Introduction Geographical, political and economic context Kyrgyzstan is a mountainous country located in central Asia and was part of the Soviet Union until 1991. The 1993 constitution defines the form of government as a democratic republic, although in subsequent years a presidential form of government was established. In 2005 a popular revolt, sparked by allegations of govern- ment interference in parliamentary elections, led to the resignation of former President Askar Akaev, who had led the country since 1990. Akaev was replaced by former Prime Minister Kurmanbek Bakiyev, who won the presidential elections in 2005 with 88.9% of the vote. After 1991, Kyrgyzstan faced a severe recession and embarked on a course of liberalization and transition towards a market economy. In 1998, as the first Commonwealth of Independent States (CIS) country, Kyrgyzstan became a member of the World Trade Organization. There was a steep fall in gross domestic product (GDP) in the early years of transition, but it has recovered since and was recorded at current international US $ 1927 (purchasing power parity, PPP) per capita in 2005, which fell slightly short of its 1990 level. Due to remittances and direct foreign investment, GDP growth resumed in 2006. Using a poverty headcount of US $ 2 a day (PPP), 21.4% of the population were poor in 2005, while the Gini coefficient stood at 30.3 in 2003. Agri- culture continues to constitute an important sector of the economy and contributed 34.1% to GDP in 2005 (1). Health status Kyrgyzstan had a population of 5.14 million in 2005, 31.5% of which was below 15 years of age (1). The majority of the population (64.2% in 2005) lives in rural areas. As in other countries in central Asia, officially recorded infant mortality does not capture actual rates, and official statistics consequently overestimate life expectancy. Survey-based estimates put life expectancy at birth in 2005 at 72.4 years for females and 64.5 years for males, which did not greatly differ from estimated life expectancies in 1990 (1). Estimated infant mortality stood at 58 per 1000 live births in 2005, which com- pares to an estimated 68 per 1000 live births in 1990 (1). Officially recorded maternal mortality is high and stood at 61 per 100 000 live births in 2005, although actual maternal mortality was estimated to be even higher, at 110 per 100 000 live births in 2000 (2). The leading causes of death are diseases of the circulatory system, followed by diseases of the respiratory system and cancer (2). Similar to other countries of the region, there has been a resurgence of tuberculosis and sexually trans- mitted diseases in recent years, and there is also a looming threat of a Human Immunodeficiency Virus (HIV) epidemic. Organizational structure Historical origins of the system During the Soviet period, the health system followed the Semashko model, with centralized planning and administration and a focus on high numbers of doctors and hospital beds rather than on outcomes and quality of care. In the years following 1991, this communist legacy remained one of the major factors shaping health policy and practice in Kyrgyzstan (3). Organizational overview The Ministry of Health (MoH) is responsible for devel- oping and implementing the national health policy and the State Benefits Programme. It is also in charge of the quality control of pharmaceuticals, medical products and equipment and of the quality of health services. The Min- istry has a supervisory role in relation to all health-related organizations (including medical education), regardless of ownership and administrative level, and direct mana- gerial responsibility for a small number of specialized republican health facilities and tertiary level facilities in the capital, Bishkek. In addition, the MoH coordinates the activities of other health care organizations by means of coordination commissions on health management (3). The Department of State Sanitary-Epidemiological Surveillance administers the sanitary-epidemiology service, which forms the cornerstone of the public HiT profile in brief: Kyrgyzstan 2008 1 KyrgyzstanHiT profile in brief Health Systems in Transition health service. The Department of Drug Supply and Procurement of Medical Equipment, accountable to the MoH, is in charge of drug policy and the monitoring and evaluation of the quality of drugs. It registers pharma- ceuticals and issues licences to producers and retailers of drugs (3). A Mandatory Health Insurance Fund (MHIF) was established in 1996. It has now become the “single payer” in the health sector. The MHIF has been given responsibility for pooling all local budget revenues at oblast level (Kyrgyzstan is divided into seven oblasts, or regions) and for purchasing health care services. In 2006, fund pooling was further centralized to the national level, providing further opportunities to equalize health expenditures across regions. The Fund has addi- tional roles in quality assurance and the development of health information systems, including systems of finan- cial management in the health sector (3). Decentralization and centralization One of the key elements of health financing reform was the centralization of financing at first the oblast and later at the national level to enable better risk pooling and to establish a split between provider and purchaser. This was seen as a way to reduce excess capacity. A complementary reform was the granting of more autonomy to health facilities to manage their budgets. With the introduction of new provider payment methods, especially official co-payments by patients, health facilities have been granted greater flexibility in internal resource allocation (3). In recent years, some of the functions of the MoH have been transferred to nongovernmental organizations (NGOs). In particular, accreditation of health facilities has been delegated to the Medical Accreditation Com- mission. Privatization has so far been largely confined to pharmaceutical and dental care (3). Public–private contracting has been limited to selected ophthalmolog- ical services in Bishkek, although there is an intention to expand this in the future. Health care financing Health expenditure Using Treasury data on public expenditure and house- hold survey data on out-of-pocket expenditures (including informal payments), the World Health Organ- ization (WHO) estimated that total health expenditure in 2004 amounted to 5.6% of GDP, equivalent to PPP US $ 102 per capita (see Figure 1). Government expen- HiT profile in brief: Kyrgyzstan 2008 2 0 1 2 3 4 5 6 7 8 9 10 1998 1999 2000 2001 2002 2003 2004 Kyrgyzstan EU15 CIS CARK % Figure 1: Trends in total expenditure on health as a percentage of GDP in Kyrgyzstan, 1998–2004, WHO estimates Notes: CARK: Central Asian Republics and Kazakhstan; CIS: Commonwealth of Independent States; EU15: EU Member States before 1 May 2004. diture was estimated to constitute 40.9% of total health expenditure in 2004 (2), which means that private out- of-pocket payments now constitute the main source of health financing. As part of the Manas Taalimi reform programme, it is intended to restore earlier levels of health spending and reverse the decline seen in the early 2000s. The Government envisages to increase health spending from 10.3% of total government expenditure in 2005 to 13.0% by 2010. In order to make better use of the limited government expenditure on health, Kyrgyzstan has developed a State Benefits Package that specifies benefits, cost-sharing obligations and coverage of the population. The State Benefits Package was introduced in two pilot oblasts in 2001 and has now been extended to the whole country. It is annually approved by the Government on the basis of the expected revenues of the oblast and national pools of funds managed by the MHIF, as well as the projected levels of utilization and other parameters. The State Benefits Package covers free primary care from the contracted family group practice in which the patient is enrolled, free public health services from local sanitary- epidemiological and health promotion centres, and in- patient care following referral, for which a patient co-payment is required. Revenue The main sources of revenue for the Kyrgyz health sector are out-of-pocket payments, general budget revenues (republican and local), contributions to the MHIF, and grants and loans from international agencies. According to the Public Expenditure Review of the World Bank, in 2004 private out-of-pocket payments constituted 51.1% of total health financing, general budget revenues (of republican and local governments) constituted 44%, social insurance contributions 4% and international loans/grants 0.9%. Of general budget revenues, 32% come from the republican budget and 68% from local governments (4). Patient out-of-pocket payments include official co- payments, payments for pharmaceuticals and informal payments. Official co-payments for drugs, meals and certain types of health services were introduced within the framework of the single payer system in the hope that they would replace unofficial out-of-pocket payments (3). The role of the MHIF in health financing increased substantially with the introduction of the “single payer” system. In 2004, 83.6% of the population were covered by the MHIF. Voluntary health insurance was legalized in 1992, but remains virtually non-existent. The amount of foreign aid in the 1990s has been significant. In the period between 1998 and 2000, the level of foreign aid was as high as 10% of total health expenditure (3), and has reached similar levels again under the Manas Taalimi reform programme. Pooling and resource allocation Prior to recent reforms, health care budgeting and resource allocation were determined according to traditional Soviet norms. The introduction of the “single payer” system consolidated budgetary (i.e. rayon, or district, city and oblast) and MHIF funds in a single pool of funds at the oblast level, with subsequent allocation of resources to health providers through a single channel (3). Payments For both budgetary and mandatory health insurance funding, hospitals are paid according to the number of cases treated. Cases are categorized according to clinical expenditure groups, which are a version of diagnosis- related groups, based on Kyrgyz hospital utilization and cost data. Co-payments are paid directly to the hospital cash desk. Providers of outpatient care, primary care, and sanitary-epidemiological services are paid on a capitation basis (3). Until recently, public sector employees in the health sector were paid according to a national pay scale for public employees, under the “tarification” system. Since 1993, their salaries have been supplemented by official premiums from paid services. Physicians have also charged or accepted unofficial under-the-table payments. Since the introduction of the mandatory health insurance system, physicians have received additional salaries from mandatory health insurance funding. Significant revisions of the remuneration of health personnel in all health care facilities were made in 2002 and 2004. While still based on the “tarification” system, the groups and grades used to calculate various additions and bonuses have been revised (3). Planning and regulation In the Soviet era, planning, regulation and management were under the central control of the Soviet state. Following independence, the MoH of Kyrgyzstan assumed a leading role in health planning, regulation and management, but it is gradually decentralizing its HiT profile in brief: Kyrgyzstan 2008 3 functions. The main regulatory functions of the MoH include: the development of methodical guidelines that are compulsory for all health care providers; the licensing and attestation of health care providers; and quality assurance procedures. The MoH is also respon- sible for financial planning and budgetary management. Kyrgyzstan has several parallel health information systems. General morbidity data are collected by health facilities at the local level, pooled at regional medical information centres, and then pooled nationally by the Republican Medical Information Centre. Data related to infectious diseases are collected by local sanitary- epidemiological departments, pooled by regional sanitary-epidemiological departments, and then pooled nationally by the Department of State Sanitary- Epidemiological Surveillance. Data on births and mor- tality are collected through health facilities and through the civil registry offices that report data to the National Statistics Committee. Additional data collection systems are through separate vertical programmes and the par- allel health systems operated by other ministries and state companies and it is unclear how far these data are captured by the Republican Medical Information Centre (5). Physical and human resources Physical resources The Soviet health system left Kyrgyzstan with exces- sive hospital capacity, and the rationalization of hospi- tals has been an important aim of health policy in the years since independence. The number of hospitals has been reduced from 304 in 1990 to 146 in 2005, with a decline in the number of acute hospital beds per 100 000 population from 986 in 1990 to 393 in 2005 (see Table 1) (2). This decline in the ratio of hospitals and hospital beds is largely due to the policy and financing changes described earlier, i.e. changes in the payment of providers under the “single payer” system. A greater emphasis on primary care has led to the estab- lishment of family group practices on the basis of pre-existing health facilities, such as feldsher-accoucher points (FAPs) or polyclinics. In addition, in each rayon a family medicine centre was established that provides in addition to primary care more specialized outpatient services (3). Human resources In 2005, there were 583 nurses (physical persons) per 100 000 population, a decrease from 901 in 1990. The ratio of physicians (physical persons) to population has also decreased since 1990, from 337 per 100 000 population to 253 in 2005 (Table 1) (2). As in many other European countries, human resources in the health sector are distributed unevenly. The northern regions are better staffed than the southern regions, where physicians are lacking. In addition, there is a countrywide excess of physicians in cities and a shortage in rural areas (3). Most health staff are employed by the state. Besides being paid irregularly, salaries in the health sector are HiT profile in brief: Kyrgyzstan 2008 4 Table 1: Selected health care resources (nurses, physicians, acute hospital beds) per 100 000 population, 2005 or latest available year (in parentheses) Physicians (physical persons) Nurses (physical persons) Acute hospital beds Kyrgyzstan 253 583 393 CARK average 283 767 525 CIS average 372 788 730 EU15 average 336 (2004) 749 (2004) 393 (2004) Source: (2). Notes: CARK: Central Asian Republics and Kazakhstan; CIS: Commonwealth of Independent States; EU15: EU Member States before 1 May 2004. very low. According to official statistics, the average monthly wage of health personnel in 2003 was only 49.2% of the national average of all occupations. The expertise of health personnel, particularly in remote areas, is insufficient, due to limited access to up-to-date medical literature and the lack of financial resources for continuous medical education. In the regions, health personnel still use methodological recommendations and clinical treatment schemes developed during the Soviet period (3). Medical education has undergone some changes, but more comprehensive reforms are under way. Systems of on-the-job training and retraining of health personnel are fragmented and mainly oriented towards inpatient care. Existing curricula have so far not been brought in line with the planned restructuring of the health delivery system; nursing education, in particular, needs further reform (3). Provision of services Public health Public health services have traditionally been provided by the sanitary-epidemiological service. In recent years, the task of health promotion has been transferred from the sanitary-epidemiological service to the newly estab- lished Republican Centre for Health Promotion, with the aim of developing a service based on modern health promotion concepts. The