Community-Based Early Childhood Development Phase II

ASIAN DEVELOPMENT BANK TA 4797

DRAFT FINAL REPORT

VOLUME I

SECTOR ANALYSIS AND STRATEGY

SECOND COMMUNITY BASED EARLY CHILDHOOD DEVELOPMENT PROJECT

KYRGYZ REPUBLIC

November 2007

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ABBREVIATIONS

ADB Asian Development Bank ADP Additional Drug Package AIDS Acquired Immune Deficiency Syndrome AKF Aga Khan Foundation AO Ayil Okmotu BCC Behavior Change Communication BFH Baby Friendly Hospital CBC Community-Based Clinicians CBECDP Community-Based Early Childhood Development Project CFC Coordinator of Family and Children DDSME Department of Drug Supply and Medical Equipment DFID Department for International Development DHS Demographic and Health Survey DSSES Department of State Sanitary Epidemiological Supervision ECA Eastern Europe and Central Asia ECD Early Childhood Development ECE Early Childhood Education EFA Education for All EPI Expanded Program on Immunization FAO United Nations Food and Agriculture Organization FAP Feldsher Accousher Point FCBECDP First Community-Based Early Childhood Development Project FGP Family Group Practice FMC Family Medicine Centre FTI Fast Track Initiative GDP Gross Domestic Product HCF Health Care Facilities HIV Human Immunodeficiency Virus HPC Health Promotion Centers HPU Health Promotion Units IDA Iron Deficiency Anemia IDD Iron Deficiency Disorders IMCI Integrated Management of Childhood Illnesses JFPR Japan Fund for Poverty Reduction KAE Kyrgyz Academy of Education KASP Kyrgyz Association of Salt Producers KFW Die Kreditanstalt für Wiederaufbau MCH Maternal and Child Health MCN Maternal and Child Nutrition MDG Millennium Development Goals MHIF Mandatory Health Insurance Fund MICS Multiple Indicator Cluster Survey MLSD Ministry of Labor and Social Development MTBF Medium Term Budget Framework MOE Ministry of Education MOEF Ministry of Economy and Finance

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MOH Ministry of Health MPS Making Pregnancy Safer NCPCS National Center for Pediatrics and Child Surgery NGO Non-Governmental Organization PEO Preschool Educational Organizations PEPC Promoting Effectiveness of Perinatal Care PHC Primary Health Care PPTA Project Preparatory Technical Assistance PRA Participatory Rural Appraisal PMO Project Management Office RCHP Republican Center for Health Promotion RMIC Republican Medical Information Center RTI Respiratory Tract Infections SCBECDP Second Community-Based Early Childhood Development Project SDC Swiss Development Cooperation SES Sanitary Epidemiological Service SGBP State-Guaranteed Benefit Package SIDA Swedish Development Association (Styrelsen för internationellt utveck lingssamarbete) SMG Stimulating (Matching) Grants SRC Swiss Red Cross STI Sexually Transmitted Infection SWAp Sectoral Wide Approach TA Technical Assistance TB Tuberculosis UCFS Units for Child and Family Support U5MR Under-five mortality rate UNICEF United Nations Children’s Fund UNFPA United Nations Family Planning Agency USAID United States Agency for International Development VAD Vitamin-A Deficiency VHC Village Health Committees VIDA-HNI Village Integrated Development Approach for Health and Nutrition Im provement VIF Village Initiative Fund VMD Vitamin and Mineral Deficiencies WB The World Bank WHO World Health Organization

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GLOSSARY

Bacillus Calmette-Guerin Vaccine for tuberculosis (BCG) (Basic) Curriculum The Basic curriculum represents a complex of specifications concerning the structure and the content of preschool care and education. The Basic curriculum reflects: (1) correlation between basic and variable part of preschool education, (2) duration of activities and weekly load for educational activity. These normatives are established in compliance with the age and physiological characteristics of child development. (Basic) Education Programs Basic program (contents and necessary materials to implement the curriculum): The educational programs reflect the main pedagogical educational ideas; content of the work with children; ways, forms and means of implementation of the educational content and mechanism of results assessment Body Mass Index Weight in kg divided by height in m2 Ayil Okmotu Executive body of the local self-government (the people’s assembly) Early Childhood Development Early childhood development refers to the physical and psychosocial development during the first several years of life. Early Childhood Education Family based and/or Institutional activities to promote the bio- psycho-social development of children (0-7years) Early Child Education Refers to the administration of an 8 week enriched early child experi- Program ence (ECE) curriculum that helps children bridge the gap between home and school and improve their readiness for formal education. Infant Mortality The number of children dying under one year of age divided by the number of live births that year. The infant mortality rate is an important measure of the well-being of infants, children, and pregnant women because it is associated with a variety of factors, such as maternal health, quality and access to medical care, socioeconomic conditions, and public health practices (http://www.medterms.com) Iodine Supplementation Refers to a range of services that seeks to address the iodine defi- Program ciency in the population. Included in this program is the provision of free iodized capsules and iodized salt. Iron Supplementation Program Refers to a range of services that seeks to address the iron deficiency in the population particularly of children and mothers. Included in this program is the provision of free iron syrup, tablets/capsules. Integrated Management of IMCI is a strategy to improve child health formulated by WHO and Childhood Illnesses (IMCI) UNICEF in 1996. It focuses on the care of children under five. It in- corporates a strong component of prevention and health promotion as an integral part of care. Thus, among other benefits, it helps to increase vaccination coverage and to improve knowledge and home- care practices for children under five, subsequently contributing to growth and healthy development. Jumgal Model A model of a village initiative introduced by the Kyrgyz Swiss- Swedish Health Project (it is popularly called “Jumgal model” since Jumgal raion in Naryn oblast was a pilot project). The main approach of the model is the establishment of Village Health Committees at community level, participatory rural appraisal (PRA) for assessing the needs of the community and establishment of action groups which aim to solve identified problems. Licensing Licensing is the permission given to educational organizations for carrying out educational activities with the purpose to ensure that the quality of education is up to the demands of the state standards.

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Life Birth Live birth refers to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life - e.g. beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles - whether or not the umbilical cord has been cut or the placenta is attached. Each product of such a birth is considered live born. (WHO) Neonatal mortality The number of children dying under 28 days of age divided by the number of live births that year (http://www.medterms.com) Primary health care Primary health care is a broad concept focusing on prevention of diseases and disabilities by changing lifestyle, behavior, vaccinations, early detection of diseases, etc. Besides the MOH, other Min- istries also focus on aspects of primary health care (for example wearing safety belts, helmets, etc). ECD is a typical example of primary health care, namely a multi-sector approach towards improving the well being of children. Primary medical care or Primary medical care or primary curative care applies to the health primary curative care service for patients consulting the primary care provider with complaints or chronic illnesses and seeking treatment for same. Be- sides general practitioners also dentists, pharmacists, midwives and physiotherapists outside hospitals may be considered as primary medical care providers Public health Public health is a task of the Government focused on protection of the community (citizens and environment) from disease. Information on mortality and morbidity are important tools. Epidemiology, sanitation, primary and secondary prevention are typical public health tasks. Secondary Care Services provided by medical specialists who generally do not have first contact with patients (eg, cardiologist, urologists, dermatologists) (http://www.pohly.com/terms_s.html) Stimulating (Matching) Grants Money transfer from the republican budget for implementation of so- (SMG) cial projects at local level. Local self-governments can make applications to the special commission of the Ministry of Economy and Fi- nance in order to receive funds from the SMG Under-Five Mortality Under-five mortality rate is the number of children dying before reaching the age of five, if subject to age-specific mortality rates of that period (WHO) Village Initiative Fund Small grants up to a maximum budget of USD 5000 provided by the FCBECDP in order to finance small local projects related to ECD. Vitamin A Supplementation Refers to a range of services that seeks to address the vitamin A Program deficiency of children and mothers. Included in the services is the provision of free vitamin A capsules.

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CONTENTS

I. INTRODUCTION...... 1 A. Background...... 1 B. Rationale...... 2 C. Experiences of the FCBECDP ...... 6 D. The Kyrgyz Government’s ECD Goals...... 8 E. Outline of the ECD Strategy...... 9

II. MATERNAL AND CHILD HEALTH ...... 13 A. Health Status of Women and Children...... 13 B. The MOH and its Policies and Programs Relevant for MCH ...... 17 C. Description of the MCH Service Delivery System ...... 25 D. MCH Service Provision at all Levels of the Delivery System ...... 30 E. Other Services relevant for MCH ...... 32 F. Resources for MCH...... 39 G. Donor Support...... 47 H. Summary of Major Challenges...... 50 I. Strategy to Improve Mother and Child Health ...... 53

III. MATERNAL CHILD NUTRITION...... 62 A. Nutrition Situation and Micronutrient Deficiencies of Mother and Children ...... 62 B. Policies and Programs related to MCN ...... 69 C. Delivery of MCN Services in Health Institutions...... 71 D. Strategies to Reduce Micronutrient Deficiencies ...... 72 E. Stakeholder Analysis...... 76 F. Human Resources and Training for Nutrition...... 78 G. Strategy to Improve Maternal and Child Nutrition ...... 79

IV. EARLY CHILDHOOD CARE AND EDUCATION ...... 93 A. Status of Early Childhood Care and Education...... 93 B. Policies and Normative Regulations related to Pre-School Education...... 96 C. Financing of Pre-Schools...... 106 D. Accreditation, Attestation and Licensing ...... 116 E. Assessment of Different Preschool Program Models...... 118 F. Training and Qualification ...... 120 G. Quality Management...... 128 F. Capacity Building ...... 130 H. Donors’ Activity ...... 131 I. Summary Overview on Major Problems Related to ECCE ...... 135 J. Strategy to Improve ECCE...... 137

V. CAPACITY BUILDING...... 155 A. Policy and Institutional Framework for ECD...... 155 B. ECD Stakeholders...... 156 C. ECD Financing Mechanisms at the Community Level ...... 161 D. Strategy for Capacity Building in ECD ...... 163

VI. ECONOMIC AND FINANCIAL ANALYSIS...... 168 A. Education and Health Finance...... 168 B. ECD Investment Plan...... 184 C. Preliminary Economic Analysis ...... 184

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ANNEXES

ANNEX 1 WHO MCH Statistics ANNEX 2 State Guaranteed Benefit Package ANNEX 3 Vitamin and Mineral Deficiency (VMD) Goals Unicef ANNEX 4 Baby Friendly Hospital – Breastfeeding Promotion ANNEX 5 PEPC Training Pilot Raions ANNEX 6 Integrated Management of Childhood Illnesses ANNEX 7 Donor and MoH Support for IMCI and PEPC Training ANNEX 8 Number of Health Facilities in Kyrgyz Republic in 2005 ANNEX 9 Number of Graduates of Medical Faculties ANNEX 10 Number of mid-level Graduates of Medical Colleges ANNEX 11 FAP’s in Need of Repair per Oblast ANNEX 12 External Assistance to the Kyrgyz Republic in the ECD Sector ANNEX 13 Global Prevalence and Trends in Nutritional Status ANNEX 14 Nutrition in Pre-service Training of Medical Doctors, Nurses and Midwives ANNEX 15 Nutrition Goals in UN SubCommittee and Nutrition in the Millennium De- velopment Goals ANNEX 16 Linkages Between Nutrition, Health, Labor Productivity and Causes of Malnutrition ANNEX 17 How Thailand tackled Undernutrition ANNEX 18 Number of State Kindergartens and Number of Preschool Age Children in all Oblasts ANNEX 19 Public Financial Management Action Plan for 2006 ANNEX 20 PEO Budget ANNEX 21 Books/Publications on ECCE and Preschool Education published in the Kyrgyz Republic

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I. INTRODUCTION

A. Background

1. In March 2004 the Government of the Kyrgyz Republic with support from the Asian Development Bank (ADB) started to implement the First Community-Based Early Childhood Development Project (FCBECDP). It is planned to be completed by December 2008. The total costs of this project are US$ 13.5 million, out of which US$ 10.5 million are a loan from the ADB and US$ 3 million are counterpart funding from the Government and involved communities. To extend the coverage of the FCBECDP and to build on the experience gained, the Government and ADB agreed on a follow-on project, the Second CBECDP (SCBECDP), which was included in the 2007 lending program.

2. To prepare the SCBECDP the Government of the Kyrgyz Republic requested TA from the ADB. The expected outputs of this Project Preparatory Technical Assistance (PPTA) are (i) a needs assessment, (ii) a policy and sector analysis and training, and (iii) a project designed for ADB financing. From November until beginning of March, the needs assessment was carried out by the team of national and international experts. The sector analysis was started in parallel and is the result of 2-3 missions of the international experts and support from a team of national experts. The results of the sector analysis are presented in this report.

3. The present strategic sector analysis report provides an in-depth analysis and strategy to improve ECD. The selected sub-sectors involved in Early Childhood Development (ECD) are Maternal and Child Health (MCH), Maternal and Child Nutrition (MCN) and Early Childhood Care and Education (ECCE). The report also looks into issues related to Capacity Building and provides an Economic and Financial Analysis of the country. This first Chapter of the report establishes the rationale for ECD in Kyrgyzstan and outlines a proposed overall strategy for improving ECD in the Kyrgyz Republic during the next 8 years (2008-2015).

4. The section on MCH first of all briefly describes the health status of women and children in the Kyrgyz Republic, which were presented and analyzed at length in the Needs As- sessment Report. Thereafter a detailed analysis of the MCH sub-sector is given, looking into MCH policies and programs, the MCH service delivery system and the provision of MCH as well as other relevant services such as public health, epidemiological surveillance and drug distribution. Furthermore, the sub-sector analysis looks into financial aspects, human resources for MCH, facilities and equipment and provides an overview on on-going donor supported MCH projects. Based on the findings of the needs assessment and the sub-sector analysis, a strategy to improve the MCH situation in the Kyrgyz Republic is presented in the last chapter of this section.

5. Similarly, the section on MCN first of all briefly describes the current nutrition situation and prevailing micronutrient deficiencies in the Kyrgyz Republic. Then it analyzes existing policies and programs related to MCN, the delivery of MCN services within health institutions, the various strategies to improve MCN that are already applied in the Kyrgyz Republic, major stakeholder as well as human resources and training issues. Based on this analysis a strategy for improving MCN within the next 8 years is outlined in the last sub-chapter on MCN.

6. In the ECCE section the current situation with regard to ECCE is briefly summarized as the detailed description has been presented in the Needs Assessment Report. The analysis of the ECCE sub-sector includes an analysis of policies and normative regulations related to pre-school education, financing issues, regulation of the sub-sector as well as quality management aspects, human resources issues such as training and capacity building and an overview over on-going donor financed ECCE projects. The last sub-chapter outlines a proposal for strategy to improve ECCE in the Kyrgyz Republic within the next 8 years.

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7. The chapter on Capacity Building analyzes ECD financing mechanisms, the policy and institutional framework for ECD as well as the various stakeholders involved in ECD at the national and especially at the local level. A capacity building strategy aiming at strengthening the various stakeholders’ skills and their involvement in ECD is presented focusing not only on the capacities of authorized governmental bodies but also on communities and families as the primary beneficiaries of ECD programs.

8. The chapter on Financial and Economic Analysis describes the macroeconomic context of the Kyrgyz Republic; it reviews the public expenditure on health and education (past and future trends) and compares them to other countries in the region. An investment plan for the ECD sector in the Kyrgyz Republic for a period of 8 years (2008 until 2015) has been prepared on the basis of the sub-sector strategies presented in the foregoing chapters. The underlying objectives and targets of the investment plan are summarized in chapter E below. The sub-sector strategies and the investment plan will be presented to and discussed with the Government counterparts in a workshop September this year.

B. Rationale

1. Importance of ECD

9. ECD refers to physical and psychosocial development during the first several years of life, with the target group from birth to age 8. There is clear evidence that the fundamentals of children’s physical, intellectual, emotional, social and psychosocial development are laid in the early years of childhood.1 Scientists have found that positive experiences in early life stimulate the formation of pathways and processes in the brain, whereas negative experiences are detrimental to brain development2.

10. Furthermore from birth until approximately 5 years of age children are growing very fast and if they receive appropriate support for “growth in cognition, language, motor skills, adaptive skills, and social-emotional functioning, the child is more likely to succeed in school and later contribute to society”3 or as UNICEF formulates it:

The early years of life are crucial. When well nurtured and cared for in their earliest years, children are more likely to survive, to grow in a healthy way, to have less disease and fewer illnesses, and to fully develop thinking, language, emotional and social skills. When they enter school, their prospects for performing well are improved. And as adolescents, they are likely to have greater self-esteem. Later in life, they have a greater chance of becoming creative and productive members of society. In just one generation, these human gains can help break the cycles of poverty, disease and violence that affect so many countries.” (http://www.unicef.org/media/9475.html)

1 Vargas-Barón, Emily 2005, Planning Policies for Early Childhood Development: Guidelines for Action; UNICEF. Young, M. E., ed. (2007): Early Child Development – From Measurement to Action. A Priority for Growth and Equity. Washington, D.C.: World Bank. http://www.worldbank.org/children. Young, M. E., ed. 2002. From Early Child Development to Human Development. Washington, D.C.: World Bank. 2 Young, Mary Eming (without year): The ECD Agenda: Closing the Gap. Grantham-MecGregor, Sally et al. (2007): Development potential in the first five years for children in Developing countries, in The Lancet, 2007, 369, 60-70. 3 Erickson, M.F. and K. Kurz-Riemer (1999): Infants, Toddlers and Families: A Framework for Support and Inter- vention, New York.

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11. Child development requires a cross-sectoral approach, as a child’s development depends on several crucial interacting factors such as the socioeconomic situation of the family, the health of the child, the nutritional status of mothers during pregnancy and of the child and of course the psychosocial development as supported through pre-school education. Scien- tific evidence exists that all these factors are highly interrelated and are crucial for ECD. The complex interrelations among malnutrition, diseases, and environmental factors such as socioeconomic status and education, make it difficult to determine the unique contribution of each one of these factors on the cognitive development of children, but require an integrative approach which takes into account all factors having an influence on child development.4

12. Ensuring optimal conditions for a child’s early years is one of the best investments that a country can make if it is to compete in a global economy based on the strength of its human capital as ECD (i) sets the foundation for developing human capital, (ii) has the highest rate of return in economic development and (iii) is the most cost-effective way to reduce poverty and to foster economic growth.5 According to Grunewald and Rolnick (2003), the potential annual return on investments in high-quality and targeted ECD programs can be as high as 16%.6 It also has been found by WB that “just 1 year in pre-school potentially increases a child’s earning capacity and income as an adult by 7-12%”.7

13. Several other studies also found that investment in ECD have wide ranging positive effects for the society. For example an assessment of the New Jersey Department of Educa- tion (2004) showed big improvements in school outcomes of pupils of high poverty school districts in 2003-4 as compared to previous years. Since 1999 provision of pre-school services for 3 and 4 year old children was mandatory.8 Another study on children attending preschool programs in Oklahoma found a 31% increase in cognitive skills and an 18% increase in language skills of low-income children with Hispanic background.9 Therefore, investing in young children makes much economic sense, which is increasingly realized by national governments and also the donor community.

2. Sector Performance

14. The Kyrgyz Republic during Soviet times was among the poorest states dependent on subsidies from Moscow, with 32.9% of population, mostly rural citizens, living below the Soviet “poverty line”10. The break-down of the Soviet Union in 1991 led to a further dramatic increase in poverty (over 60% of the population) and to a severe deterioration of ECD services. Poverty, diseases, malnutrition and the breakdown of traditional structures place major constraints on parents, communities and the society as a whole and led to a significant deterioration of the ECD situation in Kyrgyzstan. Before the collapse of the former Soviet Union in 1991, young children in the Kyrgyz Republic received a comprehensive package of ECD services, comprising child health care, nutrition, and nursery and/or preschool programs. Preg- nant women had access to antenatal care that helped maintain maternal health and mitigated risks associated with pregnancy.

4 Berkman, Douglas S.et al. Effects of stunting, diarrhoeal disease, and parasitic infection during infancy on cognition in late childhood: a follow-up study., Lancet 2002, 359. 5 Ibid. 6 Grunewald, R. and A. Rolnick (2003): Early Childhood Development: Economic Development with a High Pub- lic Return, in: The Region 17(4 supplement, December). 7 World Bank (2002): Brazil: Early Childhood Development – A Focus on the Impact of Preschools. Report No. 22841-BR. Washington, D.C. 8 Grunewald R. and A. Rolnick (without year): A Productive Investment: Early Childhood Development. 9 Gormley W.T. and D. Phillips (2003): The Effects of Universal Pre-K in Oklahoma: Research Highlights and Policy Implications. Unpublished Manuscript. 10 Falkingham, J., 1998, 'Poverty in Central Asia' in: Central Asia 2010, Prospects for Human Development, UNDP, New York

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15. This favorable ECD situation changed dramatically in the decade after 1991, when child health and nutrition services provided by the State worsened, a large number of preschool institutions were closed down, and parents were left without sufficient resources or knowledge to care for children at home. Although overall poverty has declined in recent years and the socioeconomic situation has improved, significant challenges remain to improve ECD as key indicators still show the effects of increased poverty and declining public investment in child development (Please refer to Chapter VI Economic and Financial Analy- sis).

a. Health and Nutrition

16. According to statistics from the Republican Medical Information Center (RMIC 2005) infant mortality in the Kyrgyz Republic in 2005 was 29.7 per 1000 life births. However, World Health Organization (WHO) statistics show much higher levels. According to WHO the infant mortality rate in Kyrgyzstan in 2005 was 58 per 1000 life birth.11 Neonatal mortality in Kyr- gyzstan according to WHO statistics was 30 per 1000 live births in 2004.12 Maternal mortality in 2005 was 61 per 100.000 births according to RMIC statistics. There are no data from WHO for the same year, the latest available data is from the year 2000, when maternal mortality according to WHO was 110 per 100.000 births.

17. The nutritional status of children aged 0-59 months in Kyrgyzstan, according to the most recent countrywide survey (UNICEF MICS 2006)13, was as follows:

(i) 3.4 % are underweight; (ii) 0.3 % are severely underweight; (iii) 13.7 percent are stunted and 3.7 % severely stunted; (iv) 3.5 % are wasted and 0.4% severely wasted; and (v) 5.8% are obese.

18. Unfortunately, there is a paucity of information about the nutritional status of women of reproductive age and specifically of pregnant and lactating mothers.

19. The majority of infant and child deaths in the Kyrgyz Republic are due to preventable causes, such as pneumonia and gastro-intestinal infections. Asphyxia, low birth weight and premature birth are the main cause for the perinatal and neonatal deaths. Maternal anemia is a strong underlying factor in low birth weight and contributes to neonatal mortality. Children who are born anemic and not treated in time are more vulnerable for diseases and even can develop mental and physical disorders.

20. Iron Deficiency Anemia (IDA) is the most prevalent and severe nutritional problem in the country. Information of the City Department of the Sanitary Epidemiological Supervision (SES) of the Kyrgyz Ministry of Health (MOH) shows that in the past 10 years there was no decrease in the prevalence of IDA in the population although iron supplementation has been routinely implemented. Iodine Deficiency Disorder (IDD) on the other hand has decreased since 2003. Vitamin-A deficiency (VAD) and rachitis also seem to be a problem that should be taken care of in the framework of nutritional projects.

11 This is very high compared to other countries in the region. According to WHO statistics, Kazakhstan had an infant mortality rate of 27, Ukraine 13 and Moldova 14 per 1000 live births in the same year. Tajikistan and Uz- bekistan, on the other hand, had slightly higher infant mortality rates (59 and 57) (see Annex 1). 12 Out of a group of more than 40 countries of the European Region only Kyrgyzstan, Kazakhstan, Azerbaijan, Tajikistan and Turkmenistan have a neonatal mortality rate as high or higher than 30 per 1000 live births (see annex 1). 13 Monitoring the Situation of Children and Mothers. Findings from the Multiple Indicator Cluster Survey (MICS) implemented in the Kyrgyz Republic. Preliminary Report July-August 2006/ National Statistics Committee & UNICEF.

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21. There are many reasons for the poor health outcomes in the Kyrgyz Republic. One reason is the limited access to high quality health care due to geographical and financial reasons. For people in rural areas the Feldsher Accousher Point (FAP) is the nearest and often the only health facility in reach as for many poor villagers travel costs to a FGP or a rayon hospital create huge obstacles for seeking care. Also other costs of care like co-payment of drugs and other co-payments present constraints. It is evident that advanced medical care (on oblast or national hospital level) is out of the question for poor people living in remote areas. Access to essential drugs is also a big problem in rural areas.

22. Other reasons for the poor health and nutrition status of children and their mothers are poor living conditions and a lack of knowledge of families on healthy lifestyles and prevention of diseases. Access to safe water is often not available and sanitary facilities are very poor and a source of infections. Many families don’t produce enough nutritious foods and/or cannot buy them and pregnant mothers eat the same as the rest of the family and do not get a special diet. In addition to that, there are also many problems inherent to the current health care delivery system such as:

(i) Lack of knowledge and experience of a substantial share of the medical and paramedical staff leading to (i) undiagnosed problems during pregnancy, (ii) poor quality of deliveries and neonatal care, (iii) wrong diagnoses of diseases resulting in over treating or under treating of diseases (ii) Lack of qualified staff (especially doctors) in rural areas because they emi- grate to neighboring countries, move to the major cities (Bishkek, Osh) or leave health care to find better paid jobs in other sectors (iii) The dichotomy between specialist outpatient services and specialist inpatient services creating two different levels of specialists; (iv) Lack of a functioning referral system between the different levels of care (v) Limited supervision of family doctors by specialists and very limited supervision of feldshers, midwives and family nurses in FAP’s by family doctors (vi) Lack of appropriate equipment and lack of knowledge how to operate, repair and maintain available equipment (vii) Poor conditions of the buildings of the health care facilities

23. In consideration of these problems, a major effort was launched by the MOH to reform health services. The National Health Care Reform Program “Manas” 1996–2005 was developed. Priority was given to primary health care (PHC) and family medicine. In 2006 the National Health Care Reform has entered a new phase under the Manas Taalimi 2006–2010 program. Manas Taalimi recognizes the need to improve MCH and especially the newborn component of MCH in order to reduce maternal and child mortality and to meet the Millen- nium Development Goals (MDGs). Integration of priority programs into the system of service delivery is needed and development of health care personnel capacity plays a key role. De- centralization of health care management is also included in the reform program and implies an increase of managerial and financial autonomy, along with holding health care service providers responsible for the results of their work.

b. Early Childhood Care and Education

24. After the collapse of Soviet Union, the number of kindergartens dramatically decreased from 1.604 in 1990 to 448 in 2005. According to the MOE Preschool Unit the number of preschools in 2006 compared to 2005 has slightly increased with a total number of 465 preschools. However, this is not yet official data and the actual number is higher as not all community-based kindergartens are included in this data. According to statistical data avail-

Sector Analysis and Strategy Report - SCBECDP 6 able, currently there are 800.259 children of preschool age in the Kyrgyz Republic14. How- ever, the existing preschools can cover only about 6.8 % of children (54.365) throughout the country. The coverage of children of preschool age in rural areas is even lower and amounts to only 3%. The limited number of PEOs and, consequently, the limited access to pre-school services show first negative impacts on life skills and school achievements of young children in the Kyrgyz Republic. Recent studies have shown considerable decline in student achievement in Kyrgyzstan especially at the elementary level15.

25. Major reasons for the deterioration of preschool and primary school pupils' performance are as follows: poor level of preparedness for school due to the small number of kindergartens and programs for pre-school child development; poor socio-economic family conditions; poor financing for pre-schools and as a result, a lack of basic teaching tools; low professional level of teachers; lack of a proper physical learning environment (heating, lightning, water supply, lavatories, etc.). In addition to a quantitative decline in preschool programs, the quality of preschool programs also deteriorated. Not all preschool teachers have adequate professional training and opportunities to improve their professionalism. In general there is a huge difference in the quality of education of urban and rural residents, and of wealthy and needy families.

26. Although the Kyrgyz Republic had established preschool education system before independence, preschool programs need to be updated to meet current international standards. Recognizing the need for expanding and qualitatively upgrading preschool programs, the Ministry of Education (MOE) adopted the preschool education concept in 2005, and submitted the new preschool standards in 2006 for the government’s approval. The concept and standards embrace alternative models of preschool. However, strong emphasis still needs to be put on the implementation of the pre-school standards.

C. Experiences of the FCBECDP

27. In January 2004 the FCBECDP started, a multi-sectoral project focusing on the improvement of the health, nutrition, and psychosocial development of children between birth and eight years of age in the 12 poorest raions in Jalal-Abad, Naryn and Osh oblast. The target raions are: Alai, Chon-Alai, Nookat, Kara-Khulja raions in Osh oblast; Toktogul, Chatkal, Toguz-Torou raions in Jalal-Abad oblast; and Ak-Tala, At-Bashy, Kochkor, Jumgal raions in Naryn oblast.

28. The project consists of three major components: (i) Child Health and Nutrition; (ii) Early Childhood Care and Education (ECCE); and (iii) Capacity Building. Specific objectives of the project are:

(i) to reduce IMR and U5MR (ii) to reduce IDD (iii) to reduce IDA both among children and pregnant women (iv) to improve the psychosocial development of pre-school children

14 According article 15 of the Law on Education (2003) and the State Standard (2007), preschool services are defined for children between the age of 6 months till 7 years. 15 ADB, 2004, Education Sector Development Program, Bishkek

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29. The Executing Agency is the President’s Office. The Steering Committee is established by representatives of the President’s Office, the Ministry of Economy and Finance (MOEF), the Ministry of Health, the Ministry of Education and the Ministry of Labor and So- cial Development (MLSD). According to feedback received from the Project Management Office (PMO), the system of management of the FCBECDP has proven to be effective since the President’s Office has authority to coordinate the concerned ministries and agencies. The Steering Committee might need to be enlarged since there are new state organs involved in the work with communities and children: the National Agency on Local Self-Government and Department of Child protection.

30. In the framework of the health component, 190 feldshers and 24 doctors were trained on IMCI and IMCI coordinators were appointed and trained in the selected oblasts and raions. Vaccines and refrigerators for immunization centers have been procured and contributed to sustaining universal immunization coverage in the Kyrgyz Republic. In order to improve the availability of drugs in rural areas, the project is supporting the establishment of a pharmacy network. Currently the tender documents for selecting a private pharmacy to implement the pilot project are prepared and the pilot will hopefully start soon. Furthermore, the FCBECDP rehabilitated FAPs and Family Group Practices (FGPs).

31. Salt iodization has received major support under Japan Fund for Poverty Reduction (JFPR) for Improving Nutrition of Poor Mothers and Children. The project has purchased salt testing kits and distributed them to the Ayil Okmotus (AOs). Information, education and communication (IEC) activities to increase the awareness of families on the importance of iodized salt have been conducted. Various surveys revealed that the population’s awareness on the use of iodized salt has increased and most households use iodized salt. So far, activities to reduce IDD mainly concentrated on the demand side (on the consumers). Now it is time to focus on the supply side and control the quality of iodized salt. Ensuring use of iodized salt in raions not yet covered and maintaining high levels of iodized salt consumption also is important.

32. In order to reduce IDA the project has conducted IEC campaigns to raise the awareness of the population on IDA. IEC campaigns have been conducted by FAP staff as well as by CFCs. So far, the efforts to reduce IDA undertaken by various stakeholders have not been very successful. To overcome the shortcomings it will be necessary to launch a vibrant and vigorous campaign that will inform the public and the policy-makers about the nature, extent, the consequences and costs of IDA. At the same time it is important to subsidize the use of fortified flour in well-targeted groups and selected institutions (kindergarten, preschool, etc.).

33. With regard to ECCE much work has been carried out to improve the legal base for preschool education. The State Standards for “Childcare and Preschool Education of Kyrgyz Republic” have been prepared. Now it is necessary to develop regulations and educational programs in accordance with the new State Standards’ requirements. Furthermore, the project contributed to increasing the access to preschool facilities in rural areas through the establishment of community-based kindergartens (about 70 community based kindergartens are established) and through the rehabilitation of existing kindergartens. In addition, 12 resource kindergartens were selected to provide training and methodological support to community-based kindergartens. Resource kindergartens were supplied with audio and video equipment and children’s books. The Kyrgyz State University (Arabaev) has been contracted to train trainers of resource kindergartens. In addition, the project supported training of preschool teachers and improvement of parents skills related to ECCE.

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34. Child and Family Coordinators (CFCs) have been trained to carry out IEC activities at community level and to strengthen the Ayil Okmotus’ capacity in ECD. According to the PMO they have contributed essentially to improving the families’ and communities involvement in ECD. Unfortunately, the CFC’s salaries have only been paid by ADB until the end of 2006. From 2007 onwards, the local Governments were supposed to pay them, but couldn’t or didn’t want to do so because of budget restrictions. Due to this gap in funding, the CFCs stopped their work in January 2007. CFCs did have an important function as State structures focusing on ECD in the communities do not exist. However, if CFCs will be established in the framework of the SCBECDP a mechanisms to ensure the sustainability of this measure, meaning a means to guarantee payment for CFCs, needs to be found.

35. A Village Initiative Fund (VIF) has been established and officially registered with the Ministry of Justice with the objective to provide financial aid to the communities to improve ECD. Communities can apply for financing of small projects related to ECD out of the VIF. The VIFs budget limit of 5.000 USD per project proofed to be too small and has therefore been increased to a maximum volume of up to 10 000. The capacity of AOs and communities to plan and implement VIF financed projects in general is rather low and needs to be further strengthened. It is also important to note that community initiatives should focus not so much on civil works, but more on supply of equipment, educational materials, toys, books, furniture and additional staff for FAPs or kindergartens.

36. As revealed by this description of activities, the FCBECDP has already produced a lot of outputs and positive results. However, several important issues still need to be addressed such as (i) reducing neonatal mortality; (ii) establishing a viable essential-drug distribution mechanism; and (iii) capacity building of the ECD service delivery system, with a focus on accreditation, attestation, and retention of health care workers, preschool teachers and caregivers, and social workers.

D. The Kyrgyz Government’s ECD Goals

37. The Kyrgyz Government has not yet developed a stand-alone ECD Program nor has it defined specific goals related to ECD. However, goals and targets relevant for ECD are contained in various policy and strategic documents of the Kyrgyz Republic. In September 2000 the Kyrgyz Government made a commitment to implement the Millennium Develop- ment Goals (MDGs). The MDGs which are directly relevant for ECD are:

(i) MDG 1: Reduce by half the proportion of people who suffer from hunger (ii) MDG 4: Reduce by two thirds the mortality rate among children under five (iii) MDG 5: Reduce by three quarters the maternal mortality ratio

38. Although the Kyrgyz Government has subscribed itself to achieve the MDGs by 2015, major efforts will be required to meet the targets of reducing the infant mortality rate (IMR), the under-five mortality rate (U5MR) and to sustain universal primary education. The Manas Taalimi Health Sector Reform Program recognizes the need to focus on MCH issues to ensure achievement of MDGs and states that “achievement of Millennium Development Goals is hindered by a number of factors beyond health system control, such as poverty, internal migration and low population awareness. [Therefore the] Ministry of Health of the Kyrgyz Re- public is to carry out a set of measures aimed at enhancement of effectiveness of national and state programs on mother and child health and ensure regular monitoring of their implementation for managerial decision making.” (Manas Taalimi, p. 24).

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39. With regard to Early Childhood Education (ECE), the Dakar Framework for Education for All (EFA) calls for expanding and improving comprehensive early childhood care and education, especially for the most vulnerable and disadvantaged children (Goal 1). The MOE’s goals related to ECCE are the provision of access to preschool education and improvement of the quality of education. However, so far no quantification of these goals is known to the Consultants.

40. With regard to nutrition UNICEF has prepared attainable Vitamin and Mineral Defi- ciencies (VMD) targets and has indicated their benefits for national health and social development in Kyrgyzstan. This document does not only provide the national VMD goals but also the objectives to be reached by 2010, the baseline values, targets and indicators. The VMD targets provide an important instrument for MCN in Kyrgyzstan (see annex 3).

E. Outline of the ECD Strategy

1. Principles

41. The recommended design criteria for an ECD strategy are:

(i) Integrative, cross-sectoral approach (ii) Life-cycle approach (iii) Participatory approach (iv) Targeting the poor

42. As mentioned before, ECD requires an integrative cross-sectoral approach that covers the different aspects of ECD, including health, nutrition, and care and education. This integrative approach has proven to be more effective than isolated single sector interventions, but it is also more challenging as it requires strong inter-sectoral coordination and communication systems. At central level all relevant state ministries and inter-ministerial bodies, such as the ministries of finance, education, health and nutrition, and social protection should be involved. At oblast, raion and village level all units of government as well as service providers should be included. Furthermore, civil society organizations including universities, institutes, NGOs, religious organizations, professional associations, and others need to be involved as well.

43. The life cycle approach usually includes four main initial periods16:

(i) Prenatal and perinatal: During this period nutritional supplementation is needed and home visits for prenatal education on infant development, health, nutrition and parenting skills are required as well. (ii) Zero to three: Parent education and support is essential during this early stage of development, especially for parents of vulnerable and high-risk children. (iii) Three to five: Improvement of access to pre-schools and kindergartens and provision of essential minimum standards for centre-based early care and education is required for this stage. (iv) Six to eight years: A culturally appropriate program for transition from home to school is essential.

16 Vargas-Barón, Emily (2005): Planning Policies for Early Childhood Development: Guidelines for Action; UNI- CEF.

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44. The findings of the sector analysis and the recommended strategy to improve ECD, as presented in the following chapters, will be presented to and discussed with all concerned stakeholders during a mid-term review workshop in September 2007 in order to make sure that all stakeholders’ point of views are correctly reflected. During their assessment the Con- sultants have tried to meet all relevant stakeholders and therefore hope that their comments and suggestions are truly reflected in this report. Nevertheless the consultation process the Consultant could undertake in the course of this PPTA has, of course, been limited in time and scope and doesn’t replace a nation wide participatory process to develop an ECD policy and strategy.

2. Goals and Objectives

45. The overall goal and impact of any ECD program should be to improve the health, nutrition, and psychosocial development of children up to 7 years of age and, in general, to contribute to improving the social and economic situation of vulnerable groups especially in poor regions of the country. Progress in achieving this goal will contribute significantly to meeting the national health and nutrition targets as articulated in Manas Taalimi, the nutrition goals of the VMD Strategy, the MDGs as well as EFA goals. In order to achieve this goal the following specific objectives should be reached:

a. Maternal and Child Health

46. The specific objectives and targets with regard to MCH as suggested in the MCH strategy in section II are:

(i.) Reduction in infant mortality by 25 percent; (ii.) Reduction in neonatal deaths by 30 percent; (iii.) Reduction in under-five mortality by 30 percent; (iv.) Reduction in maternal mortality of 20 percent.

47. In order to achieve these objectives the following outputs should be achieved:

(i.) To develop the policy and normative basis for improvement of MCH; (ii.) To create commitment of all stakeholders towards improvement of MCH by optimizing the health care delivery system for mother and child; (iii.) To strengthening the MCH health care delivery system through improving the capacity of health care providers; (iv.) To improve the MCH service delivery with high quality obstetric and pediatric care resulting in: (a.) accurate diagnosis of priority diseases effecting mothers and children; (b.) pregnant women receiving appropriate antenatal care; (c.) providing appropriate postnatal care; (d.) deliveries attended by the right professional and in the right facility; (e.) children receiving appropriate care at the right moment; (f.) a well-functioning referral system; (v.) To increase access to essential drugs by improving geographical accessibility to pharmaceutics; (vi.) To create an environment for health care workers that enables them to provide care of high quality by:

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(g.) providing the appropriate equipment with a good maintenance system; (h.) providing good technical and functional facilities with proper sanitation, water supply, heating and electricity ; (i.) establish a functioning M&E system; (j.) providing incentives for health workers that encourage posting in remote areas and maintaining knowledge and skills in their area of work. (vii.) To strengthen community involvement and sensitize families and communities on healthy lifestyles and appropriate health seeking behavior.

b. Maternal and Child Nutrition

48. The overall developmental objective for MCN in the Kyrgyz Republic should be to contribute to meeting the national health and nutrition targets as articulated in Manas Taalimi, the MDGs and the UN-Sub-Committee Nutrition goals, mentioned earlier. The specific objective related to MCN should be a reduction of stunting among children and a reduction of micronutrient deficiencies (IDA, VAD and IDD) among children and mothers.

49. The suggested quantified targets with regard to this objective are:

(i.) To reduce the prevalence of stunting among children less than 3 years by 25 % between 2008-2015 years; (ii.) To reduce micronutrient deficiencies IDA and VAD among pregnant women and children < 3 years by 25% and virtual elimination of IDD between 2008- 2015.

50. The outputs in order to achieve the above mentioned objective are:

(i.) Development of a National Policy and Program on Nutrition (ii.) Development of an institutional base, allocation of budget and creation of a critical mass of nutrition professionals (iii.) Development and implementation of community-based MCN interventions (iv.) Amendment of Existing Nutrition-Related MCH Programs (v.) Integration of MCN in Early Child Education (vi.) Improve the effectiveness of programs to control and prevent iron deficiency and iron deficiency anemia in the population (vii.) Sustain elimination of IDD and Vitamin A deficiency

c. Early Childhood Care and Education

51. The specific objectives with regard to ECCE as suggested in the ECCE strategy in Chapter IV are:

(i.) To improve the preschool education system and promote the access to high quality preschool education (ii.) To support the development of children in their family environment through strengthening knowledge and skills of caregivers and the community on ECCE

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52. The quantified targets with regard to these objectives are:

(i.) To increase the coverage of children by preschools by 10% (ii.) To increase the number of parents with improved parents skills by 10 % (5% by training seminars (mainly mothers n=27.000), another 5% (fathers and other members of the family) by transfer of skills and knowledge into daily life and specifically 5000 fathers by specific trainings.17 (iii.) To increase the number of trained preschool teachers by 40%18

53. Suggested outputs in order to achieve the above mentioned objectives are:

(i.) Improving policy and normative regulations on preschool education (ii.) Decentralizing attestation/licensing procedures (iii.) Creating a law on Preschool Education (iv.) Improving the financing system (v.) Improving training/qualification (vi.) Improving quality management (vii.) Empowering parents (viii.) Establishing PEOs (ix.) Mobilizing Communities and (x.) Implementing of Information, Education, Communication (IEC) component

d. Capacity Building

54. The specific objective with regard to capacity building in ECD is to create awareness and solicit commitment at policy makers’ level and at the level of AOs on the importance of ECD and to empower local communities to identify and address the needs related to ECD.

55. In order to achieve this objective, the following outputs should be produced:

(i.) Establishment of the institutional and legal basis for ECD (ii.) Building management capacity at national and local levels (iii.) Increasing the awareness on the importance of ECD and advocacy (iv.) Community Mobilization and Support to Village Initiatives

17 About 540.000 parents of preschool children in the country. 18 Total number of the preschool teachers in the Kyrgyz Republic is 2.388. 1000 preschools to be opened with two groups and two teachers for one group according present regulation.

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II. MATERNAL AND CHILD HEALTH

A. Health Status of Women and Children

56. According to RMIC data of 200519 the trend of infant mortality rate (children died under 1 year of age per 1.000 births) between 2001 and 2005 was as follows:

Table 1: Infant Mortality Rate per 1.000 Life Births from 2001 to 2005 2001 2002 2003 2004 2005

21,7 21,2 20,9 25,7 29,7 Source: RMIC 2005

57. The increase of mortality in 2004 and 2005 is due to a change in the definition for infant mortality used after 2003. Prior to 2004 the Kyrgyz Republic Government used a live/stillbirth criteria established during the Soviet era. This led to the underestimation of real infant/child mortality rates as compared to international standards. After 2004, the Kyrgyz Republic began to employ a live/stillbirth criteria recommended by the World Health Organi- zation (WHO). This was considered a very progressive move by the international maternal and child health (MCH) community and distinguished the Kyrgyz Republic from other Central Asian and Former Soviet Union countries. However, analyzing trends before and after 2004 is not advisable and can be extremely misleading. In fact, increased accuracy in reporting neonatal deaths after 2004 should initially result in rates significantly increasing when compared to pre-2004 levels.

58. According to the Multiple Indicator Cluster Survey (MICS) of 2006, overall infant mortality in the Kyrgyz Republic reached 49.8 deaths per 1,000 live births, while child mortality reached 59.1; this is significantly higher than official levels. Male mortality was 1.1 times higher than the female mortality, similar to the rest of the world. In rural areas, where the living standards are lower, child mortality is 1.6 to 1.7 times higher than in urban areas. Also the WHO estimates for infant, neonatal and under-5 mortality, as given in the table below, are much higher than the nationally reported data:

Table 2:

Source: http://www.euro.who.int/eprise/main/WHO/Progs/CHHKGZ/cismortality/20051207_1

19 RMIC (2005): Health of population and activities of health facilities of Kyrgyz Republic for 2005

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59. The WHO estimate for infant mortality in Kyrgyzstan in 2005 is 58 per 1000 live births, which is significantly higher than the infant mortality in other former Soviet Union countries.20 A reason for the big difference between official RMIC statistics and the data of other sources, such as MICS and WHO, might be that, until recently, any critical analysis of data was not encouraged.

60. Neonatal mortality according to the latest WHO estimate was 30 per 1000 live births in 2004. Out of a group of more than 40 countries of the European Region21 only Kyrgyzstan, Kazakhstan, Azerbaijan, Tajikistan and Turkmenistan have a neonatal mortality rate as high or higher than 30 per 1000 live births (see annex 1).

61. In September 2000 Kyrgyzstan adopted the Millennium Declaration. The Millennium Development Goal (MDG) for the under-five mortality rate (U5MR) is to reduce it by two thirds compared with U5MR in 1991. According to UNICEF statistics U5MR in Kyrgyzstan in 1990 was at 80 per 1000 live births. In 2005, U5MR according to UNICEF data was 63 per 1000 live births. 22 WHO estimates Kyrgyzstan’s latest U5MR to be 59 under-five deaths per 1000 live births and considers it as rather unlikely that Kyrgyzstan can reach the MDG goal by the year 2015.23

62. The majority of infant and child deaths in the Kyrgyz Republic are due to preventable causes, such as pneumonia and gastro-intestinal infections. Asphyxia, low birth weight and premature birth are the main cause for the perinatal and neonatal deaths. Maternal anemia is a strong underlying factor in low birth weight and contributes to neonatal mortality. Children who are born anemic and not treated in time are more vulnerable for diseases and even can develop mental and physical disorders. The pattern of neonatal mortality in the Kyrgyz Re- public coincides with the global causes of neonatal deaths as depicted in the figures below:

Figure 1: Estimated Distribution of Direct Causes of 4 Million Neonatal Deaths

Source: WHO Annual Report on health in 50 countries: Health in the World 2007

20 According to WHO statistics, Kazakhstan had an infant mortality rate of 27, Ukraine 13 and Moldova 14 per 1000 live births in 2005. Tajikistan and Uzbekistan, on the other hand, have slightly higher infant mortality rates (59 and 57). See Annex 1. 21 WHO includes former Soviet Union countries in the group of countries of the European Region (http://www.who.int/whosis/database/core/core_select.cfm) 22 (http://www.unicef.org/infobycountry/kyrgyzstan_statistics.html). 23 http://www.euro.who.int/eprise/main/WHO/Progs/CHHKGZ/cismortality/20051202_1

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Figure 2: Distribution of Causes of Neonatal Deaths in Kyrgyz Republic for 2006 Structure of causes of neonatal mortality, Kyrgyz Republic, 2006 Acute gastro- Infectious diseases; intestinal infections; 11,0 0,4

Congenital ; 13,1 Others; 10,8

Birth trauma; 7,6

Im- and Asphyxia; 24,5 prematurity; 30,9

Source: Republican Medical Information Center (RMIC) 2006 statistics

63. Unlike many developing countries where a majority of births take place at home and are assisted by unskilled attendants, over 95% of deliveries in Kyrgyz Republic are assisted by skilled attendants and take place in a health facility. The percentage of deliveries in a health facility in remote rural areas is a bit lower, but is still very high when compared to other developing countries. As in the rest of the developing world, the majority of neonatal deaths take place in the first seven days of life. The majority of those deaths, in turn, occur in the first 24 hours after birth. Therefore, the majority of neonatal deaths occur while mother and child are still under the direct care of the health facility. The focus of attention for improving birth outcomes and preventing neonatal mortality should therefore be directed at the quality of the delivery and newborn health services provided in health facilities and the qualification and competence of health personnel.

64. The ADB project “Reducing Neonatal Mortality” conducted a study of 144 mothers who lost their baby as neonate. These findings should be considered when developing the strategy for improving neonatal mortality data. These results are as follows:

(i.) Of all neonatal deaths 46,5% happened to primiparae; (ii.) Almost 20% were of mothers belonging to the so-called “grande multiparae” (more than 4 deliveries ); (iii.) 72,2% of dead babies were premature and 74,2% were low birth weight children; (iv.) 63% of deaths were related to pregnancy and 25% were related to delivery; (v.) Causes of neonatal mortality: immaturity was 58%, 16% due to asphyxia, almost 10% due to birth trauma and 7% due to congenital abnormalities and other causes.

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65. A Lithuanian neonatal expert visited the Kyrgyz Republic in early 2007 and observed that women were insufficiently monitored during labor to detect when the fetus was in distress and that insufficient action was taken to intervene when problems were detected. These are all indications that the quality of care at delivery should be urgently addressed. Training, supervision and availability and use of appropriate equipment at delivery should be improved at all maternal departments including raion and oblast hospitals.

66. According to RMIC 2005 data the causes of infant mortality over the last five years are as follows:

Table 3: Causes of Infant Mortality in the Last Five Years Causes of Mortality 2001 2002 2003 2004 2005

Infectious diseases 12,5 8,2 6,7 5,3 5,2 Neurology and organs of senses 2,6 2,7 2,4 2,0 1,4 Respiratory diseases 31,2 27,1 29,2 18,6 17,8 Digestion diseases 0,7 0,6 0,3 0,6 0,5 Congenital defects and diseases 10,3 10,2 11,8 11,7 10,6 Perinatal complications 38,2 46,5 44,9 58,4 61,2 Traumata and poisoning 2,8 3,3 3,0 2,3 2,5 Source: RMIC 2005

67. The percentage of deaths for congenital reasons is about the same during the last five years. The main differences are in the shift from infectious and respiratory diseases to perinatal complications. The large change in these figures suggests that different definitions are being used by staff for the cause of neonatology mortality. For example, asphyxia after birth may be classified by some people as neonatal complication and by others as respiratory infection. Further analysis of these mortality data is necessary to confirm the correct distribution of causes for infant mortality.

68. Malnutrition is a complicating factor in the majority of infant deaths. Mortality related to vaccine-preventable diseases has largely been eliminated due to high vaccination coverage. Children have to be vaccinated a number of times for full vaccination. Full coverage (children that received all vaccinations) is above 98%. This high coverage results from strengthening the Expanded Program of Immunizations (EPI)24.

69. Timely access to appropriate and affordable antibiotics is the key to preventing deaths in children with infectious diseases like pneumonia. If facilities can not provide the full course of all IMCI drugs, at least the first dose of antibiotics should be given with counseling to the family on where to obtain and how to administer the remaining doses. At present health personnel usually do not adequately explain or demonstrate how to administer medications properly, nor do they check to see if the mother understands how to do it. Compli- ance is often blamed on ignorant or unmotivated caregivers, not the quality of care provided by the primary health care provider.

24 The Asian Development Bank financed First Community-Based Early Childhood Development Project has been financing EPI vaccines since 2004 on a declining scale. The Government will finance all EPI vaccines needs from 2009 without the project support.

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70. Anemia in women and children has serious negative impacts on pregnancy and the growth and development of the child. Anemia is pervasive in pregnant women and small children throughout the country and is much more serious in rural raions. While the problem with anemia is widely recognized, compliance with treatment for both women and children is very limited due to lack of recognition by both women and health providers of the overall effects of anemia or the effectiveness of treatment. The need to take appropriate medications in sufficient quantities and for specified periods of time is not well understood by pregnant women or health providers. Cost is often cited as the major reason for not purchasing the prescribed iron tablets, but follow-up questions to mothers reveal that they may be able to find the money if they only realized the importance of the supplements. If cost were the only factor, then parents would not be purchasing unnecessary antibiotics for diarrhea, as has been documented by the household survey carried out in the framework of the PPTA for the SCBECDP (2007).

71. According to the data of the RMIC the maternal mortality rate per 100.000 births in the Kyrgyz Republic over the last five years was as follows:

Table 4: Maternal Mortality per 100.000 Live Births 2001 – 2005 2001 2002 2003 2004 2005

40,9 58,4 53,1 46,4 61,0 Source: RMIC 2005

72. International experts have observed, in maternity units, women who appeared to have heart failure due to anemia that was severe enough to require blood transfusions, but their conditions were not recognized nor treated appropriately.25 Published sources on maternal mortality in Kyrgyz Republic have various opinions on whether hemorrhage, which contributes to 25% of global maternal mortality, is a major factor in Kyrgyz Republic. In both severe maternal anemia and hemorrhage, the appropriate treatment involves blood transfusions. This requires an analysis of the safety and availability of the national blood supply. A recent breakdown in the safe blood supply in neighboring Kazakhstan caused an international scandal when unscreened blood from dubious sources was given to infants who later developed HIV/AIDS.26

B. The MOH and its Policies and Programs Relevant for MCH

73. Development and implementation of national programs and policies in the area of MCH is the responsibility of the Ministry of Health (MOH). Care for children with mental and/or physical disabilities is the responsibility of the MLSD, but for regular health care, the local health care provider will provide children with disabilities the needed care. The country has limited services for children suffering from abuse (physical, psychological or sexual). These services require special attention in the near future.

74. The current organizational structure of the MOH at central level is shown below:

25 Personal communication with Dr. Ayman El Mohandes and Dr. Barton Smith in February 2007. 26 ,February 20, 2007, BBC News website

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Figure 3: Ministry of Health of the Kyrgyz Republic Central Office

Health Policy Council MINISTER Collegium

Internal Audit Unit Assistant

Deputy Minister Deputy Minister Deputy Minister

Human Resource Pol- Economic and Finan- Directorate of Treat- Directorate for Strate- icy and Operations cial Policy Directorate ment and Preventive gic Planning and Re- Public Health Depart- Mandatory Health In- Directorate Assistance form Implementation ment surance Fund (MHIF)

Department of State Sanitary Epidemiological Supervision Education and Science Financing and Fore- Department of Individ- Department of Interna- Department casting Department ual Medical Services tional Cooperation and Republican Center for Health Promotion Reform Implementa- tion

Republican Center for Immunoprophylaxis Human Resource, Accounting and Re- Operations and Legal porting Department Department for Quality Department Control and Licensing Department of Analy- Center for Special Danger Infections of Medical and Phar- sis and Strategic Plan- maceutical Services ning Republican AIDS Association Unit of Office Man- Procurement Unit agement and Follow- Up Actions “Profilakticheskaya Meditsina” (Preventive Medicine) Scientific-Production Association

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75. As can be seen from figure 3 above there is no separate Department for MCH within the MOH. Although all Directorates and Departments will have some responsibilities towards MCH, the Directorate of Treatment and Preventive Assistance and the De- partment of Individual Medical Services are those who need to be especially involved.

76. With regard to MCH the MOH is advised by the National Center of Pediatrics and Child Surgery (pediatrics) and the National Center of Human Reproduction (obstetrics). MCH services were organizationally separated at republican level in 2002 when the departments of the former Scientific Research Institute for Obstetrics and Pediatrics were separated. Therefore improvements in MCH now require involvement of two separate bodies. This has been recognized as less efficient than desired and therefore a new strategy for perinatal care is presently being developed by the MOH with assistance of WHO. Whereas the National Center of Pediatrics and Child Surgery is a well-established institute with 40 subdivisions (21 clinical and 19 for research) staffed by 18 professors and 46 staff with PhD degrees, the National Center of Human Reproduction is only staffed with a single PhD. In the MOH, the Chief Gynecologist represents reproductive health.

1. Health Sector Reform

77. During the Soviet era, emphasis was placed on building a network of health facilities to provide universal access to health care. The delivery system was mainly focused on hospital care by medical specialists. Medical specialists worked in hospitals with an inpatient and an outpatient department. After the collapse of the Soviet Union, inpatient (hospital) care and outpatient (polyclinic) care where split as a measure to stimulate outpatient care and create additional revenue. This also created a dichotomy within specialists. The higher qualified specialists worked mainly in hospitals and the less qualified specialists in polyclinics. Patients were aware of the differences in quality provided and started to bypass polyclinics and lower level hospitals.

78. Human resource planning focused primarily on achieving an established ratio of medical specialists per population. This ratio was applied to the total number of specialists (hospitals as well as polyclinics). In hospitals the number of specialists was based on the number of beds and not on workload. Hospitals have clear incentives to admit patients and to keep patients longer than necessary because the financing was directly related to the number of admission days. Financing of the network of health facilities came from a centralized budget. Today this network of health facilities remains, although conditions and equipment have deteriorated from the lack of adequate resources over the years, especially at the primary care level, the FAPs.

79. Between 1994 and 1996, a major effort was launched by the MOH to reform health services. The National Health Care Reform Program “Manas” 1996–2005 was developed with support from WHO. Priority was given to primary health care and family medicine, ensuring access by the population to medical services within the framework of the SGBP. During the first ten years of health reform, Manas concentrated on restructuring curative health services and on financing the health care system. Polyclinics were renovated and specialists were trained as family doctors. Less attention was given to preventive health services, to the Sanitary Epidemiological Service (SES; the activities of the Public Health Office), or to health workers at community level, the feldshers and the FAP.

