Annex B FINAL Kyrgyzstan Country Findings _rev 4 16 08_.pdf

Annex B: Country Findings Kyrgyz Republic

Background: The Kyrgyz Republic has a population estimated at 5.1 million, one-third the size of Kazakhstan and one fourth the size of Uzbekistan. Its land mass is half the size of Uzbekistan and less than one tenth that of Kazakhstan. The country is four times as densely populated as Kazakhstan but about half as densely populated as Uzbekistan.

While only 7% of land is arable, 86% of arable land is irrigated. This means that the population per square kilometer of irrigated arable land is on par with that in Kazakhstan and Uzbekistan. Based on the distribution of consumption by the top and bottom deciles and the Gini coefficient, the Kyrgyz Republic is slightly more egalitarian in income distribution than either Kazakhstan or Uzbekistan. The Kyrgyz Republic’s population is two-thirds ethnically Kyrgyz and three-fourths Muslim. Its population growth rate of 1.35% figures between Kazakhstan’s 0.3% and Uzbekistan’s 1.7% rates.

At independence, the new government asked WHO to help develop a national health program and reform. In 1992, the new government issued three laws--for health insurance, the health system design, and sanitary wellbeing. These provided the structure for health reform and a new payment system. In 1994, 25 local experts were competitively recruited and trained by WHO to develop the health reform.

ZdravPlusII’s stated approach in the Kyrgyz Republic has been to help national partners to implement Manas Taalimi, The Kyrgyz Republic’s Health Sector Reform Strategy, and to help implement the donor Sector Wide Approach (SWAp) developed to support the Manas Taalimi health reform strategy. According to ZdravPlusII’s own analysis, the environment in the Kyrgyz Republic had been consistently supportive of reform until recently. In 2005, popular demonstrations led to the election of a new president. Further demonstrations in 2006 led to the adoption of a new constitution. These changes have affected the balance of power between the legislative and executive branches, and called into question the country’s vision for its future. This political instability and uncertainty could impact the continuation and deepening of the health reform process.

Kyrgyzstan PMP Analysis

The Kyrgyzstan PMP for ZdravPlus II shows that there are 31 indicators of performance for the SO and the four IRs, Population/Community Health, Service Delivery components, Resource Use and Stewardship.

An analysis of the Kyrgyzstan PMP indicates that it may not be the best barometer of progress for the project. Several of the indicator targets have been surpassed by large amounts, but many are either in suspension, show no projected targets, or need to be updated. As such, this disaggregated report does not provide a useful composite picture of performance. A summary page for each country would be advised, and could simplify forward planning.

Achievement of the target for the Strategic Objective indicator, “Percent of total outpatient visit share increased in PHC practices, relative to outpatient specialist care, from 56% in 2003 to 75%” could not be determined because the reported data covered only the first three quarters of 2007.

The three 2007 targets for the Population and Community Health component [IR 3.2.1 A and B] were exceeded by a significant percentage and targets for future years have already been overtaken by progress to date. Future targets need to be revised as they did not represent challenging goals. Also given the concerns described under Kyrgyzstan Country Findings regarding the sustainability of a number of vital associations, the VHCs and the Press Center, it might be more appropriate to change the indicators entirely and focus on tracking progress in finding sources of funding for these organizations outside of ZdravPlusII.

For the Service Delivery component there are 15 indicators that touch on almost every aspect of ZdravPlus II’s service delivery efforts. Of these, four targets were met [IR

3.2.2. E, F, I and M - “midwife training”, “TB-DOTS training”, “TB_DOTS outpatient care integrated into PHC” and “family medicine residency curriculum], one [IR 3.2.2 P “safe motherhood models in four oblasts” achieved the 2009 target, and one was partially exceeded [IR 3.2.2 N “admissions to family medicine residency program”]. One indicator, IR 3.2.2 E, “midwife training in family planning skills extended to reach 25% of rural rayons not covered by gynecologists” was particularly well constructed because it provided excellent contextual information. Of the six that have been met or exceeded, IR

3.2.2 F, I, M, P must be updated to show the on-going change expected. Four of the indicators had been suspended (IR 3.2.2 C, J, K, L – “minimum standards for primary care facilities,” “evidence based infection control practices in central rayon hospitals,” “STI surveillance established in SES,” “STI care in FGPs accessible in urban”].

