Annex T Country Tables Zdrav to ZdravPlusII KR.pdf

2/3/2008 Response to Tina's Questions -- Kyrgyzstan Most activities done in collaboration with other donors/projects, documented elsewhere, not included due to space constraints Same situation at independence for all countries although level of health financing collapse varied Tina's See ZdravPlus II Project Regonal Conceptual/Technical Overview Paper Distributed to USAID Evaluation Team for General Definition of Project Components Scale Just intended to provide a general picture, not fully specified, activities not always fit precisely across projects, generally allocated to time where most accomplished For Z+II

ZdravPlus II Remainder +R for Project Component At Independence ZdravReform ZdravPlus ZdravPlus II To Date and Beyond Roll-out

Stewardship

Legal and Policy

No comprehensive policies, patchwork of laws/regulations, governing done by decree

WHO top-down policy development of Manas Program Waivers of laws/regs to start bottom-up Issyk-Kul pilot

Solidified policies, established long-term legal framework consisting of 3 main laws

Developed and approved Manas Taalimi Plan, policy dialgoue in priority areas, solidified regulatory base

Policy dialogue in priority areas, improve regulatory base, develop Manas Taalimi II O

Institutional Structure, Roles, Relationships

(ISRR)

MOH monopoly with complete command and control

Established independent FGPs and MHIF as health purchaser

General dialogue about ISRR, developed MHIF, established associations (FGPA, HA, MAC), dialogue national vs. regional role

Some solidification of overall ISRR, more development of MHIF and decided MOH will be purchaser for public health services, development of FMSA, FGPA, HA, MAC, more delegation of MOH functions to NGO/CBO, establish EBM Unit & some development of Specialty Associations, VHC role as CBO solidified, institutional capacity building

More solidifcation of overall ISRR and institutional capacity building O

Policy Marketing Command and control, little dialogue Raw politics, donor influence

Establish Press Center, initiate policy marketing Develop Press Center, more policy marketing More policy marketing O

Monitoring and Evaluation Politically driven Politically driven

WHO HPAP establishes M&E and policy analysis functions, ZdravPlus contributes to some studies

MOH policy analysis improves, start establish NHA, increase in support for partners assessing data to refine reforms and do studies, built into service delivery QI process

Continue progression of M&E, policy analysis, and applied research studies driving evidence-based policy O

Donor/Project Coordination None Strong informal connections Strong informal connections Formalized through SWAp

Expect even more formalized and stronger O

Resource Use

Health Delivery System Structure Inverted pyramid

Establish new PHC sector through independent entities called Family Group Practices (FGPs) in Issyk- Kul Oblast

National roll-out of FGP formation through Family Medicine Centers, and largely restructure hospital sector

Continue restructure hospital sector, 2nd generation internal hospital restructuring, start restructure SES, dialogue about restructure vertical infectious disease systems

Continue 2nd generation internal facililty restructuring, continue SES restructuring, implement vertical ID system restructuring

O, P for

SES, S

for ID systems

Human Resources Planning None

Lmited dialogue on PHC workforce

General dialogue on work force planning

Intensify dialogue on workforce planning due to rural HR crisis, collect and analyze personnel data, implement a few specific interventions

Expect workforce planning and specific interventions to continue as Manas Taalimi priority O, P, S

Project Component At Independence ZdravReform ZdravPlus ZdravPlus II To Date and Beyond Roll-out

Health Financing

See writing on fragmented financing, no separation of purchaser/provider, wrong incentives in provider payment systems (PPS), etc.

MHIF implement new PPS for variable costs using payroll tax funding, health insurance added horizontally on top of budget financing system rather than separated vertically as in KZ allows MHIF time to build capacity and develop as an institution

MHIF single-payer system piloted and rolled-out nationwide with payroll tax and budget financing, oblast level pooling, and unified PPS; add SGBP and formal copayments; definition of Treasury System problem

Solidify MHIF single-payer system for SGBP including adding rural coefficient and design of performance-based payment under GAVI grant, move to national pooling, work on resolving Treasury System problem, define and approve health sector program budgets, start public health financing reform, very early design of changes in TB financing, very early work on program budgets of High-Tech Fund and capital, SWAp mechanism extends into broader governance and transparency including fiduciary risk measures such as external audit, internal audit, internal controls, etc.