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80. Beginning in 1995, the MOH, assisted by the United States Agency for Interna- tional Development (USAID), launched the Zdrav Reform Project in Issy-Kul oblast to implement reforms on health care financing and restructuring curative health services to re-orient both health services and medical personnel toward Family Medicine. Structural changes were made to improve the efficiency of the PHC delivery system. Primary and hospital health care were legally separated and FGPs and Family Medicine Centers (FMCs) were established to serve 98% of the population. This required massive retraining of specialist physicians and nurses in family medicine. FMCs were organized to coordinate PHC at the oblast level. To improve the work on health prevention and to promote healthy life styles, Health Promotion Centers (HPC) were established at oblast level. This initiative was later extended to the entire country. By 2005, the distribution of primary care facilities in the country consisted of 672 FGPs, 866 FAPs, and 84 FMCs. A small number of family doctors created private FGPs (31).

81. The National Health Care Reform has entered a new phase under the Manas Taalimi 2006–2010 program. The goal of this new phase is “to improve the health status of people through the creation of a responsive, efficient, comprehensive and integrated system of individual and public health services, increased responsibility of every citizen, family, society, state power and public administration bodies for health of each person and society in general.” This renewed effort focuses on active community involvement and partnerships with Non-Governmental Organizations (NGOs) and Community-Based Organizations (CBOs). Another emphasis is on strengthening the FAP level of PHC. Manas Taalimi also recognizes that the newborn component of MCH was ignored in the first health reform and needs special attention to reduce mortality and meet the MDG’s. Special attention is to be devoted to further integrating priority programs into the system of delivery of individual and public services. Developing health care personnel capacity plays a key role in the Manas Taalimi program. Decentralizing health care management is also included in the reform program and implies an increase of managerial and financial autonomy, along with holding health care service providers responsible for the results of their work.

82. The hospital sector has also undergone thorough restructuring. Under the Soviet system, health care budgets were based on the number of beds and subsequently the number of staff. Primary medical care, especially in rural areas received relatively little financing. Improvements in the hospital sector took place by merging of a number of monoprofile to multiprofile hospitals. In all oblasts Oblast Hospitals were created. Ineffi- cient small inpatient departments in raions have either been transformed into subdivisions of territorial hospitals or into PHC institutions. In parallel, repair and civil works have been carried out. The bed capacity of inpatient departments has been reduced by 15% during the period 2001–2006. The number of hospitals was reduced by 42%. The result of these steps was a substantial reduction in the cost of utilities and maintenance. The total number of inpatient institutions was reduced by 42%. Along with reducing space and closing buildings, efforts were also made to reduce expenditures for utilities. However, in some cases the result is that health facilities are insufficiently heated in winter.

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83. A change that has not been proposed in Manas Taalimi is to reduce the duplication of services between FMCs and hospitals. Currently both FMCs and hospitals are providing specialist out-patient services. The specialists from the FMCs and the specialists from the hospitals do not collaborate. This might on the one hand lead to problems in the quality of care due to lack of communication between the two different levels, on the other hand this might lead to a duplication of services and inefficient use of scare resources. According to information received from the MOH, the Ministry is planning to merge FMCs and territorial hospitals in raions with less than 30.000 people. This seems to be a very good reform initiative as it addresses the above mentioned problem of duplication of services (see also organogram in chapter C).

84. An efficiently run health care system requires clear guidelines for referrals to tertiary obstetric and neonatal services. Also clear functional responsibilities need to be defined for the types of tertiary care provided in each type of facility. For example it will be logical to concentrate certain tertiary care functions like advanced neonatal surgery in only one or two hospitals while other tertiary care functions (for example Neonatal Inten- sive Care Units, NICU) may be provided in all oblast hospitals. In order to improve access to tertiary care services for the whole population a significant shift of health funding from Bishkek and Chui to the southern oblasts would need to take place. Serious maternity and child health cases now require families, with their own resources, to travel to Bishkek, a journey that can be well over 700 km, effectively denying access to specialized services to a very large segment of the population. The government appropriately proposes to provide many of these tertiary perinatal services in Osh at least to cover all inhabitants of Osh Oblast, and possibly also to serve as the referral point for Jalalabad and Batken oblasts.

85. A very positive development is that the MOH has continued to develop clinical protocols for a number of pediatric and obstetrical diseases for more frequent complications (for example hypertension during pregnancy). Four neonatal protocols have been developed and accepted by the MOH:

(i.) Routine care of healthy neonates born at the anticipated birth date; (ii.) Asphyxia (neonatal resuscitation); (iii.) Meconium aspiration syndrome; (iv.) Birth traumata like intracerebral hematomata, fracture of clavicula, etc.

86. The following obstetric clinical protocols have been developed for the three different levels of medical facilities:

(i.) Physiological pregnancy; (ii.) Multiple pregnancy; (iii.) Physiological labour; (iv.) Multiple labour; (v.) Labour in breech presentation; (vi.) Preterm labour at 22-27 weeks of gestation; (vii.) Preterm labour at 28-36 weeks of gestation; (viii.) Preterm rupture of membranes; (ix.) Perineal injury (tear) I, II, III and IV degree; (x.) Obstructed labour; (xi.) Cesarean Section; (xii.) Pre-eclampsia mild;

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(xiii.) Pre-eclampsia severe; (xiv.) Eclampsia; (xv.) Postpartum hemorrhage; (xvi.) Postpartum sepsis; (xvii.) Hypertension during pregnancy; (xviii.) Pyelonephritis during pregnancy; (xix.) Surgical infection; (xx.) Other infections; (xxi.) Prevention of HIV in children; (xxii.) Prevention of vertical transmission of HIV; (xxiii.) Medical abortion.

2. Programs Related to MCH

87. A number of key programs have been introduced by the MOH in the Kyrgyz Re- public using evidence based medicine, but the national coverage remains low and there are problems with their institutionalization and financial sustainability, largely because upgrading has depended on external assistance. Examples include:

(i.) Baby Friendly Hospitals (BFH); (ii.) Promoting Effectiveness of Prenatal Care (PEPC); (iii.) Integrated Management of Childhood Illnesses (IMCI).

88. In 1994 the WHO/UNICEF Program “Protection, Encouragement and Support of Breast feeding” was introduced in the Kyrgyz Republic with the help of UNICEF. In 1996 the National Committee on Support and Encouragement of Breast Feeding was created and the normative-legal base for introducing exclusive breast-feeding in maternity departments was established through the issuance of several Ministerial Decrees. As of 2007, 31 of 56 hospitals have been certified as BFH or Hospitals with a Benevolent Atti- tude to Children. At present, 47.3% of deliveries take place in BFH and 95.3% of infants discharged from the maternity houses are exclusively breast fed (see annex 4 for detailed information on BFH Program).

89. From 1995 until 2000 the WHO Regional Office for Europe supported improvement of mother and newborn health in Kyrgyzstan within the framework of its CARAK project. After an evaluation in the year 2000 a second stage was initiated with the “Mak- ing Pregnancy Safer/Promoting Effective Perinatal Care” (MPS/PEPC) program. MPS/PEPC is currently introduced with the support of WHO, UNICEF, USAID/ZdravPlus, Project HOPE, ADB, and the NGO «Alliance of Reproductive Health», but is limited to pilot raions to date (see annex 5 for a list of pilot raions). The MPS/PEPC activities carried out in the Kyrgyz Republic and the analysis of their impact has contributed to the development of the National Reproductive Health Strategy (2006- 2015).27

27 WHO 2006, Activities Report 2001 – 2005: Making Pregnancy Safer – Promoting Effective Perinatal Care, Kyrgyzstan

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90. The IMCI Program was started in the Kyrgyz Republic in 2000 with the support of WHO, UNICEF, WB, ADB and USAID and is now included in the National Health Care Reform Program “Manas Taalimi” for 2006–2010. IMCI focuses on illnesses that com- prise 87% of sick children, seen by doctors at the primary level, e.g. ARI, pneumonia, otitis media, pharyngitis, fever, measles, diarrhea, anemia, usually in combination with poor feeding. As such it addresses the vicious cycle of malnutrition and infections. IMCI focuses on service delivery in health facilities and on raising the awareness of families and improving child care in the home setting and in the communities (see annex 6 for a detailed description of IMCI and annex 7 for a list of raions where training in PEPC and IMCI has been provided).

91. Component 3 of the IMCI Program, the so-called Community IMCI (C-IMCI), focuses on community mobilization to support different health activities. Emphasis is put on key household and community practices for child survival, growth and development. C-IMCI puts emphasis on households and communities assuming responsibility for their own health care and focuses on the sixteen key family practices that are needed to prevent or treat the major causes of maternal, infant and child mortality28. C-IMCI also promotes linkages between health facilities and the communities they serve.

92. IMCI services have been implemented by the FCBECDP (12 raions), UNICEF (5 raions) and Project Hope (2 raions). Lack of a concrete time-bound national planning and financial barriers prevented the Kyrgyz Republic from scaling up IMCI services to the entire country. A large percentage of FAP family nurses remain to be trained, even though they are the health workers with the closest ties to the household and community level and make regular home visits to women and children. Their involvement is essential to link the FAP to the communities to implement C-IMCI.

93. With support of WHO and UNICEF an IMCI manual29 has been developed and is used by all trained health professionals. Unfortunately the part dealing with mothers’ health is only one out of the 90 pages and relates primarily to her ability to take care of the child. Furthermore, IMCI protocols in Kyrgyzstan begin at 7 days of age; consequently the IMCI initiative does not address problems in the early neonatal period, from birth to 6 days. In 2006, MOH and WHO conducted an IMCI performance review of 121 trained medical workers working in 68 health facilities (35 of which were maternity houses) in Naryn, Jetyoguz, Moskovski, Aravan, Nookat and Aksyi raion.30 The report found several instances where IMCI protocols were followed but also found several areas that need strengthening, such as:

(i.) Lack of nutrition counseling by health care workers and medical workers not paying sufficient attention to the nutrition status of the child. Further- more, medical workers frequently don’t ask about nutrition of children during illness; (ii.) Over or under classification of pneumonia; (iii.) Wrong classification of anemia is frequent;

28 See annex 6 for the list of the 16 key behaviors and a detailed description and evaluation of IMCI. 29 IMCI – Counsel the mother on feeding, care for development, giving fluids, when to return and the mother’s health. 30 Quality evaluation of the Integrated Management of Childhood Illnesses (IMCI) implementation and outline of barriers for its sustainability on all levels of Primary Health Care, MOH/National Center of Pediatrics and Children’s Surgery/Health Caring Development Center of Kyrgyz Republic/WHO, Bishkek 2006.

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(iv.) Some children were hospitalized who didn’t need it, some who did were not hospitalized; (v.) Lack of demonstration of how to give medicines to a child; (vi.) Few observed mothers giving first dose of medicine to a child; (vii.) Lack of counseling on danger signs to look out for in the child in the home; (viii.) Not checking to see if mothers understood the instructions there were given; (ix.) Only 39% of medical workers completed all required tests before hospitalizing children; (x.) Need for doctor approval before hospitalizing sick children; (xi.) IMCI protocol takes an average of 18 minutes, but MOH protocols only allow 12 minutes.

94. Not all aspects of IMCI have been introduced in all raions, e.g. implementation of C-IMCI needs to be strengthened. The MOH has already expressed a strong commitment to implementing C-IMCI as part of involving the population in the Manas Taalimi Health Program for 2006-2010. The MOH has added the project as one of the priority programs in the budget for 2006-2010. To date, the MOH says that it is challenged to know how to develop a strategy to implement C-IMCI in the Republic. To implement C- IMCI it is necessary to strengthen services at the FAP level, including upgrading the quality of services provided by the Family Nurses, as well as sensitizing families and communities to the need for partnership actions. Other community structures such as local government, schools and religious leaders should also be included to encourage behavior changes that improve health status and prevent morbidity and mortality from preventable causes.

95. In general, the above mentioned programs are being implemented in a limited number of raions. Programs are not sufficiently integrated into the current health care system. There is still a shortage of trained personnel, especially in rural areas. Difficul- ties in scaling up largely come from lack of national planning and financing. Without proper co-ordination at national level and proper financing it will be difficult to solve the problems. Another problem is the duplication and competition in donor-supported programs. To avoid this, it is planned to integrate the interventions carried out in the framework of the above mentioned programs into standard ante- and post natal packages of services for pregnant women, newborns and children in the first year of life. Financing with donor assistance is required for the initial stages, with gradual incorporation into the SGBP.

96. It is rather difficult to measure the impact of the different programs with the exception of specific small programs in a few raions. The main reason is that morbidity and mortality data are unreliable. There is also a lack of population-based coverage estimates at the raion, oblast and national level. The MICS 2006 measured coverage of some important MCH indicators. Examples are exclusive breast-feeding rates, access to antibiotics for pneumonia, and vitamin A supplement coverage, all indicators that measure progress towards mortality reduction. The monitoring and evaluating capacity and using data for making decisions is still in need of upgrading at all levels. Without significant capacity building in this area, sustainable improvements in MCH services are not possible.

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C. Description of the MCH Service Delivery System

97. The following organogram provides a summary description of the overall service delivery system showing public health facilities at village, raion, oblast and republican level, which are relevant for provision of MCH services.

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Figure 4: Organogram of the MCH service delivery system

Source: Adapted version of an organogram prepared by Dr. Ainura Ibraimova, Deputy Minister of Health of the Kyrgyz Republic, in a presentation on the Kyrgyz Health Care Reform and Reproductive Health

98. Levels of care in which the different health facilities shown in the organogram above can be classified are outlined in figure 5:

Figure 5: Levels of Care

Primary Health Care = Secondary Care = Tertiary Care outpatient care Inpatient Care Providers are: Providers are: family Providers are: medi- medical specialists doctors, family nurses, Referral cal specialists Referral midwives, feldshers, Facilities are: a lim- dentists and special- Facilities are: all ited number of ists kinds of hospitals highly classified with their inpatient hospitals Facilities are: FAPs, and sometimes also FGPs , FMCs, dentist outpatient services offices and emergency services

1. Primary Health Care

99. As can be seen in the sketch above primary medical care in raions is provided in three categories of facilities31:

(i.) At the first level is the Feldsher Accousher Point (FAP). These FAPs are located in smaller villages (less than 3.000 people). FAPs are supervised by a family doctor at the nearest FGP. The staff of a FAP consists of a feldsher, a midwife and a nurse. There are some FAPs with maternity beds in remote residential settlements. (ii.) At the second level of primary medical care is the Family Group Practices (FGPs). The number of family doctors in a FGP may vary from 3-10 depending on the catchment population. In addition to family doctors, the staff of FGPs consists of nurses and midwifes. There are a limited number of FGPs with maternity/delivery beds in more remote areas. (iii.) The third level of primary medical care is provided at Family Medicine Centers (FMC). Various types of physician specialists staff the FMCs. The FMCs have a number of family doctors on their staff. Some diagnostic services are provided such as X-ray, ultrasound, laboratory, endoscopy, etc. The reception nurse decides which specialist the patient will see. A number of patients visit the FMC as first point of entry; other patients are referred to the specialists by family doctors or feldshers of the raion. It is important to realize that the director of the FMC is responsible for all primary medical care facilities and personnel in the raion. The director co-ordinates all activities with regard to primary medical care of the raion. It is also important to mention that FMCs despite offering specialized care fall under primary medical care and not under secondary care.

31 A complete list of health facilities in provided in Annex 8.

100. A very important provision of primary medical care is the emergency services. FAPs, FGPs and FMCs are open only during the day six days a week. During evenings, nights and weekends the emergency service provides all care. The medical staff of emergency services consists of feldshers and one supervising physician. When patients call for a doctor during these hours an ambulance with a driver and a feldsher visit the patient at home. In case specialist care is needed the ambulance will transport the patient to the hospital.

101. For a proper planning of number and type of facilities, travel distances from villages and towns to health care facilities are important. The MOH does not have a standard definition of the distance to health facilities considered to provide sufficient access, nor are there allocations in the national budget for creating FAPs within a certain minimum distance. Over 60% of the population in the republic lives in rural areas where FGPs and FAPs are the typical facility for care. Currently, there are over 400 settlements in the country with a population from 500 to 5.000 residents, with the distance to the closest health care facility (HCF) ranging from 4 to 20 km or more.

102. Insured patients receive the following health care services in primary care facilities free of charge:

(i.) Prevention: (a) Activities related to health protection and promotion; (b) Immunization within the national calendar of preventive vaccinations; (c) Anti-epidemic work; (d) Education of clients, patients and their family members, self-and- mutual aid-and care. (ii.) Diagnostic: (a) Patient’s examination; (b) General blood analysis; (c) General analysis of urine and microscopy of urinal sediment; (d) Microscopy of urethral and vaginal smear; (e) Analysis of discharge (microscopy of smear); (f) Identification of sugar in blood and urine; (g) Electrocardiogram; (h) Ultrasound of minor pelvis (women under antenatal care in compliance with clinical protocols). (iii.) Treatment: (a) Emergency care; (b) Immobilization; (c) Oral drugs; (d) Medical injections (intravenous, intramuscular and subcutaneous).

103. Other types of medical services provided to insured citizens (MHIF) are paid at 50% of the cost of the procedure. The procedures are outlined in the MOH approved list agreed upon with the State Department on Antimonopoly Policy.

2. Secondary and Tertiary Care

104. In the Kyrgyz Republic, specialist outpatient care, if delivered outside hospitals, is called primary health care and not secondary care (see also sketch above). This is rather confusing because specialist care is almost always regarded as secondary care (the level

29 after primary care) in other countries.32 The generalist provides care that is directly accessible for patients (primary level) and the specialists treat patients after referral by the generalist (with exceptions including emergencies, and multi-trauma patients). The more confusing is the fact that most territorial hospitals in the Kyrgyz Republic provide specialist outpatient services as well and these services are called hospital services. To avoid these confusions, it is proposed to use the term secondary care for all specialist care wherever provided.

105. Specialists in the Kyrgyz Republic belong to different health organizations: state hospitals, FMCs and private clinics. For the sake of continuity of care, however, it is advisable that all specialists belong to the staff of a hospital. After a patient is discharged from the hospital, (s)he will consult, if necessary, the same specialist later in the outpatient department of the hospital. The medical staff of a hospital should feel very responsible for the quality of care delivered to the patients. Reviewing each others work, consultations of colleagues, easy access and discussions with colleagues of diagnostic services, taking care for each others patients during night and weekend duties, holidays or days of absence due to illness or following continuing medical education meetings is considered as essential for good quality of care.

106. In modern hospitals the inpatient department is divided into multiple nursing departments which are used by different specialties. There are only separate departments for pediatrics and for obstetrics. Most hospitals divide the other nursing departments between internal specialties and surgical specialties, and keeping “clean” patients separate from potential infectious patients. Only in large hospitals each specialty may have its own department. The decision how to divide nursing departments is made by the management of the hospital in consultation with the medical staff. All specialists work in all three departments (inpatient, outpatient and day care).

107. The present situation of inpatient care in the Kyrgyz Republic is as follows. Inpatient care is provided by Territorial Hospitals and their branch hospitals. According to RMIC data there are 47 Territorial Hospitals and 17 branch hospitals in the Kyrgyz Republic (see annex 8). The size and functions of these branch hospitals differ. Some have only 5 beds and only one function with only mid-level medical personnel (for example only obstetrics, so-called maternity houses), others my have 50-70 beds and provide a number of specialty functions with some specialists available. It is important to know that the management of these branch hospitals is the responsibility of the director of the Territorial Hospital. More advanced care and so-called tertiary care like transplantology, cardiac surgery, etc, are provided in Oblast and in Republican Hospitals. The network of institutions, providing health care in Kyrgyzstan, is presented in the above organogram.

108. Inpatient emergency care is provided free of charge to patients until they have recov- ered. The level of co-payment depends on the profile of the disease, as well as the availability of rights of the patients to other health services benefits. Obstetrical admissions and admissions of children under five years of age are free of charge however, patients do have to pay for drugs.

32 A definition for secondary care is: Services provided by medical specialists who generally do not have first contact with patients (e.g. cardiologist, urologists, dermatologists) (http://www.pohly.com/terms_s.html)

D. MCH Service Provision at all Levels of the Delivery System

1. Obstetrics

109. Women will typically have their first antenatal visit, preferably in the first trimester of pregnancy, with a family doctor in the FGP. Follow-up visits will be with this family doctor, assisted by a midwife. If there are no reasons for referral to a specialist, the mother will deliver in the Territorial Hospitals or in smaller branch hospitals. The gynecologist or the midwife with the presence of the gynecologist assists the woman during the delivery. After 3 to 5 days the woman and baby may go home. Mothers have to stay in the hospital until the baby has received a BCG (Bacillus Calmette-Guerin) vaccination. Admissions and all care during the admission are free of charge. Postnatal care takes place at the FGP. The midwives of the FGPs or FAPs are visiting the mothers with their newborns at home during the first weeks after discharge from the hospital and later the mothers and babies will visit the FGPs or FAPs for follow-up care.

110. In case of potential medical complications (for example diabetes or heart disease) the woman will be referred by the family doctor to a gynecologist of the territorial hospital. In the case of new problems uncovered during antenatal care (for example hypertension) the woman will also be referred to the gynecologist for further care. Gynecologists of territorial hospitals are able to provide appropriate obstetrical care. Cesarean sections are performed in these hospitals and every territorial hospital has neonatologists at their disposal. Gyne- cologists of territorial hospitals will refer patients to oblast maternities if major complications may be expected or in case of certain co-morbidities that are too complicated for their level of hospitals.

111. Gynecologists in public facilities work either in polyclinics or in hospitals because polyclinics and hospitals are separate facilities. Gynecologists in hospitals on the other hand do not work in outpatient facilities. As mentioned above, this may lead to duplication of services on the one hand and problems with continuity of care on the other hand.

112. The ADB financed project for Reducing Neonatal Mortality in Osh has developed draft papers on Risk Classification and a Scoring System to improve the referral system of primary care providers to higher levels of care. With these guidelines, midwives and family doctors will be better informed on the conditions appropriate for referral. The MOH has adopted this model and is continuing to develop a number of treatment protocols for other complications such as hypertension during pregnancy. The ADB project will play an important role in this development.

113. The model of antenatal care, delivery and postnatal care is in principal a good model. In practice however, 25% of the population (mainly in rural areas) do not have easy access to FGPs and must rely on FAPs (feldsher or family nurse and a midwife)33. The level of care in FAPs will be lower than in FGPs. The system of FAPs was created during the Soviet era to provide basic primary medical care to the population in remote areas because it was not feasible to have polyclinics with all basic specialties available in every small village. FAPs are indispensable to guarantee geographical accessibility to a significant part of the population. Every effort should be taken to ensure that the highest possible quality of care is available at the FAP.

33 Information received from the Ministry of Health, Dinara Saginbaeva.

114. Most family doctors in a FGP are not family doctor specialist. They are physicians who worked in polyclinics as a specialist (therapist, pediatrician, gynecologist, etc) and received a family doctor registration by completing eight months of training over a two year period. This may have some impact on the quality of care available in these facilities. A team of two therapists, one pediatrician and one gynecologist was normal for a rural polyclinic in the previous health care system. Now the smaller polyclinics have been replaced by FGPs and the larger ones by FMCs.

115. Weak points in obstetrical care as revealed in discussions with gynecologists are as follows:

(i.) Knowledge of health and health care of the population is often low; (ii.) Especially outpatient care is often of poor quality due to lack of knowledge of the physicians and a poor attitude; (iii.) Knowledge and skills of physicians are not always of good level; (iv.) Equipment in hospitals is often old, poor functioning, and hospitals are lacking modern equipment; (v.) Quality of paramedical and nursing personnel could be better; (vi.) Attitude of health workers is in general good but salaries are low and motivation for self-study is not always as one may expect; (vii.) The specialist training program is too short; the residency of gynecologists should be longer to get higher qualified gynecologists especially because “primary care gynecologists” will not longer be needed after the introduction of family doctors; one has to realize that the specialization training to become a gynecologist is only two years; (viii.) A split between inpatient and outpatient care is bad for continuity of care but also for the skills and experiences of specialists and therefore integration of outpatient and inpatient services is essential; (ix.) Concentration of hospital departments into one large building instead of the present pavilion hospital buildings and being able to share expensive diagnostic and therapeutic facilities would be good.

116. In conclusion, the theoretical model of obstetrical care is quite adequate; however, in practice that there are many areas in need for urgent attention in order to improve the quality of care that is delivered.

2. Pediatrics and Neonatology

117. The model as described for obstetrics is more or less similar for pediatrics. In rural areas with FGPs, children visit first the General Practitioner. In case a referral is necessary, children are referred to the pediatrician in the FMC or to the pediatric department of a territorial hospital or to one of the smaller hospitals in the raion. As most hospitals do not have outpatient care, most of these referred children are admitted. In areas without FGPs, children go to the feldsher or family nurse at FAPs.

118. Commonwealth of Independent States (CIS) countries general pediatricians are not specialists but physicians who have graduated from the pediatric medical institute; they are trained as a general physician for children. If pediatricians in hospitals in the raions are not able to diagnose or treat the patient, they will be referred to oblast or republican pediatric hospitals. These hospitals have a department with pediatric specialists, typically with two years of specialization in a narrow specialty like pediatric hematology, pediatric gastro- enterology, pediatric cardiology, pediatric ophthalmology, etc. The system does not produce a specialist in general pediatrics.

119. Most maternity and pediatric departments are located in separate buildings; neonatology departments are available in each maternity as well as in each pediatric hospital. The result is a duplication of expensive buildings and equipment (incubators for example) and highly trained professionals. Also more nursing staff and paramedical staff are needed than necessary. This problem has not been a subject of the first health sector reform because that reform concentrated on the delivery system as such, but not on the functionality of the hospital building. This issue should therefore be addressed in the future.

E. Other Services relevant for MCH

1. Public Health and Health Promotion

120. In 2001, the responsibility for health promotion was redirected from the Department of State Sanitary Epidemiological Supervision (DSSES) to the newly created autonomous Re- publican Center for Health Promotion (RCHP). The RCHP was established to introduce new principles of work with the population and the new policy on health promotion. The RCHP aims to integrate functions on health promotion with the FAPs, the FGPs and the FMCs through established health promotion rooms within the FMC structure. Today, FMCs are staffed with a health promotion specialist who is equipped with audio-visual equipment. The health promotion specialists provide a range of health talks in health facilities. Each month they develop a plan on the content and location for health talks. Being largely FMC based, the health promotion specialists may not be delivering messages to those at highest risk, namely those not attending health facilities or those not enrolled in an FMC.

121. Health promotion specialists report monthly on the talks given and the number in attendance. The DSSES receives reports on the health talks given by the FMC health promotion unit; topics and number of attendants. A quick look at the reporting forms suggests that the number of people in the raion exposed to health education may not be optimal, especially in terms of having a lasting impact on disease prevention and control, and healthier lifestyles. From current reporting, it is not possible to determine just which segment or what proportion of the population is receiving the health messages.

122. To expand health promotion to the community, the RCHP has been instrumental in establishing village health committees (VHC) to empower communities to improve their health status. The MOH has endorsed the “Jumgal Model” for establishing VHCs. Thus far VHCs have been involved in health promotion campaigns concerning iodine deficiency, hypertension, brucellosis, and soon tobacco use. Currently, the Swiss Red Cross and the USAID ZdravPlus project are working to establish VHCs throughout the country.

123. In support of the Manas Taalimi 2006–2010 goal to develop a sustained public health service, SES/MOH with support of WHO has developed a Public Health Concept paper. This paper emphasizes restructuring the SES and the various national institutes into a more public health oriented structure. In addition, the USAID ZdravPlus project has been working on developing the public health service at the raion level. An effective public health service with a strong preventive mandate is essential for providing quality MCH and nutrition services.

124. The efforts to promote a public health approach by the MOH have been top-down. The MOH with technical support from WHO has put extensive work into developing a concept paper: “Conception of Public Health Service Development, 2006, 2006-2010 years”. However, this paper concentrates on describing the structural and organizational improvements which are needed mostly in Bishkek, such as improved national epidemiological surveillance and state regulatory functions. The top-down approach for public health reform does not yet promote empowering local health and preventive services to protect communities and to promote good health.

125. In January 2007 the USAID ZdravPlus project together with the SES accelerated efforts on public health reform by initiating a pilot project in Ton raion, Issy Kul oblast. The purpose of the Ton pilot is to develop a low cost approach from which the MOH can establish a more effective public health focused SES.

2. Epidemiological Surveillance

126. Manas Taalimi 2006–2010 emphasizes better disease control through improved epidemiological surveillance. A strong epidemiological surveillance system is essential for monitoring the status of child health and the effectiveness of child health and nutrition initiatives like IMCI, PEPC, and iodized salt. Like the national health statistics, the epidemiological surveillance system is highly centralized. However, considerable improvement in reporting has been achieved by adopting international disease classification standards and from the nationwide computerized surveillance system developed by the DSSES. Currently this computerized system is being used primarily for national level reporting rather than for local analysis and for monitoring and detecting health problems.

127. The reliability of the data being collected by epidemiological surveillance, like the health information system, suffers from a lack of adequate laboratory support. Many of the laboratory tests being used as well as the dilapidated equipment and the lack of reagents are not adequate for confirming clinical diagnoses. Like all other services, many technicians have left for better paying jobs. The laboratory staff remaining has not received supplemental training in years. The reliability of morbidity and mortality statistics is influenced by the lack of adequate laboratory support and by the lack of analysis of the data by medical workers.

128. It appears that both national and international stakeholders view national data collection and analysis and generating computerized reports and graphics at the central level as the best pathway for improving disease surveillance. While improving the national health information and epidemiological surveillance systems are certainly critical, establishing more effective public health surveillance and use of information at the service delivery level is equally critical to achieve more effective epidemiological surveillance and thereby improve the overall quality of MCH, nutrition, and other PHC services.

3. Laboratory Services

129. Along with the over all health care system, laboratory services were devastated by the break up of the Soviet Union, and the subsequent collapse of the economy. During the past 10 years of health reform FMCs, FGPs and FAPs have been rehabilitated and equipped with medical equipment from health reform projects supported by the donor community. However, many laboratories remain understaffed and are without modern equipment or modern laboratory testing capability. While laboratory capacity for certain illnesses, such as HIV/AIDS, has been upgraded, the overall structure and capacity for laboratory support remains weak. This weakness can result in misdiagnosis and thereby inappropriate treatment, as well as inaccurate morbidity and mortality reporting.

130. A recent analysis of the laboratory service conducted by the USAID CitiHope project revealed that there are 571 diagnostic laboratories throughout the country performing approximately eight million laboratory tests per year. However some laboratory staff lacks professional competence in terms of performing and interpreting test results. This deficiency results from the lack of any recent training as well as the use of outdated and sometimes non- functional equipment and methods. There is also the lack of sufficient reagents, control and calibrating devices and funds for maintenance. Hopefully the Republican Center for Quality

Control of Laboratory Diagnostics of Communicable Diseases and two reference units established in 2005 will advise MOH on how to improve the present situation.

4. Pharmaceutical Sector and Provision of Essential Drugs

a. Problems and Challenges

131. The pharmaceutical sector has undergone considerable change during the health reform process. The pharmaceutical network was privatized during the mid-nineties, except for hospital pharmacies. A new legislative base for medical products was adopted in October 2002, and put into law in April 2003. In addition a 20% VAT exemption was granted in 2003 to make drugs more affordable to the population. Foreign aid has provided significant assistance to the pharmaceutical sector through short-term humanitarian aid. Foreign loans and grants have helped to import emergency drugs and additional drugs have been donated.

132. The MHIF introduced the additional drug package (ADP)in 2000 to make drugs more affordable. The ADP was expanded to all oblasts in 2002. The co-payment mechanism of the ADP forms a part of the State Benefits Package. In this scheme pharmacies contract with the MHIF to sell an approved list of drugs to enrolled patients at a reduced cost. The average reimbursement rate was 50% (discounts on prescription drugs varied from 30 to 80%). Ac- cording to Manas Taalimi 2006–2010, children under 5 years and women are the priority categories for financial assistance in purchasing medicines. Almost all medicines used in the IMCI program are included in the list of medical products on the ADP of the MHIF. However even with the 20% VAT exemption and the MHIF co-payment plan, the lack of money for purchasing drugs remains a major problem for the poor (SCBECDP Needs Assessment Sur- vey).

133. The Program of State Benefits includes a drug discount. However, few people including many health workers know about it. The discount varies according to area of residence. The program provides discounts to children under 16 and to various additional categories of the population. According to an evaluation report, TV and radio broadcasts explaining the benefit did not reach the majority of the population. A new initiative from the MOH in Bishkek requests that the Oblast Director of Health Insurance and Chief of the Drug Supply organization identify more effective ways of communicating the information.

134. The financial assistance provided through the MHIF is limited by the absence of pharmacies in the remote villages and the reduced availability of the assistance at the FAP level as the MHIF drug package focuses on FMCs and FGPs. Currently 325 rural settlements do not have their own local pharmacy. One reason for this lack of rural pharmacies is that establishing a pharmacy in a rural area is simply not viewed as a good investment by the private sector; pharmacists prefer to work in the raion or oblast towns where economic conditions are better.

135. Establishing a reliable and affordable essential drug distribution system for remote villages throughout the entire Republic is a formidable task. Citizens not only need access to drugs, but providing better access to drugs in remote areas also requires quality assurance, rational prescription and use, and proper counseling. The existing MOH structure with the Department for Quality Control and Licensing of Medical and Pharmaceutical Services does not have the financial or the human resource capacity to monitor pharmacies, quality control, or use of drugs. MOH together with donors must develop a coordinated approach for ensuring quality control, uninterrupted supplies, and proper use of drugs. Developing a reliable pharmaceutical network for remote rural areas will require a long-term process with the MHIF, MOH, and partners.

b. Efforts to Improve the Pharmaceutical Network

136. The MOH has taken a number of measures to resolve the problem including allowing rural health workers, such as feldshers, to prescribe and sell medicines in the absence of a medical doctor, organize rural pharmacies and allowing FGPs and FAPs to open pharmacies. However, these measures so far are limited in their scope due to financial constraints.

137. The issue of rural and especially isolated FAPs having very limited access to essential drugs as pharmacies were not available to them was addressed by the MOH by issuing an Order (Prikaz) in 2001. It was allowed that Community-Based Clinicians (CBCs), such as feldshers prescribe drugs in the absence of doctors. To date 65 health workers have obtained permission to sell and store medicines and medical products in their village. Project HOPE helped to cover the initial training costs of a number of CBCs in a few selected project raions that were used as pilot sites. Training took place in summer 2006. According to the Decree, the local authorities are supposed to promote the opening of pharmacies (designa- tion of premises, finding funds, and facilitating the training of staff) in the remote areas and villages. However, in spite of the Government’s directive34 not all local authorities do provide proper support and as a consequence not all health workers opened pharmacies in their village.

138. The Village Pharmacies provide approximately 50 essential and a number of other “non-prescription” drugs which are supplied by a pharmaceutical company through the FMC. The CBC has a signed agreement with the pharmaceutical company, which specifies the selling price of the drug as well as the commission CBC receives from sales. The drug supply can be renewed as needed at the FMC Pharmacy and drugs not sold can be returned for drugs in higher demand.

139. In 2004, the MHIF of the Kyrgyz Republic and the Kyrgyz-Swiss Health Reform Sup- port Project began a pilot project to establish a not-for-profit pharmacy network in the remote villages of Jumgal raion in Naryn oblast. Makzat, a newly established non-governmental organization (NGO), opened one central warehouse in Jumgal raion centre and 13 pharmacies on the premises of existing FGPs and FAPs in 13 Jumgal villages. Funds from the Kyrgyz- Swiss Health Reform Support Project were used to purchase an initial supply of medicines. These medicines are replenished through a revolving fund mechanism. Nurses and feldshers manage the pharmacies after successful completion of a certified training program. The objectives of the pilot were to provide accessible and affordable high-quality, safe drugs; increase access to medicines supplied through the ADP; and increase the effectiveness of primary health care (FGP/FAP) in rural areas. The donors created and financed the organization and financed the equipment and furniture in the pharmacies and the salaries of the pharmacists.

140. An evaluation in November 2005 of the Jumgal pilot project by ZdravPlus/Boston Uni- versity and WHO-DFID Health Policy Analysis Project concluded that the pilot project has realized many successes in a very short amount of time. Also the community members were overwhelmingly positive. However it was also concluded that several systemic issues have to be solved before the pilot can be expanded to other remote areas. The following systemic problems were noted: inefficiencies in distributing prescription forms, lack of awareness of the program by the population, an underestimate in the per capita allowance for beneficiaries (20 som per year), and inadequate pricing for ensuring sustainability. The evaluation noted that storage; inventory and transport systems were not always adequate. The evaluation team also noted an overuse of antibiotics and the ever present over use of injections.35

34 Government Decree No. 265 of 20 April 2004, “Implementation of the Law of the Kyrgyz Republic on Pharma- ceuticals” 35 WHO- DFID, March 2006, “Project Evaluation: Rural Pharmacy Pilot in Jumgal Raion,”

141. The HOPE project has just started and has not been in place long enough to assess the effectiveness of the Village Pharmacies program. Based on the experiences of the “Jumgal” project one may expect that the HOPE project will also be successful because the content of the project is very similar.

142. The MOH is planning to open more Village Pharmacies in remote areas next year based on the experiences in both pilot projects. The MOH is very aware of the need to provide drugs to remote areas and sees the mechanisms of the projects as a way to accomplish that. The MOH is considering preparing a list of medications that the Village Pharmacies are permitted to sell. The Southern Drug Department and the insurance fund will conduct the monitoring.

143. The ADB financed FCBECDP plans to start implementation of a project with pharmacies in remote areas in three raions using the “Jumgal” model. FCBCEDP will purchase the first installment of drugs, buy equipment and furniture and pay for the training of the pharmacy workers. Private pharmacies will manage the system by taking care for supplies, transport, salaries, etc. An excellent example of public-private partnership, if it succeeds.

144. Both the MOH and donors desire to solve the problem of access to essential drugs in remote areas. The “Jumgal” model shows very promising results, but, expanding a “Jumgal” like network of local pharmacies also requires solutions to the critical issues of maintaining quality control, reliable distribution, rational use, and monitoring drug usage.

5. Monitoring, Supervision and Information Management

145. Monitoring is the regular observation and recording of ongoing activities in a project or program. Monitoring of a program involves the collection of information (data) on a regular basis to measure progress towards achieving specific program objectives. Monitoring allows program managers and stakeholders to make informed decisions regarding the effectiveness of programs and the efficient use of resources. Data from the monitoring process can be used to determine whether program/project activities need adjustment. Process monitoring involves qualitative and quantitative measurement of a project implementation process.36

146. Inadequate funding, insufficient information, and infrequent supervision continue to constrain the delivery of health services in Kyrgyz Republic. The quality of health services is further constrained by the continuing centralized and vertical approach for monitoring and supervising health programs and health facilities. Both monitoring and supervision are conducted selectively in donor supported projects: such as tuberculosis (TB), IMCI, and HIV/AIDS. This selective and centralized approach does not allow for sufficient attention to be given at the service delivery level nor does it promote timely use of information for better managing of health services at the local level. While both the FMC and the raion SES have responsibility for supervising health services, in reality supervision rarely happens due to lack of transport, funds, and staff time.

147. While supervision and monitoring are from the top down, from republican to oblast level, the management information system is from the bottom up, from the health facility to raion to oblast and to republican levels. Health workers collect extensive amounts of information, which they record in journals and then compile and report monthly to the next higher lever. Feedback or summary reports are rarely circulated back to the lower levels. This extensive effort on collecting and reporting information has minimal impact on local detection and timely correction of problems. Instead, data are compiled into large tables and incidence rates, which do not facilitate a more critical analysis at raion and service delivery levels.

36 USAID Child Survival and Health Grants Program Technical Reference Materials, 2005.

There is little analysis of information for decision making either by curative (FMC) or preventive (SES) services of the MOH. Instead information is largely historical, and used primarily for annual reporting and for long term planning.

148. Programs are monitored from Bishkek and infrequently. As an example, IMCI trainers based in Bishkek may make two visits per year to oblasts to oversee the progress of IMCI. Such infrequent visits from Bishkek are not adequate to accurately assess or to provide the much-needed support for IMCI in health facilities, particularly at the FAP level. While oblast and raion IMCI coordinators are assigned the task of monitoring IMCI in health facilities, in reality they are rarely able to visit health facilities due to lack of funding, primarily for transport. In addition, oblast and raion staff usually does not receive any follow up training on IMCI after they have attended the standard IMCI course. Consequently, supervisors at oblast and raion levels do not have the financial resources or the skills to adequately supervise the IMCI program.

149. The monitoring and supervision of programs and health facilities are also constrained by the lack of adequate numbers of senior supervisory level medical workers. Due to the staff shortage, medical workers at senior levels are assigned multiple tasks, and therefore simply do not have the time required to carry out effective supervision and monitoring. For example, someone at the national level assigned to monitoring IMCI in the oblasts may also have clinical and teaching responsibilities in Bishkek, as well as responsibilities for other MOH programs.

150. Currently, national health statistics are collected by both the RMIC and by the RSES. In addition the MHIF maintains a computerized information system on costing and health service statistics. There is an ongoing effort to better co-ordinate the RMIC and RSES information systems to eliminate duplication and to reduce the amount of information being collected. But again, both the RMIC and the RSES information systems are highly centralized and do not empower local health officials and medical workers to monitoring their own work. The lack of attention at data entry and the reliance on higher levels to produce reports leads to questions of reliability of the data being collected. The quality of the information being recorded and the lack of reliable laboratory diagnostics services raises further questions about the reliability of reported morbidity statistics, since reporting standards require laboratory confirmation for most diseases (see Laboratory Services section)

6. Regulation of the Health Sector

151. In the Kyrgyz Republic licensing by the MOH is needed for every new health facility (public as well as private). Before being allowed to start working in a new facility, the owner or responsible body has to apply for a license. Requirements are based on standards regarding the building, the equipment, the sanitation and hygiene and the required qualifications of manpower. Whether the facility is needed or not is not taken into consideration. The following criteria, requirements and conditions of licensing and extension of a license could be used:

(i.) The building and all equipment in the facility of the applicant is according to the standards. (ii.) A document of the Registration Office that the health professionals on the list of the hospital are all registered in accordance with the requirements. (iii.) The Accreditation Certificate. This document will only be required if accreditation of facilities has become compulsory. (iv.) The application has to be in compliance with the official Health Plan (is this facility needed, are the same functions in the facility planned or will the facility merge with another facility?).

(v.) Other requirements for hospitals could be added like certain functions have to be available: pharmacy, laboratory, radiology, functions diagnostic department, etc. (vi.) Also other requirements related to quality, such as certain committees have to function in the hospital.

152. Accreditation of health care facilities is based on the organization, the management, the quality of care, etc, like in most other countries with an accreditation system. The Licens- ing and Accreditation department of the MOH has published (also on the website) the “Stan- dards of Accreditation” for the different facilities. Whereas with licensing one inspects the so- called input of the facility, with accreditation one measures the process and outcome of care. Accreditation will focus on three major aspects of the delivery of care:

(i.) The organization of the facility, like management structure, written protocols and procedures, the functioning, maintenance and availability of the right equipment, the condition of the buildings, efficient utilization of facilities as well as manpower, etc. (ii.) The quality of the care given to patients like using the right diagnostic and therapeutic procedures on the right way, the outcome of care on short term as well as long term, a good functioning referral system, etc. (iii.) The satisfaction of patients regarding the attitude of health care personnel, the physicians, the sanitary conditions, the services of the so-called hotel services (food, beds, cleanliness), etc.

153. The costs of introducing and especially running an accreditation system are high. In most countries the facility has to pay the fees for accreditation. But, if almost all hospitals are owned and run by the Government, almost all costs of accreditation have to be paid by the Government. At this moment the public owned health facilities in the Kyrgyz Republic need a substantial amount of financial funds for upgrading their equipment and buying new equipment, investments in new buildings and/or refurbishing of buildings, retraining personnel, etc. Therefore it is recommended to wait with the introduction of a compulsory accreditation system and use the limited financial resources for more needed expenses in health care facilities. To continue with voluntarily accreditation as is done at this moment is certainly very good. Some years ago all health care facilities were accredited apparently without too much critical observations. The reason was that to have access to the funds of the MHIF the facility needs to be accredited.

154. An improvement of health manpower registration is envisaged in Manas Taalimi37. At this moment health professionals are registered after receiving their diploma. Extension of registration has not yet been introduced. A record of employment has to be filled in by any employer for every employee in every sector in the Kyrgyz Republic. If a health worker has not worked in a health facility for three years some extra training is required before being allowed to work again. Each health professional needs also to follow a postgraduate course every five years. Because so much attention is given to training programs for the simple reason that lack of knowledge and experience is a major factor for poor quality, it would be good to consider developing a system in which each health professional has to extend the registration based on a number of requirements. To develop such a system is not so difficult but to implement it and maintain a good system requires substantial investments in manpower and computer programs.

37 MOH, 2006, KR National Health Care Reform Program “Manas Taalimi” for 2006-2010, ,.

F. Resources for MCH

1. Financial Resources

155. In spite of a reduction in health sector spending as a percentage of gross domestic products from 4.0% in 1991 to 2.2% in 2006, during the health reform process fundamental changes have occurred in the health care financing system. The MHIF was established in 1997 as an independent body of the MOH but still under the Minister of Health. The director of the Fund is also a Deputy Minister of Health. With the introduction of mandatory health insurance the Government hoped to attract additional funds for the health care sector to be able to provide social security for the citizens. Funds for the MHIF are collected through the government’s Social Fund. The MHIF is funded by contributions paid by employers as well as by transfers from the state for low-income groups. The Fund covers all individuals, groups such as retired people and children below the age of 16 or students below the age of 18. About 70% of the population is ensured for a limited range of services. In 1998, insurance accounted for only about 4.3% of the state health budget.38

156. In 2001, a single payer system was introduced in two oblasts. Through this single payer system the MHIF pools all local budget revenues for health, thereby creating a single pool of funds for the entire oblast population. By 2004, the single payer system was introduced in the entire country. In 2000, the MHIF introduced the ADP on a pilot basis in three polyclinics working under the single payer system. This ADP now provides a co-payment mechanism for purchasing approved drugs at approved pharmacies throughout the country. However, the system has less access in rural areas due to the lack of pharmacies. In addition, new advanced payment systems for providers have been developed, such as payments based on the numbers of treated cases in inpatient facilities and per capita payment in primary care facilities.

157. The introduction of the State-Guaranteed Benefit Package (SGBP) and of co- payments for medical services played an important role in improving access of the population to medical services (see annex 2 for a description of the SGBP). SGBP represents a state social standard, determining the volume of health care provided to the population either free of charge or on a reduced basis and MHIF allocations. In parallel with the introduction of SGBP, official co-payments were introduced for certain health services, aimed at the replacement of widespread nonofficial payments and fees in health care.

158. As mentioned above, within primary care, basic medical services are provided free of charge for the entire population. For the socially vulnerable population additional mechanisms for getting reduced or free health care have been developed. In compliance with the Kyrgyz Republic legislation, specific population categories are entitled to social privileges. For receiving free medical services or for reduced fees the number of categories has been increased from 27 in 2001 to 67 in 2005.

159. In the Manas Taalimi, the demand for health sector funding was calculated for a period of 5 years. According to information received from a WB representative the demand for the state allocation was $725 million based on the minimum state standards. The estimate for investment expenditures was $111 million based on the activities in the plan of work. All in all, the total demand for financing in the health sector for the next 5 years was $ 836 million. However, the actual funding available from the state budget, taking into consideration all available financing sources, was $ 600 million. The financial gap amounted $236 million. To improve the situation and implement the objectives and targets set for the health care, part of the donor community has offered a mechanism for the Manas Taalimi program implementation based on a SWAp

38 http://www.euro.who.int/document/obs/Kyrgyzstan.pdf

160. Since 2006, funds have been pooled at the republican (national) level, where SWAp funds are merged into the health care budget. The budget of the MOH has increased (10 to 13%) since a number of donors (WB, KfW, DFID, Swiss SDC and SIDA) have pooled their donor funds with the budget of the Treasury to establish a SWAp. Through this additional funding the policies as described in Manas Taalimi 2006–2010 can be more completely implemented by the MOH. Negotiations between the “SWAp” donors and the MOH should result in increased government expenditures for priority programs in the health sector. This has led to a consolidated health care budget increase of 30.6% since 200539 and consisted of 3,527.9 million soms or 683.0 soms per capita. The sources of financing the health care budget in 2006 are shown in the table below:

Table 5: Sources of Financing of the Health Care Budget Source Nr. of soms (million) % of soms

The state budget 2,257.4 60.5% MHIF funds 550.4 14.8% Special assets 248.9 12.1% SWAp funds 283.1 7.6% Co-payments 188.1 5,0%

161. The increase in the health care revenue has provided for an increase in SGBP allocations by 26.2% compared to levels of 2005 (2,429.4 million soms), advanced technologies by 2.5% (74.2 million soms), public health care by 35.8% (192.1 million soms), and the supplementary ADP program by 20.7% (60.3 million soms). In 2006 the SGBP has expanded its coverage to include free medical services for children under 5 and women during pregnancy and delivery. The list of drugs to be reimbursed under the Supplementary ADP (including IMCI) has also been expanded. The full impact of this latter directive is yet to be realized since in rural areas pharmacies are often not available. Even when pharmacies are available, not all participate in the MHIF program.

162. An allocation of $13 million in donor assistance in 2007 is used to support the state budget, including $ 9 million for recurrent expenditures and $ 4 million for new investments, including $ 2.9 million for equipment and supplies for FAPs. The MOH’s Priority Programs for 2006-2010 include a large number of MCH subjects40:

(i.) Reduction of maternal and infant mortality due to expansion of evidence based medicine health services coverage. (ii.) Stage-by-stage extension of medical services for pregnant women, women in child-birth, women recently confined and children under 5 years of age within State Benefit Package. (iii.) To ensure extension of coverage of effective interventions for improvement of the state of health of mother and child. (iv.) To optimize the registration system of child birth and death and to provide its accessibility, reliability and immediacy. (v.) Improvement of medical staff and population awareness in pregnant women and child care issues.

39 Data for 2006 – preliminary 40 Source: POW

(vi.) Provision of pregnant women, women in childbirth and children under 1 year with drugs on all levels of medical care. (vii.) Strengthening the role of primary care providers in prevention and treatment of respiratory diseases and TB. (viii.) A number of other programs will also be of benefit for mothers and children but are less specific for this target group.

163. The five programs in the Kyrgyz Republic health budget41 do not readily allow for assessing specific government funding neither for MCH nor for matching priorities in Manas Taalimi. Some programs in the health budget corresponded with existing mandates in 2005, while others became consolidations of previous programs. Current health budget categories are:

(i.) Program of State Guarantees: separated into primary care and hospital care. Funding is pooled into the health Insurance Fund which reimburses providers using capitation and case-based payment methods (ii.) The High Technology Fund: used to fund expensive tertiary services (iii.) The Outpatient Drug Fund: a supplemental benefit provided in addition to the State Benefit Program that reimburses pharmacies according to a price schedule and approved list and includes co-payments from the beneficiaries (iv.) Public Health Services: provided by the MOH and SES and funded using input-based budgets (v.) Administration, Capital, Education and Research: also funded using input- based budgets

164. Inadequate or insufficient financing of priority health programs remains a serious obstacle for the improvement of health care quality and the reduction of newborn, infant and child mortality. Most of the Government spending in health goes into payment of wages and recurrent costs of health facilities, such as electricity and heating. Financing of supplies, equipment, maintenance and repair of equipment is not included in the local budgets, yet the local authorities are held responsible to provide for them. In spite of the MHIF, many items such as medicine and meals for patients in health facilities were not fully funded.

165. The distribution of funds among the regions was not balanced (see figure 6). Over 60% of national health revenue was allocated to the capital city of Bishkek and the surround- ing Chui Oblast.42 Since the allocation for Osh, Jalalabad and Batken oblasts and Osh City was much lower compared to other regions of the country, a total of 48.4 million soms was allocated to balance the budgets in these regions. With the introduction of the rural coefficient and small city coefficient (59.5 million soms), the gap in SGBP financing from the state budget by regions went down from 22.5% to 13.5%. To ensure the SGBP commitments, rates for financing of inpatient health care institutions were increased by 11% on average, FMC – by 55%, and FGP– by 18%.

41 World Bank Project Appraisal Document, 2005, p. 41. 42 Ibid., p. 41

Figure 6: Inequality of Regional Financing

2. Human Resources

a. Distribution of Human Resources

166. The health system is confronted with a number of difficulties with regard to human resources. The present system of human resources is not able to produce a sufficient number of professionals of the proper specialty and is not able to distribute health personnel to the areas of the country where they are needed. There is a misdistribution on two fronts. The functional misdistribution is especially clear in primary care. It has been difficult to train a sufficient number of primary care professionals and to keep the existing ones. The geographical distribution of health personnel is a serious problem not unlike in many other countries. It is very difficult to attract people to work and live in rural areas, especially remote rural areas. Consequently, it becomes very difficult to provide the minimum amount of primary care in rural and isolated areas of the country. The functional misdistribution is more serious for physicians. Geographical distribution affects all health professions, but mid-level personnel are affected to a somewhat lesser degree.

167. In 2005, there were approximately 13.000 medical doctors (including all specialties and including dentists) in the Kyrgyz Republic (RMIC data), approximately 120 less physicians than in 2003. These are 25.1 doctors per 10,000 people, a slight decrease from 2004. The number of mid-level health workers was approximately 30.000 or 58 workers per 10.000 population, a slight decrease from 2004.43 Based on WHO information in 2003 it is observed that the number of physicians per 10.000 people is lower in the Kyrgyz Republic than in some other CIS and EU countries. The data are as follows:

43 Joint Progress Review, Manas Taalimi Health Reform Program, September 2006

Table 6: Comparison of Number of Physicians per 10.000 People in CIS and EU Coun- tries Number Physi- Number Physicians per CIS Countries EU Countries cians per 10.000 10.000 People People Armenia 36 Belgium 45 Georgia 40 Denmark 29 Kazakhstan 35 Czech Republic 35 Russian Federation 42,5 France 40 Ukraine 29,5 Germany 34 Uzbekistan 27,5 Netherlands 31,5 Source: WHO Statistics

168. The number of doctors per 10.000 people in the oblasts Batken, Jalalabad and Osh is substantially lower than for the country as a whole (2005). In 2005 Osh oblast had a net loss of 290 physicians and Jalalabad oblast a net loss of 304 physicians.44 Many physicians might be registered in the official national data but are no longer functioning as physicians and therefore not registered in the oblast data. The main cities have a relatively high number of physicians. The numbers for mid-level health workers show the opposite picture.

Table 7: Number of Health Workers in Batken, Jalalabad and Osh as Compared to National Average Oblast All Doctors and Dentists Mid-level Health Workers Pediatricians

Batken 14,4 73 1,5 Jalalabad 15,3 60 1,3 Osh 14,8 65 0,8 Kyrgyz Republic 25,1 58 1,5 Source: RMIC Yearbook

169. The numbers of pediatricians (780 in 2005) show a decrease of 20% in 2005 compared to 2004. This is mainly due to the fact that many pediatricians are now registered as a family doctor after a successful training program. Despite this decrease the number of pediatricians is still higher than in western countries. In the Kyrgyz Republic there are 0,8 to 1,5 pediatricians for 10.000 people of all ages; recalling that there is a high number of pediatric sub-specialists. The number of neonatologists in the Kyrgyz Republic is 151. The number of gynecologist in the Republic is 1027 in 2005. The number of midwifes is 1094. The figures of some other specialties in 2005 are45:

(i.) All surgical specialties 1816 of which general surgeons 577 (ii.) All internal medicine specialties 3561 of which therapists 855, endocrinolo- gists 90 and cardiologists 212

44 MOH, 2006, Conception of Management of Human Resources in the Health Care Sector of the Kyrgyz Repub- lic for the Years 2007-2011 (DRAFT). 45 All data in this paragraph are from RMIC 2006.

170. In summary one can state that during the last few years, the level of staffing at the health facilities has been on the decline and the distribution of health personnel by regions remains uneven. The highest level of doctors is in Bishkek City and the Oblast Centers, and the lowest in the remote raions (Kadamjaiskii, Leilekskii, Nookenskii, Bazarkorgonskii and Toktogulskii). Currently, a total of 1.450 doctor positions and 5.260 mid-level positions are officially reported as vacant according to information of the MOH. Including the positions at primary care facilities, this means that 60% of the doctor positions and 22.0% of mid-level positions are vacant.

171. The decline in the number of health specialists is influenced by an increasing outflow of health workers due to emigration to other countries, predominantly Russia and Kazakh- stan, and to leaving the health care sector to find jobs in other professions. A net outflow of health personnel is noticed; in the first half of 2006, 416 doctors entered the work force and 437 left. Of mid-level personnel 1.472 left the health service, while 1.352 entered. This is a trend that has persisted since at least 2004, a trend that must be reversed if there is to be a solution to the health human resource problems facing the Kyrgyz Republic.

i. Physicians

172. The country recognizes two types of family doctor. One type consists of physicians, who were specialists but retrained as a family doctor (eight months training). During the last 7 years over 3,000 family doctors have been retrained from other specialties, but currently only 1,700 of those are working in their new specialty.46 The retraining is provided by the State Medical Institute of Retraining and Postgraduate Education. The other type of family doctors consists of physicians, who after their medical study followed the two-year specialization training at the Kyrgyz Medical Academy. Last year there were only 14 candidates for the 70 training positions in family medicine.

173. There are a number of reasons why new graduates do not choose family practice. An important reason seems to be the low prestige of family physicians. The low salaries of family doctors confirm the low status of family medicine. Another reason could be that most family physicians are needed in rural areas and not in the major cities where specialists provide primary medical care. The MOH has developed and is now in an early stage of implementing an incentive program to attract PHC physicians to rural areas.

