Report No. 32354-ECA Review of Experience of Family Medicine in Europe and Central Asia (In Five Volumes) Volume IV: Kyrgyz Republic Case Study May 2005 Human Development Sector Unit Europe and Central Asia Region Document of the World Bank CONTENTS Acknowledgements .................................................................................................................................. vlll ... Executive Summary........................................................................................................................................... ................................................................................................................................... ix 1 Introduction . 1 1.1. Objectives o fthe Study ..................................................................................................................... 1 1.2. The Evaluation Framework............................................................................................................... 1 1.3. Primary Research............................................................................................................................... 2 1.3.1, Qualitative Research..................................................................................................................... 2 1.3.2. Primary Health Care Facility and Physician Task Profile Surveys.............................................. 2 1.4. Secondary Research........................................................................................................................... 4 1.5, Literature Review .............................................................................................................................. 4 2 The Kyrgyz Health SystemPrior to Health Reforms .1.6. Quantitative Analysis ........................................................................................................................ 4 ......................................................................... 6 6 3 Key Problems Faced by the Kyrgyz Health System inthe Transition Period .2.1. Health System Organization and Financing...................................................................................... ................................. 8 3.1. Organizational Complexity ............................................................................................................... 8 3.2. Excess Infrastructure and Human Resources .................................................................................... 8 3.3. Allocative Inefficiency and Inequitable Financing............................................................................ 9 3.4. Inefficient Service Provision............................................................................................................. 9 3.5. Limited Incentives and L o w Pay Levels for Health Personnel ......................................................... 9 4 Kyrgyz Health Reforms:Key Legislative Changes 10 5 Key DevelopmentsinPrimary Health Care .. ...................................................................................... .......................................................................... 12 5.1. Organizational Changes................................................................................................................... 12 5.1.1. Choice ........................................................................................................................................ 13 5.1.2. UnifiedSystem o f Purchasing Care........................................................................................... 13 5.1.3. Decision Malung at PHC Level ................................................................................................. 13 5.2. Financing. Resource Allocation and Provider Payment Systems inPHC....................................... 14 5.2.1. Provider Payment Systems for PHC and the Programo f State Guarantees............................... 16 5.3. Changes in Service Provision.......................................................................................................... 18 5.4. Development o f HumanResources inPrimary Health Care ........................................................... 18 5.4.1. Training o f Family Physicians................................................................................................... 19 5.4.2. Training o f Nurses ..................................................................................................................... 22 5.4.3. Assessment o f Skills o f Family Physicians................................................................................ 23 5.4.4. Undergraduate Medical Training ............................................................................................... 23 5.5. Development o f Professional Associations .................................................................................... 25 i 6 Changes inPrimary HealthCare Services: Resultsof the PHC Facility and Task Profile . Surveys ...................................................................................................................................................... 26 6.1. Access to Primary Health Care........................................................................................................ 26 6.1.1. Coverage .................................................................................................................................... 26 6.1.2. Accessibility ............................................................................................................................... 28 . . 6.1.3. Affordability o f Health Care...................................................................................................... 29 6.2. Utilization o f PHC Services ............................................................................................................ 30 6.3. Utilization of Hospital Services....................................................................................................... 32 6.4. Primary Health Care Service Delivery ............................................................................................ 34 6.4.1. Range o f Services Provided....................................................................................................... 34 6.4.2. Availability o f Equipment.......................................................................................................... 36 6.4.3. Availability o f Drugs Usedinthe Management o f Emergencies Commonly Encountered in Primary Care ......................................................................................................................................... 37 6.4.4. Use o f Clinical Guidelines ......................................................................................................... 37 6.4.5. Immunization Service ................................................................................................................ 37 6.5. Task Profile of Doctors Working inPrimary Care.......................................................................... 38 6.5.1. Practice and Personal Information............................................................................................. 38 6.5.2. Use of Medical Equipment ........................................................................................................ 39 6.5.3. Application o f Medical Techniques........................................................................................... 39 6.5.4. FirstContact Management o f Commonly Encountered Conditions .......................................... 40 6.5.5. Health Promotion and Disease Prevention................................................................................. 42 6.5.6. Chronic Disease Management ................................................................................................... 44 6.5.7. Job Satisfaction.......................................................................................................................... 46 7 Analysis of the HealthInsuranceFundData on HospitalReferrals and Admissions for Key . Conditions ................................................................................................................................................. 48 7.1. Impact o f Expanded Service Delivery on PHCFunction................................................................ 48 7.2. Enhanced Gate keepingand First Contact Functions...................................................................... 48 .7.3. EnhancedManagement of Common Chronic Conditions............................................................... 51 8 Findingsof the Qualitative Research ................................................................................................. 57 8.1. Perception of Reforms as Complex Transformational Change ....................................................... 57 8.1.1. Comprehensive Restructuring o f the Health Systemwith New Organizational Forms.............57 8.1.2. Redesigning the Care DeliveryProcess ..................................................................................... 57 8.1.3. New Financing Systems............................................................................................................. 58 8.1.4. Changing Consumer-Provider Relationships............................................................................. 58 8.1.5. Emergence o f New Stakeholders ............................................................................................... 58 11 8.2. PHC Reforms and PerceivedBenefits for Users............................................................................. 58 8.2.1. IncreasedUser Satisfaction ........................................................................................................ 58 8.2.2. ImprovedAccess to Health Services ......................................................................................... 59 8.2.3. Continuity o f Care...................................................................................................................... 59 8.2.4. Named Physicianto Take Care of Health Problems.................................................................. 59 8.2.5. Comprehensive Health Services ................................................................................................ 59 8.2.6. Increased Awareness of fights .................................................................................................. 60 8.3, PHC Reforms and PerceivedBenefits for the Health System......................................................... 60 8.3.1. Efficient Care Delivery and Use of Resources .......................................................................... 60 8.3.2. ImprovedEquity........................................................................................................................ 60 8.3.3. Improved Transparency ............................................................................................................. 60 8.4. Barriersto Change ........................................................................................................................... 61 8.4.1. Organized and `Politicized' Resistance ..................................................................................... 61 8.4.2. Winners and Losers: The Changing Role and Power o f Stakeholders ...................................... 61 8.4.3. Fear ofthe Unknown ................................................................................................................. 62 8.4.4. Nostalgia for the Old Times....................................................................................................... 62 8.4.5. Poor Teamwork.......................................................................................................................... 62 8A.6. Financial Barriers....................................................................................................................... 62 8.4.7. Legal and Administrative Barriers............................................................................................. 62 8.4.8. Poor Communication................................................................................................................. 63 8.4.9. Lack o f Incentives...................................................................................................................... 63 8.4.10. Fear o f Crossing Boundaries.................................................................................................... 64 8.4.1 1. L o w Brand Equityfor FM ....................................................................................................... 64 8.5, Critical Factors for Successful Reform ........................................................................................... 64 8.5.1. FM as the Key Driver o f Change ............................................................................................... 64 8.5.2. Single Payer System .................................................................................................................. 65 8.5.3. User Involvement., ..................................................................................................................... 65 8.5.4. Effective and Sustained Communication................................................................................... 65 8.5.5. Sustained and Coordinated International and National Support ................................................ 65 8.5.6. A Visible and Articulated Strategy - Manas............................................................................. -66 8.5.7. Incentives................................................................................................................................... 66 8.5.8. Creating an Enabling Environment............................................................................................ 66 8.5.9. Critical Mass o f Policy Makers and Managers .......................................................................... 66 9 Key Achievementsof PHC Reforms . .................................................................................................. 67 ... 111 9.1. Organizational and RegulatoryChanges......................................................................................... 67 9.2. Financing, ResourceAllocation and Provider Payment Systems.................................................... 67 9.3. Service Provision............................................................................................................................. 68 9.4. Resource Generation ....................................................................................................................... 68 10 Remaining Challengesto be Addressed . ............................................................................................ 69 10.1. Negotiatingthe Glass Ceiling........................................................................................................ 69 10.2 Balancing Innovationwith Standardization ................................................................................... 69 10.3 Expandingthe PHC Function......................................................................................................... 69 10.4. Equityand Allocative Efficiency .................................................................................................. 71 10.5. Incentives and Retention............................................................................................................... 71 10.6. DevelopingHuman Resource Capacity to Manage Strategic Change .......................................... 72 10.7. Monitoring, Evaluationand Analytic Capacity ............................................................................. 72 10.8. Contracting .................................................................................................................................... 73 10.9. Integration, Continuum of Care and Referral Systems.................................................................. 73 10.10. Reforming the Undergraduate Medical Training Curriculum ..................................................... 