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USAID Defeat Tuberculosis in the Kyrgyz Republic
Hakmiddin lives in a small village in northern Kyrgyzstan. After being diagnosed with tuberculosis several years ago, he never completed a full course of treatment because he had to return to work. As a result, he did not receive the necessary medications. There are many people who share Hakmiddin’s struggle against tuberculosis in the Kyrgyz Republic today.

Kyrgyzstan has one of the highest rates of tuberculosis in Europe. According to the latest data, multidrug-resistant tuberculosis (MDR-TB) is now at 26 percent among new cases, compared to three percent of new tuberculosis cases worldwide. Drug supplies were limited and universal treatment standards were lacking in the country. According to the World Health Organization, only 55 percent of MDR-TB cases were successfully treated in 2011.

In response to this pressing challenge, USAID partnered with the Kyrgyz Republic to manage this deadly disease through improved services, diagnostics, new clinical guidelines, new outpatient treatment and care models. In 2012, led by the KNCV Tuberculosis Foundation, Kyrgyzstan’s National Tuberculosis Program and the Ministry of Health developed new national guidelines on MDR-TB, in collaboration with the USAID-funded TB CARE I project.

The project worked with community groups and non-government organizations to ensure more equitable access to tuberculosis in the Kyrgyz Republic in addition to diagnosis, treatment and a reduction in the social stigma attached to the disease. It also provided training for health care workers and reformed health financing systems to improve tuberculosis treatment in the country.

As a result, patients are able to receive the care they need based on the type of tuberculosis they have, including full outpatient treatment. These efforts resulted in increasing the MDR-TB treatment success rate from 42 percent in 2011 to 57 percent in 2013. In 2014, USAID followed up its previous efforts and developed a five-year project, the USAID Defeat Tuberculosis project, to ease the burden of tuberculosis in the Kyrgyz Republic and strengthen its health care system.

The project offered support for quality improvement and standardization of laboratory services. To jumpstart this process, the USAID Quality Health Care Project introduced a Quality Management System in laboratory networks in Kyrgyzstan. Seventeen lab quality control specialists in Bishkek and Chui Oblast participated in relevant training sessions. Undergraduate and continuing education institutions also integrated some tuberculosis training modules with the project’s support.

Today, 30.6 percent of the population still lives below the national poverty line and 42.7 percent of the employable population is unemployed. Therefore, providing affordable tuberculosis diagnosis and treatment for patients and reducing prolonged hospitalization to ensure people’s productivity are still challenging tasks that the country needs to address in the future.

With two more years left, the USAID Defeat Tuberculosis Project will focus more on advocating childhood and adolescent tuberculosis diagnosis and treatment, as well as the prescription of child-friendly drug formulas in the country.

Yvie Yao

Photo: Flickr

Kyrgyz RepublicIn the Kyrgyz Republic, an Asian country along the Silk Road, 41 percent of the population relies on the forest for fuel, food and other products. Small communities that depend on the forest are especially vulnerable to mismanaged forests and poverty. The World Bank is partnering with the Kyrgyz Republic to develop a sustainable strategy for managing a major resource for the country and its rural populations.

Improving sustainable forest management is an important step for the Kyrgyz Republic in order to combat poverty. Data from the World Bank shows poverty in the Kyrgyz Republic decreased from 37 percent in 2013 to 30 percent in 2014. However, the country remains one of the poorest states in Central Asia.

A study by the Food and Agriculture Organization of the UN (FAO) reported the Kyrgyz Republic as an ecologically rich country. The total forested area in the Kyrgyz Republic is more than 1.1 million hectares, approximately five percent of the country.

The forests are highly diverse and include spruce, walnut-fruit, juniper and riverside forests. In addition to timber and fuel, the forests provide nuts, fruits, mushrooms and other edible plants for communities. Forest products also provide food security during tough economic and agricultural times.

Beginning in 2016, The Integrated Forest Ecosystem Management Project (IFEMP) will be implemented in partnership with the Kyrgyz Republic over five years. The World Bank is financing $16 million for the project, which targets forest management at the national and leskhoz level. The leskhozes are state forest farms or agencies managing at the local level.