174. The Minister of Health organized a meeting with managers of oblast state administrations to discuss the different aspects of misdistribution in health staff. Many proposals were discussed on how to stimulate health workers and how to encourage them to work in rural areas. Examples of possible incentives are: allocating short-term credits and loans, subsidies for housing, land plots, fuel for the winter and other social benefits.

175. Under the Deposit Doctor Program, funds in the amount of 3,000 soms (approximately $80) are deposited monthly into an account for the doctor who may periodically draw funds from that account during a three-year service period. As of September 2006, 40 doctors had expressed interest in this program. While the Deposit Doctor Program has a potential, other incentives need also to be considered. Other programs that might be considered are stipends for medical students and those in postgraduate training.

46 MOH, 2006, Conception of Management of Human Resources in the Health Care Sector of the Kyrgyz Repub- lic for the Years 2007-2011 (DRAFT)

ii. Mid-level Personnel

176. The situation of mid-level personnel (such as nurses, midwives, feldshers, etc) is somewhat better than for family physicians, but geographical misdistribution is also a problem. There is a greater shortage of nurses in urban areas than in rural areas. There are a number of possible reasons. The most important being the ability to earn more in other professions in urban areas. Many mid-level personnel in rural areas grew up in the area and stay because their families are close and other types of work is difficult to obtain.

177. Courses for nurses have started which will upgrade them to become family nurses. Family nurses are able to provide better care at primary level and are able to replace feldshers if necessary. To date about 4000 nurses have been retrained into a family nurse. A program similar to the Deposit Doctor Program might be considered for mid-level personnel.

b. Training of Human Resources

i. Physicians

178. Physicians are trained at one of three medical faculties in the country, Kyrgyz State Medical Academy, Osh State University, and Kyrgyz-Russian Slavonic University. A fourth medical school, part of the International University of the Kyrgyz Republic, admits yearly 150 medical students from abroad (mainly India and Pakistan). This medical school is only for foreigners. There were eight universities offering undergraduate medical education in June 2006 when the government closed all but the three above. The list of medical faculties and the number of their graduates are given in annex 9. Medical study, after 11 years of primary and secondary school, takes six years followed by two years in the specialty of interest. Spe- cialization takes only two years47. The MOH is considering adding one year rotating internships after graduation from medical school before the specialization starts.

ii. Mid-level Personnel

179. Mid-level personnel are trained for three years after 11 years of primary and secondary school. They attend one of three medical schools or 11 medical colleges for their training. The list of colleges and the number of graduates are given in annex 10.

iii. Continuing Education

180. Continuing education for health personnel in the Kyrgyz Republic is currently modeled after the system that was present in the former Soviet Union. Under this system each medical worker receives postgraduate training every five years in a program administered by the State Medical Institute of Retraining and Postgraduate Education. There is some discussion on whether it might be better to offer postgraduate courses more often. The current program is administered by human resource departments of each health care facility.

47 European Observatory on Health Systems and Policies. Health Care Systems in Transition, Kyrgyzstan, Vol. 7 No. 2, 2005.

iv. IMCI Training

181. IMCI training for health workers, particularly family doctors began in 1998 and has covered much of the country. Around 700 family doctors were trained in the 5 day IMCI course in 2001; 764 family doctors are still to be trained. Their training was started by Kyrgyz State Medical Institution of Refreshing and Retraining. Recently the MOH decided to retrain (through a 12 day course) the physicians trained in 2001 but due to a shortage of funds this training has not been completed.

182. The standard WHO IMCI training course requires 11 days of training. Many of the courses provided to physicians and feldshers were reduced to 6 days. As of the beginning of 2007, 88,8% of all family doctors and 91,1% of all feldshers have been trained. The State Medical Institute of Retraining and Postgraduate Education will train the remaining doctors and feldshers this year (2007). Family nurses are trained in IMCI through the HOPE project in the Bazarkorgon and Aksy raions (Jalalabad oblast), and in the whole Batken oblast.

3. Facilities and Equipment

183. Most HCFs at all levels need major refurbishing and equipment does not meet requirements. Many HCFs do not have a water supply system, or telephone communications. The MOH and managers of HCFs at oblast and raion level attempt to attract sponsors for repairs and the procurement of equipment. In 2006, with funds from United Nations Devel- opment Program (UNDP), the NGOs “AKTED” and “Tolerance”, ARIS (Community Develop- ment and Investment Agency), ADB, «Almalyk» LLC, German Technical Corporation (GTZ) and Ayil Okmotus (AOs) civil works were completed in 22 FAPs in Batken oblast, 76 FAPs in Osh oblast and 70 FAPs in Jalalabad oblast. Out of the total 867 FAPs in the country, 277 are still in need of repair and 578 are in need of equipment (see annex 11 for a list of FAPs in need of repair and equipment in all oblasts).

184. In general, FAPs have not received medical equipment except for those in the raions covered by the FCBECDP. The upgrading of FAPs is of crucial importance for the protection of MCH in rural areas. Within the framework of Manas Taalimi, primary care is to be strengthened with a special emphasis on upgrading and increasing the capacity of FAPs. In 2007 the MOH with collaboration of SWAp donors is planning to equip FAPs. The standard list of equipment and supplies has been developed and information collected on those settlements requiring new FAPs or the repair of existing FAPs. The refurbishing of the FAP buildings remains a problem. The MOH is working with the local administrations to find a solution to this issue.

185. Under the FCBECDP, 84 FAPs and 23 FGPs were repaired in the 12 raions. The community could apply for additional funds from the Village Initiative Fund (VIF). Inpatient facilities also need to be repaired. In addition most HCFs in rural areas do not have adequate sewage disposal. They also have problems with water, sanitation, heating, and communications. A very serious situation occurs in maternity inpatient facilities where there is no water, which hampers the ability to adhere to sanitary requirements. These facilities need capital repairs to upgrade their water supply, sanitation and sewage system. Furniture in the wards is also often in poor condition (children’s and adults’ beds, by-bed cabinets, etc.).

186. All maternity departments of territorial hospitals received modern therapeutic and diagnostic equipment from the KFW (MCH-2) Project and from JICA. However, not all hospitals use this equipment efficiently or to its full capacity. Sometimes the equipment is even not unpacked. The main reasons seem to be that personnel don’t know how to use this advanced equipment. Another reason is that personnel, trained in using the equipment have left the hospital and the replacements have not been trained. The accuracy of laboratory tests is

47 often in question due to the level of training and availability of laboratory technicians. There are also problems with the maintenance and the repair of medical equipment. X-ray ma- chines are often very old and outdated. The MOH has created a Technical Maintenance Fund for maintenance of equipment in public health care facilities. However, these funds are not sufficient to cover all needs.

G. Donor Support

187. The following chapters provide a brief description of donor-financed projects – as well as those implemented by NGOs – contributing to ECD in the Kyrgyz Republic. A detailed overview on external assistance to the Kyrgyz Republic in the ECD sector in general and MCH in particular is provided in annexes 12 a) and b).

1. FCBECDP

188. ADB has supported ECD activities in the Kyrgyz Republic since January 2004 in the framework of the FCBECDP. The project’s goal is to improve the health, nutrition, and psychosocial development of children between birth and eight years of age in the 12 poorest raions in three oblasts (Jalal-Abad, Naryn, Osh). One major strategy for reaching the project’s first objective – to reduce IMR and under-five mortality rate – is the introduction and implementation of IMCI. To this end 190 feldshers and 24 doctors were trained on IMCI and IMCI coordinators were appointed and trained in the selected oblasts and raions. According to the mid-term review of the FCBECDP, the appointment of the IMCI coordinators gave an additional impulse for the broader implementation of IMCI, but due to lack of material incentives their activities have slowed down. Other obstacles to intensifying IMCI implementation, which were raised in the mid-term review, are insufficient support for IMCI implementation from the MOH, the hesitance of some doctors to apply IMCI and a high turnover of especially feldshers (20% of all trained feldshers have quit their job and were replaced by untrained staff).

189. In order to improve the availability of drugs in rural areas, the project is supporting the establishment of a pharmacy network in selected raions, following the Jumgal model. Par- ticipation will be open to private for-profit pharmacies and to NGOs who have experience in establishing a pharmacy network in rural areas. The winning pharmacy will receive seed money from ADB to buy equipment for the local pharmacy, train local staff (pharmaceutical or health staff) and buy an initial stock of drugs. In contrast to the Jumgal model, the salary of the staff needs to be covered by the pharmacy right from the beginning, so that the financial sustainability of this public-private partnership arrangement is not endangered when ADB financing stops. The pharmacy is required to offer all drugs from the essential drug list and the ADP, but can also offer other items. According to information received from the PMO, there is no price-limit except for IMCI drugs, where the selling price cannot be more than 50% of the purchase price, which means that the pharmacy is allowed to make a profit and doesn’t need to sell the drugs below market prices. This might be a problem with regard to affordability of the drugs especially in the view of limited competition in rural areas.

190. For work at the community and family level, the project appointed and trained Coordi- nators of Family and Children (CFCs) in ECD issues. Unfortunately, the CFC’s salaries have only been paid by ADB until the end of 2006. From 2007 onwards, the local Governments were supposed to pay them, but couldn’t or didn’t want to do so because of budget restrictions. Due to this gap in funding, the CFCs stopped their work in January 2007. In order to avoid the same problems in the future, the SCBECDP should collaborate with government staff and not contract additional staff.

191. The FCBECDP did rehabilitate FAPs and FGPs. Although the amount calculated for rehabilitation was too small, the actual total cost for rehabilitation was lower than estimated. However, this is due a smaller number of FAPs than initially planned have been rehabilitated. The average amount for rehabilitation of FAPs and FGPs calculated for the SCBECDP should be higher.

2. Health Sector Wide Approach (SWAp)

192. In 2006, with the implementation of SWAp to support Manas Taalimi, the Kyrgyz Re- public has gained a new opportunity to obtain additional allocations to support the health care budget. One of the features of SWAp is that funds from a number of donors are pooled to support the state health care budget within the framework of standard budget procedures, and not as separate projects. The total amount allocated by donors to support the health care budget and implement the Manas Taalimi National Program for 2006–2010, amounts to $ 57.5 million, including $ 7.5 million allocated in 2006.

193. In addition to donor funding pooled under the SWAp, involvement of donors in parallel financing of separate projects and programs is continuing. For example, a KfW project has been implemented with a total of 15,4 million Euro. The KfW project (1995-2006) was a financial support program to improve diagnostics, prevention and treatment of diseases that affect pregnant women, mothers and small children. The program includes equipment for neonatal care units, delivery rooms and children's hospitals. It also includes a substantial training program to introduce more effective medical treatment and to improve the management of hospitals. The Global Fund with $ 23.2 million, Swiss Bureau on Development and Cooperation with $ 8.2 million, and USAID with $ 3.3 million were supporting the KfW project. In total confirmed/committed parallel financing amounts to € 15.4 million and $ 34.7 million. NGO’s also bring a significant amount of private and donor funding to support MCH programs.

3. UNICEF

194. UNICEF supports activities in the areas of mother and child health and nutrition; clean water and sanitation; quality basic education for all boys and girls; and the protection of children from violence and exploitation. It especially addresses the rights of marginalized children, children in poverty, and children facing discrimination. Some of the activities supported by UNICF include: support to the development of the Code of the Kyrgyz Republic on Chil- dren; technical support to the Ministry of Health to develop child-relevant sections in the Na- tional Programme “Manas Taalimi 2006-2010”; support to 25 maternity hospitals and delivery departments in provincial hospitals to get certified as Baby-Friendly Hospital; support to the Ministry of Health to maintain immunization levels by providing vaccines, cold chain equipment, and trainings for medical personnel; provision of training in neonatal resuscitation and essential neonatal care; support to Vitamin A supplementation for children from 6 to 59 months and for women after delivery.

4. Donor Supported MCH Projects at Oblast Level

195. SDC will provide $295,866 to “Improving the Health of Women and Children through Family Planning and Breast-feeding Promotion” in Batken. A portion of these funds is allocated for reproducing the Project IEC materials for the Batken raion. Breast-feeding and BFH interventions will be supported for Batken Oblast. Batken City Hospital is already a “Baby Friendly” designated hospital. Project HOPE has helped Leilek Hospital to become Baby Friendly and will assist Kulendai Hospital as well. Project HOPE, as part of its Central Asia

Regional Program “Healthy Families” will do PEPC training in 2 out of the 3 raions in Batken and is seeking funding to do the third raion.

196. Project HOPE provided training for PEPC and IMCI in Bazarkorgon and Aksy as part of their Child Survival project. In addition, they constructed an Oblast training center and trained oblast trainers who were expected to be available for future training in Jalalabad. In February 2007, Project HOPE began training of 92 family nurses in Community IMCI (C- IMCI) in Suzak Raion. Besides training, two raion maternities and rural health facilities were supported to upgrade the quality of obstetric care. The maternities became certified as “Baby Friendly”. The MOH with assistance of Zdrav-Plus and project HOPE developed a C-IMCI curriculum. In February 2007 the curriculum was used to train family nurses in C-IMCI in Su- zak Raion in Jalalabad.

197. ADB’s Japan Fund for Poverty Reduction (JFPR) Reducing Neonatal Mortality project has been the major contributor towards analyzing and intervening in MCH in 4 raions in Osh Oblast. A major study with international neonatal experts was undertaken in 2006 and the report will soon be finalized. The project is also funding PEPC training in the 4 raions, plus the Oblast Hospital Maternity Center in Osh City. There is a perinatal center in Osh City, which hopes to be developed into the referral center for the entire oblast, and potentially the entire southern region of the country. This will be part of the MOH’s perinatal strategy currently under development.

198. Due to inadequate budget allocations for implementing MDG commitments, the Kyr- gyz Republic is closely cooperating with donors. KfW and the Japanese Government have supplied maternity facilities in the country with modern equipment. WB has purchased medical kits for 867 FAP feldshers and ambulance specialists at 60 FMCs, as well as computer and network equipment for health care facilities. In addition, office furniture for 80 health promotion rooms in FMCs has been provided. Video and audio equipment, as well as training materials were also supplied. Seven oblast FMC Training Centers were equipped with sets of office furniture, computers and training equipment. With ADB support, refurbishing of buildings have been conducted at 55 FAPs and 4 FGPs in selected raions. Equipment was also supplied to all FAPs in the 12 raions, which received community level coverage under the FCBECDP of ADB.

5. NGO Projects

199. The most widely recognized community health program, the “Community Action for Health” approach (the so-called Jumgal model) of the Swiss Development Corporation (SDC) / Swiss Red Cross (SRC), uses Participatory Rural Appraisal (PRA) to determine the key health concerns of the community. Village Health Committees (VHCs) are formed and funds are provided to assist the VHCs to address priority health needs. In partnership with ZdravPlus (USAID), the Community Action for Health approach is scheduled to be implemented in Jalalabad raions in 2007-2008. SRC/SDC, with support of SIDA, will work in Bat- ken starting in 2007 and in Osh in 2007–2008. The health education aspects of the program are developed in collaboration with the Health Promotion Units (HPUs) of the MOH. The “Community Action for Health” does not specifically address MCH unless it emerges as an issue in the PRA. There is also no specific interaction between the Communities, VHCs, or primary care facilities such as the FAPs or the FGPs.

200. The Aga Khan Foundation (AKF) implements programs in two raions of Osh oblast: Alay and Chonalay. They are also planning to start a program in one raion in Naryn oblast. The AKF program emphasizes prevention. They work with VHC’s, and prioritize 6 major areas:

(i.) Micronutrient deficiencies, primarily iron deficiency anemia and iodine deficiency disorders; (ii.) Gastrointestinal diseases and brucellosis; (iii.) Immunizations, family planning, breastfeeding; (iv.) Hygiene and sanitation; (v.) Healthy school: especially hand washing, latrine use and sanitation; (vi.) Kitchen gardens.

201. Project HOPE’s projects focus on child survival and maternal and child health. The key strategy of these projects is organizing communities to support health behavior change strategies, promoting “healthy lifestyles” and improving preventive health practices (such as antenatal care). Using population-based surveys and health facilities assessment tools, the Child Survival Project achieved improvement in child survival behaviors such as an increased percentage of exclusive breast-feeding until 6 months, children treated with oral re- hydration therapy and treatment of pneumonia with antibiotics. Training all levels of health workers simultaneously enabled them to reinforce each other’s health messages and strengthened the community-health facility interaction.

202. At the end of 2006, the three organizations (Aga Khan, Project HOPE and SDC) have shared their results in national conferences. Scaling-up of successful approaches will require co-ordination by the MOH to incorporate the lessons learned into the national health programs.

H. Summary of Major Challenges

203. The Kyrgyz Republic is committed to improve the health situation of mothers and children. This commitment is illustrated by the high priority given to MCH activities in the Manas Taalimi. However, the commitment has not been followed by adequate financing or detail planning. There are a number of organizational and human resource constraints to achieving the country’s MCH objectives. These constraints and major issues related to the further development of MCH programs are summarized in the following paragraphs.

1. Geographical Accessibility to Health Care

204. The Kyrgyz Republic is a mountainous country with the consequence that families in certain parts of the country have difficulty in accessing care appropriate to their needs. How- ever, every possible effort must be made to ensure that these families receive the highest possible quality of care within the available resources devoted to these areas.

205. In the Kyrgyz Republic health care in remote areas is provided by feldshers, midwives and family nurses working in FAPs. FAPs are located in very remote areas and in other areas with a low population density. Approximately 25% of the population relies on FAPs as the entry point in the health care system. In the “needs assessment” survey a large majority of the respondents could readily reach their nearest FAP in less than half an hour walking time. It is concluded that the geographical accessibility to a health care facility is acceptable.

2. Financial Accessibility

206. Basic medical services are provided free of charge to the entire population through the SGBP activities. For the socially vulnerable population, additional mechanisms for reduced or free health care are available. In 2006 SGBP services were expanded so that all medical services for children under 5 and for women during pregnancy and delivery were

51 free of charge. The list of drugs to be reimbursed under the Supplementary ADP (including IMCI) has also been expanded. However, for many poor villagers travel costs to a FGP or a territorial hospital may be an obstacle to seeking care.

207. Tracking specific MCH expenditures in the regular budget of the MOH is difficult because most expenses are part of primary care or hospital expenses and not shown as special items. However, the budget of the MOH for Priority Programs for 2006-2010 shows a large number of MCH subjects. However, the reality of the dilapidated physical structure of HCFs important for MCH services, lack of trained staff, and various MCH programs including IMCI which have not been scaled up to the national level after several years of implementation supported by donors, all suggest insufficient domestic financing for ensuring quality MCH services.

3. Community Health

208. Poor families in many communities are not able to provide or have access to some of the most basic needs, namely:

(i.) Access to safe water; (ii.) Sanitary facilities; (iii.) Adequate housing including heat in winter; (iv.) Nutritional food; (v.) Lifestyles (smoking and consumption of alcoholic beverages); (vi.) Pollution of the environment.

209. Communities, professionals and local governments should mobilize their limited resources and focus efforts on the above needs in more effective ways. An important aspect of quality of care is the role individuals and families play in mobilizing and understanding needs and solutions for improving health services in their community. At present many villages do have village health committees (VHCs). VHCs can play an essential role in improving MCH. Based on some studies, VHCs are not aware of MCH and the role they could play in this field.

210. The vast majority of the non-poor families in the country are increasingly able to better understand their health needs and take personal actions that protect the family or seek appropriate care when required. Poorer families in the community continue to need support to reach this same level of self health and care for their families. All levels of the health system and health workers have an important part to play in strengthening the role of health promotion, particularly in the more challenging parts of the country and fin the more disadvantaged families.

4. Quality of Primary and Secondary Medical Care

211. Quality of care has many different aspects. The analysis has shown that for most services a reasonable level of resources (physical, human and financial) is readily available in most parts of the country. However, the outcomes from services, particularly in the more remote parts of the country, are much lower than what would be expected. Consequently, a priority focus for new health interventions should be on improving the quality of care at all levels of the health system in the more challenging areas of the country.

212. Primary health care and involves family doctors, feldshers, midwives and family nurses and specialists working in outpatient facilities, including FAPs, FGPs and FMCs. The emergency services are also considered to be primary health care. In raions primary care is managed by the Director of the FMC. As almost all hospitals provide some outpatient care, secondary care--specialist outpatient and in-patient care-- is consequently provided by both hospitals and FMCs.

213. The major problems in primary medical care as well as in hospital care are shortcomings in professional knowledge or experience leading to wrong diagnosis or wrong treatments; a lack of supervision of health staff by higher levels of professionals and poor communication between the different levels of care; an inappropriate access to essential drugs; poor working conditions and limited incentives for the health professionals; a poor functioning referral system together with a dichotomy between specialist outpatient services and specialist inpatient services create two different levels of specialists. Especially if these mentioned problems are combined with a lack of appropriate equipment and/or the lack of knowledge on how to operate available equipment as well as maintenance and repairs services and the poor physical state of many health facilities one realizes that much work has to be done.

5. Human Resource Planning and Management

214. The Kyrgyz Republic does not have an integrated policy on human resources. The next phase of health development in the country will be greatly facilitated with an improved process of human resource planning and management. MCH is a priority focus of development over the next few years. MCH activities to have effective outcomes involve a complex process of bringing together a variety of human resources. Consequently, for MCH an integrated policy on human resources is essential. The human resource policy will focus on defining the appropriate personnel and their training for each level of care and service activity. Most importantly, the policy needs to address incentives for getting and maintaining the appropriate number of staff at the appropriate levels. The policy will highlight the needs for continuous human resource development including supervision and management reasonability’s to be carried out by all staff as part of learning and improvement processes.

6. Monitoring, Supervision and Information Management

215. Inadequate funding, insufficient information, and infrequent supervision continue to constrain the delivery of health services in Kyrgyz Republic. The quality of health services is further constrained by the continuing centralized and vertical approach for monitoring and supervising health programs and health facilities. Both monitoring and supervision are conducted selectively and often lead by donor supported areas: such as for TB, IMCI, and HIV/AIDS. This selective and centralized approach does not allow sufficient attention to be given to the service delivery level nor does it promote timely use of information for better management of health services at the local level.

216. While supervision and monitoring are from the top down, from republican to oblast, the information system is from the bottom up, from the health facility to raion, to oblast and to republican levels. Health workers collect extensive amounts of information, which they record in journals and then compile and report monthly to the next higher lever. Feedback or summary reports are rarely circulated back downward. There is little analysis of information for decision making either by curative (FMC) or preventive (SES) services. As a result information is largely historical and used primarily for annual reporting and for long term planning.

217. The monitoring and supervision of programs and health facilities is also constrained by the lack of adequate numbers of senior or supervisory level medical workers. Due to the staff shortage, medical workers at senior levels are assigned multiple tasks and simply do not have the required time to carry out effective supervision and monitoring. For example, someone at the national level assigned to monitor IMCI in the oblasts may also have clinical and teaching responsibilities in Bishkek, as well as responsibilities with other MOH programs.

I. Strategy to Improve Mother and Child Health

1. Goals and Objectives related to MCH in the Kyrgyz Republic

218. The objective of the ECD Strategy regarding MCH is to improve the health status and development of children and mothers through optimal health care. By strengthening the health care system, the mortality rates of newborns, infants and “under five” children as well as the maternal mortality rates will decrease and the number of handicaps due to birth traumata should decrease.

219. The suggested quantified targets with regard to this objective are:

220. The suggested outputs in order to achieve the above mentioned objective are:

(i.) To develop the policy and normative basis for improvement of MCH (ii.) To create commitment of all stakeholders towards improvement of MCH by optimizing the health care delivery system for mother and child; (iii.) To strengthening the MCH health care delivery system through improving the capacity of health care providers; (iv.) To improve the MCH service delivery with high quality obstetric and pediatric care resulting in:

(a.) accurate diagnosis of priority diseases effecting mothers and children; (b.) pregnant women receiving appropriate antenatal care; (c.) providing appropriate postnatal care; (d.) deliveries attended by the right professional and in the right facility; (e.) children receiving appropriate care at the right moment; (f.) a well-functioning referral system;

(v.) To increase access to essential drugs by improving geographical accessibility to pharmaceutics; (vi.) To create an environment for health care workers that enables them to provide care of high quality by:

(vii.) To strengthen community involvement and sensitize families and communities on healthy lifestyles and appropriate health seeking behavior.

2. Plan of Action for Improving MCH

Output 1: To Develop the Policy and Normative Basis for Improvement of MCH

221. Improvement of care for mothers and children will require the involvement of all professionals and stakeholders dealing with MCH. This will be supported by a strong commitment of local, oblast and national governments and the MOH that MCH is a high government priority.

222. The preparation of a National Strategy on MCH will lay the foundation for institutional- izing the many components of the strategy that are needed to ensure achievement of its objectives. The National Strategy will outline roles of all stakeholders, provide the legal framework for organizational structures, functional responsibilities, technical needs, mobilization of human and financial resources, enforcing norms and standards of care and general monitoring, supervision and management of the sector.

223. In addition, a major task of the MOH is to develop more clinical protocols in MCH and to see that they are institutionalized in the delivery of services. These tasks will be facilitated with strong support from the professional associations.

Output 2: Further Optimizing the Health Delivery System

224. With improving only PHC aspects, we will not be able to improve MCH to the standard the Kyrgyz Republic has set as goal as described in Manas Taalimi in 2006. It is evident that the quality of care provided by the present providers at all levels of the health care system has to be improved substantially. In addition, the health care delivery system as such should be further optimized in order to ensure the best utilization of scarce resources. As described in chapter C, specialists in the Kyrgyz Republic work at primary and secondary care levels. This can lead to duplication of services at the one hand and a break in the care continuum on the other hand.

225. For the sake of continuity of care it is recommended that all specialists belong to the staff of a hospital. If all specialists work in the hospital the consequence would be that FMCs are no longer necessary because the specialists of FMCs will be “merged” with the specialists of the hospital. Present FMCs would become in fact large FGPs with some additional diagnostic services. The hospital may provide specialist outpatient care also in some facilities outside the hospital, if this is necessary for reason of accessibility. This model is very well known because it did exist in the soviet era and many specialists are still aware of the advantages of this model. In this model, every specialist of the hospital staff is providing care to referred patients in the outpatient department of the hospital and if necessary s/he will admit the patient in day care or in the inpatient department.

226. The proposed model (figure 7 below) of the health care delivery system is a bit different from the present model as described above.

Figure 7: Proposed Health Delivery Model

Tertiary Care Regards a limited number of very advanced functions Providers are: Medical Specialists Facilities are: a limited number of highly classified hospitals

Referral

Secondary Care Providers are: Medical Specialists Facilities are: all kinds of hospitals with their outpatient as well as inpatient facilities

Referral

Primary Care = outpatient care Providers are: Family Doctors, Family Nurses, Midwives, Feldshers, Dentists. Facilities are: FAPs, FGP, Dentist offices and Emergency services

First level of entry for patients

227. The main differences between the current situation as described in chapter C and the proposed model are the position of medical specialists and the stricter referral system. In the proposed model, all specialists belong to secondary care and all specialists work in a hospital organization. It is clear that a change in the health care delivery system requires a political decision and that will take time. The reason for the proposed changes is the fact that the present system is:

(i.) Inefficient (FMCs as well as hospitals require both diagnostic and therapeutic equipment, which can be shared if specialists work within one organization) (ii.) Not logical (specialists work in primary care although specialists are not trained to provide primary care but trained to provide secondary care and there is a chance for a certain unprofessional competition between both specialist groups) (iii.) Creating a professional dichotomy between specialists with very limited experience (only outpatient care) and specialists practicing the full range of their specialty. Still both types of specialists will maintain their full registration

Output 3: Improving the Capacity of Health Care Providers

228. Training of professionals, especially of medical specialists, needs to be improved. Upgrading the curriculum and training of health workers to international standards should be considered. It is proposed to extend the length of training of the specialties in gynecology and pediatrics to 5 years after finishing medical school. The newly trained gynecologists can train residents in obstetrics and gynecology as well as train practicing gynecologists in their own hospitals. This would mean that leading gynecologists visit territorial hospitals and provide bed-side teaching to their colleagues.

229. Training of mid-level medical personnel needs improvement. Family nurses will be trained in nursing as well as in skills required for working with local communities in primary health care. A more efficient form of continuing education should be explored that will enable all health workers to receive some retraining and continuing education every year. This would be one of the requirements for extension of their registration. A different registration system for the diplomas of health care professional could be introduced, requiring an extension of the registration each 5 years but based on fulfilling a number of clear requirements.

230. In summary the following major activities are needed in order to improve the capacity of the health care providers:

(i.) Upgrading the curriculum and training of medical specialists (gynecologists and pediatricians) (ii.) Training of practicing gynecologists in territorial hospitals through bed-side teaching (iii.) Development of a strategy for more efficient continuous education of health personnel (iv.) Training of mid-level medical personnel, such as mid-wives, family nurses and feldshers (v.) Improvement of the current registration system

Output 4: Improving the Quality of the MCH Service Delivery with high Quality Obstetric and Pediatric Care

Improving the Quality of Obstetrical Care

231. Improvements in obstetrical care can be made by implementing the lesson learned from the ADB Project “Reducing Neonatal Mortality”. This project was able to achieve positive results in:

(i.) Improving primary and first referral health care services for antenatal, delivery and neonatal period; (ii.) Improving maternal health care and practices in the community.

232. Appropriate obstetric care starts with good antenatal care. Kyrgyz women do not have to be convinced to come for antenatal care. Almost all women deliver in health care facilities. This means that if the results of obstetrical care are poor (high maternal mortality and neonatal mortality) health care providers and the health care system needs to be improved. If antenatal care is mainly provided by midwives, it is good to have the gynecologists in a territorial hospital responsible for training and coaching the midwives. One of the best methods of training is bed side teaching. This would mean that every practicing midwife should work for a certain number of weeks per year in the hospital under supervision of gynecologists. Theo-

57 retical courses for midwives are also necessary, but more important are observation of the midwife during her work by higher educated professionals. The costs of these weeks training will be mainly day allowances and transportation costs to be paid to the midwife and extra payment for the gynecologists as incentive to spend time with these midwives.

233. There is a need to move more of the deliveries from raion level to oblast units. This recommendation is based on the findings that local hospitals currently do not have sufficient provision for complicated delivery or neonatal resuscitation. In principal, all deliveries should take place in hospitals that are able to cope with simple complications and be able to perform cesarean sections. It is recognized that all deliveries can not be performed in the most so- phisticated hospitals with highly specialized staff. The implication is that management decisions need to be made that institutionalize a referral mechanism that make the most efficient use of existing resources. The referral mechanism is supported by a judicious implementation of a pregnancy risk management system. The risk management system is readily used through out the country but simply needs to be better monitored and supervised to increase the effective implementation of the delivery.

234. In order to implement the referral and risk management system, the MOH needs to ensure transportation of pregnant women and children in emergency cases. One could consider the introduction of a voucher system for the transport of pregnant mothers to the nearest hospital in areas where no ambulances are available. If ambulances are available, the presence of a gynecologist in the ambulance for collecting women in labor should be considered. Additional equipment needed in ambulances includes incubators for the transportation of premature newborns to facilities capable of providing neonatal intensive care. Of course, the best way to transport a premature baby is in the uterus of the mother but sometimes a woman comes too late to a primary care facility to be transported in time.

235. Especially feldshers of emergency care may be confronted with unexpected deliveries and therefore these feldshers should be trained to do deliveries. If feldshers have only basic knowledge training to do a simple normal delivery would take an experience of doing 20-30 deliveries under supervision of a gynecologist. In hospitals with many deliveries this could be achieved within one week. Theoretical knowledge and then only basic knowledge will take a few weeks study and 4-5 full days of theoretical lessons.

236. A number of reasons have been given to explain the poor outcome of obstetrical care; examples are anemia, pregnancy toxemia, iodine deficiency, etc. Most of these conditions can be treated or prevented. Therefore, more attention has to be given to preventive measures in the improved antenatal care program. Programs in accordance with the recommended approaches of WHO such as PEPC, “On emergency obstetric care and resuscitation of newborns” and BFH should be encouraged and extended nation-wide.

237. In summary suggested activities to improve the quality of obstetric care are:

(i.) Retraining of midwifes through bedside teaching as well as theoretical training (ii.) Improvement of the operation capacity for obstetric and neonatal care of raion level hospitals (iii.) Improvement of the referral system and use of pregnancy risk classification system as a communication tool to promote the movement of delivery to higher levels (iv.) Support families to be able to cover financial and transportation needs to attend higher level facilities (v.) Equip ambulances with needed equipment and provide for the presence of a gynecologist in the ambulance (vi.) Training of feldshers to do deliveries (vii.) Extension of PEPC, BFH programs nation-wide

Improving the Quality of Pediatric Care

238. In pediatrics it has been shown that neonatal mortality is high. The most frequent cause is immature and premature deliveries. It is important to study if the incidence of immature and premature deliveries differs between rural and urban areas, between different age groups, between different social levels, etc. At the moment it is not clear if the percentage of premature deliveries leading to neonatal deaths is higher or lower depending on who or where the delivery took place and the presence or absence of pediatricians during the delivery.

239. Educating young mothers to recognize early symptoms of serious diseases will be necessary. Using community health teams for this purpose could be very helpful. Family doctors as well as family nurses could give training courses that emphasize “first aid with accidents” and early symptoms of serious diseases.

240. To reduce neonatal mortality it is necessary to introduce programs as mentioned above. The Kyrgyz Republic’s adoption of key evidence-based public health programs in MCH, such as BFH, IMCI, PEPC, and the Live Birth Criteria could have a significant impact on reducing infant and maternal mortality. To achieve the required coverage to meet this goal will necessitate a national expansion of the successful changes in the antenatal programs.

241. The implementation of all these changes would be facilitated by a number of leading gynecologists (for obstetrics) and pediatricians (for child care) taking the responsibility in a raion to introduce these programs to colleagues and then to the other levels of care. Special- ists train the family doctors and the family doctors in turn train mid-level health workers. If workers are trained by "their family doctor” and supervisor or by “their specialist” (the one you refer your patients to) it is thought that the process of upgrading the skills of health workers will be more effectively institutionalized. The overall MCH strategy mentioned above should outline how the learning materials to support this process will be developed and produced.

242. It is important that training be extended to all personnel of primary care facilities dealing with the MCH. Personnel of the emergency department should also be included. Most doctors and feldshers have been trained already in IMCI, and also a number of family nurses, but still a substantial number of nurses have to be trained.

243. Suggested activities to improve pediatric care include:

(i.) Educating young mothers to recognize danger signs and symptoms of serious diseases through community health teams (ii.) National extension of relevant programs such as BFH, PEPC, IMCI through training of trainers who can train colleagues at lower levels of care

Output 5: Improving the Access to Essential Drugs

244. The lack of availability of essential drugs in remote rural areas is considered to be a big problem. Ensuring the availability of essential drugs within the poorer communities is essential to support care for the health needs of the rural population within the context of improving the quality of care for maternal and child services. A number of pilot projects aiming at the establishment of a village pharmacy network have been implemented in the Kyrgyz Republic and are contributing to improving the access to essential drugs in the selected villages. However, a comprehensive drug distribution system with national coverage is still missing.

245. The Jumgal pilot project of establishing a not-for-profit pharmacy network in the remote villages of Jumgal raion seems to be a very promising model which could be extended to other remote villages. However, before it can be extended some systemic problems need to be solved such as (i) lack of awareness of the program by the population, (ii) an underestimate in the per capita allowance for beneficiaries, (iii) inadequate pricing for ensuring sustainability, (iv) problems with the storage, inventory and transport systems, and (v) an overuse of antibiotics and injections.48 The HOPE project has also just started a Village Pharma- cies Program, but the program has not been in place long enough to assess its effectiveness. The FCBECDP has also taken up the idea of the Jumgal model with a number of adjustments in order to address some of the shortcomings of the Jumgal model. Here, private pharmacies are supposed to manage the system and take care for supplies, transport, salaries, etc. ADB is financing the first installment of drugs, equipment and furniture and the training of the pharmacy workers.

246. The MOH is planning to open more village pharmacies in remote areas based on the experiences in the pilot projects. To this end, the MOH plans to prepare a list of medications that the Village Pharmacies are permitted to sell. The Southern Drug Department and the MHIF are supposed to conduct the monitoring. However, in order to expand a “Jumgal” like network of village pharmacies such critical issues as maintaining quality control of drugs, as well as ensuring reliable distribution mechanisms and rational use of drugs still need to be addressed.

247. A systematic evaluation of the strengths and weaknesses of the existing pilot projects and best practices from other countries as well as the development of a comprehensive strategy for extending the village pharmacy network at the national level is needed. This strategy should address aspects such as:

(i.) Definition of a list of drugs that the village pharmacies are permitted to sell and establishment of price limits (ii.) Procurement and distribution of drugs to the village pharmacies (iii.) Establishment of a provider network (iv.) Training of staff working in the village pharmacies in, inter alia, rational use of drugs (v.) Development of a licensing mechanism for staff working in village pharmacies (vi.) Establishment of quality control mechanisms

Output 6: Creating an Enabling Environment for Health Workers

248. Creating an enabling environment for health workers is a prerequisite for improving the motivation of health staff and as a consequence for improving the quality of services provided in the health facilities. Suggested activities for creating an enabling environment include:

(i.) Upgrading Infrastructure and Equipment (ii.) Improving MCH Monitoring and Evaluation (iii.) Improving Human Resources Planning, Production and Management

48 WHO- DFID, March 2006, “Project Evaluation: Rural Pharmacy Pilot in Jumgal Raion,”

Upgrading Infrastructure and Equipment

249. Equipment upgrading and refurbishing facilities in a number of FAPs has been financed by ADB and some other donors. MOH with support of the SWAp donors has made substantial financial funds available for new equipment in all other FAPs. Refurbishing of a large number of FAPs (277) is still needed, but also a number of FGPs need new buildings or major refurbishing. Besides primary care facilities, hospital buildings need major refurbishing and in a number of cases upgraded equipment. Specifically, this includes water and sanitation, reliable heating and electricity.

Improving MCH Monitoring and Evaluation

250. In order to improve MCH monitoring and evaluation (M&E), an M&E Committee at the Government level should be established to monitor the health aspects of ECD. A baseline and evaluation survey should be conducted and results should be shared with program im- plementers and stakeholder.

251. An integrated system of data collection and analysis for monitoring MCH programs should be established. The MOH should be involved in all aspects of program monitoring. This system should be integrated into the national Health Information System. The monitoring system should include information on pre- and post-training activities. Supervisory visits to work with newly trained health workers in the application of new knowledge and skills should be carried out as part of the process to improve quality medical care.

Improving Human Resources Planning, Production and Management

252. It is recommended that the Human Resources Department of the MOH develops a comprehensive plan for the planning, production and management of human resources, particularly related to the MCH program. This comprehensive plan should include goals for the number of workers by type, level and facility, functional responsibilities, training and continuing education. A key feature of the plan will be the incentives needed to meet the goals of the plan and the monitoring and supervisory aspects to regularly evaluate its progress.

Output 7: Strengthening Community Involvement

253. One of the main causes of poor health is the poor living conditions of many people and especially children. Stimulating primary health care in communities should be one of the major goals of the strategy. Communities’ involvement in improving MCH is envisioned in Manas Taalimi and needs to be further reinforced in the MCH National Strategy. The Kyrgyz Republic has extensive experience with involving communities illustrated by the creation of VHC. Lessons learned from these experiences should be incorporated into activities of the strategy.

254. Training will be one of the most important tasks outlined in the strategy. Training in for example IMCI could be combined with training in other programs. Family nurses in FAPs and FGPs need to be further trained in additional aspects of medical care for mothers and children. Health promotion activities need to be incorporated into the training and education of all health workers that are working in community services.

255. Health prevention programs should implement C-IMCI and include effective measures to sensitize families and communities on healthy lifestyles and appropriate health seeking behavior. These activities can be linked with school-based health programs to further reinforce health and development benefits for children. Health workers will require new capacities to strengthen the role of the community in health. These new capacities include quality assurance methods, and interpersonal communication and counseling skills. Specifically, capacity building measures should involve the following:

(i.) How to analyze lessons learned from previous and existing community health models (such as those implemented by the NGOs Swiss Red Cross, Project HOPE and Aga Kahn) (ii.) How to assist communities to conduct rapid community appraisals related to family and community member roles in MCH promotion (iii.) Models of interactive communication with communities about health issues (iv.) Skills in communicating with family members on specific health concerns (v.) Use and training of VHC members in approaches to promote MCH in their communities

256. Suggested activities to strengthen community involvement in improving MCH include:

(i.) Analyze lessons learned from existing experiences with community involvement (e.g. VHC) and incorporate those into a coherent strategy (ii.) Incorporate health promotion activities into the training and education of all health workers that are working in community services (iii.) Implementation of C-IMCI at national level (iv.) Implementation of school-based health programs

III. MATERNAL CHILD NUTRITION

A. Nutrition Situation and Micronutrient Deficiencies of Mother and Children

257. At the turn of the millennium malnutrition among children, undernutrition among adults and micronutrient deficiencies still remain major challenges in the developing world. Fur- thermore, overweight and obesity are becoming more widespread in both rich and poor countries – resulting in an emerging epidemic of diet-related non-communicable diseases such as type 2 diabetes and cardiovascular diseases (Annex 13). The Kyrgyz Republic is one of the poorest countries in Eastern Europe and Central Asia49, which is reflected in higher prevalence of child malnutrition, iron deficiency anemia and a lower per capita dietary energy supply50 compared to the neighboring countries (Annex 13).

1. Malnutrition and Chronic Energy Deficiency

258. The Kyrgyz Republic has significant nutrition problems but it is difficult to get a clear picture of the critical nutrition issues in the community due to limitations in the available information and the way data are presented (too aggregated). Some indicators of nutritional status, including IDA, IDD, malnutrition, overweight and active rickets, are published by the RMIC and are based on information, collected in the health facilities. Other data bases almost exclusively pertain to pregnant mothers and under-fives – the target groups in donor supported programs. Moreover, information was usually collected in the context of monitoring and evaluation of these programs and is therefore not representative for the country as a whole.

259. According to the most recent countrywide survey (UNICEF Multiple Indicator Cluster Survey (MICS) 2006)51, the nutritional status of children aged 0-59 months in Kyrgyzstan was as follows:

(i.) 3.4 % are underweight; (ii.) 0.3 % are severely underweight; (iii.) 13.7 percent are stunted and 3.7 % severely stunted; (iv.) 3.5 % are wasted and 0.4% severely wasted; (v.) 5.8% obesity.

260. Hence, under-fives tend to be stunted but not wasted. The well-analyzed MICS 2006 data (the only one identified data base, covering a representative sample of the population) illustrates that stunting does exist at 6 months of age (5%), increases moderately in the second half year but increases exponentially between 12-24 months (25%) to remain at this level till 5 years of age (Figure 8). This evolution of stunting has been confirmed globally (Figure 9), making age period 0-18 months the most critical period for young children52. It is attributable to the synergism between malnutrition and infection. After 6 months of age breast milk is not sufficient anymore to cover the daily requirements in calories, protein and micronutrients. Infections like respiratory tract infections, diarrhea, parasites and worms add increased dietary requirements. Thus, morbidity is a contributing factor or can even be the pri-

49 In 2002 GNP in the Kyrgyz Republic was at US$ 350 versus US$ 2,310 in the Eastern Europe and Central Asia (EE-CA) region. 50 Dietary energy supply in 1994: Kyrgyz Republic 2,069 kcal versus 2,850 kcal in EE-CA. 51 National Statistics Committee & UNICEF, Preliminary Report July-August 2006/.Monitoring the Situation of Children and Mothers. Findings from the Multiple Indicator Cluster Survey (MICS), implemented in the Kyrgyz Republic. 52 Shrimpton R et al, 2001, The worldwide timing of growth faltering: implications for nutrition interventions, in: Pediatrics 107 (5):e75.

63 mary cause of growth faltering. If there is no catch-up growth after an illness, a downward spiral sets in – morbidity results in growth deficits and in turn malnourished children are more prone to infectious diseases53. Therefore, there is a clear need for component 3 of IMCI (C- IMCI) which has not yet been introduced in the Kyrgyz Republic (see Part II MCH # 144 and # 148).

261. MICS 2006 reported that the prevalence of stunting was higher than the national average when mothers only had secondary education (15%), compared to those who completed higher education (9.6%). It is not clear whether this difference is attributable to better child care and feeding behavior or to less unemployment among the better educated.

Figure 8 Malnutrition among Under-Fives in Kyrgyz Republic according to UNICEF MICS 2006

Stunted Wasted Unde r w e ight

10 Percent

0 <6 mos 6-11 mos 1yr-olds 2yr-olds 3yr-olds 4yr-olds Age

53 Tomkins AM: Malnutrition and infection. Geneva, UN ACC-SCN Special Report Series, 1986; Pelletier DL: Malnutrition, morbidity and child mortality in developing countries. In Too young to die: Genes or gender? New York (NY): Department of Economic and Social Affairs, Population Division, United Nations; 1998, pp. 109–32.

Figure 9 The “Window of Opportunity” for Improving Nutrition is Very Small Pre-Pregnancy until 18-24 Months of Age.

262. In the same data source overweight appears to be an emerging problem in under- fives (2 times higher than the probability in a healthy population). Contrary to expectation in MICS 2006 obesity in children is most prevalent in Issykkul and Talas, the two regions with also the highest stunting occurrence among under-fives (Figure 10). In agreement with observations in other countries a higher prevalence of overweight was recorded among under- fives with higher educated mothers, e.g. 4.9% (secondary education) and 8.9% (higher education). These two conflicting observations underline the need to disaggregate data by categories: (i) overweight and stunted; (ii) overweight not stunted; (iii) normal weight-for-age but stunted and (iv) underweight and stunted.

Figure 10: Nutritional Situation of Under-Fives in Oblasts According to UNICEF MICS 2006

Batken

Jalalabad

Issykkul

Naryn Stunted Osh Wasted Overweight Talas

Chui

Bishkek town Kyrgyz Republic

0 5 10 15 20 25 30 Percent

263. There is a paucity of information about the nutritional status of women of reproductive age and specifically of pregnant and lactating mothers. Maternal undernutrition during pregnancy among the poor may be more common than currently thought (no data available). It is one of the major factors influencing fetal growth. Low birth weight is known to be a risk factor for peri- and neonatal death54, also in the Kyrgyz Republic (see part II chapter F). A study on factors related to neonatal mortality reported an association between low weight gain in pregnancy and higher risk for child mortality within 12 months after birth55. Thus, efforts to reduce early infant death need to include surveillance of maternal undernutrition (pre- pregnancy Body Mass Index56 < 18.5 and weight gain in pregnancy) at any level and appropriate interventions for undernourished mothers.

264. Qualitative data (dietary history) collected in the SCBECDP needs assessment survey in three oblasts illustrate the poor quality of habitual diets of families. Nutritious foods were usually eaten only once or twice a week (meat 55%, milk products 37%; vegetables and fruit 37%). Overall there was no difference in the food consumption pattern of the family and that of pregnant mothers and under-fives, indicating that intra-family distribution of available foods was equitable. One can assume that the inadequate quality of the home diet is primarily attributable to poverty – which shows the limitations of nutrition counseling without interventions to improve food security.

2. Micronutrient Deficiencies

265. Some micronutrient deficiencies, in particular IDA, IDD, VAD and zinc deficiency, contribute to high infant, child and maternal morbidity and mortality rates, as well as retardation in physical and mental development of children57. Prevalence data exists only for the donor- supported programs for IDD, IDA and VAD.

a. Iodine Deficiency Disorder

266. Information of the Department of the State Sanitary Epidemiological Supervision (DSSES) of the Kyrgyz MOH shows a comparative decrease in IDD in the past decade (Fig- ure 11). The trend was explained by an improvement of knowledge of the population about the symptoms and ill consequences of iodine deficiency and a subsequent increase in the availability and use of iodized salt.

54 Kusin JA et al:. Maternal Body Mass Index: the functional significance during reproduction, in: EurJClinNutr, suppl 3: S56-67; Kramer MS & Victora CG:: Low birth weight and perinatal mortality. In:RD Semba&MW Bloem. Nutrition and Health in Developing Countries. Humana Press 2001:57-70 55 Study of anemia among women of Kara-suu raion (district), Osh oblast. Bishkek, 2003 56 Body Mass Index = weight, kg divided by height, m2 57 Lancet, supplement 2003, Child survival,. vol 361-362, 7 articles; Jackson AA, ed. Nutrition as a preventive strategy against adverse pregnancy out comes. J Nutr. 2003; 133 supplement; Child Development Series Lan- cet 2006, 2:Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world.

Figure 11: Prevalence IDD per 100.000 Population

4666,3 4247,9

3405,1 3316

2507,9 2828,3

1327,2

266,5

1998 г 1999 г 2000 г 2001 г 2002 г 2003 г 2004 г 2005 г

Source: Department of the State Sanitary Epidemiological Supervision of the Kyrgyz Ministry of Health

267. Various studies conducted in selected oblasts confirmed the decline in IDD58. How- ever, according to UNICEF/MICS 2006 three out of four households used adequately iodized salt, more so in urban areas (84.5%) than in rural areas (70%), more in the richest households (84%) compared to the remainder of the households (69%). Therefore, continued efforts must be made to ensure the quality of iodization. Similar conclusions were reached in the FCBECDP midterm review and in the final report of Sustainable Food Fortification.59 The needs assessment survey conducted in the framework of this PPTA for the SCBECDP in January 2007 reported appropriate knowledge about the importance of iodine for health (96%), and a 90% actual use of iodized salt by household in the selected raions.

b. Iron Deficiency Anemia

268. IDA is the most prevalent and severe nutritional problem in the country. It most likely affects the whole population and not only pregnant mothers, infants and preschool children (surveys only cover these groups!). The World Bank, USAID, and UNICEF consider a country with maternal anemia prevalence of equal to or greater than 40 percent to have a problem of public health importance60 and this pertains to the Kyrgyz Republic.

269. Nationwide information on anemia prevalence in the Kyrgyz Republic was obtained through the 1997 Demographic and Health Survey (DHS) within the MEASURE DHS+ Pro- ject. About 65% of pregnant women were found to be anemic, namely 2% severe, 32% moderate, and 31% mild degrees respectively. The reported range in anemia prevalence in 2001- 2005 varied widely according to location and population - or age groups61,62,63.

58 Sultanalieva, R.B.,2006, Iodine status in organisms of children (Jalalabad, Naryn and Osh oblasts of Kyrgyz Republic). Results of the biological monitoring,. 59 JFPR 9052, 2006, Sustainable Food Fortification in Central Asia and Mongolia, Final Report, Bishkek. 60The Micronutrient Initiative: Anemia Prevention and Control: What Works. Part I Program Guidance, Washing- ton, USAID June 2003; Iron Deficiency Anemia. Assessment, Prevention and Control. A guide to programme managers. WHO 2001- WHO/NHD/013 61 2006, Report «Quality evaluation of the Integrated Management of Childhood Illnesses (IMCI) implementation and outline of barriers for its sustainability on all levels of Primary Health Care», Bishkek. 62 MOH/Kyrgyz Republic – UNICEF, 2003, Study of anemia among women of Kara-Suu raion (district),Osh oblast, 63 MOH/UNICEF, 2001, Hb level research in women of reproductive age and children under three years of age in Naryn oblast,

270. Information of the DSSES of the Kyrgyz MOH shows that in the past 10 years there was no decrease in the prevalence of IDA in the population (Figure 12) although iron supplementation has been routinely implemented with the same protocol and the same approach in order to address this problem. Possible reasons could be that: (a) available Hb values are not reliable; b) mal-absorption of iron due to tea consumption, worms, parasites; (c) iron pills are not always available; (d) low compliance (see part II chapter F).

Figure 12: Prevalence of IDА per 100. 000 Population

1714 1538,8 1506 1505 1444,1 1319,3 1301,5 1268,2

1998 г 1999 г 2000 г 2001 г 2002 г 2003 г 2004 г 2005 г Source: Department of the State Sanitary Epidemiological Supervision of the Kyrgyz Ministry of Health

271. About 43% of women interviewed in the January 2007 needs assessment survey for the SCBECDP mentioned that they were diagnosed as anemic when they were pregnant. Over 81% of them were prescribed iron tablets, but only around 8% took 60-90 tablets. Rea- sons given for not taking prescribed iron tablets included lack of money (52%), side effects (21%), and not knowing how to take them (18%). These responses demonstrate lack of compliance as the major constraint with regard to iron supplementation. Poor client response is due to a combination of causes: (a) unaffordability of prescribed pills, (b) fear for side effects; (c) unawareness of the consequences of anemia and the dietary requirements of iron- rich foods; and (d) inadequate counseling skills on the part of health personnel.

c. Vitamin A Deficiency

272. RMIC does not report on VAD among children or pregnant women attending health facilities. One UNICEF study64 conducted in Kara-suu raion, Osh oblast, in the south, and in Naryn raion, Naryn oblast, reported normal serum vitamin A level in 23% of under-five children, borderline conditions in 44% and deficient level in 33% (Figure 13). The principal reasons mentioned for VAD among children were (a) lack of information for mothers; (b) low consumption of vitamin A rich foods; (c) the high rate of infectious diseases; (d) 85% pregnant mothers did not use any vitamin preparation.

64 UNICEF, 2002, Evaluation of the prevalence of Vitamin A deficiency in the Kyrgyz Republic.

Figure 13: Deficiency of Vitamin A (in %) Among Under Fives in Karasuu Raion, Osh Oblast, and Naryn Raion, Naryn Oblast

47 47 50 44 43 40 41 39 35 40 28 30 18 20 10

0 6-12 13-24 25-36 37-48 49-60 month. month month month month

deficiency of vitA border-line condition

Source: UNICEF, 2002

d. Rachitis (Rickets)

273. According to the RMIC 2005 report the prevalence for the country as a whole was about 30 times higher among infants (4874 per 100.000) than among age group 1-4 years (177 per 100.000). In Jalalabad, Osh and Batken oblasts the lowest prevalence was reported for Jalalabad (infants 925 and 1-4 years 50 per 100.000 respectively). There are no population-based statistics for rickets published by the World Health Organization (WHO) or the United Nations Children’s Fund (UNICEF) and therefore international comparisons are not possible. However, the RMIC data on rickets in the Kyrgyz Republic is of importance in itself and regional differences should be clarified to allow preventive measures.

3. Breastfeeding and Complementary Feeding

274. The review of secondary data (surveys and research results) as well as the surveys conducted for the first and second CBECDP identified information on breastfeeding practices and the type and timing of the introduction of complementary foods. The results were equivocal. Infants/preschool child feeding is characterized by: (a) short duration of exclusive breastfeeding but continuation of breastfeeding till about the end of the second year; (b) scheduled breastfeeding instead of on-demand; (c) tea, water, other fluids are given even before 3 months of age; (d) about 30% use bottle feeding; (e) complementary foods are of low energy density (liquids, gruels) and poor quality (bread, seldom milk, meat, fish, eggs, beans, vegetables and fruit). No population-based data are available on child feeding practices during illness, nor of the factors influencing child feeding (amounts of foods given, cultural perceptions, seasonal availability and affordability, to name a few).

B. Policies and Programs related to MCN

275. The information gained from the needs assessment (clients’ perspectives) was util- ized in conducting the Policy and Sector Analysis (service providers’ perspectives) presented in the chapters below. The present chapter will review the policies, types of standard operation procedures and program implementation of the three strategies for general MCN improvement and the reduction of IDD and IDA, namely nutrition education, supplementation, and food fortification. The following chapter will analyze the role, responsibility and accountability of relevant sectors for nutrition, public-NGO-private partnership and community involvement (stakeholders analysis); and the next chapter will analyze the available infrastructure and human resources for dissemination and implementation of policies and programs (institutional analysis).

276. Current policies and programs to improve MCN were appraised in relation to international public health perspectives of nutrition as well as in the context of Manas Taalimi, namely health reforms, which supposedly contribute to the achievement of the MDGs (see also Part II, chapter B). Rather than an evaluation of single nutrition topic programs, this assessment was conducted with the outlook of how to improve efficiency and effectiveness of nutrition-related programs in ECD and how to scale up existing best practices as a joint effort of all stakeholders, with an emphasis on community awareness, empowerment and involvement.

277. Internationally the United Nations Food and Agriculture Organization (FAO) and WHO have a Subcommittee on Nutrition. FAO deals with availability and affordability of adequate diets for the population in general and for mothers and children in particular (food security). WHO’s mandate covers the prevention of nutritional deficiencies and the promotion of an adequate nutritional status, especially of children and women of reproductive age (nutrition security).

278. Food and nutrition security are not mentioned in the Kyrgyz national development strategy65, nor is nutrition one of the priority programs in Manas Taalimi. It is, therefore, not surprising that in the Kyrgyz Republic the Ministries of Agriculture and Health do not have an institutional base (department) for food and nutrition security. Drafts of a National Food and Nutrition Policy and a National Plan of Action for Nutrition are available but have not yet been legally endorsed by the Kyrgyz Government.

279. The Government of the Kyrgyz Republic undertakes measures, aimed at the prevention of negative consequences of iodine deficiency and iron deficiency. The policy and programs to overcome IDD and IDA are reflected in various documents of the Government of the Kyrgyz Republic. Prevention of VAD is by Ministerial order as well. Excluding food fortification, the programs tend to be vertical in nature, mainly health care provider oriented and child-focused.

280. The following policies, regulations, laws and programs related to nutrition exist:

(i.) Concept of National Policy on Healthy (functional) Nutrition of Population of Kyrgyz Republic till 2010” approved by the Regulation # 785 of the Kyrgyz Government (December 2003). (ii.) National program “Health Promotion of Kyrgyz Population for 2004-2010”. Prevention of diseases connected to micronutrient deficiency. (iii.) Regulation # 639 (2005) of the Government of Kyrgyz Republic “Mandatory Approval of Production Compliance”, approved list of products, which includes iodized salt and flour.