73 10.11. Communicatingthe Reforms ................................................................................................. 73 74 11 Lessons Learned .10.12.Sustainability .................................................................................... ................................. ................................................................................................................................ 75 11.1. Critical Success Factors for SustainedDevelopment of PHC ....................................................... 75 11.2. Coordination............................................................................................................ 11.3. Managing Strategic Change .......................................................................................................... 75 11.3.1. Communication............................................... .................................................... 75 11.3.2. Level of Intervention................................................................................................................ 76 11.4. Responsiveness.............................................................................................................................. 76 11.5. Monitoring and Evaluation............................................................................................................ 76 11.6. Dissemination and Cross-Learning ............................................................................................... 76 11.7. Exit Strategy.................................................................................................................................. 76 Annex 1:EvaluationFramework ............................................................................................................ 77 Annex 2: Summary of Facility Survey Instrument ............................................................................... 78 Annex 3: Summary of NIVELTask ProfileInstrument ........................................................................... ....................................................................... 79 Annex 4: HealthIndicators for the KyrgyzRepublic 80 Annex 5: HealthExpenditure inthe KyrgyzHealth System 83 Annex 6: Health SystemFinancing ......................................................................................................... ................................................................ 86 Annex 7: Provider Payment Systems for Hospitals ............................................................................... 89 Annex 8: Curriculum for Retraining Doctors as Family Physicians 90 References ............................................................................................................... ................................................... 97 iv FIGURES Figure 1: A Framework for Analyzing Health Systems.............................................................................. 1 Figure 2: Flow of Fundsinthe Kyrgyz Health SystemPrior to 1997......................................................... 7 Figure 3: GovernmentPer CapitaHealth Spending(inKyrgyz Soms) by Region.2001......................... 15 Figure 4: HealthExpenditureby Function andLevel ............................................................................... 15 Figure 5: Percentageof Total Health ExpenditureAllocated to PHC....................................................... 16 Figure 6: HealthExpenditureon Hospitalsand PHC inChui Oblast (2001-2003) .................................. 16 Figure 7: State Benefits Package............................................................................................................... 17 Figure 8: Number of Doctors andNurses per 10.000 Population ............................................................. 18 Figure 9: Number ofPracticingDoctorsby Region.................................................................................. 19 Figure 10: Number ofDoctors Retrainedas FMSpecialists..................................................................... 21 Figure 11: Number of Doctors Trainedas FGPs (Cumulative) by Region............................................... 21 Figure 12: Number ofNurses Trained as F MNurses (Cumulative) ......................................................... 22 Figure 13: Number ofNurses Trained(1998 to 2004 by Region) ............................................................ 23 Figure 14: PopulationCoverageby HealthInsurance............................................................................... 26 Figure 15: Number of People(and % ofTotal Population) Enrolled with FGPsbyRegionin2003 .......27 Figure 16: Proportion ofthe InsuredandUninsured Populationwith Access to FGP.............................. 27 Figure 17: Number o f Persons Registeredper FGP .................................................................................. 28 Figure 18: Number o f Family PhysiciansandFamilyNurses per FGP .................................................... 28 Figure 19: Distance(inkm)to PHC Facilities .......................................................................................... 29 Figure 20: Introduction of Co-paymentsinIssyk-Kuland Chui Regionsin2001 andProportion of Users PayingHealth Care Personnel.................................................................................................................... 30 Figure 21: Percentage of PopulationSeehng Health Care inthe 30 Days Prior to the Survey by Gender ........................................................................................................................................................ 32 Figure 22: Reasons for Not SeehngHealth Care...................................................................................... 32 Figure 23: Number of Hospital Beds andBeds per 1,000 Population....................................................... 33 Figure 24: Hospitalsby RegionThat Have Been Closed(2002) .............................................................. 33 Figure 25: Average Hospital Inpatient Stay per Admission (inDays)...................................................... 34 Figure 26: Percentage ofDoctors `Always' or `Usually' Performing aProcedure................................... 40 Figure 27: Common ConditionsVery FrequentlyManagedinPHC ........................................................ 41 Figure 28: CommonConditions FrequentlyManagedinPrimary Care.................................................... 41 Figure 29: CommonConditions Infrequently ManagedinPrimary Care................................................. 42 Figure 30: Percentageof DoctorsProviding HealthEducation Advice on Smolung, Diet andAlcohol DuringRoutine Consultation...................................................................................................................... 43 Figure 31: Percentageof DoctorsProviding Immunization andPediatric Surveillance........................... 44 Figure 32: Percentageof DoctorsProviding FamilyPlanning Services. Antenatal andIntra-partum Care ............................................................................................................................................................ 44 Figure 33: PercentageofFamily Physicians `Always or Usually Involved' inManaging Six Common Chronic Conditions..................................................................................................................................... 45 Figure 34: Percentageof Doctors `Always or Closely' Involved inManaging Seven Chronic Conditions .................................................................................................................................................. 45 V Figure 35: Percentage of Doctors Involved inDelivering Services for Chronic Conditions that are `Infrequently' Managed.............................................................................................................................. 46 Figure 36: Percentage o f Doctors Who Enjoy Their Work ....................................................................... 47 Figure 37: Views o f Doctors (by %) on Their Work................................................................................. 47 Figure 38: Number of HospitalReferrals per Person Registeredwith FGP.............................................. 48 Figure 39: FGP InitiatedAdmissions as a Proportion o f Total Hospital Admissions (2001-2003) ..........49 Figure 40: Total Number o f Ambulance Calls .......................................................................................... 49 Figure 41: Hospitalization of Patients Registered with FGPs as a Percentage o f Total Admissions ........ 50 Figure 42: Hospital Referrals for Acute ENTProblems (total and per 1,000 persons registered) ...........50 Figure 43: Hospital Referrals by FGPs for Acute LRTIProblems (total and per 1,000 persons registered) ................................................................................................................................................... 51 Figure 44: Number o f Referrals per Personwith Anemia ......................................................................... 52 Figure 45: Number o f FGP HospitalReferrals for Peptic Ulcer Disease.................................................. 52 Figure 46: Number of FGP Hospital Referrals for Asthma....................................................................... 53 Figure 47: Number o f Hospital Admissions per 1,000 Asthma Patients................................................... 53 Figure 48: Number o f Referrals by FGPs for Ischemic Heart Disease ..................................................... 54 Figure 49: Number o f Hospital Admissions for IHDper 1,000 Registered Patients ................................ 54 Figure 50: Number o f FGP Referrals for Hypertension............................................................................ 55 Figure 5 1: Number o f Hospital Admissions for Hypertension.................................................................. 55 Figure 52: Number o f FGP Referrals for NIDDM.................................................................................... 56 Figure 53: Number ofReferrals for NIDDM............................................................................................ 56 Figure 54: BirthRate per 1,000 Population............................................................................................... 80 Figure 55: Infant Mortality Rate per 1,000 Live Births(1996-2003) ........................................................ 81 Figure 56: Maternal Mortality Rate per 100,000 Live Births (1996-2003) ............................................... 81 Figure57: LeadingCauses of Mortality as a Percentage o fTotal ............................................................ 82 Figure 58: Health Expenditure as a Proportion of GDP (1990-2003) ....................................................... 83 Figure 59: Public Health Expenditures as a Percentage o f Total State Budget......................................... 83 Figure 60: Social FundTransfers to MHIF............................................................................................... 84 Figure 61: Plannedvs. Actual RepublicanBudget Transfers to the MHIF............................................... 84 Figure 62: Plannedand Actual MHIFRevenues....................................................................................... 85 TABLES Table 1: The RegionalPopulationRGP Profile........................................................................................... 3 Table 2: Kyrgyz Republic: Number o f Facilities and Physicians Surveyed................................................ 3 Table 3: Effectiveness Indicators- FirstContact Care ............................................................................... 5 Table 4: Effectiveness Indicators- Continuity o f Care............................................................................... 5 Table 5: Women's Services ....................................................................................................................... 35 Table 6: Services for Common Chronic Conditions ................................................................................. 35 Table 7: Essential PHC Services for Infectious Diseases.......................................................................... 35 Table 8: Extended Primary Health Care Services ..................................................................................... 36 vi Table 9: Service Provision by Rural andUrban FGPs .............................................................................. 36 Table 10: Percentage o f PracticesUsing Particular Equipment................................................................ 39 Table 11: Procedures Rarely or Seldom Performed by Family Physicians and Primary Care Doctors....39 This volume is a product of the staff o f the InternationalBank for Reconstructionand Development/The World Bank. The findings, interpretations, and conclusions expressed in this paper do not necessarily reflectthe views o f the Executive Directors o f The World Bank or the governments they represent. The World Bank does not guarantee the accuracy o f the data included in this work. The boundaries, denominations, and other information shown on any map inthis work do not imply any judgement on the part o f The World Bank concerning the legal status o f any territory or the endorsement or acceptance of such boundaries. vii ACKNOWLEDGEMENTS This report reviews the experience o f family medicine in the Kyrgyz Republic. It i s part o f a study comprising five volumes that reviews the experience o f family medicine in four countries in the Europe and Central Asia Region (ECA) - Armenia, Bosnia and Herzegovina, the Kyrgyz Republic and Moldova. The report reviews the experience, draws lessons and establishes an evidence base for detailed analysis. The study presents best practices for policy dialogue and future investments by the World Bank and other financial institutions. The detailed case studies compare these countries and draw common themes and issues. Comparisons are made with best-developed or existingmodels inthe OECD and other ECA countries that have already undertaken FMreform. The report was funded by the DutchTrust Fund. It was prepared by a research team led by Rifat Atun (Imperial College) and included Adilet Meimanaliev, Alisher Ibragimov, Nine1Kadyrova, Ainura Ibraimova and Yevgeniy Samyshkin. The Task Profile Instrument was designed by Wienke Boerma. The study was prepared under the leadership o f Betty Hanan. Kees Kostermaans and Juan Pablo Uribe were the peer reviewers. Valuable comments were provided by Joe Kutzin, Melitta Jakab, Sarbani Chakraborty, Jan Bultman, Paul Fonken, Asta Kenny and Sheila O'Doherty. ... Vlll EXECUTIVESUMMARY 1. The objectives of the study were to review the experience o f FM in Europe and Central Asia (ECA), present best practices, and make recommendations for policy dialogue and future investment. The study employed primary and secondary research, using both qualitative and quantitative methods o f inquiry and a proprietary framework o f analysis and instruments to explore key changes in policies, regulations, organizational structures, financing, resource allocation, provider payment systems, service provision, and humanresources. The impact o fFMreforms was analyzed. 