Continue solidify MHIF single-payer system including piloting performance-based payment, hopefully solve Treasury System problem, strengthen public health financing, pilot TB financing, continue work on other program budgets including High-Tech, capital, medical education, enhance broader governance and transparency activities

O, P, R, S

Health Information Systems (HIS)

Excessive but data poor, politicized and not used

New automated hospital database, HIS linked to formation of new independent FGPs

Comprehensive HIS system for MHIF single-payer, start improvement of overall HIS system

Continue solidify MHIF single-payer HIS, incorporate specific elements into RMIC integrated national system

Continue solidify MHIF single-payer HIS, incorporate specific elements into RMIC integrated national system, more links curative and public health data O

Health Management

Command and control, politics equated with management

PPS triggered some better facility level management

PPS triggered better facility level management, started health management courses for facility managers

PPS continues trigger some better facility level management, continue health management courses for facility managers and expand to public health, realized that hard to improve facility level management without more provider autonomy coming from solving Treasury System problem

Hopefully solving Treasury System problem enhances facility level health management; plan, develop, and introduce long-term health management education O,S

Service Delivery General Health System Functions

Postgraduate Medical Education Old system collapsed

Train FM trainers, start PHC doctor and nurse retraining process

Establish oblast level FMTCs and FMSA, largely finish national PHC doctor and nurse retraining, start integrating vertical training into PHC training structure including TB DOTS, start converting to long-term CME

Strengthen FMTCs/FMSA and FM faculty development, solidify PHC doctor and nurse CME/CNE, link CME to EBM/CPG and service delivery priority program QI, continue incorporate vertical program training into integrated PHC FMTC structure, initiate feldsher training

Largely the same as Z+ II to date -- just a natural progression… O

Graduate Medical Education

Not based on EBM, no outpatient clinical bases Minimal Start family medicine residency

Continue family medicine residency but hard to strengthen without reform of undergraduate ME, start linking with rotations at republican institutes especially Cardiology Institute

Solidify FM residency, decentralize and institutionalize into oblast FMTCs/FGPs for sustainability and to address rural HR crisis, improve all residency training O, S

Undergraduate Medical Education

Not based on EBM, theoretical with little practical clinical training or patient contact None

Link with Regional Council of Rectors

Realign regional Council of Rectors to focus on ME accreditation and move more to country level, undergraduate ME becomes Manas Taalimi priority

Continue develop ME accreditation and link to WFME standards, develop ME Reform Concept and initiate real movement to improve undergraduate ME O,S

EBM/CPGs Nature of clinical practice not based on evidence Minimal

Start promoting and build capacity in EBM, begin to separate functions by early work with Speciality Associations to develop new CPGs

EBM Unit established, EBM/CPG dialogue including roles and relationships of all stakeholders, continue promote and build EBM capacity, introduce CPG development methodology, continue work with EBM Unit, Specialty Associations, and FGPA/HA on developing CPGs with relatively good process/result in Asthma CPG which can be used as a model

Continue promote EBM;

strengthen roles of EBM Unit, Specialty Associations, and FGPA/HA; continue develop better CPGs; improve link to CPG implementation process using bottom-up QI O

Quality Assurance Punishment Minimal

Initiate facility accreditation through MAC, MHIF develop QA techniques linked to payment

Strengthen MAC facility accreditation and extend to private facilities, strengthen MHIF QA Continue natural progression… O

Pharmaceuticals

Pharmatsiya (some different names across country) monopoly

Pharmacy privatization, essential drug list, formalaries

Start outpatient drug benefit (ODB), limited national drug policy work, rational drug use

Strengthen ODB, donated drugs to support ODB, extend rural pharmacies including collaboration with Swiss, WHO, and USAID/CFAR, strengthen rational drug use and link to EBM/CPG, CME, health promotion