sanitary-epidemiological service operates at the national, oblast, city and rayon levels. In addition to the national office of the Department of State Sanitary- Epidemiological Surveillance, there are 7 oblast centres and 50 rayon and city centres. The physical infrastruc- ture of the sanitary-epidemiological service is weak. Many laboratories and their equipment are obsolete and in need of renewal. The Department has undergone some reorganization since 1990, but it continues to lag behind the reform process in the rest of the health sector (3). Primary health care Primary care is provided by FAPs, family group prac- tices, family medicine centres and ambulance and emer- gency care services. FAPs and family group practices are the first points of contact with the health care system for patients in rural areas. Family group practices have been formed in recent years on the basis of pre-existing health facilities (FAPs, rural doctor ambulatories, poly- clinics and rural district hospitals). They have at least one physician, in addition to nurses and midwives, and serve villages with a population of more than 2000 inhabitants (3). Family medicine centres are the largest outpatient health facilities and are situated in the main settlement in the rayon. The reorganization of primary care is still under way. Family group practices are taking on more and more responsibilities in the health system. Since 2001, small family group practices have started to merge in order to create economies of scale (3). Hospital care Secondary care is provided at the specialized outpatient and general hospital levels and differs in rural and urban areas. Rural district hospitals are the main facilities rendering hospital care in remote rural areas. They are the smallest hospital facilities, designed to have 25–30 beds. Rayon hospitals provide general hospital care at the rayon level. City hospitals of all types, including adult’s and children’s hospitals, maternity houses and gynaecological hospitals, provide general hospital care in cities (3). Oblast-merged hospitals provide specialized outpatient care, as well as general and specialized inpatient care at the oblast level. With the exception of the republican facilities, these are the largest providers in their respective oblasts and are usually situated in oblast capitals. Oblast- merged hospitals arose following a restructuring in 2000, when oblast health departments were abolished (3). Tertiary care is provided by the republican health facil- ities at the national level (national hospitals, centres and scientific research institutes) and by specialized dispen- saries and hospitals at the subnational levels (3). Social care In Kyrgyzstan, social services are the responsibility of the Ministry of Labour and Social Protection, which provides social benefits and payments for drugs to vulnerable population groups. Health care facilities, particularly hospitals, seem to perform a social care function, manifested in higher hospitalization rates and longer length of stay in wintertime. There are few links between the health and the social welfare sectors, and families remain the most important providers of social care. What social care the state does provide, is mainly provided in institutions (3). The social safety net inherited by Kyrgyzstan from the Soviet era is sophisticated but inefficient. With the assis- tance of the World Bank and other international agen- HiT profile in brief: Kyrgyzstan 2008 5 cies, the Government is trying to target the social safety net better and make it more affordable. International and local NGOs have supported the provision of social care at home and the development of community care (3). Pharmaceuticals With the break-up of the Soviet Union in 1991 and the independence of Kyrgyzstan, the drug supply in Kyrgyzstan dramatically worsened and the country encountered a shortage of drugs. The situation improved with the privatization of the pharmaceutical sector. In the early 1990s, the formerly state-owned Kyrgyz Pharmacia was turned into a joint stock company. The process of privatizing pharmaceutical retailing began in 1996, and only a few municipal pharmacies are still in public hands. In 2004, 97% of drugs were imported, mainly from other CIS countries (3). The first Essential Drugs List in Kyrgyzstan was devel- oped in 1996 and a national drug policy was adopted in 1998. In 2000, the MHIF introduced an additional drugs package on a pilot basis in three polyclinics in Bishkek and the Alamudun rayon of Chui oblast. It has now been expanded to cover the whole country and forms part of the State Benefits Package (3). Mental health care Mental health services in Kyrgyzstan are overly centralized and based on large institutions. At present, the Government is unable to adequately meet even basic human needs such as food, basic health care and shelter. As part of the attempt to reform the mental health system, in 1999 the Government enacted the Psychiatric Care Law. In 2000, the Government launched its national programme “Mental Health of the Population of the Kyrgyz Republic in 2001–2010”. Both the law and the programme anticipate a shift from institution- ally based mental health care to more localized community-based care. Implementation of the programme remains so far incomplete, due to a lack of funding, lack of trained mental health professionals to provide the necessary community-based mental health care, particularly in rural areas, and the lack of private pay psychiatrists (6). Health reforms Health reform in Kyrgyzstan has taken place in the difficult context of political and economic transition and in the face of severe economic pressures. In 1994 the MoH requested technical assistance from the WHO Regional Office for Europe in the development and implementation of a comprehensive health care reform programme. In the same year, the United States Agency for International Development began its support of the initial Issyk-Kul health reform pilot project. The ten- year national “Manas” Health Care Reform Programme for 1996 to 2005 was followed by “Manas Taalimi”, a five-year national health reform programme for 2006 to 2010. So far, the country has accomplished a number of the tasks it had set itself and has become a regional leader in health reform. A mandatory health insurance system has been introduced, followed by new provider payment methods and contract arrangements. One of the key reform measures was the introduction of the “single payer” system, which united all previous achievements of health reform and served as a catalyst for reform. The system provided for a purchaser–provider split in the health care system, pooled budgetary funds at oblast and later at the national level, based the allocation of resources to providers on enrolled population and outputs rather than on capacity norms, and introduced a State Benefits Package. One of the key lessons of the Kyrgyz experience has been that the restructuring of the health care delivery system has required new economic instruments, which in turn have had to be embedded in a reform of the financial system of the country (3). The “Manas Taalimi” programme envisages further strengthening provider payment mechanisms and the purchasing function of the MHIF (7), which will entail changes to the overall public finance system of the country. Primary care has been restructured and strengthened. There has also been some progress in the reform of medical education. Training and retraining programmes in family medicine have been set up, a school of health management established and the curricula of the State Medical Academy revised. What is lacking so far is a comprehensive system of human resources manage- ment. The pharmaceutical sector has witnessed far-reaching reforms and has now been almost fully privatized. The MoH has developed a legislative and regulative base that emphasizes the use of generics. An Essential Drugs List was developed in 1996 and subsequently revised. The removal of barriers to imports of drugs and of the 20% value-added tax has signifi- cantly improved both the physical and the financial accessibility of drugs to the population (3). The “Manas Taalimi” programme aims to strengthen FAPs, emer- HiT profile in brief: Kyrgyzstan 2008 6 gency care services, and secondary and tertiary care, reform medical education, and reform the public health system (7). The “Manas Taalimi” programme has been implemented using the sector-wide approach that aims to ensure greater transparency of the health budget and better donor coordination. Assessment of the health system Since independence, Kyrgyzstan’s health system has undergone profound changes that were to a large extent determined through the dire economic transition. The breakdown of the Soviet system of free health care for all has resulted in decreased equity when accessing health care services. The Government has responded to this development by developing a State Benefits Package and an Essential Drugs List. Despite these reforms, about half of total health financing comes from private out-of-pocket payments, which include unoffi- cial under-the-table payments. Although informal payments have to some extent been replaced by official co-payments, people with lower income continue to face difficulties in accessing health care and drugs. While Kyrgyzstan has a lower share of out-of-pocket spending than many other CIS countries for which good evidence exists, the need for patients to pay for their care remains a serious obstacle to equal access. There are important lessons that emerge from the reform process in Kyrgyzstan for other health systems in tran- sition. A number of factors have facilitated successful health reform in the country. These include sustained political commitment; involvement of the population; coordination of donors’ efforts; continuity in health reform management; and a step-by-step approach, whereby pilot projects were linked to national health reform. Kyrgyzstan will continue to face the challenge of achieving a good performance in the health sector in the context of a difficult macroeconomic and political situation. References 1. World Bank (2007). World development indicators, Washington, DC, World Bank. 2. WHO Regional Office for Europe (2007). European Health for All database (HFA-DB) [offline database]. Copenhagen, WHO Regional Office for Europe (June 2007 version). 3. Meimanaliev A-S et al. (2005). Health care systems in transition: Kyrgyzstan. Copenhagen, WHO Regional Office for Europe on behalf of the European Observa- tory on Health Systems and Policies. 4. World Bank (2004). Kyrgyz Republic public expen- diture review. Washington, DC, World Bank. 5. Ahmedov M et al. (2007). Strengthening health research systems in central Asia. A system mapping and consultative process (draft). Geneva, Council on Health Research for Development (COHRED). 6. Mental Disability Advocacy Center (2004). Mental health law of the Kyrgyz Republic and its implementa- tion. Budapest, Mental Disability Advocacy Center (http://www.mdac.info/documents/MDAC%20Kyrgyz %20Report%20-%20English%20version.pdf, accessed 26 August 2007). 7. Government of the Kyrgyz Republic (2006). Kyrgyz Republic National Health Care Reform Program “Manas Taalimi” (2006–2010). Bishkek, Government of the Kyrgyz Republic (http://manastaalimi.med. kg/eng/, accessed 27 August 2007). Acknowledgements Health Systems in Transition (HiT) profile in brief for Kyrgyzstan was written by Bernd Rechel (European Observatory on Health Systems and Policies) and is based on data available in August 2007. This HiT pro- file in brief builds on and updates the full HiT profile on Kyrgyzstan of 2005, written by Adilet-Sultan Meimanaliev, Ainoura Ibraimova, Bolot Elebesov and Bernd Rechel. The research director was Martin McKee. The Observatory gratefully acknowledges Melitta Jakab, Peyvand Khaleghian, Elina Manjieva and Adilet- Sultan Meimanaliev for acting as reviewers. The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. HiT profile in brief: Kyrgyzstan 2008 7
Vol. 7 No. 2 2005
Health Care Systems in Transition
Kyrgyzstan
European Observatory on Health Systems and Policies
2005Kyrgyzstan
The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the governments of Belgium, Finland, Greece, Norway, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.
Health Care Systems in Transition
Written by Adilet-Sultan Meimanaliev Ainoura Ibraimova Bolot Elebesov and Bernd Rechel
Edited by Bernd Rechel and Martin McKee
© World Health Organization 2005, on behalf of the European Observatory on Health Systems and Policies
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The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
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Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration KYRGYZSTAN
ISSN 1020-9077 Vol. 7 No. 2
Suggested citation: Meimanaliev A-S, Ibraimova A, Elebesov B, Rechel B. Health care systems in transition: Kyrgyzstan. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2005.
Kyrgyzstan
Contents
Foreword ........................................................................................v
Acknowledgements .................................................................... vii
Introduction and historical background ....................................1 Introductory overview ................................................................1 History ......................................................................................11
Organizational structure and management .............................17 Organizational structure of the health care system ...................17 Planning, regulation and management .....................................20 Decentralization of the health care system ...............................23
Health care financing and expenditure .....................................25 Main source of financing and coverage ...................................25 Health care benefits and rationing ...........................................34 Health care expenditure ............................................................40
Health care delivery system .......................................................51 Primary health care and public health services ........................53 Secondary and tertiary care ......................................................60 Social care ................................................................................66 Human resources and training ..................................................71 Pharmaceuticals and health care technology assessment ........75
Financial resource allocation .....................................................83
Third-party budget setting and resource allocation ..................83 Payment of providers ...............................................................86
Health care reforms ....................................................................91 Aims and objectives ..................................................................91 Content of reforms and legislation ...........................................92 Reform implementation ............................................................94
Conclusions ................................................................................101
Appendix ....................................................................................103
References ..................................................................................107
Bibliography ..............................................................................113
European Observatory on Health Systems and Policies: WHO Regional Office for Europe Government of Belgium Government of Finland Government of Greece Government of Norway Government of Spain Government of Sweden The Veneto Region of Italy European Investment Bank Open Society Institute World Bank London School of Economics and Political Science London School of Hygiene & Tropical Medicine
Kyrgyzstan
Foreword
The Health Care Systems in Transition (HiT) profiles are country-based reports that provide an analytical description of a health care system and of reform initiatives in progress or under development. The HiTs
are a key element of the work of the European Observatory on Health Systems and Policies.