65 Government of Kyrgyz Republic, Draft 20 December 2006, Country Development Strategy 2006-2010,. Bishkek

(iv.) National Plan of Action on elimination of vitamins and micronutrients deficiency in the Kyrgyz Republic for 2005-2010. (v.) Law on the “Prevention of IDD” has been revised, including the Code about administrative responsibilities. (vi.) National Program “Reduction of IDD level in the Kyrgyz Republic for 2003- 2007”. (vii.) Law “Flour fortification” has been designed. (viii.) State standards for fortified flour and iodized salt have been introduced.

281. А national law for “International Rules on Artificial Breast Milk Sale” (an article of Chil- dren’s Code “Protection of Children’s Health”) was sent to MOH in 2004, but was not accepted. Design, endorsement and implementation of the law for “Supply of Substitutes of Breast Milk in the Republic” will contribute to the creation of the environment relevant for promotion of breast feeding of early age children.

282. The Concept of National Policy on Healthy (functional) Nutrition of Population of Kyr- gyz Republic by 2010 was approved by a regulation of the Kyrgyz Government on 19th of December 2003. But this concept does not consider the interest of population to provide healthy nutrition. It mainly considers production of various food products, fortified with different biologically active supplements. Nutrition of children is addressed only from medical treatment perspective. Nutrition of pregnant/lactating women is not mentioned at all. There is a lack of fundamental actions to prevent or eliminate IDA or IDD in the concept. Nutrition is not considered through life-cycle perspective. There is a lack of attention to nutrition of children in preschool organizations. Taking into consideration the above mentioned, it is necessary to revise the Concept of National Policy of Healthy Nutrition, design a new national policy considering the interests of the population and present them for legal ratification to the Kyrgyz Government.

283. Furthermore, public health or community nutrition, with mothers and children as priority target groups, needs an institutional base and a separate program area for nutrition in Manas Taalimi. Accelerated improvement in nutrition requires (a) better information on the nutritional situation by biological and socio-economic vulnerable groups; (b) applied research to answer unsolved technical and operational questions66; (c) incorporation of proven best practices into large-scale nutrition-relevant actions; combined with strong political commit- ment67, adequate human and financial resources68. Only situation-specific, relevant (evidence-based) and well- implemented direct nutrition interventions have shown sustained improvement of 3 % per year on top of improvement due to economic growth69. Amendment of the Law of the Kyrgyz Republic: “On Health Protection of the People in the Kyrgyz Republic” (or any other relevant Law) with one Article can provide the legal basis for public health nutrition. All stakeholders should have the realization of it on their agenda.

66 How to put the life cycle approach into operation, e.g. improvement of nutrition of adolescents and women of reproductive age; How to scale up effective pilot projects; How best to tackle iron deficiency and anemia (IDA) in vulnerable group; How to apply food-based approaches to reduce malnutrition 67 Repositioning Nutrition as Central to Development, a Strategy for Large-scale Action. Directions in Development, IBRDevelopment/ the World Bank, Washington DC 2006 68 World Bank, 2003, Combating Malnutrition: Time to Act. Human Development Network - Health, Nutrition and Population Series, Washington DC 69 World Bank-UNICEF, Human Development Network, Gillespie S et al. Combating Malnutrition, 2003, Time to Act., Health, Nutrition and Population Series

C. Delivery of MCN Services in Health Institutions

284. MCN is covered as part of MCH, namely (i) antenatal-postnatal care; and (ii) for children health check-ups, growth and development monitoring, immunizations, breastfeeding promotion and counseling on proper complementary feeding (see also part II, chapter D).

285. Order # 202 (protocol)70 prescribes the frequency and timing of antenatal visits. The usual antenatal examinations are performed by an obstetrician/gynecologist of the FMC in oblasts, by doctors at the FGP in raions and by family nurses or midwives or feldshers in the villages (FAP). Mothers are weighed, and height (once, usually before 16th week of gestation) is taken. Depending on available laboratory facilities hemoglobin (Hb)71 is measured on registration (first antenatal visit) and iron pills (ferrosulphate - not the iron-folate combination) are prescribed if the mother is anemic. The second Hb test is done in pregnancy week 30– 36, if the mother was not anemic on the first visit. Hb tests are repeated on a monthly basis for anemic pregnant women72. Individual nutrition counseling is given. The Deputy Director of the FMC in Osh oblast mentioned that group discussions are organized, albeit with an unde- fined frequency (as time permits).

286. After delivery the FGP doctor visits the (lactating) mother at home for the routine postnatal check-up (daily for the first week and weekly till one month postpartum). Her weight is not measured. According to the protocol, health and nutrition counseling should be given. The visit usually takes 5-10 minutes. From the second month onwards the mother and baby have to go to the polyclinic for check-ups and child immunizations, but FGP doctors continue to do home visits once per month, apparently for the same examinations73 .

287. The FGP doctors (in raions) make home visits in the neonatal period. In cities the pediatrician does home visits for the baby and the ObGyn doctor for the mother—roughly at the same intervals but each according to their own agenda. They seldom meet. Nutrition counseling relates to the usual messages for breastfeeding. There are no special instructions for nutrition counseling of low birth weight babies and their mothers.

288. From one month of age the baby will be brought to the FGP when sick or when healthy for immunizations, growth and development monitoring and nutrition counseling. A protocol for the frequency of preventive check-ups exists from birth up to 14 years of age. All information is recorded in an ambulatory card of child development (Form # 112). This is a rich but underutilized source of information as the health data so meticulously recorded in books (and only used for reports) are not used for built-in monitoring & evaluation, situational analysis, participative planning of interventions and to identify the constraints if targets are not met.

289. Observations during field visits showed that the few (about 10) sessions lasted less than 10 minutes for antenatal care as well as infant-preschooler examinations (including weight, length/height, head and chest circumference measurements). Pregnant women and children were examined/measured with their clothes on as examination rooms were not heated. Baby and adult weighing scales were not regularly checked for accuracy. Nutrition counseling was given during the examinations, but the nature of it was more the traditional nutrition education rather than tailor-made advice.

70 The following pertains to urban areas. In the rural areas the Family Doctor visits FAP once a week, and all curative, preventive and promotive health activities are done by the feldsher and accoucher 71 Recently hemocue kits are distributed to all FAPs 72 2006, Clinical protocols for primary health care. National Program Manas Taalimi, Bishkek 73 Doctors are on call for sick patients

290. Based on reports, observations during field visits and key informant interviews a number of weaknesses were identified: (a) in general family doctors and feldshers don´t pay sufficient attention to nutrition problems, (b) many raion FAPs do not have adult weighing scales; (c) iron tablets/syrups and IMCI drugs were not always available; (d) there is a great shortage of handout materials on nutrition.

291. Some brochures were available from any of the following sources: Republic Center of Health Promotion (RCHP); the IMCI, Breast Feeding and Baby Friendly Hospitals; Com- munity Action for Health/SRC; Project Hope etc. The supply is so limited that few can be distributed to the clients. Moreover, the messages for the same topic – in content and presentation do not always agree. According to two informants this caused confusion among the staff as well as the clients.

292. Another striking observation was the absence of child growth and development monitoring cards – universally used in developing as well as in industrialized countries – and pregnant/lactating mother cards (less familiar in developing countries). These cards are kept by the mothers and are used (at least supposed to be used) for a participative approach to nutrition improvement and behavioral change. The individual card allows adjusting general messages to the individual’s needs and possibilities for actions.

293. The Baby Friendly Hospital and IMCI Programs have been discussed in the section on MCH (part II, chapter B 2). There are obvious linkages between Maternal and Child Health and Maternal and Child Nutrition but these are not yet realized. In both programs no attention is paid to the nutritional status of the mother. With support of WHO and UNICEF a good IMCI manual74 has been developed. Unfortunately the part dealing with mother’s health is only one out of the 90 pages and relates primarily to her ability to take care of the child! Furthermore, there is not only a need for refresher courses but foremost for the implementation of C-IMCI.

D. Strategies to Reduce Micronutrient Deficiencies

1. Iron Deficiency Anemia (IDA)

294. The DHS in 1997 and all reports of surveys indicate that anemia is so prevalent among women of reproductive age (over 50% among pregnant women) and children 6-36 months of age (range 20-45%) that it is justified to conclude that iron deficiency is the most serious micronutrient deficiency in the country75. It is very likely that almost all women of reproductive age and young children (the population) are iron deficient.

a. Supplementation

295. So far, efforts to reduce the prevalence through iron supplementation by distributing iron tablets or syrup for children from 6–36 months failed to produce the desired effect. Re- ported causes are (in any combination):

(i) Unavailability of iron tablets (ii) Too short use of iron tablets (iii) Women can’t afford to buy the tablets

74 IMCI – Counsel the mother on feeding, care for development, giving fluids, when to return and the mother’s health. 75 see footnote 13

(iv) Lack of compliance due to the metallic taste and black stools – or due to real or expected side effects

296. Other reasons, related to deficient iron stores are (in any combination):

(v) Low iron content of the habitual diet (notably heme iron from meat and other foods of animal origin) (vi) Poor absorption due to the high phytate content of the diet and the habit of drinking black tea with the meal (vii) Worm and parasite infestations

297. Three experimental trials for IDA in the Kyrgyz Republic have been reported. In connection with UNICEF-supported IDA pilot projects in Naryn oblast (1997-2001) 76 and in Kara-suu raion, Osh oblast (1991-93)77, the same study design was followed. A baseline survey was conducted, covering women of reproductive age and children under-three, as well as a post-survey at the end of the project. Nutrition education and iron supplementation were provided in the intervening period78. In Naryn oblast overall prevalence among women was 32%. Differences between regions were observed in prevalence and severity of IDA, viz in Kara-suu region 57%, whereas in Suzak region it was 82%. Only 39% of the diagnosed cases received an appropriate medical treatment. Among children < 3 years of age anemia was detected in 73% and about half received iron supplements (18% of age group 4-6 months). Among women the prevalence and severity of anemia after 4 years of intervention even increased. Also among children the prevalence of anemia remained around 63% with a shift from normal Hb levels to mild anemia and from mild-moderate anemia to more severe degrees. In Kara-Suu about 52% of women were anemic, of which 4% severe. Among children about 4% had severe anemia, 27% moderate (acute in report) and 53% mild (moderate in report) degrees of anemia. The post-intervention survey in 2003 revealed that 72% of all anemic women and 44% of the severe cases received an appropriate medical treatment. Anemia prevalence did not change, and remained around 53%. A similar result was observed for children. However, for both groups the degree of severe anemia decreased and that of moderate anemia increased. Both studies just illustrate a regression to the mean in Hb levels (severe ones can only become less severe and normal or mild ones tend to become more severe). The most recent trial, using sprinkles79, also did not reveal a significant effect.

298. The lack of an effect on Hb levels in experimental trials supplying women of reproductive age and young children with iron, either as tablets or syrup or as sprinkles suggest that iron stores are so depleted that a very prolonged supplementation is required and/or that supplementation should be complemented with any or a combination of the following measures: (a) reduced use of tea during meals; (b) increase of dietary intake of heme iron (animal sources of food) and (c) deworming (if relevant). The SRC surveys on worm/parasite infestations as well as a follow-up study using sprinkles for 2–3 months will probably provide more insight in this respect.

76 MOH/UNICEF, 2001, Hb level research in women of reproductive age and children under three years of age in Naryn oblast 77 MOH/KR – UNICEF, 2003, Study of anemia among women of Kara-Suu raion (district),Osh oblast 78 women 3 Iron-containing pills/day for 10 days, 2 pills/day for 10 days, another treatment (1 pill 1-2 times a day, Vitamins, etc.), and no treatment at all – children children ¼ of iron-containing pill 3x/day for one month, 1/2 of the pill 3x/a day for one month, 1 pill 3x/ day for 1 month and another type of treatment. 79 Tobias Schüth. Nov 2005 – May 2006, December 2006. Report on a Study with Weekly Dosage of Sprinkles for 6 Months. At-Bashy raion, (Naryn oblast).

b. Wheat Flour Fortification

299. In 2001 ADB joined a collaborative project to address IDA through fortification of commonly eaten food items. The salient points pertinent for the consumers are summarized here. For details, see the final report on food fortification, 200680.

300. The JFPR 9005 Regional Project81 (2001-2004) stipulated for production and providing the population with good quality iodized salt and flour, fortified with mineral-vitamin pre- mix82. In May 2004 the National Alliance (Council) for food fortification was established, consisting of all stakeholders including Ministries and agencies, non-governmental organizations, fortified food producers and academic institutes. The MOH has been playing the lead role in coordinating the work.

301. In July 2004, ADB approved grant assistance to the JFPR 9052 project “Sustainable food fortification in Central Asia and Mongolia” for the period 2004-2006. The goal of the Pro- ject is to reinforce and sustain the reduction of IDD and IDA among poor children and women in Central Asia through parallel attention to supply (production and distribution), demand (public awareness and demand creation), and regulation (quality control, implementation of regulations and legislation, and trade facilitation).

302. The revised version of the Law “On fortification of wheat flour” is not yet ratified by the Parliament. Absence of a Law on fortification of baking flour and regulating issues of production, control and distribution of fortified flour in the Kyrgyz Republic has a significant negative impact on the provision of fortified flour to population. The flour milling industry of the Kyrgyz Republic has 35 big- and medium-size enterprises and 3,143 small mills. Among these 10 big mills, 12 medium-size and 5 small mills signed the letters of agreement and joined the JFPR Project. In 2006 a total of 22 mills fortified flour.

303. Total volume of production of fortified flour in 2004 was 31.429 tons (26,75% of the expected quantity). In 2005 production of fortified flour decreased and comprised 13 thousand ton. A trend towards decrease of production remained also in 2006. The general economic situation and low interest of enterprises contributed to the decrease of production of fortified flour. Due to the absence of raw material and working capital for the development and modernization of enterprises, as well as the transition from the administrative-command to market mechanisms of management of enterprises, part of assets did not operate at all. The process of fortification at small mills is new. To a great extent fortification at small mills is impossible due to the specifics of their technological process and absence of appropriate fortification technology. Additional appropriate research is required. To cover for the additional needs in fortified flour, imports from Kazakhstan where a law on obligatory flour fortification was adopted is under consideration.

304. Fortified flour is sold in all regions of the country. According to data of a marketing survey, carried out by the company «Marketing Service Bureau» upon the order of UNICEF, fortified flour is available in 59% of trade outlets with a wide variation by regions. The small- est amount of fortified flour was sold in the Batken (9,1%), Osh (18,2%), Jalalabad (18,2%) and Issyk-Kul (20%) regions. Availability is higher in the Naryn (80%), Talas (73,3%) and Chui (44,4%) regions, as well as in Bishkek (58,5%). In trade outlets prices on fortified flour vary from 10 to 30 som/kg. The price first of all depends on the grade of flour and its packag- ing and transportation costs. The price of fortified flour of first grade across the whole Repub-

80 Ministry of Health KR/ADB Project JFPR 9052. 2006. Sustainable Food Fortification in Central Asia and Mon- golia. Bishkek. 81 ADB. 2001. Improving Nutrition for Poor Mothers and Children in Asian Countries in Transition. 82 Pre-mix #1: vitamin B1 (3.3 mg/kg), vitamin B2 (2.8 mg/kg), niacin (18.0 mg/kg), folic acid (1.5 mg/kg), iron (55 mg/kg), zinc oxide (25 mg/kg).

75 lic varies from 11,50 to 21 som/kg, fortified flour of premium grade varies from 12 to 30 som/kg.

305. Iron fortified flour as a strategy to control anemia in Kyrgyzstan has been facing a number of serious limitations. About 65% of the country's population live in rural areas and the vast majority of the rural people traditionally go to the small scale village millers to mill their own flour or barter. It is, therefore, the people in remote areas and the poor and who will most likely not be reached by the fortification strategy. Furthermore, the population is still not sufficiently aware of the existence and benefit of fortified flour.

c. The Dietary Approach to IDA

306. So far of the triple strategy to micro-nutrient deficiencies, e.g. supplementation, food fortification and improvement of home diets, the last approach has not been embarked on in Kyrgyzstan. As mentioned earlier, the very high prevalence of IDA among women of reproductive age and young children justify the conclusion that the whole population is iron deficient. Furthermore, mothers and children eat from the same family pot. Supplementation is supposed to be a short-term public health measure. Wheat flour fortification – the best approach theoretically – will in practice not reach a measurable proportion of the needy population in the near future. These are strong arguments for a combined triple and multisectoral strategy to reduce the prevalence of IDA till acceptable levels by 2015 (end year for the Mil- lennium Development Goals, MDGs).

307. In fact a start has been made on a pilot scale with the dietary approach. For example, MOH/SRC has introduced home gardening in a few raions with great success. AKF is involved in rural development, including agriculture and animal husbandry, but there is no link with IMCI and ECD. AKF has voiced their interest to introduce the Village Health Committee (VHC) concept in their project areas. Hence, there are many windows of opportunity for a comprehensive, triple strategy on IDA, but it has to be planned and structured (including food storage and preservation; home economics (low cost menu’s for nutritious meals = the best buy for 50 soms for example).

2. Iodine Deficiency Disorders

308. Due to its geographic conditions adequately iodized salt must be available and used to prevent IDD. At present universal salt iodization has been adopted legislatively. Salt (and flour) fortification was included in the National Policy for healthy nutrition of the population, approved by the Resolution of the Government of the Kyrgyz Republic, 19 December 2003, No 785. The National Program «Reduction of the level of iodine deficiency disorders in the Kyrgyz Republic in 2003-2007» was endorsed.

309. The Kyrgyz association of salt producers (KASP) was established on 14 March 2003 upon the initiative of entrepreneurs engaged in salt production. KASP is an equal partner in the State program on salt iodization. At present KASP consists of 12 enterprises out of 15 enterprises registered in the Kyrgyz Republic. These enterprises provide for production of over 60 percent of the needs of the population in iodized salt (up from 30% in 2001).

310. KASP and the Department of Sanitary Epidemiological Supervision (SES) (both republican and raion SES) have been provided with iodine checkers under the JFPR Project. They annually conduct training of salt producers on improvement of technology of salt production and quality control. KASP with the ADB financed JFPR Project implements a systematic control over the quality of produced and sold salt from all over the country. Results are disseminated among members of KASP and mass media. Joint activities are carried out

76 on promotion of iodized salt consumption. Informational materials were developed and disseminated and broadcasting of video films through the central TV channels was organized.

311. Nevertheless the production of inadequately iodized salt continues to be a problem. According to monitoring reports of the DSSES in 2005 low content of potassium iodate was identified in 25,4%, and in 2006 in 26,6% of salt samples. A significant part of inadequately iodized salt was found in the Issyk-Kul and the Naryn regions. A survey carried out by the National Statistical Committee with support of UNICEF83 in 2006 showed that in 21% cases salt was inadequately iodized.

312. The salt producers were completely dependent on free supply of potassium iodate until the JFPR Project started. The JFPR Project insisted on cost sharing for potassium iodate between the Project and salt producers first, and shifted to complete financing by the salt producers later. The main technical problem is the procurement of potassium iodate. The established mechanism of providing salt processing enterprises with potassium iodate through the KASP and local pharmaceutical trade companies allowed for partial resolution of this problem, but the issue of sustainability of providing salt producers with potassium iodate remains unresolved. There is a risk of irregular supply of potassium iodate by local pharmaceutical companies, as well as the risk of supplying potassium iodate, which does not meet the requirements of the current standards.

3. Vitamin A Capsule Distribution

313. The order #260 “Methodic recommendations on realization of vitamin “A” supplementation” of the Kyrgyz MOH was approved on 1st June 2004 (2000 samples). With support from UNCEF children between 6-59 months get a bi-annual massive dose and breast feeding mothers get vitamin “A” right after delivery at maternity houses/departments. Coverage of under-fives was almost universal (98.2–98.6%).

E. Stakeholder Analysis

1. Ministry of Health

314. Usually Nutrition is a separate unit or a department within MOH or it is based within the Department of MCH or the Department of Public Health of the MOH. However, there is no MCH Department within the Kyrgyz MOH (see part II, chapter B) and only very recently (March 2006) a separate Department of Public Health has been established at national level, but it does not include a separate unit for Nutrition. The Department of Public Health consists, among others, of the DSSES and the Center for Health Promotion (see also Part II, chapter B). Similar to MCH the MOH is advised for nutrition-related programs by national centers and universities, such as the National Center of Pediatrics and Child Surgery (NCPCS) for IMCI, the Department of Endocrinology for IDD and the Department of Hemo- tology for IDA of the same NCPCS.

315. The DSSES (see also part II, Chapter B) has a network of centers across cities and raions. There are City Centers, Oblast Centers and Raion Centers of SES – in total 54 Cen- ters of SES and 48 laboratories. Human resources are limited: a General Director and a Deputy General Director. Any of the following units have 2–3 sanitary doctors as staff. In raions usually one sanitary doctor, assisted by 1–2 sanitary nurses, are responsible for all functions, namely:

83 National Statistic Committee. Results of Multi-indicator Cluster Survey, carried out in the KR, 2006.

(i) Preschool and school health (Hygiene of children and adolescents); (ii) Food safety and hygiene, food quality of processed foods (food industry); (iii) Occupational health; (iv) Environmental sanitation, hygiene in residential and public building; (v) Radioactive safety; (vi) Electromagnetic radiation; (vii) Certification unit provides quality certificates for food and no-food products.

316. Two medical doctors are in charge of quality control of school meals (preschool and schools) as well as quality control of foods sold in markets, butcheries, bakeries etc. and eating places (café, restaurants etc.)

317. The Republican Center for Health Promotion (RCHP) of the MOH was established in 2001, as part of Manas. It is currently a unit of the Department of Public Health. RCHP has branches in each oblast and each raion. The national and oblast level Centers of Health Promotion are independent. Currently the Republican Center has six staff: two main specialists, two leading specialists, one specialist and one head. The health promotion units at raion level are integrated in FGPs. During the pilot phase 2002–2005 training of the primary level health staff with involvement of the population/community was conducted in all raions of Naryn, Talas and Issyk-Kul oblasts (300 VHCs). According to Manas Talimi the VHC approach should be nation-wide. Scaling up is the responsibility of the trained VHC. The salaries and other recurrent costs are already covered by the Republic budget (integrated in budget of FGPs). The costs of the activities (50% of budget) are borne by donors (ZdravPlus and SIDA).

318. RCHP and its branches at the oblast and raion levels offer great opportunities for community-based activities for MCN. However, there is a lack of:

(i) Human resources: there is a limited number of staff at the central level who also need graduate training in health promotion and exposure to international experiences; (ii) Materials: not tested, too limited for wide distribution; (iii) Money: very limited, low salaries.

2. Donor Organizations and Donor-Supported Programs

319. A breakdown of the nutrition-related projects and programs by funding agencies is shown in Annex 12b. Apart from the nation-wide programs, donors support prioritized interventions on a project-base in their own areas, and develop their own training and Informa- tion, Education and Communication (IEC) and Behavior Change Communication (BCC) materials. Experience from well-implemented community-based interventions, as in the Family Health Project by HOPE and the IMCI component in the FCBECDP, can result in positive behavioral change for child health and nutrition. However, once the project support termi- nates, particularly the activities for and with the community often collapse as well (see also part II, chapter G).

320. The AKF can be regarded as a donor as well as a non-governmental organization. AKF focuses on rural development, health and education and works through the Mountain Societies Development Support Program. AKF works in Alai and Chon Alai raions of Osh oblast. AKF helps farming communities to identify their development priorities, improve the yield of crops and their nutritive value, build water supply, supports sanitation and hygiene promotion projects and increase of income through livestock ownership and handicrafts manufacture. It also contributes to ECD through central and satellite kindergartens. The

78 health component will be scaled up in the coming years, following the same principles of community development. AKF is in the process of opening a College of Public Health, including a Nutrition and Dietetics Department in Naryn (expected to be realized within 1–2 years).

3. Health Care Providers and Clients

321. Nutrition knowledge of health care providers and clients is very narrow, and almost exclusively related to the modules on breast feeding and those in the IMCI package. The monitoring surveys conducted for midterm or final evaluations of projects generally show an improvement in knowledge. However, surveys only use questionnaires (as far as can be assessed none use social science methodologies to assess behavior). Thus, it is difficult to conclude whether the stated attitude indeed reflects a real change in behavior.

322. Lack of knowledge and awareness on the part of mothers and families are generally stated as the main cause of nutritional problems in the Kyrgyz Republic. While there seems to be a consensus on the matter, so far community mobilization and empowerment is the weakest component in all the existing programs, in spite of the political commitment (among others in Manas Taalimi). The VHC, to be introduced in all raions and villages, is a first step in the right direction but MCN (see also part II, chapter G) is not included in the training. To address nutritional problems at the community level, it is imperative to prioritize (a) the development of communication for behavioral change and (b) the implementation of any community-based intervention, be it C-IMCI or VHC. However, the majority of project beneficiaries belongs to the low-income group, or is even abjectly poor. It is therefore unlikely that project inputs result in improved nutrition practice (better diets, among others), if families are not given the opportunities and knowledge how to improve their access to food. Complementing VHC (or any other community-based program) with development activities as proposed in the Village Integrated Development Approach for Nutrition Improvement (VIDA-HNI) is a potentially appropriate and promising approach, as shown in the Philippines and Bangla- desh84,85

F. Human Resources and Training for Nutrition

1. Health and Other Professionals involved in Nutrition-Related Activities

323. During the sector analysis conducted in the framework of this PPTA no person with a formal education in human nutrition was identified. There are a few nutritionists (as they define their profile themselves) in the UNICEF Bishkek office, the Nutrition Department of the NCPCS, the Scientific Production Center for Preventive Medicine and the DSSES. However, those in charge of in-service trainings and refresher courses in IMCI, breast feeding promotion, BFH and IDD-IDA programs at central as well as lower levels are usually pediatricians.

324. Nutrition research or nutrition surveys are either subcontracted by MOH or involved donor organizations to experts at universities or to private consultancy firms (with some exceptions such as SRC and ZdravPlus who have own project staff involved). Although probably the most feasible approach, the major weaknesses are: (a) a lack of a local institutional memory on specific topics and (b) the missed opportunity for capacity building of top level human resources at universities or national centers.

84 Barangay Integrated Development Approach for Nutrition Improvement (BIDANI). Final Technical Report 1996. University of the Philippines, Los Baňos & Royal Tropical Institute, Amsterdam, the Netherlands. 85 Levinson FJ & Rohde JE Responses to: ‘An evaluation of the impact of a US$60 million nutrition programme in Bangladesh. Health Policy and Planning 2005; 20: 30-45.

2. Nutrition in Pre-Service Training of Health Staff

325. Public Health Nutrition as commonly taught in Asian, African and Latin-American regions throughout the six years of the Medical Faculty, Department of Public Health, includes all or most of the following topics: (i) nutrition and health; (b) malnutrition and micronutrient deficiencies (iii) nutrition epidemiology and causal models of nutritional problems; (iv) community diagnosis; (v) direct and indirect interventions; (vi) program implementation, management and logistics, surveillance; (vii) health and nutrition promotion and (viii) health and nutrition economics.

326. In the pre-service training of medical doctors, nurses and midwives “Nutrition” is taught according to the Russian system as part of the disciplines at the Medical Faculty or Academy for Nursing: physiology, biochemistry, pediatrics, obstetrics and gynecology, internal medicine (goiter and IDD in endocrinology; anemia and IDA in hematology) etc. The number of hours allocated is very limited and this illustrates how little importance is given to the subject (see Annex 14). In the nurses’ curriculum 4–6 hours are spent on menu planning and practicals (if funds are available). Teaching materials are outdated; the few textbooks available are still from Russian time. Nutrition epidemiology and community nutrition are fairly unknown concepts; not so surprising as there is only one Faculty of Public Health, which mainly deals with communicable diseases, environmental sanitation and immunizations.

327. Currently nutrition is dealt with as separate course of one or more days duration related to programs, such as IMCI, PEPC, Baby Friendly Hospitals, breast feeding promotion etc. Furthermore, there are Departments of Public Health and Medical Prophylaxis where the basics of nutrition hygiene (rational nutrition) and dietology are taught. Refresher courses of health workers (FGP/FAP), as well as regular upgrading of curricula and introduction of new modules into pre-service training (under- and postgraduate) and life-long learning have been carried out for the effectiveness of interventions.

3. Nutrition in Training of Preschool and School Teachers

328. According to Order # 202 the preschool and school nurse is responsible for supervision of school meals, hygienic conditions of the kitchen and food storage. The sanitary doctors of the SES supervise the quality of meals (composition and calorie content). Both do regular health checks of cooks. The curricula of preschool and school teachers do not have nutrition as a subject. Teachers are supposed to be agents of change and role models, particularly in early child education. They do not get any teaching in nutrition; they are not involved in school meals and they are not included in counseling of mothers/parents for child growth, development, health and nutrition. A rich and untapped human resource in the campaign for better nutrition and early child development.

G. Strategy to Improve Maternal and Child Nutrition

1. International Policies, Strategies and Programs for Accelerating Pro- gress in Nutrition

329. At the Alma Ata Conference on Primary Health Care in 1978 Health-for-All goals by 2000 were formulated, which included nutrition goals. The UNICEF Child Summit 199086 re- affirmed these nutrition goals. Unfortunately only Thailand met these goals, even before the year 2000. At the turn of the millennium the international community agreed to a set of goals (MDG) to which the participating countries and the international donor community have

86 An UNICEF Policy Review. August 1990. Development goals and strategies for children in the 1990s.,

80 committed themselves to reaching by 2015. Although nutrition is not explicitly specified in the MDGs, research evidence from the last decades show that good nutrition is essential for the progress towards reaching at least MDG 1-687 (Annex 15).

330. There are clear linkages between poverty, education, health and nutrition of the population in general and the vulnerable groups in particular88 (Annex 16, Figures 1-2). Economic growth brings a certain improvement in child malnutrition rate, but at a current rate of 0.5% per year it will take three generations (counting from the year 2000) to eliminate malnutrition among under-fives. Thus economic growth alone is not sufficient to achieve the goals of halving child malnutrition and significantly reducing micronutrient deficiencies (notably IDA) by 2015, even when using highly optimistic annual economic growth projections of 5%. This forecast leads to the conclusion that a combination of economic growth and specific nutrition programs will be needed89.

331. Currently sector-wide approaches (SWAp) are adopted by donors, meaning attention for overall government sectoral policies. The danger is that nutrition may fall between the cracks when countries do not consider it as one of their (health) priority areas. Nutrition will remain everybody’s baby but nobody’s concern. Direct nutrition interventions are often being neglected in the health sector because they are regarded as additional activities that are costly and not very effective. However, renowned nutrition programs have shown sustained improvement in nutritional status of 3% per year on top of improvement due to economic growth.90

332. UNICEF’s conceptual framework of the causes and determinants of malnutrition (An- nex 16, Figure 3) and the triple AAA approach91 to programming interventions have contributed greatly to a better understanding about prevention of malnutrition and child growth and how to improve child nutrition through counseling and empowering mothers to address the needs of their children with their own means. The current international view on nutrition strategy is based on the life cycle approach (Annex 16, Figure 4). Research work from Guate- mala, Indonesia, the Gambia, to name a few, illustrate the intricate interrelation of MCN92 and indicate that nutritional interventions that improve the maternal nutritional status are reflected in improved birth weight93, which in turn affects physical growth94 and cognitive development offspring95. Low birth weight children continue to have a higher risk to be malnourished, leading to further stunting and unfavorable birth outcomes for the next generation and the vicious cycle continues.

87 UN Standing Committee on Nutrition (SCN). March 2004. 5thReport on the World Nutrition Situation. 88 Hawkes C, et al. Linkages between Agriculture and Health in Science, Policy and Practice. Fd Nutr Bull 2007, vol. 28, no. 2 supplement. 89 Fd Nutr Bull 2000 supplement3 to volume 21. Ending Malnutrition by 2020. An Agenda for Change in the Mil- lennium. Fd Nutr Bull 2000 supplement3 to volume 21. 90 Food Nutrition Bulletin 2000: Ending Malnutrition by 2020. An Agenda for Change in the Millennium, supplement 3 to volume 21. 91 Jonsson U, Ljundquist B, Yambi O Mobilization for Nutrition in Tanzania. In: J.Rohde et al. editors. Reaching Health for All. Oxford Univ.Press, Oxford, 1993: chapter 9. The triple AAA approach begins with an Assessment of the nutrition situation, followed by an Analysis to determine local causes and determinants and subsequent programming of Actions are based on the first two AA. 92 Kusin JA, Kardjati S, Renqvist UH . Maternal Body Mass Index: the functional significance during reproduction. Eur J Clin Nutr 1994; 48, suppl.3: S56-S67 93 de Onis M et al. Nutritional interventions to prevent intrauterine growth retardation: evidence for randomised controlled trials. Eur J Clin Nutr 1998; 52, suppl 1:583-93 94 (1) Kusin JA, et al. Energy supplementation during pregnancy and postnatal growth. Lancet 1992; 340:623-6; (2) Martorell R, Kettle Khan L, Schroeder DG Reversibility of stunting: epidemiological findings in children from developing countries. Eur J ; Clin Nut 1994;48:S45-S57; (3) Grantham-McGregor SM Small for gestational age, term babies, in the first six years of life. Eur J Clin Nutr 1998; 52 (Suppl 1): S59-64.:S59-S64. 95 Series Child development in developing countries. Grantham-McGregor S et al., (1): Developmental potential in the first 5 years for children in developing countries; Lancet 2007; 369: 60–70; (3) Engle PL et al: Strategies to avoid the loss of development potential in more than 200 million children in the developing world. Lancet 2007:369:229-242

333. There are several types of nutrition programs that have reduced malnutrition effectively and overviews of those programs have been documented96. All focused on what could be done and how to apply lessons learned in one setting to the other and continue to serve as best practice projects of how nutrition can be addressed effectively. The major conclusions of the reviews of “lessons learnt” in the past decades are:

(i.) Elimination of malnutrition should be made a major focus of national strategy and economic and social policy. A life cycle approach in combination with multisectoral efforts – in partnership with all stakeholders: government, NGO’s, the private sector and the community – have the highest potential to address the underlying factors of malnutrition97. (ii.) Accelerated improvement in nutrition requires (a) better information on the local nutritional situation; (b) applied research to answer unsolved technical and operational questions; (c) incorporation of proven best practices into large-scale nutrition-relevant actions, (d) strong political commitment, and adequate human and financial resources98. (iii.) Only situation-specific, relevant (evidence-based) and well-implemented direct nutrition interventions have shown sustained improvement of 3% per year on top of improvement due to economic growth. (iv.) Many nutrition interventions have been on a very small scale, scattered and un- coordinated. They are usually implemented outside mainstream government programs and are seldom scaled up. Although there are many weaknesses in the national or sectoral nutrition programs, the national structures are none the less permanent institutions that should provide the necessary linkages and form the ‘anchor’ for continuity and sustained development effort. (v.) Interventions may be cost-effective without being affordable at scale. It is estimated that at most 20% of needs are covered by available budgets. Both aspects have to be dealt with in donor (consortium) deliberations99. (vi.) Nutrition BCC is often still practiced as IEC (written and other materials). BCC is about addressing the problems and constraints (practical, cultural) mothers and households face in feeding their children, and other family members, jointly ne- gotiating feasible solutions and providing follow-up to solve the problems. (vii.) Good governance and national government ownership as well as broad participation, meaning inclusion of civil society, non-governmental organizations, and private sector in the public sector are strategic directions and key issues for successful interventions.

96 (1) Gillespie S & Mason J. Nutrition relevant actions; ACC-SCN Nutrition Policy Discussion Paper no. 10, 1991, Geneva WHO HQ; (2) Jonsson et al. Mobilization for Nutrition in Tanzania; in J Rohde et al editors. Reaching Health-for- All; 1993. Ch 9; Bombay Oxford University Press; (3) Scrimshaw NS., editor. Community-based Longitudinal Nutrition and Health Studies, 1995 International Foundation for Developing Countries, Boston; (4) ACC-SCN Nutrition Policy Discussion Paper no. 15, 1996; How Nutrition Improves ; (5) Allen L & Gillespie S. What Works? A Review of the Efficacy and Effectiveness of Nutrition Interventions; ) ACC-SCN Nutrition Policy Discussion Paper no. 19 & ADB Nutrition and Development Series no.5, 2001; (6) Mason J et al. Improving Child Nutrition in Asia; ADB Nutrition and Development Series no.3, 2001; (7) Rohde J & Wyon J. Community- based Health Care 2002;.Management Sciences for Health, Boston, USA; (8) Gillespie S et al. Combating Mal- nutrition, Time to Act. World Bank & UNICEF 2003. 97 IBRDevelopment/ the World Bank. 2006. Repositioning Nutrition as Central to Development, a Strategy for Large-scale Action. Directions in Development, , Washington DC. 98 Gillespie S, McLaughlan M, Shrimpton R, editors. 2003. Combating 99 Heaver R. June 2006. Good work – but not enough of it: A review of:the World Bank’s Experience in Nutrition. The World Bank HNP Discussion Paper

334. The success of Thailand is a case to show that it is possible to meet the Health-for-All goals (which are similar to the MDGs for health) in less than 20 years with full government commitment reflected in an adequate budget allocation, continuity in consistent and appropriate policy and strategy, an investment in capacity building, and last but not least applied research and an adequate surveillance system to provide the evidence of what works under which circumstances and at what cost (Annex 17).

335. Given the growing importance of malnutrition and micronutrient deficiencies in the Eastern Europe and Central Asia region, which includes the Kyrgyz Republic, the WB recently (2000) made an overview of critical nutrition issues and problems. The report shows that, in addition to poverty, lack of basic nutrition knowledge among local populations and the absence of policies with a set of nutrition goals that can guide programs are among the key determinants of malnutrition in this region100.

2. Goals and Objectives related to MCN in the Kyrgyz Republic

336. The overall developmental objective for MCN in the Kyrgyz Republic should be to contribute to meeting the national health and nutrition targets as articulated in Manas Taalimi, the MDGs and the UN-Sub-Committee Nutrition goals, mentioned earlier. The specific objective related to MCN should be a reduction of stunting among children and a reduction of micronutrient deficiencies (IDA, VAD and IDD) among children and mothers.

337. The suggested quantified targets with regard to this objective are:

(iii.) To reduce the prevalence of stunting among children less than 3 years by 25 % between 2008-2015 years; (iv.) To reduce micronutrient deficiencies IDA and VAD among pregnant women and children < 3 years by 25% and virtual elimination of IDD between 2008- 2015.

338. The outputs in order to achieve the above mentioned objective are:

(viii.) Development of a National Policy and Program on Nutrition (ix.) Development of an institutional base, allocation of budget and creation of a critical mass of nutrition professionals (x.) Development and implementation of community-based MCN interventions (xi.) Amendment of Existing Nutrition-Related MCH Programs (xii.) Integration of MCN in Early Child Education (xiii.) Improve the effectiveness of programs to control and prevent iron deficiency and iron deficiency anemia in the population (xiv.) Sustain elimination of IDD and Vitamin A deficiency

339. The following sections describe the main directions and activities to achieve the three specific objectives mentioned above.

100 Rokx C et al. Prospects for Improving Nutrition in Eastern Europe and Central Asia. The World Bank, Health, Nutrition and Population Series, Washington DC, World Bank

3. Plan of Action for Improving MCN

Output 1: Development of a National Policy and Program on Nutrition

340. Public health or community nutrition, with mothers and children as priority target groups, needs an institutional base and a legal endorsement for a national nutrition policy and national plan of actions. The Concept of National Policy on Healthy (Functional) Nutrition of Population of Kyrgyz Republic by 2010 was approved by the regulation of the Government of Kyrgyz Republic of 19th of December 2003. However, this concept mainly considers the production of various food products, fortified with different biologically active supplements. There are many missed opportunities to improve nutrition of the population in general and nutrition of mothers and children specifically. Nutrition of children is addressed only from a medical treatment perspective. Nutrition of pregnant/lactating women is not mentioned. There is a lack of holistic and sustainable actions to prevent or eliminate IDA or IDD. Nutri- tion is not considered through life-cycle perspective. There is a lack of attention to nutrition in preschool organizations. Taking into consideration these limitations, it is necessary to amend the Concept of National Policy of Healthy Nutrition and design a comprehensive national policy and program.

341. In order to do this, at national level existing relevant MOH working group(s) should be complemented with representatives of the Ministry of Agriculture, Education and Labor and Social Development as well as the National Agency on Local Self-Governance Affairs as members. The working group should carry out the following key activities:

(i) Amendment of the Law of the Kyrgyz Republic: On health protection of the people in the Kyrgyz Republic (or any other relevant Law) with one Article that can provide the legal basis for public health nutrition in general, and for MCN specifically. (ii) With MOH as coordinator, formulation of an integrative nutrition policy for multisectoral stakeholders and establishment of multisectoral collaboration for food and nutrition security, particularly MCN. (iii) Revision of the Concept of National Policy on Healthy (Functional) Nutrition of Population of Kyrgyz Republic by 2010 to include community-based MCN in a life cycle perspective. (iv) Review and amendment of regulations in MCH to link up vertical programs to cover MCN, notably PEPC, BFH, IMCI.

342. Indicators to measure the achievement of the above mentioned output are:

(i) Legal base for MCN established within 2 years (ii) A national nutrition policy concept revised and national plan of action for nutrition formulated; and both endorsed after 2 years (iii) Regulations and protocols revised to integrate MCN in MCH within 2 years

Output 2: Development of an institutional base, allocation of budget and creation of a critical mass of nutrition professionals

343. Within MOH MCN should be an integral part of MCH. However, MCH is not specifically represented in the MOH organogram. Hence MCN does not have an institutional base as well. Neither is there a separate program area (and ear-marked budget) for nutrition in Manas Taalimi. Furthermore - and this pertains to all former Soviet republics – none of the medical staff in charge of nutrition-related programs have a formal education in human nutri-

84 tion. In pre-service medical and para-medical education curricula public health nutrition is superficially covered.

344. To realize the goal to reduce nutritional problems in the Kyrgyz Republic it is essential to have an institutional base for nutrition – with an allocation of a regular budget, responsible and accountable for policy, planning and implementation of cost-effective interventions. It should be accompanied by concrete human resources development for nutrition at MOH, selected national universities and institutions, to arrive at the core technical local expertise consisting of 6-8 nutrition professionals with (equivalent) master degrees or doctorates as well as a revision of curricula at medical faculties and para-medical colleges to phase out in- service trainings in MCN.

345. The relevant existing working groups at MOH and professional medical associations, complemented with additional members where relevant, should carry out the following major activities:

(i) Establishment of an institution-base for MCN at the MOH Department of Pub- lic Health and the Center for Health Promotion. (ii) Design of mechanisms for the implementation and financing of the integration of MCN in MCH and of a national nutrition program. (iii) A human resources development plan for graduate nutrition professionals and in-service nutrition trainings with specified targets.

346. Indicators to measure the achievement of the above mentioned output are:

(i) An institution base for nutrition established within one year. (ii) MCN and MCH included as a prioritized program area in Manas Taalimi with ear-marked budget lines in SWAp and/or complementary financing by donors, not participating in SWAp within one year. (iii) Core nutrition professionals trained abroad for master degrees with different but complementary majors: 6-8 within 2-4 years. (iv) In-country nutrition training packages (1-3 months duration, staggered) for oblast and raion level professionals developed and pilot-tested within one year. (v) Tested nutrition trainings packages included in other MOH training for oblast and raion level professionals within two years.

Output 3: Development and implementation of community-based MCN interventions

347. There is a need for a separate program area for nutrition in Manas Taalimi as accelerated improvement in nutrition requires (a) better information on the nutritional situation, e.g. nutritional epidemiology; (b) applied research to answer unsolved technical and operational questions101; (c) incorporation of proven best practices into large-scale nutrition-relevant actions; combined with strong political commitment,102 adequate human and financial resources.103 Only situation-specific, relevant (evidence-based) and well-implemented direct nutrition interventions will follow the Manas Taalimi concept of evidence-based practice, not only clinical but also in public health.

101 How to put the life cycle approach into operation, e.g. improvement of nutrition of adolescents and women of reproductive age; How to scale up effective pilot projects; How best to tackle iron deficiency and anemia (IDA) in vulnerable group; How to apply food-based approaches to reduce malnutrition 102 IBRD/World Bank. 2006. Repositioning Nutrition as Central to Development, a Strategy for Large-scale Action. Directions in Development. Washington DC. 103 The World Bank. 2003. Combating Malnutrition: Time to Act. Human Development Network - Health, Nutrition and Population Series. Washington DC.

348. At national level the same multisectoral working group(s) (as mentioned above) should be established (or revitalized) with MOH as lead sector/coordinator. Key activities to be carried out by this working group in order to develop and implement community-based MCN interventions are:

(i.) Revision of the format of data analysis and data presentation of institution- based indicators (RMIC) relevant for built-in monitoring and evaluation and remedial actions. (ii.) Establishment of a nutritional surveillance system to assess trends in the nutrition situation, magnitude of nutritional problems in the community as well as specific vulnerable groups, including relevant information systems for monitoring and evaluation of interventions. (iii.) Establishment of a nutrition research unit, potentially as part of the planned Evidence-Based Medicine Center of MOH and its network of resource centers and/or affiliates. (iv.) Development and implementation of an applied nutrition research agenda to provide the evidence-base for cost-effective interventions in the various geographical and cultural settings. (v.) Incorporate modules for community-based MCN in the current revision of pre- service and in-service training modules of medical and paramedical staff. (vi.) Strengthening of the RCHP with adequate professional expertise and capacity to deal with the main nutritional problems, e.g. child stunting, IDA, IDD and the promotion of adequate dietary intake and dietary behavior. (vii.) Development, production and distribution of health and nutrition promotion packages, which are needs based, and well tested for comprehension and socio-cultural acceptability

349. Indicators to measure the achievement of the above mentioned output are:

(i) Revised management information system for MCH to include MCN within one year. (ii) An infrastructure established and applied research agenda formulated for evidence-based nutrition interventions within two years. (iii) Pre- and in-service training modules and refresher courses for MCN developed within one year and gradually implemented in the course of the second year. (iv) RCHP has formulated a comprehensive 5-year plan for human resources development, MCN promotion packages and IEC materials within one year and gradually acquired funds to implement the 5-year plan.

Output 4: Amendment of Existing Nutrition-Related MCH Programs

350. At present the maternal component of MCH includes antenatal and postnatal care with nutrition education, Safe Motherhood, and PEPC strategy. The child component is covered by the BFH from birth till discharge, and thereafter by child clinics for growth monitoring, nutrition education/breast feeding promotion and immunizations, and the Breast Feeding Promotion program. The recently introduced IMCI caters to sick children and includes nutrition counseling and breast-feeding promotion. All these programs are vertical institution- based programs without planned linkages. Furthermore, none of these programs have well designed community-based activities with involvement of the mothers, families and the community.

351. It is essential to amend MCH services, explicitly including MCN into coordinated and integrated services with clearly defined linkages between institution- and community-based components. The purpose of these activities is to improve the effectiveness of MCH services to address existing and potential nutritional problems among mothers and young children. Guidelines (protocols) for monitoring in antenatal care (PEPC), postnatal care (BFH and IMCI) and related appropriate actions should be reviewed and amended when relevant to include MCN.

352. Antenatal care will focus on identifying and treating undernourished and anemic mothers. Postnatal care will consider mother and infant as an interrelated dyad, using a mother-child card which integrates monitoring lactating mothers’ nutritional status (weight, or Body Mass Index, Hb levels) with monitoring of the infant/child’s growth, and development. The regular child health services (growth monitoring, immunizations, IEC/BCC) and IMCI will be organized as a continuum, covering the child when healthy and sick, with clearly defined linkages between institution-based and community based components.

353. In order to improve services for pregnant mothers existing protocols should be reviewed and revised, where relevant, to include:

(i) Antenatal care • An upgraded mother card, for the mother to keep with all relevant information of her health and BCC messages • Analysis of weight gain in pregnancy and appropriate action, if inadequate • Identification of risk pregnancies (delivering a low birth weight baby and/or complications at delivery) and criteria for special assistance and care at delivery (PEPC)

(ii) Iron supplementation • Introduction of untargeted iron supplementation throughout pregnancy • Review existing IEC/BCC materials to encourage compliance, formulate new strategies and pilot test innovative methods, approaches and materials

354. In order to improve services for infants and young children and their mothers existing protocols for the peri-neonatal period and age group 0-36 should be reviewed and revised where relevant to include:

(i) Peri-neonatal period • Care and breast feeding of normal and low birth weight newborns • Counselling and/or continuation of iron supplementation if mother’s postpartum Hb has not returned to normal level • Counselling and/or intervention for mothers with postpartum (week 4-6) Body Mass Index104 < 18.5 and Body Mass Index > 25

(ii) Age group 0-36 months • Smooth referral from PEPC – BFH (who will discharge mother and child after 1-4 weeks) to regular child health services, with special guidelines for risk children (low birth weight, anemic, feeding problems or otherwise) • Develop and use a mother and child health and nutrition card (upgraded IMCI child chart of physical development), to be kept by the mother and as a tool for participative maintenance of acceptable maternal and child nutritional status • Development of well-tested IEC and BCC materials for proper infant and child feeding, child feeding during and after illness; prevention of IDA and IDD

104 weight, kg divided by height, m2

(iii) IMCI – integrated components 1-2 (institution-based) and component 3 (community-based) • Review IMCI manuals, components 1-3 to include relevant nutrition topics mentioned in Services for 0-36 months age period • After a needs assessment for trainings and refresher courses in IMCI components 1-3, draft an agenda for trainings, using the new manuals • Review manuals and IEC/BCC materials for C-IMCI • Formulate guidelines for VHC to ensure linkages between secondary and primary level health care providers and in turn with the community • Establish at grass root level functional groups, composed of multisectoral services providers from government, NGOs and civil society to address MCN – with full involvement of the clients (mothers, families). These could be VHC or other existing community committees, scaled up into VIDA-HNI.

355. Indicators to measure the achievement of the above mentioned output are: 356. (i) Revised guidelines and protocols for coordination and/or integration of vertical programs in MCH (accepted interfaces), including new MCN components formulated and endorsed by MOH (ii) Number of trained FGP staff to monitor MCH program, including new MCN components (iii) Quality of the actions taken by FGP staff; such as collecting information, analysis of program, proposal for improvement, initiatives to improve services (iv) Number of new materials developed, such as the mother-child health and nutrition card, upgraded IMCI manuaIs (v) Numbers and types of pilot tested BCC materials available (vi) Number of village committees established and functional (vii) Availability of iron supplements and IMCI drugs in local pharmacies

Output 5: Integration of MCN in Early Child Education

357. Early Child Education has many entry points, which in the current strategy of a life cycle approach, automatically interface with MCN (educationability = children should in the first place have the capacity and conducive environment to learn). Preschool (and school) teachers, the parents and the children can work as a team to improve the health and nutritional status of the children under 8 years of age. It has been shown everywhere that behavior is very resistant to change. The younger the clients the more likely that a change can be achieved as children are the most “moldable” (flexible) and open for change, particularly if approached in peer groups. Furthermore, these children can greatly influence their parents’ behavior.105 Although stunting cannot be reversed at preschool age, interventions at this age can prevent further increase in linear growth deficits and prevent a severe degree of stunting, with related functional impairments.

358. In order to integrate MCN in ECCE the following key activities should be carried out:

(i) Establishment of a working group representing MOH and MOE to review pre- service teacher training curricula and to agree on MCN modules to be incorporated (ii) Interface with ECCE Plan of Action for objective 2: capacity building and IEC to conduct a pilot project for a nutrition component in preschools with partici-

105 Experience in the Sri Lanka, Sarvodaya preschools – in the Netherlands campaign against smoking, for example.

pation of preschool teachers, mothers and families of the preschool children: (a) what to do = situation analysis; (b) how to do = guidelines; (c) training of trainers; (d) implementation, monitoring and evaluation; (e) manual development; (f) scaling up.

359. Indicators to measure the achievement of the above mentioned output are:

(i) Integration of child nutrition and early child education in PEO (ii) Improved knowledge, attitude and practices of preschool teachers, mothers and children in school and at home with regard to nutrition (iii) preschools are used as window of opportunity for other community-based health, nutrition and development activities

Output 6: Improve the effectiveness of programs to control and prevent iron deficiency and iron deficiency anemia in the population

360. Reduction of the prevalences of IDA, IDD and VAD and the promotion of activities to prevent these deficiencies feature in Manas Taalimi as key activities (pg. 61). Inter-sectoral collaboration includes activities on fortification of food products with iodine, iron and vitamins (pg. 60): “Continuation of activity on prevention and reduction of micronutrient deficiency will require development of new innovative approaches, support from justified activities and development of mechanisms of sustainability and financial independence. […] In the context of transitional period of establishment of family medicine it is essential to fulfill further integration of vertical specialized programs into general health services delivery system and improve monitoring system that allows for timely response on effectiveness of motherhood and childhood protection programs.” (page 72)

361. The Manas Summit overview meeting, May 2006, re-stated the holistic policy to address these nutrition issues. Expansion of the scope of health services provided in the context of SGBP includes supplementation of pregnant women and children with micronutrients such as iron, vitamin A, folic acid (for women under 12 weeks of pregnancy) as well as coun- tryside extension of such programs as IMCI, Breast Feeding, Child Care and programs on child nutrition pre-tested in pilot regions (Manas Taalimi, pg 80):

“For the reduction of micronutrient deficiency it is necessary to establish a working group at the level of MOH, which would consist of specialists from different sectors and which would review all existing materials with further development of normative legal base, including clinical guidelines and protocols. It is necessary to conduct a work on BCC in relation to nutrition at the local level, with regards to reduction of micronutrient deficiency among children and mothers of reproductive age, as well as to adapt training manuals for Health workers and all groups of population with regards to geographic location.”

362. Thus, to the letter and in spirit Manas Taalimi provides obvious entry points for an integrated and holistic approach to micro-nutrient deficiencies.

363. Iron deficiency is the most common nutritional disorder in the world and the Kyrgyz Republic is not an exception. It results from consuming diets with insufficient iron, reduced dietary iron bioavailability, iron losses due to parasitic infections, and these factors usually operate concurrently. Hence, the five measures to control IDA, namely supplementation, BCC, food fortification, diversification of diets and parasitic disease control, need to be im-

89 plemented as concerted efforts106. Currently Kyrgyz Republic focuses on supplementation, food fortification and BCC.

364. However, the sector analysis (section B) identified major weaknesses in the supply, distribution and consumption of iron supplement in target groups of MCH and PHC. Food fortification still has a very low coverage. BCC is not well defined and lacks client oriented (felt and real needs) and applicable messages (is it possible to follow the advice). Furthermore, primary level health workers have limited skills and commitment in actively encouraging mothers to comply with supplementation for themselves and their infants. While these problems are widely acknowledged by the key informants and clients, their cause, extent and contribution to the lack of effectiveness have not been sufficiently analyzed as a basis for improving performance.

365. To promote the effectiveness of programs to control and prevent iron deficiency in the population and IDA, particularly in the vulnerable groups, it is essential to formulate operative directions for policies and programs that will help to ensure mutual re-enforcement to reach explicitly agreed upon targets for:

(i) Enhanced efficiency and effectiveness of the supplementation program (ii) Well tested and uniformly used IEC materials and BCC modules, which ac- commodate clients perceptions and include clients’ participation (iii) Better accessibility and use of fortified wheat flour (iv) An innovative approach for food security and dietary diversification (v) Intensified (parasitic) disease control in primary health care and IMCI

366. Supplementation: In Manas Taalimi there will be an expansion of the scope of health care services for pregnant women and children under 5 in the context of SGBP. Iron (-folate) tablets and iron (multi-micronutrient) containing syrup/tablets for children 0-24 months107 must be included in the essential drug list. It is strongly recommended to amend the Order for antenatal care with respect to IDA, frequency of Hb measurements and the prescription of iron tablets (preferably iron-folate tablets). The strategy108 should be:

(i.) Untargeted (all pregnant women) iron-folate supplementation during the whole pregnancy and Hb is measured in the first trimester and the last trimester for monitoring and evaluation OR (ii.) Targeted to anemic pregnant women BUT Hb should be measured in all pregnant women at each antenatal visit (iron tablets subscription as usual)

367. Furthermore appropriate IEC materials should be developed and a focused and vibrant BCC campaign should be implemented. The latter requires staff with skills in appraising community’s attitude and practice (what do they do and why) and community mobilization.

106 (a) Gillespie S, Kevany J, Mason J. Controlling iron deficiency. Administrative Coordinating Committee – SubCommittee on Nutrition (ACC-SCN), Febr 1991; (b) Allen L, de Benoist B, Dary O,Hurrell. Guidelines on food fortification with micronutrients. WHO-FAO. WHO Geneva 2006 107 0-6 months babies included if their mother was anemic during pregnancy 108 The same principles guided the WHO recommendation for distribution of vitamin A massive dose capsules. IDA prevalence among pregnant women in Kyryzstan is over 40%, the cut-off to conclude that IDA is universal. See also reference: Imrpoving Child Healththrough Nutrition: The Nutrition Minimum Package. BASICS 2003.

368. In view of the magnitude of IDA and the inconclusive evidence of the effectiveness109 of iron supplementation it is advisable to do an in-depth study, including a dietary assessment, a full laboratory analysis of iron status and issues related to compliance, preferably in combination with trials of iron supplementation and deworming. This can be done as part of an action-research with the VHCs (Community Action for Health approach in Manas Taalimi) or included in on-going sentinel studies.

369. Development of IEC Materials and BCC Modules: It is necessary to conduct work on BCC in relation to nutrition at the local level, with regards to reduction of micronutrient deficiency among children and mothers of reproductive age, as well as to adapt training manuals for health workers and all groups of population with regards to geographic location. The MOH should encourage the HPU’s to become involved in sensitizing the population on what they can do to deal with anemia at any point of the life cycle. They should publicize that anemia (1) is preventable and treatable (2) has serious negative effects on the mother and the infant and (3) side effects of iron (-folate) tablets are not serious and can be overcome.