Strengthen ODB, continue link rational drug use EBM/CPGs, medical education, service delivery priority program QI, population health promotion O

Infrastructure All owned by state, massive and deteriorating

Support Kyrgyz partners in specification for WB project equipment, contribute architectual plans for FGPs, limited equipment and renovation

Support Kyrgyz partners in specification for WB project equipment, initiate facility inventory databases, limited equipment and renovation

Strengthen facility inventory databases, limited equipment and renovation, move to extend PHC strengthening to include FAPs and equip them through Manas Taalimi Likely minimal… O

Service Delivery Priority Programs

General Practice/Hypertension

Problems inherent in system including weak PHC Included in FM Included in FM

Became service delivery priority program, linked CME, EBM/CPG, ODB and rational drug use, facility level QI, and health promotion to improve service delivery

Continue QI expansion and solidification at PHC level, link to hospital level including new CPGs P, R, O

Maternal (Safe Motherhood) and family planning

Problems inherent in system including weak PHC and not evidence-based

Some inclusion in FM and some specific family planning activities

Some inclusion in FM, increase access to FP through rural midwife/IUD program

SM became service delivery priority program, linked intensive training/CME, EBM/CPG, rational drug use, facility level QI, and health promotion to improve service delivery across levels of care, first pilot then roll-out. FP linked to SM, post-partum and post-abortion, received and integrated contraceptives into program, and continued rural midwife/IUD program Continue roll-out P, R, O

Child Health

Problems inherent in system including weak PHC and not evidence-based Started integrating into FM

Solidified integration into FM, IMCI included in FM retraining, IMCI facility level supervision and QI in Issyk-Kul Oblast

Solidify integration into FM, Asthma CPG development and implementation serves as model

Continue solidify in FM, continue develop and implement new CPGs O

TB

Excess capacity in vertical system, not evidence-based treatment, reach of vertical system no longer able to control all TB-related issues Minimal

Integrated TB DOTS into PHC retraining and some linkages on health promotion

See Askar's program summary and other writing -- generally, policy dialogue including stewardship and restructuring, start design of change in TB financing, integrate TB DOTS into ME, integrate TB DOTS into PHC, link civilian and prison TB systems, health promotion. All activities in collaboration with Project HOPE.

Much work required to strengthen integration between general health system and vertical TB system and restructure and change financing of vertical TB system O, S

HIV/AIDS Not yet emerge None Some linkages in FM and health promotion

Incorporate into Safe Motherhood, PHC training, health promotion including in VHCs, dialogue on linkages HIV/AIDS and broader health system and financing

Decision on nature of vertical HIV/AIDS system, restructuring and financing, and continue link service delivery and health promotion O,S

Population and Community Health

Marketing the Reforms Population role not seen as important

Free choice of FGP and enrollment

Continue free choice of FGP and enrollment, promote benefits and rights, MHIF complaint line, promote FM/PHC

Incorporate enrollment in FGP into health financing linked to capitated rate, intensify promotion of benefits and rights

Expand activities and link with more open society O

Health Promotion -- Government Not yet emerge

None although did independent mass media campaigns on selected health topics

Limited support for Republican Center for Health Promotion

Limited support for Republican Center for Health Promotion

Limited support for Republican Center for Health Promotion O

Health Promotion -- Providers Linked to Service Delivery Not yet emerge Minimal

Started facility level health promotion to empower population with information and change nature of relationship between FGPs and population, start improving inter-personal communication skills of providers

More intense and focused health promotion at health provider level directly linked to service delivery priority programs, continue improving inter-personal communication skills of providers

More intense and focused health promotion at health provider level for service delivery priority programs P, R, O

Health Promotion -- Community-Based Entities Not yet emerge None

Minimal, connected to various consumer organizations

Collaborate with Swiss to roll-out Village Health Committee model including contribution to building civil society

Continue roll-out VHC model and broader linkages to civil society and democratization P, R, O