HiTs seek to provide relevant comparative information to support policy- makers and analysts in the development of health care systems in Europe. The HiT profiles are building blocks that can be used:
• to learn in detail about different approaches to the organization, financing and delivery of health services;
• to describe the process, content and implementation of health care reform programmes;
• to highlight challenges and areas that require more in-depth analysis; and
• to provide a tool for the dissemination of information on health care systems and the exchange of experiences of reform strategies between policy-makers and analysts in different countries.
The HiT profiles are produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate comparisons between countries, the profiles are based on a template, which is revised periodically. The template provides the detailed guidelines and specific questions, definitions and examples needed to compile a HiT. This guidance is intended to be flexible to allow authors to take account of their national context.
Compiling the HiT profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health
European Observatory on Health Systems and Policiesvi
Kyrgyzstan
care system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, including the WHO Regional Office for Europe health for all database, Organisation for Economic Cooperation and Development (OECD) Health Data and data from the World Bank. Data collection methods and definitions sometimes vary, but typically are consistent within each separate series.
The HiT profiles provide a source of descriptive information on health care systems. They can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health care systems. This series is an ongoing initiative: material is updated at regular intervals. Comments and suggestions for the further development and improvement of the HiT profiles are most welcome and can be sent to info@obs.euro.who.int. HiTs, HiT summaries and a glossary of terms used in the HiTs are available on the Observatory’s website at www.euro.who.int/observatory.
Kyrgyzstan
Acknowledgements
The HiT on Kyrgyzstan was written by Adilet-Sultan Meimanaliev (American University in Central Asia), Ainoura Ibraimova (Deputy Minister of Health, Director-General of the Mandatory Health Insurance
Fund), Bolot Elebesov (Deputy Director-General of the Mandatory Health Insurance Fund) and Bernd Rechel (European Observatory on Health Systems and Policies). The HiT was edited by Bernd Rechel and Martin McKee (European Observatory on Health Systems and Policies).
The European Observatory on Health Systems and Policies is grateful to Joe Kutzin (WHO Regional Office for Europe Regional Adviser for Health Financing), Sarbani Chakraborty (World Bank) and Tobias Schüth (Swiss Red Cross) for reviewing the report and to the Ministry of Health and the National Statistical Committee of Kyrgyzstan for their kind support.
The current series of Health Care Systems in Transition profiles has been prepared by the research directors and staff of the European Observatory on Health Systems and Policies. The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the governments of Belgium, Finland, Greece, Norway, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.
The Observatory team working on the HiT profiles is led by Josep Figueras, Head of the Secretariat, and research directors Martin McKee, Elias Mossialos and Richard Saltman.
Technical coordination was provided by Susanne Grosse-Tebbe, and production and copy-editing was led by Francine Raveney, with the support of Shirley and Johannes Frederiksen (layout) and Janet Barber (copy-editor). Administrative support for preparing the HiT on Kyrgyzstan was undertaken by Caroline White and Pieter Herroelen.
European Observatory on Health Systems and Policiesviii
Kyrgyzstan
Special thanks are extended to the WHO Regional Office for Europe health for all database, from which data on health services were extracted; to the OECD for the data on health services in western Europe; and to the World Bank for the data on health expenditure in central and eastern European countries. Thanks are also due to national statistical offices that have provided data.
This document and the data included reflects the situation at April 2005.
Kyrgyzstan
Introduction and historical background
Introductory overview
General information
Kyrgyzstan is a central Asian state that gained its independence following the dissolution of the Union of Soviet Socialist Republics (USSR) in August 1991. The country is bordered to the north by Kazakhstan, to
the west by Uzbekistan, to the south by Tajikistan and to the east by China. The territory of the country is 199 900 km2. The capital is Bishkek, located close to the northern border.
Kyrgyzstan is very mountainous, with almost 90% of the territory 1500 m above sea level. The average altitude is 2750 m, the highest point being 7439 m (Mount Jengish Chokusu) and the lowest point 394 m (in the south-western part of the country). Due to the mountainous relief, the population is concentrated in river valleys and along lakesides. The average population density is 25 people/ km2. The climate is continental with an average annual temperature ranging from 10–13 °C in low altitudes to –8 °C in higher altitudes (1).
At the end of 2003, the population of the country was estimated to be 5.01 million, the majority of which (65%) lives in rural areas. Kyrgyzstan is a multiethnic society. The main ethnic groups are Kyrgyz (67.4%), Uzbek (14.2%) and Russian (10.3%), while the remaining 8.1% include a large number of smaller minority groups (2). Kyrgyz and, since May 2000, Russian are the two official languages of the country. The predominant religion is Sunni Islam, followed by the Russian Orthodox faith, although the state is formally secular.
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Source: UN Carthographic Section.
Political structure
On 31 August 1991, the Kyrgyz Supreme Soviet voted for independence from the USSR. Six weeks later, Askar Akaev was re-elected as President of the new country. In December 1991, Kyrgyzstan became a member of the Commonwealth of Independent States (CIS). A new constitution was adopted on 5 May 1993, with several amendments since. The constitution defines Kyrgyzstan as a sovereign, unitary, democratic republic built on the principles of a constitutional, secular state.
In January 1995, Akaev was re-elected President for a new 5-year term. Referenda in February 1996 and October 1998 significantly expanded the power of the President and consolidated a presidential style of government. Akaev was re-elected President for a third term in October 2000. A referendum in February 2003 approved constitutional changes and affirmed Akaev’s final term in office.
Fig. 1. Map of Kyrgyzstan
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Parliamentary elections in February 2005, that were found to fall short of international standards by the Organization for Security and Co-operation in Europe (OSCE), triggered mass demonstrations, setting in train a sequence of events that led to the resignation of President Akaev in April 2005. New presidential elections were planned for June 2005, but the political situation remained unclear at the time of writing (April 2005).
The parliament (Jogorku Kenesh), constituted after independence, had 350 members. Following a referendum held in 1995, its structure was changed into a bicameral body with a total of 105 seats, consisting of the Assembly of People’s Representatives and the Legislative Assembly. The sessional Assembly of People’s Representatives numbered 70 elected deputies representing territorial interests, while the full-time Legislative Assembly was a standing body of 35 elected deputies representing the population as a whole. The structure was changed again in 1999. The Assembly of People’s Representatives was reduced to 45 members and the number of deputies in the Legislative Assembly increased to 60, 45 of whom were elected directly, while 15 were elected according to party lists. Following parliamentary elections in 2005, the parliament will be unicameral with 75 full-time members elected for 5 years based on single-mandate electoral districts. There are more than 30 registered political parties.
Executive power is represented by the government, which operates through the ministries, state committees and administrative agencies, and by local state administrations. The government is headed by the Prime Minister, who is appointed by the President, and consists of the senior ministers and chairs of state committees. Local state administrations in oblasts (regions) and rayons (districts) are headed by Akims (governors) – all appointed by the President for four years. In 1996 the President established a new Security Council to act as an inner cabinet. Unlike the broader cabinet, it was not accountable to parliament.
The Office of the Procurator General supervises the implementation of legislative acts and is responsible for criminal prosecution in courts. The highest judicial bodies are the Constitutional Court and the Supreme Court. Judges in both are elected by the Jogorku Kenesh on the recommendation of the President and have a 10-year term. Judges in lower courts are appointed by the President for a 7-year term, in consultation with the Jogorku Kenesh. After independence, a new institution, the court of aksakals (elders) emerged in rural areas and was institutionalised in 1995. Aksakals deal with land boundary disputes, divorces and property disputes, domestic violence, livestock thefts and other local disagreements. They operate within the framework of the Kyrgyz legal code and their decisions are subject to appeal to higher courts at the rayon
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or city level. Arbitration courts existed until 2003, when their legal status was revoked after a referendum. The Supreme Arbitration Court has become a kollegia (department) of the Supreme Court, which supervises compliance with the Procedural Code on Arbitration and the Law on Bankruptcy (Insolvency). The former local arbitration courts are in the process of being re-established within the general judicial system.
Local self-governing bodies are represented by local keneshs (councils) and local governments (including mayors’ offices). Deputies of local keneshs are elected for 5 years; heads of local governments are elected for 4 years. There are three territorial levels of local keneshs: primary (villages and towns), rayon and oblast levels. The local self-governing bodies are responsible for dealing with local matters.
The country is divided into seven oblasts (Batken, Chui, Issyk-Kul, Jalal- Abad, Naryn, Osh and Talas oblasts). The capital, Bishkek, and Osh city are separate administrative regions with a status equivalent to oblasts. The oblasts are divided into 40 rayons.
Kyrgyzstan is a member of the United Nations and several regional organizations: the Commonwealth of Independent States (CIS), the Shanghai Cooperation Organization (SCO), the Eurasian Economic Community (together with the Russian Federation, Belarus, Kazakhstan and Tajikistan) and the Central Asian Economic Community (with Kazakhstan, Uzbekistan and Tajikistan). In October 1998, Kyrgyzstan became the first CIS country to become a member of the World Trade Organization (WTO).
Demography and health
Despite large-scale emigration, the population of Kyrgyzstan grew overall during the 1990s, from 4.46 million in 1991 to 5.01 million in 2003 (�), since birth rates were still much higher than death rates. The country has a young population: 34.5% are children and adolescents, 57% are people of working age and 8.5% are above working age. The reported literacy level of the adult population, at 98.7%, is very high (2).
The last 15 years have seen a declining birth rate, with a decrease of almost a third between 1991 and 2003, from 29.1 to 20.9 per 1000 population. The declining trend started in 1988, most likely as part of the general reaction to the worsening socioeconomic situation seen throughout the Soviet Union. After reaching its lowest point in 2000, the birth rate began to increase in the following years, a trend that is expected to continue, as the girls born in the time of the babyboom of the 1980s are now reaching reproductive age (2). Similar to the
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rest of the former Soviet Union, the death rate had been increasing until 1994, when it peaked at 8.36 per 1000, but has declined since.
An enormous emigration in the early 1990s led to a transient decrease in the population in 1993 and 1994. The peak outflow was in 1993 (121 000), when ethnic Russians, Jews and Germans were leaving the country to seek residence in their respective “kin-states”. In the mid-1990s emigration declined, but increased again in 1999 following communal strife in the southern parts of the country. Russians remain the largest group of emigrants (57%), followed by Ukrainians, Germans and Kyrgyz (6–8% each) and Kazakhs, Uzbeks and Tatars (4% each). Over 70% of emigration originates in Chui oblast and Bishkek, which are also the targets of internal migration flows (2).
Table 1. Demographic indicators, 1991–2003
Indicators 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Mid-year population (in million) 4.46 4.52 4.51 4.51 4.56 4.63 4.67 4.77 4.84 4.88 4.93 4.97 5.01
Births per 1000 population 29.1 28.6 26.1 24.6 26.0 23.6 22.0 22.2 21.4 19.7 19.8 20.2 20.9
Deaths per 1000 population 6.9 7.2 7.7 8.3 8.2 7.6 7.4 7.4 6.8 6.9 6.6 7.1 7.1
Sources: (4–6).
Table 2. Life expectancy at birth
1991 1995 1996 1997 1998 1999 2000 2001 2002 2003 Both sexes 68.8 65.9 66.6 66.9 67.1 68.7 68.5 68.7 68.1 68.2
Females 72.7 70.4 70.1 71.4 71.2 72.6 72.4 72.6 72.1 72.5
Males 64.6 61.4 62.3 62.6 63.1 64.9 64.9 65.0 64.4 65.0
Sources: (4,5).
Trends in life expectancy in Kyrgyzstan have followed trajectories very similar to those seen in the former Soviet Union as a whole (7). Life expectancy declined in the years after 1991, showing signs of recovery since 1994. However, life expectancy has still not reached its 1991 level. In 2001 life expectancy was almost 10 years lower than in the European Union (EU), reaching 68.66 years at birth in Kyrgyzstan compared with 78.21 years in the EU (�). As in the rest of the former Soviet Union, there is a substantial gender gap in life expectancy; in 2003, females could expect to live for 72.5 years, while male life expectancy was, at 65 years, 7.5 years lower.