IR 3.2.2 A, “”adherence to select evidence-based CPGs or standards of care improved in FGPS by 50%,” is unclear because the timeframe is not stated (annually? by 2009?), the targets do not match the indicator and there is a minimal progression in the annual targets. The targets for IR 3.2.2 B and D, “adherence to select evidence-based CPGs for SM in pilot sites” and “CME established nationwide in FM training centers” are not clearly defined. IR 3.2.2 G, “reliable referral system developed between TB penitentiary and primary health care systems” was reported as of September 20, 2007 and shows no progress toward reaching the targets in 2007. Updated information is needed. One indicator, IR 3.2.2 O, “FGP package of services,” will be measured for the first time in 2008.

There are 10 indicators for the Resources Use component. Of these, one target related to payment of PHC practices and hospitals was partially met [IR 3.2.3 A], the target related to IR 3.2.3 G, “incentive systems to retain rural doctors and nurses and attract new students to family medicine” was set at one for 2007 and it was met. However, there are no forward targets for the next two years even though the indicator implies that there will be more than one system. The 2007 target for IR 3.2.3 I related to “human resource database analysis on staffing needs” was not met. The IR on oblast funding [IR 3.2.3B] was met in its first year, raising the question of why the same target is shown for 5 straight years. Similarly, through 2009 the targets for IR 3.2.3 C, “total expenditures allocated to primary health care” were exceeded in 2007, necessitating an updated target.

It would be useful to add in the notes for this IR what is the ideal percentage for this allocation so that reviewers would know the context for these numbers. How close to the “ideal” are they? In 2006 the targets for the IR 3.2.3 H “SES restructured and savings retained” and IR 3.2.3 J “National Health Accounts established” were set for 2008.

Finally, two indicators are in suspension, IR 3.2.3 D, “co-payments and some fees introduced at FGP level in some oblasts” and IR 3.2.3 K “referrals from family doctors to narrow specialists reduced from 30%-10%.” To provide context, a note should be added to IR 3.2.3 K as to whether 10% is considered the ideal referral rate under the reformed system.

The Stewardship component had two IR indicators. The target of one per year for IR

3.2.4 A “specifically identified policies or laws/regulations approved” was met for 2006 and 2007, but future targets have been recorded. The target for IR 3.2.4 B “number of products created by different mechanisms enhancing policy dialogue or policy marketing/participation submitted to government or used for advocacy or public outreach” was exceeded by over 100% but future targets have remained constant.

Stewardship: In the Kyrgyz Republic, ZdravPlusII has focused its work on stewardship on: (1) the Mandatory Health Insurance Fund; (2) the legal framework for the health system; (3) the development of the Manas Taalimi Health Sector Reform Strategy; (4) the Center for Health System Development; (5) associations including the Family Group Practice Association, the Hospital Association, and the Medical Accreditation Commission; (6) selected studies with WHO; and (7) the Ministry of Health Press Center.

Across the board, counterparts and partners familiar with ZdravPlusII’s work in these areas judge it to be of high technical quality, implemented with a collaborative approach, and very often fundamental to the progress that the Kyrgyz Republic has made in each of these areas.

The project concept of stewardship incorporates some elements of the broader concept of health governance which USAID now uses. In a well governed health system, the Ministry of Health should operate as the steward of the health system, with oversight and accountability. Citizens, civil society, and the private sector should be empowered to provide input and to assume new health sector roles and responsibilities. Civil society and the media should have the skills and capacities to exercise oversight and hold policymakers and providers accountable. Mechanisms should be in place to create synergies between the government and these other actors in health. This vision of governance is radically different from the reality that the Kyrgyz Republic faced at independence and the system of governance the country inherited from Soviet rule.

