Executive Summary of Kyrgyzstan Report
Kyrgyzstan, a former Soviet State, is located in Central Asia bordering Kazakhstan to the North, Uzbekistan to the West, Tajikistan to the South and China to the East. The capital is Bishkek located in the North of the country. With a Gross Domestic Product per capita of US$ 2,200 at Purchasing Power Parity, Kyrgyzstan is classified as a low income country. Life expectancy at birth is 69 years and Kyrgyzstan is ranked 120 out of 182 on the UNDP’s Human Development Index. Following the collapse of the Soviet Union, Kyrgyzstan faced a severe economic recession which impacted its capacity to adequately fund its health system.
Despite many challenges for the Kyrgyz health system people with diabetes are given special attention with a Diabetes law that addresses the free provision of all aspects of care including insulin, oral medicines, consultations and laboratory tests.
The International Diabetes Federation estimates that the prevalence of diabetes in Kyrgyzstan for those aged from 20-79 will increase from 4.3% in 2003 to 5.8% in 2025. Data from the Ministry of Health show an increase in the number of cases of 26.9% from 2002-2008 with total cases in 2008 at 28,893 with 2,238 people requiring insulin. Prevalence rates vary greatly between regions in Kyrgyzstan with a range of 503.0-1,550.1 cases per 100,000 population. Rates of Type 1 diabetes in the capital city compared to those in a rural area in Children under 14 (2007) are 8.4 times higher.
Implementing the RAPIA in Kyrgyzstan had as its aim to clearly identify the barriers to medicines and care that people with diabetes in Kyrgyzstan face in order to affect sustainable change in addition to increasing the data on diabetes and its financial impact on the health system and people with this condition.
Key Findings Organisation of the Health System
- Varying patient pathways for Type 1 and Type 2 diabetes in the different regions visited were observed
- Consultations work well, but people face long waiting times and short time spent with the doctor
- Education is not included in the consultation
- Referrals and counter-referrals were described as working well
· Some self-referrals were noted especially from the periphery to Bishkek
- Osh regional and Osh Children’s Hospital were able to manage diabetes at quite a high level and therefore avoided referring patients to Bishkek
- Close collaboration at district level between the hospital and Family Medicine Centre
- Every year one or two inpatient stays at different levels of the health system are planned for patients
Data Collection
- Disease surveillance for Non Communicable Diseases is included in the National Health Programme
- A diabetes register is being developed which has been piloted in some areas of the country
- The data flow from facilities to the Ministry of Health works well, but issues were raised about the reliability of data and the use of data for planning
Prevention
- The National Health Programme includes the use of mass media to promote disease prevention, but only some awareness activities are organised around World Diabetes Day
- Early detection of diabetes due to lack of knowledge was a problem for both:
· General population
· Healthcare workers
- Some problems exist treating some complications due to:
· Training
· Diagnostic tools
- Lack of priority given to patient education
Diagnostic tools and infrastructure
- Problems with the availability of some laboratory tools
- Problems with reagents and consumables were variable in the facilities visited
- Financial constraints were stated as the main problem for poor supplies of reagents and equipment
- Major lack of tools for the diagnosis of complications was present
Drug procurement and supply
- Difference between recommendations from World Health Organization Essential Medicines List and Kyrgyz Essential Medicines List
- About US$ 2 – US$ 3 million spent on diabetes supplies representing 1.4-2.0% of total expenditure on health
· Estimated 75% spent on insulin
· High overall cost due the purchase of insulin in penfills and analog insulin
- High tender prices compared to international guidance prices
- Problems with quantification of needs for diabetes supplies
- The main problem with insulin was not the overall supply, but the distribution of this total amount throughout the country
- Committee comprising the Ministry of Health, Diabetes Association of Kyrgyzstan and Physicians responsible for preparing the tender, which is carried out by lots
- Procurement law states that tenders need to be carried out by lots
· Issues raised whether State Procurement Law is adapted to the purchase of medicines
- No issues were reported with customs procedures
- Medicines in Kyrgyzstan are exempt of any Value Added Taxes and import duties
- The cold chain was stated as not being a problem
- Large quantities of insulin stored at some facilities at District level
Accessibility and affordability of medicines and care
- Only one District visited at the time of this study did not have insulin (92% availability of insulin)
· Insulin is available for free
- A problem however was noted with syringes with 75% of facilities visited not having syringes
- Oral medicines available in the public sector Glibenclamide and Repaglinide