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According to official death registration statistics, cardiovascular disease is the main cause of death. In 2003 diseases of the circulatory system constituted 47.1% of recorded mortality, diseases of the respiratory system 12.7%, injuries and poisonings 10.2%, neoplasms (cancer) 8.7%, diseases of the digestive system 5.9%, infectious and parasitic diseases 3.5% and other causes 11.9% (�).
The officially recorded infant mortality has decreased in the past decade, reaching 20.9 per 1000 live births in 2003. However, serious concerns have been raised about the quality of official statistics on infant and child mortality in all central Asian republics. There are three main factors that contribute to the discrepancy between official data and estimates by international organizations: the continued use of the Soviet definition of live birth (despite the official adoption of the definition of live birth established by the World Health Organization); misreporting by medical staff; and failure to report births and deaths of children to the authorities (9). These factors combine to understate the real situation in Kyrgyzstan. For example, calculations based on the 1997 Demographic and Health Survey estimated an infant mortality rate of 61 per 1000 live births for the period 1992–1997, twice the official estimate of 29 for the period 1993–1996. There are notable differences between different population groups. Based on these survey data, infant mortality in the poorest quintile in 1997 was, at 83.3 per 1000 live births, almost twice as high as for the richest quintile, in which it was 45.8 per 1000 live births (10). Table 3 shows how World Bank estimates, based on survey data, have consistently reported higher infant mortality rates than those of official statistics. If World Bank estimates reflect the real situation, life expectancy in Kyrgyzstan would be reduced by two years (11). Following Kyrgyzstan’s adoption of the WHO criteria of a live birth in 2004, infant mortality in the first 10 months of 2004 showed an increase of 21% compared to the same period in the previous year (Republican Medical Information Centre preliminary data).
According to official data, the structure of infant mortality is the following: perinatal causes (44.9%), diseases of the respiratory system (29.2%), infectious and parasitic diseases (6.7%), congenital malformations (11.8%) and other
Table 3. Infant mortality rate per 1000 live births
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Official statistics 29.7 31.5 31.9 29.1 28. 1 25.9 28.2 26.1 22.7 22.6 21.7 21.2 20.9
World Bank estimate – 65.6 – – 62 – 60 – – 57 52 – –
Sources: (3–5,8).
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causes (7.4%). However, in view of the underreporting and misreporting of infant deaths, these data should be treated with caution.
Table 4. Maternal mortality
1991 1995 1996 1997 1998 1999 2000 2001 2002 2003 Maternal mortality per 100 000 live births 76.4 67.4 65.0 76.4 54.7 46.1 46.5 49.9 58.4 53.1
Sources: (4,6).
According to national statistics, maternal mortality has also decreased in the past decade. It is reported at 53.1 per 100 000 live births in 2003 compared with 76.4 per 100 000 live births in 1991, far above the EU average (which is below 10 per 100 000 live births). However, as is the case with infant mortality, actual maternal mortality rates may be much higher. The United Nations Children’s Fund (UNICEF) estimated that in 2000 maternal mortality was 110 per 100 000 live births, more than double the official rate for the same year (12).
Table 5. Infectious diseases
1991 1995 1996 1997 1998 1999 2000 2001 2002 2003
Tuberculosis incidence per 100 000 populationa 56.5 73.3 87.5 112.6 108.9 131.8 150.9 135.1 145.8 138.2
New HIV casesb 0 2 2 2 6 10 16 149 160 132
Syphilis per 100 000 population 2.0 73.6 164.7 167.8 144.2 110.8 87.5 60.6 53.8 48.2
Sources: (3–6). Note: a Data on the number of tuberculosis cases have included the penitentiary system since 1999; b Data on the number of new HIV cases are from the Republican AIDS Centre and include all cases registered in Kyrgyzstan, of both Kyrgyz nationals and foreigners.
Even though mortality from infectious and parasitic diseases constitutes a comparatively small percentage of overall mortality (3.5%), morbidity has grown dramatically over the last decade. The recorded incidence of tuberculosis more than doubled between 1991 and 2003, from 56.5 to 138.2 per 100 000. Multidrug-resistant tuberculosis is widespread and it is believed that prisons contribute greatly to the spread of the disease (1�).
The recorded incidence of sexually transmitted infections has also increased dramatically. The recorded incidence of syphilis, for instance, rose from 2.0 per 100 000 in 1991 to 48.2 per 100 000 in 2003, reaching its peak of 167.8
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per 100 000 in 1997, although the recent decline may in part be due to under- recording or increased private treatment. Similarly, a decreasing trend in the incidence of gonorrhea (from 55.5 per 100 000 in 1991 to 27.4 per 100 000 in 2003) may not reflect the real situation because of self-treatment and treatment in private and non-medical facilities. The incidence of other sexually transmitted infections such as chlamydiosis and mycoplasmosis is also growing (1�).
Although the absolute number of officially registered HIV cases is still comparatively low, an exponential increase has been recorded since 2001. The country is still at an early stage of the HIV/AIDS epidemic, but there are a number of factors in place that create a potential for a dramatic increase: widespread injecting drug use, migration, extensive commercial sex work, marginalization of vulnerable groups and low public awareness of HIV/AIDS (1�).
Malaria was rare until 2002, when a dramatic increase was recorded, thought to reflect increased migration from Afghanistan to the southern part of Kyrgyzstan (�). In 2002, there were 2744 registered cases of malaria, although this number declined to 468 in 2003 (�). Viral hepatitis is also a problem, particularly in the southern regions of the country. There is a high prevalence of infection with viral hepatitis B among medical personnel that come into contact with the virus (1�).
Recent years have also seen an increase in parasitic diseases. The incidence of brucellosis and echinococcosis doubled, from 14.7 per 100 000 in 1991 to 50.3 per 100 000 in 2003 and from 6.0 per 100 000 in 1992 to 11.6 per 100 000 in 2000, respectively. The increase is thought to be related to economic difficulties and, in particular, weaknesses in the veterinary service (1�).
As a land-locked mountainous area, Kyrgyzstan is especially vulnerable to iodine deficiency unless salt is iodized. The rate of iodine deficiency has sharply increased. Sampling studies have shown that 52% of children and adolescents in the northern regions have some evidence of iodine deficiency, while in the southern regions this figure reaches 87% (1�). The number of people with recorded iodine deficiency rose from 5260 in 1995 to 109 435 in 2003 (�). As in other parts of central Asia, iron deficiency among women is common, largely due to patriarchal patterns of distribution of food within families. The 1997 Demographic and Health Survey found that over 60% of women (including 90–95% of pregnant women) and 50% of children under three had anaemia. In 2003, the number of registered cases of anaemia was 95 385 (�).
Over the past decade, there has also been an increase in alcohol and drug abuse. In the last five years recorded consumption of alcohol in Kyrgyzstan has increased by 28% and deaths resulting from alcohol intoxication have risen by 130%. The incidence of alcoholic psychosis has increased fourfold (1�). There
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has also been a dramatic increase in the use of illicit drugs, with an estimated fourfold increase over the past decade (1�). Use of opium and, more recently, heroin has increased in comparison with hashish consumption. Unlike in other parts of Asia, an estimated 95% of users inject opium intravenously, a factor associated with a rapid growth of HIV among intravenous drug users in the southern part of the country in 1999 (1�).
The extent of violence against women is increasingly recognized. Nearly 30 000 women have turned to the ten crisis centres in the country in the past three years, seeking assistance after suffering various forms of violence. Some sources also describe trafficking in human beings, with an estimate of almost 4000 Kyrgyz women each year becoming victims of the trade in humans (1�).
Economy
In Soviet times Kyrgyzstan was heavily subsidized from Moscow, with direct subventions contributing to up to 25% of republican income. Its role in the Soviet division of labour was, like much of central Asia, as a producer of raw materials. With the dissolution of the Soviet Union and the transition from central planning, the country encountered a severe economic recession leading to a period of hyperinflation. In all central Asian republics, real output was lower in 1999 than it had been a decade earlier, and inequality and poverty increased (17). To cope with these economic pressures, Kyrgyzstan has embarked on a resolute course of liberalization, and has since 1994 cooperated closely with the World Bank and the International Monetary Fund.
Indicators 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
GDP (m som) 5 355 12 019 16 145 23 399 30 686 34 181 48 744 65 358 73 883 75 240 83 421
GDP real growth rate (%) -15.5 -20.1 -5.4 7.1 9.9 2.1 3.7 5.4 5.3 -0.5 6.7
Inflation (% end of period change in consumer price index) 929.9 62.1 32.1 34.8 13.0 16.8 39.9 9.6 3.7 2.3 5.6
Budget balance (% of GDP) -7.1 -7.7 -11.5 -5.4 -5.2 -3. -2.5 -2.0 0.4 -1.0 -0.8
Per capita GDP in US $ (average exchange rate) 234 244 325 392 374 340 255 279 308 315 377
Sources: National Statistical Committee for GDP, inflation and budget balance data. World Bank, 2003 (18) for GDP real growth rate, budget balance, and per capita GDP in US $.
Table 6. Macroeconomic indicators, 1993–2003
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Prices and trade were liberalized in 1992–1996 and two rounds of privatization implemented in 1991–1993 and 1994–1995. In 1992 a two-tier banking system was established, with the National Bank working as the Central Bank and the creation of several joint stock commercial banks. The tax system has also been reformed since 1992. The legislation necessary for a functioning market economy has been developed steadily.
The national currency – the Kyrgyz som – was introduced on 10 May 1993. Tight fiscal and monetary policies helped to achieve a relative degree of macroeconomic stabilization. In 1996, the economy started to recover with 7.1% growth of GDP, attributable mainly to the development of a gold-mining Canadian-Kyrgyz joint venture, known as Kumtor. The 1998 economic crisis in the Russian Federation slowed economic growth, revealing the vulnerability of the Kyrgyz economy to external shocks. However, the average annual real growth rate of GDP in 1996–2001 was 5.6%. In 2002, GDP fell by 0.5% due to a recession in the energy sector and an accident at the Kumtor gold mine in July, but resumed again in 2003 with 6.7% growth (19). In spite of this macroeconomic stabilization, however, a large proportion of the population continues to live in poverty.
Kyrgyzstan is the only central Asian country so far to have joined the World Trade Organization, exposing its internal market to direct foreign competition. The country has borrowed heavily from abroad and currently its foreign debt is US $1.73 thousand millions, equivalent to US $345 per capita.
About half of the population works in agriculture, which is the largest sector of the economy, contributing to 35.2% of GDP in 2003. Industry and construction accounted for 22.9% of GDP. The mining industry, especially gold mining, is of particular importance and a major source of exports. Other than gold, however, Kyrgyzstan has few readily exploitable natural resources. Another important branch of the economy is the production of electrical energy, mainly on the basis of hydroelectric power. The country has only a small manufacturing sector. Services contributed to 34.9% of GDP in 2003 (20).
On the United Nations Development Programme (UNDP) Human Development Index (a composite measure of life expectancy, adult literacy and educational attainment, and per capita GDP), Kyrgyzstan ranked at 0.701, occupying the 110th place out of 177 countries worldwide in 2002 (21). Poverty increased markedly in the 1990s, although it was not unknown prior to the dissolution of the Soviet Union. Using a national poverty threshold of 75 roubles per month, it has been estimated that in 1989 32.9% of the population in Kyrgyzstan lived in poverty, compared to 11.1% of the overall Soviet population (17). After 1989, poverty increased and so did inequality. The Gini coefficient (a measure of income inequality) increased from 0.26 in 1989 to 0.47 in 2000
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(22). In 1998, on the basis of the US $2.15 per day absolute poverty line used by the World Bank, 49.1% of the Kyrgyz population was poor, rising to 84.1%, when using the US $4.30 per day poverty line (2�). People living in poverty are concentrated in rural and mountainous regions and many are children. Since 1999, when peak levels of poverty were recorded (64.1% according to the national poverty line), a reduction has been achieved, but in 2003, 40.8% of the population was still living below the national poverty line (22,2�).