Instead, the state role went far beyond stewardship to encompass direct management of the entire health system. Citizens participated as recipients of services and were not empowered to provide input. The notion of independent organized civil society did not operate nor did the country have an independent press. In the health sector, ZdravPlusII has made impressive contributions to fundamentally transforming health governance.

The picture now is one of a greater diversity of voices engaging in health governance--including a variety of institutions and more active citizenry. Although the project components are organized differently, with elements of health governance woven into several components, ZdravPlusII’s work has made critical contributions to improving health governance in the Kyrgyz Republic.

The creation of the Mandatory Health Insurance Fund (MHIF) as a single payer is at the core of the reform of the health system in the Kyrgyz Republic. Leaders of the MHIF, other partners and observers consider ZdravPlusII’s technical assistance critical to its current capacity and successful operation. Local policy counterparts assess ZdravPlusII’s technical assistance throughout the MHIF’s development as “outstanding”. From the earliest stages, ZdravPlusII worked actively to help iron out potential inconsistencies between health reform and the new insurance law of 1996, which otherwise could have created conflict between the Ministry of Health and the MHIF. In 2003, with legal support from ZdravPlusII, the MHIF reached a turning point with the passage of a law to pool local as well as national health funds into the MHIF. By 2007, 70% of state spending for health was channeled through the MHIF with 30% channeled through the Ministry of Health (MOH). The MHIF now covers 80% of the Kyrgyz population. A special additional drug benefit that provides discounts on drugs through private pharmacies has led to the substitution of less costly outpatient care for more costly inpatient care. The MHIF conducts quality assessment of its contracted health facilities by tracking hospital deaths, unusually short or long hospital stays, and hospital stays with multiple surgeries. The MHIF may still need technical assistance to develop a practice of routinely analyzing the information now at its disposal to detect and address any evidence of fraud or misuse of the health insurance fund.

The Kyrgyz Republic’s health reform has required new laws, resolutions and Ministry of Health prikazes and new legal arrangements for civil society participation. The most compelling evidence of ZdravPlusII’s critical role in building this legal framework is that the Ministry of Health issued a prikaz mandating the ZdravPlusII lawyer to coordinate all health legislation, effectively giving ZdravPlusII the role of guiding the Ministry’s own two legal advisors. While project staff were the team’s only information source on ZdravPlusII’s legal contributions, the project’s track record on the legal framework is very impressive. As noted earlier, one major accomplishment was the 2003 passage of the legal arrangements for a single payer system with all health service delivery funds under a single institution. The government resolution making it legal for health facilities to retain, invest and distribute revenues above expenditures was another important contribution. ZdravPlusII has contributed to greater transparency in health system employment by defining requirements for positions and establishing procedures for competitive selection. ZdravPlusII helped set up arrangements enabling the MHIF to transfer public resources to private providers meeting contracting requirements, although this has not yet been fully exploited. More work remains to level the playing field for private sector participation, by equalizing terms for licensing, accreditation and tax payment. So far, legal work has focused largely on establishing an enabling framework.

One important future test of this framework will be to what extent it helps resolve problems that emerge in implementation, such as resolving financial misuse of MHIF funds, violation of patient rights, or corruption.

The Kyrgyz Republic’s Manas Taalimi represents the Kyrgyz Republic’s vision and plan for ongoing reform in the health sector. This strategy forms the basis for the Sector Wide Approach that channels external donor resources in support of a common national health reform program. ZdravPlusII provided technical assistance to develop Manas Taliimi and the SWAp, helped organize health summits to build agreement about the strategy, and conducted technical reviews of it. A powerful illustration of the quality of the outcome of the Manas Taliimi strategy development and the SWAp is that the Ministries of Education and Finance have requested MOH help with the development of a SWAp for education. According to a World Bank representative, DfID studied the Kyrgyz SWAp and concluded that “it is the best and most successful example of a SWAp around the world.”

