmap to 2030 and Beyond. Cambridge: Cambridge University Press, 2022. (https://s3.amazonaws.com/sustainabledevelopment. report/2022/2022-sustainable-development-report.pdf). DOI: 10.1017/9781009210058. 15. SDG Indicators Database [online database]. New York: United Nations Department of Economic and Social Affairs; 2022 (https://unstats.un.org/sdgs/UNSDG/IndDatabasePage). 16. COVID-19 support mission to Turkmenistan, 6–16 July 2020. Copenhagen: WHO Regional Office for Europe; 2020 (https:// www.euro.who.int/en/countries/turkmenistan/publications/ covid-19-support-mission-to-turkmenistan,-616-july-2020). 17. Triple Billion Targets Dashboard [website]. Geneva: World Health Organization; 2022 (https://portal.who.int/ triplebillions/PowerBIDashboards/Countries). 18. Global Burden of Disease Compare Data Visualization [online database]. Seattle: Institute for Health Metrics and Evaluation, University of Washington; 2022 (https://vizhub.healthdata. org/gbd-compare/). 19. United Nations Children’s Fund and Government of Turkmenistan Country Programme of Cooperation for 2021- 2025. Ashgabat: United Nations Turkmenistan; 2022 (https:// turkmenistan.un.org/en/171757-united-nations-childrens- fund-and-government-turkmenistan-country-programme- cooperation-2021). 20. Global Health Expenditure Database [online database]. Geneva: World Health Organization; 2022 (https://apps.who. int/nha/database/Select/Indicators/en). 21. Implementing alcohol policies in the Commonwealth of Independent States: a  workshop of “First Mover” countries. Copenhagen: WHO Regional Office for Europe; 2020 (https:// apps.who.int/iris/handle/10665/335946). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Uzbekistan 75 2.6. Republic of Uzbekistan This country brief outlines the Republic of Uzbekistan’s priorities for improving their population’s health and well-being from 2022–2025. These priorities have informed the development of the Roadmap and its action areas and reform initiatives. This brief is not intended to be exhaustive or prescriptive. Rather, it intends to highlight key issues and areas where Uzbekistan may benefit from and contribute to united action for better health and well-being in Central Asia. The brief identifies a compiled list of Uzbekistan’s national health and well-being priorities (Table 2) that will inform the development and implementation of the Roadmap for Health and Well-being in Central Asia. 2.6.1. Health, well-being and sustainable development progress in Uzbekistan Uzbekistan is a lower middle-income country whose gross domestic product (GDP) has multiplied over four times since 2000, growing from approximately 13.8 to 59.9 billion US dollars (US$) between 2000–2020 (1), although GDP fell from 86.1 to 52.6 billion US$ between 2016–2018. Between 2018–2019, Uzbekistan’s annual GDP growth rate averaged 5.6% per year. However, this rate fell to 1.7% in 2020 as a consequence of the coronavirus disease 2019 (COVID-19) pandemic. Correspondingly, Uzbekistan’s unemployment rate was, on average, 5.8% of the total labour force between 2017–2019, but this figure increased to 7.0% in 2020 due to the pandemic (1). In 2013, Uzbekistan’s poverty headcount ratio using national poverty lines was recorded as 14.1% of the population, slightly below the WHO European Regional average that year of 15.4% (2). In 2018, this figure had reportedly declined to 11.4% of the population, below the then European Regional average of 14.9%, but it is uncertain if this decline in the poverty rate was due to effective poverty reduction efforts or imprecise poverty estimation techniques. The World Bank is now working with the government of Uzbekistan on major revisions to poverty estimates (2). Uzbekistan has a population of approximately 34.2 million people (1). Between 2017–2020, Uzbekistan’s population grew, on average, by 1.8% each year (1). The population is young: the percentage of Uzbekistan’s population aged less than 15 years was 28.8% in 2020, which is twice the European Union (EU)’s average of 14.1% (1). In contrast, the percentage of Uzbekistan’s population aged 65 years or older was 4.8% in 2020, which is more than four times smaller than the EU’s percentage of 20.8% for the same metric (1). Despite this, Uzbekistan’s population is slightly ageing. Between 2015–2020, the percentage of the population aged 65 years or older grew from 4.1% to the 4.8% it is now (1). According to the 2020 Human Development Index (HDI), Uzbekistan ranks 106th out of 189 countries and territories and it is categorized as a country with high human development (3). Uzbekistan’s HDI increased from 0.669 to 0.720 between 2010–2019. This represents an average HDI growth of 0.51% per year, which is approximately two-thirds of Europe and Central Asia’s average growth of 0.76% per year during the same period. For reference, Europe and Central Asia’s average HDI increased from 0.735 to 0.791 between 2010–2019 (3). Embedded in Uzbekistan’s improved HDI is their steady increase in life expectancy over the past decade. Between 2010–2019, life expectancy increased from 72.91 to 75.21 years (+2.30 years) for females and from 67.51 to 70.76 years (+3.25 years) for males (4). However, these figures are still significantly below the WHO European Region’s average of 81.29 years for females and 75.09 years for males (4). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)76 Since 2016, the diplomatic and economic ties between Uzbekistan and its neighbours have also significantly improved (5). Until the coronavirus disease 2019 (COVID-19) lockdown, this included cooperation in making borders more open and safer for legal trade and the transit of people and goods. These improvements have increased regional cooperation to tackle common challenges, which is a  precedent that indicates promising potential for effective subregional cooperation for health and well-being across Central Asia. Building back better and leaving no one behind after the COVID-19 pandemic will be imperative to sustain the progress on health, well-being and sustainable development that Uzbekistan was making prior to the pandemic. This is especially true for the progress the country was making on poverty reduction, which is especially vulnerable to redaction from the pandemic (6). Despite economic, social and political improvements, Uzbekistan still faces significant environmental challenges manifested in the inefficient use of natural resources (for example, water), land degradation and desertification, waste management, loss of biodiversity and climate change (5). While reforms have been viewed favourably, there is a risk that inequitable distribution of the gains may increase vulnerabilities and social tensions. These risks have been compounded because of COVID-19 and the resultant new forms of vulnerability. Ensuring that no one is left behind will therefore be critical for Uzbekistan to overcome the crisis and move forward with its development priorities, including the Sustainable Development Goals (SDGs). 