In May 2001, the Kyrgyz Government approved a Comprehensive Development Framework for the period 2001–2010, setting out a vision of socioeconomic development and poverty alleviation (2�). The National Poverty Reduction Strategy 2003–2005 constitutes the first phase in the implementation of the Comprehensive Development Framework. The Strategy was adopted as a medium-term action programme for economic, social and political reforms, developed in close collaboration with the International Monetary Fund, the World Bank and other international organizations (2�). Kyrgyzstan has also become one of the member countries of the CIS-7 Initiative, which was launched in April 2002. The Initiative is sponsored by bilateral donors, the International Monetary Fund, the World Bank, the European Bank for Reconstruction and Development and the Asian Development Bank. It aims to promote poverty reduction, growth and debt sustainability. It encompasses seven low-income CIS countries: Armenia, Azerbaijan, Georgia, Kyrgyzstan, the Republic of Moldova, Tajikistan and Uzbekistan (2�).
History
The territory that is now Kyrgyzstan has had a fluid relationship with neighbouring states and spheres of influence throughout recorded history. The first reference to the ethnonym Kyrgyz can be found in Chinese manuscripts dating back to the 2nd century BC, referring to peoples who inhabited the higher reaches of the Yenisei River, which flows to the Arctic Ocean through Siberia. It has been subsequently mentioned by Persian and Arab historians. In the 11th century AD, Kyrgyz was listed in Makhmud Kashgari’s encyclopaedia Kut Bilim as one of the 22 Turkic tribes.
Historically, present-day Kyrgyzstan lay on the intersection of paths travelled by nomadic and migrating populations between central Asia and Asia Minor, as well as across the steppes to Eastern Europe. It has been a zone of cultural interaction between the central Asian nomadic peoples and settled populations. One of the branches of the Great Silk Route went through the territory of what is now Kyrgyzstan.
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The 16th to 19th centuries were a period of almost constant war involving a sequence of invaders: the Kalmak Khanate, Dzhungar Khanate, Kokhand Khanate and Tsin China. In the 18th century Kyrgyz tribes made the first contacts with the Russian Empire, into which they were absorbed by the end of the 19th century.
Many elements of the history and culture of the Kyrgyz people can be found in the national heroic epic Manas. As the Kyrgyz language was unwritten until 1924, the Manas, along with other minor epics, had been passed down from generation to generation by word of mouth. In 1995, Kyrgyzstan celebrated the 1000th anniversary of the epic.
Kyrgyzstan entered the 20th century as part of the Turkestan Krai of the Russian Empire. Punitive operations by the Czarist army against the mass revolt of the central Asian peoples in 1916 and the subsequent Stalinist “collectivization” resulted in migration of many Kyrgyz to China. Initially under Russian influence, the traditionally nomadic Kyrgyz began to settle. As already mentioned this process intensified under the Soviet regime, especially during the “collectivization” and industrialization of the twentieth century.
Following a brief period of independence after the 1917 revolution, in 1918 Kyrgyzstan became part of the Turkestan Autonomous Soviet Socialist Republic within the USSR. In 1924 the territory of present-day Kyrgyzstan became the Kara-Kyrgyz Autonomous Oblast, a constituent part of the USSR. Two years later, in 1926, the official name changed to Kyrgyz Autonomous Soviet Socialist Republic (Kyrgyz ASSR) and in 1936 it was designated as a full republic entitled the Kyrgyz Soviet Socialist Republic (Kyrgyz SSR). The Kyrygz Republic gained its independence in August 1991.
Historical background of health services
In the beginning of the 20th century, the health care system of present-day Kyrgyzstan comprised only a very small number of medical facilities, all located in cities. In 1913, there were only six hospitals (four city and two rural hospitals), nine outpatient facilities and five pharmacies. After present-day Kyrgyzstan was included in the Soviet state, a health care system based on the Semashko model was developed. Nikolai Semashko, the founding father of Soviet health care, announced the principles on which the Soviet health care system was to be based at the Congress of Medical-Sanitary Departments in 1918:
government responsibility for health care;
universal access to free health services;
a preventive approach to diseases.
•
•
•
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On the basis of these principles, the Soviet state developed a unified health system, owned and controlled by the state. The main emphasis was placed on the fight against infectious diseases and the establishment of a network of health facilities. In the Kyrgyz Republic, typhus and cholera were the main diseases in the 1920s. The period 1927–1929 was characterized by the extensive and rapid development of a network of health facilities, including hospitals, ambulatories, feldsher points and mobile health facilities.
Specialized health care began to develop in 1925. The first maternity house and children’s consultation centre were opened in Frunze (the name of Bishkek in the Soviet era), a venereal ambulatory was reorganized into a venereal dispensary, and venereal points were also opened in Tokmok and the village of Kochkor. In 1928, the first medical college was opened to train middle- level health personnel (midwives, feldshers, nurses, laboratory assistants, X-ray laboratory assistants and technicians). Mobile medical groups to fight tuberculosis, trachoma, syphilis and other skin and venereal diseases started functioning from 1935. Efforts in the field of sanitation and epidemiology also improved. In 1938, the Sanitary-Bacteriological Institute was opened. By 1940, the health care system of the country was able to offer all basic elements of health care, including clinical care, pharmacies, sanitary-epidemiological (san- epid) services and forensic medicine. There was one dispensary for tuberculosis, 11 dermato-venereal dispensaries, 9 san-epid stations, 10 sanatoria and 59 pharmacies. Medical education was provided by the Kyrgyz State Medical Institute (renamed the Kyrgyz State Medical Academy in 1996), established in 1939, and in 5 medical colleges.
Table 7. Development of the health care system, 1913–1940
1913 1925 1928 1940 Doctors 21 75 155 600
Hospital facilities 6 17 29 112
Outpatient facilities 9 16 45 319
Hospital beds 100 445 955 3 824
Beds per 10 000 population 1.2 – – 24.1
Women’s, children’s consultation centres and polyclinics – 1 7 66
Beds for pregnant and confined women 12 20 142 755
Pharmacies 5 13 – 59
incl. in rural areas – 6 – 37
Sanatoria – – – 15
Source: (1).
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During the Second World War, the Kyrgyz Republic was not directly affected by conflict and expanded its network of health facilities. In the cities the number of beds increased from 2353 in 1940 to 3867 in 1945. The number of inpatient facilities in rural areas grew from 79 in 1940 to 94 in 1945, while the number of beds grew from 1471 to 2073. Thirty-four feldsher points and 26 women’s and children’s consultation centres were also established.
In the post-war years, hospitals were integrated with outpatient facilities and inpatient facilities for mother and child health, and san-epid services were reorganized. In the 1950s and 1960s, the main focus was on an expansion of the material base of the health care system, i.e. the enlargement of existing facilities and the construction of new ones.
Throughout the period 1923–1970, with the support of the Soviet state and the Russian Society of the Red Cross, over 150 medical expeditions were organized into remote areas. Besides providing medical examinations and treatment to the population, they also trained local health personnel. These efforts contributed to a significant decline of infectious diseases. In 1926, the incidence of malaria was 1000 per 10 000 population, declining to 505 in 1932 and 1.5 in 1955. After 1960 malaria was virtually eradicated, although the disease has re-emerged in recent years.
A number of other serious infections were also eradicated after 1923: cholera (1926), plague (1928), endemic smallpox (1936), relapsing fever (1955), spotted fever (1955), dermal leishmaniasis (1955), pappatacci (sandfly) fever (1956), trachoma (1963), ancylostomiasis (1964) and poliomyelitis (1970). Relative to the pre-revolutionary period, the incidence of pertussis was reduced by 98%, typhoid by 94%, measles by 93% and scarlet fever by 68%. Rabies, diphtheria, anthrax and Q fever were virtually eradicated, with only a few sporadic cases. Considerable successes were also achieved in the control of tuberculosis and venereal diseases.
By 1980 Kyrgyzstan had put in place a comprehensive health care system by Soviet standards, including 267 health facilities, 54 san-epid services and 9 medical colleges. There were also two industrial facilities in Frunze, one for the repair of medical equipment and the other for the production of pharmaceuticals.
Although achieving enormous success in the fight against infectious diseases and the establishment of a network of health facilities, the Soviet system of health care was fraught with weaknesses. Health services were ineffective and, facing growing demands with a worsening health status as well as new opportunities for treatment offered by technological progress, they became financially unsustainable, a situation exacerbated by the diversion of funds into the military-industrial complex from the 1960s onwards. Perverse incentives
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Table 8. Development of the health care system, 1940–1980
1940 1950 1960 1970 1980 Health facilities 112 138 261 273 267
Hospital beds 3 824 7 106 1 627 31 900 43 600
Hospital beds per 10 000 population 24.1 40.3 73.5 106.5 119.4
Doctors of all specialties 600 1 751 3 413 6 223 10 400
Doctors per 10 000 population 3.8 9.9 15.4 20.8 28.5
Middle-level health personnel 2 552 4 765 10 807 21 645 32 700
Middle-level health personnel per 10 000 population 16.1 27.0 48.8 72.3 89.5
Beds for pregnant and confined women 755 1 015 2 589 4 016 4 479
Pharmacies 59 100 – – 296
in rural areas 6 70 – – 190
Sanatoria 15 – – – 139
beds, in thousands 2.4 – – – 35.7
Source: (1).
built into the health financing system contributed to the expansion of physical capacity, without necessarily improving health care. The key element in all areas of planning was the so-called “normative optimum”, i.e. the development of “scientifically-based” optimal norms and standards set by elite committees in Moscow. The health sector used norms such as the population’s need for health services (e.g. number of beds or doctors per 10 000 population), or the workload for doctors and middle-level health personnel (e.g. visits per hour, number of patients per doctor, approximate norms of rendering physiotherapeutic services, lab tests).
Emphasis was put on infrastructure, not outcomes. In addition, the health care sector was financed on the basis of the so-called “residual” principle, which meant that the health sector received funding only after all other sectors (defence, industry, agriculture, etc.) had been paid for. Salaries for health care personnel were low, resulting in poor motivation and requests for informal payments by clients.
In the late 1980s the health status of the population began to deteriorate. The health care system was no longer able to respond to the health needs of the population. A package of health reforms planned for 1985–1990 was not accomplished, being caught up in the political changes in the USSR. After the
European Observatory on Health Systems and Policies1�
Kyrgyzstan
country gained independence, health reforms remained on the agenda of the new state, although economic reforms were given a higher priority.
Kyrgyzstan
Organizational structure of the health care system
Before Kyrgyzstan became independent, the health system was highly centralized and controlled from Moscow. The Ministry of Health of the USSR was the principal planning and management body in the Soviet
Union. Health care in the 15 Soviet Socialist Republics was supervised by the republican ministries of health, but their role was confined to carrying out supra- Soviet directives of the Ministry of Health of the USSR. This structure was replicated at republican level. Local health facilities at the oblast, city and rayon levels were obliged to follow the orders of the republican ministries of health. Paradoxically, this was viewed by the USSR as an element of decentralization. In the late 1990s this legacy remained one of the major problems facing health management in Kyrgyzstan.
Currently, the government has the following responsibilities in the health sector. It adopts, after approval by the parliament, a health policy, an action plan for its implementation and a strategy of health care development. It also adopts, finances and controls the implementation of national, state and specific programmes on health protection and the development of the state health system. The government reports annually to the parliament on the health of the population and on the execution of the consolidated health care budget.
The Ministry of Health implements the health policy and develops and implements, in cooperation with other agencies and sectors, a State Benefits Programme and other targeted health programmes. It is responsible for the quality of health services and the quality control, safety and effectiveness of pharmaceuticals, medical products and equipment. While it has a supervisory role in relation to all health-related organizations (including medical education), regardless of ownership and administrative level (as had the Ministry of Health
Organizational structure and management
European Observatory on Health Systems and Policies1�
Kyrgyzstan
of the USSR), and approves their policy and programme documents, it has direct managerial responsibility only for the small number of specialized republican health facilities and the tertiary level facilities in Bishkek. In addition, the Ministry of Health coordinates and controls territorial health bodies and organizations through coordination commissions on health management. It reports annually to the government on the health of the population.
The Department of State Sanitary-Epidemiological Surveillance (DSSES) acts through a separate line of responsibility and is directly accountable to the Ministry of Health, thus creating challenges relating to coordination at the oblast level. It administers the san-epid service, which forms the cornerstone of the public health service. It is headed by the chief sanitary doctor who is also a Deputy Minister of Health. The Department emerged in 1997 from the former Republican Sanitary-Epidemiological Service and the Sanitary-Epidemiological Department of the Ministry of Health.