· However, Repaglinide is not included on the essential list
- Some facilities using their own funds or funds from City budgets bought some Metformin
· Metformin first line of treatment in the clinical guidelines, yet not purchased centrally in sufficient quantities
Healthcare workers
- Despite facing many challenges, low salaries and lack of access to proper tools for care, the level of knowledge, care and dedication provided by doctors in Kyrgyzstan should be commended
- National clinical practice guidelines are currently being developed
- Many regions and districts have an Endocrinologist
· Not necessarily a specialist, but will serve as a focal point for diabetes and other endocrine disorders
- Family General Practitioners were not able to treat diabetes
· “Scared” of treating diabetes, especially using insulin
- Nurses in Kyrgyzstan play no role in diabetes management
- Different training programmes have been initiated, but did not provide healthcare workers with the practical tools they needed to manage diabetes
Adherence issues
- Poor adherence due to:
· People with Type 2 diabetes needing to purchase Metformin
· Poor knowledge
Patient education and empowerment
- Diabetes schools and education centres have been established in some facilities
- Doctors are responsible for delivering education, but are often too busy to do this
- Information and education materials are sometimes present, but not adapted to the Kyrgyz context with regards to diet and socio-economic situation
- Patient education for Type 1 diabetes was extremely well delivered
- Education for people with Type 2 diabetes was extremely poor
Community involvement and diabetes associations
- The Diabetes Association of Kyrgyzstan was established in 1998 with as its mission to protect the rights of people with diabetes
- Diabetes Federation created in 2008 by parents with children with Type 1 diabetes
· Activities are focused on patient education
- Most of the activities of these associations are focused in Bishkek
· Despite resource constraints they have been able to do some important work for people with diabetes in Kyrgyzstan
Positive policy environment
- Included in the National Health Programme is cardiovascular disease
· Common risk factors with diabetes
· Diabetes risk factor for cardiovascular disease
- In 2006 a law on diabetes came into being
· Primary prevention and a commitment to healthy lifestyles
· Actions that are scientifically justified
· Free provision of medicines and self-monitoring devices
· Training of healthcare workers including in diabetes education and counselling
· Social aspects
Recommendations
Organisation of the Health System
- Standardisation and organisation of patient pathways
- Include diabetes patient education as an integral part of the medical consultation
- Assess the use of yearly inpatient care for people with diabetes
Data Collection
- Clearly define the role of the diabetes register and ensure it is used for planning and decision making
- Improve the use of all data collected (quality and reliability) and use this data for planning and reporting
Prevention
- Increase the use of socio-culturally adapted means of primary prevention
- Increase awareness of diabetes, its risk factors and symptoms for healthcare workers and population as a whole
- Improve patient education
Diagnostic tools and infrastructure
- Improve availability of diagnostic tools and tools for the management of diabetes related complications
· Define the tools which should be present at different levels of the health system
Drug procurement and supply
- Follow WHO guidance for the types of insulin and medicines purchased
· Link purchases with clinical guidelines
- Review State Procurement Law to see if this is adapted to the purchase of medicines
· Make amendments if necessary
- Improve planning of purchases
- Improve distribution system of insulin and other diabetes supplies
Accessibility and affordability of medicines and care
- Link supply of syringes to supply of insulin
- Ensure main oral medicines required by people with diabetes, e.g. Metformin are purchased in sufficient quantities
Healthcare workers
- Increase practical training for healthcare workers at different levels of the health system
- Define the role of nurses in diabetes care
· Provide appropriate training
Adherence issues
- Increase in appropriate patient education and improved availability of medicines especially Metformin
Patient education and empowerment
- Development of patient education materials
· In Kyrgyz and Russian
· Adapted to the socio-cultural context
Community involvement and diabetes associations
- Define and expand role of diabetes associations
- Link diabetes with Kyrgyz-Swiss Village Health Committees project
Positive policy environment
- Emphasise the link between cardiovascular disease and diabetes and the common risk factors
- Develop a diabetes action plan that is integrated with measures specific for the cardiovascular disease national plan
A full copy of the report can be downloaded here:
Despite many challenges for the Kyrgyz health system people with diabetes are given special attention with a Diabetes law that addresses the free provision of all aspects of care including insulin, oral medicines, consultations and laboratory tests.