2. Kyrgyz Republic inherited a health system based on the Soviet Semashko Model, characterized by centralized planning; hierarchical administrative organization; a very large provider network dominated by hospitals and tertiary provider units; parallel health systems for line ministries and large organizations; a poorly developed PHC level fragmented by a tripartite delivery model that provided services separately for adults, men and children, as well as a large number o f vertical programs delivered by narrow specialists; absence o f family physicians at PHC level which lacked gate keeping function; a surfeit o f human resources concentrated in cities. The system was also characterized by an inequitable resource allocation system based on historic activities and inputs that favored large hospitals in urban centers at the expense o f rural areas; line-item budgeting o f provider units and salary-based payment systems that encouraged inefficiency and discouraged improved performance; strict care-delivery protocols, not based on current evidence, that encouraged excessive referral to the secondary care level; highly curative and disease focused services (partly attributable to the nature of medical training) with limited health promotion or prevention; and a system that allocated users to doctors and prevented them from exercising choice or meaningfully participatingintheir health care. 3 . Prior to independence, the Kyrgyz Republic devoted 3.5 percent' o f its GDP to health. Rapid economic decline further compromised the low level o f funding to the health sector and led to underinvestment - creating a substantial funding gap between the level o f financing needed by the health system and the resources available. The Kyrgyz Government sought to reform the health system to mobilize additional resources to address key problems - namely, organizational complexity; excess infrastructure and human resources; allocative inefficiency and inequities in financing; inefficient service provision; and limited incentives and low pay levels for healthpersonnel. 4. From 1992, the Kyrgyz Government introduced key legislations to create an enabling environment and establish platforms for systemic, comprehensive and multifaceted health reforms with objectives o f reducing inefficiencies, enhancing equity and access (financial and geographic), and improving quality. 5, Despite a severely resource-constrained environment, the achievements o f FM-centered PHC reforms in the Kyrgyz Republic have been remarkable. The results clearly point to expanded scope o f services inPHC with enhanced gate keeping and first-contact functions. There i s a substantial secondary- to-primary shift with consequent improvement inthe efficiency and effectiveness o f the health system. 6. High-level support for FM reforms has been strong; the MOH has a clearly articulated health reform strategy and has succeeded in coordinating donor agencies to ensure alignment of inputs to reduce duplication and optimize value added by multilateral and bilateral organizations actively involved in the health sector, namely, WB, WHO, ADB, USAID, UNICEF, UNDP, DFID, SDC and JICA. Close '4.15% in 1990. ix collaboration between the donor community and the government has led to emergence o f an `operational SWAP.' KEYACHIEVEMENTS: ORGANIZATIONAL ANDREGULATORY CHANGES 7. Key laws and regulations have been developed to create an enabling environment for FM and PHC reforms. Family medicine i s recognized as a specialty inthe legal profession. 8. The tripartite system of pediatric, women's and adult clinics has been consolidated into unified PHC centers providing services for adult men and women and children. New PHC provider organizations have been established: FGPs with autonomy to manage budgets and contract with the Mandatory Health Insurance Fund, and FMCs comprising FGPs and narrow specialists. 9. The scope and content of FGP services have been articulated in law and defined in detail in the State GuaranteedBenefits Package. 10. The gate keeping function o f PHC has been established, with FGPs acting as the first point o f contact for patients. 11. A large number of PHC centers have been refurbished. Users have been given the freedom to choose their family physicians. 12. Limited accreditation has been introduced, and a number o f PHC and hospital facilities have been accredited. 13. Mandatory Health Insurance (MHI) with co-payments has been introduced, providing additional resources to the health system and creating a transparent environment with regard to payments to health service providers. There i s empirical evidence to show that the new system has benefitedthe poor. FINANCING, RESOURCEALLOCATIONAND PROVIDER PAYMENT SYSTEMS 14. A key achievement is the Single Payer System, which has enabled pooling o f all sub-national budget funds for health care in the Territorial Department o f the Mandatory Health Insurance Fund in a "single-pipe funding" to the State GuaranteedBenefitsPackage. 15. New provider payment methods have been successfully introduced inthe pilot regions for FGPs based on simple per capita mechanism. Direct and indirect contracts have been introduced for FGPs, includingpartial fundholding for pharmaceuticals. SERVICE PROVISION 16. A State Guaranteed Benefits Package has been introduced for the entire populationand provides free basic2PHC services for all citizens, regardless o f their insurance status and enrollment. Citizens not covered under the MHI scheme are subject to formal co-payments for referral services in outpatients or hospital inpatient services providedby narrow specialists. 17. Citizens insuredunder the MHIFreceive an outpatient drugpackage that provides certain drugs at reduced rates and lower co-payments for referral services inoutpatients and as inpatients inhospital. N o t all PHC services are free. Only basic P H C services included inthe Benefits Package are free. X 18, There i s excellent coverage for immunizations and widespread provision o f basic PHC services in all regions. 19. In the regions that have introduced the FGP model, the scope and content of services have expanded significantly. The task profile survey shows statistically significant difference inthe application of medical techniques and use o f equipment when delivering PHC services. Further, FGPs in advanced reform regions provide more health promotion as well as manage more first contact and chronic conditions as comparedwith intermediate and early reformregions. 20. There i s evidence from the qualitative research that the new model i s welcomed by the users and the health professionals, who identify many benefits including user-centeredness o f the model, having a named doctor, user choice, the more comprehensive nature o f the FM model, empowerment o f the FM team, and increased emphasis on teamwork. 21. Analysis of the MHIF data demonstrates a substantial and appropriate shift from secondary to primary level with a decline in the number o f hospital referrals for key acute and chronic conditions that are expected to be managed in a PHC setting. This finding i s critical to demonstrate that changes are having the desired benefits o f enhanced care management in the PHC setting with reduced referrals to hospitals -with consequent improvement inefficiency and effectiveness. 22. Evidence-based guidelines have been introduced for 162 common conditions encountered in PHC.This will enhance quality o fPHC services delivered, reduce unnecessary interventions and diminish referrals to hospitals. RESOURCE GENERATION 23. A critical mass o f FM specialists and nurses, which meet 60-70 percent o f the numbers needed, have participatedin short-course retrainingprograms. KEYCHALLENGES ANDRECOMMENDATIONS 24. Family Medicine and PHC reforms inthe Kyrgyz Republic have been highly successful and have evolved rapidly, but have reached a glass ceiling that needs to be negotiated. Many o f the key stakeholders wish to see acceleration in the pace o f reforms, particularly to broaden the role o f FGPs and the scope o f services they deliver; build on the payment mechanisms, contracts, and the autonomy afforded to the PHC providers to introduce more flexible contracts with incentives to improve performance, quality, and provide additional services - health promotion, prevention and extended PHC; increase remuneration for FGPs and FGP nurses trained as specialists; further refine resource allocation taking into account need and equity o f access, favoring rural and poorer areas with higher health needs; place more emphasis on evidence-based medicine; and change reporting mechanisms that reinforce the old tripartite model and hinder unified service provision. Further legislative changes are needed to accelerate and support the next major phase o f development. 25. Countrywide standards on scope and quality o f services have succeeded inestablishing minimum quality standards and equitable services to Kyrgyz citizens. However, in the future, a balance must be struck between standardization and innovation. Contracts with the FGPs should be used to encourage different parts o f the system to progress at varying paces to extend the scope o f services provided inPHC to levels providedincountries with more advanced PHC systems. 26. The presence o f narrow specialists at FMCs, which can be accessed directly by patients, i s a source o f inefficiency and a key barrier to developing PHC. This leads to fragmentation o f the first xi contact function; fracture o f the gate keeping function; adverse impact on continuity o f care; hindrance to practicing integrated and holistic family medicine and extended PHC; duplication o f hospital OPDs; and creation o f false and potentially destructive perception o f separate rural and urban models o f PHC. This source o f inefficiency should be eliminated by converting all FMCs to FGP centers. The narrow specialists who work in FMCs should be either gradually transferred to hospitals or retrained as family physicians. 27. Although FM reforms have been introduced to all regions and now cover the majority o f the insured population, major inequities in access to services and funding exist. The next phase o f reforms should strengthen the focus on equity by changing resource allocation mechanisms to take into account poverty and health needs and substantially modify the current patterns that favor urban areas and Republicanhospitals. 28. Allocative inefficiencies between level o f care and type o f institution persist. In particular, Republicanhospitals in Bishkek still consume a significant portion o f the health system budget. This can be illafforded; mechanisms are needed to reduce resources allocated Republican units and to reallocate these funds to PHC level. 29. Limited incentives and poor salaries o f FM specialists are two major problems that need to be addressed immediately to retain the `early adopters' and leaders and to give them the opportunity to innovate and lead change. 30. Although the new payment mechanisms do provide some incentives, there needs to be a stronger indication that FM i s valued on par with hospital specialties. A visible salary differential between GPs and FM specialists, as well as between the narrow specialists who work in PHC and the FM specialists, would send a strong signal that FM i s valued. Non-economic incentives, such as clearer development paths, opportunity of attachment to academic units, and continuing medical education, are mechanisms that should be utilized. 31. Undergraduate training i s not aligned with international trends, i s highly curative in focus, and i s designed to produce narrow specialists. Undergraduate training in FM should be expanded to sensitize medical students to the specialty early in their studies and to ensure that future narrow specialists are acquainted with the scope and activities o f FM, thereby creating a better common understanding between narrow specialists and FMPs. 32. Implementing PHC reforms i s a complex, strategic change process and there is insufficient managerial capacity to accelerate the pace o f development. It i s necessary to rapidly develop a critical mass o f middle and senior level managers and health professionals to act as change agents along with local capacity to deliver training programs. 33. As with the other countries inthis study, a fundamental problem with the PHCreforms is the lack o f systematically collected data. Although the Kyrgyz Republic has developed an impressive M&E system within the MHIF, the PHC component o f the system needs enhancing and analytic capacity at MHIFfurther expansiontoregularly analyze data to generate timely informationto informdecisions. 34. Contracts, which have been successfully introduced inthe pilot regions where the FGP model has been implemented, can be used as an effective tool to further improve equity, service quality, efficiency and effectiveness. However, to achieve these objectives there needs to be a move from simple per capita contracts to more sophisticated contracts with explicit quality and performance criteria and commensurate incentives to reward FGPs that achieve these. However, such a shift will require significant analytical and execution capacity at MHIF and MOH to develop, implement, manage and monitor more xii sophisticated contracts; robust information systems in PHC to capture relevant and timely data on activities and outcomes; appropriate incentive systems; and more stability inhealth care financing (i.e., no accumulation o f debts or arrears to healthproviders). 35. An effective FM-centeredPHC system has been introduced, but incentives should be created to achieve further substantial secondary-to-primary shift and to develop extended PHC. 36. Vertical integration in the system i s limited with precarious links between PHC and the hospital levels. There are excellent financing and organizational foundations (FGPs with budgetary autonomy, contracts, per capita payment system, partial fundholding) on which to build and introduce payment systems, such as full fundholding, to encourage innovation and strengthen the interface between primary and secondary levels. 37. Communication between and within levels o f the health system and with the public i s critical activity that needs to be enhanced to rectify misperceptions o f FM which create barriers to full scale-up and sustainability of an FM-centeredPHC system. A clear and all-embracing communication strategy i s necessary to increase visibility o f PHC reforms, inform key stakeholders o f the expected benefits and increase ownership. CRITICAL SUCCESSFACTORS 38. The study has identified a number o f critical success factors. These include (a) Branding FMand image building to improve the status o f FM specialists as compared with narrow specialists; (b) Improving work environment and conditions for FMteams; (c) Investing in communication between and within levels o f the health system and with the public to share objectives and values o f FM, develop trust and increase ownership; (d) Improving coordination o f key agencies; (e) Developing a holistic approach to reform with simultaneous multifaceted interventions to achieve an enabling legal environment; organizational restructuring to enable new provider forms with increased autonomy; new financing methods; resource allocation mechanisms that address inequities; provider payment methods that overcome limitations o f systems based on line-item-budgeting and salaries; contracts and evidence-based care guidelines to enhance quality and establish minimum standards; (f) Approaching reforms as a strategic change process; (g) Ensuring sensitivity and responsiveness to rapidly changing context; (h) Ensuring robust M&E systems are put in place to assess impact o f reforms; and (i)Having a clearly articulated and planned exit strategy between projects to ensure sustained transformation. xiii xiv 1. INTRODUCTION 1.1. OBJECTIVES OFTHE STUDY 1. The objectives of the study were to review the experience of FM in Europe and Central Asia (ECA), present best practices, and make recommendations for policy dialogue and future investments. 1.2. THEEVALUATION FRAMEWORK 2. Kutzin suggests a three-step approach to evaluating health reforms describing clearly: (i)key contextual factors drivingreform; (ii) the reform itself and its objectives, and (iii) process by which the the reform was (is being) implemented.' To this approach three elements can be added: (iv) describing clearly the changes introduced by the reforms; (v) analyzing the impact o f these changes on health system objectives and goals; and (vi) establishing whether the reforms have achieved the policy objectives set by the Government or by the agency leadingthe reforms. 