370. Fortifying Flour: It is reasonable to assume that large sections of the population are iron deficient. In such a situation food fortification is the recommended intervention. Many constraints still need to be overcome which need to be addressed at policy as well as program levels:

(i.) Donors should support local efforts for a legislative base for compulsory flour fortification (ii.) To enhance and sustain flour fortification, one has to create a demand through a well targeted promotional BCC110 (iii.) To reach the needy in rural areas (for the market not an interesting section of the population), projects like the SCBECD can play a pivotal role to familiarize the population with fortified flour, to enhance accessibility by supporting/creation village outlets and by using (subsidizing) the fortified flour for preschool meals.111

371. Indicators to measure the achievement with regard to flour fortification are:

(i) Legal basis endorsed within two years (ii) Within 5 years 50% of institutions and (pre-) schools use fortified flour (iii) Existing IEC-BCC materials gradually used throughout the country (iv) New IEC-BCC materials pilot tested and impact evaluated (v) Within 5 years availability in shops/markets increased to 100%; knowledge and awareness of families increased to 75%; use increased to 25%

372. Food Security and Dietary Diversification: The very high prevalence of IDA among women of reproductive age and young children justify the conclusion that the whole population is iron deficient. Supplementation is supposed to be a short-term public health measure. It can only phase out if iron (and other micronutrient) requirements can be met by the habitual (daily) diet. Wheat flour fortification – the best approach theoretically – will in practice not reach a measurable proportion of the needy population in the near future. These are strong arguments for a multisectoral strategy to reduce the prevalence of IDA till acceptable levels by 2015. Malnourished/anemic pregnant mothers and children must have adequate diets but

109 Efficacy under standard conditions are already proven 110 Many Informational and promotional materials have been developed in the ADB Project JFPR 9052 : “Sustain- able Food Fortification in Central Asia and Mongolia” but the project was terminated end of 2006. It is strongly recommended to continue to use these materials, and modify them as required 111 We were told that MLSD and MOH will subsidize the use of fortified flour in State institutions, such as preschool and schools, hospitals, orphanages etc. However, no order to this effect could be traced.

91 cannot have them if families don’t produce enough nutritious foods and/or cannot buy them. MOH/SRC has already introduced home gardening in a few raions with great success.

373. Hence, the health sector needs partnerships with other sectors to improve overall and particularly micronutrient status of mothers and children (a) for food production with Ministry of Agriculture and Water Resources; (b) for the safety net of the Ministry of Labor and Social Development for abjectly poor families (c) in combination with income-generating activities. Nutrition as part of community development can and should be integrated in the VHC strategy. It is in line with AOs mandate of village development and AOs can tap different (government) funds. One can envisage several community groups working together: VHC, the preschool parents group, food production groups, income generating groups etc. as part of VIDA-HNI. Experiences in the Philippines and Bangladesh show that such an approach is feasible and effective in improving MCN.

374. AKF is involved in rural development, IMCI and ECD. There are many windows of opportunity for a comprehensive attack on IDA but it has to be concretized. The SCBECDP can take the initiative for the dietary approach as a partner with the MOH and relevant other sectors, donors and NGOs.

375. Key activities related to food security and dietary diversification include:

(i) Establish a multisectoral working group at the MOH (departments dealing with VHC and/or IMCI and/or PEPC etc.) acting as coordinator with a clear mandate to develop the bottom-up integrated approach with a description of each actor’s responsibility and accountability. (ii) Establish at grassroots’ level functional groups, composed of multisectoral service providers from government, NGOs, civil society and targeted clients with AO as coordinator to reach an agreement on (a) the modalities for collaboration; (b) role and responsibilities of each actor, including the clients (mothers, families, community); multi-partite funding for jointly selected interventions. (iii) Empower grass root level functional groups to take care of the identified health and nutrition problems with appropriate and well-defined support from government and/or NGOs through seminars and trainings. (iv) Provide on-the-job training for situational analysis (evidence-based112 village information systems), selection of activities, planning and management (village development plan113), description of each actor’s responsibility (job descriptions) and transparent resource allocation (village budget plan), resulting in annual plans, which are continuously updated. (v) Implement (a) C-IMCI; (b) VHC; (c) Aga Khan Foundation community development projects; (d) others –to be selected locally. (vi) Establish a support system for continuous supervision, training, management and planning, resource allocations etc.

376. Suggested indicators to measure the achievements related to food security and dietary diversification are:

(i) Multisectoral working groups with MOH as coordinator established and functional. (ii) Pilot project(s) for a VIDA-HNI designed, discussed at village and raion level, and implemented in partnership with stakeholders, including clients.

112 What are the problems, who suffers most and why 113 with agreed upon targets and indicators, such as 10% increase per year of families eating an adequate diet every day = covering daily requirements – indicator triple mix meals = staple + pulses/beans or animal products + dark green leafy vegetables and/or yellow vegetables and fruits

(iii) Review of lessons learnt from pilot project(s) done, resulting in prototypes for VIDA-HNI by geographical region and/or other different criteria (urban-rural, majority ethnicity, major occupations etc.) (iv) Scaling-up of situation specific prototypes.

377. Intestinal Parasitic Disease Control: The current IMCI algorithm does not promote routine deworming of children. WHO’s program for parasite control estimates the total cost of deworming a child for common intestinal parasites at less than $0.25 per year, including drugs, delivery, equipment, health education materials, training personnel and monitoring and evaluation.

Output 7: Sustain elimination of IDD and Vitamin A deficiency

378. As mentioned in the section above the strategy for iodization of salt for elimination of IDD can be considered successful. It is, however, essential to maintain vigilant and continue to monitor the quality of iodized salt at the production and sales sites. Similarly, the vitamin A capsule distribution, supported by UNICEF met their targets and the program appears to be well implemented nation-wide (section B).

379. In order to maintain the positive results related to IDD continued efforts with regard to food fortification (iodized salt and iron fortified flour) should be undertaken with the aim to guarantee a 100% good quality iodized salt provision and utilization within two years.

IV. EARLY CHILDHOOD CARE AND EDUCATION

A. Status of Early Childhood Care and Education

1. Present Situation related to Pre-School Education

380. Early childhood care and education (ECCE) has a significant impact on the individual development since most mental and psycho-social abilities are shaped in the first years of life. During the first years of a child’s life, ECCE is primarily provided by parents as they are the primary caregivers or by other family members using their knowledge and skills in this context. From age 3, pre-school educational organizations (PEOs) play an important complementary role. Within the field of child care and education it is important to highlight the links between child health, child nutrition and access to PEOs. Most efficient ECD programs integrate family support, health, nutrition and PEOs.

381. After the collapse of the Soviet Union, the years 1992-1995 showed a dramatic decrease in kindergartens from 1380 to 416. Since 2002, the number of children attending PEOs and the number of PEOs have slowly increased. By the end of 2005, 448114 PEOs were reported to exist in the Kyrgyz Republic. Pursuant to statistical data available, 800.259 children are of preschool age115 in the Kyrgyz Republic116 in 2005. However, the existing 448 preschools can cover only 6.8% of children (54.365) throughout the country. The number of preschool age children and number of state kindergartens in all raions are in annex 18.

382. There is a widespread belief among educators that the benefits of pre-primary education are carried over to primary school. Teachers in particular say that the lack of academic skills is one of the most common obstacles children face when they enter school. They also perceive preschool education as facilitating the process of socialization and self-control necessary to make the best of classroom learning117. The limited number of PEOs and, consequently, the limited access to preschool services show first negative impacts on life skills of young children in the Kyrgyz Republic. According to a UNESCO/UNICEF (2001/2005) survey, more than 40% of primary school pupils failed the numeracy test and almost 56% failed the literacy test in 2005, which is 22.6% more for the first and 14.9% more for the latter compared to tests made in 2001.

Table 8: Monitoring Results of Numeracy, Literacy and Life Skills in 2001 and 2005

Life skills Literacy test Numeracy test

Passed Failed Passed Failed Passed Failed 2001 75 25 59.1 40.9 81.4 18.6 2005 77.9 22.1 44.2 55.8 58.8 41.2 Source: UNICEF, 2006118

114 National Statistics Committee of Kyrgyz Republic. 2006. Education and Science in Kyrgyz Republic. Statistics Collection, Bishkek. 115 According article 15 of the Law on Education (2003) and the State Standard (2007), preschool services are defined for children between the age of 6 months till 7 years. 116National Statistics Committee of Kyrgyz Republic. 2006. Education and Science in Kyrgyz Republic. Statistics Collection, Bishkek 117 The Institute for Fiscal Studies. Giving Children a Better Start: Preschool Attendance and School-age Profiles. WP06/18 118 Unicef. 2006. Monitoring of Learning Achievements (4th grade), Bishkek 2006, p.74.

383. The “Monitoring Progress in Education (8th grade)”119 report supported by Unesco evidences lower achievements in mathematics and natural sciences within this period (2002 –2003) for the Kyrgyz Republic120. The findings of this research suggest that progress in education is slower in rural than in urban schools. This conclusion is supported by data from MOE and the results of the General Republican Test for school leavers, which has been set since 2003 (Fast Track Initiative (FTI), 2006, p. 11)121.

Table 9: Average Values of Test Results by Category of Candidates

2003 2004 2005 Total in the Republic 114.2 122.4 112.7 Bishkek school leavers 136.4 144.3 137 Oblast centre school leavers 120.1 127.1 118.5 Rural school leavers 108 114.9 103.6 Source: National Statistics Committee of Kyrgyz Republic. 2006. Education and Science in Kyrgyz Republic. Statistics Collection. 2006

384. Feedback received during focus group interviews with regional educational departments also indicates a substantial risk that school relevant developmental processes show a general deterioration in regions without institutionalized ECCE services. In addition, preschool teachers – based on their professional experience - report a substantial lack of preparation for children not attending PEOs. Together with the empirical data collected within the scope of the above mentioned monitoring and testing instruments, the pedagogical experience of teachers and education departments demonstrates, too, that the decline of preschool services in post-Soviet times had a negative impact on the general development potentials (in terms of future school achievement) of children in the Kyrgyz Republic.

385. Besides the limited number of preschools, knowledge and information on childhood care of parents and communities, especially in rural and remote areas, and educational initiatives of parents on the local level of AO are insufficient. Therefore, increasing the number of PEOs as well as capacity building of parents and communities in ECCE represent a major prerequisite to stop the decline of skills of preschool children in the Kyrgyz Republic.

386. In order to increase the number of preschools, alternative models have been introduced. These alternative models of preschools established with external assistance aim at initiating change processes both on the level of organization, e.g. community based PEOs, and on the level of service delivery, e.g. half day models. Alternative PEOs were established by ADB, UNICEF, Aga Khan and Save the Children (Denmark). The total number of alternative preschools has reached about 100. Other donors, within a broader context (e.g. by means of grants for renovation of premises) also support community initiatives in all oblasts (e.g. World Bank’s ARIS) and food (Mercy corp).

119 UNESCO. 2003. Monitoring Progress in Education (8th grade). Bishkek 120 UNESCO. 2005. EFA Global Monitoring Report. (Data available at: http://portal.unesco.org). 121 World Bank, Unicef, MOE. 2006. Education for All: Fast Track Initiative. Accelerating process towards quality universal primary education. Bishkek.

387. The FCBECDP assisted the MOE to improve ECCE in the Kyrgyz Republic by providing the necessary legal basis for alternative PEOs, integrative training of parents and professionals in ECCE in selected raions, capacity building and mobilization of communities to establish PEOs, financial support for renovation of buildings, procurement of furniture, educational and stimulating equipment and support for resource kindergarten. Outputs of the FCBECDP with respect to education and care show systematic changes in the Kyrgyz Re- public: new educational standards on “Preschool Education and Child-care” were approved, a substantial number of parents and professionals were trained, community based PEOs were established and norms and regulations began to be developed.

388. However, despite efforts of the Kyrgyz Government and international donor organizations to improve ECCE and to increase the number of preschools the situation regarding PEOs is far from being satisfactory, especially if we take into account an increasing birth rate in the Kyrgyz Republic. Major problems still remain unsolved: (i) the lack of both knowledge and access to information of family caregivers and the community on ECCE, and (ii) the lack of PEOs, including issues of training and quality compared to international standards.

2. Knowledge, Skills and Practice of ECCE in Families

389. Based on the difficult economic situation, the position of young children and their families has become even more problematic in rural areas. Due to the economic pressure on the families, the importance of active education processes in the family is underestimated. Children tend to be left on their own, without age adequate stimulation. Knowledge on ECCE in families is poor, as the families lack books, journals or possibilities to exchange their concerns. The most important professional source of knowledge are the FAPS, even though there are medical and care oriented. Adequate learning materials (toys, books etc.) are rare due to insufficient financial means of the families. Moreover, these materials are not available in rural areas.

390. According to focus group interviews, parents or other family members (e.g. grandmothers or older siblings) show limited knowledge concerning the importance of ECCE and therefore a lack of practical skills for care giving (including issues of education, health and nutrition). This lack has a negative influence not only on creating a supportive environment at home, but also on understanding the significant role of PEOs contributing to the children’s psycho-social development. Results of the needs assessment conducted in the framework of preparing the SCBECDP show that main care and education activities within the family consist in watching TV together, teaching basic hygiene and correcting misbehavior.

391. Fathers show almost no involvement in care and education activities during the first years of the child’s life; and many of them left their families for jobs in Russia, work on the fields or selling goods on the market. Older children usually take care of younger ones. Be- sides that, the issue of child labor becomes more and more relevant as after the 5th year of life, children become involved in field and hard household work. In 2003 4000 children did not attend school, 5000 to 7000 children under 15 are estimated to be living and working on the streets (source: Laborsta, ILO (2003). http://www.ilo.org.stat)

392. Since knowledge and access to information on care and education in rural areas is limited, most of the available know-how is provided by health facilities or TV programs. Tradi- tional knowledge of grandmothers (“babushkas”) on care and children development is not necessarily correct (e.g. tea, using “beshik” etc.). Moreover, in some cases grandmothers cannot get involved in child care since the economic situation of families forces them to participate in income generating activities.

393. Recent TV programs (Keremet-Koch), developed in the framework of the FCBECDP- in cooperation with UNICEF and Aga Khan, training programs for parents (FCBECDP) in selected raions and the implementation of VHCs are a first step to provide families with the required information on ECCE. Based on lessons learnt from the FCBECDP as far as the empowerment of parents is concerned, a special focus should be put on the sustainability and transferability of knowledge and new skills into daily life and daily activities of the family, including fathers.

B. Policies and Normative Regulations related to Pre-School Education

394. The current situation regarding policies and norms in the Kyrgyz Republic can generally be described as transitory. Based on previous documents on preschool education (order of the Minister of Education Science and Culture Kyrgyz Republic from 23 October 1997, 376/1) people tend to be more aware of the importance of educational services in the child’s early years of life.

395. The approval of the Kyrgyz State Standard on “Preschool Education and Child-care” on Jan 14, 2007, opens possibilities to diversify the existing, mostly state based system of preschool educational organizations (PEO). However, within this context most of former So- viet Union based norms and regulations are currently under revision. Therefore statements on norms and regulations can only reflect the current discussion and provide suggestions based on currently available data.

396. With respect to self governance and finance two major changes have been made to establish a system of decentralization: The Government’s regulation “on activities plan for decentralization for 2006–2007” (May, 2006, № 365) and the Methodical directions “on order of forming and executing of local budgets of Kyrgyz Republic for 2007” will in future allow a two level system of budget forming by local authorities, with major impacts on establishing PEOs. However, some political decision making processes or concrete implementation strategies are still pending, mainly regarding the implementation of the new State Standard and the two level system of budget forming.

397. A number of different policies are identified in the field showing the complex interrelation between different ministries and agencies and between their respective areas of actions:

(i.) Education (ii.) Social Welfare and Child Protection (iii.) Decentralization and Budget policy

1. Education

398. The MOE within its Education Development Strategy of the Kyrgyz Republic (2007– 2010), in accordance with the Country Development Strategy of the Kyrgyz Republic 2006– 2010 and with a view to achieving the MDGs, defined sustainable development goals and EFA goals. Furthermore it includes a strategy for reforming the educational system by (i) identifying medium-term educational system development (2010), and (ii) identifying problems and proposing solutions and mechanisms for their implementation.

399. Based on the Constitution of the Kyrgyz Republic, the Law on Education (1992) and a series of national educational programs, the main principles and objectives to be achieved in the area of education are identified. However the majority of policy documents with an educational agenda unfortunately did not receive financial support and therefore a couple of issues remain open:

(i.) Ensure equal access to education (ii.) Update the content of educational and learning technologies (iii.) Improve quality (iv.) Use resources more effectively and efficiently (v.) Make management democratic

400. By Government Resolution #504, dated July 30, 2002, of the Kyrgyz Republic, EFA goals were developed and approved. EFA goal 1 focused on expanding and improving Early Childhood Development measures. Taking into account that in 1990 almost four times more PEOs were operating and despite the progress achieved, this EFA goal is far from being fully implemented in the Kyrgyz Republic.

401. The decline in PEOs required a new medium-term Education Development Strategy (till 2010) consolidating the experience and achievements of previous years in choosing the directions for development and assurance of financial support by:

(i.) Maintaining the existing PEO network (ii.) Expanding alternative development programs for children of primary school age (iii.) Optimizing the management and financing system (iv.) Training adults in skills on the care and development of younger children

402. However, the infrastructure, availability (see Figure 14), equipment and the quality of PEOs still do not meet international standards. Only 9% of the children in preschool age (3-7) are estimated to attend pre-schools, but 68% of the parents would like to enroll their children in PEOs (MOE 2006122). Rural areas have less facilities and material than urban areas: consequently, equal access for preschool children - especially in rural and poor areas -seems to be more a wish than a reality.

122 MOE, Education Development Strategy of the KYRGYZ REPUBLIC 2007-2010; Approved by the Ministry of Education on 19.10.06 (order # 658/1)

Figure 14: Development of preschool units and children in preschool education in the Kyrgyz Republic

units thousandthousand people people 1600 160,0

1400 140,0

1200 120,0

1000 100,0

800 80,0

600 60,0

400 40,0

200 20,0

0 0,0 1992 1993 1994 1995 1996 1997 19981999 2000 2001 2002 2003 2004 2005 2006 Number of preschool institutions Number of children (thousands)

Number of community based kindergartens Source: National Statistics Committee of Kyrgyz Republic. 2006.123

403. In addition to increased donor activities in the field of ECCE, the general government policy124 started to highlight the importance of preschool education as the first impacts of decreased PEO attendance on school performance parameters became obvious. Government efforts and strategies include preschool education as an integrative part of the education system. However the position of the preschool system within the overall scope of educational strategies is still insufficient.

404. In order to increase the number of PEOs, community based kindergartens were established through the FCBECDP and other donors (e.g., UNICEF, Aga Khan). By 2007 the number of community based kindergartens reached 100.

405. The strategy of the Kyrgyz Government focuses on combining efforts with ongoing and planned projects funded by ADB, Soros-Kyrgyzstan Foundation, the WB and other donor agencies and local authorities—especially in rural and poor areas. The preschool system (within the FTI-strategy) should be strengthened by:

(i.) Adequate material, essential furniture, developmental and educational toys (ii.) Creating equipped resource centers (iii.) Developing, testing and implementing child development and school preparation programs (iv.) Monitoring and evaluation of the implementation process

123 National Statistics Committee of Kyrgyz Republic. 2006. Education and Science in Kyrgyz Republic. Statistics Collection. Bishkek. P.41, 2006. 124 National Action Plan on Education for All, 2002; Country Development Strategy of the Kyrgyz Republic 2006- 2010; Education section; FTI 2006.

2. The Role of Social Protection and Health

406. There is a high political awareness that issues of education have to be seen in close relation to the child’s welfare and its social protection. In addition, the close link to Health and Nutrition should be emphasized here, e.g. regarding the general strategy that “every child should have at least one warm meal in school”125. The new State Standards recommend that the PEO is responsible for the quality of food and medical workers should control it126.

407. The importance of State Standards of the Kyrgyz Republic regarding “Preschool Edu- cation and Childcare” was supported by a President’s Decree “on urgent measures for the improvement of the children’s status in the Kyrgyz Republic” (2006). Preschool education in this context is also considered as one of the necessary and preventive tools for children at risk within the context of children’s rights. Besides that, work on advocacy of children’s problems and rights is included in the state policy and should be presented in the framework of the “National communicative Media strategy on the promotion of children’s rights in the Kyr- gyz Republic” (2007-2010), developed with the support of UNICEF and the participation of the key stakeholders.

408. The “Code on Children” defines strategies and structures of Child Welfare or Child Protection. CFCs – involved in the FCBECDP – are supposed to become “inspectors” and will work according to the guidelines of this code. The “National Poverty Reduction Strategy” (2001/2006) aims to improve the developmental and life situation of preschool children, by:

(i.) Assisting families and children; (ii.) Involving local communities, families and children in activities designed to reduce poverty; (iii.) Developing mechanisms of social partnership and community involvement in education.

409. Increasing the attendance of kindergartens for children from extremely poor or disadvantaged families is a major task to decrease developmental risks related to poverty or other disadvantages.127

3. Decentralization Policy and Important Stakeholders

410. The National Strategy on Decentralization consists of two parallel processes128:

(i.) Decentralization of public administration; (ii.) Delegation (devolution) of part of the state responsibilities to local self governance bodies (Law “On local self-governance and local state administration” (№5, 2002) and national strategy on “Decentralization of state governance and development of local authorities in Kyrgyz Republic till 2010”, approved by President’s Decree N 381, 2002).

125 Government Regulation of Kyrgyz Republic N 900, 2006 126 State Educational Standard. Preschool education and Child-care of Kyrgyz Republic. Chapter 12 “Organization of children’s nutrition”. Pp. 12.4-12.5. 127 Dunst, C. J.; Snyder, S. W.; Mankinen, M. (1989). Efficacy of early intervention. In: M. C. Wang; M.C. Rey- nolds, Walberg (eds.), Handbook of special education. Vol 3, 259-294. Oxford: Pergamon, Karoly, L.A. et.al (1998). Investing in our Children. Washington: Rand 128 UNDP. 2005. Political and Administrative Central Governance Programme. Kyrgyzstan.

100

411. The organigram below describes the structure of key stakeholders on preschool policy and operative level in the Kyrgyz Republic:

Figure 15: Schematic Structure of Key Stakeholders on Preschool Policy and Opera- tive Level in Kyrgyz Republic Educational Department of White House

Ministry of Labor and Ministry of Justice Ministry of Finances National Agency on Local Social Protection Self-Government

Ministry of Education, Science and Youth Policy Normative regulations, policy development, control

Oblast Education Department Kyrgyz State University named after Administrative department of MOE I. Arabaev Teachers preparations

Raion parliament

Kyrgyz Academy of Education Raion Education Department Curriculums development, Qualification course for teachers

State/ municipality kindergarten Public Foundation Regional Institutes of Qualification Step by Step for teachers Resource kindergarten (training) Qualification course for teachers

Community based initia- Other (Waldorf) tives Aga Khan Donors, International and non-government organizations (ADB, UNICEF, WB, Save Community, AO Save the Chil- the Children, Step by Step, Aga Khan …) dren, Every st Programs of cooperation with MOE, joint 1 ADB child Mercycorp strategy development FTI CBECD (WB) Teachers’ preparation, kindergarten estab- (UNICEF) project lishment, coverage of children from vulnerable families and children with special needs

Schematic overview by TA team SCBECD project

101

412. The government’s plan for decentralization for 2006–2007 aims to shift more responsibility and power, also with regard to budget planning, to local authorities (see annex 19). Since the local authority (AO) will then be responsible for social planning processes and financing of PEOs, this plan will have a major impact on future strategies. AOs will then need the necessary tools and knowledge of how to establish and run PEOs. Currently the responsibilities with regard to ECE are as described below.

413. The Educational Department of the White House is responsible for coordinating the edition of documents to be approved by the Government. Given the socio-cultural development, including the preschool and school system in the Kyrgyz Republic, the Educational Department of the White House wishes to be involved in the further process of the CBECD because of the political responsibility to be assumed, The importance of municipality-owned initiatives needs to be emphasized here.

414. The Ministry of Education, Science and Youth Policy (MOE) is considered as the key player in the field of the PEO. The MOE is highly aware of the preschool situation and is very concerned about its collapse during the last decade. Since independence, major efforts on the political and strategy level have been made towards sustainable strategies and implementation of structures in the field of ECD in the Kyrgyz Republic. Major constraints are connected with the difficult economic situation. The MOE clearly recognizes future risks (as far as the decline of developmental parameters is concerned). Frequent personal turnover is considered as a threat to move on with the efforts undertaken so far.

415. The Ministry of Labor and Social Development (MLSD) highlighted the importance of sustainable development in the field of ECD. Based on the structure of Social Protection, social workers are seen as key operative players within AOs, assessing well the family needs and necessary support, including child related issues. From the side of the Ministry it is suggested that social workers of the AO might play a more important role within the 2nd phase of the ADB CBECD project.

416. The Ministry of Justice was involved in the approval of the State Standard of the Kyr- gyz Republic “Preschool Education and Childcare”. In addition, the Ministry of Justice will play a key role regarding future development of a necessary “Law on Preschool Education.”

417. The Ministry of Economics and Finances emphasized that budget and policy planning (done until 2009) is within the responsibility of the MOE. Concerning Community based “alternative” education initiatives; they are under the control of local authorities and local budgets. This structure is based on the new Government Regulations on the “Two Levels Budget System” signed in 2006.

418. The National Agency on the Local Self-Government Affairs and Local Development forms policies and coordinates the work of local authorities. The Agency points out the importance of Raion parliaments and AO (e.g. regarding local budgets) when it comes to using existing structures for community based kindergartens (e.g. school buildings) flexible. Even though it might not be possible to establish community based kindergarten in each village - local budgets have capacities for sustainable development, mainly based on initiatives of the villages. The National Agency furthermore highlights the necessity of social planning processes.

419. State Agency on Tourism, Sport, Youth Affairs and Children Protection under Gov- ernment: This new Agency is supposed to start work as a special department for children under the Government. Work will be directed following a (proposed) application of inspectors on children in the framework of the Children’s Code.

102

420. Kyrgyz State University named after I.Arabaev: This University provides higher education for students who want to become preschool teachers (5 years). Regional branches under the umbrella of the University were closed (according to attestation results implemented by MOE, August 2006). The Kyrgyz State University is actively involved in working groups regarding new Standards and, currently, in training processes of resource kindergarten and community based kindergarten teachers within the 1st ADB CBECD project.

421. The Kyrgyz Academy of Education can be considered as a substructure of the MOE since it is responsible for retraining, development and publishing of educational methodological papers. The Academy is closely collaborating with two regional Institutes of Teacher’s Qualification. The development of educational programs, including those for alternative PEOs, is part of its priorities. The Academy expresses readiness for support through regional Institutes of Teacher’s Qualification. This professional support could be realized, if financing for it would be provided. The Academy is supporting the dissemination of the content of the Preschool Standard’s through including it in their curriculum and program for teachers’ qualification. The Academy also contributes to the development of the normative base for alternative pre-schools.

422. Oblast and raion education departments: Representatives of educational departments collect data, promote and monitor the activities of preschool establishments. Due to logistic issues and the legal status of community based kindergartens and lack of concrete monitoring tools, the effectiveness of their work is under review.

423. Ayil Okmotus: AO is regarded as a crucial player in terms of community preschool initiative promotion. AO manages and plans local budgets and preschool strategies, mobi- lizes and cooperates with key-initiative persons, the community (parents) and educational departments. According to current legislation, the structure of AO also includes specialists of social work which work with families. AOs express there willingness to initiate community based projects, on the other hand they point out major financial problems. Effectiveness of AOs in the field of establishing PEOs depends to a high degree on active strategies on social projects of international organizations and impulses from parents or key persons. Initiatives from the side of AOs are mainly restricted by the financial situation and priorities (e.g. water supply of the villages.)

424. State kindergartens are PEOs which are mainly based on the concepts and infrastructure of the former Soviet Union. Due to the collapse of the system, a majority of State kindergartens were closed. Structure, staff, pedagogical approach and equipment are mainly based on former Soviet examples. State kindergartens (443 in 2005) usually cover urban areas and provide full day services. 20 special kindergartens for children with special needs can also be identified in the Kyrgyz Republic. A specific medical-psychological commission assesses whether a child with special needs is able to attend a mainstream kindergarten or a special kindergarten.

425. Resource kindergartens (especially created within international projects) serve as methodological and training resource center. However, lessons learnt from the first ADB- financed CBECDP indicate, that there is a necessity to clarify methods of dissemination and know how transfer towards community based PEOs. Furthermore, the functions of resources kindergartens are not clarified within the new State Standards.

426. Within the last years – primarily based on international projects – new “alternative” forms of PEOs were established in order to fill the “gap” that was left by the collapse of the former Soviet system. Community based PEOs – within the new State Standards – have been currently legalized. The situation of the infrastructure, training of the teachers, equipment, and the budget show heterogeneous pictures, primarily depending on the initiative of key persons, the community (mahala) or parents. Within the FCBECDP project e.g. 70 new

103 preschool institutions have been established in 2006 and are functioning; they are attended by 1,527 children129.

Suggestions

427. As mentioned above, the last decade has seen a rising awareness of early childhood education in the Kyrgyz Republic. Policies in different fields highlight the significance of support processes and of necessary policies in this area. Involved stakeholders report high motivation to improve the general situation of preschool children in the Kyrgyz Republic. The first concrete steps have been undertaken and show concrete results (New State Standards, Community based kindergartens e.g. within the FCBECDP project etc.).

428. Preschool education is seen as an integral part of general strategies in the field of education. However a concrete implementation (through a specific Law on Preschool Educa- tion or financing strategies, cost models etc.) is still pending and the process to develop the legal framework will take some time. Given the variety of initiatives, a risk of fragmentation on the level of the policies involved is likely to be expected.

429. In order to combine efforts in the field of education, health, social protection, poverty reduction, decentralization and self governance, all relevant partners will be required to coordinate activities and to combine joint efforts in the different fields of policy (education, poverty reduction and social protection). The following steps need to be taken:

(i.) To strengthen the importance of educational processes during the first years of the child’s life and the impact on school education a specific Law on Pre- school Education should be worked out or the existing Law on Education, with a special focus on equal access to preschool education, should be amended. A clear gender strategy should be included into a future Law on Preschool Education. (ii.) To ensure availability and financing of PEOs – especially in rural areas – normative models of financing should be worked out, comparable to those in the field of school education, especially with respect to ongoing decentralization processes. Models of financing might be related to costs per capita and specific costs for different kinds of PEOs. Besides that, the decision will be made by the working group of MOE and other Ministries in relation to sharing of costs between state, local budget and parents. (iii.) To strengthen the process of decentralization and empower communities to establish and run PEOs. CBOs and AOs should be supported to establish new PEOs in order to increase the number of PEOs. (iv.) To enable equal access of vulnerable groups of the Kyrgyz society, especially through prevention programs, specific attention has to be paid to disabled and socially disadvantaged children.

430. Norms and regulations within the field of education are needed for the following aspects:

(i.) The conceptual framework of PEOs (organization, forms, financing, licensing) (ii.) The educational framework (curricula and programs) (iii.) Professional requirements and professional training issues

129 Community based ECD Project (President Office and ADB), 2006. Midterm review of the Project implementation.

104

431. As mentioned above, the situation in the Kyrgyz Republic with respect to norms and regulations is transitory. Even though the New State Standards are approved, there is a need to adapt the existing regulations on PEOs, e.g. the “Typical regulation on PEO of Kyrgyz Re- public” approved by MOE’s Order №376/1, 1997 (see below). This process will take at least half a year (till autumn 2007). In addition, it is not always possible to clearly distinguish between norms and regulations on the organization of PEOs and pedagogical models or contents since the current norms and regulations tend to combine the conceptual terms of education and care.

432. Until 14th January 2007 (date of approval of State Standard), the “Typical regulation on PEO of the Kyrgyz Republic” (1997) regulated the conceptual and pedagogical setting of PEOs (especially education and care for state based kindergartens). Furthermore, the “Typi- cal regulations on Special Preschool Establishments for Children with Mental and Physical Disabilities” (1997) covered the field of children with special needs. These documents mainly defined the organization of the “typical state kindergarten” (e.g. in terms of numbers of children, ownership, behavioral and pedagogical norms.

433. Existing regulations are currently enlarged by the State Standard of the Kyrgyz Re- public on “Preschool Education and Child-care”, approved on January 14, 2007. This standard legalizes the establishment of “alternative” – non state-owned PEOs. Based on the new Standards the MOE plans to analyze the existing normative bases until May 2007 and to present projects of new normative documents by September 2007.

434. The standards themselves are based on:

(i.) Existing laws on Education (1992/2003), the National Educational Program (Bilim) (1996), the “National plan of action on Education for All”, the Sala- manca Declaration (1994) and the Convention on Children’s Rights (1994 in the Kyrgyz Republic) (ii.) Examples of international best practices and local experience (iii.) The “Basic Law of the Kyrgyz Republic” guaranteeing gender equality (№60, 2003) (iv.) The “Law on “Protection of life and health of the citizens of the Kyrgyz Repub- lic” (1997/2005) (v.) Sanitary Rules and Provisions (2000) relevant for PEOs.

435. The new “State Standard of the Kyrgyz Republic Preschool Education and Child-care” represents a big state-of-the-art step towards (i) promoting community based kindergartens or other alternative forms; and (ii) providing equal access to preschool services for all preschool children in the Kyrgyz Republic (including state kindergartens). The new standards (inter alia) address aspects of:

(i.) General definitions of the PEOs (ii.) General provisions (iii.) Educational program documentation (iv.) Age groups periods and group forming (v.) Child development indicators (vi.) Principles of educational and pedagogic activities (vii.) Allowed minimum of the contents included in the Preschool Educational Pro- gram (viii.) Basic curriculum of the preschool educational organization (ix.) Developing environment aspects (x.) Materials and equipment (xi.) Health, sanitary norms, nutrition and safety of the children (xii.) Buildings and sights

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(xiii.) Qualification demands for preschool teachers (xiv.) Family and community participation (xv.) Monitoring of Standard implementation (xvi.) General aspects of financing (xvii.) Appendices

436. The approval of State Standards demands further work on the concrete implementation. There will be a need to:

(i.) Define exactly the scope and requirements for the different alternative PEOs, which are mentioned within the Standard. This includes exact definitions of “educational activities and care”. The standards make a distinction between “education” and “care”. (ii.) Define concrete implementation steps, especially when it comes to “tuning” processes towards the “old” “typical regulations” (iii.) Clarify e.g. the operational definitions (e.g. the function of “resource centers or resource kindergartens”).

437. Furthermore the aspect of financing is kept open within the State Standard. However, the State Standards enable bodies (AOs, private founders) to create alternative forms within the state’s legal framework. However, financing, concrete definitions of the forms and quality indicators for these new forms are left open. As pointed out before, the aspect of financing has to be seen in the wider context of the pending Law on Double Budgets. Other aspects like concrete monitoring and evaluation tools, intake criteria or the situation of children with special needs have to be addressed in further discussion. The “State Standard of the Kyrgyz Republic on Preschool Education and Child-care” is a starting point for both the development of a Law on Preschool Education and the necessary administrative instructions for the executive bodies to implement these standards.

438. There will be a need to clarify, whether a specific Law on Preschool Education is necessary or whether existing Laws on Education can be amended. However, current international examples highlight the importance of a specific Law on Preschool Education, as such a law is likely to address - in a more child-centered way - the specific requirements of PEOs. PEOs in this context are seen as autonomous educational services, not only for school preparing purposes, but also for providing opportunities enabling peer-related, play-centered activities. A separate Law “on preschool education” in the Kyrgyz Republic should address this issue.

439. Besides that, concrete profiles of alternative PEOs should be worked out:

(i.) Define specific forms and profiles of PEOs (e.g in terms of organisation staff requirements, opening hours, intake procedures, parent co-operation, and inclusion of children with disabilities). (ii.) Define education and care related activities in the PEOs in order to facilitate financial models taking into account that alternative forms might not need care-activities. On the other hand, pure care-facilities might not need educational activities. A clear distinction between “education” and “care activities” (including other activities related, among others, to health e.g.) should facilitate cost-ratio-models for the different alternative forms. (iii.) Define concrete monitoring tools with respect to both the curriculum and the programs. (iv.) Create an information strategy of all stakeholders regarding the new State Standards.

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(v.) In connection with the issue of financing (see below), create comparable cost models for the different forms (taking into account the age of children, the relation between “education and care” and staff requirements.

440. Relevant stakeholders working in the field of ECCE aim to increase the number of PEOs and create a new legal base (State Standard), which allows the diversification of the existing state PEO system. To strengthen the importance of preschool education, a future “Law on Preschool Education” (a political strategy observed in many transition countries) should complement the new “State Standard”; especially with respect to equal access to PEOs, overall organization of preschool education and financing.

C. Financing of Pre-Schools

1. Expenses and Government Spending on Pre-Schools

441. Until now, the “Typical regulations on Preschool Establishments” (1997) regulated the financial situation of state-owned PEOs. Data on community based PEOs are not available at the moment.

Figure 16: State Budget Expenditure on Education (as % of GDP)

8,00 7,00 6,00 5,00 4,00

% GDP 3,00 2,00 1,00 0,00

0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 years

Table 10: State budget expenditure on education (in million soms) State expenditure on education 2001 2002 2003 2004 2005

Total in million soms 2847.6 3350.4 3753.6 4361.3 4917.7 Total in % GDP 3.9 4.4 4.5 4.6 4.9 High professional education 490.3 657.3 747.3 864.3 943.3 Secondary education (including 1847.4 2020.1 2289.8 2603.9 3017.3 primary vocational education) Primary education 11.1 15.9 17.0 18.3 22.4 Preschool education 190.0 219.5 232.1 257.2 304.1 Source: National Statistics Committee of Kyrgyz Republic. 2006. Education and Science in Kyrgyz Republic. Sta- tistics Collection. Bishkek. P.30

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442. With state budget expenditure on education at the size of 4.69% of its GDP the Kyr- gyz Republic’s expenditure on education is slightly below the average of all countries (5.62% of GDP, including public and private sector) compared in the OECD study “Education at a Glance” (2005). Out of the total state budget on education in Kyrgyzstan, 6.18% are spent on preschool, compared to 25% which are spent on primary education and 10% for secondary education (source MOE).

443. Compared to most European countries the ratio between costs for all educational programs and pre-primary education in the Kyrgyz Republic (6.18%) is rather low (most European countries dedicate around 10% of their educational costs to pre-primary education) (OECD, 2005). Government financing for PEOs in 2005 was 290.8 million soms (approximately 7.27 million $). Available data show the following budget split up:

Table 11: Expenses of Kindergartens by the Category of Expenses in Million Soms Other costs Social ex- Other (e.g. Salaries Food (communal, penses sponsors) educational) Overall 304.1 129.6 29.8 107.0 24.4 13.3 Source: MOE 2005 *Government regulation (2001 No775) on “participation of parents community to support material and education base of preschool and out-school establishment in Kyrgyz Republic”: Parents payment on a voluntary base (urban area: 160 soms/year; rural: 100 soms).

Figure 17: Share of Budget for Kindergartens in %

Other (e.g. sponsors) Other costs 4% 8%

Salaries 43%

Food 35%

Social expenses

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444. In 2005, the overall budget for kindergartens, including expenditures both by the public and by the beneficiaries was 304.1 Million soms or 6.18% of the general costs for education system in the Republic. Compared with the budget expenditure in 2001, the general expenditures on education in 2005 have shown an increase of 20.25%. Concerning the expenditures for PEOs, the increase between 2001 and 2005 was 60%. At the same time, the num ber of enrolled children increased only by 20%. It cannot be clearly said whether this substantial increase in costs is due to external factors (inflation, increase of salaries) or due to system immanent factors (lack of coordination). The increase of children enrolled in this period can only partly explain this cost explosion.

Figure 18: Financing of Preschool Education 2001-2005

350,00

P 300,00 250,00 200,00

150,00 100,00

millions soms in GD in soms millions 50,00 0,00 2001 2002 2003 2004 2005 years

445. Based on documents of the MOE, the estimated cost per child attending a kindergarten in 2005 was 6,256 soms or about 162.49 $ (including donations). The MOE states that 3,673 soms come from the state budget money. Compared with the year 2000, the cost per child in 2005 has increased by around 36%. With respect to the year 2000 data, government spending in urban and rural areas show big differences.

Table 12: Costs for Kindergarten (2000)130 Government Costs per Child per Year in Kindergarten Oblast (som) Total City Raion National Average 3,530 4,296 2,579

130 Technical Proposal for the Implementation of the Grant from the Fast Track Initiative Catalytic Fund for Pre- school and Primary Education to the Kyrgyz Republic. April 20, 2007.

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446. Concerning the cost per child in school, the average budget spending per pupil (child in care) in primary education does not exceed 2,229 soms; the budget allocates not more than 2,000 soms (or 10 soms per day) for training needs and the salaries of teachers calculated per student without considering expenses for utilities.131 The real expenditure per child in the Kyrgyz Republic for PEOs compared to international figures is low. However, this data does not reflect real purchasing power or percentage of GDP and, therefore, needs to be interpreted with prudence.

Table 13: Costs per Child of Kindergarten Attendance per Year* (Alphabetic Order) Equivalence Country Currency Amount Source in US dollar Austria State Salzburg (1998). Costs for Service (Salzburg) Euro 4,156 5,453.87 Report (Kosten der Betreuung)* 1998 Associated States Commission (Bund- Germany Länder-Kommission) (2002). Finance report Euro 4,556 5,978.93 (2002) on education (BLK-Bildungsfinanzbericht) 2001/2002). Bonn* Kyrgyz Republic Soms 6,256 162.49 MOE (2005)** (2005) Russia TACIS (1998). Addressing the Social Impact (Volgograd) Rubles 4.200 160.14 of Economic Restructuring and Privatization (1998) in Russia. TACIS Program of EU** Department für Bildung und Kultur (2005). Switzerland Swiss 4,825 3,942.90 Global budget „Primary schools and kinder- (2005) Franks garten“** Belarus UNESCO (2006). Belarus. Early Childhood US dollar 605 605 (2006) Care and Education. Geneva** Bartik (2006). The economic Benefits of Uni- USA (2006) US dollar 5,856 5,856 versal Preschool Education. Michigan** *including parents contributions **no data available about parent contribution

447. The current financial situation regarding PEOs is extremely fragmented, both for state kindergartens and for alternative forms. Based on informal data, kindergartens partly negoti- ate directly with parents – in terms of “forced voluntary contributions”, both with respect to the salaries of kindergarten teachers and to maintenance costs of the buildings.

448. Even though point 1 of the President’s Decree (1992, No 48) says that 50% of the costs for food should be covered by the parents, the reality is slightly different if we compare the state contribution for food (9 -14 soms) with the real costs for food. The contributions to be paid by parents to both community based and state kindergartens differs a lot and range between 25 soms/month and 600/700 soms/month.

131 National Statistics Committee of Kyrgyz Republic: Education and Science in Kyrgyz Republic, Statistics Collec- tion, Bishkek, .2006, p.30)

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Table 14: Norms on Food for Children in Kindergarten132 Opening hours

9-10 hours (10,5) 12 hours 12-24 hours Age groups Till 3 years 9 soms 12 soms 3-7 years 12 13 14 Source: MOE (2007)

449. Special attention should be paid to the nutrition component. At the moment the total amount from the state budget for nutrition is elevated.

Figure 19: Financing of Nutrition Component 1- General financing of PEO 2- Financing of nutrition

1 2

450. However, the allocation of costs for nutrition within the different oblasts shows a different picture: Taking into account, that the state standard requires 12 soms/child for nutrition in PEOs, some oblasts allocate much less financial means. Therefore the budget for nutrition in the different regions does not cover real costs for food.

Table 15: Comparative Matrix: Financing of Nutrition in PEOs throughout the Oblasts133 Financing of Oblasts nutrition per Osh Osh Issyk- one child a Jalalabad Batken Naryn Talass Chui Bishkek day (soms) obl. (urban) Kul Actual Fi- 4.7 2 2 2.7 2.6 3.4 2.6 5 12 nancing State standard of 12 soms financing

451. The State policy on ECCE takes into consideration the problem of malnourished children. The FTI strategy includes a support for nutrition components for preschools.134 Taking into account the importance of health parameters for an efficient educational development of the child, the local authority should make provisions for feeding children and include such costs in its budget for preschool education. Good examples of such decisions show that AO could give one cow per kindergarten to provide children at least with milk.

132 Government regulation No 510, 2002 133 Report Data of Ministry of Financing - 2005 134 Technical Proposal for the Implementation of the Grant from the Fast Track Initiative Catalytic Fund for Pre- school and Primary Education to the Kyrgyz Republic. April 20, 2007.

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2. Costs of Different Preschool Program Models and Suggestion an Opti- mal Mix of Models for Reaching Children in Need.

452. The analysis of expenditures and their efficiency is the basis to develop norms and financial models (including alternative PEOs). As stipulated in the existing Law “on Educa- tion”, the “state guarantees financial and material support for early childhood education and provides access to educational services of state PEOs for all groups of population” (Article 15)135. Actually, the state budget covers costs for education, care and nutrition (50%) during full day services. However, so far no differentiation is made (also regarding staff requirements or remuneration) between care and education activities. Assuming that every child requires – based on his/her age – care processes, whether the child attends a kindergarten or not, care activities and respective staff costs (regarding care) should be up to the parents. The MOE is also aware of this primary responsibility of parents and their obligation to provide the necessary financial coverage. Therefore, differentiating care and education activities and subsequently getting higher parents’ contributions for the costs of child care can lead to a reduction of the state expenditures on pre-school education in state PEOs. Subsequent available budget parts should be used to cover staff costs (in terms of educational activities) in alternative PEOs. Distinguishing between “care” and “educational” processes” will also have a substantial impact on the state kindergartens, as parents contributions in state PEOs will have to increase.

453. It should be emphasized, however, that international financing systems in the field of PEOs are very different from each other and have to be adapted carefully to the cultural and financial background of the country. Central European (federal) models are mainly based on mixed finances (state budgets/municipality budgets/parent contributions). Concerning Child Protection or Child Welfare, parents are entitled to receive subsidies if the income situation of the family does not allow the parents to pay kindergarten fees. US American PEOs are primarily financed by parent contributions. Post Soviet systems (e.g. Belarus) are still primarily based on state budgets.

Figure 20: Model of Cost Sharing

…% … % … %

Education State Local Parents Care Budget Budget

Nutrition

135 Law “on Education” № 92, 2003. Article 15.

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454. Financing models should take into account the ratio of input of the different sources (state, AO, parents, other) and the situation of socially disadvantaged children. Furthermore, normative cost models also have to cover different structures of alternative PEOs (in terms of opening hours, necessity of care processes, facilities etc.). To define more relevant priorities on financing of different PEO models, a preliminary cost table was developed:

Table 16: Comparison of preliminary annual budgets for different community based PEO models, KG Som Model 1 Model 2 Model 3 Full day group Half day group Two shifts groups Expense items 25 children 25 children on 25 children (total - 50) KG Som Salary 48,895 27,223 49,046 Allocations to the Social Fund 10,268 5,717 10,300 Travel allowance 30,128 30,128 30,128 Public utilities 23,867 16,391 19,195 Rent 0 0 0 Transport service 0 0 0 Other service purchase 190,725 32,025 38,400 Other current costs 0 0 0 Sub-Total Recurrent costs 303,883 111,484 147,069 Buildings and constructions 201,400 201,400 201,400 Equipment and mechanisms 334,234 152,222 152,222 Other capital assets 0 0 0 Sub Total Capital Investments 535,634 353,622 353,622 TOTAL: 839,517 465,106 500,691

455. The “full day” model is a classical kindergarten model with child nutrition. The most state PEOs are operated by this model, but in the current situation capital costs for building maintenance and equipment which is financed by local budgets are only 3.3%136 from total public spending on Pre-schools. The “Half day” model was calculated for 25 children in the group spending 3 hours in a day in PEO without child nutrition for child pre-school education development. “Two shifts” model was developed for 50 children per 25 in one shift (without nutrition) which allows involving maximum number of the children in pre-school education and care activity with minimum unit costs per child (for detailed information regarding PEO budget see annex 20).

456. In order to analyze salaries for preschool teachers in accordance with different models of PEOs, hourly wage for preschool teachers was presented in this preliminary table, as it is necessary to take into account “care” and “education” components. It is suggested in Table 17 to calculate the salary as follows:

136 Ministry of Finance, Ministry of Education

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(i.) Care component: These services are delivered by preschool teachers during the whole time in which the child is in the kindergarten; it includes caring about the child’s safety, behavior, hygiene etc. To make easier calculations for different alternative models, costs for caring were estimated on the basis of working hours (4 soms137 per hour for one group of children). These costs should be covered by parents. For disadvantaged families, support from local budget should be provided. (ii.) Education component: According the basic curriculum of the State Standard, children should have 11-17 learning activities per week. The duration of the learning activity is about 15 minutes. Calculations of the costs of education activities should also include participation of the preschool teacher in stimulating free play of the children and conducting out door activitie (in general 2 activities during half a day). Payment for one “lesson” can be 6 soms. (iii.) Additionally, payment for seniority (according to tariff scale).

457. Preliminary calculation of the monthly wage fund is presented in Table 17. However such calculations require approvals of MOE and MOEF.

Table 17: Calculation of PEO wage fund, KG Som Budget line Unit Quantities Unit costs Monthly wage fund (KG Som) Full day Half day Two shifts (KG Som) Full day Half day Two shifts 25 child. 25 child. 50 child. 25 child. 25 child. 50 child.

Salary 4,075 2,269 4,087 month 1,940 1,184 2,369 1.1. Teacher Salary 1.1.1. Care component hour in a 126 63 126 4 504 252 504 month

1.1.2. Education component learning 155 113 227 6 932 680 1,361 activity (15 minutes) times in a month

1.1.3. Teacher Assistant hour in a 126 63 126 4 504 252 504 month 1.2. Administrative staff staff month 718 466 932 1.3. Junior service staff month 1,416 618 786 1.3.1. Cleaning times in a 42 21 42 8 336 168 336 month 1.3.2. Cooking days in a 21 30 630 month 1.3.3. Watching days in a 30 30 30 15 450 450 450 month

458. Figure 21 provides the comparison for average unit cost per child in a year for different models of community based PEO. It is obvious that “Two shifts” model is more profit- able: total annual unit cost for “Two shifts” model is KGSom 10,014 (including: current unit cost - KGSom 2,941 and capital unit cost - KGSom 7,072) in compare with KGSom 33,581 for “Full day” model and KGSom 18,604 for “Half day” model.138

137 This rate is taken approximately. Real normative should be developed very careful with assistance of experts. 138 This calculation has been reviewed by Corazon Posadas – Int. Economist

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Figure 21: Average annual unit costs per child for different models of PEO

40,000 Capital Unit Costs 35,000 Recurrent Unit Costs 30,000

25,000 21,425 20,000

KG Som KG 15,000 14,145 10,000 206 7,072 5,000 12,155 6,050 4,459 2,941 0 Existing State Full day Half day Two shifts PEO (2005) PEO Models

459. Detailed information regarding unit costs is presented in Table 18. The unit costs for preschool education in 2005 were KGSom 6,256 (inclusive of private contributions) This is mostly recurrent unit cost, capital unit costs is only around 3.3% from total costs. Calculation of the unit costs for new community PEO shows that it is possible to reduce the recurrent unit costs to KGSom 4,459 in Model 2 (Half day) and KGSom 2,941 in Model 3 (Two shifts) due to nutrition absence.

Table 18: Average annual unit costs per child for different models of PEO # Annual Unit Costs (KG Som) Budget line Existing State PEO Full day Half day Two shifts (2005) I. Recurrent Unit Costs 6,050 12,155 4,459 2,941

II. Capital Unit Costs 206 21,425 14,145 7,072

TOTAL UNIT COSTS 6,256 33,581 18,604 10,014

460. Based on the unit cost analysis it is suggested to create 1,000 community PEOs with total enrolment of 50,000 children based on “Tow shifts” model, which allows to involve additionally 10% form children 3-7 years old, per 50 children in one community PEO. This model is used in Investment plan calculation. Based on the above calculations, Model 2 will be the most cost-effective option. However, based on practice Model 1 will be the most feasible option, since most mothers would be working full day. In order to count salaries for preschool teachers in accordance with different models of PEOs, hourly wage for preschool teachers was presented in this preliminary table, as it is necessary to take into account “care” and “education” components. However such calculations should be developed and approved by MOE and MOEF.

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Suggestions

461. Expenditures in the field of PEOs should be more efficient and more equally distributed between oblast and state and alternative PEOS. Existing data (costs per child in PEO, overall costs, parent contribution) do not show a clear picture about the real costs within the PEOs. To improve (in terms of high return on investment) the general educational budget situation (on the basis of a GDP percentage) in the field of preschool education, the following steps are necessary:

(i.) including data about existing “alternative PEOs” into existing databases and statistics (ii.) creating a normative comparable cost model for the entire Kyrgyz Republic (iii.) performing model-calculations for all models of PEOs (home or community based; full or half day) in the framework of the future financing of the preschool system

462. This normative cost model should be based on:

(i.) An analysis and definition of “education” and “care”-related processes in accordance with the forms and profiles of the PEOs (half day, full day). Follow- ing the example of current initiatives with respect to schools (the Govern- ment’s regulation “on minimal standards of budget financing of educational establishments in the Kyrgyz Republic”) a normative cost model for PEOs will have to be established. Pressure on the AO is to be avoided. (ii.) A clear definition of cost factors (salaries, operating costs, maintenance, equipment, food) and cost responsibilities (state contribution, AO, parents) taking also into account the different forms or profiles of PEOs (full day, half day, including nutrition), but also e.g. medical services in the PEO (nurses) or supportive services e.g. by FAPs).

463. As the Double Budget might delegate financing of PEOs to AOs, including state kindergartens, there is a big need that AOs are provided with the necessary budget and financing tools. (e.g. a set of rules how to create budgets for PEOs). With the continuous budget problems of AO, there is a risk that services will decline again since the PEO systems will depend only on AOs.

464. Costs of PEOs and stakeholders’ contributions throughout the Kyrgyz Republic (State, AO, parents, others) show a high diversity. Costs per child at the existing state-based kindergarten systems, are substantially higher compared to the school system. Financial efficiency of preschool system should be increased to provide quality and sustainability of alternative models of PEOs.

465. To reduce costs and to increase the number of involved children the main strategy should be to promote half day and/or 2 shift models. However - if relevant - the needs of parents regarding the time of enrollment (e.g. full day employment of mothers) also have to be considered. Therefore future models should ensure a high extent of flexibility (e.g. in terms of mixed groups): some children might attend PEO only in the morning; others in the afternoon, in single cases (solving the issue of nutrition at noon) children might stay the whole day.

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D. Accreditation, Attestation and Licensing

466. Activities of non-governmental educational organizations are regulated within article #25 “Aspects of licensing of educational activity” of the Regulations “on licensing of business activity” (approved by Government 2001) under the existing Law “on Licensing of non- governmental organizations” (1997). According to the Kyrgyz Law on Education139 licensing is the permission given to educational organizations for carrying out educational activities with the purpose to ensure that the quality of education is up to the demands of the state standards.

467. The application process to establish a PEO is centralized. Necessary documents (descriptions of the organization’s structure, material base in terms of necessary stimulation material, staff, certificates from sanitary and fire-safety station, budget and document on ownership) are directly submitted to the department on licensing at the Ministry of Education. Be- fore that, according to the regulation for typical PEOs (full-day, established during Soviet time) (No. 376/1, 1997) preschool establishments should be registered by the “relevant body of justice” and present necessary documents.

468. State kindergartens or establishments do not need to go through the formal procedure of licensing as they are established under local authority following local instructions or rules, which unfortunately were not available. However, the process of establishing a state kindergarten is regulated by local authorities’ regulations and instructions, which also require presentation of obligatory documents including descriptions of organization’s structure, material base, staff certificates as well as certificates from sanitary and fire-safety station etc.

469. According to the Law on Education (2003) accreditation/attestation is the recognition of the status of educational organization or educational program. State Accreditation is given by a state accreditation organization. The Law differentiates between Institutional Accredita- tion (confirmation of the status of an educational organization by an accreditation organization) and Program Accreditation, which is the confirmation of the correspondence of an educational program to the state or other educational standards140. According to information received from the MOE, there are guidelines how to implement educational activities; unfortunately this document is not available. To obtain the right to issue educational certificates, an accreditation or attestation process centralized with the MOE and one of its commissions has to be undergone This attestation process (even though the difference between accreditation and attestation is not clearly defined) also applies to PEOs since they provide similar documents (on health or vaccination) for each child attending a PEO. The MOE has stated, however, that such procedures can also be assumed by the oblast education department for preschool inspection.

139 Law on Education (2003), chapter 1, general regulations, Article 1: Main terms 140 Ibid.

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Figure 22: Attestation/accreditation: State PEO

IV Official status of state PEO III Attestation/accreditation II by MOE’s commission (Bishkek) Preparation of documents together with local authority (ownership, commission etc.)

I Initiative for establishing under local authority

Note: developed by TA for the SCBECDP (2007)

Figure 23: Licensing: Non-state PEOs

Official status of private II PEO Preparation of documents for MOE’s licensing department and licensing procedures I (Bishkek) Initiative for establishing Note: developed by TA-CBECDP (2007)

470. Current legislation on licensing in the educational field does not distinguish between different forms of PEOs, as these alternative forms of kindergartens (until January 14, 2007) were not legalized. All public educational services have to follow the standards executed by the MOE. Current alternative forms could not be attested or licensed because of their problematic legal status (private or state) and the problem of their compliance with requirements established during the soviet times for state full day kindergartens.

