ORDER OF THE GOVERNMENT OF THE KYRGYZ REPUBLIC

of February 16, 2006 No. 100

About the National program of reform of health care of the Kyrgyz Republic "Manas taaly" for 2006-2010

For the purpose of realization of the tasks set by the President of the Kyrgyz Republic Bakiyev K. S. at republican meeting on October 15, 2005, in the priority directions of further development of health care of the Kyrgyz Republic the Government of the Kyrgyz Republic decides:

1. Approve the enclosed National program of reform of health care of the Kyrgyz Republic "Manas taaly" for 2006-2010.

2. To the ministries, the state committees, administrative departments, local public administrations and local government bodies to adopt to execution the National program of reform of health care of the Kyrgyz Republic "Manas taaly" for 2006-2010.

3. "Manas taaly" for 2006-2010 to assign general coordination on implementation of the National program of reform of health care of the Kyrgyz Republic to the Ministry of Health of the Kyrgyz Republic.

4. To the Ministry of Health of the Kyrgyz Republic to develop and approve the actions plan, monitoring indicators on implementation of the National program of reform of health care of the Kyrgyz Republic in a month "Manas taaly" for 2006-2010.

5. To impose control over the implementation of this resolution on management of social and cultural development of the Office of the Prime Minister of the Kyrgyz Republic.

 

Approved by the order of the Government of the Kyrgyz Republic of February 16, 2006 No. 100

The NATIONAL PROGRAM of REFORM of HEALTH CARE of the KYRGYZ REPUBLIC "MANAS TAALIMI" for 2006-2010

List of reducings

     Сокращение                 Наименование сокращения

     DFID            Департамент международного               развития
                     Великобритании
     DOTS            Короткий курс     лечения    (туберкулеза)    под
                     наблюдением
     KfW             Немецкий банк развития
     PAL             Практический подход к легочному здоровью
     SWAp            Широкосекторальный подход
     АДО             Амбулаторно-диагностическое отделение
     АБР             Азиатский Банк Развития
     БДОР            Больница доброжелательного отношения к
                     ребенку
     ВБ              Всемирный Банк
     ВБИ             Внутрибольничная инфекция 
     ВВП             Валовой внутренний продукт 
     ВТО             Всемирная торговая организация 
     ВОЗ             Всемирная организация здравоохранения 
     ГСВ             Группа семейных врачей
     ГУКВ            Главное управление    координации   и   внедрения
                     реформы здравоохранения
     ДГСЭН           Департамент                      государственного
                     санитарно-эпидемиологического надзора
     ДЛОиМТ          Департамент лекарственного     обеспечения      и
                     медицинской техники
     ДМ              Доказательная медицина 
     ДП ОМС          Дополнительная программа ОМС
     ИВБДВ           Интегрированное ведение     болезней     детского
                     возраста
     ИППП            Инфекции, передающиеся половым путем
     КГМА            Кыргызская государственная медицинская академия
     КГМИПиПК        Кыргызский государственный  медицинский  институт
                     подготовки и повышения квалификации
     КДО             Консультативно-диагностическое отделение
     КОР             Комплексная основа развития Кыргызской Республики
                     до 2010 года
     КР              Кыргызская Республика
     КРСУ            Кыргызско-Российский славянский университет
     КФПЛЗ           Кыргызско-Финская программа по легочному здоровью
     КШППРЗ          Кыргызско-Швейцарский проект  поддержки   реформы
                     здравоохранения
     ЛС              Лекарственные средства
     МВД             Министерство внутренних дел
     МГА             Местные государственные администрации
     МЗ              Министерство здравоохранения
     МО              Министерство обороны
     МСУ             Органы местного самоуправления
     МЮ              Министерство юстиции
     НДС             Налог на добавленную стоимость
     НИИ             Научно-исследовательские институты
     НПО             Неправительственные организации
     НСК             Национальный статистический комитет
     НССБ            Национальная стратегия сокращения бедности
     НЦ              Национальные центры (научные центры)
     НЦКТ            Национальный центр кардиологии и терапии
     ОМС             Обязательное медицинское страхование
     ООБ             Областная объединенная больница
     ООН             Организация Объединенных Наций
     ОРИ             Острые респираторные инфекции
     ОшГУ            Ошский государственный университет
     ПАПЗ            Проект анализа политики здравоохранения ВОЗ/DFID
     ПГГ             Программа государственных гарантий
     ПМСП            Первичная медико-санитарная помощь
     ПРООН           Программа развития Организации Объединенных Наций
     РМИЦ            Республиканский медико-информационный       центр
                     Министерства      здравоохранения      Кыргызской
                     Республики
     РЦУЗ            Республиканский центр укрепления здоровья
     РО "СПИД"       Республиканское объединение "СПИД"
     СНГ             Содружество независимых государств
     СМИ             Средства массовой информации
     СМП             Скорая медицинская помощь
     СПБ             Среднесрочный прогноз бюджета
     СПЭПП           Содействие повышению эффективности  перинатальной
                     помощи
     ССЗ             Сердечно-сосудистые заболевания
     ССС             Сердечно-сосудистая система
     ТБ              Территориальная больница
     ТУ ФОМС         Территориальные управления   Фонда  обязательного
                     медицинского страхования
     УЗИ             Аппарат для ультразвуковых исследований
     ФАО             Всемирная продовольственная организация
     ФАП             Фельдшерско-акушерский пункт
     ФВТ             Фонд высокотехнологичных  (дорогостоящих)   видов
                     медицинской помощи
     ФОМС            Фонд обязательного медицинского страхования
     ФТО             Фонд технического обслуживания
     ЦРТ             Цели развития тысячелетия
     ЦСМ             Центр семейной медицины
     ЧР              Человеческие ресурсы
     ЮНИСЕФ          Фонд ООН помощи детям
     ЮНФПА           Фонд народонаселения ООН
     ЮСАИД           Американское агентство по международному развитию
 