ZdravPlusII developed the legal framework for the Center for Health System Development (CHSD), which carries out policy analysis for health. It has an evidence based medicine department and a medical library. This center has carried out studies with ZdravPlusII and WHO support that analyze key elements of the health reform, such as the financial sustainability of the state guaranteed benefits package. The creation of this center is an important step toward institutionalizing the health policy function and the capacity to conduct high quality health policy analysis. The evaluation team lacks information about how and how widely the results of CHSD work are discussed and how they are incorporated into health policymaking.

On the provider side, ZdravPlusII has helped the Kyrgyz Republic to constitute several dynamic institutions that offer health educators, facility managers, and health care providers with voice, support, and input into policymaking. These include the Kyrgyz Republic Medical Institute for Continuing Medical Education, the Medical Accreditation Commission (MAC), the Hospital Association (HA), and the Family Medicine Association (FMA). ZdravPlusII has supported all of these both technically and financially. Looking ahead, their shared vulnerability is the lack of plans for ongoing financial viability.

The Kyrgyz Republic Medical Institute for Continuing Medical Education is the main Kyrgyz institution responsible for training and retraining primary health care practitioners. It receives support from several donors and considers ZdravPlusII as having taken the lead in donor cooperation. ZdravPlusII played a critical role in helping the Institute introduce a new specialization in family medicine in the Kyrgyz Republic.

ZdravPlusII helped constitute the Medical Accreditation Commission as an independent body to accredit primary health care facilities, and secondary hospitals. The Commission also provides input into health policymaking. ZdravPlusII support included its legal constitution, grant funding for operation, and training of its members. MAC has begun to accredit dental, rehabilitation and laboratory services. The leadership of MAC established an affiliation with ISQUA on its own initiative. MAC is initiating its second round of accreditation of primary health care facilities and secondary hospitals. In Issyk Kul oblast, facilities have begun to develop an understanding about accreditation.

Since the Kyrgyz Republic is building a health care model of consumer choice in facilities, more needs to be done to increase the public’s awareness about what accreditation means and what level of accreditation each facility has earned, for example, by posting accreditation certificates at facility entrances and educating the public about the meaning of gold, silver and bronze accreditation status. More also needs to be done to make MAC a financially viable entity over time. At present, 90% of its funding comes from the project and only 10% from charges to facilities. In part, this is because ZdravPlusII has given the MAC resources to carry out project activities. Factoring out these activity-specific resources, the share of funding that MAC is able to raise from charges to facilities is still insufficient to cover its basic operations. The Commission has no plan for when or how it will reach financial viability. Unlike many other accreditation bodies, the technical assessment the commissioners make is not final but rather must be vetted by a policy level steering committee. This might make it vulnerable to external forces.

The Hospital Association includes all 85 public hospitals. It provides hospital directors with a common voice vis-à-vis the Ministry of Health and provides input into health policymaking. ZdravPlusII has helped the Hospital Association through legal advice and by providing the Association with funding to carry out activities. Like the Medical Accreditation Commission, the Hospital Association lacks a defined plan and timetable to achieve financial sustainability.

The Family Medicine Association is an association of the health facilities that employ family physicians. Of all family doctors in the Kyrgyz Republic, 2200 work for facilities that pay to join the Family Medicine Association. The Association provides input into health policymaking. For example, it helped develop legal regulations for health reform.

The Association relies on ZdravPlusII for advice and support. This association is also vulnerable as it lacks a financial sustainability plan. In addition to the Family Medicine Association, the Kyrgyz Republic has a separate association for family group practices (the Family Group Practice Association (FGPA)). The respective roles of the FMA and the FGPA are not entirely clear to the evaluation team.

The Kyrgyz Republic is developing several civil society institutions that can provide a collective voice for patients. For example, the Diabetes Association represents the concerns of diabetes patients and is affiliated with Diabetes Associations internationally.

