In 1996, Kyrgyzstan started the healthcare reform. For 26 years, a few large-scale programmes have been implemented. However, this sector still have many issues.
Many hospitals of Kyrgyzstan have no infrastructure, many under the table payments, shortage of qualified specialists, especially in the regions, whereas mortality from non-communicable diseases is still high. When new minister Alymkadyr Beishenaliev came in October 2021, a new wave of changes was introduced to the healthcare system – healthcare facilities and medical universities are being optimised this time.
What has happened lately?
As part of the reorganisation of healthcare facilities, family medicine centres have been attached to territorial hospitals. Thus, in-patient hospitals, family medicine centres and dental clinics have been merged in the regions. According to Minister Alymkadyr Beishenaliev, these settings have had duplicated functions, incomplete use of laboratory and diagnostic equipment.
“The reform will allow optimising the allocation and use of personnel, financial and material resources at all healthcare levels,” the minister said.
As a result, according to deputy minister of health Zhalalidin Rakhmatullaev, currently there are 17 family medicine centres, 61 general practice centres, 686 general practitioner groups, 1,057 rural health posts, and 126 in-patient hospitals in the republic, some of which are merged into family medicine centres.
The Bishkek Research Centre of Traumatology and Orthopaedics (BRCTO) was changed into the emergency care hospital. This change was accompanied by the scandal: ex-director of now-non-existent BRCTO, prominent orthopaedic surgeon Sabyrbek Dzhumabekov did not want to leave the office, which he held since 2004. He was an active oppositionist to the changes.
Tuberculosis service organisations, drug rehabilitation centres and mental health centres are also being optimised now.
The ministry of health does not know how much money would be saved due to the optimisation.
“We are making the calculations,” Rakhmatullaev said.
Concurrently, the ministry moves out private clinics from the buildings of state healthcare facilities. In Bishkek, one building was already returned to the maternity hospital No. 2, the contract with the clinic “Ismankulov eye microsurgery”, which was located in the territory of the city hospital, was dissolved. This event was also accompanied by the scandal. On March 10, minister Alymkadyr Beishenaliev came to the hospital and found out that the clinic did not move out, and threatened to come with some guys and break everything to pieces.
Moreover, the ministry of health revoked form No. 6, which is required for acquiring a licence, from 12 private medical educational institutions as their clinical sites did not meet the existing standards. In fact, it means that these universities will not be able to continue teaching medical disciplines.
According to Bakyt Dzhangaziev, deputy minister of digital development, in 2021, the ground for the digital healthcare development were laid in 2021. The “My health profile” information system, laboratory information system, vaccination registration system, and resource management information system have been developed. All these systems have been launched in the pilot mode, and this year they will be refined and applied across the country.
“My health profile” collects all available data on every person’s health. For example, the status of insurance, the allocated clinic, reasons for visiting a clinic, reasons for hospitalisation, laboratory test results, as well as information about the vaccination. We used this profile to automate the process of issue of certificates of no registration with psychoneurologic or narcological dispensary. The automation of the process will save us 30 million som (285.78 thousand dollars),” Dzhangaziev said.
Structural changes will not contribute to full-fledged reform
According to chief cardiac surgeon of the country, professor Kaldarbek Abdramanov, the recent reform in healthcare system cannot be called a reform. He said that it requires deep changes in the financing mechanisms.
“However, structural changes are also the elements of the reform. Beishenaliev is now alone trying to do something as he assumed the responsibility. It is important what outcome we will have,” he said.
According to healthcare expert Aibar Sultangaziev, the change of political elites is happening now. As he said to CABAR.asia, the heads of most large medical facilities have not changed for 15-20 years. Basically, his recent decisions are relevant as many of them have considered hospitals as their property.
“However, everything is happening randomly. The system was rather stable, adapted to the provision of services, maybe not the best ones, and most often paid ones. But this system was formed when nothing was invested into the healthcare sector. They adapted themselves to the existing conditions. There are concerns that it can affect the medication supply chains, services. […] But this is not the reform, but the change of political elites,” the expert said.
Current medical insurance system does not contribute to development of public-private partnership
Compulsory medical insurance is a public form of social protection, whose purpose is to guarantee quality medical and p disease-prevention service to the insured.
The State Guarantees Programme was developed and introduced in 2001. It is the national social standard of healthcare that determines the scope of medical services provided to the population free of charge or on favourable terms at the expense of the budget and compulsory medical insurance fund. Concurrently, co-payment was introduced for some kinds of medical services that was meant to replace unofficial exactions and payments that overwhelmed the healthcare system.
In Kyrgyzstan, an employer makes monthly payments of all kinds of contributions to the Compulsory Medical Insurance Fund (FOMS) at the rate of 2 per cent. According to Aibar Sultangaziev, another critical point is the change in the medical healthcare system. As he said, no country in the world contributes such a tiny percentage to the healthcare.
“For example, in Moldova and Estonia, the rate of contributions is 7 per cent, in Kazakhstan – 4 per cent, in Germany – 15 per cent,” the expert said. “In our country, a large-scale category of people do not make these contributions at all. The military personnel, prosecutors, all penitentiary system, all police officers do not contribute to their health. We pay for them, which is unfair. We have one million of migrants who don’t pay for their health either, but they come here for treatment.”
The experts share the opinion that as long as the FOMS does not have sufficient resources, private clinics won’t be interested in cooperating with the state. Payments to the Fund must be based on the market price and be in line with the expenditures.
“The FOMS rate of treatment of one disease, say, is 3 thousand som (28.58 dollars). No private clinic will agree to work on such terms. As long as there is no money, there will be no normal reform. We have an apartment with total area 50 square metres, but we want it to be 100 square metres. And every time we shift the furniture hoping to expand it. Never will it happen,” Sultangaziev said.