1. Introduction

1.1. The national program of reform of health care of the Kyrgyz Republic "Manas taaly" for 2006-2010 and its succession with the National program of reform of health care system of the Kyrgyz Republic Manas (1996-2006)

After independence acquisition Kyrgyzstan headed for creation of the democratic state with market economy. Because of gap of the economic connection established during the Soviet period, sharp reducing production volumes there came economic downturn. Health care, on an equal basis with other sectors, faced problem of insufficiency of financial resources, impossibility to contain the powerful infrastructure inherited from the Soviet period with dominance of the hospital sector and excessive specialization of medical authorities.

The basic principles of the Soviet health care were the public nature of health care, general availability and free of charge medical services. However, supercentralizations of management, high level of bureaucratization, lack of flexibility, fragmentirovannost and duplication inherent in system in delivery of health care, inefficient methods of financing, need of content of bulky infrastructure did not allow to provide the declared principles of general availability and free of charge.

The expense burden on health care services laid down on population shoulders more and more, the level of unofficial payments increased. It affected deterioration in demographic indicators, especially among households with low income level.

As well as in all sectors of Kyrgyzstan, there was need of cardinal reorganization of health care system. With assistance of the World Health Organization in 1994-1996 the National program of reform of health care system of the Kyrgyz Republic Manas (1996-2006) was developed (further - the Manas Program).

The multiformity, forming of the infrastructure corresponding to the needs of the population for medical care and financial resources, decentralization of management, increase in managerial and financial autonomy of the organizations of health care became the main lines of the created model of health care of the Kyrgyz Republic. The health care sector was divided into "suppliers" and "buyer" of medical services. Development of primary health care, family medicine, the free choice of the family doctor, ensuring availability of medical services to the population within the Program of the state guarantees were recognized as priorities. The new methods of financing oriented to resulting effect and compensations of health workers depending on quality of the performed work began to take root.