2.6.1.1. Looking forward: the health, well-being and sustainable development trajectory of Uzbekistan Uzbekistan has formally aligned its policies with the 2030 Agenda for Sustainable Development by integrating the SDGs into national strategies and programmes (7). This commitment was formally established in 2018 with a decree of the cabinet of ministers regarding measures to implement national goals and objectives in the field of sustainable development up until 2030 (8). Through this decree, Uzbekistan adopted 16 national SDGs, 125 related targets and 206 indicators. It also established a Coordination Council, headed by the Deputy Prime Minister, to oversee implementation across 21 government agencies, with the Ministry of Economy serving as the Secretariat (7). In accordance, Uzbekistan’s Ministry of Health (MoH) developed the Concept on Health Sector Reform of the Republic of Uzbekistan (2019–2025) (hereinafter, the 2025 Concept) with extensive support from WHO and through an inclusive intersectoral and interministerial process (9). It was approved by Presidential Decree 5590 on 7 December 2018, and it is fully in line with the national SDG targets. It is also aligned with the outcomes of the Thirteenth General Programme of Work 2019–2023 (GPW) and the European Programme of Work, 2020–2025, “United Action for Better Health” (EPW). The 2025 Concept was established with three main goals (9): 1. increase life expectancy by improving outcomes in the prevention and treatment of the diseases and conditions that cause most premature death and disability; 2. reform the system of financing and organizing health care to ensure equal access to medical care, financial security of the population and fair distribution of resources; 3. Strengthen the capacity of health authorities, increasing the role and responsibility of their leaders to implement the tasks of the 2025 Concept and improve the quality of medical care for the population of the Republic. To support these goals, the 2025 Concept outlines 11 main objectives, as well as nine main directions for further development of Uzbekistan’s health-care system. These nine main directions include to (9): 1. improve legislation in the field of health care; 2. improve the system of organization and the management of health care; 3. improve the health financing system; 4. improve the quality and accessibility of medical care, support a  healthy lifestyle and prevent and combat communicable and noncommunicable diseases (NCDs); 5. improve the system of medical care for mothers and children; Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Uzbekistan 77 6. develop private health care, public-private partnerships and medical tourism; 7. further develop the domestic pharmaceutical industry; 8. form an effective system of training, retraining and advanced training of medical personnel, as well as the development of medical science; and 9. introduce information and communication technology (ICT) and e-health. All 206 indicators that the 2025 Concept outlines as the markers of the effectiveness of implementation provide projected targets for achievement by 2025. For example, Uzbekistan hopes to increase the life expectancy of its female and males to 77.8 and 72.1 years, respectively. More information regarding all objectives, indicators and targets can be found in the 2025 Concept (9). In 2020, Uzbekistan’s United Nations (UN) Country Team finalized the United Nations Sustainable Development Cooperation Framework 2021–2025 for Uzbekistan (hereinafter, the CF UZB) (10). The CF UZB outlines three strategic priorities, including “Inclusive human capital development leading to health, well-being and resilient prosperity”, which contains two outcomes. The second outcome, Outcome 4 of the overall CF UZB, posits: “By 2025, the most vulnerable benefit from enhanced access to gender-sensitive quality health, education and social services.” To achieve outcome 4, the UN Development System in Uzbekistan will (10): • promote universal health coverage (UHC) through health system strengthening; • provide technical support for efficient and sustainable service delivery systems; • support inclusive and equitable quality education and promote lifelong learning opportunities for all; • bring together government and civil society to introduce and deliver universal social protection benefits and improve the social security system; • strengthen partnership with Uzbekistan’s parliament the Oliy Majlis, nongovermental organizations and women led organizations to achieve transformative results for gender equality and women’s empowerment; and • as an immediate priority due to the COVID-19 pandemic, the UN will give support to addressing the emerging needs of the population for social protection and strengthening resilience to possible future pandemics. More specifically, outcome 4.1 of the CF UZB aspires for the following: “By 2025, capacities of health system and stakeholders are strengthened to implement efficient and transparent, innovative and inclusive Universal Health Coverage-focused policies and programmes, comprehensive responses to health emergencies and to promote a healthy lifestyle and health literacy among all age groups as well as quality professional development opportunities and a decent work environment for health-care employees” (10). Through the CF UZB, the UN Country Team has identified that the highest health priorities in Uzbekistan to address are to: 1) promote quality and affordable health care for all; 2) focus on NCDs, HIV and tuberculosis (TB); 3) develop innovative health financing to address high out-of-pocket expenses; and 4) improve health-care infrastructure (10). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)78 Uzbekistan’s draft 2022–2023 biennial collaborative agreement (BCA) is still being negotiated (7). However, it will honour all pre-existing international and national strategic frameworks for health and well-being that Uzbekistan has committed to between 2022–2023, including those referenced in this brief. Notably, these include the GPW, EPW, SDGs, 2025 Concept and CF UZB. So far, Uzbekistan’s draft 2022–2023 BCA identifies the following transformative actions as essential to help Uzbekistan achieve each of its pre-existing health commitments: • create a system and culture of prevention: strengthen primary health care (PHC), with a  focus on family physicians and health-care managers, while also overcoming institutionalized resistance to the rationalization of hospital care; • move from disease- to people-centred programmes: boost efforts to combat NCDs, including mental health and road safety, while also ending communicable diseases and preventing the next pandemic; • secure the social contract in health: establish equitable social health protection from general tax revenues and create common goods for health while managing expectations for private sector engagement; • make digital health coverage universal: pursue the digitalization of the health sector while making sure that under-connected and otherwise vulnerable populations are not left behind; • build a resilient and green health sector: respond to the health impact of climate change with new investment in health infrastructure and equipment while also mitigating the footprint of those investments. 2.6.1.2. SDG 3 progress: Ensure healthy lives and promote well-being for all at all ages SDG 3 aims to ensure healthy lives and promote well-being for all at all ages. In 2021, a  thorough analysis of Uzbekistan’s progress achieving SDG 3 revealed areas where health and well-being have been advanced and where challenges remain (11). These trends are summarized in Table 19. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Uzbekistan 79 Table 19. Selected targets and indicators to track Uzbekistan’s progress on SDG 3. SDG 3 Targeta Statusb Description Indicator(s) 3.1 Target achieved By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births. • 3.1.1: Maternal mortality ratio: Decreased from 41.0 to 29.0 per 100 000 live births from 2000–2017. 3.2 Target achieved By 2030, end preventable deaths of new-borns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-five mortality to at least as low as 25 per 1000 live births. • 3.2.1: Children under-five mortality rate: Decreased from 62.0 to 17.4 deaths per 1000 live births from 2000–2019. • 3.2.2: Neonatal mortality rate: Decreased from 28.1 to 9.9 deaths per 1000 live births from 2000–2019. 