The Kyrgyz Republic also has an Alliance for Patients Rights, which was formed with support from another donor. Patients can call upon the Alliance for help addressing issues of violation of their rights in health. Another emerging patient association is the Association for Women with Breast Cancer. ZdravPlusII has not yet worked with these patient associations. This might be worth exploring as a potentially important avenue for strengthening the voice of the clients and broader civil society in the health system.

Beginning in 2002, ZdravPlusII helped the Ministry of Health to establish a Press Center to share information on health reform and the health system with the public through engagement with the Kyrgyz press. Although the MOH was meant to take over staffing and operating this unit beginning in 2007, ZdravPlusII continues to staff the unit, which maintains contact with an estimated 35 journalists who report on health and has a listserv of 250 journalists for distributing health information. This press center has helped to establish journalist resource centers at the oblast level. Among accomplishments, ZdravPlusII has helped the media to learn to cover health issues constructively. The staff of the center think that members of the Kyrgyz public who follow health news most closely, for example retired people, are very familiar with the state guaranteed benefit package thanks to their work. The Center has focused considerable effort on the public relations function of covering specific activities of the Ministry of Health. It has also directly produced several educational video clips about the Kyrgyz health reform process, covering timely topics of public interest such as the co-payments with the Mandatory Health Insurance Fund. From the evaluation team’s understanding, the MOH Press Center then had to buy airtime to show these videos. The evaluation team did not have information to indicate the impact of these videos among the Kyrgyz public.

Rather than directly producing videos, another approach might be to help television reporters to gain access to appropriate health facilities, workers, patients and the public to do their own coverage of these topics. Ideally it would be desirable for the local press to take ownership of health coverage and to develop their own materials, or at least for the television stations to run the MOH Press Center videos at their own expense. The fact that the MOH has not started to fund the Press Center from its own resources after five years is of concern. At a minimum, it suggests that the MOH has not developed a way to institutionalize this center. It may also indicate that the MOH has not perceived the Center to provide substantial value added to its work.

The single most important remaining challenge for ZdravPlusII in the stewardship component in the Kyrgyz Republic is to strengthen the institutional and financial sustainability of the many new and important entities it has helped to create or support thus far. This includes helping associations including the MAC, the FGPA and the HA to develop and implement sustainability plans. It also includes handing over the financing and operation of the Press Center to MOH. This center also could do more to ensure that patients are fully informed about the State Guaranteed Benefits Package and about patient rights. Beyond this challenge, additional efforts may be required to refine elements of the legal framework for reform. ZdravPlusII can help the government to move from developing legislation to demonstrating its effectiveness at resolving legal problems.

ZdravPlusII would do well to take advantage of opportunities to strengthen civil society organizations, such as the Alliance for Patients Rights, and to help the state engage effectively with the private sector in health.

Resource Use: In the Kyrgyz Republic, ZdravPlusII has focused its work on resource use on core issues in human resources, health financing, and health information systems.

It has also worked to improve Kyrgyz health system capacity in health management.

Much of ZdravPlusII’s work in these areas has been through ensuring that the Manas

Taliimi Health Reform Strategy and the SWAp address these issues appropriately. In human resources, ZdravPlusII has worked to improve understanding of the dynamics and scope of problems of out-migration of health human resources. It has also worked to develop the Deposit Doctor Program that provides incentives to attract physicians to work in rural areas.

As noted earlier, effective health financing should mobilize adequate funds to pay for health needs from sources that are reliable over time; should pool them to promote efficient purchasing and spread the costs of health care; and should allocate resources to optimize health impact, promote efficiency and enhance equity. ZdravPlusII has contributed fundamentally to greater resource mobilization, better pooling and more effective allocation. The most substantial achievement ZdravPlusII has helped bring about is the operation of the Mandatory Health Insurance Fund, which has a State Guaranteed Benefit Package, graduated co-payments, differential state subsidies to population subgroups, and national pooling of health funds. Under this system, the Kyrgyz Republic has achieved the remarkable goal of insuring 80% of its population and subsidizing an additional 8-11%. This system relies on capitation based payment for primary care and case based payment for hospitalization. ZdravPlusII has helped to develop and refine provider payment arrangements, including the development of differential coefficients for rural areas. ZdravPlusII contributed to the development, costing and analysis of the financial sustainability of the state guaranteed benefit package.

