Copyright © Westminster European 2011

Key messages

• Independenceandthetransitionto democracyactedasacatalysttobegin reformsinthehealthsystem.

• ThecomprehensiveManasandManas Taalimihealthreformprogrammes radicallyrestructuredthehealthsystem andlinkedreformstomeasurable outcomes.

• Politicalsupport,coupledwithstrong healthsectorleadersandcapacityonthe ground,werecriticalinpromoting continuous,strategicandproactive politicalengagement.

• Healthsystemreformrevitalized primarycare,increasingcoverageof essentialinterventionsandstrengthened healthsystemresponsiveness.

• Goodgovernance,apolitical cultureofopennessandeffortsto promoteaccountabilitywithinatop- downdecision-makingculturewerethe mostsignificantcontextualfactors.

• Othercontributingfactorswerea well-educatedpopulation, empowermentofwomen,solidarityand improvementsininfrastructure.

First published in 1985, the Good health at low cost report sought todescribe how some developing countries were able to achieve betterhealth outcomes than others with similar incomes. An iconic publicationof its day, it highlighted the linkages between the wider determinantsof health and their impact on health outcomes using country casestudies. In an extension to the original analysis, recent research exploresfive new countries asking why some developing countries are able toachieve better health outcomes. With chapters focusing on Bangladesh,Ethiopia, Kyrgyzstan, Tamil Nadu (India) and Thailand, ‘Good healthat low cost’ 25 years on has identified a series of inter-linking factors,within the health system and beyond. This third briefing in the series focuses on findings from Kyrgyzstan.

‘Good health at low cost’ 25 years onSoonafterindependencein1991tradeagreementsandguaranteedsubsidiesended,triggeringasevereeconomiccrisis.By1995Kyrgyzstan’sGDPwasapproximatelyhalfits1989level.Thisledtoafallinpublicspendingandlimitedallocationofresourcestothehealthsector.TheGovernment’sspendingdecreasedby67%between1990and1996.Since2001,thecountryhasbeenclassifiedasalow-incomecountrywithaGDPpercapitaofUS$433.

InresponsetothecrisistheMinistryofHealthputinplacearadicalrestructuringofthehealthsystemthroughtheManasandManasTaalimiprogrammeswhichlinkedreformstomeasurableoutcomes.Thisledto:ashiftfromspecialist-orientedcaretofamilypractice;implementationofabasicbenefitspackage;healthfinancingreforms,includingtheintroductionofcontractingandaconsolidatedsingle-payersystem;andliberalizationofthepharmaceuticalmarket.

‘Good health at low cost’ 25 years on What makes an effective health system? Page 01

‘Good health at low cost’ 25 years onWhat makes an effective health system?

AnemergingcivilsocietymeantthatKyrgyzstanwasperceivedtobeoneofthemostpoliticallyopencountriesincentralAsiaanditbecamearegionalcentrefordonorsandinternationalorganisations.ThishelpedKyrgyzstantomakeambitiousreformsmorerapidlythanneighbouringcountries.

Achieving better health in KyrgyzstanOverthepastdecade,Kyrgyzstanhasmadesteadyimprovementsinthehealthofitspopulation.Theinfantmortalityratehasreducedbyalmost50%between1997and2006,from66to38deathsper1000livebirths(basedonsurveydata).Theunder-5mortalityratehasdecreasedfrom72to44deathsper1000livebirthsduringthesameperiod.Lifeexpectancyhasbeenrecoveringsincethemid-1990swhensocioeconomicproblemswereattheirworst;yetlifeexpectancyishigherinKyrgyzstanthancountrieswithgreaterresources,suchasRussiaandKazakhstan.

Copyright © Westminster European 2011

Bishkek

KAZAKHSTAN

CHINA

UZBEKISTAN

TAJIKISTAN

AFGHANISTANPAKISTAN

KYRGYZSTAN

Kyrgyzstan: A regional leader in health system reform

Credit: © 2006 Dmitry Shevkun/IFES, Courtesy of Photoshare

‘Good health at low cost’ 25 years on What makes an effective health system? Page 02

Further reading Chapter 5, Kyrgyzstan: A regional leader in health system reform. In Balabanova D, McKee M and Mills A (eds). ‘Good health at low cost’ 25 years on. What makes an effective health system? London: London School of Hygiene & Tropical Medicine, 2011. Available at http://ghlc.lshtm.ac.uk

AcknowledgementsThe authors are grateful to those who provided their truthful views, experiences and comments on the historical development of the health system in Kyrgyzstan. Special thanks are extended to Jenny Maisonneuve, Ainura Ibraimova, Joe Kutzin and Melitta Jakab. Our gratitude is extended to the team at the London School of Hygiene & Tropical Medicine who provided technical assistance and supervised this work.

The opinions expressed are those of the authors and do not necessarily reflect the views of the London School of Hygiene & Tropical Medicine.

Readers are encouraged to quote material from this briefing in their own publications by acknowledging the original source.