3.3 Significant challenges remain By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases. • 3.3.1: New HIV infections: Increased from 0.03 to 0.13 new infections per 1000 uninfected population 2000– 2019. • 3.3.2: Tuberculosis incidence: Decreased from 99 to 67 incidence per 100 000 population from 2000–2019. 3.4 Significant challenges remain By 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being. • 3.4.1: Risk of dying between the ages of 30 and 70 from one of four main NCDs (cardiovascular disease, cancer, diabetes, or chronic respiratory disease): Decreased from 34.2% to 25.3% from 2000–2019. • 3.4.2: Suicide mortality rate: Decreased from 10.1 to 8.0 deaths per 1000 population from 2000–2019. 3.5 Challenges remain Strengthen the prevention and treatment of substance abuse. • 3.5.2: Alcohol consumption per capita among population aged 15 years and older: Decreased from 3.0 to 2.6 litres of pure alcohol from 2000–2019. 3.6 Challenges remain By 2020, halve the number of global deaths and injuries from road traffic accidents. • 3.6.1: Death rate due to road traffic injuries: Increased from 9.7 to 11.7 deaths per 100 000 population from 2000–2019. 3.7 Target achieved By 2030, ensure universal access to sexual and reproductive health-care services. • 3.7.2: Adolescent birth rate: Decreased from 21.1 to 18.9 per 1000 women aged 15–19 years from 2000–2017. 3.8 Challenges remain Achieve UHC, including financial risk protection, access to quality essential health- care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. • 3.8.1: Service coverage indexc: Increased from 52.0 to 71.0 from 2000–2019. 3.9 Challenges remain By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination. • 3.9.1: Age-standardized mortality rate attributed to household air pollution: 14.0 deaths per 100 000 population in 2016. • 3.9.1: Age-standardized mortality rate attributed to ambient air pollution: 69.0 deaths per 1000 population in 2016. • 3.9.2: Mortality rate attributed to unsafe water, unsafe sanitation and lack of hygiene: 0.4 deaths per 1000 population in 2016. • 3.9.3: Mortality rate attributed to unintentional poisonings: Decreased from 1.4 to 0.8 deaths per 1000 population from 2000–2019. 3.a Challenges remain Strengthen the implementation of the WHO Framework Convention on Tobacco Control. • 3.a.1: Age-standardized prevalence of current tobacco use among persons aged 15 years and older: Decreased from 16.1% to 12.3% from 2000–2018. Notes. NCDs: noncommunicable diseases; SDGs: Sustainable Development Goals; UHC: Universal health coverage. a For brevity, some SDG 3 targets and indicators were excluded when the health issues they addressed were not relatively high priorities or needs in Uzbekistan’s context (for example, tropical diseases) or if there was no data available for their indicators. b The status assigned to each target was determined by an analysis carried out by the Sustainable Development Report (11), which was authored by the Sustainable Development Solutions Network. All data used to create the Sustainable Development Report are based on Sachs et al. (2022)’s publication (12). The indicators selected for this table represent some of the many indicators that were considered when these assessments were made. c There are significant limitations associated with this measure of service coverage. Source: Adapted from (11, 13). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)80 2.6.2. Lessons learned from the COVID-19 pandemic In 2020, the Uzbekistan: Consolidated Multilateral COVID-19 Socio-economic Response & Recovery Offer (hereinafter, the Response & Recovery Offer) was devised for Uzbekistan across many development partners, including the UN system and WHO (14). The strategic preparedness and response plan included the following areas of effort: 1) health coordination; 2) risk communication and community engagement; 3) surveillance and laboratories; 4) infection prevention and control (IPC); 5) case management; 6) operation support and logistics; and 7) essential health services (14). The Response & Recovery Offer also overviews the impact of the COVID-19 pandemic in Uzbekistan with macroeconomic, social, employment and environmental consideration, and it offers detailed analyses of lessons learned. For each of these areas of effort identified, lessons have been learned regarding the need to improve their respective services for future health emergencies. The greatest challenge in Uzbekistan’s health sector, beside maintaining the concerted whole-of-government and whole-of-society COVID-19 containment and response effort, has been the continuation of essential health services for the population (14). This is particularly true for the most vulnerable in Uzbekistan, such as women, children, migrants, elderly and chronically ill. The pandemic highlights the importance of continued investments in health- system strengthening to be better prepared for the continued low transmission of the COVID-19 virus, and for future outbreaks. Ensuring appropriate support, including protective, psychological and financial support, to frontline medical workers – over 80% of whom are women – will also be an important element of maintaining essential health services during and post-pandemic (14). Moreover, essential services to people with chronic medical conditions (for example, TB and HIV) have been disrupted in Uzbekistan, and persons with chronic conditions have experienced difficulties in accessing medicines. Socially and economically marginalized groups, including people with disabilities, returning migrants, people living with HIV, people living in institutions and people who use drugs, are also experiencing more acutely the impact of the lockdown measures, both from a health and socioeconomic perspective. Lockdown measures have also been seen to increase rates of gender-based violence (GBV) in Uzbekistan (14). With respect to children in poverty, according to the estimates from the monthly phone interviews of Listening to Citizens of Uzbekistan, the pandemic resulted in increasing child poverty by 20%, which implied that more than 500 000 children fell into poverty (5). The World Bank and United Nations Children’s Fund analysis shows that, had the pandemic not occurred, child poverty in Uzbekistan could have fallen from 24% to 16% from March-October 2020. Therefore, although Uzbekistan’s general poverty rate decreased between 2013–2018 (2), progress on poverty reduction remains fragile and subject to the pandemic situation, especially for children. Additionally, the percentage of children living in households that reported being unable to buy enough food for family members increased twofold, from 6% to 12% (5). Even before the coronavirus outbreak, it was recognized that there were several challenges and risks to meeting the country’s SDG targets. Weak policy coherence and insufficient integration – of both the 2030 agenda and international human rights obligations with national development strategies and programmes – remain significant barriers in this regard. The complex and fast-paced reforms being initiated before the pandemic could be derailed if the reforms do not incorporate citizen engagement and popular support following the hardships from COVID-19. Not completing the reform process could have a ripple effect on the entire health system and risk further progress towards the health- related SDGs (5). Other challenges to achieving the SDGs include the ongoing limited administrative capacity, frequent reorganizations of ministries and departments, high staff turnover, weak internal coordination, and