For working off of mechanisms of restructuring of provision of medical services and change of funding mechanisms for health care in the Issyk kul region in 1994-1996 the pilot (demonstration) project financed by YuSAID is realized. The design of the project of reforming of health care expected the 4,5 of year financed by the World Bank and based on accurately certain policy within the Manas Program was at the same time developed. In pilot areas (The Chuya and Issyk kul regions) within four components structural changes in provision of primary health care, rehabilitation of treatment and prevention facilities, change of methods of financing and implementation of management of medicines were provided.

For carrying out further reforms in 2000 the design of the second project of reforming of health care for 2001-2005 financed by the World Bank, directed to deepening and distribution in the republic of the transformations begun in pilot regions within the first project was prepared.

Reforming of health care got political support from the country leaders that was reflected in such strategic documents as the Complex basis of development of the Kyrgyz Republic till 2010 and the National strategy of reducing poverty in the Kyrgyz Republic for 2003-2005.

Results of the ten-year period of reform of health care show that, despite the most difficult economic situation, thanks to support of management of the state and partners from the World Health Organization, the World Bank, Deutsche Bank of reconstruction and development, Asian Development Bank, YuSAID, PROON, DFID, the international organizations of the U.S. Governments, Japan, Switzerland, Global Fund for fight against tuberculosis, malaria and HIV/AIDS, the international non-governmental organizations to Kyrgyzstan it was succeeded to overcome system crisis of health care.

The health care system created in Kyrgyzstan which received the name "Kyrgyz Model of Health Care" allows to keep availability of medical services to the population in all regions within the Program of the state guarantees, and gives the chance to function to the sector in the conditions of market economy, quickly reacting to needs of the population. The majority of the carried-out changes received steady nature, thanks to fixing in a number of the laws, and need their further institutionalization.

For fixing of the achieved results and giving of stability of system in 2004 the Ministry of Health of the Kyrgyz Republic asked in the World Health Organization for technical assistance on development of strategy of further reform. This initiative was supported, and the Ministry of Health of the Kyrgyz Republic started development of the new program of reforming of health care calculated for 2006-2010.

The national program of reforming of health care of the Kyrgyz Republic which received the name "Manas Taaly" (further - the Manas Taaly Program) is based on succession of the Manas Program and aimed at providing provision of the high-quality services of health care meeting requirements of society.

Within the Manas Taaly Program further development will be gained by qualitatively new service of public health care based on functional separation of activities for prevention and strengthening of health on the basis of control of diseases from supervising functions on protection of health and functions of provision of services.

Significant results in strengthening of health of the population as showed experience of creation of rural committees of health in Dzhumgalsky district of the Naryn region, can be reached by more active involvement of the population and partner interaction with community-based, non-governmental and public organizations, close cooperation with mass media, and also local government bodies.

Further strengthening of potential of primary level of health care sector, increase in role of family medicine in integrated solution of medical and sanitary problems of certain patients, families and societies in general is planned.

In the hospital sector it is necessary to perform further optimization of activities which will allow to provide high-quality medical services on the basis of vertical and horizontal integration, succession in rendering medical services.

Much attention is planned to be paid to further integration of priority programs into the created system of provision of individual and public services, with increase in role of leaders of the centers and institutes in health care organization activity coordination, to monitoring of indicators of health of the population, development of the methodical materials based on scientific data.

The essential part is assigned to development of the personnel potential of health care system meeting the requirements of modern health care. At the same time special attention will be paid to reducing disproportions in personnel resources, to fixing of medical personnel on places, optimization of system of medical education.

The role of the Ministry of Health of the Kyrgyz Republic in carrying out state policy in the field of protection and strengthening of health, strengthening of intersectoral interaction, coordination of activities of the donor organizations will be strengthened. Implementation of the new methods of strategic management oriented to result and based on partner relations coordination of activities of the subordinated organizations and delegation of performing functions by it is planned.