3. The evaluation used a framework to analyze key changes in health system elements and intermediate goals inrelation to PHC. This i s shown inFigure l2 Annex 1). (See Figure 1: A Framework for Analyzing Health Systems Organisational ,pq , , Health D Efficiency Effectiveness Choice 4. This framework builds on that developed by Hsiao3and identifies four levers available to policy makers and managers in health systems. Management and modification o f these levers enables policy makers to achieve different intermediate objectives and goals. The `organizational arrangements' lever refers to the policy environment, stewardship function, and structural arrangements inrelation to funding agencies, purchasers, providers and market regulators. Financing and resource allocation levers refer to resource collection, pooling, allocation, and the mechanisms and methods used for paying health service providers. The `provision' lever refers to the `content' - the services provided by the health sector rather than the structures within which this `content' i s delivered. The intermediate goals identified in the framework - equity, technical and allocative efficiency, effectiveness, and choice - are frequently cited 1 by others as end goals inthemselves. However, in this framework efficiency, equity, effectiveness and choice are taken as means - contributing to attainment o f the health sector's ultimate goals o f health, financial riskprotection and user satisfaction. 5. This framework was used to analyze key changes in health system elements and intermediate goals. An important finding of literature search and country visits was the lack o f systematically collected data at PHC level. Therefore, primary research was undertaken to generate original data to complement secondary research findings. 1.3. PRIMARY RESEARCH 6. Primary research comprised three elements: (i) Qualitative research; (ii) Primary Health Care Facility Survey; and (iii) Physician Task Profile Survey. 1.3.1. QualitativeResearch 7. Qualitative research involved 57 key informant interviews to ascertain perceptions o f FM reforms, critical success factors, barriers and enablers that influenced the introduction and diffusion of FMreforms. 8, The qualitative research explored the goals and objectives o f the reforms, changes in structures and processes, key enabling factors and obstacles, major achievements and lessons learned. 9. A semi-structured questionnaire was specifically developed for the study for face-to-face, in- depth interviews o f key informants. The questionnaire was piloted initially in Estonia, then refined and iteratively tested inthe four countries studied. 10. Purposive sampling was used over two stagese4An initial set o f key informants was interviewed for the first stage of the study using a semi-structured questionnaire. The data emerging from the initial set o f interviews were analyzed to identify key emerging themes, which were explored further using a refined and shortened topic guide to allow in-depth exploration.' The second stage also employed purposive sampling with `snowballing' to capture a multi-level, multi-stakeholder sample o f key informants, representing the key stakeholders involved in PHC reforms in both policy development and implementation. 11. The analysis informed the detailed case study by capturing key structural and procedural changes, issues related to design and implementationo f PHC reforms, the drivers and barriers to reform, the factors influencing the establishment o f an enabling environment for change and the lessons learned. 1.3.2. Primary Health Care Facility and Physician Task Profile Surveys 12. These two elements of primary research were done concurrently to explore changes in service delivery and practice o f family physicians as a result o f the PHC reforms and training o f physicians as FM specialists. It was not possible to do a pre- and post-intervention study as there were no data or baseline studies that analyzed service delivery patterns and physician practices before the reforms and after the introduction o f changes. 13. We undertook two cross-sectional studies simultaneously: (i)Primary Health Care Facility survey, and (ii)Physician Task Profile survey. 2 14. We used two-stage sampling with probability proportional to size. Three regions were selected based on the relative stage o f development o f PHC care reforms: Issyk-KulOblast, an "Advanced" and rural region; Bishkek City, an "Intermediate" and urban region; and Osh, an "Early" and rural region. In the second stage of sampling a random sample o f PHC facilities proportional to the size o f the population served inthe region were identifiedusinga randomnumber generator program (Table 1). Total for Bishkek (1) 775.3 115 Total for Issyk-Kul(2) 422.0 58 Total for Osh (3) 1256.8 127 15. A total o f 100PHC facilities and 200 doctors worlung within these facilities were surveyed. Ifa doctor was not present at the PHC facility on the date o f the visit to the facility, the facility was dropped from the study (Table 2). Advanced Region for Less Advanced Region Developing PHC/FM Total PHC/FMReforms for PHC/FM Reforms Reforms Issyk-KulOblast Bishkek City Osh 15 Facilities 34 Facilities 5 1 Facilities 100 Facilities 30 Doctors 68 Doctors 102 Doctors 200 Doctors 16. The PHC Provider Facility Survey and the Survey o f Task Profiles o f PHC doctors (FMspecialist and GPs) were administered concurrently by interviewing PHC directors (for the Facility Survey) and doctors working inthe PHC facilities for the Task Profile Survey. 1.3.2.1. PHC Provider Facility Survey 17. This component of the primary research used a facility survey instrument developed specifically for the study. The instrument drew on guidance and methodologies developed by the World Bank and a number o f internationally available facility The instrument was developed by the research team (Atun and Ibragimov) and refined following discussions with collaborators in Bosnia and Herzegovina, the Kyrgyz Republic, and Moldova to ensure appropriateness to the local context, and field tested in the Kyrgyz Republic before application in the four countries included in the study. It was piloted in each country including the Kyrgyz Republic to adapt it to the circumstances o f the health care system. 18. The instrument (Annex 2) comprises sets o f questions to capture information on: (i) General characteristics o f PHC facilities and the population size served; (ii) Scope o f services; (iii)Organization of services; (iv) Availability and composition o f PHC staff, availability o f essential emergency drugs, availability o f equipment and services; (v) Comprehensiveness o f services; and (vi) Quality o f services. 19. The instrument was coded and a computer program was written in Microsoft Access@ for data entry and analysis. We performed statistical analysis to test for observed differences. 3 1.3.2.2. Survey of TaskProJiles of Family Physicians 20. The second component o f the primary researchwas a cross-sectional survey o f family physicians to explore their `task profiles' using a validated instrument developed by the NIVEL Group in the Netherlands8 The instrument, previously tested and validated in 32 European countries, i s available in Russian. It enables collection o f detailed data on the preventive, promotive and curative services provided by family physicians and their skills (Annex 3). The instrument was obtained from the author, Dr.WGW Boerma, and, withhis lundpermission, usedinthe study. 21. The survey o f the Task Profiles o f Family Physicians aimed to identify the scope and availability o f services and skills o f doctors working at PHC level and to identify similarities and differences between FMspecialist andnon-specialist GPs. 22. The instrument was tested in the four study countries and minor modifications made to ensure contextual sensitivity. The instrument was coded and a data collection and entry program developed in Microsoft Access. Data were transferred to SPSSB for statistical analysis. 1.4. SECONDARY RESEARCH 23. Secondary research comprised two elements: (i)A review o f international and in-country publishedliterature to ascertain key legislative changes related to the reforms and to identify changes in financing, resource allocation, provider payment systems, organizational changes and regulation, and service provision; and (ii) Analysis o f cross-sectional and longitudinal data on referral and admission. 1.5. LITERATURE REVIEW 24. The literature review was supplementedby documentary analysis of published reports, key legal instruments and policy documents from the four countries, World Bank Publications (including aide memoirs), Health Systems in Transition reports published by the European Observatory on Health Systems Research, and relevant studies on WB HNP projects inthe ECA Region. 1.6. QUANTITATIVE ANALYSIS 25. Secondary research involved aggregation and analysis o f quantitative data (cross-sectional and, where available, longitudinal data) from studies undertaken in the country, from the routinely collected statistics and from the MHIF database. Longitudinal as well as cross-sectional data were used to inform the case study. The longitudinal data were used to assess changes in certain indicators before and after the PHC reforms. Cross-sectional data were infrequently available. 26. Drawing on internationally validated instruments and indicators, key outcomes influenced by effective delivery o f PHC - for conditions commonly managed in PHC, such as diabetes, acute respiratory illness and hypertension - were analyzed.' This element o f the evaluation aimed to establish to what extent the reforms have led to attainment of key attributes o f a PHC system - namely, first contact, continuity, comprehensiveness and coordination. 27. First contact refers to care that i s accessible at the time o f need, especially for acute conditions. Therefore, the indicators o f effectiveness in this dimension should focus on the common acute clinical conditions that a PHC team should be able to diagnose and manage - without resorting to referral to secondary care. One way o f measuring this would be to look at `avoidable hospitalizations' for common acute clinical conditions - for instance, admissions for acute ENTproblems, urinary tract infections (UTI) and bronchiolitis (Table 3). 4 Table 3: Effectiveness Indicators -First Contact Care Acute conditions Aggregate number o freferrals by FMPs to hospital outpatients for acute ENT problems (Otitis media ICD 10 codes H65 and H66 and tonsillitis ICD 10 code 503) Aggregate number o freferrals by FMPs to hospital for acute UTI(ICD 10 code N39.0) Aggregate number o freferrals by FMPs to hospital for LRTI (bronchitis, bronchiolitis, pneumonia) inchildren aged under 5 (ICD 10 codes J10-18 and ICD 10 codes 520 and J21) 28. Ongoing care focuses on the long-term health o f a person - not on the short-term duration o f the disease - where the role of PHC i s to manage the health of the person to prevent illness and worsening o f chronic conditions. Therefore, the evaluation in this area focused on effective management o f chronic conditions. 29. There are a number o f conditions that can be effectively managed by the PHC team with low referral rates to secondary level - for instance hypertension, ischemic heart disease, non-insulin dependent diabetes mellitus, depression and asthma (Table 4). Table 4: EffectivenessIndicators - Continuity of Care Ongoingcare: Chronic illness Aggregate number o f hospitalizations for hypertension (ICD il0) Aggregate number o f referrals to hospital admission for hypertension Aggregate number o f hospitalizations for NIDDM(ICD E l1) Aggregate number o f referrals to hospital for NIDDM Aggregate number o f hospitalizations for asthma (ICD J45) Aggregate number o f referrals to hospital for asthma Aggregate number o f referrals to hospital for ischemic heart diseaseiangina Aggregate number o f admissions to hospital for ischemic heart diseaseiangina (ICD i20 & ICD i25) 30. Inthe Kyrgyz Republic, we were able to access three-year data onreferraland admission patterns from the MHIF. 2. THE KYRGYZHEALTHSYSTEMPRIORTO HEALTHREFORMS 31. The Kyrgyz Republic has a population o f five million and occupies a territory o f 199,900 km2.l' Almost 70 percent of the territory i s mountainous and difficult to access by transport. The hard-to-reach rural population comprises almost 70 percent o f the total. The poverty rate remains highbut has declined from 52 percent in2000 to 40 percent in2003." 32. The broad populationhealth indicators for the Kyrgyz Republic have improved inthe period 1996 to 2003: life expectancy increasedfrom 66.6 to 68.6 years, infant mortality declined from 25.9 to 20.9 per 1,000 live births, and average maternal mortality rate fell by 18.5 percent, from 65 to 53.1 per 100,000 live births.However, inter-regional differences remain (Annex 4). 2.1. HEALTH SYSTEMORGANIZATION AND FINANCING 33. The Kyrgyz Republic inheriteda health system based on the Soviet Semashko model: a centrally managed and integrated public health system in which all the system assets were state-owned, health professionals were state employees and access to care was free at the point o f delivery. Parallel health systems existed for Ministries o f Internal Affairs, Defence, Railways, Labour and Social Affairs and the Ministry of National Security, as well as large enterprises, creating a vast health care provider infrastructure. A parallel public healthnetwork, the Sanitary Epidemiological System (SES), existed with a focus on surveillance and preventionbut with limitedhealth promotion or education activities. 34. Six levels o f health care providers existed inthe delivery system focused on curative services and dominated by hospitals: (i) feldsher-midwifery post (FAP) staffed by community nurse/midwifes; (ii) rural physician clinic (SVA) staffed by non-specialist general practitioners; (iii) polyclinics, staffed by therapeutists (general doctors) who looked after adults, pediatricians who looked after children, gynecologists who were responsible for women's health, as well narrow specialists (such as ENT surgeons, neurologists, ophthalmologists, cardiologists) who worked at PHC level and received patients directly following referral; (iv) basic rural hospitals (SUBS) staffed by rural physicians and narrow specialists; (v) central district hospitals, and; (vi) Specialists hospitals (women's hospital) and Republican hospitals (incapital city Bishkek) which provided tertiary care services, and specialist institute^.'^"^ 35. PHC level was fragmented with a tripartite polyclinic system comprising adult, women's and children's consultation centers and dispensaries for dermato-venereology, narcology, psychiatry and tuberculosis. Adult centers were staffed with therapeutists and narrow specialists; women's polyclinics with gynecologists and related narrow specialists; and children's polyclinics staffed by pediatricians and pediatric narrow specialists. These polyclinics had a large number o f nurses and ancillary staff, who assisted doctors but didnot practice independently. 36. An ambulance network, staffed by emergency specialists and therapeutists, provided after-hours care inurban areas, providedhome visits, administered treatment and transported illpatients to hospitals. 37. Administratively, the health system was highly hierarchical and divided into regional administrative units (oblasts), each with its own Regional Health Department (RHD). In large and medium-sized cities a City Health Department (CHD) was responsible for managing medical services. Cities and rural areas were divided into districts (rayons), each served by a rayon hospital, polyclinic and a network o f rural SVAs and FAPs. Oblast or city health department chiefs, appointed by the regional governor with MOH approval, administered PHC and secondary services for the region. In turn, each central rayon hospital (located in the central town o f each district) had a chief physician with responsibilityfor local primary and secondary health care services. 6 38. The structure of the health system, allocation of infrastructure and resources, and staffing levels within the health system were determined by centrally planned normatives. Line-item budgetingwas the provider payment method used to finance health service providers, with funding determined by input and activity parameter: at hospital level the number o f beds, number o f patients treated, total number of inpatient days, length o f stay; and at PHC level according to number o f staff or consultations (Figure 2). Figure 2: Flow of Fundsin the Kyrgyz Health SystemPrior to 1997 ~~ Collection & Pooling & Purchasing Sources o f Funds Intermediaries Service Providers u Republican M O H Taxes to institutes and ~ ~ ~ ~uliliz~llonnormsl b . i ~ ~ ~ Norm-bared line national centers item budgets budget Other Republican Hospitals o f other Ministries Oblast Health Oblast general & specialist hospitals & Taxes to Departments polyclinics Local Inhatlrwturc and Norm-baaed line ulilirslion normi item budgelr Source: "Resource allocation and purchasing in Kyrgyz Health System", Kutzin J et al. 7 3. KEYPROBLEMSFACEDBYTHE KYRGYZHEALTHSYSTEMIN THE TRANSITIONPERIOD 39. The declaration o f independence and decoupling from the Soviet Union in 1991 was followed by severe economic and social challenges. Between 1992 and 1995 the GDP o f the Kyrgyz Republic declined by 50 per~ent.'