From the very beginning of the Kyrgyz Republic’s health financing reforms, partners note that ZdravPlusII’s piloting of case based payments and provider payment innovations in Issyk Kul formed the basis for the system the MHIF adopted and rolled out nationwide. Innovations in provider payments led the Kyrgyz Republic to successfully apply for $1.15 million in grant funding from GAVI HSS to apply performance based funding at the family medicine center. ZdravPlusII is now helping the MHIF and MOH with second generation refinements in health financing such as making treasury regulations on funds flow compatible with the operational needs of autonomous health facilities and introducing program based budgeting in the MOH. ZdravPlusII is also now helping the MOH transform the way it finances public health services.

ZdravPlusII helped bring about the success in the financing of individual health services that led the public health sector to seek to reform its own financing. ZdravPlusII is also helping develop differential hospital case based payments for different levels of TB care.

This is critical so that hospitals do not face disincentives to treat more difficult TB patients. ZdravPlusII is also reportedly collaborating on national health accounts, although the evaluation team did not have information about the status of this work.

As noted earlier, effective health information systems should produce, analyze, disseminate and use reliable and timely information on health determinants, health systems performance and health status. ZdravPlusII has worked to improve the collection, management and use of information at all levels of the health system, from the individual facility to the national MHIF and MOH. This work has laid the groundwork for more sophisticated evidence-based decision making and accountability in the health system. The many improvements in health information that ZdravPlusII helped to introduce are almost too numerous to mention. At the facility level, ZdravPlusII piloted innovations in Issyk Kul that have been rolled out nationwide. One impressive example is the set of clinical information forms that are now known nationwide as the “Purvis” forms after the ZdravReform consultant who developed them. The software ZdravPlusII developed to analyze health information is now used nationwide. ZdravPlusII trained health facility directors to use computers and e-mail and to analyze information. As a result, facility directors can now monitor results more effectively. ZdravPlusII helped the Ministry of Health do away with 65 forms for primary data collection and 30 forms for statistical reporting. It helped move the health system from manual to automated processing. At the national level, the Ministry of Health now finances a Medical Information Center established as an independent legal entity. This center operates a computerized information system that integrates medical, financial, service delivery, population and human resources databases. The MIC shares its data with the MHIF and provides access to associations like the Hospital and Family Group Practice Association.

The MIC has branches in all oblasts. As an illustration of how far the Kyrgyz Republic’s health information system has progressed with ZdravPlusII assistance, a recent assessment using global Health Metrics Network standards for health information systems found Kyrgyz Republic’s health information system to be adequate overall. The Health Metrics Network has selected the Kyrgyz Republic as one of a handful of intensive pilot countries for health information system support.

In the face of all this progress, ZdravPlusII faces an important unfinished agenda in resource use. In human resources, the challenge is to develop human resource policies and plans based on realistic assessments of the serious risk of out migration of physicians. ZdravPlusII needs to ensure that its support for physician training goes hand in hand with effective measures for physician retention. An alternative approach in this context might be to train other types of health care professionals less likely to migrate, such as midwives. Such a strategy would need to be assessed for its political viability in the Kyrgyz context. In financing, two important challenges remain. One is to build measures that mitigate the natural tendency for capitated payment at the PHC level to provide less care or over-refer to the hospital level in order to save resources for improving facilities and staff salaries. While such measures can certainly be introduced, people at various levels of the Kyrgyz health system do not seem aware of any need to anticipate, monitor or mitigate this tendency. Another related challenge is for the MHIF to begin to mine the rich information now at its disposal to establish expected financing patterns, identify outliers, and address any issues of misuse or corruption underlying these exceptions. In information, the greatest remaining challenge is to help health institutions exploit the information at their disposal more fully for decision making and to disseminate more information to the public. Part of the answer might be to introduce more agile interfaces that would allow users to combine and analyze various databases with greater flexibility (for example, to analyze population and service information together).