limited cross-government approaches (5). In the wake of COVID-19, reforms remain in a high-risk hiatus where internal resistance and bottlenecks may increase, including in the health sector. Therefore, Uzbekistan is putting systems in place to monitor reforms on a regular basis and has become increasingly proactive in communicating with the people about the overall reform agenda as well as the COVID-19 response. Despite this, there have still been concerns that reforms are taking place in a relatively opaque environment with insufficient – albeit incrementally improving – public accountability (5). Additionally, in August 2020, Germany’s Robert Koch Institute, in collaboration with the WHO Regional Office for Europe, participated in an Intra-Action Review for COVID-19 in Uzbekistan to identify current best practices, gaps and Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Uzbekistan 81 lessons learned, as well as to propose priority areas to improve and strengthen the COVID-19 response (2). These priority areas include: 1) reviewing, updating and implementing the National Strategic Preparedness and Response Plan for COVID-19; 2) establishing a national Public Health Emergency Operations Centre; 3) introducing an integrated digital surveillance and reporting system; and 4) refining treatment guidelines and diagnostic procedures (2). Finally, the Response & Recovery Offer outlines long-term improvements needed in Uzbekistan’s health system for COVID-19 pandemic response and recovery, as well as steps to take to prepare for the next pandemic (14). It argues that better understanding is needed on the damage the pandemic has had on the national health system through delays or cancellation of health services. Regular monitoring of specialized care facilities, such as children’s HIV day- care centres and residential care institutes remains limited. Immunization campaigns require long-term planning and mobility to ensure there are adequate supplies, trained vaccination personnel and adherence to regular vaccination schedules in all parts of the country. The supply of essential medical supplies, including personal protective equipment (PPE) for all types of health workers, has been a challenge that needs to be systemically addressed for future emergencies. The purchase of essential drugs for chronic diseases and the regulation of drug prices will also need long-term planning to ensure they are widely available. Training of all health personnel on IPC methods needs to be done on a continuing basis. Additionally, there is insufficient digital health system preparedness for monitoring persistent low-level transmission and future COVID-19 outbreaks. Medical data is still gathered by hand at health facilities and collected on paper-based forms. While some facilities collect some data in a  locally designed health management information system (HMIS), paper-based documentation is still required by law. Some of the data is subsequently sent by email to higher levels, but the system is still paper based, so lockdowns result in a delay of reporting. A new HMIS is foreseen for Uzbekistan, but this will likely be delayed due to the COVID-19 pandemic. 2.6.3. Closing the Health Gap: aligning Uzbekistan’s priorities with the EPW Uzbekistan’s current national health priorities and gaps are discussed below in context of the EPW’s framework. 2.6.3.1. Core Priority 1: Moving towards UHC Moving towards UHC is a high priority for Uzbekistan. Uzbekistan’s 2025 Concept outlines several of its priorities for moving towards UHC by 2030. Some of these include to (9): • increase the availability of high-quality local medical services through the creation of large multidisciplinary medical institutions; • develop and implement national clinical standards for the most common diseases and conditions based on evidence-based medicine and international standards; • create a unified register of medical services in the health-care sector; • development and implement patient routing schemes that ensure a rational sequence and continuity of the stages of medical care; • further develop clinics of higher medical educational institutions by strengthening their human resources for health (HRH) and material and technical bases; • detect early factors in the development of NCDs, including through the improved introduction of medical examinations and screening studies; • create a  modern model of long-term medical care for patients who are elderly or have specialized mental health needs; • further develop the public health system, promote healthy lifestyles and proper nutrition, educate citizens in the spirit of responsibility for their own health and the health of others, as well as improve their cultural and medical literacy; and • prevent the prevalence of antimicrobial resistance (AMR), including through strict adherence to appropriate schemes and regulations for antimicrobial therapy, develop methods and expansion of microbiological diagnostics when prescribing antibacterial therapy and produce new types of antibacterial drugs. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)82 These priorities complement the priorities outlined in the CF UZB (10), which calls for: • promoting UHC through health system strengthening; • a strengthened PHC system; • evidence-based health sector policies; • a health management information system; • improved supply chain management; • ensuring population’s access to safe and affordable medicines; • revised service delivery models with multi-profile facilities based on strategic planning; • a health workforce upgraded to international standards; • affordable and sustainable universal health insurance; • support mechanisms and protection of the rights of health-care workers to ensure quality professional development and decent working conditions; • technical assistance on case management of HIV and TB (with a focus on drug-resistant TB); • implementation of an enhanced and sustainable system on vaccine-preventable diseases; • implementation of an intersectoral programme on AMR; • strengthened laboratory services; • improved capacity for the diagnosis and treatment of NCDs and mental health disorders; • improved training for clinical staff; and • the development of postgraduate training. Progress towards UHC is monitored in two dimensions: the coverage of essential health services and financial hardship. Each is covered further in the context of Uzbekistan below. Coverage of essential health services In 2019, 548 300 more people in Uzbekistan (1.6% of the population) were covered by essential health services than in 2018. By 2023, this number is projected to be 2.06 million more people (5.9% of the population) (15). Coverage of essential health services is defined as the average coverage of the 14 SDG 3.8.1 tracer interventions. Of these 14 indicators, positive progress is projected for ten of them in Uzbekistan by 2023 (Table 20). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Uzbekistan 83 Table 20. Projected percentage point changes in normalized valuesa across the 14 SDG 3.8.1 tracer interventions for service coverageb from 2018–2023 in Uzbekistan. Service Coverage Indicator 2018 value (%) Projected 2023 value (%) Projected change (%) Basic sanitation 99.9 100.0 +0.1 Care seeking for pneumonia for children under 5 75.0 76.1 +1.1 DTP3 immunization 98.0 98.3 +0.3 Health worker density 88.3 100.0 +11.7 Hospital bed density 100.0 100.0 0.0 IHR core capacity index 44.0 72.3 +28.3 ITN use N/A N/A N/A Mean fasting blood glucose 68.8 58.7 -10.1 Need met for family planning 83.7 84.1 +0.4 Non-elevated blood pressure 48.8 48.4 -0.4 People living with HIV receiving ART 57.8 72.2 +14.4 TB cases treated 72.1 73.3 +1.2 Tobacco non-use 87.7 88.4 +0.7 Women who received antenatal care visits 4+ times 92.2 93.1 +0.9 Notes. ART: Antiretroviral therapy; DTP3: Three doses of diphtheria tetanus toxoid and pertussis vaccine; IHR: International Health Regulations (2005); ITN use: Insecticide-treated bed net use among people at-risk of malaria; TB: Tuberculosis. a Some indicators in this chart have been transformed to have values between 0 and 100 (0 worst–100 best). Further information regarding the indicators can be found at (15). b There are significant limitations associated with this method of measuring service coverage. c N/A indicates the data is not available. Source: Adapted from (15). Communicable diseases and NCDs are significant public health burdens in Uzbekistan. In 2019, 8.21% of deaths in Uzbekistan were caused by communicable diseases and maternal, prenatal and nutrition conditions (1), and 19.03% of disability-adjusted life years (DALYs) were attributable to communicable diseases (16). In comparison, the EU’s averages for these two metrics in 2019 were 5.55% and 4.04%, respectively. As above forementioned, one of the main directions of Uzbekistan’s 2025 Concept involves the explicit prevention and treatment of communicable diseases (9). Similarly, the draft 2022–2023 BCA calls to review major programmes and assess the need for improved efficiency to address TB, HIV and viral hepatitis in Uzbekistan. To do so will require (7): • the implementation of policy and technical guidance in accordance with the latest WHO recommendations of drug-resistant TB case management; • a strengthened TB e-surveillance system; • strengthened prevention efforts and universal access to hepatitis treatment, including the elimination of hepatitis C in some pilot regions of Uzbekistan; and • the provision of technical assistance to ensure equitable access to HIV services. The percentages of deaths and DALYs attributable to NCDs in Uzbekistan in 2019 were 85.28% (1) and 70.16% (16), respectively. A  more systematic, high quality health information system that improves the monitoring of service delivery for NCDs, progresses sustainable health financing policies, and enhances the assessment of providers’ performance is needed to improve the health system and tackle Uzbekistan’s burden of NCDs (7). Therefore, Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)84 Uzbekistan is committed to achieving a PHC system that is accessible, equitable, integrated, and community-oriented and which includes support for NCD screening and prevention. To do so, the following priorities have been identified in the draft 2022–2023 BCA, in addition to those established by the 2025 Concept and CF UZB (7): • develop an implementation roadmap for the long-term improvement of PHC, including multidisciplinary teams centred on task-shifting from narrow specialists to family physicians and from general practitioners to nurses; • implement population cardiovascular risk stratification at the PHC level with best-practice models scaled-up towards population health management approaches; • strengthen PHC capacity in cardiovascular, diabetes and chronic obstructive pulmonary disease /asthma management and address the four main NCD risk factors, including by strengthening implementation research capacity in the areas of general NCD prevention and nutrition; • establish a health workforce e-registry and conduct a health workforce needs assessment to direct national strategy development in this regard; • establish or strengthen the managerial competencies of oblast hospital networks; • scale up the health service delivery model – which was supported by strategic purchasing and piloted in the Syrdarya region – across other regions of Uzbekistan with the knowledge of the best practices and lessons learned; and • develop continuous quality improvement and performance monitoring and evaluation frameworks to direct implementation. Uzbekistan’s 2025 Concept also establishes improving the health and well-being of mothers and children as a key objective. Relevant priorities to achieve this objective include to (9): • expand and improve the quality of medical care for women of reproductive age and children; • improve the system for diagnosing, treating and rehabilitating children with hereditary, genetic, primary immunodeficiency (orphan), congenital and acquired diseases; • implement national projects aimed at reducing child mortality and satisfying the care needs of children with disabilities; • gradually create large, multidisciplinary medical centres for mothers and children through public-private partnerships. Finally, to improve HRH, Uzbekistan’s 2025 Concept also calls for significant improvement in the organization and management of the health-care system. Relatedly, it also calls for the formation of an effective system of training, retraining and advanced training of medical personnel, as well as the development of medical science and research (9). Together, these initiatives will help: 1) improve strategic planning of HRH; 2) improve the training and education processes of HRH; 3) improve the employment conditions of HRH; and 4) support the development of science, modern technologies and innovations in the field of medicines. Financial hardship Ensuring everyone can access high-quality health services without facing financial hardship is a key target of the EPW and SDGs. At the governmental level, the percentage of GDP spent on health in 2018 in Uzbekistan was only 2.02%, which is significantly lower than the WHO European Region’s average of 4.87% (17). To achieve the targets of the 2025 Concept and achieve UHC, Uzbekistan plans to increase public health spending to 5.0% of GDP (9). At the patient level, the percentage of health expenditure covered by out-of-pocket payments in 2018 in Uzbekistan was 60.34%, which is twice the WHO European Region’s average of 29.82% for the same metric (17). The 2025 Concept calls for this figure to be reduced to 30.0% (9) by 2025. To achieve these targets, the 2025 Concept outlines priority actions to improve the health financing system. These primarily involve improving the regulation of medical spending and pricing, as well as completing the steps necessary to establish a  strong foundation for implementing compulsory medical insurance that extends UHC to all Uzbek Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Uzbekistan 85 citizens. Additionally, the 2025 Concept identifies two more main directions dedicated to reducing financial hardship: 1) develop private health care, public-private partnerships and medical tourism; and 2) further develop the domestic pharmaceutical industry. Both initiatives seek to improve access to essential health services and medicines by increasing the number of avenues available for procurement or care. More information regarding the priority actions associated with any of the main directions can be found in the 2025 Concept (9). Flagship Initiative 1: The Mental Health Coalition Mental, neurological and substance use conditions, including depression, anxiety disorders, psychosis, epilepsy, dementia and alcohol-use disorders, pose a major challenge in Uzbekistan. Between 1991 and 2017 there was a 15% increase in the incidence of people registered with mental disorders (2). Real rates of disorders such as anxiety and depression may be even higher, given the low uptake of treatment and the stigma surrounding mental health conditions. The government has responded to this challenge by starting to improve the provision of mental health services (2). Special care should be given to people with specialized or severe mental health needs or for people with mental