~ This led to a severe shortfall in resources pooled for health system financing with the government able to cover only 45-50 percent o fhealthsystem expenditure^.'^,'^ 40. Prior to independence, the Kyrgyz Republic devoted 3.5 percent3 o f its GDP to health (as compared with the EU average o f 7-10 percent o f GDP but in line with other post-Soviet countries). Rapid economic decline further compromised the low level o f funding to the health sector - creating a substantial funding gap between the level o f financing needed by the health system and the resources available. The Kyrgyz Government sought to reform the health system to mobilize additional resources to address key problems, namely: (i) organizational complexity; (ii) excess infrastructure and human resources; (iii) allocative inefficiency and inequities in financing; (iv) inefficient service provision; (v) limitedincentives andlow pay levels for healthpersonnel. 3.1. ORGANIZATIONALCOMPLEXITY 41. Presence o f multiple health systems with limited integration created significant duplication o f services and inefficiency. Up to 7 percent o f total health expenditures was consumed by services o f other ministries.l7 42. Structural inefficiencies were exacerbated by four administrative levels - rayon, municipality, oblast and republican - with overlapping catchment populations and duplicated provision. Each government level funded its own facilities: republican institutes funded from republican level taxes; oblast facilities funded from oblast taxes; and rayodcity facilities funded from rayodcity taxes. Each level attempted, albeit unsuccessfully, to find resources to keep facilities operational rather than co- operating for orderly rationalization o f the infrastructure or human resources. 43. A highly hierarchical system, with central planning driven by normatives and with an administrative culture, prevailed: unable to respond to contextual changes in a timely and efficient manner. Centrally developed normatives limited locally driven innovation. 3.2. EXCESS INFRASTRUCTURE AND HUMAN RESOURCES 44. Health system had an excess o f hospitals and human resources. Expenses for utilities consumed much o f the funding allocated to hospitals, leaving meager resources for staff, equipment, consumables and maintenance o f the infrastructure. 45. Although there were an excess number o f human resources, in particular physicians, these were inequitably distributed, with highconcentration inthe capital City o f Bishkek and insufficient numbersin rural areas. 4.15% in 1990. 8 3.3. ALLOCATIVE INEFFICIENCY AND INEQUITABLEFINANCING 46. Fragmented revenue collection arrangements for health system financing - with each level responsible for supplyingresources for their own providers - led to inequities. Poorer rural areas could only raise limited resources despite having higher health needs, in contrast to urban and better-off areas that had more resources and a surfeit o f providers. Hence, a system was needed that unified and pooled financial resources at a single organization and then allocated these resources according to need. 47. The prevailing resource allocation system favored hospitals and urban areas at the expense o f primary care and rural areas, resultinginpoorly targeted investments. 48. Resources were allocated to providers as budgets according to norms based on inputsand historic activities. Hence, a large number o fbeds and lengthy admissions at a hospitalmeant more staff positions, a greater budget and supplier-induced demand. 49. Line-item budgeting provided very limited ability to wire funds between budget lines. There were no incentives that rewarded good performance and promotedimproved efficiency, equity or quality. 3.4. INEFFICIENT SERVICE PROVISION 50. The services providedwere not user focused. The users were not able to select and register with a named primary care physician, had limited involvement in decision making and were passive recipients o f services rather than active participants inthe healthproduction process. 5 1. A number o fproblems existed inrelation to level ofintegration and gate keeping, inparticular: (i) Fragmented first contact function at PHC level where users could directly access narrow specialists; (ii) Limited gate keeping with excessive referrals of patients to narrow specialists at PHC level and hospitals; (iii) integrationbetweenprimaryandsecondarycarelevelswithfracturedcontinuumofcare;(iv) Limited Predominance o f national vertical programs, such as immunization, which prevented horizontal integration within PHC; (v) Limited capacity at PHC level to resolve problems, leading to a hospital- centric health system; (vi) Limited emphasis on health education, promotion and prevention; and (vii) Poor diffusion o f evidence-based care guidelines. 3.5. LIMITED INCENTIVESAND LOW PAY LEVELS HEALTH FOR PERSONNEL 52. Doctors and nurses working in the health system have low salaries, raging between US$30-100 per month. Those working in PHC have lower income levels as compared with those in hospitals. Although family physicians have marginally higher salaries than narrow specialists who work in PHC centers, the latter have greater opportunity to augment their income through additional private work. L o w salaries have ledto difficulties inattracting and retaining health professionals inrural areas. 53. Faced with these challenges, the Kyrgyz Government, in collaboration with the WB, WHO, USAID, SDC, DFID, ADB and JICA set out to introduce a comprehensive Health Care ReformProgram to address these issues and develop an equitable and efficient health system providing high-quality services. 9 4. KYRGYZHEALTHREFORMS: KEY LEGISLATIVECHANGES 54. In 1992, the Kyrgyz Government introduced a number of key legislations to establish platforms for systemic and holistic health reforms with objectives o f (i)Reducing inefficiencies; (ii) Improving equity and access (financial and geographic); and (iii)Improving quality.18 55. The Health Protection Act established the general legal framework and articulated roles and responsibilities of state bodies involved in health protection. The Medical Insurance Law provided a basis for financing the health care system through medical health insurance (compulsory and voluntary). The Sanitation Law, referring to the Article 35 o f the Constitution, defined measures to ensure rights o f citizens to sanitation and environmental health safety - and delegatedresponsibility for overseeing this to the Department o f Sanitation and Epidemiology within the MOH.19 56. In 1993, user fees were introduced for hospital services. In 1994, Kyrgyz Government endorsed the `Healthy Nation' followed by a Memorandum o f Understanding between the WHO Regional Office for Europe and the Kyrgyz MOH to implement a comprehensive Healthcare Reform Program - appropriately named after the Turkic Epic Manas, which epitomizes the spirit o f the Kyrgyz people. A Manas Policy Team was established to lead the implementation the reform program. The same year, in line with the Manas Program, the Government agreed to implement a Health Insurance Demonstration Project inthe Issyk-Kulregion fundedby USAID." 57. In 1994, the Kyrgyz Government approved the National Health Policy, which aimed to: (i) Develop a unified health financing system; (ii)Establish an FM-centered primary care system; (iii) Downsize the hospital sector through rationalization o f (a) rural hospitals (SUBS) by closing down, transforming into outpatient facility, or reducing number o f beds; (b) specialty hospitals by mergingwith general hospitals, and Republican Institutions, following a detailed study; and (iv) Create more equitable resource allocation systems. 58. In 1994, the Social Fund, a quasi-government authority, was set by merging the Pension Fund, the Employment Fund and the Social Insurance Fund, with responsibility to collect all social and healthinsurance payments -which amounted to 39 percent o f the payroll tax. 59. In 1996, the Kyrgyz Government approved the Manas Health Care ReformProgram and in 1999 revised its Health for All Policy ("Health Care in XXI Century"). In 1997, the MHI scheme was introduced,21 and the autonomous MHlF established. The MHIF became an agency o f the MOH at the end o f 1998. The Law on Health Financing was introduced to develop a Single Payer System that "integrates financial resources for health care from state budget revenues and mandatory health insurance contributions for the purpose o f a single-pipe funding o f public health services, curative medical services and pharmaceutical^."^^ 60. Health expenditures have remained low by regional and international standards and in2003 was 4 percent o f the GDP, comprising 2.1 percent public sector and 1.9 percent private sector (See Annexes 5 and 6 on Health Expenditure and Health System Financing). The financing reforms aimed to improve allocative and technical efficiency by changing the provider payment systems based on line-item budgeting to capitated payment to newly established primary care organizations - FGPs, case-based payment to hospitals and fee-for-service payment to outpatient specialists (See Annex 7 for hospital payment systems). 61. Changing payment systems required organizational and legal changes, including: (i) Creating providers with increased managerial autonomy, such as stand-alone FGPs or autonomous hospitals able to 10 contract with the MHIF; (ii) Restructuring o f PHC to develop FGP units and larger PHC centers with FGPs as structural units; (iii) Rationalization o f outpatient polyclinics (for children, adult and women consultation) by establishing multi-profile polyclinics as a first step to establishing FGP centers; (iv) Defining an essential package o f services to be provided by FGPs; and (v) Developing a referral and counter-referral system. 62. Official co-payments were introduced with the Single Payer Reforms for: (i) Specialist outpatient care both inFMCs and Ambulatory-Diagnostic Departments; and (ii) inpatient care inhospitals. 63. Legislative changes also aimed to rationalize the organizational structures. In 2000, the oblast health departments were abolished and replaced by Regional Health committee^.^^ The MOH role has gradually evolved into one o f stewardship with responsibility for policy making and budget setting. The decentralized nature of the health system (to oblast, city and rayon levels) and local-government financing o f health providers requires close collaboration with regional administrative structures and the center to implement policies.24 The M O H has retained the roles of: supervising the activities o f all health institutions - including training and research institutions - and approving their policies and programs; administering Republicanhealth facilities; and implementing and monitoring o f health reforms trough the Department o f Reform Coordination and Implementation (which succeeded the Manas Health Policy Unit). The Department coordinates support of intemational and bilateral agencies for PHCreforms, and established successful collaboration between the WB, WHO, USAID, ADB and the SDC. 64. Three key laws were enacted in 2003: "On the Single Payer System in Health Financing o f the Kyrgyz Republic", "On introducing amendments and additions to the Law o f the KR ", and On Health Insurance o f Population o f the KR' stipulating payment o f insurance premiums from the republican budget for mandatory health insurance o f pensioners. In the same year, the "Concept on health financing system reform in the Kyrgyz Republic up to 2006 and health care development up to 2010" was adopted.25 5. KEY DEVELOPMENTS INPRIMARY HEALTH CARE 65. A key feature of the PHCreforms inthe Kyrgyz Republic is the comprehensive and multifaceted approach to development o f PHC adoptedby the MOH. Key elements o fthe PHCreforms included: 66. a) Organizational changes: Establishing new PHC provider structures in form o f FGPs with increased managerial autonomy; Restructuring of PHC to develop FGP units and larger PHC centers with FGPs as structural units; Rationalization o f tripartite outpatient polyclinics into multi-profile polyclinics or FGP centers; introduction o f contracts between MHIF and FGPs and PHC organizations; establishing a unified purchaser; introduction o f competition on the demand side by introducing o f choice for users to select FGPsthrough open enrollment; and establishing more inclusive decision making mechanisms at the local level. 67. b) Changes in financing, resource allocation and provider payment systems: Introduction of mandatory health insurance; State GuaranteedPackage o f Services which ensures free PHC services to all Kyrgyz citizens; increasedhealth expenditure to PHC level; new provider payment systems based on per capita financing mechanisms; introduction o f partial fundholding scheme, where FGPs control budgets for essential drugs (withinthe Outpatient DrugsPackage). 68. c) Changes in service provision: Defining an essential package o f services to be provided by FGPs; introduction o f an essential drugs list; introduction o f evidence-based guidelines; refurbishment and equipping o f the PHC centers; developing referral and counter-referral systems. 69. d) Training and re-skilling o f human resources: Retraining o f therapeutists (generalist doctors), gynecologists, pediatricians and narrow specialists working at PHC level as family physicians; training a cadre o f FGP nurses; establishing a continuing medical education program for family physicians and FGP nurses; implementinghealthmanagement training for managers. 5.1. ORGANIZATIONALCHANGES 70. The restructuring o f PHC began in 1995 inthe Issyk-Kulregion, with the retraining o f PHC team members (see section on training), refurbishment and equipping o f FGP centers, and establishment o f FGPs throughout the rural community. The reforms were supported by USAID and implemented as part o f the ZdravRefonn Project led by Abt Associates. By 1996, enough FGP teams had been trained for 83 FGP centers, which began an enrollment campaign to register patients. The PHCreforms coveredrural as well as urban areas. Inurban areas the rationalizationo f the tripartite polyclinic structure into unified and integratedpolyclinics staffed by FGPsbegan in 1996. 71. In 1996, the Kyrgyz Government secured WB assistance to support the implementation of the Manas Health Care Reform Program. The four-year Health Sector Reform Project (1996 to 2000) was designed to extend the PHC reforms to Bishkek and Chui regions. In 1997 and 1998 the PHC reforms supported by USAID and WB were rolled-out to Chui, Jalal-Abad and Osh regions and Bishkek City. Between 1998 and 1999, the FGP practices in Chui region and Bishkek City began an enrollment campaign. In 1998, partial fundholding was introduced in 14 FGPs in Issyk-Kulregion and per capita payment scheme introduced to FGPs in Bishkek City. In 1999, under the Social Sector Reform Project, the ADB further extended the PHC reforms to two southern oblasts. 72. There are now three types o f PHC providers in the Kyrgyz Republic: (i)FAPs (feldsher- obstetrical ambulatory points), (ii)FGPs, and (iii) Medicine Centers (FMCs). Family 12 73. FAPs are the smallest health care facilities4, situated in remote areas and meant to serve a population o f 500-2000. Usually staffed with at least two specialists (a feldsher and midwife), the scope o f FAP services is limited to the very basic care, antenatal and postnatal care (deliveries are referred to the nearest hospital), immunization and healtheducation. 