The Department of Drug Supply and Procurement of Medical Equipment, which is also directly accountable to the Ministry of Health, is in charge of drug policy and the monitoring and evaluation of the quality of drugs. It registers pharmaceuticals and issues licenses to producers and retailers of drugs. The Department is headed by a director-general and was set up in 1997, as the result of a merger between the former Republican Centre on Standardization and Quality Control of Drugs and Medical Equipment, the Ministry of Health Department on Drugs and Medical Equipment and the Ministry of Health Pharmacological Committee.
The Mandatory Health Insurance Fund (MHIF) is the “single payer” in the health sector. It has been given responsibility for pooling funds and purchasing health care services, as well as for budgetary health funding. It also has additional roles in quality assurance and the development of health information systems. It is headed by a director-general who is also a Deputy Minister of Health. The fund operates through its territorial departments, present in each oblast and Bishkek and Osh cities. Initially established as a fund under the government in 1997, it was transferred to the Ministry of Health in 1998. The MHIF is accountable to the Ministry of Finance and local state administrations on the use of budgetary resources and health care financing.
Local state administrations are owners of health facilities providing primary and secondary care, including polyclinics and regional and district hospitals (except those owned by other central government ministries and some enterprises), and are in charge of health care on their respective territories. Through their coordination commissions on health management they implement the national health policy, develop and implement territorial health programmes, and control the implementation of national, state and
19Health Care Systems in Transition
Kyrgyzstan
Fig. 2. Organizational structure of the health care system
Kyrgyz State Medical Academy
Parliament
Government
Health facilities
President
Other ministries
Republican health facilities
Oblast merged hospitals
Oblast state administration
Territorial hospitals
Department of Drug
Supply and Procurement of Medical Equipment
Department of State Sanitary- Epidemiological Surveillance
San-epid (regional and municipal level)
Mandatory Health
Insurance Fund
Coordination Commissions on
Health Management
Ministry of Health
Private health providers
Affiliates of territorial hospitals
Family medical centres (regional
and municipal level)
Family group practices
Feldsher-obstetrical points
Territorial divisions of Mandatory Health
Insurance FundNGOs
Medical colleges
Source: Adapted from (28).
targeted health programmes. They draw up the health care budget and ensure its execution and are responsible for strengthening the capacity and improving the working conditions of health personnel. Local state administrations report annually to local keneshs on the population’s health.
Parallel health services provided by ministries and agencies other than the Ministry of Health continue to exist. The parallel system includes services provided by seven ministries, five large state-owned joint stock companies, and enterprises and organizations partially funded by the state. In 1998, parallel health services accounted for about 6% of total governmental health care expenditure (29). These health facilities are directly accountable to their respective agencies and funded from the republican budget.
The private health sector has developed since the 1990s. Starting with pharmacies, it later expanded to include the provision of health services. In 2003, the Ministry of Health issued 254 licenses for private medical practices, of which 49 were for legal entities and 205 for individuals. Private health facilities can bid for contracts from the public sector and participate in the State Benefits Programme. So far, this has mainly been seen in relation to drug supply, in the
European Observatory on Health Systems and Policies20
Kyrgyzstan
framework of the additional drug package of the MHIF at the outpatient level (see the section on Health care delivery system). Public purchases of health services from private providers also take place. The MHIF, for example, has a contract with a private ophthalmologic hospital.
Nongovernmental organizations (NGOs) have emerged in the health sector mainly in the form of professional associations. They include associations of physicians and pharmacists, nurses, cardiologists, patients with diabetes, and blood donors. The Association of Family Group Practices and the Hospitals Association, both established in 1997, work closely with the Ministry of Health on health reform.
Planning, regulation and management
In Soviet times, planning, regulation and management were under the central control of the Soviet state. Following independence, the Ministry of Health of Kyrgyzstan has assumed a leading role in health planning, regulation and management, but is gradually decentralizing its functions.
The overall management of the health system still largely follows a hierarchical top-down model. Laws, decrees or other regulations are adopted by the Jogorku Kenesh, and the Ministry of Health subsequently issues orders that are compulsory for all government-owned health facilities. The administrations of health facilities, in turn, issue internal orders, with timetables and responsibilities. They are obliged to monitor their implementation and to report the results back to the Ministry of Health.
The Ministry of Health directly administers the republican health facilities, such as the scientific research institutes and national centres. It also manages the Kyrgyz State Medical Academy, even though until recently it was unable to control the number of admissions there. It appoints the heads of state health care organizations and its prior agreement to appointments by local state administrations of heads of municipal health organizations has to be obtained.
The main regulatory functions of the Ministry of Health include: the development of methodical guidelines that are compulsory for all health care providers; the licensing and attestation of health providers; and quality assurance procedures. The Ministry coordinates the activities of donors and distributes humanitarian aid. It also procures centrally drugs and medical equipment for health facilities in the public sector.
The Ministry of Health is also responsible for financial planning and budgetary management. It develops a health budget based on national health
21Health Care Systems in Transition
Kyrgyzstan
policies and health revenue estimates. In particular, it plans the scope and types of health services needed for the country’s population and the financial resources required to provide these services.
The role of the Ministry of Finance is crucial in the budgetary process, as is the role of local finance departments, since both exercise fiscal power over budgetary funds. With the introduction of the single payer system, however, their role in the sector has been basically simplified to revenue collection. The single payer system, including the roles of the Ministry of Finance and other financing bodies, is discussed in more detail in the sections Health care financing and expenditure and Financial resource allocation.
At subnational level, health planning and regulation are the responsibility of local state administrations. Before a major reform of local governments in 2000, these functions were performed by oblast health departments. Following their abolition, however, these functions were transferred to oblast merged hospitals and then to supervisory councils for health management, which became the coordination commissions on health management in 2003.
The coordination commissions on health management are collegiate bodies composed of the local representatives of central government, as well as representatives of the corresponding kenesh (council), local health organizations and social protection bodies, the oblast finance department, educational bodies, the veterinary service, trade unions and nongovernmental organizations. A coordination commission is chaired by the head of the oblast administration (mayors in Bishkek and Osh cities), who forms and appoints members the commission. The chair of the commission has two deputies: a head of an oblast health facility and a head of the territorial department of the MHIF. The commission meets as needed, but not less than once a quarter. The decisions of coordination commissions are mandatory for all local health facilities. The coordination commissions are accountable to the corresponding oblast state administration and the Ministry of Health (2�).
At the facility level, the authority for health planning, regulation and management is vested in the administration, which has financial and managerial autonomy. The head of a state or municipal health facility is required to have higher professional education in medicine, economics or public administration and to undergo attestation and registration in health management.
The regulation of private health providers, including healers (practitioners of traditional medicine), is based on licensing. Private health providers have to maintain and submit all necessary files and statistics. Interaction between private and public health providers, including participation in the implementation of the State Benefits Programme, is based on contracts.
European Observatory on Health Systems and Policies22
Kyrgyzstan
The involvement of citizens in health planning has remained limited. Nevertheless, in regions designated as pilot areas, the population’s feedback has been used for future planning. Various surveys, by means of interviews and the use of focus groups and participatory rural appraisal studies, have been conducted with the aim of learning about people’s experience of the reforms and their general expectations of the health care system (Box 1).
Following the introduction of co-payments in Issyk-Kul and Chui oblasts in 2001, a rapid assessment using participatory rural appraisal tools was carried out in these regions. The findings of these studies helped to identify drawbacks of the policy and make necessary corrections. Respondents identified both positive and negative aspects of the new policy.
Positive Negative Patients contribute one half of the treatment costs, the Government the other half. That’s fair.
Health is worth co-payments
Good for those who are insured
Expenditures for surgery treatment were previously 3–5 times higher
No need to search for drugs in various pharmacies when admitted to hospital. Treatment is provided immediately following admission.
Good attitude of health personnel (seem to be more attentive)
Trust in qualification of maternity personnel
No more requests for informal payments and/or gifts
Amount of co-payment fee is too much for the services provided
Co-payment for deliveries is much too high
Co-payment erects a barrier for access to hospital treatment for many people, especially the unemployed, the low income groups and the uninsured. People may go to hospitals later, when things have become more complicated.
Drugs are not regularly supplied, which prolongs hospital stays
Drugs included in the Essential Drugs List are less expensive, and may be less effective Lack of information on co-payment policy
No telephones at many hospitals, which makes communication with the family expensive, as regular travel is needed
Poor conditions of maternity wards (no water supply, non-working laundries, no soap/ detergents, no diapers provided, poor quality of food)
Source: Schüth, 2001 (30).
Box 1. People’s attitudes towards co-payments: findings of a participatory rural appraisal study
2�Health Care Systems in Transition
Kyrgyzstan
Decentralization of the health care system
As mentioned previously, the Ministry of Health is responsible for developing national health policies and establishing clinical standards. However, these are actually implemented by local health authorities and providers.
Prior to recent reforms, the health care system was fragmented into four levels of government administration: republican, oblast, city and rayon, serving overlapping populations. Furthermore, many national programmes, such as immunization schemes, were operated through separate vertical systems. The fragmentation of health care budgets was one of the major challenges to the reform of health care financing and of the health care delivery system. One of the key elements in the reform of health financing in the initial pilot oblasts (Chui and Issyk-Kul in 2001, and now extended nationally) was the centralization of financing at the oblast level to enable better risk-pooling and to break the integration of finance and provision that contributed to excess physical capacity. A complementary reform was the granting of more autonomy to health facilities to manage their budgets. With the introduction of new provider payment methods, especially co-payments by patients, health facilities have been given greater flexibility in the internal allocation of resources.
Local governments are involved in health management at the oblast level through:
participation in coordination commissions on health management;
budget transfers by oblast finance departments to territorial departments of the MHIF;
rationalization of health facilities;
health personnel policy;
social protection of vulnerable citizens by issuing of “social passports” and financing the provision of health care to patients exempted from co- payments.
In recent years, some of the functions of the Ministry of Health have been transferred to NGOs. In particular, accreditation of health facilities has been delegated to the Medical Accreditation Commission. The Association of Family Group Practices and the Hospitals Association contribute to monitoring the quality of health services and participate in the development of clinical protocols.
The private sector is still comparatively small and comprises mainly ambulatory care and pharmacies. Privatization in the health sector started in the pharmaceutical sector. In the communist system, drugs used to be procured centrally and sold at fixed, state-regulated prices. In 1992, local pharmaceutical
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companies were merged into the conglomerate Galenical Drugs Business Project, which was controlled by the state and headed by the state combine Kyrgyzpharmindustria. Following the second wave of privatization in 1994– 1995, however, the companies were transformed into joint-stock companies or companies with limited liability. The monopoly state company, Kyrgyz Pharmacia, which was responsible for the procurement and distribution of drugs, was privatized in 1994. By 1996 pharmacies were almost fully privatized, with the exception of a few municipal pharmacies.
Privatization of other sectors of health care has remained much more limited. The programme of privatization for 2001–2003 prohibited the privatization of health facilities as well as other elements of the social infrastructure, with the exception of unused buildings and dental clinics. Private providers, however, are allowed to construct new private health facilities.
Kyrgyzstan
Main system of financing and coverage
Historical background
Health planning and financing in the Soviet era was highly centralized and placed an emphasis on maintaining and expanding the existing network of health facilities rather than improving the quality and efficiency of
health services. Soviet planning was generally based on five-year state plans. Every state plan on health care included six components:
1) development of the network of health facilities;
2) human resources development (need estimates, medical education and post-graduate training);
3) human resources management;
4) capital investments (construction and maintenance of facilities);
5) material and technical supplies (including furniture, equipment, laboratory supplies, drugs and clothing of personnel);
6) budget.
The planning of the network of health facilities was based on the performance of health facilities, demographic and health indicators (population size, age and sex distribution, urban/rural distribution, morbidity and mortality) and pre-set norms of health services (number and distribution of hospital beds and health staff).
Human resources were planned on the basis of specialties, and according to planning norms such as the ratio of specialists per population. Planning of the workforce was based on indicators such as the number of workers, the number of positions occupied, average wages and the salary pool.