Decentralization of management in health care system assumes increase in managerial, financial autonomy and responsibility of suppliers for results of activities. For increase in efficiency of organization activity of health care accumulation of means of health care at the republican level and transition to the strategic purchases in system of the Single payer oriented to requirements of the population and priorities of health care is planned. At the same time mechanisms of increase in financial stability of suppliers, equalizations of level of financing of regions will be implemented.

Further transformations in health care sector for ensuring its stability are planned to be performed on the basis of shirokosektoralny approach (SWAp). The agreement with the World Bank and Deutsche Bank of development (KfW) is reached upon investments into the project on health care reforming - 3, which will be implemented within the Manas Taaly Program on the basis of shirokosektoralny approach. At the same time active participation of other international organizations in program implementation "Manas taaly" is expected.

The national program of reform of health care of the Kyrgyz Republic "Manas taaly" for 2006-2010 is logical continuation of the Manas Program. In basis of the Manas Taaly Program the analysis of results, problems and the experience accumulated for previous years is pledged. Successful realization of the tasks facing health care sector, pledged in the Complex basis of development of the Kyrgyz Republic till 2010, the Millennium development goals, the Manas Taaly Program directed to preservation and promotion of health of the population will allow to make essential contribution to reducing level of poverty.

1.2. Development of the National program of reform of health care of the Kyrgyz Republic "Manas taaly" for 2006-2010

The Manas Taaly program is developed in case of technical support of WHO/DFID. For its development the expert group of consultants of local specialists to which duties coordination of development of different components of the program belonged was created. It was developed in the atmosphere of openness, with involvement of the main participants of health care system.

On working meetings with the medical public of all areas, cities of Bishkek and Osh, republican healthcare institutions, the office of the Ministry of Health of the Kyrgyz Republic, new approaches to further reforming of health care were discussed. In general, the offered directions of further development got support from health workers, during the meetings constructive proposals on realization mechanisms were stated.

Program implementation mechanisms within shirokosektoralny approach, transition to accumulation of means of health care at the republican level, forming of the budget of health care on program basis were in details discussed with financial and economic employees of the Ministry of Economics and finance of the Kyrgyz Republic, the Central Treasury of the Ministry of Economics and finance of the Kyrgyz Republic, TU of Federal Compulsory Health Insurance Fund and the international consultants for fiducial assessment on working meetings and "round tables".

The big contribution to development of the program was made by representatives of the donor organizations and the international consultants during discussion of strategy within the Manas Taaly Program, mechanisms of their realization.

Distinctive feature of the Manas Taaly Program is the possibility of its realization within the shirokosektoralny approach meaning consolidation of efforts of the Government of the Kyrgyz Republic, donor community. The Kyrgyz Republic is given opportunity of support of the budget of health care from the accumulated means of donors, and also in the form of parallel financing for achievement of effective objectives and tasks.

The work plan on program implementation "Manas taaly", calculation of cost of actions were in details discussed during the missions of the World Bank, Deutsche Bank of development, the British international development agency.

The national program of reform of health care of the Kyrgyz Republic "Manas taaly" for 2006-2010, mechanisms of its realization were provided on "round table" on October 6, 2005 in which took part the President of the Kyrgyz Republic Bakiyev K. S., members of the government of the Kyrgyz Republic, representatives of non-governmental organizations, donor community and medical public.

Work result of "round table" was the joint statement of the Government of the Kyrgyz Republic and donor community on commitment to further development of health care sector on the basis of shirokosektoralny approach within the National program of reform of health care of the Kyrgyz Republic "Manas taaly" for 2006-2010.

2. The lessons learned from the National program of reform of health care system of the Kyrgyz Republic Manas (1996-2006)

The short description and the analysis of the major achievements of 10 years' reforming of health care within the Manas Program, their influence on indicators of health of the population, including on indicators of the Millennium development goals in the field of health care, and also on the indicators reflecting achievement of the main goals of health care system determined by WHO are provided in this Section.