The International Diabetes Federation estimates that the prevalence of diabetes in Kyrgyzstan for those aged from 20-79 will increase from 4.3% in 2003 to 5.8% in 2025. Data from the Ministry of Health show an increase in the number of cases of 26.9% from 2002-2008 with total cases in 2008 at 28,893 with 2,238 people requiring insulin. Prevalence rates vary greatly between regions in Kyrgyzstan with a range of 503.0-1,550.1 cases per 100,000 population. Rates of Type 1 diabetes in the capital city compared to those in a rural area in Children under 14 (2007) are 8.4 times higher.
Implementing the RAPIA in Kyrgyzstan had as its aim to clearly identify the barriers to medicines and care that people with diabetes in Kyrgyzstan face in order to affect sustainable change in addition to increasing the data on diabetes and its financial impact on the health system and people with this condition.
Key Findings Organisation of the Health System
- Varying patient pathways for Type 1 and Type 2 diabetes in the different regions visited were observed
- Consultations work well, but people face long waiting times and short time spent with the doctor
- Education is not included in the consultation
- Referrals and counter-referrals were described as working well
· Some self-referrals were noted especially from the periphery to Bishkek
- Osh regional and Osh Children’s Hospital were able to manage diabetes at quite a high level and therefore avoided referring patients to Bishkek
- Close collaboration at district level between the hospital and Family Medicine Centre
- Every year one or two inpatient stays at different levels of the health system are planned for patients
Data Collection
- Disease surveillance for Non Communicable Diseases is included in the National Health Programme
- A diabetes register is being developed which has been piloted in some areas of the country
- The data flow from facilities to the Ministry of Health works well, but issues were raised about the reliability of data and the use of data for planning
Prevention
- The National Health Programme includes the use of mass media to promote disease prevention, but only some awareness activities are organised around World Diabetes Day
- Early detection of diabetes due to lack of knowledge was a problem for both:
· General population
· Healthcare workers
- Some problems exist treating some complications due to:
· Training
· Diagnostic tools
- Lack of priority given to patient education
Diagnostic tools and infrastructure
- Problems with the availability of some laboratory tools
- Problems with reagents and consumables were variable in the facilities visited
- Financial constraints were stated as the main problem for poor supplies of reagents and equipment
- Major lack of tools for the diagnosis of complications was present
Drug procurement and supply
- Difference between recommendations from World Health Organization Essential Medicines List and Kyrgyz Essential Medicines List
- About US$ 2 – US$ 3 million spent on diabetes supplies representing 1.4-2.0% of total expenditure on health
· Estimated 75% spent on insulin
· High overall cost due the purchase of insulin in penfills and analog insulin
- High tender prices compared to international guidance prices
- Problems with quantification of needs for diabetes supplies
- The main problem with insulin was not the overall supply, but the distribution of this total amount throughout the country
- Committee comprising the Ministry of Health, Diabetes Association of Kyrgyzstan and Physicians responsible for preparing the tender, which is carried out by lots
- Procurement law states that tenders need to be carried out by lots
· Issues raised whether State Procurement Law is adapted to the purchase of medicines
- No issues were reported with customs procedures
- Medicines in Kyrgyzstan are exempt of any Value Added Taxes and import duties
- The cold chain was stated as not being a problem
- Large quantities of insulin stored at some facilities at District level
Accessibility and affordability of medicines and care
- Only one District visited at the time of this study did not have insulin (92% availability of insulin)
· Insulin is available for free
- A problem however was noted with syringes with 75% of facilities visited not having syringes
- Oral medicines available in the public sector Glibenclamide and Repaglinide
· However, Repaglinide is not included on the essential list
- Some facilities using their own funds or funds from City budgets bought some Metformin
· Metformin first line of treatment in the clinical guidelines, yet not purchased centrally in sufficient quantities
Healthcare workers