471. According to MOE’s comments, a new draft of the “Regulation on Licensing of Educa- tional Activity” (which includes all educational facilities and institutions) is being developed, in which community based establishments are not represented. This document shows substantial differences in comparison with previous regulations and it is still under discussion at the MOE.

Suggestions

472. Three major aspects should be highlighted:

(i.) Norms and regulations regarding licensing/attestation/accreditation show a high complexity (legal, sanitary and program aspects) and multiple responsibilities. Generally, the system is centralized with the possibility of delegation towards oblast and partly AO level, even though the procedures are not clearly defined. There is a danger of decreasing efficiency since it is not clear which body is responsible for the concrete procedures. Therefore, current efforts to establish and license community based kindergartens are not systematic.

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(ii.) The system of licensing – due to centralized processes and logistic/transport problems in terms of “on site-inspections” could be time consuming. On the other hand decentralized bodies might not always have the know how to assess the required quality or standards of PEOs. In this case, the delegated regional educational department should be trained and have the necessary adopted monitoring tools and instructions adapted to alternative models.

473. Application of “alternative” PEOs, if they are not established by the local authority, will require a decentralized system of attestation/licensing including also basic requirements of the state kindergartens (hygiene and safety). It is thus necessary to:

(i.) Create a decentralized board (including e.g. parent representative, raion/oblast educational department, AO, health and safety specialist) which are able to deliver “licenses” to alternative forms of PEOs by using an administrative shortcut. (ii.) Define criteria for alternative PEOs, as they might not have to meet all criteria as state kindergartens (e.g. if they are working on a half- or seasonal -basis or home based). (iii.) Provide in depth training of all relevant decentralized stakeholders regarding “licensing processes”. To do so, it is necessary to clearly define the different alternative forms of PEOs (full day, half day, full day care services, mobile services, multifunctional centers). (iv.) Create monitoring tools based on the State Standard and relevant regulations on safety, hygiene, developmentally appropriate environment, under consideration of the different “alternative” forms. A future attestation process therefore will require a link between the existing legislation on e.g. safety and hygiene and on specific requirements based on the definition of the alternative forms.

474. Licensing in a broader sense will also have to include issues of professional qualification, equipment and pedagogical concepts since the new state standards in this context offer new perspectives (e.g. with respect to person centred approaches).

475. Existing community based PEOs are not yet included in the official attestation/accreditation systems. Most community based PEOs work in a kind of legal “grey zone”. In addition, non-governmental education services are required to undergo centralized procedures of licensing at the MOE (Bishkek). This centralized process might make licensing difficult e.g. for community based PEOs in remote rural areas.

E. Assessment of Different Preschool Program Models

476. Within the Kyrgyz Republic, several preschool program models are identified, even if (theoretically) most of them should fit into the State Standard based Curriculum or basic program (with the exception of the mother schools). The table below shows an overview of the applied models:

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Table 19: Overview of Preschool Models

Age Health com- Nutrition Manage- Financing Model Duration Program Group size range ponent component ment State 0,6-7 Full day Basic program 25 (official) Nurse is pre- Yes State State Kindergarten (rarely In reality 40 sent Parent con- 1.5-7) +possible sup- and more tribution for plementary offers nutrition Resource 3-7 Full day Basic program 25 (official) Nurse is pre- Yes State State kindergarten Knowledge trans- In reality 40 sent Parent con- (state kin- fer to community and more tribution for dergarten) based kindergar- nutrition ten Methodological help Community 3-7 flexible Mostly not submit- 25-30 absent Supported Community Parents based kin- ted partly by par- based AO dergarten of ents and Other (in- the Merci Corp come gener- FCBECDP ated) Home based 5-7 Part-time Individual Home Up to 10 absent Supported Parents kindergarten (lessons) Program partly by par- AO ents Other (income gener- ated) Aga Khan 3-7 Full day, Adopted base 30-35 No informa- No informa- Community Parents half day program tion available tion available based AO Waldorf Kin- 3-7 Full day International Wal- 25 absent Yes private private dergarten dorf program Mother Differ- Lessons Mother school 20 absent absent State Parents school ent age few times a program week (under state kindergarten) Special kin- 3-7 Full day Special program 25 Nurse is pre- Yes State State dergarten according to type sent Parent con- of disability tribution for nutrition

477. The preschool education system is presented mostly by traditional full-day state kindergartens, which have to base their work on curriculums not yet adapted to the new State Standard. Alternative models of PEOs have no clear descriptions and regulations (profiles) according to their specific forms of work and curriculums. They organize their work according to available methodical materials. According to international experience, evaluation of the quality and effectiveness of educational organization’s work include aspects such as concept, process, result, etc., which are presented below in relation to existing PEOs

478. Concept: With the exception of “authorial” programs (including in this context “Step by Step, Waldorf or Mother School), all concepts have to fit into the basic program or have to be approved by the Kyrgyz Academy. It is not yet clear on which conceptual grounds recently established alternative community based forms are working since most of them did not undergo the licensing or monitoring processes. Most of them will be based on former Soviet experience. However, new state standards will allow some kind of variation of the program. As concrete steps of implementation are still pending, this issue remains open. Evaluation shows that services for children under 3 years are rare.

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479. Structural parameters include:

(i.) Opening hours, number and qualification of staff, working contracts and salaries (ii.) The physical structure of the PEOs including equipment and buildings

480. As most models – based on the experience and preference of the parents – represent “full day models”, till now structural issues generally focus on the number of beds available. The qualification of the teachers especially in community based PEOs was not relevant. Also regarding availability of material, quality of food, heating, size of the groups the gap between urban and rural areas is considerable (see above). Clear monitoring regulations are often missing. Especially community based kindergartens show a lack of clear regulations with respect to structural issues (e.g. does a half day kindergarten need beds or meals?).. Within the household survey, parents assessed the quality of the buildings as at least “poor” by 62.5% of the parents (39).

F. Training and Qualification

1. Norms and Regulations on Basic Training of the Preschool Teachers

481. By the end of 2005, there were 3.6 thousands preschool teachers, with 53% having a higher education, 35 % with specialized secondary education (vocational school), and 5% with secondary education. However, MOE have general data on the education level of preschool teachers, without a clear reference to preschool pedagogy. Preschool teachers can follow an education as school teachers and take what is necessary for them to know in preschool pedagogy. Under these circumstances, in-service training has a very big importance (see below). However, research data of “Preparation of personnel on social work in the Kyr- gyz Republic” (2006)141 show that the percentage of current social workers who have a specific professional education in the field is not more than 7.8%. Most social workers have another educational background (book-keepers, engineers etc.). About 95.9% did not follow a re-training course. As a consequence, about 86.5% of respondents pointed out difficulties in their work because of lack of professional skills and knowledge.

482. The basic teacher training is performed at the Kyrgyz State University within the field of Higher Education and according to a defined curriculum. The preparation of teachers focuses on the provision of basic skills and knowledge on preschool education. The official de- nomination of the profession is “methodologist in preschool education”.

483. The Curriculum for the preparation of students is developed according to a revised Soviet pedagogic handbook. Available literature mostly comes from Russia. Some materials are provided by international organizations working in cooperation with this University (UNI- CEF, Step by Step etc.). A comparative curriculum analysis indicates that the curriculum is primarily theory based (around 70% of the contents) and focuses less on methodological- didactical issues. Since the new state standards define the competences of the professionals, there will be a need to adapt the current professional training curriculum to the requirements of the new standards.

141 Secretariat of the State Program “New generation” on children rights implementation and Kyrgyz Academy of Education (with support of Unicef), 2006. Preparation of personnel on social work in the Kyrgyz Republic

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484. Concerning other institutions of professional education (faculties on preschool education at regional universities and colleges), available data indicate that due to the low number of students (connected with the observed lack of kindergartens) most courses are not running. Following the successful completion of grade 9, students may go for a secondary vocational education. Most vocational schools are situated in the oblast centers and designed to prepare primary school teachers. The difference between curriculums of vocational and higher education is that vocational schools follow a more practical approach including subjects learnt during educational work in internships. Students of vocational schools are conferred the title “preschool teacher” only in Bishkek in comparison with university students (“methodologist in preschool education”).

2. Norms and Regulations on Teachers’ Continuous Training

485. There is a 3-years refresher system for active kindergarten teachers. Courses for teachers are offered by the Kyrgyz Academy of Education (once every three years). Offi- cially, three categories of preschool teachers are trained separately: teachers, directors of kindergartens and methodologists. Participants are categorized by their degree in studies (higher and secondary-specialized education). However, in reality this differentiation might not be possible because of financial and logistic difficulties. The refresher system was worked out during Soviet times to cover all teachers in the oblast one by one within programs reoccurring every 3 years. Transport issues (especially the cost factor) and absence of support mechanisms for community teachers are serious obstacles to reach the goals defined by the refresher system.

486. Even though the Kyrgyz Academy of Education is doing a lot to create adequate material – both for teachers and children – the methods used are largely based on post Soviet approaches. This is specifically true for the time scheduled to be reserved for each child and the efforts put into school preparation classes. A discussion process will be needed to find an answer to the question of how and to which extent an individual centered portfolio approach could be integrated into the current work of the Kyrgyz Academy.

487. Especially in the light of the new State Standards, both basic training (Kyrgyz State University) and further education (Kyrgyz Academy of Education) should follow concerted actions, including the regional level (Institutes of Teachers’ Qualification). At the regional level, Institutes of Teachers’ Qualification (Karakol city in Issyk oblast and Osh city in Osh oblast) are responsible for re-training of preschool teachers in the northern and southern regions.

488. On the operative PEO level (“Typical Regulation on PEO”, 1997), a pedagogical council within the PEO should evaluate the needs for participation of preschool teachers in qualification courses. However, the practical implementation of this refresher system is limited by pending cost factors (e.g. to cover transport costs and per diem).

489. Raion and oblast educational departments are responsible for the monitoring of the qualification of the preschool teachers. This is mainly based on the process of data collecting within an annual work schedule. Available data do not show clear rules regarding this monitoring process. Generally, the training situation is “in danger”. As it was pointed out, information is rarely accessible due to logistical problems. Basic training focuses primarily on theoretical issues. Students do not experience real working conditions in e.g. rural kindergartens.

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490. In-service training in a state kindergarten is generally regulated within a 3 years programme in which professionals are obliged to pass a series of courses. The local educational departments are collecting data on this issue. Two ways allow the access to work as a “teacher” in the field of a “state” kindergarten: (a) via the vocational school system (through a secondary education); (b) via university (through a tertiary education). Trainings are organized either by the Institute on Teachers’ Qualification or by Kyrgyz Academy of Education (KAE) or by donors or NGOs. However, two aspects have to be highlighted: The concrete in- service training (i) depends to a high extent on available resources (transport costs.) and (ii) is primarily based on former Soviet books and programs. There is a tremendous shortage in modern materials for preschool teachers in Kyrgyz language and books or materials in general. Resource training centers face similar challenges in terms of sustainability: only as long as international organizations finance and organize trainings or re-trainings, the systems work.

Figure 24: In-Service Training:

STATE PEO Community based kindergarten

Kyrgyz Academy of Educa- Institutes of Teacher’s Qualification Resource centers under external sup- tion (Bishkek) (Osh, Karakol) port (CBECDP, UNICEF, AGA Khan)

In-service training In-service training Monitoring by Educational De- X partment Field work Field work

Vocational school (Bish- University (Bish- X Without basic training (some cases) kek) kek)

Basic training (during So- Basic training viet time)

491. Resource training centers have been created by AKF, Step by Step, and UNICEF. AKF supported a resource center at the Teachers’ Institute in Osh and finances training and re-training of the preschool teachers of pilot kindergartens (transport costs, per diem, and salary for trainers who are lecturers of this Institute). UNICEF organized resource kindergartens in Batken, also with the purpose to conduct training and re-training programs for preschool teachers of pilot kindergartens. UNICEF covers the costs for the participation in the training and finances activities of a team of trainers from Bishkek (NGO-base with lecturers from the Arabaev State University) which organizes cycle trainings for preschool teachers of pilot kindergartens.

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492. Work of the Step by Step program was directed towards the institutionalization of training-centers. They were created based on model state kindergartens in oblast centers. Local trainers were trained. Eleven training centers throughout the country now offer their services, but training needs to be paid. The FCBECDP also conducted trainings of preschool teachers of community based kindergartens. Representatives from regional educational departments and resource kindergartens were involved in trainings to prepare them for future training activities. In-service training activities in the field of state PEOs are functioning, but the monitoring process of the educational departments remain unclear. Furthermore, training contents and training methods (with the exception of donors’ activities) still follow the former Soviet tradition. Future standards and regulations will have to include the issue of in-service training and monitoring, both for state PEOs and community based PEOs. In addition, basic professional requirements for alternative PEOs will have to be defined.

Suggestions

493. Improvement of pre-service and in-service training demands organization of access to training service at the local level. Curriculums of training institutions should be reconsidered according new State Standard’s requirements and international experience (70% practice in preschools for students).

494. Financing issues might be taken into account within local budget planning to support regular opportunity for in-service training. External support seems to be necessary for organization of necessary educational materials, introducing with international experience and training of trainers on the local level to provide access to training service (involving Institutes of Teachers’ Qualification, available training centers and resource kindergartens).

495. Major recommendations related to teachers’ continuing training are summarized as follows:

(i.) Incorporation of necessary professional competences described in the new State Standards in the basic training curriculum of the Kyrgyz State University. (ii.) Adjustment of the methodologies used in the teachers retraining by the Kyrgyz Academy of Education to individualized portfolios. (iii.) Cascade training models within the scope of “refresher training”: KAE-> Insti- tutes of Teachers’ Qualification -> Resource Kindergarten -> community- based kindergarten (iv.) Creation of a financial model for refresher training programs (v.) Collection of data about the staff for the monitoring structures in order to strengthen the monitoring system for retraining

496. As pointed out in previous chapters of this analysis, fluctuation of professionals is high; no empirical data on staff changes are available. The performance of the preschool teachers – based on the data of the household survey – requires improvement. However, major differences could be observed e.g. between state kindergartens and community based kindergartens, and also between urban and rural areas. An incentive system for kindergarten teachers to work in rural areas and an obligatory internship system for students to work at least some time in a rural community based kindergarten should be established. However, costs factors might be inhibiting. The training of the kindergarten teachers should not be privatized. As education is a crucial part in all democracies, training or re-training of educators should follow a state monitored process.

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497. The Basic curriculum represents a complex of specifications concerning the structure and the content of preschool care and education. The Basic curriculum reflects: (1) correlation between basic and variative part of preschool education, (2) duration of activities and weekly load for educational activity. These normatives are established in compliance with the age and physiological characteristics of child development.

498. The Basic Curriculum for PEO meets the goals and objectives of preschool education and care, specified in the Concept of preschool education system development. Within the framework of alternative models of preschool education, and also in conditions of insufficient professional and financial resources, the Basic Curriculum can be used in a flexible way of the integrated occupations when various themes/subjects can be incorporated in one occu- pation for an all-around development of the child is provided.142

499. The new State Standard of the Kyrgyz Republic on “Preschool Education and Child care” includes the above mentioned structured curriculum for different age groups, children with special needs being also targeted. This curriculum defines contents and quantities (units per week) for different age groups. It includes different areas of knowledge and skills:

(i.) Environmental education (ii.) Language development (iii.) Reading and writing (iv.) Numeracy (v.) Designing (vi.) Fiction (Literature) (vii.) Music (viii.) Physical education (ix.) Modeling (x.) Drawing (xi.) Kyrgyz Language/Russian Language

500. In addition to this regulation for teachers concerning compulsory subjects and quantities (units/week), the State Standard also introduces the concept of a person centered individualized “portfolio”143. This simultaneous presence of two concepts, which actually represent the two poles of methodological approaches in PEOs (individual approach versus a set of predefined school preparation indicators to be reached by the child), reflects the transition from quantity based models (how many children reached target parameters after PEO) ) towards the more individualized open models enabling individual learning experience and focusing much more on educational plans and learning competences (learn to learn) rather than on learning contents. With this latter, the PEO is an autonomous area of pedagogical activities, clearly distinguished from a PEO using the curriculum centered quantitative models preparing for school.

501. The two models are closely connected with the existing socio-economic developments; the basic perceptions on childhood and socialization will need to be reflected and discussed in a scientific dialogue. However, especially for kindergarten teachers, working in the field and being socialized in former systems, this new person centered approach is likely to be a challenge since it requires new forms of work and skills (a kindergarten teacher gives impulses, structures the environment for the child and offers support, if necessary).

142 State Standard: Preschool Education and Care of Kyrgyz Republic. 2007 143 Portfolio assessment is an effective means of evaluation that encompasses many products of the child. Portfo- lios includes observations and notes of the teacher and can be used to form a total judgment of what is needed for the child's further growth, based on daily events of the classroom, without interrupting the class day. (Lynne Milles. Portfolio assessment with preschoolers. 1994)

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502. Basic program (contents and necessary materials to implement the curriculum): Be- side the above mentioned intrinsic polarity within the curriculum, the State Standards also highlight the freedom to choose a program. Programs can be seen as the contents of the curriculum. Programs are closely connected to available materials and e.g. textbooks, both for teachers and for children.

503. These educational programs reflect the main pedagogical educational ideas; content of the work with children; ways, forms and means of implementation of the educational content and mechanism of results assessment (Source: Recommendations on additional educational programme development. Approved by order of Ministry of Education of Kyrgyz Re- public # 270/1, 2002).

504. Until January 14, PEOs had to follow a “Basic Program” designed by the Kyrgyz Academy of Education or “authors programs” in accordance with the requirements of the curriculum. Due to the modifications of the curriculum and the person centered “portfolio approach” this existing state program (that is the contents which are taught within the framework of the curriculum) are now under revision. Unfortunately, no information about the ongoing adaptation processes by the Kyrgyz Academy of Education is available.

505. Major suggestions related to the Educational Framework are:

(i.) Initiate a scientific dialogue about the basic assumptions of PEO-philosophy: Create a strategy within the MOE, how the MOE defines PEO in comparison to school education (ii.) Differentiate curriculum and/or program requirements regarding the different possible forms of alternative PEOs (iii.) Create concrete tools and methodological material for the personcentered (portfolio) approach (iv.) Train kindergarten teachers and responsible stakeholders (e.g. in view of creating materials and books)

506. Norms and regulations on qualification requirements and salaries: No data was available from the Ministry regarding the current professional training level of teachers in state kindergartens. Data about the qualification level of heads of the kindergartens are available. Intake and providing professional staff face the problem of access to training and high fluctuation of employed teachers because of the low salary.

507. The salary rate of state preschool teachers is based on regulations on the staff/children ratio. The staff ratio for kindergarten is defined within Government Regulation # 404 (1995), appendix #3: “Typical staff of preschool establishments”. According to this document which refers to typical kindergartens and based mostly on former Soviet rules, the staff of a kindergarten should include full day positions: director and cook; half-day: maintenance worker, laundry worker and additional staff depending on the number of groups.

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Table 20: Staff Ratio and Rate of Salary Units in Typical State Kindergartens Position Rate of salary units depending on groups quantity at the kindergarten Number of groups 1 2 3 4 5 6 7 8 9 10 11 Director of a kinder- 1* 1 1 1 1 1 1 1 1 1 1 garten Janitor - - - 0.5 1 1 1 1 1 1 1 Book-keeper - - - - 0.5 1 1 1 1 1 1 Cook 1 1.5 1.5 2 2 2 2 2 2 2 2 Maintenance worker 0.5 0.5 0.5 0.75 1 1 1 1.5 1.5 1.5 1.5 Worker for repair - - - 0.5 0.5 0.5 0.5 0.5 0.5 0.5 1 and technical work Laundry 0.5 0.5 0.5 1 1 1.5 1.5 1.5 1.5 1.5 2 Cleaner 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 *- the numbers show the rates of salary units and staff ratio based on the position and multi-typed according to quantity groups in kindergartens (e.g., rate of salary “0.5” – can be interpreted as part-time work and “2” – may mean involvement of two persons for this work).

508. The preschool teachers’ rate of salary and staff ratio is presented separately in the table below which is based on open hours:

Table 21: Staff 6 days open (per week) 5 days open (per week) Position Open hours Open hours 9 10 12 24 9 10 12 24 Nursery groups (till 3 years old) Preschool teacher 1.5* 1.67 2 3.6 1.25 1.55 2.0 3.0 Nurse 1.33 1.45 1.75 2.75 1.1 1.3 1.5 2.5 Preschool groups (from 3 years old) Preschool teacher 1.5 1.67 2 2.2 1.25 1.55 2 2 Assistant of preschool 1 1.25 1.5 1.5 1 1.15 1.25 1.5 teacher *- the numbers show the rate of salary and staff ratio based on the position and multi-typed according to quantity of open hours (e.g., rate of salary “2” – may mean involvement of two persons for this work).

Table 22: Simplified Structure of Staff:

Staff in a typical kindergarten

Per kindergarten (100%) Director of the kindergarten, cook Per kindergarten (50%) Maintenance worker, laundry worker Per group 2 kindergarten teachers 1 assistant More than 3 groups Bookkeeper, janitor, cleaning persons 6 groups Methodologist

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509. A group consists – based on the typical standards – of 30 children (from 4 years of age), the new state standards suggest 25. Groups of younger children (based on the typical regulation) have 25 children; the new state standards suggest smaller groups.

Table 23: Number of Staff per 100 Children Function Number

Director 1 Preschool teachers 8 Assistants 6 Janitor 0,5 Cook 2 Maintenance worker 0,75 Repair worker 0,5 Laundress 1 Cleaning person 0,5 Sum 20,25

510. According to the above table, at least 20 persons are working in this kindergarten for 100 children. For smaller children (less than 3 years) there is even more staff present (e.g. a nurse). Compared to other international data, the staff-children ratio is high, explaining partly the high costs of preschool education in the Kyrgyz Republic. Analysis is needed whether professional activities regarding maintenance, laundry, cooking etc. could be out-sourced.

511. Data about the concrete status and activities of the professionals in the kindergartens are necessary to assess staff-child ratio towards sustainable developments. Staff issues of state kindergartens should be analyzed in order to assess cost-effectiveness. Based on job descriptions and a possible division between “educational activities” and “care” specific job requirements should be defined. The decision making process is initiated by the working group under MOE and will be handled within the administrative regulation for the Law of Pre- school Education after expertise, planned within the national program, and inclusion of international consulting support.

512. Salaries of preschool teachers are defined according to the “Common Tariff Scale” in compliance with the existing labor legislation. This scale is made up of different categories based on the work experience in education with 23 point scale ranging from 530 to 3,180 soms (new official tariff scale of January, 2007). A preschool teacher (high education, work experience more than 20 years) would be in category 8 which would represent a salary of about 1,440 soms. Based on a possible division into “educational activities” and “care” (considered within the State Standards) and in view of alternative forms (e.g. half day operation) the salary-scheme should also be reconsidered

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513. Norms and regulations on social workers’ training and continuous education: Within the field of Early Childhood Care and Education, social workers play a crucial role, too; aspects of professional training are therefore included in the sector analysis. The necessity of a long-term strategy on the preparation and re-training of social workers with respect to children’s rights protection has been adopted by the State Program “New Generation”144 till 2010 (2001/2004). A Center on training and re-training of social workers was created under the MLSD. This body was supposed to create an educational-methodical frame to coordinate activities of educational institutions.

514. Within the state sector, training and re-training of social workers is implemented by the Institute of Social Development and Business under the MLSD, Bishkek Humanitarian University and its Institute of Continuous Education, Institute of Personnel Qualification and re-training under the Arabaev State University, Jalalabad’s, Osh’s and Batken’s State Uni- versities. Actually, re-training courses (cycle sessions during 2 years) are only possible under the Kyrgyz Academy of Education. The subjects taught refer to the overall concept of “social pedagogy” (since 2006). The basic training and further education curriculum of social workers show a lack in contents on child development and early child care.

515. Major recommendations related to training and re-training of social workers are that knowledge and skills of social workers – especially in the field of Early Childhood Develop- ment and Care – should be increased. The role of Inspectors for Child Protection (former CFCs or the FCBECDP within the newly created State Agency on Tourism, Sport, Youth Af- fairs and Child Protection under the Government is pending. Professional training requirements in this field are not defined yet.

G. Quality Management

1. Conceptual Quality

516. The current legislation in the Kyrgyz Republic regarding pedagogical concepts focus on the “curriculum” within the new State Standard. The curriculum is “filled with contents” through a series of subjects (Kyrgyz language, reading and writing, numeracy, designing etc.). Even though the new State Standard allows for “alternative programs” (e.g. using other methodological approaches like Montessori, Waldorf….) the didactical approaches observed in PEOs are still “soviet-based”, to the extent that the focus is more on school preparatory classes than on self-guided learning processes. Current international theories put a focus on social learning processes with peers and on methods enabling children to learn how to learn (Social Learning Theory, 2002; Braithwaite's Social Learning Theory, 2004; Waldorf and Montessori methodology). According to these theories, a person centered approach is more likely to empower children to learn such skills and, consequently, to better succeed in school. Since different concepts exist and alternative models are explicitly authorized by the new State Standard, a better visibility of all educational approaches should allow parents to opt for the program they prefer for their children.

144 This program also emphasizes the task to provide access to preschool education.

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2. Structural Quality

517. The assessment of the physical conditions is based on the visits and on focus groups of the national and international experts in February 2007 in Uzgen and on household survey data. The quality of the buildings is assessed as at least “poor” by 62.5% of the parents (39). Visited establishments during the focus group meetings – with increasing distance to central urban structures – showed a continuous decline in infrastructural quality (e.g. sanitary facilities, heating).

518. Especially the situation of sanitary facilities is catastrophic. Some kindergartens reported not being heated, as power generators did not work. Some kindergarten rooms were heated with small iron ovens. The physical conditions of both existing state and community based PEOs are poor. In most cases, basic repairs and improvements (roofs, heating, toi- lets) are needed. PEOs in rural areas do not have enough furniture and lack basic pedagogical material. What is available primarily comes from initiatives of preschool teachers or – in the case of community based PEOs – from parents.

519. Findings during the visits and focus groups indicate a comparable shortage in toys, equipment, books etc., specifically with respect to rural areas. Material is mostly created on the teachers’ own initiative, partly supported by the parents. “Expensive” materials and toys are locked, so that children cannot damage them. Generally, the availability of toys, didactical equipment or books is “poor”.

520. Furthermore it could be observed that community based kindergartens – compared with existing state kindergartens suffer a substantial shortage of equipment. Under FCBECDP, community based kindergartens were provided with equipment. However some community based kindergartens, which got a grant only for rehabilitation from international organizations have not enough equipment. This lack is partly compensated by initiatives of the kindergarten teachers creating their own methodological materials with the help of parents. Available literature in PEOs is primarily based on the former Soviet tradition. Interna- tional experience (e.g. in terms of internet access) at least for the resource kindergarten should be available. Due to missing data, basic qualification of professionals in community based PEOs is not likely to meet the necessary state requirements. Clear regulations and job profiles would be necessary in this context. Given the high staff fluctuation and low salaries, only about 50% of the preschool teachers have a higher education in the field of preschool education.

3. Formative Quality (the Pedagogical Process)

521. The new State Standard of the Kyrgyz Republic on “Preschool Education and Child care” includes a structured curriculum for different age groups, children with special needs being also targeted. In addition to this regulation for teachers concerning compulsory subjects and quantities (units/week), the State Standard also introduces the concept of a person centered individualized “portfolio”. This simultaneous presence of two concepts which actually represent the two poles of methodological approaches in PEOs (individual approach versus a set of predefined school preparation indicators to be reached by the child) reflects the transition from quantity-based models towards the more individualized open models of individual learning experience and focusing much more on educational plans and learning competences rather than on learning contents. With the latter, the learning field is an autonomous area of pedagogical activities, clearly distinguished from settings based on quantitative models preparing for school.

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4. Result Quality

522. The quality of PEOs till now is primarily measured by the academic achievements in school relevant areas (writing, reading, numeracy). In future person centered approaches will have to respect much more the individual and comprehensive development of the single child and not of the cohort. The quality of a PEO cannot be measured on the basis of whether the majority of children reaches certain criteria, but whether the individual child reaches his or her individual development goals. This includes also the individual stimulation of highly skilled children. It has to be highlighted, that the quality of the individual pedagogical process cannot be measured by statistical outcomes (how many children reach a certain goal), as it is done now in Kyrgyz Republic.

Table 24: Comparison between Quantitative and Individual Portfolio Approach

Quantative Approach Individual Portfolio Approach

Number of children reaching a predefined Assessment of the individual goal, respecting Result goal individual resources and needs Assessment 1 test for all children Individual assessment Strengths Statistical data Individual tailor made stimulation Tendency, that highly skilled children are Reduced statistical comparability Weakness not identified by these data

5. Quality Monitoring

523. For state PEOs, quality monitoring is implemented by educational departments. Cur- rently, their tools are focused more on parameters of preparation for school. Adequate monitoring instruments (e.g. for structural requirements) need to be developed in conformity with the State Standard, which includes aspects of environment, curriculum, pedagogical process, qualification, family and community involvement as well as indicators of children development. Moreover, quality management now cannot cover alternative PEOs, since normative regulations have to be developed, including instructions and criteria with respect to different alternative forms.

F. Capacity Building

524. The development of the preschool education system and the implementation of the State Standard depend on a high extent on community mobilization and cooperation with the local authorities, mainly on motivated, skilled key persons. In the field of preschool education, mostly former kindergarten teachers or specifically skilled professionals in the social and the medical field show these capacities. Of course, infrastructural issues (such as transport, bad conditions of premises) have to be taken into account, too, when it comes to defining the type of service required (full day versus half day service).

525. Pending questions of financing represent a big threat to sustainable structures. Based on models which are likely to be realized (e.g. pursuant to the Law on Preschool Education providing for equal access of children to PEOs) communities – in order to be part of empowerment processes - require concrete (project management) skills and information concerning education and care.Especially the close cooperation between donors (e.g. activities of ARIS) is necessary to provide sustainable structures in the field of PEOs.

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526. The ARIS project is directed towards a general community support to implement any social community project according to the needs and decision making processes of the community, including the repair of kindergartens.

527. The policy of the WB’s projects include the following strong components: bottom-up approach, mechanisms of complex approach by key ayl assembly (Kenesh), work related to the needs of different target groups, village profile development, community based decision- making processes and cooperation with local authorities, territorial community authority (juridical public association) connected with ayl parliament. Policy includes transparency and audits.

528. Sustainability of community mechanisms after the activities carried out by the project support is seen as a challenge. Competition between leaders of AOs and stakeholders (highlighting the “personal factor”) and fluctuation of professionals in AO are the factors which create some threats for future work.

H. Donors’ Activity

529. The sector is characterized by the fact, that state structures (e.g. raion or oblast educational department) are partly delegating services to International organizations, funds and NGOs. A complex landscape of activities thus run the risk to be too focused (e.g. in the southern provinces of the Kyrgyz Republic) or to be overlapping. This sector is characterized by joint implementation of legal norms. On the other hand operative work is constrained due to the practical non-availability of documents, norms or regulations145.

ADB Amount: $10, 500,000 for CBECDP, and $500,000 for technical assistance Coverage: 12 raions in Jalalabad, Osh and Naryn oblasts

530. The FCBECD project, under the President’s Office, implements an integrative policy in ECD (social mobilization, health, PEO implementationIn relation to the education component, activities such as preschool teachers’ training, parents’ training, IEC on ECD and establishing kindergartens are carried out. Kindergartens are rehabilitated with support from the Village Initiative Fund, and didactical equipment, educational materials, and furniture is purchased. Activities cover Nook at, Alai, Chorale, Kara-Kilda raions in Osh oblast; Toktogul, Chatkal, Toguztoro raions in Jalalabad oblast and whole Naryn oblast. The strengths of the project is its integrative approach: community mobilization and parent training connecting health, education, care and nutrition, application of alternative models of preschool education, close work with the MOE.

531. The advisory technical assistance for Strengthening Institutions for Community-Based Early Childhood Development has assisted MOE in developing the preschool concept, preschool standards, and training modules for community-based preschool teachers, state kindergarten teachers, parent’s education.

145 See annex 12a for a complete overview on donor activities in ECD including ECCE.

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UNICEF Amount: $ 250.000 (2007) Coverage: new residential district in Bishkek, whole Batken oblast (since 2007), 1 raion in Talas oblast

532. According to information presented by UNICEF, during the last year, 3 resource kindergartens, 1 preschool class and 5 community based kindergartens were established within Batken raion; in 2007 they will start to cover whole Batken oblast. Besides that, training of preschool teachers, consultations for parents, advocacy of ECD was organized. UNICEF provides for play equipment, furniture, and educational materials. These are its main activities in the field of ECD. Thus, target groups include children, teachers, parents, community and key administrative groups within Bishkek, Talas and Batken oblast. A recent joint IEC strategy with the FCBECD project (television program) on the awareness and knowledge of parents on early development and care reflects the cooperation between the donors.

533. Community mobilization and communication are strong components of UNICEF policy. According to lessons learnt, advocacy on ECD for local authority and increasing knowledge, attitudes and practice on ECD among parents (including different pathways of communication, e.g. TV,) are new strategies. The lack of a real (easy understandable) normative base on community based kindergartens and alternative forms are pointed out as a big challenge.

World Bank: ARIS project Amount: $ 15.5 millions (for community grants) Coverage: whole republic* *see capacity building 526-528

Aga Khan Fund Amount: N.A. Coverage: Alai and Chonalai raions in Osh oblast

534. The Aga Khan Fund works in close collaboration with oblast and raion education departments in Osh, oblast and raion administration and AO. Cooperating with the community, Aga Khan initiates mobilization to create Village Organization. Cooperating with Osh Institute of Teacher’s Qualification and resource centers, Aga Khan conducts preschool and primary school teachers’ trainings, trainings for parents, workshops for women’s groups; local seminars in the kindergartens to exchange experience; seminars for local government administrations; advocacy of ECD. They also work out teachers’ guidelines, organize preschool groups and develop curriculums, educational materials and children’s books (in Kyrgyz). The Fund supports renovation and construction of kindergartens; furniture (including beds), kitchen equipment, play equipment, teaching-learning materials; classroom equipment, educational equipment, office costs, libraries organization (preschool, school age), advocacy on ECD through Mass Media.

535. Big achievements have been identified with respect to the institutionalization of 21 branches of kindergartens which are now financed by the local budget. New alternative forms will be implemented this year e.g. mobile kindergartens for children, joining their parents at the pasture (jailoo) in the mountains. The lack of a normative base is seen as a threat, as educational departments showed some reluctance to integrate alternative models of preschool education within local budgets and parents had to cover all costs. Extensive parents’ contribution – due to their difficult financial situation – is a threat to sustainability.

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Public Foundation “Step by Step” Amount: N.A. Coverage: Chui, Osh, Jalalabad, Issykkul oblasts’centers

536. “Step by Step” focuses their activities on preschool teachers’ (re-)training, special courses for students within higher education, parent education programs, ECD community centers (initiative groups and resource kindergartens). Specialists of the fund adopt curriculums and develop educational materials (in Kyrgyz). The foundation has training and resource centers in Osh, Jalalabad, Naryn, Talas, Issyk-Kul, Chui and Batken oblasts with involvement of local kindergartens, schools, universities and Institutes of Teachers’ Qualifica- tion. Services should be paid,since the Foundation has a “self-financing” status now.

537. A state of the art approach – providing a program on preschool education, methodical material and monitoring structures are strengths of this organization. However, Step by Steps provide trainings which the trainees are asked to pay.

Mercy Corp Amount: $2.55 millions Coverage: whole republic

538. Mercy Corp provides food for preschools (oil, rice, flour), but also supports the repair of buildings and furniture in the entire country. The training component includes training of kindergarten teachers on monitoring for food consumption.

539. Strengths of Mercy Corp include community involvement, the methods of transparency (available information on all costs and project budget for community), organization of steering committee providing feedback and recommendations for kindergartens. They have a nutrition training module for preschool teachers and conduct trainings in the kindergartens which got a grant. Obstacles are noticed in relation to low mobilization and sustainability. The future work is also threatened by relatively high community contributions (40-50%), by a lack of local specialists on the repair and reconstructing and fluctuation of professionals in PEOs (including the necessity to train new teachers on issues of nutrition). Mercy Corp plans to promote sustainability through economic projects in terms of income generating activities (business and micro credits).

Save the children (UK) Amount: N.A. Coverage: Osh (Nookat, Uzgen), Jalalabad (Bazar-Korgon, Nauken), Naryn (Naryn city, Atbashi), Chui (Shopokovo, Tokmok), Talas (Baka-ata), Issyk-Kul (Karakol city)

540. In the framework of ECD, Save the Children UK focuses on inclusive education of children with special needs. Save the Children UK conducts teachers’ training, consultations for parents and advocacy of ECD. Specialists work out teachers’ guidelines, curriculums, educational materials and children books (in Kyrgyz). Funds support the publication of educational materials. The activity areas include Nookat and Uzgen raions in Osh oblast; Bazar- Korgon and Nauken raions in Jalalabad oblast; Naryn city and Atbashi raion in Naryn; Sho- pokovo and Tokmok in Chui: Baka-ata in Talas; Karakol in Issyk-Kul. 541.

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542. Strengths are recognized in the field of support of preschool education in rural areas, involving teachers to coordinate all relevant patterns and support of the community to organize business. According to work experience Save the Children (UK) will take into account for future work that the community should be more involved within planning and implementation processes; furthermore mechanisms of monitoring should be developed, which should be implemented by participants of the project themselves (including exchange of experience). Low mobilization of parents and low salaries of the teachers are seen as risks for the future work.

Save the Children (Denmark) Amount: N.A. Coverage: Naryn (Jumgal), Issyk-Kul (Jeti-Ogus), Chui oblast, Jalalabad city, Osh (Osh city and Aravan)

543. ECD issues are covered by training professionals of the Department on Family and Children Support, training of social workers, teachers in state kindergartens, (foster) parents, staff of day care centers and professionals of family resource centers. Save the Children worked out guidelines for teachers and seminar materials. Besides that there is support for construction or the repair of buildings, purchase of building, furniture, sanitary engineering, wheelchairs, educational materials etc. Material support is provided only if sustainability is assured by local budget. Save the Children (Denmark) shows a strong policy component including establishing of PEOs, support and strong interest of parents. Due to easy accessibility of PEOs, parents have close contact to their children and their development. The following problems need to be mentioned: mistrust of donors because of political destabilization, fluctuation of workers because of low salary, fluctuation of heads of local authorities.

Every Child Amount: N.A Coverage: Osh oblast, Talas oblast, 1 children's home in Chui oblast and 1 children's home in Jalalabad

544. Every Child focuses its activities on the social support and work with vulnerable families and children at risk. Training activities are directed towards social workers, teachers of special schools for children without parents. Material support includes furniture or equipment for children homes, publication of methodic materials for social workers, single financial support for families re-integrating children form orphanages, micro credits for families. Areas of activities include Nookat raion in Osh oblast, Talas oblast, children homes in Jalalabad and Chui. Activities with at-risk families are recognized as strengths of “Every Childs” policy. De- pendence of community and social workers on external support, lack of a normative base and passivity of state officials are seen as serious obstacles.

Child Rehabilitation Center «Umut-Nadejda» Umut-Nadejda conducts training seminars on medical pedagogy for preschool and school teachers, professionals of state and non-government establishments, parents, in close cooperation with UNESCO, Bread for World, UNICEF etc. Specialists develop curriculums for teachers (preschool and school), curriculum for integrative schools and preschools and professional preparation of young persons with special needs. Activities are carried out in Bish- kek, Alamedin raion of Chui oblast, village Ornok in Issyk-Kul oblast.

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Center of alternative humanitarian pedagogy 545. This center implements workshops and consultation on Waldorf pedagogy in Central Asia. A resource center in Bishkek supports alternative curriculum development on preschool and school education and innovation methodical approaches for teachers’ qualification.

I. Summary Overview on Major Problems Related to ECCE

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National Im- Low socio-economic status Limited intellectual potential pacts

Consequent Low developmental parameters Poor school achievements Impacts

Key Insufficient ECCE Sector Problem

Low quality of ECCE Limited access to PEOs Lack of knowledge and Lack of capacity of commu- Bad nutrition and Deficient in PEOs skills on ECCE in family nity on ECCE health condition Sector Outputs

Lack/ obsolete Low number of alternative Absence of sustainable knowledge on ECCE models of PEOs local structure on capacity of professionals building and IEC on ECCE Limited number state of the Lack of quality man- PEO’s agement Lack of access to ECCE Improper physical condition information materials and Obsolete educational of the facility leading to not methodological materials materials, approach functioning

Lack of learning and Financial difficulties in family play equipment to pay for preschool services

Bad physical condi- Lack of knowledge on how to tions of state PEOs establish PEOs

Lack of access to pre- and in-service training in raions

Sector Inputs Centralized attestation/licensing Insufficient financing system Insufficient coordination on ECCE Dependence on donors support

Imperfect legal base on preschool education and ECCE and lack of Policies comprehensive strategy on ECCE

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J. Strategy to Improve ECCE

1. Goals and Objectives related to ECCE in the Kyrgyz Republic

546. According to the analysis of the problems provided above, the two overall objectives related to the improvement of ECCE in the Kyrgyz Republic should be:

(i) To improve the preschool education system and promote the access to high quality preschool education (ii) To support the development of children in their family environment through strengthening knowledge and skills of caregivers and the community on ECCE.

547. The quantified targets with regard to these objectives are:

(i.) To increase the coverage of children by preschools by 10% (ii.) To increase the number of parents with improved parents skills by 10 % (5% by training seminars (mainly mothers n=27.000), another 5% (fathers and other members of the family) by transfer of skills and knowledge into daily life and specifically 5000 fathers by specific trainings.146 (iii.) To increase the number of trained preschool teachers by 40%147

548. The outputs related to the improvement of the preschool education system and the promotion of access to high quality preschool education (objective 1) are:

549. The outputs related to strengthening knowledge and skills of families and communities with regard to ECCE (objective 2) are:

(i.) Empowering parents (ii.) Establishing PEOs (iii.) Mobilizing Communities and (iv.) Implementing of Information, Education, Communication (IEC) component

550. The following figure provides an overview over the suggested ECCE strategy:

146 About 540.000 parents of preschool children in the country. 147 Total number of the preschool teachers in the Kyrgyz Republic is 2.388. 1000 preschools to be opened with two groups and two teachers for one group according present regulation.

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Figure 25: General Strategy on ECCE

ECCE-strategy

To support the development of children To promote access to PEOs

Objective 2: Objective 1 Capacity building Improvement of preschool educa- (Knowledge, skills and practice of tion ECCE in family and community) system

PEOs Normative bases Parent Em- (State Standard) powerment Parents

Attestation/licensing Community Monitoring AO mobilization Law on Preschool and establi- Project devel- partments Education shing PEOs opment de- Educational Village committee Village committee Financing Financial support for alternative PEOs Training (basic and in- service)

Quality management IEC

Donors Ministry of Education Other stakeholders

551. To reach the above mentioned objectives and outputs, all key stakeholders, including government structures, donors, local authorities and the community need to be involved. MOE has the main responsibility for improving the preschool education system and should therefore play a coordinating role in the multi-sectoral interrelationship on ECCE issues. Other stakeholders should assist MOE in decision-making processes and support activities on ECCE development.

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2. Plan of Action for Achieving Objective 1

Output 1: To improve the policy and normative regulations on preschool education

552. In 2007, following the State Standard’s approval, MOE already started a process of developing the normative base for ECCE. The main focus of this work is (i) the development of a new normative base in relation to alternative models of preschool education, and (ii) the improvement of the regulations in relation to state kindergartens.

553. Normative regulations regarding PEOs stipulate to provide equal access to high quality preschool education, including children from poor families and children with special needs. Fur- thermore they ask for the involvement of families and communities in terms of social mobilization processes.

554. To support these administrative regulations on establishing community based PEOs, which have inter-departmental character, preparatory actions for developing a law on preschool education are already undertaken and working groups to prepare this law have already been established. The draft of the Law should be finalized before the start of the SCBECDP.

555. In order to achieve output 1 the following major actions should be taken:

1. To increase information about the new State Standard 2. To develop administrative instructions and regulations 3. To support implementation of the State Standard

1. To increase information about the new State Standard

556. First activities to increase information of major stakeholders about the new State Stan- dard have already been initiated by the FCBECDP in terms of designing an information strategy about the new standards for relevant stake holders. However, the information strategy still needs to be implemented and relevant bodies such as oblast and raion education departments and state kindergartens still need to be informed about the requirements of the new State Standard. Furthermore, subsequent training will be necessary to raise the awareness and guarantee the implementation of the new Standard. The information campaign itself will help to underline the importance of early age development and to promote initiatives on establishing alternative models of PEOs.

557. Recently, MOE released an Order “on the Government’s regulation for the State Stan- dard realization”. This Order is a declarative document which is designed to authorize relevant educational state departments to take the necessary measures on the State Standard implementation. Representatives of MOE confirmed that educational departments in oblasts started to inform (state) kindergarten teachers on the new requirements.

558. Some raion (state) PEOs (best practice models) are considered as information points for other PEOs. It is their goal to implement the Standard by means of workshops. MOE considers these state kindergartens as “resource centers” providing information transfer. A general information strategy (including information tools) has to be worked out to ensure dissemination to the front line professionals.

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Key activities (already started in 2007 and will be completed in 2008/09)

(i) A working group consisting of representatives of the MOH and other relevant stakeholders should be established in order to develop and implement an information and training strategy to support the implementation of the new State Stan- dards. The strategy should identify relevant target groups, executive bodies, the training agenda and schedule. (ii) Expert groups work out necessary information material for the relevant bodies, including didactical aids (iii) Prepare key dissemination persons (on oblast level) to disseminate the information on the local level (iv) Plan and perform workshops on the local level (v) Evaluate information transfer

2. To develop clear administrative instructions and regulations (initiated in 2007, fin- ished in 2008/09)

559. After approving the state standard in January 2007 first steps of MOE were undertaken to discuss administrative instructions and regulations. A working group is implemented and starts the concrete work within the 2nd half of 2007. While developing the law on preschool education a set of new administrative instructions and regulations is required. However, there is a need for decisions to be taken with respect to which aspects should be defined on the level of the Law and which on the level of the Standard or subsequent administrative regulations.

560. The following administrative instructions and regulations seem to be necessary:

(i) Regulations and instructions regarding the functioning of different alternative models: e.g. clear definitions of alternative PEOs, opening hours, professional requirements, staff ratio, TOR, inclusion of children with disabilities and disadvantaged families. A clear operationalisation of key terms of the State Standard is necessary to ensure service delivery according to the standards. This includes also a definition of resource kindergartens. According to experience of the FCBECDP, there are open challenges of resource kindergartens regarding the support of community based initiatives, training or consulting and parents training (see RRP of FCBECDP)148. It is important – with the help of national and international consultants to define a methodology of information transfer between resource kindergartens and community based PEOs. (ii) Regulations on curricula to be implemented in alternative PEOs. Current curricula are primarily designed for full-day PEOs. (iii) Definition of basic professional requirements for work in the field (including alternative PEOs). Adopted and approved professional training-models for alternative PEOs have to be considered. Existing material from the FCBECDP, parents training programs or resource books and other should be taken into account. (iv) Sanitary, safety, nutrition and other norms for community-based models need to be approved (in accordance with existing laws).

148 Report and Recommendation of the President to the Board of the Directors on a Proposed Loan and Technical Assistance Grant to the Kyrgyz Republic fort he Community Based Early Childhood Development Project. Bishkek, 2003.

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(v) Whether financing is part of a law on preschool education or part of administrative instructions remains an open question. It is suggested, however, that issues of access and financing are regulated by a law. (vi) Regulation/article on donors activity and coordination

Key activities:

(i) Working group of MOE with involvement of relevant international organizations and other stakeholders identifies relevant aspects which need clear regulations and subsequently elaborate the necessary regulations. (ii) International and local consultants assist to contribute experience and knowledge. (iii) Work out operative definitions e.g.: opening hours for different forms of alternative PEOs, child staff-ratio etc. (iv) Publish and disseminate operative definitions. (v) Release necessary orders.

3. To support implementation of the State Standard

561. To implement the State Standard throughout the Kyrgyz Republic, both an implementation strategy and monitoring tools are necessary. The implementation in selected raions could facilitate the development of a roll-out strategy for the Kyrgyz Republic. In order to support implementation of the State Standards the following key activities are necessary:

(i) Define a strategy on the implementation of the state standard and evaluate the same through MOE (ii) An area for implementing the State Standards will be defined (iii) Implement the new State Standard in selected areas. In this context monitoring tools (see below) and information of the education departments on raion and oblast level are necessary (iv) Evaluate experience and provide feedback on the results to the MOE (v) A roll-out strategy for the Kyrgyz Republic will be elaborated by MOE (vi) State Standards will be implemented in the Kyrgyz Republic (vii) Working group of MOE with involvement of the representatives of the key stakeholders elaborates monitoring tools regarding the concrete implementation of the State Standards (viii) An Expert group – in cooperation with national consultants - works out necessary monitoring documents (ix) Train key stakeholders of Educational Departments on oblast and raion level on how to use these documents (x) Brochures of monitoring tools and necessary meeting/presentation are printed

Output 2: To Decentralize the System of Licensing, Attestation/Accreditation

562. Decentralization of the attestation and licensing process stimulates the establishment of PEOs, as administrative processes become more participative and decentralized. A law on preschool education might provide the necessary legal frame for the decentralization process. In- volvement of parents and AO, as the founders of community based models, in a “mixed board” of the PEOs will provide transparency and a cooperative approach.

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563. In order to achieve output 2 the following key actions should be carried out:

(i) Develop regulations on attestation and licensing demands and relevant committee/board working group of MOE with involvement of relevant international organizations and other stakeholders to include this issue in panel tasks on law and administrative regulations development, as operational definitions of PEOs, licensing and monitoring processes represent different stages of quality management. (ii) An expert (sub) group of MOE defines necessary bodies (iii) Define regulations on licensing (iv) Elaborate necessary tools through the expert sub-group (v) Transfer information to the newly established commissions (vi) The MOE informs the relevant (local) bodies on the functioning of the commissions (vii) Give feedback to MOE about concrete implementation

Output 3: To Develop a Law on Preschool Education

Figure 26

564. In 2007, MOE already initiated a working group to develop a law on preschool education. By covering a broad field of relevant aspects (access, financing) the law should strengthen the preschool system within the education system and support the legal status of alternative models of PEOs. A law on preschool education (comparable to other recent international tendencies) is necessary to ensure:

(i.) Equal access of children (ii.) Financing models enabling equal access for children in whole Kyrgyz Republic (iii.) Sustainable development of PEOs

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565. In order to achieve output 3 the following key action still need to be carried out:

1. Analyze the existing legal base and available international examples. (a.) Create a working group under MOE (approved by MOE’s Order) and start the analysis process (b.) Define relevant areas to be included in the law and get assisted by a national legal consultant able to present and reflect a wide range of different laws (c.) Subgroups work out draft suggestions: e.g. access to preschool education, the position of preschool education within the process of life-long-learning, the financing of PEOs, responsibilities of different stakeholders (state, AO, parents etc.) (d.) Initiate a political consensus finding process 2. Initiate the drafting process for the law and get assisted by relevant stakeholders 3. Collect expert-feedback 4. Present the draft of the law to the Parliament 5. MOE prepares the final version and submits it to the Parliament

Output 4: To Improve Financing

566. A sustainable preschool education system depends on the efficiency of a financing system. The State Standard defines different components of service delivery: education, care and nutrition. In relation to different preschool models, different combinations of these components can be taken into consideration. Financing issues remained open under the State Standard and require a deeper analysis in order to (i) increase cost–efficiency of PEOs, and (ii) to create financial models considered as normative cost-models for all forms of PEOs to ensure equal access for all children.

567. Increase cost-efficiency of PEOs: An analysis of the current budgets of PEOs reveals that in order to increase the cost-efficiency of existing PEOs it is necessary to reconsider the budget items in relation to “education and care” activities and nutrition” and to specify how to finance alternative models of PEOs. The current situation, is such that in state kindergartens “education and care” are covered by the state budget while in community based PEOs parents have to cover these two cost aspects by themselves.

568. Major activities needed to increase the cost-efficiency of existing PEOs include:

1. Identification of necessary data regarding budgets of PEOs (including alternative PEOs), e.g. regarding the budget situation of alternative PEOs, as there are no data available 2. Define education and care related activities in close association with job descriptions and job requirements of professionals in PEOs or equal parent contributions in state and alternative PEOs 3. Analyze child-staff ratio and reduce non-pedagogical staff

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569. To create financial models considered as normative cost-models for all forms of PEOs: Analysis of costs and its efficiency is the basis to develop norms and financial models (including alternative PEOs). As stipulated in the existing Law on Education, the “state guarantees financial and material support for early childhood education and provides access to educational services of state PEOs for all groups of population” (Article 15)149.

570. Currently, the state budget covers costs for education, care and nutrition (50%) during full day services. No differentiation is made (also regarding staff-requirements or remuneration) between care and education activities. However, it is supposed that differentiating care and education activities will allow cost reductions (in state PEO) as parents will have to cover care costs and will make available budgets for alternative PEOs. However, at the same time “care” activities and nutrition components cannot be excluded completely from the budget, as they are important for families especially in rural areas where poverty is more visible and chances to organize care for young children are very limited.

571. According to international experience (OECD 2001, p. 9) Laws on Preschool e.g. in Ger- many or Austria (as presented in the seminar for MOE in February 2007) refer to a principle of cost sharing between state, municipal budgets and parents. As outlined in the Sector Analysis above, most western financing models are mainly based on shared cost models, mainly following a 30:30:30 rule (state budgets/municipality or AO budgets/parent contributions). However, concerning Child Protection or Child Welfare, parents from weak social backgrounds might be entitled to receive subsidies if the income situation of the family does not allow the parents to pay kindergarten fees.

572. Financing models should also take into account the ratio of input of the different sources (state, AO, parents, other) and the situation of socially disadvantaged children. Furthermore normative cost models also have to cover different structures of alternative PEOs (in terms of opening hours, necessity of care-processes, facilities etc.).

573. Major activities needed to develop normative cost-models for all forms of PEOs include the following steps:

1. Calculate financing models and define norms in relation to different forms of PEOs (state, alternative). Financial experts from MOE – assisted by national consultants - perform model calculations 2. Develop and approve regulations on financing (costs sharing between the state and local budgets, parents and others) 3. Define activities, specific job profiles and salary models 4. Create work time models for alternative PEOs

574. To define more relevant priorities on financing of different PEO models, a preliminary cost table was developed:

149 Law “on Education” № 92, 2003. Article 15.

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Table 25: Input Cost effectiveness analysis, creation of normative Name cost model Relevant periode 0-60 Main activities (ToR) Supporting MOE in cost analysis regarding sustainable 2 workshops in financing of PEOs Bishkek during 1 day in 2008 and 2 in Stimulating meetings of working groups 2009. 50 participants for each

workshop Providing input and model calculations

Moderating working group meetings

Summarizing and disseminating results Necessary resocurces Staff National Education Specialist Close cooperation with the working International Economic Specialists (0.5 month) National group on laws is Economic Specialists (12 month) necessary Target group Involved Ministries, Policy Makers Transport In Bishkek Accomodation Quantity 12 months national consultant Economist Duration Material Basic presentation material, hard copies, model calculations. Translation 100 pages, printiong - 1,000 copies Deliverables/Product Protocols, Draft of a normative cost model Monitored/controlled by MOE

Output 5: To improve the training (basic and in-service) of professionals

575. ECCE issues are interdisciplinary and connected with areas such as health care, social protection etc. A solid basic training and constant interdisciplinary upgrade of information on ECCE is necessary. Special attention should be paid to nutrition issues, as the problem of malnourished children represents a major obstacle for child development and efficiency of education. Well trained professionals are an indicator of quality. Furthermore, every child has the right to obtain adequate education and care. Especially in the field of alternative PEOs, the issue of basic training and professional requirements remains open.

576. Basic training on the tertiary level is theory focused. Available literature and theoretic background is based on former Soviet tradition. Access to international literature and methodology is limited. The new State Standards introduce new concepts and a profile of competences which have to be included in the basic training. Basic training on the secondary level is practice oriented; however, due to the difficult economic situation (salaries of preschool teachers) the courses do not attract enough participants.

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577. Theoretically, in-service training in state PEOs exists, but the lack of both resources and necessary monitoring processes of the educational departments represent major constraints. Especially in the field of alternative PEOs, strategies concerning training of professionals are missing. Resource kindergartens cannot always fulfill the role they are given. Institutes for Teacher Qualification are likely to become centers of dissemination once the logistic problems of information transfer are solved.

578. Major actions to achieve output 5 include the following steps:

1. Modernize training contents and methods enabling access to international literature 2. Adapt existing curricula both on the tertiary and secondary level to the new State Standards 3. Increase access to basic and in-service training 4. Find sustainable financing systems regarding in-service training (especially for professionals who do not have an adequate basic education) 5. Strengthen information cascades and networks (from Teacher Qualification Insti- tute to resource kindergarten or alternative PEOs) 6. Define monitoring and control requirements for teachers’ in-service training 7. Provide sufficient training material for the teachers in relevant languages

1. Modernizing training contents and methods enabling access to international litera ture

579. Both the contents of the “teaching” units and the teaching methods (“directive” school oriented approach) might restrict the creative potential of children. Within the international con- text150 (Ftenakis, W. (2002). Bildungsraum Kindergarten. www.ftenakis.de) preschool is seen as an autonomous pedagogical field, which is based on different principles other than those refer- ring to school-education: e.g. stimulating activities of the child, initiating social learning processes, developing the child’s abilities to learn “how to learn”, just to enumerate the basic concepts of western preschool pedagogy.151,152

580. With the specific socialization that has occurred in the former USSR, both parents and professionals are likely to express some reluctance to accept such new approaches. However, these new concepts should be considered as complementary methods to stimulate the child and initiate “self guided learning processes“, in addition to already practiced directive models of “teaching”. Therefore, future professional training curricula should satisfy the new requirements. However, lack of language skills of both professionals and students (e.g. English) and lack of access to modern media (internet) are major constraints.