74. FMCs are the largest outpatient health facilities, staffed by 10-20 specialists. Their scope o f services ranges from general care to specialized care and instrumental diagnostics, thus combining PC services and secondary outpatient care. FMCs are renamed oblast- and rayon-level polyclinics but are now staffed by FGPs and narrow specialists, who also work inoutpatient departments. 75. FGPs are being developed as the main providers o f PHC, to provide comprehensive PHC based on FM principles to the population registered (enrolled or assigned) with the practice. An FGP usually consists o f three to five doctors comprising physicians, pediatricians and obstetrician-gynecologist, three to five nurses, and a practice manager, although these numbers vary by region and FGP. The physicians who work in FGPs are those who have been (or are being) retrained as FMPs. There are two organizational forms o f FGPs: (a) freestanding and autonomous and (b) a unit within a freestanding polyclinic (in urban areas). FGPs have to meet licensing and accreditation criteria before they can be contracted by the HIF. 76. A key objective o fthe PHC reforms i s to expand to the whole o fthe Kyrgyz Republic. Currently, independent FGPs dominate in rural areas, and the polyclinics in urban areas have been replaced by FMCs. 5.1.1. Choice 77. Citizens, who were previously assigned to a district physician according to their place o f residence, now have a choice o f FGPs in urban areas; but in rural parts, due to a limited number o f providers, they are assigned to an FGP within the rayon catchment boundaries. Citizens can change practices at each annual registration period. Practices that attract more patients receive more capitation funds andhence have an incentive to provide high-quality and user-friendly services to attract patients. 5.1.2. Unified System of Purchasing Care 78. A unified system has been established for purchasing services from PHC level - addressing the fragmentation that existed. The MHIF and its Territorial Departments (TD-MHIF) contract PHC providers and pay them for the services they provide to insuredpersons and those in exempt categories. In PC, physicians receive payment based on the number o f people registered with them. Hospitals are paid according to the case mix and the number o f cases they treat. The Republican M H I F pools payroll tax revenues (collected by the Social Fund) and Republican budget transfers for children, pensioners, and those who receive social benefits (which come from republican tax revenues). The TD-MHIF i s a purchaser o f health services usingall funds includingtaxes collected at the local level. 5.1.3. Decision Making at PHC Level 79. Within each region there are a large number o f stakeholders involved in decision making, including: (i) The oblast govemor; (ii)Oblast Supervisory Board; (iii) Territorial Department o f the FAPsare not independent legal entities (so they are not facilities) butrather units accountable to FGPs. FAPs are located invillages with populations less than 1500. Ingeneral, FAPs serve 24.4% of the population. 13 Mandatory Health Insurance Fund (TD-MHIF); (iv) Oblast Merged Hospital (OMH) responsible for inpatient care; (v) Oblast Family Medicine Center; 15;(vi) Oblast Sanitary Epidemiological Service (SES); (vii) Oblast HealthPromotionCentre; (viii) FMC; and (ix) Oblast Medical Information Center.26 80. At the rayonlevel, a similar stakeholder groupingexists with: (i) Akim(head o fthe rayon); (ii) an Rayon Supervisory Board; (iii) Territorial Hospital (TH) with OPD6; (iv) Rayon F M C including FGPs; (v) Rayon Sanitary Epidemiological Services; (vi) Rayon Health Council, which i s a grouping o f the Village Health Committees'; and (viii) Council's Interdepartmental Emergency and Anti-epidemic om mission.^' 81. At the village level, the key stakeholders involved indecision making comprise: (i) head of a the group o f villages (Ayil Okmotu); (ii) FGPs which have direct contracts with the TD-MHIF'; (iii) FAPs, staffed by feldshers and/or nurses/midwives; (iv) Village Health Councils inNaryn Oblast.** 82. There are good examples o f initiatives that have succeeded in engaging the community at the local level in decision making related to PHC. For instance, the Kyrgyz-Swiss Health Reform Support Project has undertaken studies to ascertain user perspectives on health care services29and co-payment policy3o,as well as access and quality o f PHC31. Following these studies, the Kyrgyz-Swiss Health Reform Support Project has successfully developed a model that allows community participation in decision making and priority setting. This model o f health promotion through community action (Jumgal Model) enables rural communities themselves to analyze their health priorities and establish health committees to work voluntarily to improve health intheir villages. The model has established a process whereby the health problem in the village i s addressed by people themselves, facilitated by trained FGP/FAP staff, then through community action involving the health committee. Several health- promotive activities have been successfully i m ~ l e m e n t e d . ~ ~ 5.2. FINANCING, RESOURCEALLOCATION AND PROVIDERPAYMENT SYSTEMSINPHC 83. There are significant inequities in resource allocation to regions. Government per capita health spending by region is highly inequitable and can vary by almost three-fold, with lowest expenditure in Batken and highest in Bishkek. Bishkek City attracts most o f the Republican budget to pay for the Republicanhospitals (Figure 3). OPD i s not involved inthe decision making process because the OPD i s a department o f the hospital. ti 'These See under 5. Councils are only inNarynand Talas oblasts where Kyrgyz Swiss Health Reform Support Project works in area o f Community Action for Health. * Only freestanding FGPs which are legal entities can be directly contracted by the MHIF (currently there are 31 freestanding FGPs). IfFGP i s a part o f FMC then contract i s made with the FMC. 14 Figure3: GovernmentPer Capita HealthSpending(inKyrgyz Soms) by Region, 2001 200 100 0 Bishkek Chui Issyk-Kul Jalal- k r y n Osh Talas Batken KR Abad Republican Budget Local Budget Mandatory HIF Source: Treasury, MHIF,National Statistics Office 84. As well as regional inequities inresource allocation, there is allocative inefficiency by level o f care. In 1994, 7 percent o f the total health care budget was allocated to PHC, increasing to 10.3 percent in 1995 as compared with 71.7 percent allocated to hospitals. By 2003, share o f PHC had increased to almost 25 percent while that for hospitals declined to 56.8 percent o f the total health expenditure (Figure 4 and Figure 5). Figure4: HealthExpenditurebyFunctionandLevel I 100% I I 80% 60% 40% 20% 0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 1 Secondary carelkaspitals c Ambulalory Care (PHC) w Public health (SS, elc.) w Education of health professionals Heallh research instltules Capital Investments Administratlon and other services Source: Ministry o f Health, Health Insurance Fund Figure 5: Percentageof TotalHealthExpenditureAllocated to PHC Percentage of Total Health Expenditure Allocated to PHC I 1 0 %of health expendnure I 2001 2002 2003 Year ~ ~~ Source: MinistryofHealth,HealthInsuranceFund 85. Inadvanced reform regions, such as the Chui Oblast, that have successfully implemented PHC reforms, there has been a marked shift in the proportion o f health expenditure allocated to PHC, which has reached 30 percent o f total health expenditure (Figure 6). Figure6: HealthExpenditureonHospitals andPHC in Chui Oblast (2001-2003) 80.0 70.0 60 0 50.0 40.0 30.0 20.0 10.0 Hospitals Rimy Care chui oblast Source: HealthInsuranceFund 5.2.1. Provider Payment Systemsfor PHC and the Program of State Guarantees 86. Since 2004 all PHC providers are paid on capitation. The FMCs and FGPs (including FAPs) are paid a capitation fee per user registered with them from TD-MHIF. The per capita fee covers FGP team salaries, basic medical equipment and drugs. A planned move to partial fundholding i s currently being discussed (where family physicians will be given budgets to purchase specialist outpatient services). 16 87. The Program o f State Guarantees, also known as the State Guaranteed Basic Package was introduced in 2001. The Package defines the health services and entitlements o f various categories o f the population. The Program o f State Guarantees provides free basic PHC services for all citizens, regardless of their insurance status and enrollment, as part of the State Guaranteed Benefits Package. Citizens not covered under the MHI scheme are subject to formal co-payments for referral services in outpatients or hospital inpatient services provided by narrow specialist^.^ 88. Citizens insured under the MHIF receive access to an outpatient drug package that provides certain drugs at reducedrates and lower co-payments for referral services inoutpatients and as inpatients inhospitals. 89. The pooled oblast budget funds pay for the full costs o f care for persons who are in exempt categories and who do not need to contribute co-payments toward services. The complementary package i s funded by the payroll taxes collected by the Social Fund and transferred to the MHIF, and transfers from the Republicanbudget to the MHIF (Figure 7). Figure7: StateBenefitsPackage I I Health services not included into the State Benefits Programme P Population eligible for 100%or partial privileges Privileges for insured citizens Unlnsured citizens State Benefits Programme: Free health services at point of delivery .........,.......,...........,..,.........,,.....,....,...,.....................................................................................................................,. ., 046 Population coverage 100%, 90. Inline with the Single Payer Reforms, official co-payments were introduced gradually inwaves: initially in Issyk-Kul and Chui in 2001; Talas and Naryn in 2002; Jalal-Abad and Batken in 2003; Osh and Bishkek Cities in2003; and inOsh Oblast in2004. The MOHnow sets the level o f co-payment based on the co-payment policy enacted in2003.33 Co-payment levels for specialist outpatient care vary by type of service provided. For inpatient care patients pay a flat fee per admission. The level o f co-payment depends on the insurance status and the service provided. For instance, admissions for surgical interventions attract higher co-payment than for diagnosis and treatment. Co-payments made by insured patients, for services (such as outpatient specialist and inpatient care) when referred, are lower than co- payments made by uninsured patients. Patients who use outpatient specialist and inpatient care without referral make higher co-payments than patients with referral. 9Insuredpatients pay 50% ofthe service cost according to the price list. Consulting services of outpatient specialists included inthe State Guaranteed Package (Benefit package) are free ifpatients are referred by FGP. 17 91. Some population groups are fully or partially exempt from paying co-payments. Providers receive a higher fee from the M H I F for treating exempted patients. This way, they do not have incentives to favor patients who can afford co-payment. These population groups include low-income pensioners, cancer patients, TB patients and World War I1veterans. Hospitals set aside a reserve fund to provide exemptions for those who cannot pay. 92. In addition to the official out-of-pocket payments, there are semi-official user charges for consumables (e.g., drugs and medical supplies), unofficial user fees or under-the-table payments, and fees charged by private providers o f health services for goods and services (the largest category o f which are pharmaceuticals). Collectively these constitute over 50 percent o f the total health expenditure. 5.3. CHANGESINSERVICE PROVISION 93. Inadditionto the State Guarantees, which specify core services to be deliveredto the population, there has been a positive movement to enhance the quality o f services through development and implementation o f evidence-based care guidelines. The guidelines also help coordination o f primary and secondary care levels by definingthresholds for referrals. 94. The rationalizationof the tripartite polyclinic structures into unified FGPs and FMCshas created an enabling environment for delivering holistic care for patients, health promotion and prevention activities. The changes inservice provision will be analyzed indetail inthe next chapter. 5.4. DEVELOPMENT OF HUMAN RESOURCESPRIMARYHEALTH IN CARE 95. By international standards, the Kyrgyz Republic has a large number o f doctors. The number o f physicians per 1,000 people at start o f transition was 3.2 as compared with the OECD average o f 2.1 per 1,000. The number of doctors and nurses declined between 1996 and 2003 but much o f the decline has been inthe number o f nurses (Figure 8). Figure 8: Number of DoctorsandNursesper 10,000 Population 1996 1997 1998 1999 2000 2001 2002 2003 -Doctors all specialties " Total # of nurses I Doctors in practice +Nurses in practice I 96. However, despite an excess o f doctors and health personnel, inequities in the distribution o f the health workforce exist with a shortage in rural regions and a surfeit o f doctors in the capital Bishkek (Figure 9). 18 Figure 9: Number of Practicing Doctors b y Region 0 4 I 1996 1997 1998 1999 2000 2001 2002 +Kyrgyz Republic +Bishkek Chui d-lssyk-Kul +Naryn --eTalas i -0sh -8- Jalal-Abad Batken 97. The shortage o f health personnel inrural areas has worsened over the last five years, as medical graduates are unwilling to work inrural areas and there i s no obligation to do so - as was the case inthe Soviet period, with a mandatory three-year posting to rural areas. 98. A successful training programhas beenintroducedto train doctors andnurses inFM. Bythe end o f 2004, approximately 75 percent o f the primary care physicians and nurses in the country had been retrained as family physicians and FGPnurses. 5.4.1. Training of Family Physicians 99. Family medicine was established as a specialty in the Kyrgyz Republic in 1997 as part o f the PHC reforms, a key element o f the Manas program. Family medicine training has been successfully introduced in the country since 1998. There are several training programs related to FM and FGP Nursing. 100. National efforts supported by international technical assistance aimed to institutionalize FM training at five levels: (1) undergraduate training for medical students; (2) post-graduate training - a two- year FM residency for doctors graduating from medical school; (3) Retraining program for physicians practicing as general practitioners; (4) continuing medical education (CME) for FM teachers, and for practicing family doctors and nurses; and (5) a bachelors degree program for PHCnurses. 101. Several short training programs were developed initially to start the process o f training in FM. These short programs were gradually extended as retraining courses and specialist FM residency programs for doctors and a Bachelors program for nurses. 102. A one-year training of FM trainers (TOT) program was introduced in 1997. The program has both theoretical and practical elements and i s delivered by US-trained family physicians and supported by USAID and WB. The trainers have been trained at the Center for Continuous Medical Education in Bishkek. Most o f the trainers who have completed training now work either in the national network of FM Training Centers associated with the Center o f Continuous Medical Education or for the Kyrgyz Medical Academy. By 2003, a total o f 63 doctors had been trained as FM trainers. The program was 19 extended to doctors from neighboring countries; 12 doctors from Tajihstan were trained and nine fiom Kazakhstan. 103. The elements o f the TOT programs have been developed into stand-alone training modules that can be used as short courses for C M E for the FMTrainers and practicing family doctors from the Kyrgyz Republic and the neighboring countries. For instance, 26 doctors trained inthe one-year WB- and DFID- financed TOT program in Uzbekistan have spent one-month clinical clerkships at the Bishkek FM Training Center. Similarly, the FMNursingFaculty o f the Kyrgyz State Medical Institute for CME has successfully piloted a two-week faculty development course for teachers from nursing schools. 