Service Delivery: In the component of Service Delivery in The Kyrgyz Republic, ZdravPlus II’s efforts extended to the areas of medical education and training, EBM and

CPG development, quality assurance, pharmaceuticals, infrastructure, public health and SES reform, continuous quality improvement (CQI), safe motherhood and family planning, and infectious diseases (TB). ZdravPlus II has met the objectives to-date for each of these areas, with notable achievements in strengthening primary health care and prevention services and promoting EBM and quality improvement. However, there will continue to be challenges in these areas as ZdravPlus II moves toward the end of the project and more work to ensure sustainability in each of these areas is needed.

The medical workforce challenges inherited from the Former Soviet Union health system include an excess supply of health professionals who are overspecialized, exacerbated by the dearth of providers in rural communities. In order to strengthen the capability of Kyrgyz doctors and nurses to deliver primary health care services, ZdravPlus II works to improve human resources and workforce planning by promoting medical education reform, contributes selectively to improving information systems to provide better data for decision-making, and supports specific country level dialogue and programs to address the rural human resources crisis.

Efforts in medical education reform include both training for new medical professionals and continuing medical education (CME) for existing professionals. Advocacy to standardize the medical education system has been challenging as some are resistant to change. New medical graduates still lack appropriate training and also receive limited expertise in public health and health management. To increase the number of primary health care providers, a clinical residency in family medicine was established and ZdravPlus II has worked to promote this residency option to medical students. According to information from the Kyrgyz Medical Institute for Continuing Education, the Kyrgyz Republic had 4 residents in family medicine in 2007, 7 in 2008 and will have 18 in 2009.

Though increasing, in the past, Institute informants note that enrollment has represented only 10% of medical graduates and only 50% of those have actually gone on to work in primary health care. Implementing partner STLI mentors family medicine, family nurse, and feldsher trainers who provide on-going clinical training to medical students and existing providers. Each oblast has a re-training branch for existing providers, which helps with efficiencies and travel requirements for providers. Currently 3,500 providers have been re-trained, and in-service training is held annually. However, low salaries compared with neighboring countries cause frequent migration among providers as well as trainers. STLI coordinates curriculum development for CME and is also developing distance-learning modules in a web-based format. Existing providers can raise their categorical rating by receiving additional training, therefore increasing their payment rate from the MHIF. STLI has also contributed to a concept paper for a national CME program that sets a minimum requirement of 150 credit hours of CME every 3 years for all medical doctors.

In addition to education reforms, attracting providers to rural areas and retaining them is challenging given low salaries. Not enough doctors are entering the public medical system; for example, at the Balykchi Hospital in Issyk Kul Oblast, 8 of the 44 active providers are eligible to retire but they continue to practice because no other doctors are available to replace them. The Deposit Doctor Program was set up in an attempt to mitigate the rural provider shortages but challenges remain. The ZdravPlus II HR Specialist and the HA completed the development of a database module on both the oblast and national level in order to contribute to the development of options for mitigating the rural human resource crisis, human resources planning, and health facility management.

Beginning reforms to SES and promoting public health will also have important outcomes in shifting paradigms in the approach to health care in the Kyrgyz Republic.

Although the reforms to health care have been in place for a number of years now, SES has had independent financing streams that precluded them from the reform process.

However, better integration of SES into the health care system and modernization of their functions has become an inevitable next step. In addition, health promotion and disease prevention need to be developed, as patient ownership of health care had not been a priority under the Soviet system. It was decided that merging SES and health promotion would maximize the effects of each of these functions, resulting in a surveillance system with involves health promotion. Another key aspect of this approach is involving the community in the process.

