251. Starting in 1996, the Government has been conducting purposeful work on health care reforms under the “Manas” National Health Program. A number of demographic indicators have improved as a result of the reforms. The average life expectancy has increased to 68.6 years, which is comparable to the level of the1970s. The general mortality rate has gone down from 6.8 (1999) to 6.6 (2001) deaths per 1,000 people. The infant mortality rate has declined from 22.7 deaths per 1,000 live births in 1999 to 21.7 in 2001. However, an increase in the infant mortality figure is expected due to the adoption of new criteria for live births counting used by the World Health Organization (WHO) member countries. A reduction in the overall morbidity rate is noted along with progress in combating some infectious diseases.
The main outcomes of the short- and medium-term strategies of the Manas Program implemented with the technical and consultative support of the international donor organizations, include participation of both the medical community and the population in its implementation, establishment of the family group practices and the universal introduction of mandatory medical insurance (MMI) throughout the Republic. By the year 2002, 83.7 percent of the population was covered by the mandatory medical insurance system.
252. In January 2001, several pilot areas of the Chui and Issyk-Kul regions have introduced new funding mechanisms for general health institutions. These include formal co-payment for medical services by patients and official bodies and implementation of the Program of State Guarantees to provide citizens with medico-sanitary services. The objective of the Program is to exercise the rights of citizens to receive free or concessional medical treatment and preventative assistance.
New methods of funding and the Program of State Guarantees were launched in Talas and Naryn regions on March 1, 2002. The new methods of funding accumulated health sector funds at the regional level, and encouraging rational use of limited resources for targeted social assistance to the most vulnerable groups of the population. The use of new methods ensures transparency of financial flows, improved provision of medicines and food to patients. The introduction of the pilot programs in combination with restructuring and reinvestment of saved funds, has resulted in almost the doubling of average per patient expenditures. Out of that, expenditures for food rose 1.8 times and supply of medecines 2.2 times. Salaries of doctors has risen on average 2.8 times, and those of middle and lower medical personnel, 2.5 times. The number of indigent patients who have received free medical treatment has increased five times. These measures, according to WHO estimates, have led to a decline of informal payments in the health care sector.
253. Along with these achievements, the following issues have been revealed in the reform process:
· A growing incidence has been recorded of diseases such as tuberculosis (127.3 cases per 100,000 of the population in 2001 compared with 114.4 cases in 1999), brucellosis (21.0 cases per 100,000 1999 compared with 37.6 cases in 2001), echinococcosis (477 cases in 2001 compared with 310 cases in 1995). It is important to emphasize that diseases such as brucellosis and echinococcosis must be tackled on intersectoral level in close interaction with the Ministry of Agriculture, Water Resources and Processing Industry.
· An AIDS/HIV epidemic has started in 2001. As of July 1, 2002 there were 200 registered cases, mostly among drug addicts of Osh region.
· Another unresolved issue is the problem of viral hepatitis in southern regions of the Republic. There is high incidence of infection with viral hepatitis B among medical personnel that come into contact with the virus.
· The consumption of alcohol has increased in the past five years by 28 percent, and mortality rate due to the abuse of alcohol has jumped by 130 percent. The number of alcoholic psychoses has increased four fold.
· In the past ten years, drug addiction has increased almost four times. Opium drug addiction (and recently heroin) compared with the hashish addiction is on the rise. In 95 percent of cases the opium is used intravenously. Growth can therefore be predicted in parental forms of viral hepatitis and the spread of HIV infection among this category of drug addicts. The growing number of adolescents consuming alcoholic beverages and narcotic substances is alarming.
· The rate of iodine- and iron-deficiency diseases has sharply increased. Sampling studies have shown that 52 percent of children and adolescents in the northern regions have some kind of iodine-deficiency disease, while in southern regions this figure has reached 87 percent. This situation has urged the Government to pass a Law on prevention of iodine deficiency in the Kyrgyz Republic. Artificial supplementing of for the natural iodine deficiency with the help of iodized salt has not happened. The share of iodized salt consumed by only 17-20 percent of the population.
· In recent years, the number of diseases related to blood and haematogenic organs has doubled, 92.4 percent of that is accounted for in the form of iron-deficient anemia. The anemia plagues 60 percent of women of childbearing age and 50 percent of children less than three years of age.
· Despite progress made with family planning, use of contraceptives and abortions remain burning issues.