104. An excellent four-month program to retrain doctors working in primary care as FMPs was introduced in 1998 with support o f USAID and WB (Annex 8). The program i s practical in its focus and the training content reflects local needs, developed with considerable input from local trainers with mentoring by international experts. The training i s delivered mostly by local FM trainers but with occasional direct involvement o f US.-trained family physicians. In addition, a two-month retraining program has been developed for nurses. The average age o f the retrained family physicians (and nurses) i s around 50 years. 105. In1998, separateFMresidencyprograms started atboththe Kygyz StateMedicalAcademy and the Center for Continuing Medical Education in Bishkek. Both o f these programs relied heavily on specialty rotations in hospitals and had a high dropout rate. In 2001, with the help of ZdravPlus and AMA (American International Health Alliance), these two institutions created a joint national FM residency program inBishkek. The program i s designed for 50 residents per year. Inboth 2003 and 2004, 42 residents graduated from the program. The number o f new applicants to the program has since declined, probably due to the low status o f FMPs and uncertainty regarding adequate income levels on graduation from the program. The residency training program was expanded to Osh in September 2004 and has 23 residents inthe first class, equal to that inBishkek. 106. To date, more than 2,200 doctors have been trained as FM specialists inthe four-month retraining program for doctors who work in PHC.34 The training, which began in Bishkek, Issyk-Kul and Chui regions in 1998 has been successfully expanded to Osh, Batken, Jalal-Abad, Naryn and Talas regions and i s projected to reach more than 2,700 family physicians and 4,000 nurses by the end o f 2005 (Personal correspondence, Dr Paul Fonken - STLI trainer, FM Training Center, Bishkek, 2004). (Figure 10 and Figure 11.) Figure 10: Number of Doctors Retrained as FMSpecialists 2002 2003 2004 2005 Year Figure 11: Number of Doctors Trained as FGPs(Cumulative) by Region ISFGPDoctors Already Retrained AddRionalDoctorsto be Retrained by Dec 2005 107. The focus o f training in FM i s now shifting to improving and expanding a national continuing medical education program (CME) for FMPs and for FM nurses. The 1,000 doctors and 1,400 nurses currently involved with the C M E system receive ongoing training on an annual basis from the FM trainers associated with the Center o f Continuous Medical Education. This new CME system, which began inIssyk-KulOblast in2001, was expanded in2004-2005 to include 3 pilot rayons in Osh and Chui Oblasts and all the FGP doctors in the other oblasts. In2005, a similar C M E program will begin for the FGP doctors inBishkekand Osh cities. 21 5.4.2. Trainingof Nurses 108. Retraining nurses in FM started in 1998. Nurses are a critical part o f the new FGP model, which encourages teamwork and a broader role for FMnurses. Prior to introduction o f FMreforms the nurses had a very basic role - acting as assistants to doctors, with very limited competence level. They had very little motivation or incentives for independent practice. They did not have access to basic equipment that would allow assessment and preparation o f patients independently prior to their consultation with doctors or performing triage function. However, the training programs aim to improve the competence base of nurses to enable them to extend the scope o f services they provide as part o f the FMteam. 109. A one-year training o f nurse trainers began in 1997. The training i s delivered at the Kyrgyz Postgraduate Medical Institute and i s supported by ZdravPlus Project, funded by USAID. By 2003, 64 nurses had been trained as FM nurse trainers. As with the TOT program for FM doctors, this program was extended to nurses from the neighboring countries to train eight nurses from Tajikistan, six from the Kyrgyz Republic and three from Uzbekistan. 110. In1998, the Postgraduate Medical Institutebegan a program to retrainnurses working inPHC level as family nurses to work in FGPs. The FM nurse trainers who have been trained work in Family Medicine Training Centers inregions and are involved inthe program o fretraining FGP nurses invillages and cities. Between 1998 and 2004 more than 3,200 nurses were trained as FM nurses (Figure 12). The cumulative target, by the end of 2005, i s to train 3,700 nurses. Figure12: Number ofNursesTrained as FMNurses(Cumulative) 4,500 4,000 2 3 a2 3,500 3,000 P .-gg xg u) .% 5 2,500 -t22s 2,000 1,500 a ,$ -ma 1,000 5 0 500 0 1998-2001 2002 2003 2004 2005 Year 111. The nurse training started inIssyk-Kuland Chui regions and gradually extended to others. The trainednurses are well distributed in all the regions (Figure 13). 22 Figure13: Number of NursesTrained(1998 to 2004 byRegion) Bishkek Chui Issyk- Osh Batken Jalal- Narin Talas kul Abad Annual awage 199&2001 2002 2003 2004 (Sept) 112. The increase in the number o f FM specialists and the number o f trained FMnurses i s against a backdrop o f decliningnumbers o f physicians andnurses inthe Kyrgyz Republic as a whole. 5.4.3. Assessment of Skills of Family Physicians 113. Skills o f the doctors retrained as FMPs were evaluated using Objective Structured Clinical Examinations (OSCEs) - a method widely used in Western countries for formative and summative assessment o f medical students, introduced to Central Asia in 2000 to assess undergraduate medical students, doctors retrained as family physicians, and FM trainer^.^^'^^ The overall result o f the OSCE was 60.2 percent with a range o f 68 percent (inJalal-Abad Oblast) and 51 percent in Chui Oblast. Scores for illnesses usually managed in PHC ranged fi-om 56.4 percent for pneumonia to 63.3 percent for hypertensive disease. The study, which also included a survey o f FGPs, identified a number o f factors which adversely influenced the quality o f family physicians' work, including: (i)unavailability o f necessary equipment in some FGP centers (such as peak flow meters, ophthalmoscopes, otoscopes, ECG- machines); (ii) training, reluctance o f FGPs to practice mixedadmissions (i.e., caring for women, despite adult men and children); (iii) low motivation due to low wages and poor conditions o f work; (iv) inadequate time devoted to practical-skills acquisition during training.37 The survey also identified a number o f factors which adversely influenced the quality o f FGP nurses' work, including: (i) uneven distribution o f nurse training in regions; (ii) inadequate equipment for nurses; (iii) inadequate utilization o f the skills o f the trained nurses; (iv) low motivation for nurses to work independently. 114. Findingshave serious implications as supporting training without accompanying investments for equipment means that maximum gains from the training investment cannot be reaped. 5.4.4. UndergraduateMedical Training 115. There are seven medical faculties involved in undergraduate training: (i) Kyrgyz State Medical Academy, (ii)Kyrgyz Russian Slavonic University, (iii)Osh State University, (iv) Kyrgyz-Uzbek University in Osh, (v) State University o f Karakol, (vi) A private university in Jalal-Abad, and (vii) State faculty inJalal-Abad. 116. The Kyrgyz-Turkish University, which has a medical faculty, has not yet started training of physicians. 23 117. Presence o f a large number o f medical faculties means insufficient critical mass o f staff and training facilities to guarantee high quality o f training but also results in the overproduction o f medical graduates in a country that already has an excess number o f doctors. To meet the needs, two medical faculties and an annual intake o f 400-500 students are sufficient. The numbers o f state-financed medical students are controlled centrally but there are no limits on the admission o f commercial students, including foreign students. As the state budget i s not adequate to cover the running costs o f medical faculties and training costs, there i s an incentive for the medical faculty to admit an excess o f medical students - especially those that are fee-paying, which constitute around 77 percent o f the student body and are a source o f important income for the faculties. Consequently, the current intake i s over four times the required figure, with around 1,100 students admitted in 2002.38 This leads to overproduction o f undergraduate medical students who are unable to find jobs in the health sector when qualified. One study estimates that on graduation, only 25 percent o fmedical graduates finde m p l ~ y m e n t . ~ ~ 118. There are two chairs o f FM: (i) the Kyrgyz State Medical Academy, and (ii) Kyrgyz State at the Medical Institute for Retraining and CME. The Kyrgyz State Medical Academy provides training in FM to undergraduate medical students as well as a residency program. The other remaining medical faculties have no chairs o f FMand their undergraduatemedical students receive no training inFM. 119. FMteaching inthe undergraduate curriculum is limited. The Ministries o f Health and Education jointly approve the medical school curricula. The Soviet model o f three-pronged undergraduate medical training prevails inall the medical faculties, including the Kyrgyz State Medical Academy, with students choosing at entry to university therapeutists, pediatrics, and hygiene/epidemiology. Hence, generalist training at undergraduate level does not exist: for instance, general physicians are not trained inpediatrics and vice versa. Although the system o f central planning maintains uniform standards across the country, it hinders innovation and adaptation to changing needs. The faculties can vary approximately 15 percent o f the whole medical curriculum from the standard specified by the MOE and the MOH. This limits introduction o f new methods and courses. 120. The `spiral' curriculum used in the Kyrgyz Republic i s based on a pre-Flexenerian model where the students study basic diseases followed by more complex ones in the same discipline. The faculty structure i s hierarchical and designed to map onto the curriculum, for instance, with separate kafedra teaching basic examination skills and general and specialized subject areas within a discipline. Hence, the curriculum i s designed to produce specialists rather than generalists, utilizing didactic teaching methods, with an emphasis on theory, disease and cure rather than health, normal development, prevention and promotion. It i s not surprising, therefore, that in 2002 around 70 percent o f the graduates were admitted to narrow specialty residencies. 121. Although some donors have given important support to FM development, especially through the retraining program, there has been limited donor support for undergraduate and residency training programs in FM. For instance, a Council o f Rectors of Central Asia (COR) was established in 2001 with fundingfrom USAID through ZdravPlus and ANA. The Council, which includes 30 members fromboth state and private medical schools, meets on a regular basis to harmonize methods and improve curricula inline with international standards. The Council meeting in 2003 inBishkek focused on clinical skills and assessment. 122. However, these initiatives are not addressing the fundamental problems with the undergraduate curriculum, which needs to be urgently reformed with substantial refinement o f the existing practices to embrace modem teaching and training methods, as well as content that i s more appropriate to needs o f the Kyrgyz Republic. 24 5.5. DEVELOPMENTPROFESSIONAL ASSOCIATIONS OF 123. The Association o f Family Doctor Groups and the Association o f Hospitals were established in 1997. The Association o f FGPs has a limited role in licensing and accreditation activities but plays an important advocacy role to inform key stakeholders at different levels on the benefits o f reforms. The Association of Family Doctor Groups i s active inlobbying parliamentarians. 124. The FGPA closely cooperates with the MOH in development o f healthlaws, participates inissues related to activities o f PHC providers, and also plays an important role in disseminating information on health reforms to family physicians and FGP nurses by training health facilities staff and through their Web site, bulletins and other publications, and conferences. 125. In 2003 the FGPA became a member of the World Family Doctors Association (WONCA). 25 6. CHANGES INPRIMARY HEALTHCARE SERVICES: RESULTSOF THE PHCFACILITYAND TASK PROFILESURVEYS 6.1. ACCESSTO PRIMARY HEALTH CARE 6.1.1. Coverage 126. The Kyrgyz Republic i s one o f the few post-Soviet countries that offers free basic PHC services for all citizens, regardless o f their insurance status and enrollment, as part o f the State Guaranteed Benefits Package. Citizens that are insured under the MHIF receive anoutpatient drug package that provides certain drugs at reduced rates. Additionally, insuredpeople have lower co-payment for referral care (for outpatient laboratory diagnostic tests, which are not included into the State Guaranteed Benefits Package, and for hospital services). 127. The MHIF coverage has expanded since 2001 and now covers around 80 percent o f the population (Figure 14). Figure 14: Population Coverage by HealthInsurance 5,500 100% 90% 4,500 80% I 3,500 1 ?Js I 2'500 40% 500h 1,500 8 30% ' 500 20% 10% -500 - 2001 2002 2003 0% Year Population(000s) Nlmber of people insuredw dh MHF (000s)-P% covered by hMF of papulation 128. In2003, around 75 percent ofthe populationwas enrolled with an FGP, although the enrollment rate varied by region (Figure 15). Figure15: Number of People(and YOof TotalPopulation) Enrolledwith FGPsbyRegionin2003 1,200 1,000 In 800 U '5 != 600 0 400 200 0 Bishkek Chui Issyk- Naryn Talas Osh Batken Jalal- KuI Abad insured Iuninsured 129. Although in 2003 around 18 percent of the population had no health insurance, almost 100 percent of the population insured by the MHIFwas registered with an FGP (Figure 16). Figure16: Proportionofthe Insured andUninsuredPopulationwith Access to FGP 100% 20% 90% 18% 80% 16% 70% 14% ,_ I 60% 12% j 50% 10% 40% 8% 5e5 30% 6% 1 20% 4% 9 j s 10% 2% 0Yo 0% 2001 2002 2003 Year 130. Between 2001 and 2003, the number of persons registered per FGP increased from 6,200 to 7,900 (Figure 17). 27 Figure 17: Number of PersonsRegistered per FGP 8,000 .:e7,000 6,000 0 En 5,m 3aa4,000 E 3,000 0 c 2,000 n z 5 1 , m 0 2001 2002 2003 , Year Awage size of patient list in group practices 131. In the same period, the number of Family Physicians and nurses per FGP increased from 3.1 doctors to 4 doctors and from 1.2 nurses to 1.4 nurses (Figure 18). Figure 18: Number of Family Physiciansand Family Nurses per FGP I 4 1 - 2001 2002 2003 Year Aerage numberof FDs in group practice 0 Numberof family nurses per FD 6.1.2. Accessibility 132. There i s good accessibility to PHC centers except in rural and mountainous areas where access can be very difficult. Primary health care facilities are located close to patients' homes, with a median distance o f 1-2 km (Figure 19). For most patients (73%) the travel time to the nearest health facility i s less than half an hour. The majority o f patients walk to the health facility, and only one in three incur travel expenses when attending health facilities (26% inBishkek to 43% inBatken). The highest costs are incurred by those who travel to health facilities by ambulance. Most people report being able to see a healthprofessional within 30 minutes o f arriving at a health facility. 28 Figure 19: Distance(in km)to PHCFacilities FGP (enrolled) Private pharmacy (not enrolled) Mnimum Mxtrrum State pharmacy 6.1.3. Affordability of Health Care 133, A household survey in2001found that o f the households that neededhealth care inthe year prior to the survey, 18 percent had found it very difficult to pay for such care and a further 42 percent reported difficulties. More than half of the households surveyed reported reducing regular consumption to meet health care costs, a third received help from relatives and a further 27 percent borrowed money - going into (or extending) debt. Just under half (46%) o f households reportedthat, because o f inability to afford health care, household members who hadbeen illinthe year prior to the survey didnot seek health care.4o These figures, however, refer to all health services and drugs and preceded the introduction o f official co- payments. 