Health care financing and expenditure
European Observatory on Health Systems and Policies2�
Kyrgyzstan
The building of health care facilities was mainly financed through centralized budgets, while resorts, spas and sanatoria were mainly financed through the funds provided by trade unions, enterprises and collective farms.
The budget of the USSR consisted of the Union budget and the budgets of the republics. The republican budgets consisted of the national and local (territory, oblast, city, rayon, and village) budgets. Budget classification was very important. It strictly tied expenditures to certain sections, paragraphs and chapters of the budget, with no flexibility of shifting funds between different budget lines. Health care was assigned to section “203”, consisting of 22 paragraphs corresponding to programmes or types of health facilities. The paragraphs ranged from paragraph 1 (hospitals and dispensaries in cities, towns and villages) to paragraph 22 (other facilities and activities). For each paragraph, there were 18 chapters (i.e. line items), starting with chapter 1 (salary) and ending with chapter 18 (other expenses).
The budgets of health facilities usually consisted of three main sections: plan or network indicators; staff and contingents; and chapters and their calculations. The funding for inpatient facilities was based on infrastructure, i.e. the number of beds, average annual bed occupancy and expected bed-days, resulting in the perverse incentive for hospitals to use as many beds as possible for as long as possible. For outpatient facilities, the network indicator was the number of visits, resulting in an incentive not to treat patients but to refer them to higher levels of care. The “staff and contingents” section was used to calculate the salary pool. The average monthly wage was determined according to annual “tarification” in each health care facility. “Tarification” defined the annual salary pool of each health facility, taking into account the qualifications of staff, their length of service, place of work, position occupied and special conditions of labour.
In addition to budgetary funds, health facilities were allowed (as were all facilities financed by state budgets) to have special funds, the sources for which were approved by the council of ministers of the republics. In the health sector, funds from the following services existed:
prosthetic dentistry;
paid services of departments of preventive disinfection and deratization (the elimination of rats);
auxiliary farms belonging to health care facilities;
production workshops belonging to facilities for tuberculosis or mental health;
collection of placental blood;
sanatoria and physiotherapeutic care;
other services.
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27Health Care Systems in Transition
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Current situation
Currently, the Kyrgyz health sector is financed from the following main sources of funds:
general budget revenues (republican and local);
contributions to the MHIF;
the Public Investment Programme;
out-of-pocket payments.
According to the 2004 Public Expenditure Review of the World Bank, private out-of-pocket payments constitute the main source of health financing, contributing to almost half of total health financing. General budget revenues (of the republican and local governments) constitute 44%. The Public Investment Programme, which is financed by loans from the World Bank and the Asian Development Bank, constitutes 0.9% of health financing, while social insurance contributions contribute 4% to total health financing. Of the general budget revenues, 32% come from the republican budget and 68% from local governments (�1).
Since 1997, the funds of local governments include “categorical grants”, which are transfers from the republican budget to oblasts to provide basic services in health and education. The size of categorical grants allocated to each region was meant to be determined on a weighted per capita basis, but so far they have only been used to fill gaps in the local budgets for salaries.
Government health spending decreased from 4.0% of GDP in 1995 to 1.8% in 2003. The decline occurred both because overall public spending declined and because the share of the state budget allocated to health fell from 13.6% in 1995 to 9.0% in 2003 (�2). It is likely that this decline in government health spending has caused an increase in the share of private out-of-pocket payments, both formal and informal, in recent years.
Complementary sources of finance
Mandatory health insurance The MHIF was established in 1996 and has received insurance premiums since 1 January 1997. The MHIF manages an extrabudgetary fund for insured persons which is separate from the budget of the Ministry of Health. At oblast level, the Fund is administered through the territorial departments of the MHIF. Voluntary health insurance was legalized in 1992, but remains virtually non-existent.
The health insurance system is compulsory and opting out is not permitted. Funding sources for the MHIF vary according to different population groups,
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as shown in Table 9. The MHIF is not a source of funds; it receives transfers from the Social Fund and the republican budget on behalf of defined categories of “insured” persons. The Social Fund collects revenues covering employees and contributions for farmers. Contributions for children, social beneficiaries, pensioners and the military are transferred from the republican budget. The insurance status of a person is identified by social security identification, pensioner’s identification or mandatory health insurance policy.
Table 9. Funding and coverage of the Mandatory Health Insurance Fund
Population group Funding source Employees, including employees in the formal sector
2% payroll contribution by employer
Civil servants and public enterprises 2% payroll contribution by employer (i.e. the Government) to Social Fund
Self-employed Voluntary purchase of mandatory health insurance policies
Private farmers 6% of the basic rate of land tax
Personnel of the Ministry of Defence, National Guard, and forces of the Ministry of Interior
Value of 1.5 x minimum salary from the republican budget
Children under 16; enrolled school children under 18; and enrolled students of basic, secondary and higher professional education institutions (except part-time and evening students) under 21
Value of 1.5 x minimum salary from the republican budget
People with disabilities since childhood and persons receiving social and state benefits
Pensioners
Registered unemployed
Sources: (33,34).
Note: Until 2003, the value of 1.5 x minimum salary for pensioners and registered unemployed was collected and paid by the Social Fund; for children and social beneficiaries there were lump- sum transfers from the republican budget. However, de facto no funding has been appropriated for the registered unemployed.
The role of the MHIF in health financing increased substantially with the introduction of the “single payer” system in Chui and Issyk-Kul oblasts in 2001, whereby the MHIF pooled all local (i.e. rayon, city and oblast) budget revenues for health, creating a single pool of funds at the oblast level. It also purchased services from these funds for the entire oblast population using the same methods as used nationally for insured persons, thus becoming the single purchaser of health care in the oblast. By mid-2002, the single payer system had been extended to two more oblasts (Naryn and Talas), covering 50% of the territory and 33% of the population of the country at the time. By 2004, the whole country was covered by the single payer system.
29Health Care Systems in Transition
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Within the single payer framework, the MHIF took over the management of local budget funds for health. The new system of financial planning is based on new “norms” according to which purchases are to be made on the basis of final outcomes or population needs (number of treated hospital cases for inpatient care and total number of persons enrolled in primary care; area population for providers of outpatient and san-epid services) rather than financing the capacity (beds and staff) of health facilities. In addition, it aims to overcome regional disparities through coefficients in the allocation of funds that take account of the population, remoteness and economic characteristics of regions. The new system has the following main characteristics and aims:
a commitment to provide health care to 100% of the population within the State Benefits Programme;
a purchaser-provider split with the MHIF acting as the sole purchaser (the “single payer”) of health services;
the consolidation of the sources of health funding (budgetary and MHIF funds and out-of-pocket payments);
the pooling of budgetary funds at the oblast level;
the replacement of unofficial out-of-pocket payments by more transparent official co-payments;
resource allocation irrespective of chapters and budget lines;
streamlining the referral system and building it into the health care system, from primary to higher levels of care.
More details on this reform are provided below.
Figure 3 shows how coverage of the population by the MHIF has increased since 2000. In 2002, the inclusion of farmers increased coverage to 86.2% of the population. By 2004, coverage had decreased to 83.6%, following changes in the number of employed. In 2004, the staff of the Ministry of Defence, Ministry of Interior and the National Guard were included, as were refugees.
While the separation of collection and pooling responsibilities between the Social Fund and the MHIF are well defined, the amounts allocated to the MHIF have always been less than the amounts that should have been transferred. As shown in Table 10, the transfers from the Social Fund to the MHIF have been consistently lower than planned or collected revenues. In 2002 only 54.8% of premiums paid to the Social Fund by employers were transferred to the MHIF. Rates of transfer for pensioners were even lower and, in 2002, none of the planned transfers took place. The reasons for this non-transfer of revenues by the Social Fund lie in its own financial problems. As a result, the money meant for the MHIF was effectively cross-subsidizing other sectors, particularly pensions. This situation might change in the future as, since 2004, contributions
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1901 1925 2024 2024 2024
871 898
1598 1470 1564
536 527
529 529
543
109 115
9791
59
0
500
1000
1500
2000
2500
3000
3500
4000
4500
2000 2001 2002 2003 2004
Children under 16 Employees Pensioners Others
73% 83%
86% 83% 84%
Fig. 3. Population coverage by the Mandatory Health Insurance Fund, in thousands and %, 2000–2004
Source: (35) and Mandatory Health Insurance Fund data.
Note: The percentages over each column show the extent of population coverage by the MHIF; Others include unemployed, self-insured and social benefits.
for pensioners have been expected to come from general budget revenues, i.e. the republican budget.
However, there have also been problems with the transfer of funds from the republican budget. Although the percentage of transfers has been higher than the percentage of transfers from the Social Fund, in 2002, only 64% of planned transfers from the republican budget were actually carried out. This shortfall has affected vulnerable groups. In 2003, budget execution for children was only 33%.
Since January 2003, Social Fund transfers to the MHIF have vastly improved and the Social Fund is no longer allowed to build up arrears to the MHIF. This new regulation has been included by the International Monetary Fund as a condition in the agreement on the new Poverty Reduction and Growth Facility (the International Monetary Fund lending facility for low-income countries that comprises national poverty reduction strategies). In fact, in 2003–2004 the Social Fund has repaid 109.9 million som of its debt to the MHIF, both in cash and via clearings.
�1Health Care Systems in Transition
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Table 10. Revenue transfers to the Mandatory Health Insurance Fund, in million som and %, 1997–2003
1997 1998 1999 2000 2001 2002 2003
Transfers from Social Funda
Employees
MHIF premiums collected by Social Fund 41.0 82.8 117.1 138.3 166.6 184.9 198.5
Revenues transferred to MHIF 9.2 30.9 73.1 89.4 80.5 102.1 145.9
Percentage of collections transferred 22.4% 37.3% 62.4% 64.6% 48.3% 54.8% 73.5%
Pensioners
Planned revenues for pensioners 15.0 38.0 48.0 48.0 80.0 80.0 284.2
Revenues transferred for pensioners 0.0 9.8 14.5 12.5 7.8 0.0 145.9b
Percentage of planned transferred 0.0% 25.8% 30.2% 26.1% 9.8% 0.0% 51.3%
Unemployed
Planned revenues for unemployed 0.0 8.5 9.0 9.0 9.0 9.0 9.0
Revenues transferred for unemployed 0.0 1.3 6.0 3.1 2.5 0.5 1.0
Percentage of planned transferred 15.3% 66.7% 34.4% 27.8% 5.9% 11.1%
Social Fund total
Total planned/collected revenues by Social Fund 56.0 129.3 174.1 195.3 255.6 275.3 293.2
Revenues actually transferred by Social Fund 9.2 42.0 93.6 105.0 90.8 102.6 146.9
Percentage of planned/collected transferred by Social Fund 16.4% 32.5% 53.8% 53.8% 35.5% 37.3% 50.1%
Transfers from republican budget
Children
Planned transfers 35.0 46.5 56.4 35.0
Actual transfers 25.5 24.7 46.3 29.0
Percentage of planned transferred 72.9% 53.1% 63.9% 82.9%
Social beneficiaries
Planned transfers for social beneficiaries 5.0 3.8 5.1 5.0
Actual transfers for social beneficiaries 4.2 2.3 5.0 1.1
Percentage of planned transferred 84.0% 60.5% 98.0% 22%
Republican budget total
Republican budget planned transfers 40.0 50.3 61.5 40.0
Republican budget actual transfers 29.7 27.0 51.3 30.1
Percentage of budget actually transferred 74.3% 53.7% 83.4% 75.3%
Total MHIF revenues
Total planned MHIF revenues 56.0 129.3 174.1 235.3 305.9 336.8 333.2
Total actual MHIF revenues 9.2 42.0 93.6 134.7 117.8 153.9 191.2b
Percentage of actual revenues 16.4% 32.5% 53.8% 57.2% 38.5% 45.7% 57.4%
Source: Mandatory Health Insurance Fund.
Note: a Data do not include clearing payments by the Social Fund. b Including the repayment of 14.2 million som of the Social Fund debts for 2002.