- Despite facing many challenges, low salaries and lack of access to proper tools for care, the level of knowledge, care and dedication provided by doctors in Kyrgyzstan should be commended
- National clinical practice guidelines are currently being developed
- Many regions and districts have an Endocrinologist
· Not necessarily a specialist, but will serve as a focal point for diabetes and other endocrine disorders
- Family General Practitioners were not able to treat diabetes
· “Scared” of treating diabetes, especially using insulin
- Nurses in Kyrgyzstan play no role in diabetes management
- Different training programmes have been initiated, but did not provide healthcare workers with the practical tools they needed to manage diabetes
Adherence issues
- Poor adherence due to:
· People with Type 2 diabetes needing to purchase Metformin
· Poor knowledge
Patient education and empowerment
- Diabetes schools and education centres have been established in some facilities
- Doctors are responsible for delivering education, but are often too busy to do this
- Information and education materials are sometimes present, but not adapted to the Kyrgyz context with regards to diet and socio-economic situation
- Patient education for Type 1 diabetes was extremely well delivered
- Education for people with Type 2 diabetes was extremely poor
Community involvement and diabetes associations
- The Diabetes Association of Kyrgyzstan was established in 1998 with as its mission to protect the rights of people with diabetes
- Diabetes Federation created in 2008 by parents with children with Type 1 diabetes
· Activities are focused on patient education
- Most of the activities of these associations are focused in Bishkek
· Despite resource constraints they have been able to do some important work for people with diabetes in Kyrgyzstan
Positive policy environment
- Included in the National Health Programme is cardiovascular disease
· Common risk factors with diabetes
· Diabetes risk factor for cardiovascular disease
- In 2006 a law on diabetes came into being
· Primary prevention and a commitment to healthy lifestyles
· Actions that are scientifically justified
· Free provision of medicines and self-monitoring devices
· Training of healthcare workers including in diabetes education and counselling
· Social aspects
Recommendations
Organisation of the Health System
- Standardisation and organisation of patient pathways
- Include diabetes patient education as an integral part of the medical consultation
- Assess the use of yearly inpatient care for people with diabetes
Data Collection
- Clearly define the role of the diabetes register and ensure it is used for planning and decision making
- Improve the use of all data collected (quality and reliability) and use this data for planning and reporting
Prevention
- Increase the use of socio-culturally adapted means of primary prevention
- Increase awareness of diabetes, its risk factors and symptoms for healthcare workers and population as a whole
- Improve patient education
Diagnostic tools and infrastructure
- Improve availability of diagnostic tools and tools for the management of diabetes related complications
· Define the tools which should be present at different levels of the health system
Drug procurement and supply
- Follow WHO guidance for the types of insulin and medicines purchased
· Link purchases with clinical guidelines
- Review State Procurement Law to see if this is adapted to the purchase of medicines
· Make amendments if necessary
- Improve planning of purchases
- Improve distribution system of insulin and other diabetes supplies
Accessibility and affordability of medicines and care
- Link supply of syringes to supply of insulin
- Ensure main oral medicines required by people with diabetes, e.g. Metformin are purchased in sufficient quantities
Healthcare workers
- Increase practical training for healthcare workers at different levels of the health system
- Define the role of nurses in diabetes care
· Provide appropriate training
Adherence issues
- Increase in appropriate patient education and improved availability of medicines especially Metformin
Patient education and empowerment
- Development of patient education materials
· In Kyrgyz and Russian
· Adapted to the socio-cultural context
Community involvement and diabetes associations
- Define and expand role of diabetes associations
- Link diabetes with Kyrgyz-Swiss Village Health Committees project
Positive policy environment
- Emphasise the link between cardiovascular disease and diabetes and the common risk factors
- Develop a diabetes action plan that is integrated with measures specific for the cardiovascular disease national plan
A full copy of the report can be downloaded here:
| Kyrgyzstan RAPIA Report |