2014年-世界发展银行全球_Kyrgyz_Republic_Public_Expenditure_Review_Policy_Notes___Health_54页_1mb

Kyrgyz Republic Public Expenditure Review: Health Sector Summary

Executive Summary

The Kyrgyz Republic has undergone significant health financing and organizational reforms over the past two decades, with the Manas and Manas Taalimi health reform programs setting the foundation for a comprehensive overhaul of the health system. These reforms have positioned the country as a regional leader in health system improvements, despite challenging economic and social conditions. The health system has achieved notable progress in health outcomes, access to services, and financial protection, with life expectancy exceeding that of several former Soviet republics, and infant and under-5 mortality rates halved between 1990 and 2010. However, the system still faces financial sustainability challenges, particularly due to the growing funding gap of the State Guaranteed Benefits Package (SGBP).

The SGBP, which guarantees free primary and emergency care, has been expanded to include co-payment exemptions for specific social categories and priority medical conditions. However, the current targeting mechanisms are not effective in reaching the poorest segments of the population. About 57.5% of SGBP beneficiaries are not in the bottom two income quintiles, and 51.3% of the poorest are not exempt from co-payments. The report recommends adopting a proxy means test (PMT) or a mean-tested approach to improve targeting and reduce the financial burden on the health sector.

The report also highlights the need for modernizing hospital services, improving cost-effectiveness of priority disease management, and self-financing dental and balneology services. Additionally, it suggests harmonizing the rules of financing sources, reallocating savings from unfilled positions, and improving the procurement process for hospital drugs and medical supplies. The introduction of centralized procurement under the Mandatory Health Insurance Fund (MHIF) is recommended, although current capacity is limited and would require time and enhanced institutional capabilities.

Key Outcomes of the Kyrgyz Health System

• Health Outcomes: The Kyrgyz Republic has achieved positive health outcomes, including improved child and maternal health, reduced infant and under-5 mortality, and high immunization rates.
• Access to Services: Utilization of both hospital and outpatient services is relatively equal across income groups.
• Financial Protection: The health system has a low incidence of catastrophic and impoverishing out-of-pocket (OOP) spending.
• Epidemiological Challenges: The country faces a significant burden from non-communicable and chronic diseases, particularly cardiovascular diseases (CVDs), tuberculosis (TB), and HIV infection.
• Funding Gap: The SGBP faces a substantial funding gap, estimated at 20–27% of the total program cost, due to expansion of co-payment exemptions and increased salaries for health workers.

Key Policy Recommendations

• Improve Targeting of Co-payment Exemptions: Use proxy means test or mean-tested approaches to better target the poor.
• Optimize Hospital Services: Introduce modern technologies like day and laparoscopic surgery to reduce unnecessary hospitalizations and improve efficiency.
• Enhance Cost-effectiveness for Priority Diseases: Focus on prevention and management of CVDs through risk factor screening, mass media campaigns, and secondary prevention with pharmaceuticals. Increase tobacco taxes to reduce CVD-related morbidity and generate additional revenue.
• Self-financing of Dental and Balneology Services: Shift to private provision and targeted subsidies for these services to improve efficiency and equity.
• Harmonize Financing Rules: Align the rules for budget funds, MHI/Social Fund payroll contributions, patient co-payments, and special means to improve flexibility and reduce administrative inefficiencies.
• Reallocate Savings from Unfilled Positions: Reduce the number of unfilled positions and ensure better use of resources through revised staff norms and training for managers.
• Improve Procurement Efficiency: Implement centralized procurement through framework agreements, while maintaining flexibility for individual facilities to purchase drugs and medical supplies.

Structure of the Health System

• Mandatory Health Insurance Fund (MHIF): Administers the SGBP and manages payments to providers based on output-based mechanisms.
• Ministry of Health (MoH): Develops national health policy, implements health programs, and oversees the quality of care and accreditation.
• State Guaranteed Benefits Package (SGBP): Provides free primary and emergency care, with co-payment for inpatient and specialized outpatient services.
• Additional Drug Package (ADP): Offers drug benefits to those enrolled in the MHI, covering specific diseases and conditions.
• Private Sector: Has been gradually growing, including pharmacies, outpatient, and hospital services. However, legal mechanisms for contracting private providers under the SGBP are still underdeveloped.

Challenges and Opportunities

• Uninsured Population: About 23% of the population is uninsured, with lower coverage in Bishkek and informal labor markets contributing to underreporting.
• Fiscal Sustainability: The SGBP faces a funding gap due to expansion of exemptions and increased salaries, necessitating further reforms to ensure financial sustainability.
• Quality of Care: While access has improved, the quality of care remains a challenge, with a need to focus on improving care delivery and outcomes.
• Procurement Capacity: MHIF lacks the capacity to implement centralized procurement, requiring time and institutional strengthening to improve efficiency and quality.

Conclusion: The Way Forward

The Kyrgyz Republic must continue its health reform efforts by focusing on improving the targeting of co-payment exemptions, optimizing hospital services, enhancing cost-effectiveness of priority disease management, and strengthening the procurement process. These measures are essential to ensure the financial sustainability and effectiveness of the health sector, while also improving the quality of care and health outcomes for the population.