European Observatory on Health Systems and Policies�2
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Out-of-pocket payments
The level of out-of-pocket payments has been significant and they continue to be a major source of revenue for the health system. In 1994 nearly 70% of patients paid for outpatient care and 86% paid for hospital care (��). In 2001 the proportion of patients paying for outpatient care declined to 22%, but the proportion of those paying for hospital care remained high at 87% (�7). Household survey data from 2001 allow for an overall estimate that in 2001 public funding (including state budget and MHIF expenditures) accounted for only 48.7% of health financing, with private out-of-pocket payments accounting for 51.3% (�7,��).
There are four types of out-of-pocket payments in the health sector:
informal under-the-counter payments in cash or kind for services and goods in public health facilities that are meant to be provided without payment;
purchase of goods and services from private suppliers, mainly outpatient drugs from private pharmacies and bazaars (markets), but also private health care;
official user fees;
official co-payments by patients to health facilities included in the single payer system.
Unofficial out-of-pocket payments include under-the-table payments to health personnel, purchase of drugs and medical supplies needed for care in public facilities, and own provision of food and other non-medical inputs in hospitals. Under-the-table payments to health personnel are common, with patient survey data from the period prior to the implementation of the single payer reform indicating that such payments were made in about 60% of cases. Approximately 80% of patients either paid for or contributed drugs and medical supplies, and 93% of patients had friends or family members provide food for them. While payments for drugs and medical supplies were both the most frequent form of payment and absorbed the greatest share of patient spending in hospitals (about 65%), payments to specialists were quite high, especially for surgery (��). Informal payments can have a significant impact on access to health care services, and particularly affect the poor.
Official user fees were permitted in 1993 as “paid medical services”. Currently, they are regulated by the Law on Non-Budgetary Activity of Public Health Facilities. Prices of health services must be approved by the State Commission on Anti-Monopoly Policy under the Government. User fees are charged in both outpatient and hospital care facilities. Official user fees are captured in health budgets as “special means”. Since 2001, when co-payments were introduced in the two oblasts that had implemented the first phase of the
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single payer reform, most user fees have been incorporated into the system of official co-payments. Currently, special means include non-medical services (e.g. rent, transportation, health-unrelated chemical and laboratory tests), medical services to foreign citizens, dental care (except services included in the State Benefits Programme) and medical services rendered upon individual request (e.g. cosmetology, abortions, anonymous treatment).
Official co-payments for drugs, meals and certain types of health services provided as part of the State Benefits Package form an integral part of the single payer system. Co-payments have been introduced in outpatient care facilities and in hospitals. The level of co-payments is fixed, but varies across patients exempt from co-payment, insured patients and uninsured patients, as well as across types of medical intervention (therapeutic or surgical in hospitals; and costly or regular tests in outpatient facilities). It was hoped that co-payments would replace unofficial out-of-pocket payments. Evidence from the first year of implementation in the pilot regions suggests that unofficial payments have indeed declined, although further research is needed to determine whether these achievements are to be sustained. A threat to the sustainability of this early success has been the continued reduction in local budget allocations to the health sector (��).
As one part of the comprehensive set of reforms in pooling and purchasing embodied by the single payer system, the State Benefits Package has been a first attempt to clarify the responsibilities of the state in the provision of health care and to replace unofficial out-of-pocket payments by a system of transparent and official co-payments. While initial success has been achieved, longer term success in terms of replacing informal by formal payments (and eventually lowering such payments) depends on maintaining or increasing government health spending while implementing cost-saving measures for the restructuring of the health service delivery system.
External sources of funding
External sources of funding include humanitarian aid, technical assistance, grants and credits. The amount of foreign aid in the 1990s has been significant. The National Health Accounts (NHA) database collected for 1998–2000 from the facility level shows that the level of foreign aid was as high as 10% of total health expenditure. However, there were considerable year-to-year variations, as some projects were phased out and others started.
The main donors that have been particularly active in supporting the health reform process have been the World Bank, WHO, the United States Agency for International Development (USAID), the United Kingdom Department for
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International Development (DFID), and the Swiss Agency for Development and Cooperation (SDC). In early 2003, the Global Fund to Fight AIDS, Tuberculosis and Malaria approved a grant of US $17 million for HIV/AIDS and US $1.1 million for tuberculosis.
The Department of Health Care Reform, MANAS, which administers the MANAS Health Care Reform Programme and is accountable to the Ministry of Health, has coordinated donors’ activities in the health sector. Many donors have supported the implementation of vertical programmes, for example on tuberculosis, HIV/AIDS, sexually transmitted diseases, acute respiratory infection, family planning and reproductive health, vaccination and procurement of drugs. The USAID-funded ZdravReform (later ZdravPlus) Project supported the initial pilot project in comprehensive health care reform begun in Issyk- Kul oblast in 1994, and WHO initiated support of the national MANAS Health Care Reform Programme. Two World Bank-funded health sector reform projects (World Bank Health-I, 1996–2000, and World Bank Health- II, 2001–2005) aimed at structural changes in the health sector and supported integrated activities, including renovation and equipment of health facilities, strengthening of health information systems and health financing reform. The Asian Development Bank has supported similar activities in the southern parts of the country. The Swiss Agency for Development and Cooperation, through its contractor, the Swiss Red Cross, has supported the restructuring of health care in Naryn oblast as well as primary care development, which has included a new emphasis on community action for health and health promotion.
Health care benefits and rationing
A clearly defined package of health care benefits was first developed by the Government and piloted in Issyk-Kul and Chui oblasts in 2001 in the form of a State Benefits Package, entitled Programme of State Guarantees on the Provision of Citizens of the Kyrgyz Republic with Medical-Sanitary Care. A crucial part of the single payer reform, the package specifies the benefits, cost-sharing obligations and coverage of the population. Primarily based on the approved planned amounts of health financing from the state budget and from MHIF fees, the State Benefits Package may be expanded according to external humanitarian aid and grants, and other additional resources mobilized by local state administrations. The State Benefits Package is annually approved by the Government on the basis of expected revenues of the oblast and the national pools of funds managed by the MHIF, and according to projected levels of utilization and other parameters.
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Fig. 4 shows how the coverage of the State Benefits Package, both in terms of population and health care services, links to funding sources. The basic benefits package for the entire population is funded through the contributions by local governments to territorial departments of the MHIF. The package consists of free primary care from the contracted family group practice in which the person is enrolled, and inpatient care on referral, for which a co-payment is required. The basic benefits package also provides for free or nearly free referral care for certain categories of the population. Exemptions from co-payments are funded from the oblast pool through the payment of a higher base rate to hospitals. For insured persons, contributions made on their behalf to the national MHIF pool of funds entitle them to reduced co-payments for inpatient care and outpatient specialist services, and also provide access to an outpatient drug benefits package. Being “insured” in the Kyrgyz context is thus akin to having a voluntary “Medigap” policy in the United States or a “mutuelle” in France. Coverage is complementary to that funded from general revenues (��).
Fig. 4. Funding and coverage of the State Benefits Package in the single payer system
Funding source
Benefits
Private
Private, out-of-pocket
Social Fund payroll tax; Republican budget
transfers for “insured”
Budget – local governments “buy” universal coverage
for their populations
Population coverage 0% 100%
Co-payment
“uninsured”
S ervices contracted by M
H IF
S ervice coverage
Health care services not covered
Basic Benefit Package: free primary care from family group practice in which patient enrolled, referral care with co-payment
Complementary benefits: reduced co-payment,
outpatient drugs
F ul
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xe m
pt
P ar
tia lly
e xe
m pt
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The State Benefits Package for 2004 included:
free-of-charge primary care services from feldsher-obstetrical points, family group practices and family medicine centres in which patients are enrolled, and from ambulance departments and stations;
specialized outpatient care services from family medicine centres and outpatient-diagnostic departments of hospitals, subject to co-payments;
hospital care services, including surgery, subject to co-payments;
dental care – free and paid services;
optical and hearing aids for a limited number of categories;
san-epid services.
Originally comprising some 40 categories with different exemption levels for co-payments in 2001, the State Benefits Programme included 52 categories in 2004. Forty-four categories are entitled to full exemption from co-payments: 18 categories are for different groups of the population and 28 categories are for medical conditions.
Population categories 1. Participants of the Great Patriotic War
2. People handicapped in the Second World War and the Batken War
3. Former prisoners of concentration camps
4. “Labour warriors” later rehabilitated
5. “Heroes of the USSR” and holders of the order “Honour” of third degree
6. “Heroes of socialist labour”
7. Holders of the highest distinction “Baatyr of the Kyrgyz Republic”, holders of the order of “Manas” of first degree
8. Participants of military operations on the territory of other countries
9. Survivors of the Chernobyl nuclear disaster
10. People with disabilities inflicted during military service
11. People with disabilities of disability groups I and II
12. People with disabilities with eyesight and hearing problems
13. People with disabilities since childhood of disability groups I and II
14. Children with disabilities under 16 years of age
15. Children under 1 year of age
16. Orphans living in public child homes, family child homes, boarding schools for orphans and children without parental guardianship
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17. People living in hospices and boarding schools
18. Children under 16 years of age from families with more than 3 minors
Medical conditions 1. Acute cardiac infarction (in the first 2 months)
2. Tuberculosis
3. Bronchial asthma
4. Oncological diseases in the terminal phase
5. Congenital syphilis, syphilis under 18 years of age
6. Mental diseases (paranoid schizophrenia, affective disorders of different genesis)
7. Epilepsy
8. Diabetes mellitus
9. Diabetes insipidus
10. Leukaemia
11. Haemophilia
12. Aplastic anaemia
13. Leprosy
14. Post-vaccinal complications
15. Plague patients and exposed persons
16. Cholera patients and exposed persons
17. Typhoid patients and exposed persons
18. Paratyphoid patients and exposed persons
19. Anthrax patients and exposed persons
20. Hydrophobia
21. Meningitis
22. Diphtheria
23. Acute brucellosis (hospitalization for primary treatment)
24. Women registered as pregnant and subject to consulting at the outpatient level
25. Women coming to hospitals with pregnancy pathologies
26. Conscript soldiers sent by military-medical commissions
27. Servicemen of a fixed-term service with an emergency condition and in cases when it is impossible to render qualified health services in agencies’ health facilities
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28. Individuals in detention or serving a sentence, with an emergency condition, in cases when it is impossible to render health services in penitentiary health facilities.
Categories 1–4, 6–9 and 11 are also entitled to the free provision of drugs at the outpatient level.
There are eight categories which are entitled to partial exemptions from co-payments. In hospitals, the following categories of patients are exempted from 85–90% of the average cost of treatment:
1. Women coming for deliveries
2. Patients with acute brucellosis coming for their continuous treatment
3. Pensioners with pensions of less than 480 som (for Bishkek pensioners with pensions of less than 960 som)
4. Beneficiaries of social benefits
5. Patients with malaria
6. Patients with severe forms of viral hepatitis.
Pupils and students under 21 years of age are exempted from 60% of the average cost of treatment. They are also entitled to a 50% exemption of diagnostic costs in outpatient facilities.
The insured categories (see Table 9) are exempt from co-payments to 60–66% of the average cost of treatment in hospitals, and to 50% of diagnostic costs in outpatient facilities. In addition, the MHIF provides an additional drug benefits package at the outpatient level for the insured which includes drugs and medical products from the Essential Drugs List.
The uninsured categories (21% of the population in 2003) are entitled to free primary care, but have to pay the full cost of specialized outpatient treatment and 51–60% of the average cost of treatment in hospitals.
If, regardless of their exemption status, patients are self-referred, i.e. are without a referral from a lower level health facility, they have to pay the full cost of specialized outpatient treatment and the full amount of the average cost of treatment in hospitals.
Women in childbirth have been exempt from co-payments in hospitals since November 2001. Before then, most women of reproductive age were not covered, because of the characteristics of statutory insurance. Although about two-thirds of all patients discharged from hospitals in February 2001 were insured, about 80% of maternity cases were not insured (�9). Until 2001, most delivering mothers faced a very high fee, often much higher than previous informal payments, particularly in rural hospitals. Official co-payments for deliveries have now been set at a lower rate (200 som).
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Urgent hospital care (accident and emergency care) is rendered free of charge. However, once the emergency stage has passed, patients have to contribute co-payments to their hospital care.
It should also be noted that, if the actual cost of treatment is three times higher than the average cost of treatment in hospitals, the treatment-controlling commission of the health facility is required to charge patients the costs of drugs for further treatment, irrespecti