150 Secretariat of the Standing Conference of the Ministers of Education and Cultural Affairs. 2006, The Education System in the Federal Republic of Germany 2004: A description of the responsibilities, structures and developments in education policy for the exchange of information in Europe. Bonn 151 Child and Youth Welfare Act (Kinder- und Jugendhilfegesetz – R46), 1990: The Kindergarten is designed to support and supplement the child's upbringing in the family, compensate for any developmental deficiencies and afford the child optimum opportunities for his/her development and education. The children should discover the world through play and develop their abilities and skills. The children are supported in this by qualified staff. It is also the responsibility of the Kindergarten to improve the transfer for children to primary school in line with their level of development. 152 Textor, M.R. (2005) Elternarbeit im Kindergarten. Ziele, Formen, Methoden, Norderstedt: BoD. Heimlich, U. and Behr, U. (2005): Integrative Qualität im Dialog entwickeln. Münster: LIT. Carle, U. (1995). Mein Lehrplan sind die Kinder. Weinheim: Juventa.

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581. In order to modernize training contents and methods, the following activities will need to be undertaken:

(i) Enable internet access for young professionals (e.g. in resource kindergarten) (ii) Introduce international material by improving access to international literature (e.g. summary of state of the art pedagogical approach for PEOs in Western countries, methodological textbook for students) (iii) Increase knowledge on interactive methods for key training institutions through training seminars to be directed by international trainers (iv) Provide material for both professionals and children in relevant languages, in cooperation with KAE and local authors, all based on international know-how

2. Adapting existing curricula both on the tertiary and secondary level to the new State Standards

582. Since curricula for professional preparation still focuses on old norms and regulations, an update for basic-training is necessary in order to comply with the competence profile described in the new State Standard. Key activities needed include:

(i) The Arabaev University adapts the existing curriculum to become a PEO professional (methodologist) regarding the competence profile of the State Standard (ii) Secondary schools adapt theoretical and practical training of the State Standard (iii) Adapt existing material (e.g. produced during the FCBECDP) is adapted to key concepts of the State Standard

3. Increasing the access to basic and in-service training

583. In-service training for the teachers especially in the field of alternative PEOs is primarily considered as a cost factor. Possible incentive models should stipulate the efficiency and motivation of training. For instance, the annual or bi-annual increase of salaries could be connected with in-service training. This system could help to promote the active work of resource kindergartens. To approve the quality of work, payment can be arranged based on monitoring processes by educational departments together with parents.

4. Finding sustainable financing systems regarding in-service training (especially for professionals who do not have an adequate basic education)

584. This issue is closely connected with a general model of financing. In this context, clear requirements how to access the professional field have to be defined, preferably through a law on Preschool Education. Bodies running a PEO (state, AO, NGO or private) should be responsible to fulfill these requirements. Key activities needed are:

(i) An expert group analyzes current financing models with respect to in-service training (including alternative PEOs) under consideration of basic job requirements (ii) Incentive systems should be taken into account (e.g. a professional – after a certain number of seminars - could become a trainer)

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5. Strengthening of information cascades and networks

585. To facilitate efficient in-service training in the Kyrgyz Republic, it is necessary to ensure that information is transferred easily between teacher training institutions, resource kindergarten and community based models. With this regard it is necessary to:

(i) Prepare a clear design and methodology of information transfer from training institutions through resource kindergartens to community based PEOs. (ii) Use Institutes of teacher’s qualification and resource kindergartens for short term professional preparation of preschool teachers and trainers of resource kindergartens (iii) Define criteria for resource kindergartens (iv) Establish resource kindergartens (v) Establish a clear methodological cascade from KAE towards Teachers Qualifica- tion Institute

6. To define monitoring and control requirements for teachers’ in-service training

586. For state kindergartens a 3-years system of obligatory in-service training theoretically exists. However, education departments on raion and oblast level only collect descriptive data on performed training activities of the professionals. A feedback-control system, that professionals are obliged to in-service training does not exist. For alternative PEOs, monitoring does not exist.

Key activities:

(i) Education department on raion and oblast level monitors the continuity of in- service training by means of a data base (ii) Heads of PEOs take care that staff members regularly attend in-service trainings

7. Providing sufficient training material for the teachers in relevant languages

587. Methodological material for teachers is mainly available in Russian and primarily based on above mentioned “directive” methods. Even if the FCBECDP created teaching material both in Russian and Kyrgyz, adequate material is still missing. At the moment, some material is already developed by local specialists, which can be (re)printed and distributed (see also annex 21). In order to provide sufficient training material for teachers in relevant languages it is necessary to:

(i) Stimulate the production of methodological and training material in Kyrgyz or other relevant languages in Kyrgyz Republic (ii) Print and distribute stimulating and training aids (iii) (Re)print materials which have been published e.g. based on donors`support (iv) Distribute aids to kindergartens and organize acquisition of educational materials (toys, books for children etc.)

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Output 6: Improving the quality of services

588. Based on international approaches153, quality management is based on 5 aspects: (i) pedagogical concepts and programs, (ii) structures (including the qualification of professionals and e.g. availability of material, (iii) processes, (iv) results and (v) sustainability. Improving quality not only requires (pre-)defined quality indicators, but also monitoring tools and a quality management system. In all pedagogical fields, full participation of all relevant stakeholders is important (parents, AO, educational departments, professionals etc.) to ensure a dialogue about quality.

589. On the level of existing concepts, the current situation in the Kyrgyz Republic is determined by a quasi-monopole of 1 program (designed by KAE). On the level of structures, state-of- the-art information and material are extremely poor and infrastructures show numerous problems. The number and quality of beds is seen as the most significant indicator. Evaluation of the process is primarily oriented towards academic skills (tested at the end of the year). Sustainabil- ity – due to the limited number of enrolled children – remains open.

590. Major action in order to achieve output 6 include:

1. Improve conceptual quality by stimulating the diversity of PEO programs and methodological approaches and provide more options for parents 2. Improve the quality of infrastructure 3. Define and increase the quality of the educational processes 4. Transform person-centered concepts into results 5. Define quality indicators involving relevant partners (including parents)

1. Stimulate a diversity of programs and methods and provide more options for par ents (conceptual quality)

591. Both the lack of programs particularly designed for different forms of alternative PEOs and the quasi monopole of KAE do not really leave a choice for parents regarding PEO programs. Approval of so-called “authorial” programs (which are not state based) normally takes long. Approval mechanisms therefore should be simplified.

Key actions:

(i) Stimulate alternative service providers (e.g. NGOs, Montessori, bilingual PEO etc) to create and implement alternative programs by easy approval mechanisms (ii) Develop a system of approval of alternative programs by responsible bodies (iii) Stimulate existing (state) PEOs to implement new methods by involving parents, their needs and competencies

153 Peterander, F.; Speck, O. (eds), 2004, Qualitätsmanagement in sozialen Einrichtungen. München: Reinhardt

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2. Increase the quality of infrastructure, including availability of adequate pedagogi cal material

592. Both the situation of the premises, especially in remote areas including heating and sanitary facilities, and the availability of pedagogical material (toys, books, methodological literature, consumables) are insufficient – compared to international standards. Therefore, in order to increase the quantity and quality of PEOs, a major effort has to be made to rehabilitate suitable premises. Basic rehabilitation of houses represents the priority (roof, floors, heating). Small re- payments in already existing PEOs have to be assessed as secondary.

Key actions:

(i) Develop a national plan how buildings can be rehabilitated in selected raions, in addition to the Village Initiative Fund (VIF) (ii) Use existing premises (e.g. schools) (iii) Include donors in order to create sustainable financing models (iv) Create or reprint material for children (with a special focus on material in Kyrgyz)

3. Increase the quality of pedagogical processes

593. In most European QM processes, the quality of the pedagogical process is highlighted, especially from the point of view of the parents: which activities are performed with my child? how is the atmosphere? Does my child feel well? Are the children able to follow individual goal oriented processes? are the individual needs of the child met? Are the children able to explore actively their “surroundings”? are they supported by the professional? And so forth. The pedagogical process in Kyrgyz PEOs, as far as programs are concerned, is primarily school oriented and leaves only few space for own activities. In this context, programs and methods used by the professionals still follow former Soviet models of directive “preschool” settings. A lack of information on child centered, relationship-based approaches could be observed.

Key actions:

(i) Inform professionals about relevant quality indicators in the field of processes (e.g. ECER-Scale –) Harms, T., Clifford, R.M. (1980). Early Childhood Environ- ment Rating Scale – revised (ECER). New York: Teachers College Press (ii) Make professionals become aware of person-centered approaches (iii) Inform parents on different methods in preschool pedagogy (iv) Include person-centered concepts into basic and in-service training (see above)

4. Introduce individualized person-centered result evaluation

594. Portfolio concepts and individual stimulation processes request individual (result) evaluation processes. Of course, such a procedure is a challenge compared to relatively standardized existing approaches in the Kyrgyz Republic (in terms of numeracy or reading skills assessed for all children at the end of the kindergarten year). The evaluation of individual competencies could complement those basic school-preparatory skills, which till now represented main criteria of evaluation. It is important not to destroy this national tradition. The aspect of individualization should be added.

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Key actions:

(i) Introduce the concept of individual evaluation of basic and in-service training (ii) Create tools to facilitate individualized evaluation

5. Define quality indicators

595. Participation, transparency and involvement of relevant stakeholders are basic principles of quality management. The definition of quality indicators itself is a dialogue process, especially with respect to the involvement of parents. Quality indicators should be defined on all quality levels, international scales could be adapted to national needs

Key actions:

(i) Actively involve educational departments, parents and other relevant stakeholders in quality management of all educational and care services (ii) Working group defines mechanisms of involvement of relevant stakeholders in monitoring processes

3. Plan of Action for Achieving Objective 2

596. Capacity building in ECCE aims to increase knowledge and skills of families and communities regarding care and education of pre-school children in a sustainable way in the Kyrgyz Republic. Full participation of involved stakeholders (especially of parents and AOs) and transfer of information into daily care and education practice are major principles in this field. Increased knowledge and skills of the parents on ECCE will improve the practice of child care and stimulate child development. Establishing PEOs and performing IEC aims at making professionals and parents become more aware of the early years of a child (for future successful education and well-being) and enlarge the social and intellectual potential of Kyrgyz children.

597. In order to achieve objective 2 the following outputs will need to be produced:

1. Empower parents regarding ECCE 2. Mobilize and support community initiatives and AO on the question of how to establish a PEO 3. Increase the number of PEOs by establishing services (including initial financial support from basic rehabilitation of premises) 4. Raise the awareness of the population of the Kyrgyz Republic with regard to ECCE by means of IEC component

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Output 1: Empowering parents

598. Parents’ empowerment is based on 2 columns, (i) on mobilization within the community (e.g. by means of parents’ committees to initiate necessary steps towards community based PEOs. Based on lessons learnt from the FCBECDP (CFCs), this process should be guided by key persons within the community, mainly coming from the educational field, preferably a former kindergarten teacher. (ii) Parents’ empowerment can be achieved through parents’ programs which aim to increase knowledge and skills of parents regarding care and education processes in the family. Sustainability is reached by a high degree of transfer of the gained knowledge into daily life practice, specifically with respect to the father’s role in the family.

Key actions:

(i) Adapt existing material regarding parent empowerment to transfer knowledge into daily practice. Despite the fact that some age adequate material for children is available in Kyrgyz and Russian (see annex 22), not much of this material is available due to economic restrictions and information transfer to remote villages. (ii) Create and publish adequate training material for parents and children. The production of material which relates to daily life issues of the child (e.g. a calender with age-adequate exercises) will increase the sensitivity of parents and on the other hand stimulate the development of the child. Existing literature will have to be reviewed and with the help of external consultants modified so that it can be used within the selected regions of the parent training programs. (iii) Design specific modules for fathers. Existing data indicate a lack of involvement of fathers in ECCE in the Kyrgyz Republic. Taking into account that fathers need different forms of training (e.g. producing toys together with a trainer) specific modules for fathers will need to be created with the help of an international consultant. The focus will be on joint activities of the child with the father. (iv) Identify key persons for working with the community and providing training on ECCE: Lessons learnt from the FCBECDP and focus group data indicate that successful mobilization of the community depends on motivated “key persons” (first project’s CFCs). To increase the efficiency of these key persons they should have a pedagogical or social-medical professional background (preferable former kindergarten teachers). (v) Adapt existing training materials for key workers (former CFCs) regarding the aspect of empowerment and nutrition. (vi) Include successful CFCs in the training of new key workers to ensure high quality information. (vii) “Prepare” training institutions (preferably local Institute for Teacher Qualification) in order to train key persons. To enable a “cascade of information” from the training institutions to community based PEOs, the trainers themselves have to be prepared; to ensure sustainability, the Insitute for Teacher Qualification should provide the training to the CFCs and Resource-kindergartens. The Institute of Teacher Qualification should ideally be directly trained by the authors of the training material. Already existing material within the FCBECDP to train the trainer can be used and adapted.

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(viii) Train key persons on parents’ empowerment. Key persons are prepared within a training seminar to (i) mobilize the community and (ii) to raise the parents’ awareness and inform them on ECCE. Local structures (Institute for Teacher Qualifica- tion) should be used as they also serve as dissemination structure for resource kindergartens. (ix) Perform parent empowerment seminars in the communities. The parents’ empowerment is based on training sessions. Lessons learnt show that training sessions have to be time adequate (not too long, 1 session max. 2 hours). Further- more, during these training sessions, parents will be provided with material (e.g. the calendar) which they can use at home with their children and make a direct transfer of what they have learnt.

Output 2: Mobilizing and supporting community initiatives and AO to establish PEOs

599. Despite major efforts in the field of health (VHCs), communities do not always have sufficient information on possible initiatives in the field of education. In this context, the communities (especially in remote areas) need easily understandable and clear information (PEO guideline) on how to start initiatives in the field of ECCE (e.g. how to establish a PEO for their children, including issues of financing.)

Key actions:

(i) Inform AO and relevant stakeholders on the project (orientation seminar). AO requires concrete information on how to mobilize parents or how to establish a PEO. After training of the key workers, they organize meetings in the AO, inform- ing about the importance of ECCE and about the project. (ii) Summarize experience from successful founders of PEOs. To support this process, concrete and easily understandable information (in Kyrgyz and Russian) is necessary. Existing work of the FCBECDP should be considered. (iii) Based on this experience a working group of successful PEO-founders should develop an easily understandable guideline for AO and communities on how to establish a PEO for communities. (iv) Inform and train key persons regarding this PEO guideline. Within the above mentioned training process of the key workers – within the first days of their training - they are provided with information material and instructed how to use it efficiently in the AO. (v) Key persons in close cooperation with AO initiate processes of community mobilization (using the PEO guideline). (vi) Concrete steps towards establishment of PEOs.

Output 3: Increasing the number of PEOs (including initial financial support for basic rehabilitation of premises)

600. Lessons learnt from the FCBECDP on how to establish community based kindergartens indicate that till 2015 the coverage of children in community based PEOs is likely to be doubled. Supposing that a community based PEO is consisting of at least 2 groups (á 25-30 children) 125 new PEOs will be established (for 6250 till 7500 preschool children) in the selected raions. It

154 means within the structure of 125 PEOs 250 groups á 25-30 children are likely to be established. Throughout the Kyrgyz Republic, supposing that the national strategy will also be implemented in other oblasts, 1000 new PEOs consisting of at least 2 groups each of 25 – 30 children) could be opened, reaching a total target number of 50.000 new created places To reach these target numbers, it would be worth while to consider the inclusion of state PEOs to increase the number of enrolled children. e.g. by introducing flexible time-shift models or through rehabilitation of premises which are not in use.

Key actions:

(i) Community initiatives – supported by key persons – initiate concrete steps to establish PEOs (e.g. performing a concrete needs analysis in the community, looking for premises, designing a project plan, creating a legal body, application for grants…) Lessons learnt within the 1st ADB project show that a concrete needs assessment in AO gives a clear picture which kind or PEO is needed. The next step includes looking for adequate premises, in close cooperation with AO, FAP and/or school. (ii) Key worker assist AO or parents initiatives to apply for a grant (Village Initiative Funds). (iii) Basic rehabilitation of selected PEOs which will be newly established (iv) Community initiatives perform all necessary steps to run a PEO (licensing processes, staff recruitment (v) Initiative group organizes necessary equipment

Output 4: Raising the awareness of the Kyrgyz population through IEC

601. Lessons learnt from the FCBECDP indicate that using media (TV) shows a high information impact on the target groups (young children, parents). This strategy therefore should be followed, as watching TV also represents one of the major common activities of parents together with their children. Existing programs (Keremet-Koch) should be enlarged and continued

Key actions:

(i) Include the production of further series of Keremet-Koch in the project design (ii) Perform all necessary production steps – in coordination with other donors

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V. CAPACITY BUILDING

602. The Kyrgyz Republic has gained substantive experience in building capacity of communities, social mobilization and community participation. Different existing models and approaches tailored to involve communities in development processes were studied during the PPTA. Cur- rent work of Village Health Committees (VHCs), Village Initiative Funds (VIFs), Child and Family Coordinators (CFCs), other community-based organizations (CBOs) shows that local capacity exists, but needs empowerment to be harnessed. Empowering communities means that communities should have voice, decision-making powers and access to needed resources. These objectives are achievable through the involvement of all stakeholders and using their potential and opportunities.

A. Policy and Institutional Framework for ECD

603. To provide every child of early age with access to services needed for valuable and comprehensive physical and psycho-social development and to improve ECD in the Kyrgyz Republic it is necessary to analyze and take into consideration existing problems and shortcomings of institutions relevant for ECD and to involve these institutions in the capacity building process.

604. The New Generation Program is the main policy document on childhood development in the Kyrgyz Republic. This Program established the general policy framework for improving child development in the Kyrgyz Republic. One of the major activities of this Program was the development and adoption of the Child Code on 9th of June 2006. The Kyrgyz Republic’s Child Code, which is the first initiative of this kind in Central Asia, incorporated international standards and norms on child development, particularly the United Nations Convention on the Rights of the Child, into national law.

605. The Child Code established a legal base of authorized state organs for protection of children’s rights and interests. According to this Code, Units for Child and Family Support (UCFSs) should be established in each raion under the raion state administration. They serve as a specialized state organ for the protection of rights and legal interests of children. Their functions include prevention of violation of law by children; identification of children temporarily or perma- nently deprived of his or her family environment; investigation of situation of children in crisis; monitoring of families that adopted or fostered children; control of conditions in special facilities where children live at the expense of the state budget etc. The analysis of the UCFS’s tasks and functions shows that these organizations are designed to protect children from any form of violation and abuse, but not to contribute to child development.

606. The UCFSs should operate under the supervision of the Commission on Child Affairs which is a non-permanent interdepartmental organ consisting of representatives of the police department, education, health, social protection, and raion state administration or local self- government. The commission should also include four representatives of civil society organizations. It should monitor the work of UCFS and approve their decisions and reports.

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607. To date UCFSs have been established only in few raions (Issykata raion, Jumgal raion, Talas raion). In Issykata raion the work of the UCFS includes workshops on social patronage, work with orphans etc. Vulnerable families have been identified and classified by the UCFS and a Family Development Plan was developed for these families. In addition, a district socio- psychological committee and an inspector of children’s rights protection started functioning. Nu- merous trainings have taken place for different groups, including state servants, specialists, and community leaders. The Issykata UCFS is successful because of strong political and financial support of the local state administration, which allocated its own resources for activities to support children (the raion is located in Chui oblast and has a strong economical basis for the local budget).

608. Currently the existing legal and institutional framework for children with special needs is too narrow, since relevant laws and institutions are designed more to deal with children placed in special circumstances (orphans, juvenile offenders etc.), rather than focusing on early childhood development. Resources mostly aim at the protection and support of children living in adverse situations. The new regulations should expand authorized state organs’ activities on inclusion of children with special needs in a full and decent life and facilitate those children's active participation in the community as well.

B. ECD Stakeholders

609. ECD is a cross-sectoral issue which needs the involvement of many different sectors and institutions. The main stakeholders for ECD in the Kyrgyz Republic are the Ministry of Education and Science (MOE); the Ministry of Health (MOH); the Ministry of Labour and Social Develop- ment (MLSD); the Department on Child Protection under the State Agency on Physical Culture and Sport, Youth Affairs and Child Protection; the Ministry of Finance; the National Agency for Local Self-Government and Regional Development, local state administrations and self- governments; non-governmental organizations and community based organizations.

1. State Ministries and their Local Branches

610. The MOE is responsible for pre-school education issues. On the national level there are the Deputy Minister of Education and Science, who is responsible for school and preschool education, the Department on Preschool Education Accessibility and Quality Control, and a specialist for preschool education in the MOE. The MOE controls the training of directing staff of PEOs in higher education and professional institutions including the specialists working with children with special needs.

611. MOE has limited human resources. The main office of MOE has only one position of a specialist responsible for preschool education, which is not enough for administering the whole scope of work. Moreover, this person is at the same time the supervisor for Batken oblast, which doubles the functional responsibilities. Financial shortages not only restrict the MOE’s capacity to expand the number of needed specialists, but also its capacity to organize meetings at the community level to examine the needs of the population (e.g. with regard to preschool facilities) and to provide material incentives to pedagogical specialists working in preschool facilities.

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612. Also the educational system for preparing professionals in preschool education is rather limited. The Arabaev State University prepares preschool specialists with a higher education degree only; the Pedagogical school in Bishkek prepares teachers for kindergartens; in Osh State University is a department for preparing teachers for elementary schools. There is no educational institution in Batken and Jalalabad oblasts preparing specialists working in the area of ECE.

613. At the oblast and raion levels the government is represented by territorial branches of the ministries and local state administrations. The shortage of human resources in the sphere of preschool education at the national level can also be observed at the oblast level. There is only one specialist on preschool education in each Oblast Department of Education. The specialist is responsible for the following tasks: organization of seminars and training, provision of methodical assistance to PEO staff, coordination of activities of PEO staff; supervision of education and care activities in PEOs; registration of orphans and semi orphans, as well as children from poor families; education of disabled children; examination of the quality of education in PEOs.

614. At the raion level the raion departments of education are coordinating the work of secondary schools and preschool facilities as well as raion children’s and youth clubs for physical training and centers of children’s art154. The MOE has its own printed periodicals through which it can reach the professional community at the raion and oblast level.

615. The MOH controls and administers medical treatment of mothers and children through medical and prophylactic establishments (hospitals, sanatoriums etc), research institutes and centers at the national, oblast and raion level. There is no special MCH and MCN unit in the MOH head office, but the Directorate of Treatment and Preventive Assistance is responsible for these issues. The oblast structures are represented by oblast hospitals with the network of FMCs, FGPs and FAPs, centers of the SSES and other establishments. The health education system is affiliated to the MOH.

616. Among the most important medical establishments related to ECD at oblast and raion levels are FMCs and FGPs, Health Promotion Centers, Centers of Human Reproduction, and maternity wards in the oblast hospitals. These institutions organize informational campaigns on disease prevention and healthy living and maintain relationships with public units, communities, associations, and mass-media on the issues of public health, prevention of diseases and promotion of healthy living.

617. The MLSD implements the national policy on social protection and support of vulnerable groups of the population, including children and families. In the regions the Ministry has the oblast Departments. The Ministry is responsible for the maintenance of the house-boarding schools for disabled children. Furthermore, it deals with the problems of neglected and homeless children; controls the maternity leave payments and other social benefits. The Ministry maintains a database on needy families and has a system of monitoring of families and children at risk. It cooperates with NGOs and local authorities working on social issues. The Ministry coordinates the work of social workers in AOs. Recently the Institute of Social Development and Business was established, preparing specialists in the sphere of labor and social protection. However the government does not cover tuition fee of students.

154 The issues relating to the activities and conditions of these clubs and centers working with children of early age need further examination.

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618. The Department of Child Protection under the State Agency on Physical Culture and Sport, Youth Affairs and Child Protection was created recently according to the government’s regulation from April 20th, 2007. The Agency is an authorized body in the sphere of protection of the rights, freedom and legal interests of children. The Agency carries out the inspection and monitoring of all establishments related to children (pre-schools, boarding schools, secondary schools). It develops standards for services for children including services provided in special facilities and boarding schools; it controls the work of state and private facilities for orphan children; and it carries out the accreditation of such establishments. The Department should have a leading role in supporting ECD in the Kyrgyz Republic.

619. The Ministry of Finance has the authority to financially support local initiatives including those related to ECD. The main mechanism through which it can support community efforts on ECD is the so-called Stimulating (Matching) Grant (SMG). SMGs are financial means granted by the republican budget for implementation of approved projects. Stimulating (matching) financing implies existence of co-financing from applicants including resources from AOs, raions, oblasts and international organizations. Such scheme of financing allows mobilizing the maximum of resources for implementation of ECD initiatives, especially related to the construction or rehabilitation of FAPs, PEOs, clean water supply etc.

620. Local state administration structures, including oblast state administrations and raion state administrations, coordinate the activities of regional branches of the ministries and agencies. One of the deputy heads of local state administration usually is assigned the responsibility for social issues including problems of families; only a small number of staff supports him/her. There is a special interdepartmental medical commission under the raion state administration working with children with special needs. It consists of health workers as well as education and social protection specialists. The task of this commission is to identify orphans, homeless children and children without birth certificates and to request the support of state organs that are in charge to resolve these issues.

2. Local Self-Government

621. The structure of the local self-government includes a representative body – local Ke- neshs (Councils) – and an executive body – AO, the people’s assembly – and other forms of local self-management. There is a permanent commission on social issues of the local councils aiming at the elaboration of local social and economic development plans and responsible for controlling their implementation. In many AOs there is a position of leading specialists on social issues (a social worker). Although the social worker should cover social protection of all needy members of the community, he/she is a main informational source and aid in ECD at village level, because collecting information on the social situation in every family is a main responsibility of the social worker. The ongoing reforms in decentralization allow the local self-governments greater control over their resources and wider participation in the decision-making process. Lo- cal self-governments therefore can play a key role in the process of mobilization and integration of all efforts in ECD activities at local level.

622. However specialists in AOs have no special focus on children at early age, since there is no special practice on ECD. There is substantial lack of specialists working with children with special needs. There is no reliable information on children of early age with special needs available as the established state registration system concentrates mostly on children of school age and those children who applied for state social benefits.

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623. Cadres of state organs and local-self-government need training as well. In accordance with the law of the Kyrgyz Republic on Municipal Civil Service, once in five years, local self- government officials and specialists have to be retrained and improve their skills at regional Cen- ters and the Institute of Public and Municipal Administration of the Academy of Management under the President of the Kyrgyz Republic. However, this norm is not implemented regularly and retraining takes place when international organizations invite municipal servants. There is no permanent system of training and retraining of civil and municipal services.

624. The effectiveness of the work of all state government organs is deterred by shortages in human and financial resources, frequent organizational changes and high staff turnover in governmental and municipal institutions. In the local state administrations, education and social protection organs there are only 1-2 specialists on social issues (including ECD) working for the whole raion. They do not have funds for traveling and organizing meetings and workshops with representatives of AOs and communities. As it is seen from the Needs Assessment Report, most of the community members have no information on ongoing ECD programs and activities in their raions. The lack of community participation makes cooperation and coordination between the different governmental organs responsible for ECD in the Kyrgyz Republic very difficult.

625. Another shortcoming is the lack of cooperation between state government bodies, local self-governments and other stakeholders in ECD. State organs in oblasts concerned with health, education, and social protection work on particular problems of children and families, but never try cooperating as was revealed during the Inception Workshop conducted in the framework of this PPTA in November 2006155. For example, education authorities deal with children attending pre-schools and schools, but have no information on children at early age; social workers have information and work with those families which apply to social benefits but are not involved in ECE. Furthermore, there is no practice of regular meetings with the groups of population.

3. Community-Based Organizations and Structures

626. The table below shows that the number of officially registered NGOs and CBOs in the oblasts is very big. However, most of them were established in the framework of projects funded by international organizations (e.g. UNDP project on poverty alleviation) and stopped working actively after completion of the donors’ projects due to a lack of financial resources.

Table 26: The number of NGOs and CBOs (2005)156 Oblast Number of NGOs and CBOs

Batken 1110 Jalalabat 737 Osh 1927 Issyk-Kul 569 Naryn 630 Talas 4529 Chui 2722

155 See inception workshop report. 156 ARIS, 2006, Major social-economic indications and condition of social infrastructure in AOs in the republic for 2005, Bishkek

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627. Interviews with the target groups demonstrated that the most actively working CBOs are the Councils of Aksakals (elderly men), youth committees, women’s committees, VIFs, as well as Village Health Committees (VHC) and Parents’ Committees. CBOs, as a rule headed by informal local leaders, have experience in working with communities and their potential is essential for revealing the needs of children and their families, organizing joint actions for supporting the needy children and implementing project activities at the village level.

628. The FCBECDP has gained important experience in creating Coordinators of Families and Children (CFCs) at the community level. These coordinators have been chosen on a competitive basis and were trained to carry out the following tasks: (i) identify the needs of families with children; (ii) distribute information on ECD and (iii) support communities in the development of project proposals to receive grants. ADB funded the salaries of CFCs (US$ 20 per month) until De- cember 2006. From January 2007 onwards, AOs were supposed to take CFCs on their payroll, but none of them did. As a result, CFCs stopped working. As CFCs played an important role in strengthening ECD at the local level, it would have been very desirable to retain their positions. However, considering the lack of sustainability due to the lack of financial resources of AOs, training and contracting of new CFCs doesn’t seem to be an option.

629. The Kyrgyz Swiss Health Reform Project introduced a model, which successfully works in many oblasts of Kyrgyzstan (it is popularly called “Jumgal model” since Jumgal raion in Naryn oblast was the pilot raion were it was implemented). The rationale of the model lies in the establishment of VHC at community level. They used a participatory rural appraisal (PRA) methodology to assess the needs of the community where local people expressed their ideas of what should be done at first place. Therefore, people began realizing that jointly they can solve problems of the community. Individuals responsible for specific issues, for example anemia, were appointed and a group of action was created. All activities are on a voluntary basis. The main motivation of the volunteers’ work is their belief in their and their children’s health, as well as reputation and social recognition of those people in their community.

630. There is a lack of collaboration between the state sector and civil society organizations. The latter have been involved in social sector projects supported by donors, but are not experi- enced in implementation of specific ECD interventions. Professional associations and organizations of local entrepreneurship and small businesses are not developed in many rural places and therefore do not play a major role for the CBECDP.

4. Parents

631. The Needs Assessment Survey revealed that parents’ knowledge of child development and child caring is very limited. The parents’ knowledge of MCH and MCN issues and key preventive behavior is very low; a big percentage of mothers do not know the basics of “a healthy way of life”; education of children within a family mostly includes watching TV programs, correcting misbehavior of children, and teaching personal hygiene. The survey demonstrated that parents have a lack of information and a low level of awareness about the importance of early age for the future development of their children.

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632. Most of the households covered by the needs assessment survey were poor. According to a recent study, seventy-five percent of the poor population lives in rural areas157. The unemployment rate among the parents interviewed in the needs assessment survey conducted in the framework of this PPTA was extremely high: 86% of surveyed mothers and 67.2% of fathers were unemployed. Therefore, parents’ payment capacities for ECD services are limited. Most of the children of the families covered by the survey do not attend PEOs, but are raised in the families without getting imparted the essential skills needed for their psychosocial development.

633. In rural areas, the big number of children in average families limits the families’ budget spending on each child. In addition, there are risks related to the environment (shortage of clean water, environmental pollution, sanitary conditions in households) that make it difficult to provide adequate care for early age children. Parents of disabled children experience embarrassment when bringing their children to public places. This was confirmed by the UCFS specialists in Is- sykata raion where they organized a special group for disabled children in the kindergarten. It can be said that the general public has no tolerance to children with disabilities. The project should address the issue of increasing tolerance towards children with disabilities who should have an opportunity for development.

C. ECD Financing Mechanisms at the Community Level

634. Presently all settlements (villages, cities) are transferred to local self-governments. There are 473 local self-governments including AOs and town councils with their own budget and staff. There is an ongoing process of decentralization of the fiscal system and budgeting in order to give the local self-governments opportunities to raise their own revenues and create their autonomous budgets. However, reforms in budget policy towards decentralization have started only recently and most of local authorities do not yet clearly understand the mechanisms and advantages of these reforms. Furthermore, most local officials are not very actively seeking to solve social and economical problems of the population including the problems related to ECD issues.

635. Currently most local self-governments are dependent on transfers from the republican (national) budget. Almost 90% of AOs do not generate enough revenues to cover their expendi- tures158. Local budgets do not include special budget lines for social programs and ECD, since the republican budget finances only some operational costs (communal services, electricity, heating, salary of staff). Lack of financial resources leads to a lack of flexibility in resource allocations. Budget expenditure has to follow the scheduled figures determined by the MOF. It is supposed that the introduction of the two-level budget (national and local), starting from 2008, instead of the recent four level (national-oblast-raion-AO) budget will make public expenditures at local level more demand driven and decrease administrative costs at the expense of different oblast and raion organizations funded by local budget which will be abolished).

157 2007 The Social tendencies of the Kyrgyz Republic, Issue 2. Bishkek 158 Ministry of Finance of the Kyrgyz Republic, 2004, “About mechanism of stimulating (matching) grants”, Bishkek

162

636. Local initiatives and projects receive additional funds from two main sources: the state budget through the so-called Stimulating (Matching) Grants (SMG) and international donors’ funds. Investments from the republican budget and resources provided by international donors are not included into the local budgets; therefore there are disproportions in volumes of capital investment and spending on maintenance of facilities. AOs and communities create social facilities like schools, kindergartens, water supply systems which need to be maintained through local resources and sometimes have more financial commitments than they can afford. This leads to significant imbalances in financing different facilities at local level159.

637. SMG is a money transfer from the republican to the local budget which is the supplementary financial resource for implementation of social projects at local level. Local self-governments make grant applications to the special commission of the MOF. The decision making process on co-financing of projects under the SMG involves several independent levels represented by AOs, raion and oblast commissions and the Commission of the MOF. Reportedly, to date the Commission received 477 SMG applications for 446, 4 million soms, whilst the government allocated 150 million soms in the state budget for this purpose. In the first semester of 2007 365 projects were approved for a total amount of 83,0 million soms. Among the approved projects are rehabilitation projects of 19 kindergartens and 35 hospitals. Since 2003 the MOF provided more than 1 billion soms through SMG160.

638. The FCBECDP created the Village Initiative Fund (VIF) out of which small projects at village level aimed at improving ECD are financed. The small grant projects are mainly directed to the establishment of community-based kindergartens; rehabilitation of FAPs, and creation of play grounds. The VIF is established by the MOF and legalized by the Ministry of Justice. Pro- jects from AOs are submitted to the oblast project coordination office, and then sent to Bishkek, where the selection committee selects projects for supporting. Until today 413 project applications were received, 195 of them were selected. A disadvantage of the VIF scheme is that it supports only projects with a budget up to 10,000 USD.

639. The Community Development and Investment Agency (Agentstvo Razvitiya i Investiro- vaniya Soobschestv -- ARIS) is financing community initiatives nationwide. ARIS supports communities through different donors’ funds. For instance, ARIS is implementing the WB’s Village Investment Project (VIP-I) with 15,5 million USD for community initiatives. The project is directed towards general community support to implement any social community project according to the needs and decision making processes of the community, including the repair of FAP’s and kindergartens. The policy of the WB project includes the following strong components: bottom-up approach, mechanisms of complex approach by key local council (Kenesh), work related to the needs of different target groups, village profile development, community based decision-making processes and cooperation with local authorities, territorial community authority (juridical public association) connected with a local council. Policy includes transparency and audits.

640. An important issue is that it is difficult to collect the monetary contribution of the communities, which is a requirement of almost all village investment projects financed by international donor and partner organizations. Thus, Urban Institute Bishkek (USAID’s contractor) has been providing grants to local communities for their infrastructure development. Cost sharing must be at least 10% of the total estimated project cost for the cities and 5% for villages161. In the Second VIP contributions of the beneficiary communities will be at least 25% of the AO grant allocation.

159 Ministry of Finance of the Kyrgyz Republic, 2004, “About mechanism of stimulating (matching) grants”, Bishkek 160 www.minfin.kg 161 http://www.ui.kg/indexe.htm

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By December 2005, for the 1,303 VIP funded micro-projects community contributions totaled just under US$3 million, including US$600,000 in cash.162 In other words, the communities’ share is usually up to 25% of the project costs. Since communities often apply to different donors, sometimes their members need to contribute to several projects at the same time.

641. On the other hand, ARIS’s experience shows that the communities are keen to share costs of the initiatives based on their needs and priorities. Therefore, every project proposal should also include a “sustainability plan” with detailed arrangements for post investment operations and maintenance of the projects results. This condition is a proven mechanism to avoid unaffordable projects at community level.

D. Strategy for Capacity Building in ECD

642. Capacity building as a strengthening of skills, abilities, and resources of all organizations and stakeholders involved in ECD issues is needed for improving ECD in the poorest raions of the Kyrgyz Republic. It is a well known fact that strengthening of the capacity of communities and their partners is an essential condition for the effective realization of social projects at the local level, especially those aiming to address the needs of the poor population. The sustainability of projects designed and implemented with the support of the communities is higher compared to projects developed without their involvement.

643. The specific objective with regard to capacity building in ECD is to create awareness and solicit commitment at policy makers’ level and at the level of AOs on the importance of ECD and to empower local communities to identify and address the needs related to ECD.

644. In order to achieve this objective, the following outputs should be produced:

(v.) Establishment of the institutional and legal basis for ECD (vi.) Building management capacity at national and local levels (vii.) Increasing the awareness on the importance of ECD and advocacy (viii.) Community Mobilization and Support to Village Initiatives

Output 1: Establishment of the Legal and Institutional Basis for ECD

645. In order to strengthen the capacity of authorized governmental bodies and NGOs/CBOs to plan, implement and monitor ECD activities, the legal basis for ECD needs to be improved and developed. Until recently the general legal documents dealing with human rights issues, health and education had indications on children’s rights, their well-being, and development. However in the situation of social and economical hardships, children were found as a group least protected by laws and regulations. The “New Generation Programme” stipulated a plan of action to improve childhood in Kyrgyzstan. In particular, the Children’s Code was adopted as a basic document for the protection of children’s rights and interests. To present there is a general legal framework for development of children in Kyrgyzstan, but mechanisms for the implementation of the legal framework still need to be developed. Laws and bylaws to the Children’s Code and other legal acts describing structures, procedures, and practices related to ECD issues need to be developed. The law on pre-school education, which is currently being developed, could be

162 Second Village Investment Project, Project Appraisal Document, July 6, 2006, p.54-55.

164 expanded into a law on ECD. In addition, the law on local self-government should be modified and amended in order to increase the accountability of the Heads of AOs for ECD.

646. The institutionalization of the recently established Department on Child Protection under the State Agency on Physical Culture and Sport, Youth Affairs and Child Protection should be supported mainly through support to the development of regulations, manuals, job descriptions, and support with needed equipment. Special tools and techniques aiming at identification and targeting of poor caregivers of early age children, children with special needs, and other vulnerable groups need to be elaborated in cooperation with relevant stakeholders, particularly those working with children with special needs such as disabled, mentally retarded, orphans, half- orphans, homeless, neglected, and those coming from poor families and families having many children. An adequate system of inclusive care for such children needs to be developed and expanded at the national level. These tools and techniques might be piloted in some raions and then distributed nationwide.

647. Establishing the Units for Child and Family Support (UCFSs) in each raion needs to be supported. To date there are only a limited number of pilot UCFSs in the Kyrgyz Republic because of lack of financing. The staff of the newly established UCFSs needs to be trained in ECD and the units need to be supported with computers and office equipment.

648. Key actions to be taken

(i) Development of the normative basis for ECD according to the Action Plan of the New Generation Programme. (ii) Assessment of the needs of the Department of Child Protection for effective functioning and for extension of its coverage to all important fields of work and all raions. (iii) Institutionalization of the Department by improving and developing the necessary legal documents and regulations. Technical assistance for the development of the legal basis of the Department (development of regulations, manuals, job descriptions) and support with equipment will be needed. (iv) Support to the process of establishing UCFSs in all raions of the Kyrgyz Republic through staff training and procurement of equipment (v) Organization of training on ECD issues among all central ministries and agencies involved in this work including the topics on legal basis (local and international) of childhood development, strategic planning, computer skills, tools of monitoring and evaluation, project management. (vi) Development of annual and quarterly working plans on ECD should become standard practice for all levels of the authorized state organ on children’s issues with regular reporting to higher organs, public, and communities.

Output 2: Building Management Capacity at National and Local Levels

649. The capacity to manage ECD activities at the national and local levels needs to be strengthened. The role of ministries is to provide policy guidance and to support oblasts in the implementation of the policies. To this end, ministries and agencies concerned need to be trained in policy analysis and ECD policy development. At national level management guidelines for oblast and raion level need to be prepared. The guidelines should include an overall ap-

165 proach to management and specific tools for carrying out the ECD approach. Training material needs to be prepared to facilitate introduction and use of these management approaches and tools.

650. Local state administrations and specialists on child and family issues need to be trained in planning, implementation, monitoring, and evaluation of ECD activities at local level, general aspects of early childhood development (ECD), financial management, including transparency, accountability and reporting arrangements, operations and maintenance of preschools, including cost sharing schedules etc. AO should be supported to integrate ECD issues in their social and economic development plans and they should be trained in monitoring of ECD indicators. Child and Family Coordinators should be trained in each AO. In order to ensure the sustainability of this measure, the position should be legalized through a Government Order and it should be included in the AO’s budget. Local state administrations, local self-governments, NGOs and CBOs should be supported through establishment of the UCFSs at raion level.

651. Based on the existing experiences with community-based initiatives of ARIS, SRC and the AKF CBOs focusing on ECD issues named Parents’ Committees should be established in each village. A Parent’s Committee usually exists in each school. The Committees provide help and support to school initiatives, such as organization of festivals, competitions, renovation of the school facilities etc. Borrowing this name for a Committee focusing on ECD issues at the village level will contribute to the acceptance of these Committees by the population. Supposedly these committees will consist of (but not restricted) parents and caregivers of children from birth till 17 years of age. Therefore this will become a long-term structure based on the core interest of parents in better well-being and development of their children.

652. A special system for identifying and analyzing the needs of children and their families with further creation of a complete and comprehensive data-base on AO level will need to be established. The system should be based on regular household surveys conducted by the local administrations with the active support of communities. The existing system of monitoring and evaluation of ECD indicators will be improved by taking into consideration of the information from the created and regularly updated data-base. Since social workers usually do not perform household surveys, but people seeking state social benefits come to them to fill in social pass- port data, it is clear that AO’s are not able to maintain a proper and comprehensive monitoring system. Therefore, community volunteers should support them in undertaking the surveys.

653. Key actions to be taken:

(i) Training for governmental bodies at the local level on management of ECD activities including, inter alia, how to organize the work with communities, how to examine the needs of people related to ECD services; how to conduct household surveys; how to control the quality of ECD services. (ii) Training of AO personnel on planning the work on ECD, establishing alternative forms of kindergartens, fundraising, strategy of social mobilization, PRA training, etc. (iii) Training of CFCs in ECD issues including children with special needs; etc. (iv) Training for NGOs and CBOs on micro-project financing and accounting.

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Output 3: Advocacy and increasing awareness on the importance of ECD

654. To achieve this output firstly the state specialists responsible for ECD need to be trained on a regular basis. Their task is to transfer knowledge and skills to the community members. Due to frequent changes of the personnel especially at AO level it is important to develop pre- service training programs, clear job descriptions and manuals which will allow personnel to easily adopt and follow the functional responsibilities needed in work with families and children.

655. Mass-media specialists, including TV journalists, should receive training on how to cover children’s problems in mass-media. A proper attention should be paid to create a tolerant environment for disabled children and children with special needs. TV programs and regular publications for children and parents aimed at increasing their awareness on the importance of ECD and knowledge on ECCE, health promotion and disease prevention, nutrition and promoting fortified food will be developed; TV spots, educational films, posters and flyers on ECD should be developed and distributed in remote areas at national level. A knowledge exchange in journalism will be organized.

656. An integrated Communication and Advocacy Strategy that includes all ECD components should be developed and implemented. The strategy should target decision makers and pressure groups whose behavior directly influences ECD policies and environment in the Kyrgyz Re- public.

Key actions to be taken

(i) Development of a Communication and Advocacy Strategy for ECD in Kyrgyz Re- public. (ii) Organization of informational campaigns on ECD goals, activities, and mechanisms of implementation at all levels: national, oblast and raion administrations, AOs, local councils, and parents. (iii) Organization of informational and educational campaigns for the beneficiaries of ECD services (knowledge and skills in ECD, healthy life style, nutrition etc). (iv) Work with international partners in the mass-media having experience in covering children’s issues for organization of the exchange programs and trainings for local journalists with issuing of the special TV and multi-media programs and projects.

Output 4: Community Mobilization and Support of Village Initiatives

657. A process of mobilization of the communities to organize village initiatives in ECD should be initiated through raising the communities’ awareness on the possibilities of funding their initiatives through the Village Initiative Fund (VIF) and Stimulating (Matching) Grants. Communities should be encouraged to apply for funds from VIF and SMG and they need to be trained on how to write the project proposals and apply for funds. The maximum financing per project of USD 10,000 needs to be reconsidered due to increasing costs of construction material and services. Special attention should be paid to the proposals co-funded by Stimulating (Matching) Grants. As a result communities and CBOs will increase the total amount of the financing their initiatives.

658. The community mobilization process should start with a first community mobilization meeting organized by AO head. The purpose of this meeting is to increase the communities’

167 awareness on the importance of ECD, on measures and ways to improve ECD in their community and on existing mechanisms to fund ECD project activities. In these meetings, communities should select volunteers who are interested to work on ECD issues in their communities and who will receive various training. The training should include training in participatory situation analysis, project planning and monitoring as well as proposal writing. The community will be assisted by the volunteers to conduct a participatory ECD situational analysis in their villages in order to identify specific needs related to ECD. After the situation analysis the volunteers should support communities to identify and prioritize possible projects. Upon selection of the project, the volunteers should commence project preparation and designing. In developing proposals, communities may choose to work with schools, FAP, women’s group, or NGOs. The ECD project proposals will be submitted to AO heads, who will review the proposals and forward them to the respective funding agency.

Figure 1: Project Cycle

Step 1: Step 2: Step 3: Step 4: Project Training & project Prioritization Proposal Orientation conduct of PSA Development

Step 8: Step 7: Step 5: Fund release in Committee Review & AO and Raion Staff tranches Approval Endorsement

Key actions to be taken

(i) Trainings of local volunteers, activists and leaders to support and coordinate the village initiatives; (ii) Trainings on project writing and application process for receiving the Stimulating (Matching) Grants. (iii) Organization of experience exchange between communities. (iv) Support to the established Parents’ Committees by organizing trainings and knowledge exchange. (v) Establishing participatory monitoring and evaluation mechanisms of ECD at community level.

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VI. ECONOMIC AND FINANCIAL ANALYSIS

A. Education and Health Finance

1. Macroeconomic Context

659. The Kyrgyz Republic is a low-income country with a gross national income (GNI) per capita of $440 in 2005 (Atlas method). The country of 5.2 million people is landlocked and mostly mountainous. The agricultural and industrial production base is small, leaving the country vulnerable to natural disasters and external shocks. The agriculture, gold mining, and trade sectors have witnessed strong growth. Other sectors of the economy, notably manufacturing, have remained stagnant or have declined continuously. On the demand side, consumption (including imports) and public investment led the recovery, fueled by ample external financing. More recently, investments by (public and private) enterprises and net exports have been prominent. The country has made considerable progress in attaining macroeconomic stability in the past few years. Average GDP has grown at about 5 percent a year since 1996, and the high rates of poverty have started to decline since 2000. The Kyrgyz Republic has implemented broad systemic reforms to create the foundations of a market economy. Some 70 percent of farm land is now privately owned as a result of generally equitable land reform, and the economy is relatively open with a liberalized foreign trade regime and full convertibility of the Som, the Kyrgyz currency. After independence, the government began a series of measures aimed at improving the efficiency of the public sector.

660. During 2000-2006, the Kyrgyz Republic recorded positive growth in GDP due to substantial investments in macroeconomic stability. Annual real GDP grew by 7.0% in 2004, dropped to -6% in 2005163, and returned to 5% in 2006164. Much of the growth has been spurred by the agriculture, gold mining and energy sectors. Revenues and expenditure as a percentage of GDP was 21.9 and 22.8 percent respectively in 2006, with a budget deficit of 3.5% in 2006. The positive trend in economic growth is expected to continue in the medium-term, as the Medium Term Budget Framework, 2007-2009, projects GDP to reach 7% in 2009, and with population growing at a slower pace (1% per year), per capita GDP is expected to increase by 14% annually over the medium-term. Debt service has been reduced to about 14.2% of exports of goods and services in 2004, and short term outstanding debt is just US$7.5 million during that year165. The high burden of external debt remains a critical economic challenge and in the medium-term economic policies will continue to focus on macroeconomic growth and fiscal consolidation. The key economic reforms to achieve this objective are: reform of the tax regime, introducing labor market flexibility, continuing control expenditures, and linking budget formulation to priorities to the Government policy. Table 27 provides the macroeconomic indicators. It shows that real GDP growth is projected to average just over five percent per year up to 2008.

163 Political crisis occurred in March 2004 which affected the economic situation in 2005. 164 Ministry of Finance, Medium-Term Budget Framework 2007-2009. 165 ADB, 2006, Key Indicators of Developing Asian and Pacific Countries

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Table 27: Selected Country Indicators and Trends (2003-2009) Particulars Actual MTBF Projection 2003 2004 2005 2006 2007 2008 2009 Gross Domestic Product (GDP) 83,871.6 94,350.7 100,115.5 111,113.0 122,379.3 135,620.0 150,861.8 (mln KG Som)

GDP real growth rate (%) 7.0 7.0 -0.6 5.0 5.5 6.5 7.0

Population (thous.person) 5,037.3 5,092.8 5,138.7 5,190.2 5,242.1 5,294.6 5,347.7

GDP per capita (US$) 445.1 471.7 561.6 613.4 673.0 741.2

Inflation rate (%) 5.6 2.8 4.9 4.5 4.0 4.0 4.0

External debt/export of goods and 1.7 1.9 1.9 2.4 2.5 3.1 3.7 services (%)

State Budget Deficit (% of GDP) 4.8 4.4 4.2 3.5 3.0 2.8 2.7

Public Expenditures (mln KG Som) 16,895.9 18,841.7 20,143.7 25,301.2 31,332.1 34,123.6 37,263.7 Public Expenditures as a share of 20.1 20.0 20.1 22.8 25.6 25.2 24.7 GDP Public Expenditures per capita 75.9 88.9 94.9 127.9 157.0 169.3 183.1 (US$)

Public Revenue 15,212.8 17,005.9 19,975.4 21,833.3 24,151.2 27,260.2 30,807.9

Public Revenue as a share of GDP 18.1 18.0 20.0 19.6 19.7 20.1 20.4

Average wage (KG Som) 1,920.4 2,202.5 2,569.5 2,859.8 3,180.1 3,505.8 3,842.9

Poverty (% of population ) 49.9 45.9 43.5 41.5 39.0 37.0 34.5

Exchange rate (KG Som per 1 US$) 44.2 41.6 41.3 38.1 38.1 38.1 38.1 at the end of period

Source: Ministry of Finance, Medium-Term Budget Framework 2007-2009

661. Despite pro-poor growth in the past few years, the country remains one of the poorest in the world with about 41.5 percent of the population below the poverty line ranking 109 out of 177 countries (2005) in terms of human development index, making the Kyrgyz Republic eligible for grant funds from the International Development Agency, the World Bank's concessional lending facility. Despite steady growth in agriculture, almost three quarters of the poor live in the rural and mountainous regions. Moreover, access to basic public services such as running water, public sewerage, health, and education has deteriorated over the past decade. Reducing poverty will require strong and sustained economic performance with strong growth at the grass roots, especially in the rural areas. It will also require growth in small and medium enterprises, improved debt management, better social protection strategies, and good governance. Income equality is moderate as evidenced by the current Gini index of 34.8166; and unemployment rates are 8.1 percent in 2006. The inflation rate in 2006 was 4.5 percent167.

166 Human Development Report 2005. 167 Ministry of Finance

170

662. In view of the country’s low income and high poverty levels, enhanced growth is the most fundamental requirement for progress in poverty reduction, consistent with fiscal and external sustainability. Reforms in the public sector (i.e. fiscal and public expenditure reforms) will play a significant role in encouraging the development of the private sector, while ensuring that resources are efficiently targeted to the most vulnerable groups of the population. Public expenditures in health and education have suffered most from the fiscal adjustment. Policy reforms, in particular, have not been matched by progress in the areas of institutional reform and governance. The level of corruption is very high and is a major impediment to enhancing public service delivery and the investment climate. The administrative capacity of the various levels of government is very weak and severely limits the capacity to prioritize and implement policies. The Gov- ernment has initiated a series of public expenditure management reforms, including better budget formulation and execution and a move towards results-based monitoring. Government economic reform strategy is expected to address these issues, which are reflected in the Me- dium Term Budget Framework’s (2007-2009) increased spending for these public reform initiatives.

2. Education and Health Finance

663. Public expenditures in health and education have suffered most from the fiscal adjustment after 1998, and private contributions have gained in importance as a source of finance. The poor regions have been negatively affected, and there is a wide divergence in the quality of these services throughout the country. The large rural population makes matters more difficult. A series of reform initiatives, mainly in health but also in education, has been implemented successfully in small oblasts and now can be extended to the larger ones. Since health and education represent the bulk of resources managed by the lower levels of government, there is a need to tighten coordination between social sector reforms and adjustments to the intergovernmental finance framework. Moreover, the acute scarcity of public funds in the Kyrgyz Republic necessi- tates the allocation of funds that will achieve the best results for education and health outcomes. Although many households are willing to bear part of the cost of these services, government intervention is required for services that provide public goods and concurrently ensure that public resources are efficiently targeted to the most vulnerable groups of the population.

664. Sector Financing Reforms. A major challenge of the education delivery is the high proportion of rural population (65 percent), which affects both the delivery and demand for education. Rural schools have relatively high costs, lower teacher utilization rates, are deterrent to school attendance and performance. Declining education quality and access results mainly from cumulative budgetary neglect. This has led to increasing reliance on non-budget sources (uneven local financing, parental contributions, and supplementary income). In education at the compulsory level, co-payments are not desirable. There exist deficiencies in the financing and budget process for education, including the major discrepancies in resources available for urban schools and the lack of incentives for efficient delivery at the local level. Education reforms currently address issues affecting sector performance and efficiency, including unequal capacity for local financing, depressed teacher salaries, lack of efficiency incentives, school rehabilitation needs and transparency in access. This reform can be supported by gradual increases in budget allocations, which could reach to 5 percent in 2009. To address the issue of inequality in service delivery among the regions168, the following are being undertaken: (i) development of a capitation-based formula by MOEF for primary and secondary and primary health care facilities; (ii) increased funding for resource poor areas; (iii) approach to budget formulation based on mini-

168 Presently education spending favors urban and relatively resource-rich regions.

171 mum standards of education service delivery; and (iv) increased depressed teacher salaries, among others.

665. In health, measures were adopted through its health sector strategy known as “Manas”169 to redress imbalances in the health care delivery network and strengthen its orientation towards preventive and primary health care; improve equity in resource allocation; and to address constraints to health services. This reform program resulted in increased share of primary care in overall health expenditure (7 percent in 1994 to 18 percent in 2004); improved equity in health service utilization; expanded PHC through family medicine model (90 percent by 2005); reform in hospital financing, “rightsizing” of the health infrastructure and human resources; and significant moves toward formalizing informal payments. A combination of reforms in health financing and payment systems included the establishment of a single-payer system centered on the Mandatory Health Insurance Fund (MHIF) in 1997-and ADP. Progress has been made in developing a comprehensive health care financing reform that has shown potential gains to improved public resources management for health care. Public health funding, however, has been on a decline, and remains focused on tertiary care, which has had negative impact on poor populations.

666. Public Expenditure on Education and Health. Public resources allocated to health and education together represented 8.5 percent of GDP and 37.1 percent of total government spending (Table 28). Education and health spending indicated increased at an average of about 12 percent from 2004 to 2009170. The share of the consolidated public budget allocated to the education sector was essentially the same (23 percent) in 2004 as in the 1990’s. In spite of this level of commitment, the share of GDP fell by about half during the same period. The effects of the budgetary contraction in education programs included widespread deprivation of the basic educational materials, infrastructure, and teacher salaries.

169Manas Taalimi Health Reform Program was developed in 2005 by the MOH as a successor to the Manas strategy and is an extension of the health goals embedded in the National Poverty Reduction Strategy (NPRS) (2002) and Comprehensive Development Framework (CDF). It aims to institutionalize the reforms initiated under Manas I and to strengthen parts of the health system. It will be implemented through a SWAp (Sector Wide Approach program). 170 MTBF projected data however does not reflected the salary increases implemented in 2006.