This policy briefing was edited by Pamoja Consulting http://www.pamoja.uk.com

Kyrgyzstanhasmadesignificantprogressonarangeofintermediatehealthsystemobjectives,suchasexpandingcoverageofessentialcare(especiallyintheareasofmaternalandchildhealth)andincreasingfinancialprotectionandequity.Antenatalcarecoverageisonlyslightlylessinruralthaninurbanareas,at95.4%and99.0%,respectively.Improvedcontraceptiveusehasledtofewerunplannedpregnancies,fewerabortionsandlongerintervalsbetweenbirths.Childhoodimmunizationcoverageishighat98–99%.Thesuccessfulpromotionofbreastfeeding,vitaminDsupplementationandfoodfortificationhasmitigatedtherisksofirondeficiencyanaemiaandiodinedeficiency.

Paths to SuccessOurresearchshowsthatKyrgyzstanhasmaintainedorimprovedthehealthofitspopulationbecauseoftheswiftactionbyGovernmentanddonorstobuildthefoundationsofastronghealthsystemsoonafterindependence.Inspirationalnationalleaders,capacityintheMinistryofHealth,arelativelylowturnoverofstaffandcapacitybuildingbydonoragencieshaveallbeenkey.Improvingfinancialprotectionandaccesstohealthservicesforthepoorestinthecountryhavebeenconsistentpolicygoalssinceindependence.Thisincludedthetransformationofservicedeliverythroughtheimplementationoftwonationalhealthplans;theManas(1996–2006),andtheManasTaalimi(2006–2010).ThepoliticalprocessinKyrgyzstanhasbeencharacterisedbyitscomprehensiveness,continuity,accountabilityandtransparency.Intersectoralcooperation,multi-stakeholderengagement

anddonorcoordinationwerealsocrucial.TheManasprogrammeledtoashiftfromspecialist-orientedcaretofamilypractice,abasicbenefitspackageandhealthfinancingreforms.Thefamilymedicinemodel,whichaimedtoprovideuniversalcoverageofessentialprimarycare,wasintroducedin1997andextendedtothewholecountryby2000.Itincluded:trainingofanewcadreoffamilypractitioners;theintroductionofafamilymedicinecurriculumatpostgraduateandundergraduatelevels;andnewprocesses,suchasreferralprocedures,communicationchannelsandpeersupport.

Afterindependence,shortfallsinpublichealthspendingresultedinendemicinformalpaymentsmadedirectlytohealthcareprofessionals.KyrgyzstanundertooktheonlydocumentedmeasuresinCentralandEasternEuropeandtheformerSovietUniontosuccessfullyreducetheburdenofinformaloutofpocketpayments.Thepost-SovietsysteminKyrgyzstancombinesgeneraltaxationandmandatoryhealthinsurance(includingtheStateGuaranteedBenefitsPackage).Thishasresultedinuniversalcoverageandspecificvulnerablegroupsareentitledtoessentialservicesforfree.Since2001,theMandatoryHealthInsuranceFundhasbeenresponsibleforpoolingthehealthbudgetfundsandmergingfundingstreamsfrominsurance,stateandregionalbudgets.ThishasallowedtheGovernmenttoaddresssocioeconomicandhealthinequalities.

VillageHealthCommitteeshaveplayedavitalroleinthehealthreformprogramme,creatingaplatformforlocaldecision-makingandpartnershipsbetweenruralcommunitiesandtheGovernment.TheCommitteesareindependentandvolunteerledandmembersaretrainedbyprimaryhealthcarestaff.PublichealthprioritiesareidentifiedbythecommunityandpreventionactivitiesareledbytheCommittee.

Changesoutsidethehealthsectorwerealsoimportant.Nationaleconomicgrowthresultedinincreasesinincomeandadeclineinpovertyratesbetween2000and2007.By2008thereweremorewomeninparliamentthananyothercentralAsiancountry–ameasureofwomen’sempowerment.Femaleliteracyisalmost100%andincreaseduseofcontraceptionhasresultedinadramaticdeclineinthetotalfertilityrate.

Lessons learned and future challengesKyrgyzstan’shealthsystemisconsideredamodelofgoodpracticeincentralAsiaandcertainfeaturesarebeingreplicatedthroughouttheregion.Positivechangewasmadepossiblethrough:consistentgovernmentleadershipandsupportforhealthsystemreforms,thecoordinationofmultipleactors,nationalownershipofreform,acomprehensiveapproachand

communityinvolvement.Thedesignandimplementationofreformshavebenefitedfromcontinuityinpolicyandstaffingandstronghumanresourcecapacityinthehealthsectorandingovernment(bothclinicalandmanagerial).

Theseriesofinter-linkingfactors,asintheotherstudycountries,thathavemadeKyrgyzstan’shealthsystemsuccessfulinrealisingbetterhealthforitspopulationcanbeexpressedbyfourwordsallbeginningwithC–referredtoasthe4C’s.TheyareCapacity(theindividualsandinstitutionsnecessarytodesignandimplementreform),Continuity(thestabilitythatisrequiredforreformstosucceed),Catalysts(theabilitytoseizewindowsofopportunity)andContext(theabilitytotakecontextintoaccountinordertodevelopappropriateandrelevantpolicies).

SomeofKyrgyzstan’sremainingchallengesincludegrowinginternalandexternalmigrationaffectinghealthworkerretention,whichisimpactingonaccessibilityandavailabilityofhealthservices.Kyrgyzstanwillalsoneedtoaddresslowpublichealthspendingandpersistingoutofpocketandinformalpayments(despitetheformalguaranteeoffreeaccesstoabasicpackageofhealthcare).Finally,thereisaneedforenhancedfinancialprotectionandanequityfocus,particularlyfordisadvantagedgroups.

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