134. The introduction of official user fees has had a positive impact on the extent o f unofficial under- the-table payments, which have de~lined.~'A survey, undertaken by WHO, o f patient expenditures for hospital care before and after the introduction o f Single Payer Reforms found that official co-payments substitutedinformal payments and made themtran~parent~~(Figure 20). Figure20: Introductionof Co-paymentsinIssyk-Kuland ChuiRegionsin2001 andProportion of Users PayingHealthCarePersonnel 90% i 80% 70% 60% 50% 40% 30% 20% 10% 0% Before official co-payment Fiw months after official co- payments 1I Chui and Issyk-Kul .All other oblasts Source: Mandatory HealthInsurance Fund" 135. An important impact of the official co-payment policy has been the positive effect on the poor. After the introduction of the policy, patients entitledto exemption from co-payments experienced a four- fold reduction in their total direct expenditures when hospitalized - indicating pro-poor impact of policies. 136. A study conducted by the Kyrgyz-Swiss Health Reform Support Project in2001 to elicit patient views about the co-payment policy showed that the acceptance o f the policy was mixed but generally positive.43 About 75 percent o f the patients interviewed preferred the co-payment policy to the previous system o f informal payments; low-income respondents hold the same opinion. Many insured patients notedthat they paid less with co-payment than previously for the same treatment. Patients welcomed that they now knew o f costs inadvance and could prepare for it. Those interviewed acknowledged that health care was not free and that the sharing o f the burdenbetween the state and the individual was fair.44 137. Giventhe now-visible extent o fco-payments, several local governments have argued for reducing their funding to the health sector, citing the revenues generatedby co-payments. However, official co- payments have merely formalized and made more transparent the previously unseen and unmonitored forms o f payments and hence do not represent new funds that can be used to fill funding gaps in the sector. 6.2. UTILIZATION PHC SERVICES OF 138. There are significant regional differences in consultation rates for PHC, with residents of Bishkek, Chui and Issyk-Kul(where FMreforms are more mature) twice as likely to consult a doctor as compared with those from other regions. Insurance status was significantly correlated with health service lo WHO study on dischargedpatients, JosephKutzin, 2001, WHOiDFIDHealthPolicy Analysis Project(HPAP) 30 use, with those covered by the MHIF 1.27 times more likely to consult a health professional than those not covered - after controlling for age andregion.45"' 139. The majority (73%) o f those surveyed consulted with doctors working inthe State sector. Most consultations were in health facilities: 30 percent o f all consultations took place at the FGP where the patient was enrolled and 10 percent in the patient's home (as compared with 14% in 1994). The poor tended to use PC facilities, nurses and feldshers more frequently than the non-poor - who were better able to afford the higher costs o fpolyclinic and tertiary care. 140. Two-thirds o f patients receive a prescription for at least one item, and nearly one-fifth receive a prescription for four or more items. Of these, the majority (77%) obtain all the items prescribed and a further 14 percent obtained some of the items. Only 9 percent did not obtain any items prescribed- a significant improvement on the situation in 1994, when only 66 percent obtained all the medicines prescribed, 23 percent obtained only a part, and 11percent obtained none at all. However, when asked why they had not obtained the medicines, over half (61%) o f respondents inthe 2001 Household Survey cited that the drugs were too expensive, compared with a third (35%) in 1994. Thus, the main constraint appeared to be the patients' ability to pay for drugs rather than drug availability. However, this study was establishedbefore the Additional Outpatient DrugPackage was introduced to enhance access to drugs and should be interpreted with caution. 141, More than three-quarters (77%) o f patients incurred some costs as a result o f using a health care service in the 30 days prior to the survey. Average expenditure on health care was 148 soms, o f which spending on prescriptions accounted for t w o - t h i r d ~ . ~ ~ 142. Just over one in five (22%) patients paid a fee for the consultation. This compared with a quarter (25%) in 1994. The percentage o f population paying for services and the average amount spent varied according to the type o f facility and provider. Only 10 percent o f people who visited an FGP where they were enrolled reported malung any payment, compared with 42 percent who visited an FGP where they were not enrolled. The amount paid was also higher at an FGP where the patient was not enrolled (mean 227, median 140 soms) compared with FGP where the patient was enrolled (mean 52, median 20 soms). There was no difference inthe likelihood o f making a payment for the consultation between those patients who reportedbeinginsured by the MHIFand those who didnot. 143. Although the richpaid more inabsolute terms than the poor, payments for health care represented greater burden for the poor than the rich; health care expenses for one member o f the household constitute around 10 percent o f the total household monthly budget for the poorest households, compared with 5 percent for the richest. 144. Around 10 percent of people surveyed sought treatment in the 30 days prior to the survey and a further 13percent who needed treatment didnot seek care (Figure21). This studywas done inFebruary 2001, prior to the implementationof the co-payment policy. Figure 21: Percentage of PopulationSeeking Health Care in the 30 Days Prior to the Survey by Gender Male Female Sought treatment Neededtreatment but did not seek Source: Falkingham, J. Health, health seeking behavior and out of pocket expenditures inKyrgyzstanin 2001. 145. Many o f those who did not seek care self-medicated using herbal treatments or drugs but around 13 percent citedthat services were too expensive (Figure 22). Figure 22: Reasons for Not Seeking Health Care ,... . .... . . .. ... .. 1 50 I 40 I '.ME==j Women 1 Percent of 30 I total 20 I 0 Setf- Self- Believed Too Too Notime Other medicated mdicated problem farlpoor expensive I i! using using would go sewice herbs drugs away I Source: Falkingham, J. Health, health seekingbehavior and out of pocket expenditures inKyrgyzstan in2001. 6.3. UTILIZATION OF HOSPITAL SERVICES 146. The Kyrgyz Republic inherited a vast health care infrastructure with 11.9 beds per 1,000 population in 1990, one o f the highest inthe ECA Region, as compared with 4.5 per 1,000 inthe EU.The number of hospital beds has since gradually declined to reach 5.5 per 1,000 population in 2002 (Figure 23). 32 Figure23: Number ofHospitalBeds andBedsper 1,000 Population 1996 1997 1998 1999 2000 2001 2002 # beds +# beds per 1,000 population 147. However, much of the decline i s due to closure o f rayon hospitals with limited rationalization o f the Republicanfacilities inBishkek City (Figure24). Figure 24: HospitalsbyRegionThat HaveBeenClosed(2002) 300 250 3200 u) Batken P Jalal-Abad 8 Osh S 5 150 Talas Naryn n 8 Issyk-Kul za E 100 Chui 50 Bishkek 0 Demolished Rented Transferredto Transferredto Conswed otherhealth non-health facilities facilities 148. The hospital admission rates in 1990 were 2412per 1,000 population per year, with an average length of stay of 14.9 days per inpatient admission. The average length o f stay per admission remains highandin2001was 13 days per admission (Figure25). l2 It shouldprobablybe 124. 33 Figure25: Average HospitalInpatient Stay per Admission(inDays) 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Source: WB database 2004 149. The Household Survey undertaken in 2001 showed that the most significant factors influencing hospitalization were economic status, age and chronic illness. After adjusting for other factors, the persons from the richest fifth o f the households were significantly more likely to use hospital services and were 1.3 times more likely to be hospitalized as compared with those living in the poorest fifth o f households. Chronic illness increased the likelihood o f hospitalization by six times. A third o f all hospitalizations were to Central Rayon Hospitals with Maternity and City hospitals accounting for one- fifth each of the total. Although the majority of inpatients were referred from a PHC unit - such as an FGP (22%), polyclinic (28%) or FAP (11%) - 22 percent o f the hospitalizations were self-referred and a further 11percent due to emergen~ies.~' 6.4. PRIMARY HEALTH SERVICECARE DELIVERY 150. The facility survey of 100 PHC units and 200 doctors provided information on the nature and scope of services currently provided inPHC setting (See Methodology section). 6.4.1. Range of Services Provided 151. All the FGP units surveyed responded that they provided general medical and services, general pediatric services, pediatric development checks and immunizations, with around 90-98 percent providing healthpromotion services and home visits. 152. Not all the FGPs provided General Obstetric and Gynecological services. Around 90 percent o f the FGPs provided family planning services. Antenatal services were provided in all o f the FGPs in intermediate and early reform regions but in only 88 percent o f FGPs in Issyk-Kul.Around 90 percent o f the FGPs provided postnatal care but much fewer provided intra-partum care, especially inBishkek, an urban area with good access to maternity hospitals. This difference was statistically significant (Table 5). 34 Table 5: Women's Services Service/activity Advanced Intermediate Early Advanced vs. Advanced vs. ISSyk-Kul Bishkek Osh Early Intermediate T-test (p) T-test (p) General Obs and 76.5% 84.4% 1 88.2% I >0.05 >0.05 Gyns Prenatal care* 88.2% 100% 100% <0.05 > 0.05 Intra-partum care* 58.8% 18.8% 64.7% <0.05 >0.05 Postnatal care 88.2% 93.8% 92.2% >0.05 >0.05 Family planning 94.1% 96.9% 98% >0.05 >0.05 153. More than 90 percent o f the FGPs provided services for common chronic conditions, namely, diabetes, asthma, chronic heart disease and hypertension. Although the FGPs in advanced reformregions were more likely to provide this service as compared with early reform regions, the differences were statistically not significant. However, there was a difference inthe proportion o f FGPs providing mental health services, with around 88 percent o f the FGPs in advanced reform regions providing services in comparison with intermediate and early reform regions. This difference was statistically significant (Table 6). Table 6: Services for Common Chronic Conditions Service/activity Advanced Intermediate Early Advanced vs. Advanced vs. Issyk-Kul Bishkek Osh Early Intermediate T-test (p) T-test (p) Diabetes 94.1% 96.9% I 92.2% I >0.05 >0.05 Asthma 100% 100% 94.1% >0.05 >0.05 Hypertension 100% 100% 94.1% >0.05 >0.05 Ischemic Heart 94.1% 96.9% 92.2% >0.05 >0.05 Disease Mental health* 88.2% 59.4% 58.8% <0.05 c0.05 154. Almost all the FGPsprovided services for managing acute respiratory and diarrhea illness. All the FGPs inBishkek provided services for managinghepatitis as compared with 88 percent inIssyk-Kuland Osh. This difference was statistically significant. Around 80-90 percent o f the FGPs provided services for tuberculosis and STI but only around 30-40 percent provided services for HIV patients, although the difference between the regions was not statistically significant (Table 7). Table 7: Essential PHC Services for Infectious Diseases 35 155. The proportion o f FGPs providing extended PC services was lower than that for services for common conditions. Only 9-30 percent o f FGPs provided nutritioddietetics services with lowest proportion (9.4%) in Bishkekas compared with 23.5 percent in Issyk-Kuland 31.4 percent in Osh. This difference was statistically significant (Table 8). Around 44-73 percent o f the FGPs provided minor surgery and day care observation, 34-45 percent provided ambulance services and 82-90 percent provided laboratory tests. The differences between the regions were statistically not significant (Table 8). Table 8: Extended Primary Health Care Services 156. Analysis o f the data by urban and rural FGPs showed no statistically significant difference for most o f the services except for intra-partum care and services to patients with hepatitis, which were more likely in urban areas as compared with mental health, and day care observation services that were significantly more likely to be providedinrural FGPs (Table 9). Table 9: ServiceProvision by Rural and Urban FGPs Intra-Dartum care I 35.8% I 6.4% 0.0049 Hepatitis 98.1% 85.1% 0.0165 Mental health 54.7% 74.5% 0.0404 Day care observation 47.2% 80.9% 0.0004 6.4.2. Availability of Equipment 157. The availability o f essential medical equipment inFGP units in advanced regions was compared with those inintermediate and early reformregions. There was no statistical difference inthe availability o f basic equipment that was present in most FGPs, such as stethoscope, thermometer, spatula, adult weighing scale, child weighing scale, measuring bar on wall, disposable needles and syringes, pelvimeter, vaginal speculum, obstetric stethoscope, sponge bowl, intravenous line, instrument tray. 158. A number of essential equipment typically present inWestern PHCunitswere present inless than 50 percent o f FGPs but no statistically significant differences in availability were noted between FGPs in advanced reform regions and intermediate/early reform regions. These included obstetric delivery kit, sphygmomanometer, pocket flashlight with adjustable focus, tape meter, examination table, otoscope, autoclave, kidney bowl, suture ht,catheter set. 159. A number o f equipment, which would typically be available in advanced PHC units in European and North American countries, were rarely available in the Kyrgyz FGPs; but there was no statistically significant difference between advanced reform regions and intermediate/early reform regions. These 36 included respiratory nebulizer, ECG machine, adrenaline box, oxygen concentrator, cylindrical sterilizationbox, and surgical floor lamp. 160. Several types o f equipment, commonly used inPHC, were widely available in FGPs in advanced reform regions but less so in intermediate/early reform regions. This difference was statistically significant and included ophthalmoscope, sight test chart, nasal speculum, reflex hammer and dressing kits. 161. When the availability of instruments and equipments were analyzed by urban and rural FGPs no statistically significant difference was noted for many equipment that were widely available in FGPs. These included thermometer, child scale, spatula, dressing kits, disposable needles and syringes, pelvimeter, obstetric stethoscope, intravenous line and sponge bowl. Several types o f equipment were available only in less than 50 percent o f the FGPs but no statistically significant difference was noted between urban and rural FGPs. These included catheter set, obstetric delivery kit, oxygen concentrator, adrenalin box, examination table. 162. However, statistically significant difference (p<0.05) was noted for the availability o f several basic types o f equipment that were commonly available inurban FGPs (>go%) but in only 50-70 percent of rural FGPs. These included adult scale, measuring bar on wall, instrument tray and vaginal speculum. Several other types of basic equipment that were available in over 75 percent o f the urban FGPs were available in less than 50 percent o f the rural FGPs. The difference was statistically significant (p<0.05) and included such equipment as ECG, ophthalmoscope, otoscope, autoclave, reflex hammer, tape meter, sight test chart, nasal speculum, kidney bowl, pocket flashlight with adjustable focus. Some equipment that was available in less than 55 percent o f urban FGPs (such as sphygmomanometer, nebuliser, cylindrical sterilization box, floor surgical lamp, suture kit) were rarely (