Financing of the health sector from the national budget was reduced from 2.3 percent of GDP in 1999 to 1.9 percent in 2001. The resources allocated from the budget for health services cover only 50 percent of the actual needs of the sector. The patient covers the other half of the cost of medical services. Insufficient financing of the health sector fosters growth of informal payments for medical treatment. The problem is aggravated by inefficient use of the scarce resource available to the health sector. The multilevel system (republican, regional, city, district and village) of financing and service provision, as well as the cumbersome infrastructure add a significant share to the irrational use of resources. The lack of funds accumulated through the mandatory medical insurance system is due not only to the low medical insurance fees but also to the appropriation of accumulated funds by the Social Fund and the Ministry of Finance for other purposes.
The low and undifferentiated wages and salaries for health workers and the lack of incentives for improvement of skill and service quality have also negatively affected the quality of medical assistance and lowered the prestige of the medical occupation.
All of these factors have significantly reduced accessibility of medical assistance, especially for the poorest layers of the population; negatively affecting the quality of medical assistance and epidemiological situation in the country.
Goals and Priority Areas in the Health Sector
254. The principal goal in the health sector is to ensure fair and equal access for all, including the most vulnerable layers of the society, to free medical services under the program of state guarantees. The policy of the Government in maintaining access to public health services will be focused as follows:
· formation of an effective system of medical assistance oriented at primary medical services;
· development of new funding methods; and
· strengthening the role of public health care.
255. Further activities in the health sector will be directed at the creation of a sustainable and transparent system of primary medical and sanitary assistance, mobile ambulance and flexible and effective in-patient assistance. This will become possible only with sustainable funding of the health care system. Hence, measures requiring attention include:
· Gradual increase of health sector funding through greater state financing and further development of mandatory medical insurance. Clarifying sources of paying insurance premiums on behalf of pensioners, involvement of students and the military in the mandatory medical insurance system, expanding funds for mandatory medical insurance of children. The aim is to achieve a level of annual state funding of the health sector of 2.5 percent of GDP.
· Improvement of the system of collecting MMI insurance premiums that would ensure their automatic entering into MMI accounts.
· Annual revision of the state guarantees program to adjust the level of co-payment by the population for certain types of medical services provided by medical institutions.
· Spreading the new health sector funding mechanisms throughout the Republic to provide for fair distribution of resources, restructuring of the medical assistance system, and introduction of new labor remuneration mechanisms in the health sector.
· Improvement of physical infrastructure and adequate equipping of family medicine centers, general hospitals, as well as several maternity houses (under the Public Investment Program).
· Promotion of the private sector in the health care system.
· Preparation for, and the introduction in the year 2004 of, the new WHO live birth criteria to improve medical assistance rendered to pregnant women, upgrade nursing of under-weight newly-born, and bring medical statistics into compliance with international standards.
· Promotion and enhancement of family planning activities to reduce the number of abortions and increase the use of contraceptives.
· Prevention of diseases, including infectious, sexually and intravenously transmitted diseases. Immunization of children; ensuring state independence of vaccine supply.
· Encouraging and improving production of iodine- and iron-rich food products.
· Social mobilization, rationalization and optimization of sanitary and epidemiological services; involvement of the population, local communities, not-for-profit organizations, mass media and the State TV and Radio Corporation in addressing issues of promoting and improving health.
· Targeted attraction of direct foreign investment and rational use of limited PIP resources.
256. The following activities will be continued to further the reforms under the development strategy:
· Formation of a comprehensive medical care system. The development strategy provides for improvement in physical infrastructure of the special health agencies (ambulance, oncology, ophthalmology, vascular surgery, etc.). Thus, efforts will focus on attracting and coordinating donor grant funding and mobilized domestic funds. Financing of the High Technology Fund of the Ministry of Health will be increased.
· Further expansion of the mandatory medical insurance system through higher insurance premiums and participation of employees in the payment of the premiums.
· Active development of additional MMI programs to supply insured citizens with medicines at the outpatient level.
· Expanding state financing capacity in order to increase the scope of the State Guarantees Program for the provision of free and concessional medical assistance.
· Introduction of incentives to secure medical personnel in rural areas in order to provide people living in remote areas with accessible and good quality medical services.
· Large-scale development of a health care information system.
Taking into account the main goal of the State in the health sector and based on the measures provided in the stabilization and development strategies, it is intended to:
· Strengthen public health and promote a healthy life style and behavior for the people in order that they might fully realize their health potential and play an active role in society.
· Improve the main demographic indices and reduce the level of infectious and parasitic diseases through holistic intersectoral coordination.
· Expand access to quality primary medical services based on the family medicine principle and improve the quality of in-patient medical care.
· Achieve fair and effective distribution of health sector resources with better coverage and equality.