The Kyrgyz Republic or simply Kyrgyzstan is a sovereign state in Central Asia. Kyrgyzstan is a landlocked country with mountainous terrain. It is bordered by Kazakhstan to the north, Uzbekistan to the west and southwest, Tajikistan to the southwest and China to the east. Its capital and largest city is Bishkek.
Kyrgyzstan’s recorded history spans over 2,000 years, encompassing a variety of cultures and empires. Although geographically isolated by its highly mountainous terrain, which has helped preserve its ancient culture, Kyrgyzstan has been at the crossroads of several great civilizations as part of the Silk Road and other commercial and cultural routes. Though long inhabited by a succession of independent tribes and clans, Kyrgyzstan has periodically fallen under foreign domination and attained sovereignty as a nation-state only after the breakup of the Soviet Union in 1991.
Since independence, Kyrgyzstan has officially been a unitary parliamentary republic, although it continues to endure ethnic conflicts, revolts, economic troubles, transitional governments and political conflict. Kyrgyzstan is a member of the Commonwealth of Independent States, the Eurasian Economic Union, the Collective Security Treaty Organization, the Shanghai Cooperation Organisation, the Organisation of Islamic Cooperation, the Turkic Council, the Türksoy community and the United Nations.
Ethnic Kyrgyz make up the majority of the country’s 5.7 million people, followed by significant minorities of Uzbeks and Russians. Kyrgyz is closely related to other Turkic languages, although Russian remains widely spoken and is an official language, a legacy of a century of Russification. The majority of the population are non-denominational Muslims. In addition to its Turkic origins, Kyrgyz culture bears elements of Persian, Mongolian, and Russian influence.
Healthcare Reforms in Kyrgyzstan
“Good health at lowcost” 25 years on Soon after independence in 1991 trade agreements and guaranteed subsidies ended, triggering a severe economic crisis. By 1995 Kyrgyzstan’s GDP was approximately half its 1989 level. This led to a fall in public spending and limited allocation of resources to the health sector. The Government’s spending decreased by 67% between 1990 and 1996. Since 2001, the country has been classified as a low-income country with a GDP per capita of US$ 433. In response to the crisis the Ministry of Health put in place a radical restructuring of the health system through the Manas and Manas Taalimi programmes which linked reforms to measurable outcomes. This led to: a shift from specialist-oriented care to family practice; implementation of a basic benefits package; health financing reforms, including the introduction of contracting and a consolidated single-payer system; and liberalization of the pharmaceutical market.
An emerging civil society meant that Kyrgyzstan was perceived to be one of the most politically open countries in central Asia and it became a regional centre for donors and international organisations. This helped Kyrgyzstan to make ambitious reforms more rapidly than neighbouring countries.
Achieving better health in Kyrgyzstan
Over the past decade, Kyrgyzstan has made steady improvements in the health of its population. The infant mortality rate has reduced by almost 50% between 1997 and 2006, from 66 to 38 deaths per 1000 live births (based on survey data). The under-5 mortality rate has decreased from 72 to 44 deaths per 1000 live births during the same period. Life expectancy has been recovering since the mid-1990s when socio economic problems were at their worst; yet life expectancy is higher in Kyrgyzstan than countries with greater resources, such as Russia and Kazakhstan.
Kyrgyzstan has made significant progress on a range of intermediate health system objectives, such as expanding coverage of essential care (especially in the areas of maternal and child health) and increasing financial protection and equity. Antenatal care coverage is only slightly less in rural than in urban areas, at 95.4% and 99.0%, respectively. Improved contraceptive use has led to fewer unplanned pregnancies, fewer abortions and longer intervals between births. Childhood immunization coverage is high at 98–99%. The successful promotion of breastfeeding, vitamin D supplementation and food fortification has mitigated the risks of iron deficiency anaemia and iodine deficiency.
Paths to Success-
Our research shows that Kyrgyzstan has maintained or improved the health of its population because of the swift action by Government and donors to build the foundations of a strong health system soon after independence. Inspirational national leaders, capacity in the Ministry of Health, a relatively low turnover of staff and capacity building by donor agencies have all been key. Improving financial protection and access to health services for the poorest in the country have been consistent policy goals since independence. This included the transformation of service delivery through the implementation of two national health plans; the Manas (1996–2006), and the Manas Taalimi (2006–2010). The political process in Kyrgyzstan has been characterised by its comprehensiveness, continuity, accountability and transparency. Intersectoral cooperation, multi-stakeholder engagement and donor coordination were also crucial. The Manas programme led to a shift from specialist-oriented care to family practice, a basic benefits package and health financing reforms. The family medicine model, which aimed to provide universal coverage of essential primary care, was introduced in 1997 and extended to the whole country by 2000. It included: training of a new cadre of family practitioners; the introduction of a family medicine curriculum at postgraduate and undergraduate levels; and new processes, such as referral procedures, communication channels and peer support. After independence, shortfalls in public health spending resulted in endemic informal payments made directly to health care professionals. Kyrgyzstan undertook the only documented measures in Central and Eastern Europe and the former Soviet Union to successfully reduce the burden of informal out of pocket payments. The post-Soviet system in Kyrgyzstan combines general taxation and mandatory health insurance (including the State Guaranteed Benefits Package). This has resulted in universal coverage and specific vulnerable groups are entitled to essential services for free. Since
2001, the Mandatory Health Insurance Fund has been responsible for pooling the health budget funds and merging funding streams from insurance, state and regional budgets. This has allowed the Government to address socioeconomic and health inequalities. Village Health Committees have played a vital role in the health reform programme,
creating a platform for local decision-making and partnerships between rural communities and the Government. The Committees are independent and volunteer led and members are trained by primary health care staff. Public health priorities are identified by the community and prevention activities are led by the Committee. Changes outside the health sector were also important. National economic growth resulted in increases in income and a decline in poverty rates between 2000 and 2007. By 2008 there were more women in parliament than any other central Asian country – a measure of women’s empowerment. Female literacy is almost 100% and increased use of contraception has resulted in a dramatic decline in the total fertility rate.
Lessons learned and future challenges
Kyrgyzstan’s health system is considered a model of good practice in central Asia and certain features are being replicated throughout the region. Positive change was made possible through: consistent government leadership and support for health system reforms, the coordination of multiple actors, national ownership of reform, a comprehensive approach and community involvement. The design and implementation of reforms have benefited from continuity in policy and staffing and strong human resource capacity in the health sector and in government (both clinical and managerial). The series of inter-linking factors, as in the other study countries, that have made Kyrgyzstan’s health system successful in realising better health for its population can be expressed by four words all beginning with C – referred to as the 4 C’s. They are Capacity (the individuals and institutions necessary to design and implement reform), Continuity (the stability that is required for reforms to succeed), Catalysts (the ability to seize windows of opportunity) and Context (the ability to take context into account in order to develop appropriate and relevant policies). Some of Kyrgyzstan’s remaining challenges include growing internal and external migration affecting health worker retention, which is impacting on accessibility and availability of health services. Kyrgyzstan will also need to address low public health spending and persisting out of pocket and informal payments (despite the formal guarantee of free access to a basic package of health care). Finally, there is a need for enhanced financial protection and an equity focus, particularly for disadvantaged groups.