According to ex-minister of health Talantbek Barytaliev, contributions to FOMS should be at least 5 per cent and still this will not be enough. Motivational factors should be introduced here.
“We pay to FOMS, but still buy medicines in the hospital ourselves because this money is not enough,” ex-minister said. “Of course, everything is interdependent, and once we have developed economy and large GDP, we will have sufficient contributions to social needs. Now half of the budget is allocated to the social sector, which is wrong. This system contributes to dependency. Every citizen must make a decent contribution to their health.”
He also said that social interrelations and healthcare system must be in line with the free economic market, where Kyrgyzstan exists. Moreover, there’s no need to fear profound reforms, there will always be special programmes for the socially vulnerable groups of people.
Severe shortage of doctors is due to underpayment
In Kyrgyzstan, there is a shortage of over 3 thousand healthcare workers, President Sadyr Zhaparov said in 2021. According to him, doctors quit jobs because of underpayment.
Almost 14 thousand healthcare workers work in the republic, and one fourth of them are in the retirement age. According to deputy minister Zhalalidin Rakhmatullaev, 145 healthcare workers left the country last year. There is a particular shortage of staff in the regions. The system needs emergency physicians, obstetrician-gynaecologists, paediatricians, etc.
Salary was increased by 50 per cent to doctors, paramedical personnel and other staff from July 1, 2021, and the base rate of junior and technical staff was indexed by 1.4. Thus, previously, the average salary of doctors was 8.5 thousand som (80.98 dollars), and now they earn nearly 13 thousand som (123.85 dollars). The paramedical staff with previous salary of nearly 8 thousand som (76.22 dollars) now earn approximately 12 thousand som (114.33 dollars), and the junior and technical staff have their salary increased from 6.5 thousand to 10 thousand som (from 61.93 to 95.27 dollars).
Minister Alymkadyr Beishenaliev announced that the salary of doctors would be increased by 50 per cent from April 1, 2022. And the president promised to healthcare workers to simplify the mortgage loan process. It is unclear whether this information can be relied on amid the rise in the dollar and economic crisis in Russia.
The staff issue should be solved in terms of not only quantity, but also quality. Ex-minister Talantbek Batyraliev said that the postgraduate training of medical workers should be revised.
“The whole world provides postgraduate training of doctors for 5 more years. And we can do it just for 3-6 months, for 2 years. This time is not enough to train a good cardiologist, surgeon or gynaecologist. Therefore, the reform must take such moments into account,” he said.
What else should the reform take into account?
The hospitals of Bishkek and Osh are overcrowded now. People have to go to big cities because of the shortage of specialists, lack of necessary infrastructure in the regions. Healthcare expert Aibar Sultangaziev suggested to create big medical hubs in seven regions.
“What is a hub? Every regional hospital must have a large diagnostic base: tomographic scanners, ultrasound, X-ray, best equipment, modern laboratory. In-patient hospitals must offer modern methods of treatment. If we direct resources to the development of such hubs, we will be able to solve this issue in 2-3 years,” the expert said.
Staffing problems will also be taken into account. Residents should be sent for internships to countries with advanced medicine, for example, Germany, Turkey, on a contractual basis. Upon their return back home, they should work in such hubs, whereas the state will be responsible for their accommodation and decent wage.
According to chief heart surgeon of the country Kaldarbek Abdramanov, huge money could be made based on the domestic capacities of the healthcare system. He stands for the creation of public pharmacies and large laboratories on the base of state healthcare facilities.
“I am not against private pharmacies and laboratories. But what prevents us from developing public alternatives? Millions of money go to private pharmacies and laboratories. We do not have a large and modern public laboratory. This is nonsense,” Abdramanov said.
According to him, in case of scarce cash resources, management and healthcare are out of question. Now the healthcare system has a fixed budget: 40 per cent go to wages, 40 per cent go to medications, 10 per cent go to utility charges, and 10 per cent remain for development.
“What is there to manage?” Abdramanov said.
Talantbek Batyraliev again reminded that the whole spectrum of problems in the system cannot be solved by curtailment or optimisations. All reforms must take into account not only existing conditions, but also the future challenges. For example, increase in population, priority of any diseases.
“And the most important thing is that we should improve the infrastructure of healthcare facilities. Once you go to a hospital, you have nowhere to stand, no place to deliver meals to patients. Who feels comfortable there? The patient feels uncomfortable, their relatives also feel uncomfortable, and the state has to listen to these complaints. Therefore, this is the high-priority task standing before us,” ex-minister said.
Low standard of living moves preventive care into the background
The best way to protect and maintain one’s health is the preventive care. This is clear to all – the population and the decision-makers. All healthcare programmes place a special emphasis on preventive care, they execute outreach all the time. However, the outcomes are not the best: in Kyrgyzstan, non-communicable diseases are the cause of death in 76.8 per cent of people aged 25-64.
According to expert Aibar Sultangaziev, this is caused by the low standard of living in the country. In developed countries, a person knows they should pay a lot as they are interested in their health. In other words, the level of consciousness and priorities of expenditures are different.
“Our people go to hospital only when they cannot walk. They have different priorities in their mind: they need to buy bread today instead of going to gym or running. Second, our culture, mentality must change. Upper class people do not undergo regular check-ups. The very few people take care of their health,” he said.
In turn, the state must create conditions for the physical activity of people, according to the expert. It should also work over other factors – ecology, provision of clear drinking water, creation and maintenance of hygienic standards, infrastructure, healthy nutrition, etc.