In the analysis data of the researches conducted by the Draft of the analysis of policy of health care of WHO/DFID (PAPZ), data of the Republican Medico-information Centre (RMIC) of the Ministry of Health of the Kyrgyz Republic, Fund of compulsory medical insurance under the Ministry of Health of the Kyrgyz Republic, the Zdravplus project of YuSAID were used.

2.1. Implementation of the National program of reform of health care system of the Kyrgyz Republic Manas (1996-2006)

For achievement of main goals of the health care systems determined by WHO namely:

- justice in resource allocation,

- efficiency,

- availability of services of health care,

- responsiveness of system to needs of the people

within the Manas Program complex structural transformations of system of the organization, financing and management of health care were begun.

The main components of reforms were:

- structural changes of system of provision of medical services: PHC strengthening, forming of institute of family medicine, restructuring of hospital network;

- data of the new methods of financing of health care oriented to resulting effect;

- improvement of quality of the provided medical care;

- strengthening of role of public health care;

- introduction of new methods of management in health care system in the conditions of bigger autonomy of the medical organizations.

2.1.1. Structural changes of system of provision of medical services: PHC strengthening, forming of institute of family medicine, restructuring of hospital network

For increase in efficiency of health care, cost reduction on the expensive hospital help structural transformations are carried out:

- there was legal separation of primary health care and stationary service. Groups of family doctors and the Centers of family medicine are created. By the beginning of 2005 it is created 85 TsSM as a part of which it is developed 673 GSV, besides, functions 31 GSV as independent legal entities. The regional TsSM coordinating activities of primary health care in each area are organized. Preparation and retraining of doctors and family medicine nurses are carried out. The principle of the free choice of group of family doctors is entered for what the population addition to GSV was performed. Also the new methods of per capita financing at primary level stimulating medical personnel to improvement of quality of the provided services were at the same time entered;

- for improvement of economic and physical availability of medicines to the population the compulsory health insurance Additional program for provision of medicines of insured citizens at the out-patient level (DP compulsory health insurance) is entered;

- events for strengthening of material and technical resources of the organizations of health care of primary level, including repair, equipping were held by the medical and laboratory equipment;

- for increase in efficiency of primary health care and improvement of succession of service of ambulance and family doctors in 2004 departments of emergency medical service were allocated from hospitals and transferred to TsSM.

The restructuring and rationalization of excessively developed hospital network which began since 1996 became one of key tasks of reform. For 2001-2004 there were considerable changes, such as optimization of manpower ceiling, reducing bed fund, release of the empty and inefficiently used buildings and constructions. Events for merging of specialized agencies, creation of hospitals of general profile were held. In all regions of the republic the regional joint hospitals are created. Inefficiently working small hospitals are transformed to structural divisions of territorial hospitals or to the centers of family medicine, or group of family doctors. Repair work was in parallel carried out.

More rational approach to use of resources was resulted by reducing bed fund. So, the number of hospital beds was reduced on 14, by % - with 30313 in 2001 to 26040 in 2004. At the same time the total quantity of medical institutions was reduced by % 44,2 - with 256 in 2001 to 143 in 2004.

Along with reducing the areas and closing of buildings efforts on expense reduction for utilities by means of effective planning and control, including implementation of energy-saving technologies were made.

2.1.2. Change of methods of financing

During reform in health care of the Kyrgyz Republic, despite reducing share of financing of health care in structure of GDP with % 4,0 in 1991 to % 1,9 in 2002, there were fundamental changes in system of financing of health care.

The main source of financing of health care for 1996-2004 were the taxes arriving in the government budget. In 1997 for attraction of additional sources of financing the compulsory medical insurance (CMI) with creation of compulsory health insurance Fund which created bases was step by step entered into health care sector and social protection of citizens:

- for implementation of contractual strategy,

- emergence of additional sources of financing of health care,

- improvements of availability of medical services, especially for socially vulnerable categories of the population (the pensioners, children, persons receiving social benefits),

- approbations and implementations of progressive methods of payment of medical services,

- introductions of monitoring system on quality indicators,

- mechanisms on protection of the rights of the population in case of receipt of medical services.