disabilities, who experience even greater degrees of stigmatization (5). Therefore, a key priority will be to promote and support the implementation of WHO tools and guidelines on mental health at the PHC level, including the WHO Mental Health Gap Action Programme Guidelines and the Caregivers Skills Training for families raising children with disabilities and developmental delays. In 2021, the WHO Regional Office for Europe published a study regarding the prevention and management of mental health conditions in Uzbekistan and why they deserve investment (18). The study also provides an overview of Uzbekistan’s mental health care treatment, prevention and policy contexts. The main recommendations from the study include to (18): • increase the capacity of the health-care workforce and system to provide mental health interventions, including integrating mental health into PHC and strengthening community service provision; • leverage health financing and delivery reforms to extend the coverage of mental health conditions, medicines and services by publicly funded health insurance or benefit packages as part of the broader move towards UHC; • invest in the evidence-based, cost-effective clinical and population-based mental health interventions modelled in the economic analysis of the study, such as treatment of the most common mental health conditions in nonspecialized health-care settings and school-based social-emotional learning to prevent depression and suicide; and • establish and strengthen monitoring and surveillance systems to estimate the prevalence of mental health conditions and track patient outcomes. Flagship Initiative 2: Empowerment through Digital Health The introduction of digital health ICTs and e-health platforms are a high priority for Uzbekistan. As a main direction of the 2025 Concept, several priority actions are outlined to achieve the country’s goals for digital health empowerment. These priorities include to (18): • implement an eHealth system and introduce health information systems and databases that are integrated on the basis of unified national standards and that offer services to health-care patients and providers; • use ICT as a fundamental mechanism for monitoring the performance of medical organizations and the state of development of the industry; and • develop telemedicine for the exchange of information between medical organizations and the provision of remote medical and educational services (consultations, operations, master classes, etc.) Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)86 2.6.3.2. Core Priority 2: Protecting against health emergencies In 2019, Uzbekistan better protected 4.87 million more people (14.0% of the population) from health emergencies than in 2018. By 2023, this number is projected to reach 11.45 million people (33.0% of the population). In 2019, Uzbekistan scored 77.5% within the Health Emergency Protection Index (HEPI). HEPI is calculated based on three sub-indicators: 1) preparedness; 2) prevention; and 3) detection and response (15). Preparedness In 2020, Uzbekistan scored 55.0% in the preparedness sub-indicator. This sub-indicator assesses emergency preparedness by averaging the scores of all 13 International Health Regulations (2005) (IHR) core capacities at the country level, which are reported through the States Parties Annual Report tool (15). Prevention In 2019, Uzbekistan scored 98.0% in the prevention sub-indicator. This sub-indicator assesses efforts to prevent health emergencies through routine and targeted vaccine campaign efforts. It includes vaccination coverage for five major infectious diseases: measles, polio, meningococcal meningitis A, yellow fever, and cholera (15). Detection and response In 2021, Uzbekistan scored 100.0% in the detection and response sub-indicator. This sub-indicator assesses the appropriateness of a country’s reaction to an event of potential public health concern. It averages the time from a public health event’s start to detection, notification and response to provide an overall measure of timeliness (15). Uzbekistan’s health system performs well with regard to childhood immunizations, but less well with regard to other communicable diseases. For example, coverage for basic immunization services in Uzbekistan is good. In 2018, 96% of infants received their first dose of the measles vaccine, and 99% of those infants received their second dose (2). This share is higher than the WHO European average of 91% for the second dose, but in line with rates in neighbouring countries. Access to effective TB treatment stood at 92% among new and relapse cases, 78% among previously treated cases registered in 2018 and 61% among multi-drug and rifampicin resistant TB cases started on second-line treatment in 2017 – very close to the average of the WHO European Region. However, there were fluctuations over the past decade and the rate in 2017 was lower than in 2005. Rising rates of multidrug-resistant TB make progress more difficult (2). Additionally, work on HIV prevention and response in Uzbekistan remains challenging, and levels of HIV- related stigma and discrimination are high. The government does provide antiretroviral therapy with support from the Global Fund, but adherence is a challenge (2). In light of the COVID-19 pandemic, and to reinforce protection against future health emergencies, Uzbekistan’s MoH is implementing a Joint External Evaluation of IHR, in collaboration with WHO (2). WHO also continues to support Uzbekistan’s health system response to COVID-19 through technical assistance to strengthen the health system, the training of health workers, procurement of essential equipment, enhanced surveillance systems and building infectious disease laboratories (2). The CF UZB calls for strengthening resilience to future health emergencies (10). This goal can be achieved through: 1) existing interventions aimed at strengthening the social protection system, improving shock-responsiveness and integrating institutional reform; 2) the expansion of the existing social protection system in order to ensure coherence between social assistance, labour market and social insurance programmes; and 3) support to roll out the single registry, Labour Market Information System, as well as active labour market policies and compulsory medical insurance (10). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Uzbekistan 87 Additionally, Uzbekistan’s draft 2022–2023 BCA identifies three main priorities for protecting against future health emergencies (7): 1. The capacity and quality of public health laboratories should be strengthened through the Better Labs for Better Health initiative to ensure readiness for successful detection and tracing of disease transmission that is essential for the prevention and control of health emergencies, including COVID-19 by: a. implementing laboratory quality management systems through training and mentoring of central and regional laboratories; and b. supporting national laboratory policies and strategic plans and establishing laboratory networks for emergency preparedness and response. 2. The monitoring, control and distribution of PPE for medical staff should be improved by improving strategic planning. 