ZdravPlus II has supported working groups on public health curriculum and skills training for SES staff, setting the political and legal structure and creating a pilot to improve the delivery of public health services and integrate the involvement of the community. A pilot was established in Ton Rayon of Issyk Kul Oblast. The pilot set up a Public Health Coordination Council which includes SES, the local village administration, the local providers, and the village health committee, and other key stakeholders. The Council meets quarterly with SES as its lead. SES has been trained in risk factor analysis and to develop integrated action plans. The next steps in this process are formalizing the Council within the MOH and SES, and establishing pilots in one rayon of each oblast.

There is also a need to continue policy dialogues with the MOH and SES to institutionalize best practices learned at the pilot sites.

As the Kyrgyz move toward institutionalizing evidence based medicine, a structure has been set up for the development and implementation of CPGs. Committees include representatives from the MOH, MAC, special departments of the MOH, health providers, and medical/patient/professional associations.

Population and Community Health: In the area of Population and Community Health, ZdravPlus II undertook activities in the areas of Village Health Committees and Healthy Schools. These efforts were primarily to market the health reforms to the public but also include elements of civil society building that links closely to the Stewardship component. ZdravPlus II is rolling out the Swiss Red Cross Community Action for Health (CAH) model. Piloted in Issyk Kul Oblast, 276 VHCs are now active in Issyk Kul and Jalalabad Oblasts. The CAH activity is the core of the Manas Taalimi Population Involvement Component.

VHCs are formed when village members elect the committee members, and the committees then analyze the health challenges in the village and develop strategies for addressing them. The VHCs work with the local primary health care provider, oftentimes the feldsher, who trains the VHCs and helps them to develop health promotion campaigns. The Swiss Red Cross has rolled out this model in the Oblasts where it works.

This model is expected to be extended to all Oblasts by the end of 2008. Many of the VHCs have federated at the rayon level as Rayon Health Committees (RHC) in Issyk Kul Oblast and are registered as NGOs. The RHCs have participated in the development of the Kyrgyz Republic’s GAVI grant application.

The VHCs also bring democracy building and civil society mobilization benefits. For example, one VHC lobbied for the construction of new FAP in Issyk Kul Oblast due to the low quality of the building and the local government undertook construction of a new facility. In addition, one Issyk Kul rayon allocated some of its budget to the VHC to conduct a malaria campaign as it was identified as an issue of importance among local residents. In addition, many VHC members have been elected to the local government and their increased role in the community and local government empowers citizens to ownership of their health care and in their governance.

The MOH is committed to the CAH approach, and this approach is written into Manas Taalimi. Currently, the MOH pays the salaries of the primary health care staff that engage the VHCs and ZdravPlus II pays for the trainings and transportation costs. An estimated 2.5-4.5% of the regional budget would be needed to maintain these functions.

These costs are anticipated to be transferred in full to the MOH. This has not happened yet, and this move will be critical to the sustainability of this activity after the close of ZdravPlus II. The VHCs are still nascent groups and will need continued support to build their capacity as sustainable community entities.

Conclusion:

ZdravPlusII has made impressive contributions to the health system in the Kyrgyz Republic through all four components in fundamental and significant ways. The creation of the Mandatory Health Insurance Fund (MHIF) as a single payer is at the core of the reform of the health system in the Kyrgyz Republic. Under this system, the Kyrgyz Republic has achieved the remarkable goal of insuring 80% of its population and subsidizing an additional 8-11%. ZdravPlusII has contributed to the current understanding in the Kyrgyz Republic about issues and options for the health workforce.

In service delivery, ZdravPlusII has had notable achievements in strengthening primary health care and prevention services and promoting EBM and quality improvement. By the end of this project, the Kyrgyz Republic health system will operate in fundamentally different and better ways because of ZdravPlusII’s engagement. The remaining challenges are to ensure the sustainability of local institutions that will bear the responsibility of continuing to operate and strengthen the health system. The long-term viability of the health system will depend on continued political support, engagement of strong civil society entities, increased public spending on health, and solutions that engage the private sector and respond to the needs and interests of urban as well as rural residents. Special attention is warranted to tackle the threat of human resource migration.