Means of compulsory health insurance, components in general expense structure of health care sector gradually increased with % 0,8 in 1997 to % 19,6 in 2004.

Development of compulsory health insurance was performed within health care reform, progressive methods of financing, new to the republic, - in the treated case in hospitals, according to the per capita standard rate - at primary level were fulfilled.

In 1999-2000 with increase in share of means of compulsory health insurance, wider scope of the population and healthcare institutions the compulsory health insurance system, the contradiction of the incentives pledged in payment of medical services in compulsory health insurance (on resulting effect) and on the basis of itemized budget financing began to be felt (depending on capacity and states). Need of transition to single rules of payment for medical services ripened. In 2001-2004 new methods of financing with creation of system of the Single payer are step by step entered.

There was transition from the system of financing fragmented on levels of administrative division to accumulation of means of local budgets at the regional level where categorical grants from the republican budget (Fig. 1) also arrived.

Fig. 1. Accumulation of means of health care in system of the Single payer

System of the Single payer (2001-2004)

Note: Fig. 1. is in the Adviser company in printing option and it is provided at the request of users.

Technical and institutional capabilities of compulsory health insurance Fund for accumulation of financial flows, to introduction of new payment systems of suppliers of medical services were used for creation of system of the Single payer in 2000-2004 on behalf of Federal Compulsory Health Insurance Fund and its territorial administrations with transfer of financing of healthcare institutions for resulting effect.

Since 2001, thanks to amending and amendments in some laws, funds of local budgets began to be accumulated at the regional level. Mechanisms of accumulation of funds for health care - in the form of standard rates of assignments on health care for each area having the tax potential (The Chuya, Osh regions), or at the expense of income redistribution, remaining at the disposal of regional budgets from regulated taxes were fulfilled. Irrespective of option of receipt of funds on health care, the possibility of equalization of financing of health care in one area between areas appeared.

Along with transition to progressive methods of financing during health care reform, at least important role was played by introduction of the Program of the State Guarantees (PSG) and copayment for the medical services influencing both demand, and the offer and that is at least important, the health cares stimulating transition of the organizations to managerial and financial independence.

PGG is the state social standard in the field of health care determining amount of the medical care provided to the population free of charge or on favorable terms by budget funds and compulsory health insurance. In parallel with introduction of PGG the copayment by the population for some types of medical care designed to replace the unofficial requisitions and payments which overflowed health care is entered.

Big recognition among the population was gained by DP compulsory health insurance on provision of medicines of insured citizens at primary level which promoted increase in demand for primary services of health care based on evidential medicine, to improvement of availability of high-quality medicines and reducing complications in case of number of the diseases regulated at primary level.

2.1.3. Improvement of quality of the provided medical care

For improvement of service quality of health care the whole complex of actions directed to increase in professional competence of workers of health care, implementation of mechanisms of stimulation, improvement of material and technical resources of the organizations of health care, availability of medicines, introduction of the principles of evidential medicine, monitoring and modern quality management methods of the rendered services was performed.

High-quality reorganization of system is carried out to - and post-qualifying education, reorganization of faculties of KGMA and review of training programs according to the undertaken reforms in health care system is performed. The republican Center of continuous training of health and pharmaceutical workers is transformed to the Kyrgyz state medical institute of retraining and advanced training for training of specialists in family medicine, post-qualifying and life-long education.

For the purpose of providing the population with safe, effective and high-quality medicines it is developed and the State medicinal policy providing rational use of medicines including the list of the vital medicines takes root.

For improvement of quality of diagnosis of diseases, medical care, standardization of approaches to treatment the process of development of clinical protocols based on the principles of evidential medicine is implemented. Developed about 200 clinical protocols which take root into clinical practice.

Accreditation standards and licensing for the organizations of health care are developed and implemented.

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