3. Technical assistance on establishing a logistics system should be provided based on WHO recommendations. One of Uzbekistan’s strongest lessons learned from the COVID-19 pandemic is the value of regional cooperation for mitigating the harmful effects of health emergencies. Uzbekistan takes part in regional coordination and information sharing in the sphere of disaster risk reduction, initiated and organized by the Centre for Emergency Situations and Disaster Risk Reduction in Kazakhstan (5). In September 2020, Uzbekistan participated in the Central Asia UN Member States regional dialogue on COVID-19. Additionally, Uzbekistan participates in the annual regional Forum of Heads of National Disaster Management Agencies, and the country is engaged in developing the regional strategy for disaster risk reduction and contributes to compiling the regional risk profile (5). After several years of consideration, Uzbekistan is also now a constructive participant in the UN’s Special Programme for Central Asia Regional Cooperation (SPECA). SPECA is entering a new stage of development, in which Uzbekistan is expected to contribute. The country also joined other Central Asian countries and Afghanistan in adopting the SPECA Strategy on Innovation for Sustainable Development. It calls for knowledge-sharing and cooperation in importing and creating innovative solutions to national and regional sustainable development challenges. Uzbekistan is also a signatory to the Bishkek Declaration “Strengthening Regional Cooperation to Support Socioeconomic Recovery in the Wake of COVID-19” adopted in 2020 (5). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)88 2.6.3.3. Core Priority 3: Promoting health and well-being In 2019, 66 400 people in Uzbekistan (0.2% of the population) experienced worse health and well-being than in 2018. By 2023, that number is projected to reach 373 900 fewer people (1.1% of the population) (15). The healthier populations (HPOP) index uses 16 outcome indicators related to social, environmental, and behavioural risks to assess the number of people whose lives have become healthier. In Uzbekistan, six of the 16 indicators are projected to improve between 2018 and 2023 (Table 21). Table 21. Projected changes in the normalized valuesa of the 16 indicators of the HPOP index from 2018–2023 in Uzbekistan. HPOP Indicator 2018 value (%) Projected 2023 value (%) Projected change (%) Access to safely managed drinking water sources 58.9 59.0 +0.1 Access to safely managed sanitation services N/A N/A N/A Adults not obese 84.4 82.2 -2.2 Ambient air quality 72.9 74.6 +1.7 Best practice policy implemented for healthy fats production 85.7 85.7 0.0 Children under 5 developmentally on track N/A N/A N/A Children (aged 5–19) not obese 96.1 95.3 -0.8 Children under 5 not overweight 94.6 96.0 +1.4 Children under 5 not stunted 89.3 91.5 +2.2 Children under 5 not wasted N/A N/A N/A Primary reliance on clean household fuels 85.1 83.2 -1.9 Reduced alcohol use 89.6 89.6 0.0 Reduced child (aged 1–17) violence N/A N/A N/A Reduced partner violence N/A N/A N/A Reduced road traffic mortality 97.9 97.7 -0.2 Reduced suicide attempts 99.1 99.3 +0.2 Tobacco non-use 88.3 88.8 +0.5 Notes. HPOP: healthier populations. a Some indicators in this chart have been transformed to have values between 0 and 100 (0 worst–100 best). b N/A indicates the data is not available Further information regarding the indicators can be found at (15). Source: Adapted from (15). Promoting health and well-being will require Uzbekistan to prioritize the prevention, and addressing the risk factors propelling its high burden, of NCDs. The 2025 Concept is highly focused on preventing and addressing the four common risk factors related to lifestyle and behaviour: tobacco use, harmful use of alcohol, inadequate physical activity and unhealthy diet. WHO works with the government of Uzbekistan to promote opportunities for healthy choices for all socioeconomic groups, including through the introduction of new approaches such as healthy settings and Health in All Policies approaches. These approaches will support policies that promote healthy lifestyles, including nutrition and health literacy for all age groups, with a particular focus on vulnerable groups (2). Uzbekistan’s smoking prevalence is relatively low at 12.3% in adults aged 15 years or older (15). However, significant work remains to fully implement the WHO Framework Convention of Tobacco Control. In regards to the harmful use of alcohol, Uzbekistan was one of the “first-movers” of countries who implemented the WHO Global Strategy to Reduce the Harmful Use of Alcohol and the WHO European Action Plan to Reduce the Harmful Use of Alcohol 2012–2020 (19). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Uzbekistan 89 By doing so, Uzbekistan adopted the WHO’s three best-buy interventions in reducing the alcohol attributable burden, including to: 1) increase taxes on alcoholic beverages; 2) enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising; and 3) enact and enforce restrictions on the physical availability of retailed alcohol. Progress here should be sustained and broadened, especially in lieu of the worrying trends observed in relation to increase spirit consumption (19). Finally, reducing Uzbekistan’s persistently high burden of NCDs will require a sustained increase in investment to strengthen monitoring, treatment, evaluation and prevention at the PHC level. In terms of risk factors as a share of all deaths, high systolic blood pressure and dietary risks are the biggest drivers of mortality, estimated to be involved in 30.7% and 28.2% of all deaths respectively (2). Obesity levels among adults (16.6% in 2016) are lower than the average of the WHO European Region (23.3%), but they have nearly doubled since 2000, with women more likely than men to be obese. Levels of low physical activity (19.1% in 2016) are below the average of the WHO European Region (29.3%), but rates of inactivity are much higher for women than men (2). Air pollution is also a significant risk factor, and environmental health challenges and extreme weather events are also significant concerns. For example, the age-standardized mortality rate attributed to household and ambient air pollution in Uzbekistan was high in 2016 at 81.14 per 100 000 population, which is more than two and a half times greater than the WHO European Region’s average for this metric of 30.0 per 100 000 population (4). Around two thirds of air pollutants are caused by land vehicles (2). There is no indication of a national air quality policy and environmental issues in general are not a  high priority. In cities such as Tashkent, Farghona and Olmaliq, nitrogen dioxide and particulates exceed WHO recommended levels, whilst in rural areas heavy use of agricultural chemicals has led to degrading air quality. There is some air quality legislation – such as the Law on the Protection of Atmospheric Air – but local enforcement capacity is limited (2). Fortunately, with the support of the Central Asian Regional Environmental Centre (CAREC), regional cooperation in the energy sector has improved. Energy ministers from nine countries signed an agreement in Tashkent in September 2019. This is a step towards establishing a Regional Energy Market to ensure clean, reliable and affordable supply of electricity to all the CAREC Member States (5). Finally, combatting AMR is a high priority for Uzbekistan, as noted in the 2025 Concept (9). To combat AMR, a number of priorities have been recognized in Uzbekistan, including to: • build capacity to strengthen national AMR surveillance and improve diagnostic capacity • support research for monitoring AMR in the food chain • monitor antimicrobial consumption and promote antimicrobial stewardship and prudent use • raise awareness among professionals and the public and • facilitate intersectoral coordination to support the implementation of the National AMR plan. Flagship Initiative 3: The European Immunization Agenda 2030 In 2018, vaccine coverage of at-risk groups for epidemic or pandemic prone diseases was 97.0% in Uzbekistan (15). Similarly, the proportion of the target population with access to three doses of diphtheria tetanus toxoid and pertussis vaccine immunization was 96.0% in 2019 (15). Uzbekistan recently graduated from Gavi, The Vaccine Alliance support; therefore, it will be essential to ensure the sustainability of the national immunization programme to maintain universal vaccination coverage. Three ways in which this goal can be supported is by: 1) increasing the timeliness of vaccination by improving capacity of PHC specialists; 2) strengthening work with the public and media to promote vaccine acceptance and combat scepticism; and 3) integrating and expanding the “zero dose” programme aimed at identifying and vaccinating missed, unreached and under-vaccinated children (7). Uzbekistan is therefore committed to implementing the European Immunization Agenda 2030, as well as facilitating an equitable COVID-19 vaccination campaign. The WHO Regional Office for Europe is well-suited to support these efforts, especially by convening subregional cooperation across CA through Roadmap development and implementation. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)90 Flagship Initiative 4: Healthier Behaviours: incorporating behavioural and cultural insights Overall an estimated 63% of premature mortality in Uzbekistan is attributable to behavioural risk factors which, if properly addressed, could potentially save an estimated 3.9 million life years (2). Incorporating behavioural and cultural insights in future programmes will be crucial to the promotion of healthy choices, particularly for nutrition, and will see a special focus on supporting vulnerable groups. WHO also provides technical support for efficient and sustainable service delivery systems in reproductive, sexual, women, new-born, child and adolescent health at all levels of care and in school settings (2). As an example of an area where BCI-informed policy-making is needed, concerted efforts need to be taken to combat the discrimination and marginalization that women and LGBTQIA+ people experience. This is especially true for when these groups seek sexual and reproductive health services, particularly in relation to care-seeking for HIV and sexually transmitted infections. Therefore, safeguarding and, where possible, increasing social spending in areas such as health, social and child protection and education is a  priority to protect Uzbekistan’s most vulnerable groups from poverty and social exclusion. This requires improved planning, budgeting, allocation and monitoring of public finances and increasing the effectiveness and efficiency of social spending, including better targeting of and outreach to the most vulnerable groups. There is also a need to explore alternative, innovative funding sources and to prioritize spending on areas that maximize return on investments (for example, early childhood development). This aligns with the EPW’s intent to develop an investment case for developing a knowledge and evidence base in this area of work. Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025) Republic of Uzbekistan 91 References6 6 All online references were accessed on 05 April 2022. 1. World Bank Open Data [online database]. Washington, D.C.: The World Bank; 2022 (https://data.worldbank.org/). 2. Health Systems in Action Uzbekistan. Copenhagen: European Observatory on Health Systems and Policies, WHO Europe; 2021 (https://eurohealthobservatory.who.int/publications/i/ health-systems-in-action-uzbekistan). 3. Human Development Reports: Latest Human Development Index Rankings [website]. New York: United Nations Development Program; 2022 (http://hdr.undp.org/en/content/ latest-human-development-index-ranking). 4. World Health Data Platform: The Global Health Observatory [online database]. Geneva: World Health Organization; 2022 (https://www.who.int/data/gho/data/indicators). 5. United Nations Common Country Analysis: Uzbekistan. Tashkent: United Nations Uzbekistan; 2021 (https:// u z b e k i s t a n . u n . o r g / e n / 12 6 4 3 8 - u n i t e d - n a t i o n s - common-country-analysis-uzbekistan#:~:text=This%20 update%20to%20the%20Uzbekistan,and%20multiple%20 socio%2Deconomic%20groups.). 6. Poverty and Shared Prosperity 2020: Reversals of Fortune. Washington, D.C.: World Bank; 2020 ( ht tps : //o p e nk nowle dge .wo r ldbank .o rg / b i ts t ream / handle/10986/34496/9781464816024.pdf). 7. Biennial Collaborative Agreement between the Ministry of Health of the Republic of Uzbekistan and the Regional Office for Europe of the World Health Organization 2022/2023 [DRAFT]. Copenhagen: WHO Regional Office for Europe; 2022. 8. Decree of the Cabinet of Ministers of the Republic of Uzbekistan on measures to implement the national goals and objectives in the field of sustainable development for the period up to 2030. Tashkent: Government of the Republic of Uzbekistan; 2018 (https://lex.uz/ru/docs/4013358). 9. Concept of the Development of the Healthcare System of the Republic of Uzbekistan (2019-2025). Tashkent: President of the Republic of Uzbekistan Sh. Mirziyoyev; 2018 (https://www. lex.uz/docs/4096199). 10. UN Sustainable Development Cooperation Framework for Uzbekistan 2021-2025. Tashkent: United Nations Uzbekistan; 2020 (https://unsdg.un.org/resources/ un-sustainable -development-cooperation-framework- uzbekistan-2021-2025). 11. Sustainable Development Report 2021: The Decade of Action for the Sustainable Development Goals. Country Profiles. New York: Sustainable Development Solutions Network; 2021 (https://dashboards.sdgindex.org/). Compendium of the Roadmap for Health and Well-being in Central Asia (2022–2025)92 12. Sachs JD, Lafortune G, Kroll C, Fuller G, Woelm F. Sustainable Development Report 2022  - From Crisis to Sustainable Development: the SDGs as a  Roadmap to 2030 and Beyond. Cambridge: Cambridge University Press, 2022. (https://s3.amazonaws.com/sustainabledevelopment. report/2022/2022-sustainable-development-report.pdf). DOI: 10.1017/9781009210058. 13. SDG Indicators Database [online database]. New York: United Nations Department of Economic and Social Affairs; 2022 (https://unstats.un.org/sdgs/UNSDG/IndDatabasePage). 14. UZBEKISTAN: Consolidated Multilateral COVID-19 Socio- Economic Response & Recovery Offer. New York: UN Sustainable Development Group; 2020 (https://unsdg.un.org/ resources/uzbekistan-consolidated-multilateral-covid-19- socio-economic-response-recovery-offer). 15. Triple Billion Targets Dashboard [website]. Geneva: World Health Organization; 2022 (https://portal.who.int/ triplebillions/PowerBIDashboards/Countries). 16. Global Burden of Disease Compare Data Visualization [online database]. Seattle: Institute for Health Metrics and Evaluation, University of Washington; 2022 (https://vizhub.healthdata. org/gbd-compare/). 17. Global Health Expenditure Database [online database]. Geneva: World Health Organization; 2022 (https://apps.who. int/nha/database/Select/Indicators/en). 18. Prevention and management of mental health conditions in Uzbekistan: the case for investment. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/ handle/10665/348760). 19. Implementing alcohol policies in the Commonwealth of Independent States: a  workshop of “First Mover” countries. Copenhagen: WHO Regional Office for Europe; 2020 (https:// apps.who.int/iris/handle/10665/335946).

COMPENDIUM OF THE ROADMAP FOR HEALTH AND WELL-BEING IN CENTRAL ASIA (2022–2025) World Health Organization Regional Office for Europe UN City, Marmorvej 51 DK-2100, Copenhagen Ø, Denmark Tel: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.who.int/europe The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Türkiye Turkmenistan Ukraine United Kingdom Uzbekistan WHO/EURO:2022-5904-45669-65599