In a press release, the World Bank said the IFEMP’s main objectives will be accomplished “through investments in management planning, ecosystem restoration and infrastructure.” Improved data collection and distribution is an important aspect of IFEMP. The project will update the National Forest Inventory and increase access to the information at all levels. Ultimately it is estimated IFEMP will improve the management of one-tenth of Kyrgyz forests and introduce sustainable forest management to almost half of all the forests.

According to the FAO study, “forests are potentially valuable to rural people as a means of income generation and, thus, poverty reduction.” Recent efforts focusing on sustainable forest management strategies aim to better serve both the environment and those in poverty.

In the World Bank’s press release, Jean-Michel Happi, World Bank Country Manager in the Kyrgyz Republic, said, “We are pleased to support the project that will contribute to improving the lives of rural people by protecting and improving the natural resource base of forests and pastures on which the livelihoods and communities are dependent.”

Cara Kuhlman

Sources: FAO, IMF, World Bank 1, World Bank 2
Photo: Kygryzstan

Kyrgyz USAID Tuberculosis
How can a government ensure that resources devoted to health are used efficiently and effectively? Which performance-based incentive is really providing the desired outcome? How responsive are health policies to the actual needs of its target community? The Health Finance and Governance (HFG) project was launched by USAID in 2012 to help answer these questions. It is a five year- 209 million dollar global project to improve health finance and health governance in partner countries. The end goal is to improve health outcomes and access to health care, as well as generate evidence on the most efficient improvements to health management.

HFG works on five broad topics relating to financing health projects: transparency and accountability, pricing and management, development of evaluation metrics, and capacity building. Perhaps the single most important factor in dealing with these issues is that local, regional and cultural aspects contribute to the problems and the solutions. No one solution can fit all countries or even all target populations within one country. Let us consider just one example of HFG’s work.

In 2013, the Kyrgyz Republic had a tuberculosis (TB) incidence rate of 141 for every 100000 people. It is among the countries suffering from the most high multi-drug resistant TB (MDR-TB) burden in the world, yet TB detection rate at 66 percent, and drug susceptibility testing coverage, at 25 percent is still low. The WHO cites poor coordination of TB data management, insufficient oversight of treatment and monitoring of adherence to treatment, and non-compliance by patients and health providers to the prescribed antibiotic regimen as well as poor infection control as causes for rampant prevalence of TB and the spread of MDR-TB.

In the 1990s, the Kyrgyz Republic transitioned its general hospital system to case-based financing, where funds are provided to a hospital based on the previous years bed occupancy levels. This incentivized hospitals to increase hospitalizations, which not only is not always required leading to ineffective use of funds, but also exposes the patient to an infection-rich environment where depressed immune systems can acquire secondary, drug resistant infections.

The HFG assisted the Kyrgyz Republic to transition to a financing system that is based on the number of patients treated. Under this model, the hospital would receive a set fees for complicated MDR-TB cases and a lower fees for less complicated cases. This kind of financing structure also stimulated hospitals to require bacterial confirmation of the disease as opposed to a more subjective clinical diagnosis, which would reduce the number of cases treated in error. To complete this transition successfully, the government had to be fully involved to ensure that finances saved by reduced hospitalizations would be reinvested to provide better support for TB outpatient services like patient transportation, supplies, and social support.

In this region, this kind of approach integrates well with more standard approaches of launching rapid diagnostics like the work done by the National TB program and TB Reach, or providing access to new antibiotics like the End TB Erogram run by Partners In Health, Medecins Sans Frontieres, Interactive Research and Development and UNITAID. There is still a long way to go and a lot of gaps to fill. As about 44 percent of the financing for TB projects in Kyrgyzstan comes from foreign aid, assistance in mobilizing domestic resources can make health projects more sustainable. This would parallel the work of HFG in Nigeria where it is working to increase the resource mobilization capacity to support HIV/AIDS treatment.

When the various arms of the government work effectively with each other and with private sector and donor organizations, inefficiencies and wastage in development projects can be resolved. However, the first step remains identifying these gaps and designing novel solutions to fill them. When the HFG completes its term in 2017, a full measure of its successes can guide further development decisions.

Mithila Rajagopal

Sources: HFG, Medecins Sans Frontiers, StopTB, WHO, The World Bank
Photo: USAID