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Table 28: Public Expenditure on Education and Health (2004-2009)

Particulars 2004 2005 2006 2007 2008 2009

Total Education and Health 6,283 7,201 9,373 8,512 9,624 10,507 Expenditures (mln. KG Som) Public Education Expenditures 4,357 4,918 6,314 5,671 6,527 7,125 (mln. KG Som) Public Health Expenditure 1,926 2,283 3,059 2,841 3,097 3,381 (mln.KG Som)

Total Education and Health 6.7 7.2 8.4 7.0 7.1 7.0 Expenditures as a share of GDP (%) Total Education and Health 37.2 38.2 37.0 33.6 30.7 30.8 Expenditures as a share of State Budget Expenditure (%)

Public Education Expenditures as a 4.6 4.9 5.7 4.6 4.8 4.7 share of GDP

Public Education Expenditures as a 23.1 24.4 25.0 18.1 19.1 19.1 share of Public Expenditure (%) Public Education Expenditures per 20.6 23.2 31.9 28.4 32.4 35.0 capita (US$)

Public Health Expenditure as a share of 2.0 2.3 2.8 2.3 2.3 2.2 GDP Public Health Expenditure as a share of 10.2 11.3 12.1 9.1 9.1 9.1 Public Expenditure (%)

Public Health Expenditure per capita 9.1 10.8 15.5 14.2 15.4 16.6

Source: Ministry of Finance, Medium-Term Budget Framework 2007-2009

667. From a regional perspective, education expenditure as a share of GDP is significantly lower than it was shortly after independence; it now appears to be similar to the share in other countries of the Former Soviet Union. Per capita expenditure on education shows a wide divergence, with expenditure levels in Kyrgyzstan being in the middle range among the countries compared. Currently, Kyrgyzstan ranks at the middle of the list of the countries of the former So- viet Union, in terms of public expenditure on health sector, expressed as a share of GDP and per capita health expenditure. Compared to countries in the same economic ranking, Kyrgyzstan is comparable (Table 29). While the recent high rates of economic growth will have led to increasing levels of real expenditure in the sector there is a clear need for structural change to assure quality service delivery. Per capita spending in health is still way below the prescribed amount of $34171. This level of expenditure has been augmented by private contributions.

171 WHO standards.

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Table 29: Regional Comparisons of Education end Health Expenditures, 2001-2006

Countries 2001 2002 2003 2004 2005 2006 Per Per Per Per Per Per % % % % % Capita Capita Capita % GDP Capita Capita Capita GDP GDP GDP GDP GDP ($) ($) ($) ($) ($) ($) Education Kyrgyzstan 3.1 9.7 4.4 14.6 4.5 17.0 4.6 20.6 4.9 23.2 5.7 31.9 Armenia 2.5 16.1 2.1 15.5 2.1 19.1 2.5 30.4 Kazakhstan 3.7 67.8 4.4 62.1 4.0 56.5 4.2 4.4 Azerbaijan 3.8 24.6 3.9 27.2 3.7 30.1 3.7 32.9 3.4 35.0 Tajikstan 2.4 3.9 2.6 4.5 2.4 5.8 2.7 8.1 3.5 11.5 Mongolia 9.6 36.7 9.7 37.2 10.2 39.5 11.3 46.1 11.1 46.6 Low income countries 3.5 (average) Health Kyrgyzstan 1.8 5.7 1.9 6.70 1.9 7.3 2.1 9.1 2.3 10.8 2.8 15.5 Armenia 1.3 8.7 1.2 8.5 1.2 10.8 1.3 15.8 Kazakhstan 1.9 27.0 Azerbaijan 0.8 0.9 6.5 0.8 0.9 1.0 14.9 Tajikstan 1.0 1.5 0.9 1.6 0.9 2.2 0.9 2.9 1.1 3.8 Mongolia 5.2 19.7 5.4 20.8 5.1 19.9 5.9 23.9 6.0 25.2 Low income countries 1.2 5.80 (average) Source: ADB Key Indicators, 2006

a. Education Finance

668. In terms of relative shares, general education (Grades 1 to 11) comprises the majority of education funding, accounting for about 75 percent of total public education expenditures. Higher education consists of about 25%, with secondary vocational education representing only 4% of total budgets. Fees are the mainstay of higher education funding, consisting of more than 75 percent of the total higher education budget. Pre-school education represents about 6% of the general education budget. From 2001 to 2006, total education expenditure grew at an average of 8.6 percent in real terms. Table 30 provides the summary of education funding.

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Table 30: Summary of Education Funding: 2001 –2006, KGS mln. Type of the education 2001 2002 2003 2004 2005 2006

Pre-School education 185 217 231 223 304 346 General education 1,516 1,685 1,799 2,081 2,097 2,118 Primary vocational education 156 174 231 267 318 302

Secondary vocational education 85 79 88 101 127 137

Higher education, including: 516 644 765 875 960 859 budget financing 130 134 190 197 219 225 tuition fees 385 511 576 679 741 634 Other Education Expenditures* 392 551 637 810 1,113 2,553

Total Public Education Expenditures 2,849 3,350 3,753 4,357 4,918 6,314

* Other Education Expenditure includes:Out-of-school services, Development of methodology end education support service, Management and administration.

Source: Ministry of Finance, Ministry of Education

669. The MTBF, 2007-2010 provides information on the budget estimates for the period until 2010 (Table 31). This table shows different source of funding. Table 31 provides an overview of the projected spending on education over the period.

Table 31: MTBF Forecasts of State Budget Expenditures for Education, 2007-2010 In KGS mln.

Particulars Approved Forecast

2007 2008 2009 2010 Current Education expenditures 6,151.9 6,823.7 7,410.3 8,346.1 as a share of GDP, % 5.0% 4.8% 4.6% 4.7% as a share of previous year, % 110.9% 108.6% 112.6% as a share of Total State Budget expenditures, % 21.4% 22.1% 21.3% 20.9% Investments, including: - Internal co-financing and promotional grants 467.8 593.4 628.3 658.8 as a share of GDP, % 0.4% 0.4% 0.4% 0.4% as a share of previous year, % 0.0% 126.9% 105.9% 104.9% as a share of Total State Budget expenditures, % 24.7% 28.0% 27.8% 31.3% - External funds 456.7 565.8 457.6 281.1 as a share of GDP, % 0.4% 0.4% 0.3% 0.2% as a share of previous year, % 79.0% 123.9% 80.9% 61.4%

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Particulars Approved Forecast

2007 2008 2009 2010 as a share of Total State Budget expenditures, % 8.8% 9.9% 10.9% 12.7% Total financing 7,076.4 7,982.8 8,496.1 9,285.9 as a share of GDP, % 5.8% 5.6% 5.3% 5.2% as a share of previous year, % 123.9% 112.8% 106.4% 109.3% as a share of Total State Budget expenditures, % 19.8% 20.6% 20.6% 21.0% Source: Medium-Term Budget Framework 2007-2010

670. This statement is consistent with the approach taken in this Report on the issue of entrepreneurship and seeking efficiencies. NPRS demands efficiency and greater self reliance of the education sectors. The objectives of the proposed Project are consistent with such an approach. Under some of the present arrangements, funding is driven by formulas which entrench inefficiencies and which do not permit savings in one area to be allocated to higher priority needs. The opportunity to reallocate resources, as stated in the MTBF will give the PVS, and the new Agency, the opportunity and the incentive to adopt new staffing and financing arrangements which result in significant quality improvements in the training programs offered. Public spending on education as a percentage of total government spending are projected to increase from current levels (KGS 6.3 million in 2006 approved budget to KGS 7.1 million in 2009. The MTBF provides a more detailed breakdown of its forecasts, but not for early child education separately.

671. Preschool Education and Early Child Development (ECD). Recent studies have shown considerable decline in student achievement in Kyrgyzstan especially at the elementary level172. The preschool education system has contracted drastically due to the closure of departmental kindergartens owned by enterprises and state farms which became bankrupt. The number of public pre-school institutions (PEOs) declined (1,604 in 1990 to 448 in 2005, with number of preschool students at 54,365) due to the general socio-economic crisis in the country, unemployment, and increased internal migration and the majority of kindergarten buildings being sold. Rural preschools had the most reduction in schools, and despite the rural population being 65 percent, only 27 percent of preschool enrollment are rural. There also has been a decline in school infrastructure, current curriculum does not provide sufficient student development or modern training, and there is a lack of textbooks, and there are documented problems with school administration, monitoring and evaluation.

672. Major reasons for the deterioration of preschool and primary school pupils' performance are as follows: poor level preparedness for school due to the small number of kindergartens and programs for pre-school child development; poor socio-economic family conditions; poor financing for schools and as a result, a lack of basic teaching tools; low professional level of teachers; lack of a proper physical learning environment (heating, lightning, water supply, lavatories, etc.). In addition to a quantitative decline in preschool programs, the quality of preschool programs also deteriorated. The existing 448 kindergartens currently employ 2,388 teachers, not all of whom have adequate professional training and opportunities improve their professionalism. Considering the importance in developing school skills and forming the ability to learn, there is a huge difference in qualitative education between urban and rural residents, and between wealthy and needy families. Although the Kyrgyz Republic had established preschool education

172 ADB, 2004, Education Sector Development Program, Bishkek

176 system before independence, preschool programs needed to be updated to meet current international standards. Recognizing need for expanding and qualitatively upgrading preschool programs, the Ministry of Education (MOE) adopted the preschool education concept in 2005, and submitted the new preschool standards in 2006 for the government’s approval. The concept and standards embrace alternative models of preschool. Table 32 shows the declining budgetary allocations to pre-school education. Majority of the pre-school funding sources are mainly from the local budget and special funds (87 percent).

Table 32: Pre-School financing from different sources: 2001-2004173, KGS thousand

Particulars 2001 2002 2003 2004 Ave. Average 2001-2004 % Share Total for Pre-School Education 184,825 217,255 231,031 222,556 213,917 100.0 Republican Budget 2,585 3,450 4,497 4,802 3,833 1.8 Republican Budget (special funds) 2,460 5,630 4,683 4,103 4,219 2.0 Local Budget 131,377 148,431 159,877 150,927 147,653 69.0 Local Budget (special funds) 30,657 39,921 40,921 40,921 38,105 17.8 Parents' Contribution, 50% on Food Exp. 17,746 19,824 21,055 21,805 20,107 9.4

Source: Ministry of Finance, Ministry of Education

673. Government financing in 2005 was KGS 290.8 million ($7.27 million), the majority of which went on salaries (45 percent) and food (36 percent, part of which is borne by parents). Preschool building maintenance is financed by local governments. During the prior years, cost expenditure by item comprised the following: salaries - 49 percent, utilities – 33 percent, food – 13 percent (excluding parents contribution of 50 percent, as mandated by law), with relatively small sums available for consumables and repairs (Table 33).

173 Latest information available from MOF and MOE

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Table 33: Public Spending on Pre-Schools (without Special Fund and Parents' Contribution): 2001–2004174, KGS thousand

Particulars 2001 2002 2003 2004 Ave. Average 2001-2004 % Share

Sum total for State Budget 133,962 151,881 164,373 155,728 151,486 100.0 1. Expenditures for Pre-school staff 60,065 71,681 81,573 81,878 73,799 48.7 1.1.Salary 46,983 56,796 65,263 65,492 58,633 38.7 1.2.Allocations to the Social Fund 13,082 14,885 16,311 16,385 15,166 10.0 2. Children social protection 17,775 19,844 21,076 21,826 20,130 13.3 2.1. Food expenditures 17,746 19,824 21,055 21,805 20,107 13.3 2.2. Schoolarships 0 0 0 0 0 0.0 2.3. Medicaments 29 20 21 21 23 0.0 3. Utilities 48,943 52,799 52,676 46,976 50,349 33.2 3.1. Water Supply 5,014 10,098 10,037 10,037 8,796 5.8 3.2. Electricity 13,160 15,708 15,783 10,283 13,733 9.1 3.3 Gaz 347 27 27 27 107 0.1 3.4. Heating 29,645 25,649 25,553 25,553 26,600 17.6 3.5. Communication 351 309 269 69 249 0.2 3.6. Other Utilities & Rental Fees 428 1,008 1,008 1,008 863 0.6 4. Equipment, inventory and materials 384 566 856 856 665 0.4 5. Major repairs of buildings 4,240 4,452 5,665 3,165 4,380 2.9 6. Other 2,554 2,541 2,528 1,028 2,163 1.4 6.1. Travel Allowance (Local) 76 104 104 104 97 0.1 6.2. Vehicle Maintenance 194 282 282 282 260 0.2 6.3.Other Purchases & Services 2,285 2,155 2,142 642 1,806 1.2

Source: Ministry of Finance, Ministry of Education

674. The substantial increases in preschool education as projected by MTBF is attributable mainly to the projected annual wage bill increase (by an average of 15%) beginning from 2006. Additional funds in the MTBF forecast are targeted to address the currently low teachers’ salaries. However, funding for capital investment, and corresponding maintenance and other recurrent expenses should be ensured (Table 34).

174 Latest information available from MOF and MOE

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Table 34: MTBF Forecasts for Pre-School Education Expected changes 2005 2006 2007 2008 % Projection expenditure increasing is: 304.1 346.1 405.2 443,3 13.8% in 2006 as compared with 2005 mln.KGS mln.KGS mln.KGS mln.KGS (including (including (including (including 17.1% in 2007 as compared with 2006 Special Special Special Special means) means) means) means) 9.4 % in 2008 as compared with 2007 Source: Ministry of Finance, Medium-Term Budget Framework 2006-2008

675. Preschool education as a percentage of general education is currently about 6.2 percent of the general education budget, 25 percent of the primary education budget and 10 percent of the higher education budget (Table 35). The unit costs for preschool education in 2005 was KGS 6,256 (inclusive of private contributions), with government cost per student at KGS 3.673. The norms on food expenditures at kindergartens approved by government are: kindergarten groups: until 3 years old: 9-10 open hours – KGS 9; 12-24 open hours – KGS 12 - 3–7 years old: 9-10,5 open hours– KGS 12; 12 open hours – KGS 13; 24 open hours – KGS 14. Fifty percent of food costs are covered by parents; and annual payment of parents on voluntary basis are: (i) in urban areas – KGS 160, (ii) in rural – KGS 100.

Table 35: Costs for Preschool Education, KGS Million

2001 2002 2003 2004 2005 General Education Expenditure 2, 847.6 3,350.4 3,753.6 4,361.3 4,917.7

Preschool Education 190.0 219.5 232.1 257.2 304.1

% Preschool to General Education Expenditure 6.67 6.55 6.18 5.90 6.18

Source: Ministry of Finance, Ministry of Education

b. Health Finance

676. The arbitrary nature of budget execution, departures from original budget allocations and uncertainty of resource availability continue to affect the health sector. Inequality in access to health services has improved during the last 10 years, as a result of the Manas program, with a larger share of health spending going to primary and preventive care175. Allocations for public health and health promotion remain limited. Manas reforms, combined with the development of a financing system that mitigated financial barriers to care – since primary care is free, the incentive to bypass it has been reduced – led to improvements in both access and quality of care. With the move from financing inputs to programs in the health sector this problem may become more acute; therefore, close monitoring of budget execution will be an essential part of the Ma- nas Taalimi program, as will an integrated approach to public financial management reform that addresses systemic problems of budget execution rather than insulating a single sector alone.

175 The World Bank Report No: 34079-KG. Project Appraisal Document on a proposed grant in the amount of SDR 10.4 mln (US$ 15.0 mln equivalent) to the Kyrgyz Republic for a Health and social protection project. November 23, 2005. page 2

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677. The table 36 below shows increased spending in health, as real public health expenditures grew twofold from KGS 1,378 million in 2001 to KGS 3,059 million in 2006. From 2001 to 2006, public expenditure on health increased from 1.9 percent to 2.8 percent as a share of GDP, and 11.2 percent to 12.1 percent of government expenditure, respectively; and republican spending increasing from 30 percent to 90 percent of total government health expenditure and local government spending on health falling from 70 percent to 9 percent, also as a share of total government health expenditure. Budget execution has repeatedly challenged the ability of the MHIF to meet contract commitments with providers, which has in turn led to the accumulation of defacto arrears to providers.

Table 36: Total Health Expenditures by Funding Sources

Particulars 2001 2002 2003 2004 2005 2006

Public Health Expenditures 1,378.3 1,527.3 1,630.0 1,925.6 2,283.3 3,059.1 (mln.KG Som), including: Budget funding 1,290.1 1,430.1 1,528.2 1,808.1 2,147.6 2,886.5 Special funds 88.2 97.2 101.8 117.5 135.7 172.6 Republican budget 429.4 450.8 499.3 699.9 113.2 2,773.2 Local budget 949.6 1,076.4 1,130.6 1,225.7 2,170.1 285.9

Source: National Statistic Committee

678. Public to private shares in total health spending indicate a growing share of private out- of-pocket expenditure, which grew from 2.4 percent of GDP in 2001 to 2.8 percent in 2006, representing over 50 percent of health spending (Table 37). MHIF grew at an average growth rate of 33 percent from a narrow base, budgetary sources grew by only 5 percent, and private funding grew by 14 percent during the same period. The breakdown of per capita spending by funding source is likewise shown in the table.

Table 37: Public-Private Shares and Total Health Expenditures

Annual average growth rate % 2000 2001 2002 2003

As share of GDP (%) Budget 1.9 1.7 1.9 1.8 -0.9 MHIF 0.2 0.2 0.2 0.4 23.0 Private 2.3 2.4 2.7 2.8 6.9 Total 4.4 4.3 4.8 5.0 4.4 As share of total health expenditures (%) Budget 42.2 39.6 38.7 36.3 -4.6 MHlF 4.9 4.2 4.6 7.2 16.4 Private 53.0 56.2 56.7 56.4 2.2 Total 100.0 100.0 100.0 100.0 0.0 Per capita health spending nominal (in KGS) Budget 247.5 255.7 283.1 300.6 7.2 MHlF 28.5 26.9 33.4 60.0 36.8

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Annual average growth rate % 2000 2001 2002 2003

Private 310.8 362.9 415.0 467.1 16.8 Total 586.8 645.5 731.5 827.7 13.7 Per capita health spending real 2000=100 (in KGS) Budget 247.5 243.2 263.6 286.3 5.2 MHlF 28.5 25.6 31.1 57.1 33.5 Private 310.8 345.2 386.4 444.8 14.4 Total 586.8 614.0 681.0 788.2 11.4 Source: The World Bank: Project Appraisal Document on a proposed grant on the Kyrgyz Republic for a Health and Social Protection Project. 2005

679. Projected health spending (MTBF) have likewise indicated increased spending from 2.7 percent to 3.3 percent of GDP from 2006 to 2008, respectively, in support of government health sector reforms (Table 38).

Table 38: MTBF Forecasts for Health, 2006-2008 In KGS mln.

Growth Growth Growth Grow Particulars 2004 2005 2006 2007 2008 % % % th %

Total current and projected budgets for Health 3,107.6 3,607.5 16 4,132.1 15 4,684.0 13 4,893.5 4 Actual Expenditures 2,664.6 3,047.7 14 3,601.1 18 4,355.3 21 4,731.7 9 % 86 84 87 93 97 including: Financing the current health needs from all sources: 2,144.4 2,438.7 14 3,072.6 26 3,750.6 22 4,462.5 19

Actual expenditures % 69 68 74 80 91 As share of GDP % 2.3 2.4 2.7 3.0 3.3 including: State budget for current financing 1,516.1 1,731.,4 15 2,305.8 33 2,817.6 22 3,387.0 20

Actual expenditures % 49 48 56 60 69 State budget financing for disableds’ health insurance 123.8 129.4 4.5 141.9 10 233.5 65 287.2 23

Special funding 93.9 131.5 40 140.7 7 161.8 15 186.1 15 Actual expenditures % 3 4 3 3 4 MHIF 203.5 224.0 10 268.8 20 322.3 20 386.8 20 Actual expenditures % 7 6 7 7 8 Co-payment of population 207.1 215.4 4 215.4 0 215.4 0 215.4 0 Actual expenditures % 7 6 5 5 4 Additional PIP financing 520.2 609.0 17 528.5 -157 604.7 14 269.2 -274

Recovering of the needs % 17 17 13 13 6 Source: Medium-Term Budget Framework 2006-2008

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680. Projected health spending (MTBF, 2007-2010) provides information on the budget estimates for the period until 2010 (Table 39). This table shows different source of funding.

Table 39: MTBF Forecasts of State Budget Expenditures for Health, 2007-2010 In KGS mln.

Particulars Approved Forecast

2007 2008 2009 2010 Current Health expenditures 3,098.3 3,414.5 3,771.0 4,472.8 as a share of GDP, % 2.5% 2.4% 2.3% 2.5% as a share of previous year, % 446.5% 110.2% 110.4% 118.6% as a share of Total State Budget expenditures, % 10.8% 11.1% 10.8% 11.2% Investments, including: - Internal co-financing and promotional grants 60.1 78.1 78.5 74.0 as a share of GDP, % 0.0% 0.1% 0.0% 0.0% as a share of previous year, % 10.0% 130.0% 100.0% 90.0% as a share of Total State Budget expenditures, % 3.2% 3.7% 3.5% 3.5% - External funds 107.0 458.2 310.9 123.6 as a share of GDP, % 0.1% 0.3% 0.2% 0.1% as a share of previous year, % 0.0% 430.0% 70.0% 40.0% as a share of Total State Budget expenditures, % 2.1% 8.0% 7.4% 5.6% Total financing 3,265.4 3,950.7 4,160.4 4,670.4 as a share of GDP, % 2.7% 2.8% 2.6% 2.6% as a share of previous year, % 275.7% 121.0% 105.3% 112.3% as a share of Total State Budget expenditures, % 9.1% 10.2% 10.1% 10.6% Source: Medium-Term Budget Framework 2007-2010

681. Projected health spending (MTBF) by level of care has shown an increase in spending at primary health level, as this is expected to increase to about 30 percent of total expenditure in health. Almost 70 percent of government health expenditure in 2003 still went for inpatient care, down from 85 percent in 2001 (Policy Research Paper 30, WHO, DflD Health Policy Analysis Project, 2005). This is a significant share when compared with the OECD average of 38 percent going to inpatient care, especially considering the differences in age structure and epidemiological profile between Kyrgyz Republic and OECD countries (Table 40).

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Table 40: Health Expenditure by Level of Health Care, 2004-2008. KGS mln

Particulars 2004 2005 2006 2007 2008 Primary health care 760.3 870.3 1,035.0 1,276.7 1,391.2 Current financing 566.0 642.8 837.5 1,050.8 1,290.6 As a share of total expenditures,% 74.4 73.9 80.9 82.3 92.8 Public budget (including special funding and MHIF 463.9 531.8 708.6 900.3 1,114.4 from Republican budget) As a share of total expenditures,% 61.0 61.1 68.5 70.5 80.1 MHIF 81.4 89.5 107.4 128.9 154.6 As a share of total expenditures,% 10.7 10.3 10.4 10.1 11.1 Co-payment 20.7 21.5 21.5 21.5 21.5 As a share of total expenditures,% 2.7 2.5 2.1 1.7 1.5 PIP financing 194.4 227.5 197.4 225.9 100.6 As a share of total expenditures,% 25.6 26.1 19.1 17.7 7.2 Secondary Health care 1,197.7 1,347.3 1,576.8 1,829.4 2,024.1 Current financing 1,070.9 1,198.8 1,447.9 1,681.9 1,958.4 As a share of total expenditures,% 89.4 89.0 91.8 91.9 96.8 Public budget (including special funding and MHIF 762.3 870.5 1,092.9 1,294.6 1,532.4 from Republican budget) As a share of total expenditures,% 63.6 64.6 69.3 70.8 75.7 MHIF 122.1 134.5 161.2 193.5 232.2 As a share of total expenditures,% 10.2 10.0 10.2 10.6 11.5 Co-payment 186.4 193.8 193.8 193.8 193.8 % в общих расходах 15.6 14.4 12.3 10.6 9.6 PIP financing 126.9 148.5 128.9 147.5 65.7 As a share of total expenditures,% 10.6 11.0 8.2 8.1 3.2 Specialized Hospital care 231.9 272.3 371.0 514.3 622.2 Current financing 231.9 272.3 371.0 514.3 622.2 As a share of total expenditures,% 100.0 100.0 100.0 100.0 100.0 Public budget 231.9 272.3 371.0 514.3 622.2 As a share of total expenditures,% 100.0 100.0 100.0 100.0 100.0 Public health 277.5 328.5 335.3 401.9 333.5 Current financing 104.7 126.3 159.8 201.1 244.0 As a share of total expenditures,% 37.7 38.4 47.7 50.0 73.2 Public Budget 104.7 126.3 159.8 201.1 244.0 As a share of total expenditures,% 37.7 38.4 47.7 50.0 73.2 PIP financing 172.8 202.3 175.5 200.8 89.4 As a share of total expenditures,% 62.3 61.6 52.3 50.0 26.8 Other activity and services 197.3 229.2 282.9 333.1 360.8 Current financing 171.0 198.4 256.2 302.6 347.2 As a share of total expenditures,% 86.7 86.6 90.6 90.8 96.2 Public budget 171.0 198.4 256.2 302.6 347.2 As a share of total expenditures,% 86.7 86.6 90.6 90.8 96.2 PIP financing 26.3 30.8 26.7 30.5 13.6 As a share of total expenditures,% 13.3 13.4 9.4 9.2 3.8 Total health expenditures 2,664.7 3,047.6 3,601.0 4,355.4 4,731.7 Current financing 2,144.4 2,438.6 3,072.4 3,750.7 4,462.5 As a share of total expenditures,% 80.5 80.0 85.3 86.1 94.3 Public budget (including special funding and MHIF 1,733.8 1,999.3 2,588.4 3,212.9 3,860.3 from Republican budget) As a share of total expenditures,% 65.1 65.6 71.9 73.8 81.6

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Particulars 2004 2005 2006 2007 2008 MHIF 203.5 224.0 268.6 322.3 386.8 As a share of total expenditures,% 7.6 7.3 7.5 7.4 8.2 Co-payment 207.1 215.4 215.4 215.4 215.4 As a share of total expenditures,% 7.8 7.1 6.0 4.9 4.6 PIP financing 520.3 609.0 528.5 604.7 269.2 As a share of total expenditures,% 19.5 20.0 14.7 13.9 5.7

Source: Ministry of Finance. Medium-Term Budget Framework 2006-2008

c. Future Trends in Health

682. The introduction of the State Guaranteed Benefit Package (SGPB) and of co-payments for medical services played an important role in the improvement of access for the population to medical services. SPB represents a state social standard, determining the volume of health care provided to the population either free of charge or on reduced basis and MHIF allocations. In parallel with the introduction of SPB, co-payments were introduced for certain health services, aimed at the replacement of widespread nonofficial payment and fees in health care. Within Pri- mary Health Care (PHC), SPB basic medical services are provided free of charge for the entire population. For the socially vulnerable population, mechanisms for getting reduced or free health care have been developed. In compliance with the Kyrgyz legislation, population categories entitled to social privileges when getting medical services are being expanded on an annual basis (2001 - 27 categories, 2005 - 67 categories). The population has received the ADP, for drugs supplied for the insured at the PHC level. Within the framework of this program part of the cost of drugs purchased at the pharmacies contracted by the ADP, is reimbursed from the MHIF.

683. When Manas Taalimi was developed, demand for health care sector funding was calculated for the next 5 years. The demand for the state allocations was estimated based on the minimum state standards and comprised of 725 million USD; the estimation of demand for investment expenditures was based on the activities according to the plan of work and comprises 111 million USD. All in all, the total demand of the health care sector for the next 5 years is 836 million USD. However, the actual funding available from the state budget, taking into consideration all available financing sources, is 600 million USD. The financial gap amounts to 236 million USD. To improve the situation and implement the objectives and targets set for the health care, the donor community has offered financing the Manas Taalimi program implementation through a sectoral wide approach, SWAp. The budget breakdown, however, makes tracking government and donor investments in programs that have been proven to impact on infant, child and maternal morbidity and mortality difficult. In addition, certain changes in protocols, especially in Making Pregnancy Safer (PEPS) and Integrated Management of Child Illness (IMCI) if implemented, should result in cost-savings, especially in drug utilization, that could be redirected from ineffec- tive, unnecessary and expensive treatments to support these programs. With the current documentation, it is difficult to see how this could be documented and shared with all stakeholders as evidence of supporting Manas Taalimi’s commitment to priority maternal and child health programs.

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B. ECD Investment Plan

684. Based on the sub-sector strategies presented in this report, an ECD investment plan was calculated for the sector assuming target indicators in ECD. The investment plan estimates the funds required to cover the measures suggested in the sub-sector strategies to improve MCH, MCN, ECCE, and capacity building. In particular, investments are needed for the rehabilitation and upgrading of FAPs, FGPs, Territorial Hospitals and PEOs. Equipment, furniture and supplies will also be need for PEO, UFCS, and a minimum package of drugs. Consulting services include nutrition specialist, public health specialist, ECCE specialist, materials development specialist, legal specialist, economist, public relation specialist, among others. Training and material development will cover trainers’ and staff in the areas of nutrition and home economics, ECCE, IMCI, advocacy and social marketing. Workshops and seminars will include overseas and local training at the oblast, raion, and AO levels. Systems development will be required for monitoring and data collection at all levels. The investment plan and the ECD strategy will be presented to and discussed with Government counterparts and adapted according to the comments received.

C. Preliminary Economic Analysis

1. Economic Analysis

685. This Economic Analysis was undertaken in accordance with ADB Guidelines as outlined in the Guidelines for the Economic Analysis of Projects. The Analysis is based on the proposed project interventions and describes the economic rationale and target beneficiaries, provides with/without project analysis, documents economic benefits and economic costs, and compares the economic internal rate of return (EIRR) with the economic opportunity cost of capital (EOCC), which is assumed to be 10%176. The period of analysis covers a 20-year period (the five-year project period plus 15 years following the conclusion of the project), carried out in constant 2006 US Dollar prices. Sensitivity analysis is also performed to assess the impact on the results of changes in assumptions and parameter values.

686. In Kyrgyzstan, the level of spending in the health and education sectors has been very low since Independence, and the quality of services has declined substantially. Healthcare facilities are often in poor condition and staff are not well paid, which has contributed to an increase in informal charges for services that are supposed to be provided free of charge. The level of use of preschool facilities has declined in many areas, while other areas have only limited access to these facilities. The project will improve the quality of services provided by preschools, by rehabilitating a number of preschool buildings, by supporting the development of improved teaching materials, and by providing training in child-centered approaches. In addition, community-based facilities will be established to provide ECD services in places which currently do not have access to these services. The expectation is that these investments will increase the level of use of preschool and related services. This in turn is expected to have a positive impact on the future productivity and earnings of children in the project area, especially those from poorer households.

176 ADB, 1997, Guidelines for Economic Analysis of Projects, Manila.

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687. The Project is intended to improve access to quality health and preschool education services for the poorer segments of population, with an emphasis on improving the health and education status of children from poor households. Targeting of activities towards poor households will be accomplished through a combination of geographical targeting and steps to remove barriers to access. In needy areas without access to existing facilities, community-based facilities will be the primary means for delivering services.

2. Economic Rationale

688. Education and health are powerful instruments for poverty alleviation and growth. The economic rationale for investing in ECD has proven that well-managed early childhood programs can have significant and long-lasting benefits for participants. These include higher levels of educational attainment, higher lifetime earnings, and a reduced risk of incarceration. Major gains from ECD stem from health and nutrition components as indicated by benefits in increased productivity through healthy years of life gained. High-quality pre-school education increases the ability of low-income children to profit from elementary and secondary education, thereby increases high school graduation rates, and thus generates the following economic returns, alone worth more than double the investment: less need for welfare assistance; fewer claims for unemployment benefits; higher income tax payments; less burden on the criminal justice system; fewer children needing the costs of an added year in school; and fewer children needing costly special education services. In most cases the social benefits far exceed the cost of the programs. There is also a strong argument for investments in child health. Problems that develop early in life can have long-lasting impacts on future health and productivity. There are several cost-effective public health interventions that can substantially improve the future prospects of children.

689. Early childhood interventions to improve health, education and nutrition, especially in the first 3-4 years of life can have a long lasting effect. Such measures improve school readiness, which together with psychological aspect increase the child’s ability and motivation to learn and remain in school. (Psacharopoulos, 1995). Most of the development of a child’s brain, nervous system and motor system is completed by the age of 6. Much of it is accomplished by the age of 2; and if it can be said that ‘learning begins at birth’, then it also can be said that good health and nutrition begin in the womb (Heaver and Hunt, 1995). Child development interventions must therefore start with the health and nutritional status of the mothers as early as possible during pregnancy, because this determines the health and nutrition of the future child. Benefits incidence analysis confirms that public expenditures on basic education (including ECD) are the most pro-poor form of public expenditure on education.

690. The economic benefits associated with early childhood education come in several different forms. At the level of the child, early childhood education is associated with higher educational attainment and increased socialization, both of which contribute to higher expected earnings. At the household level, the availability of quality early childhood education may contribute to increased labor force participation on the part of women. At the community level, early childhood education would be expected to increase the cost-efficiency of primary education by promoting earlier entry into school and reducing grade repetition. In other locations, early childhood education - through its impact on socialization – has also been associated with a reduced incidence of criminal behavior and incarceration, which leads to significant economic benefits for the larger community. The benefits to the children themselves and their families include reduced childcare expense and increased lifetime earnings. The public also benefits substantially from increased graduation rates that result in crime reduction. Benefits include reduced property loss

186 as well as less personal injury, pain, and risk of death. Total public benefits, including taxpayer benefits, thus exceed eight times the initial investment.

691. Further, there are additional benefits that are not quantified here, which include: higher state and local sales, property, and other taxes paid as a result of increased incomes; improved nutrition and health, resulting in lower public (Medicaid) and private medical costs;4“multiplier” effects on families, as both parents and children of educated children achieve higher education and themselves generate the benefits described here; and increased ability for parents to work while their children are well cared-for, resulting in increased incomes, reduced need for public assistance, and increased tax payments. Society pays in many ways for failing to take full ad- vantage of the learning potential of all its children, from lost economic productivity and tax revenues to higher crime rates to diminished participation in the civic and cultural life of the nation.”6 A better educated and more stable workforce leads to a more productive society. High-quality preschool education for all children is the first step.

ANNEX 1

WHO MCH Statistics

ANNEX 1 WHO MCH Statistics

Infant Mortality per 1000 Live Births in European Region Country Value Latest Year Albania 16.0 2005 Andorra 6.0 2005 Armenia 26.0 2005 Austria 4.0 2005 Azerbaijan 74.0 2005 Belarus 7.0 2005 Belgium 4.0 2005 Bosnia and Herzegovina 13.0 2005 Bulgaria 12.0 2005 Croatia 6.0 2005 Cyprus 4.0 2005 Czech Republic 3.0 2005 Denmark 4.0 2005 Estonia 6.0 2005 Finland 3.0 2005 France 4.0 2005 Georgia 41.0 2005 Germany 4.0 2005 Greece 4.0 2005 Hungary 6.0 2005 Iceland 2.0 2005 Ireland 4.0 2005 Israel 4.0 2005 Italy 4.0 2005 Kazakhstan 27.0 2005 Kyrgyzstan 58.0 2005 Latvia 8.0 2005 Lithuania 7.0 2005 Luxembourg 4.0 2005 Malta 5.0 2005 Monaco 3.0 2005 Montenegro 9.0 2005 Netherlands 4.0 2005 Norway 3.0 2005 Poland 6.0 2005 Portugal 4.0 2005 Republic of Moldova 14.0 2005 Romania 16.0 2005 Russian Federation 11.0 2005 San Marino 3.0 2005 Serbia 8.0 2005 Slovakia 7.0 2005 Slovenia 3.0 2005 Spain 4.0 2005

Annex 1 1 Sweden 3.0 2005 Switzerland 4.0 2005 Tajikistan 59.0 2005 The former state union Serbia and Montenegro 13.0 2004 The former Yugoslav Republic of Macedonia 15.0 2005 Turkey 26.0 2005 Turkmenistan 81.0 2005 Ukraine 13.0 2005 United Kingdom 5.0 2005

Uzbekistan 57.0 2005

Neonatal Mortality Rate (per 1 000 Live Births) Country Value Latest Year Albania 9 2004 Andorra 2 2004 Armenia 18 2004 Austria 3 2004 Azerbaijan 35 2004 Belarus 3 2004 Belgium 2 2004 Bosnia and Herzegovina 10 2004 Bulgaria 7 2004 Croatia 5 2004 Cyprus 2 2004 Czech Republic 2 2004 Denmark 3 2004 Estonia 4 2004 Finland 2 2004 France 2 2004 Georgia 25 2004 Germany 3 2004 Greece 3 2004 Hungary 5 2004 Iceland 1 2004 Ireland 4 2004 Israel 3 2004 Italy 3 2004 Kazakhstan 32 2004 Kyrgyzstan 30 2004 Latvia 6 2004 Lithuania 5 2004 Luxembourg 3 2004 Malta 3 2004 Monaco 2 2004 Netherlands 3 2004 Norway 2 2004 Poland 5 2004

Annex 1 2 Portugal 3 2004 Republic of Moldova 12 2004 Romania 10 2004 Russian Federation 7 2004 San Marino 2 2004 Slovakia 4 2004 Slovenia 2 2004 Spain 2 2004 Sweden 2 2004 Switzerland 3 2004 Tajikistan 38 2004 The former state union Serbia and Montenegro 9 2004 The former Yugoslav Republic of Macedonia 9 2004 Turkey 16 2004 Turkmenistan 37 2004 Ukraine 7 2004 United Kingdom 3 2004 Uzbekistan 26 2004

Maternal Mortality Ratio (per 100 000 Live Births) Country Value Latest Year

Albania 55 2000 Armenia 55 2000 Austria 5 2000 Azerbaijan 94 2000 Belarus 36 2000 Belgium 10 2000 Bosnia and Herzegovina 31 2000 Bulgaria 32 2000 Croatia 10 2000 Cyprus 47 2000 Czech Republic 9 2000 Denmark 7 2000 Estonia 38 2000 Finland 5 2000 France 17 2000 Georgia 32 2000 Germany 9 2000 Greece 10 2000 Hungary 11 2000 Ireland 4 2000 Israel 13 2000 Italy 5 2000 Kazakhstan 210 2000 Kyrgyzstan 110 2000 Latvia 61 2000 Lithuania 19 2000

Annex 1 3 Luxembourg 28 2000 Netherlands 16 2000 Norway 10 2000 Poland 10 2000 Portugal 8 2000 Republic of Moldova 36 2000 Romania 58 2000 Russian Federation 65 2000 Slovakia 10 2000 Slovenia 17 2000 Spain 5 2000 Sweden 8 2000 Switzerland 7 2000 Tajikistan 100 2000 The former state union Serbia and Montenegro 9 2000 The former Yugoslav Republic of Macedonia 13 2000 Turkey 70 2000 Turkmenistan 31 2000 Ukraine 38 2000 United Kingdom 11 2000

Uzbekistan 24 2000 Source: WHO Statistics http://www.who.int/whosis/database/core/core_select_process.cfm#

Annex 1 4

ANNEX 2

State Guaranteed Benefit Package

ANNEX 2 STATE GUARANTEED BENEFIT PACKAGE

1. After gaining independence, Kyrgyzstan started with democratization following the principles of the market economy. Due to the collapse of the economic relations existing during Soviet times and sharp reduction in manufacturing, the country found itself in an economic decline. The health care system, like other sectors, faced a lack of resources. The burden of cost of health services was shifted from Government to the population, with the growth in informal payments reaching over 50% of the health budget, according to World Bank experts.

2. The change affected demographic indicators. On the backdrop of declining birthrates, from 29.3 per 1000 of general population in 1990 to 24.6 in 1994, general mortality increased from 7.0 per 100.000 in 1990 to 8.3 in 1993, infant mortality increased from 30.0 per 1000 live births in 1990 to 31.9 in 1993, maternal mortality increased from 70.1 per 100.000 live births in 1992 to 80.1 in 1994.

3. To lighten the financial burden for the population and to reduce the level of informal payments, the country introduced the State Guaranteed Benefit Package (SGBP) together with a system of co-payments for medical services. SGBP is a state healthcare standard that sets the minimum amount of health services that the population can receive for free or at reduced cost, supported through the state budget and the Mandatory Health Insurance Fund. Co-payments are contributions of the citizens to cover the costs of medical services that are not included in the SGBP.

4. The SGBP was introduced gradually. In 2001 it was piloted in Chui and Issyk-Kul oblasts. In 2003 SGBP was spread throughout the country. The implementation of the program was accompanied by an expansion of categories of population eligible for reduced costs or free medical services (year 2001 - 29 categories, 2006 - 70). In 2006 SGBP expanded even further. Until 2006 free medical services at all levels of the system were provided to children aged up to 1. However, starting from 2006 free medical services cover children up to 5 years of age. Moreover, women during pregnancy and delivery, as well as retirees aged 75 + receive all types of medical services under SGBP for free, other retirees at reduced cost.

5. The introduction of new methods of funding and co-payment was complemented by a significant improvement in the supply of medicines, as well as higher staff salaries. This process has helped to limit the amount of informal payment by patients.

6. Under the SGBP, emergency medical assistance is provided to all citizens for free. In PHC the insured population receives the following health care services free of charge:

а) Prevention: • Activities related to health protection and promotion; • Immunization within the national calendar of preventive vaccinations; • Anti-epidemic work • Education of clients, patients and their family members self-and-mutual aid-and care.

b) Diagnostic: • Patient’s examination; • General blood analysis; • General analysis of urine and microscopy of urinal sediment; • Microscopy of urethral and vaginal smear; • Analysis of discharge (microscopy of smear);

Annex 2 1 • Identification of sugar in blood and urine; • Electro cardiogram;

c) Treatment: • Emergency care; • Immobilization; • Prescription of medicines for treatment; • Medical injections (intravenous, intramuscular, subcutaneous).

7. Other types of medical services provided to insured citizens (Mandatory Health Insurance Fund), are paid at the level of 50% of the cost of tests/procedures according to the MOH approved list.

8. The Government Decree (no.100, 16 February 2006) approved “Manas Taalimi” National Health Care Reform Program. The Program funding accumulates at the republican level and is program-based. The Mandatory Health Insurance Fund is in charge of funding individual medical services provided under SGBP.

Annex 2 2

ANNEX 3

Vitamin and Mineral Deficiency (VMD) Goals Unicef

ANNEX 3 UNICEF ILLUSTRATION OF ATTAINABLE VITAMIN AND MINERAL DEFICENCY (VMD) TARGETS AND THEIR BENEFITS FOR NATIONAL HEALTH AND SOCIAL DEVELOPMENT INDICATORS

Kyrgyz Republic VMD Strategy Development

Connections among VMD goals, objectives and targets, and their linkages to development impacts (poverty reduction benefits) Targets Health and National VMD Human development Objectives (2005-10) Baseline values and human goals outcome(s) indicators benefits 1 Reduce prevalence of a. Eliminate severe IDA among 2.2% severe anemia; DHS 0%; Hb and Reduced maternal reproductive Maternal anemia among women women of child-bearing age 1997 ferritin mortality; Approx. 1,000 infants each reproductive of child-bearing age b. Reduce IDA by 33% among 15.7%; Hb and year protected against perinatal health; Neonatal 23.6% anemia; DHS 1997 women of child-bearing age ferritin mortality survival Reduce prevalence of Reduce anemia among 6-24 2 Improved brain development among anemia among infants month-olds by 33% 50% anemia; DHS 1997 33.9%; Hb 15,000 children aged 6-24 months & young children Intelligence; 3 Eliminate iodine Universal salt iodization by >90% Human capital deficiency 2006 72% household use of iodized households 10-15% intellectual endowment to formation salt; latest monitoring data use iodized >20,000 newborns every year salt Eliminate vitamin A a. Sustain current vitA >95% of target 4 98%; 2004 monitoring report deficiency supplement coverage groups; 2x/yr b. Eliminate severe vitA 0.8% serum retinol; 2003 0.0%; serum Approx. 300 young children each year deficiency among underfives Child survival and survey retinol protected against dying from common by 2010 development childhood infections c. Reduce prevalence of low 12.5% serum retinol; 2003 8.3%; serum vitA among underfives by 33% survey retinol by 2010

Potential targets

5 Less neonatal deaths/year; less NTD incidence Reduce fetal FA Unknown NTD incidence; newborns each year require Reduce urban NTDs by 75% in urban areas Neonatal survival deficiency estimate neurosurgery and/or grow up with life- <5/10,000 long paralysis 6 Improved resistance against common Child survival and Reduce zinc deficiency Not specified Unknown Not specified childhood illness development

Annex 3 1

Draft National Plan of Action to Eliminate VMD in Kyrgyz Republic 1. NPA adoption 1.1. Define the roles and responsibilities of acting partners, timeline, financial needs, reporting requirements and funding sources 1.2. Discuss draft NPA with high-level leaders in government, science, consumer groups and food processing industries and obtain official adoption 1.3. Conduct a high-level policy-advocacy event to obtain broad NPA acceptance Establish and conduct Leadership oversight: 2. National VMD 2.1. Assure nomination of a high-level politician as Chair and establish adequate technical support for National Fortification Alliance Alliance management annual oversight meetings 2.2. Assure balanced and adequate level memberships that includes the interests of all main acting and supportive partners 2.3. Define oversight functions based on (a) regular demand for information on progress, and (b) use of the information from monitoring for program decisions 2.4. Ensure annual public reporting of progress being made toward achieving the goal

IDD Goal Objective Component Outputs (Products) Activities (Inputs) Sustainable USI by 2006 National 3. USI legislation and/or 3.1. Draft legislation to mandate the iodization of household salt, animal salt and food-grade salt used in IDD iodized salt regulation enacted various industrially processed common foods (bread, cheese, pickles, etc) Elimination supplies 3.2. Enact a Ministry of Health directive banning the sales of non-iodized table salt for consumer use by 2007 3.3. Define ways and procedures for SES to enforce the law and MOH directive 3.4. Ensure acceptance by all parties involved or affected 3.5. Pursue enactment of draft law/directive and enforcement procedures 4. National supplies of 4.1. Obtain readiness by salt import firms to import (purchase) only iodized salt for human and animal iodized edible salt consumption ensured 4.2. Establish industry-based quality assurance of edible salt supplies (production and imports) 4.3. Support SES (food inspection) in development of an appropriate module for quality control of all salt sold in markets and to food processing industry 4.4. Support salt importers and producers in ethical product promotion through their sales channels 4.5. Enable community insistence on iodized salt supplies through rapid testing at wholesale (by retailers) and retail shops (by communities) Education and 5a. Advocacy and re- 5a.1. Conduct advocacy on USI and IDD elimination as part of a national milestone event each year information advocacy among communication national leaderships takes place 5b. Critical gatekeeper 5b.1. Conduct information and education for leading medical, educational, food industry, media and public

groups are being health professionals informed and educated 5b.2. Conduct information on IDD and USI for dissemination through retail networks for household, animal and food industry salt 5c. Broad public 5c.1. Conduct educational activities through mass media acceptance for USI is 5c.2. Develop information and education for leading medical, educational, food industry, media and public being stimulated health professionals 5c.3. Develop information on IDD and USI for dissemination through the salt retail networks for household, animal and food industry salt 5.c.4. Insert essential knowledge of IDD and USI in ongoing educational curriculums at primary and technical professional levels

Annex 3 2 Monitoring and 6a. Supply of edible salt 6a.1. Develop system for regular reporting by salt importers and producers of edible salt supplies to retail Evaluation is being monitored shops and food/feed producers 6a.2. Set up system for annual reporting on results from quality control inspections in markets by SES 6b. Population iodine 6b.1. Develop and strengthen capacity on household salt iodine and urine iodine assessment and nutrition status is being reporting monitored 6b.2. Design regular data collection and reporting on edible salt use (National Statistical Committee) and iodine nutrition status in population (Scientific Centers Pediatrics and/or Endocrinology) 6b.3. In 2007, conduct a national survey to affirm optimal population iodine nutrition and sustainable attainment of the goal IDA Goal Objectives Component Outputs (Products) Activities (Inputs) Reduce IDA 1. All 6-24 National 7a. Feasibility and 7a.1. Conduct a study using sprinkles for infant feeding (12-24 months old children) in poor, displaced prevalence month-old supplies of acceptability of iron communities located close to Bishkek by one-third children appropriate supplementation among 7a.2. Use the study results for advocating on the need and feasibility to address IDA and its of 1997 levels consume supplement for 6-24 month old children consequences in infants and young children by 2010 twice weekly infants & young established (using Hb an iron children 7b. Appropriate high- 7b.1. Register the infant supplement (sprinkles) with Government as part of essential pharmacoetical levels among supplement level directives to secure registry pregnant by 2008 infant iron supplement 7b.2. Establish MOH Decree to earmark funding for adequate infant iron supplement (sprinkles) supplies women) (sprinkles) supplies to 6- 7b.3. Pursue feasibility and cost-effectiveness assessments for the local production of sprinkles for infant 24 month-old children in nutrition Kyrgyz Republic ensured Education and 8a. Advocacy and re- 8a.1. Conduct advocacy on infant/young child iron supplementation as strategic part of IDA elimination in information advocacy among national milestone events communication national leaderships takes place 8b. Critical gatekeeper 8b.1. Conduct information and education for leading medical, educational and public health professionals groups are being informed and educated 8c. Broad public 8c.1. Conduct educational activities through mass media acceptance for infant supplementation is 8c.2. Develop information on infant/young child iron supplementation for dissemination through the being stimulated immunization points 8c.3. Insert essential knowledge of iron supplementation in ongoing educational curriculums at primary and technical professional levels Monitoring and 9a. Supply of iron 9a.1. Develop system for regular reporting of supplement supplies from national receipts through to Evaluation supplements (sprinkles) supplies at immunization points is being monitored 9a.2. Set up system for annual reporting on numbers of infants/young children supplied with iron preparations 9b. Iron nutrition status 9b.1. Develop and strengthen capacity on infant/young child iron status assessment and reporting among 6-24 month-old 9b.2. Design regular data collection and reporting on use of supplements and iron nutrition status among children is being 6-24 month-old children (Center of Pediatrics & Child Surgery) monitored 9b.3. In 2009, conduct a national survey to affirm attainment of the objective 2. All National 10a. Feasibility and 10a.1. Support and follow the conduct of a study using sprinkles for reproductive-age women (Kyrgyz-

reproductive supplies of acceptability of iron Swiss Health reform Project) women (2nd appropriate supplementation among 10a.2. Use results for advocating on the need and feasibility to alleviate IDA and its consequences in trimester supplement for reproductive women reproductive-aged women (or entire families) until 6 reproductive established months post- women 10b. Appropriate high- 10b.1. Register the reproductive-age women sprinkles (or family sprinkles) with Government as part of partum) level directives to secure essential pharmaceutical registry (See 7b.1)

Annex 3 3 consume iron supplement 10b.2. Establish MOH Decree to earmark funding for adequate sprinkle supplement supplies (See 7b.2) once weekly (sprinkles) supplies to 10b.3. Pursue feasibility and cost-effectiveness assessments for the local production of sprinkles for an iron reproductive-aged reproductive-age women (or families), (See 7b.3) supplement women (or families) in by 2007 Kyrgyz Republic ensured Education and 11a. Advocacy and re- 11a.1. Conduct advocacy on iron supplementation among reproductive-aged women (or families) as information advocacy among strategic part of IDA elimination in national milestone events (See 8a.1) communication national leaderships takes place 11b. Critical gatekeeper 11b.1. Conduct information and education for leading medical, educational and public health groups are being professionals (See 8b.1) informed and educated 11c. Broad public 11c.1. Conduct educational activities through mass media (See 8c.1) acceptance for infant 11c.2. Develop information on reproductive-aged women iron supplementation for dissemination through supplementation is prenatal clinics being stimulated 11c.3. Insert essential knowledge of iron supplementation in ongoing educational curriculums at primary and technical professional levels (See 8c.3) Monitoring and 12a. Supply of iron 12a.1. Develop system for regular reporting of supplement supplies from national receipts through to PHC Evaluation supplements (sprinkles) prenatal clinics is being monitored 12a.2. Set up system for annual reporting on numbers of reproductive-aged women (or families) supplied with iron preparations (See 9a.2) 12b. Iron nutrition status 12b.1. Develop and strengthen capacity on pregnant/lactating women iron status assessment and among reporting (See 9b.1) pregnant/lactating 12b.2. Design regular data collection and reporting on use of supplements and iron nutrition status among women is being pregnant/lactating women monitored 12b.3. In 2009, conduct a national survey to affirm attainment of the objective (See 9b.3) 3. Wheat National 13. Flour fortification 13.1. Draft legislation to mandate the fortification of flour with iron complex premix in all mills producing flour fortified flour legislation and/or premium and/or 1st grade flour fortification supplies regulation enacted 13.2. Enact a Ministry of Health directive banning the sales of non-fortified premium or 1st grade flour for at milling consumer use stage: At 13.3. Define ways and procedures for SES to enforce the law and MOH directive least 50% of 13.4. Ensure acceptance by all parties involved or affected all premium and first 13.5. Pursue enactment of draft law/directive and enforcement procedures grade flour 14. National supplies of 14.1. Obtain readiness by flour import firms to import (purchase) only fortified flour for human and animal being fortified flour ensured consumption fortified with 14.2. Establish industry-based quality assurance of fortified flour supplies (production and imports) iron complex 14.3. Support SES (food inspection) in development of an appropriate module for quality control of all premix by flour sold in consumer markets and to flour processing industries (bakeries) 2010 14.4. Support flour importers and producers in ethical product promotion through their sales channels Education and 15a. Advocacy and re- 15a.1. Conduct advocacy on flour fortification as strategic part of IDA elimination in national milestone information advocacy among events (See 9a.1 and 11a.1) communication national leaderships takes place 15b. Critical gatekeeper 15b.1. Conduct information and education for leading medical, educational, food industry, media and groups are being public health professionals (See 9b.1 and 11b.1) informed and educated 15b.2. Conduct information on flour fortification for dissemination through retail networks for household and industry flour 15c. Broad public 15c.1. Conduct educational activities through mass media (See 8c.1 and 11c.1)

Annex 3 4 acceptance for flour 15c.2. Develop information and education for leading medical, educational, food industry, media and fortification is being public health professionals (See 8c.2 and 11c.2) stimulated 15c.3. Develop information on flour fortification for dissemination through the food retail networks for households 15.c.4. Insert essential knowledge of IDA and flour fortification in ongoing educational curriculums at primary and technical professional levels Monitoring and 16a. Supply of fortified 16a.1. Develop system for regular reporting by flour importers and millers of fortified flour supplies to retail Evaluation flour is being monitored shops and food producers 16a.2. Set up system for annual reporting on results from SES quality control inspection 16b. Population iron 16b.1. Develop and strengthen capacity on household flour use and iron status assessment and reporting nutrition status is being 16b.2. Design regular data collection and reporting on fortified flour use and iron nutrition status in monitored population 16b.3. In 2010, conduct a national survey to affirm attainment of the national goal (one-third reduction in anemia among pregnant women) VAD Goal Objectives Component Outputs (Products) Activities (Inputs) Reduce 1. Conduct National 17. National vitamin A 17.1. Based on vitamin A part of adopted NPA, conduct negotiation with Government and donors for vitamin A two times a supplies of supplement supplies for securing the supplies of vitamin A supplements for 2006 through 2009 deficiency year high- appropriate 2006 through 2009 17.2. Enact Ministry of Health directive to earmark an annually increasing share of Government funding prevalence in dose vitamin supplements ensured for adequate national supplies population to A capsule Education and 18a. Advocacy and re- 18a.1. Continue conducting advocacy on vitamin A supplementation as strategic part of VAD elimination less than 5% distribution information advocacy among in national milestone events by 2010 until 2009 communication national leaderships (Using serum takes place retinol 18b. Critical gatekeeper 18b.1. Continue conducting information and education on VAD elimination for leading medical and public among groups are being health officials young informed and educated children) 18c. Broad public 18c.1. Continue twice annual educational and mobilization campaigns on capsule distribution through acceptance for vitamin A mass media supplementation is 18c.2. Continue updating and disseminating educational information on vitamin A supplementation being stimulated through immunization points 18c.3. Insert essential knowledge on vitamin nutrition in ongoing educational curriculums at primary and technical professional levels Monitoring and 19a. Supplies of vitamin 19a.1. Continue twice annual reporting of national supplement supplies based on national receipts and Evaluation A supplements is being distribution to immunization points monitored 19a.2. Set up verification system for reporting on numbers of infants/children supplied with high-dose vitamin A supplements twice a year 19a.3. Ensure dependable reporting on numbers of post-partum women receiving a high-dose vitamin A supplement 19b. Vitamin A status 19b.1. Develop/strengthen capacity on vitamin A status assessment and reporting among young children among infants/children (Center of Pediatrics & Child Surgery?) is being monitored 19b.2. In 2010, conduct national survey to affirm attainment of national goal 2. Vitamin A National 20. Feasibility and 20.1. Review existing data (National Statistical Committee) on habitual household purchases of food that fortification vitamin A- acceptability of vitamin A potentially could be fortified with vitamin A: sugar, margarine, fats/cooking oils) and dicide on appropriate of fortified food fortification of strategic food or mix appropriate supplies foods in the national 20.2. Conduct an industry assessment (location, size, feasibility, economic stability) of the foods identified food established food supply of Kyrgyz for potential fortification vehicle(s) products Republic established 20.3. Use the results of the steps above for a Round-Table discussion with food industry leaderships to ongoing by start a national vitamin A fortification effort 2009 20.4. Develop a national plan-of-action for vitamin A fortification with appropriate benchmarks leading to foods being fortified by 2009

Annex 3 5 21. National supplies of 21.1. Develop appropriate legislation and Ministerial directives to ensure exclusive imports and supplies of vitamin A-fortified foods vitamin A-fortified foods ensured 21.2. Develop industry-based quality assurance of vitamin A-fortified food supplies (imports and local production) 21.3. Support SES in development of an appropriate module for quality inspection in the markets and in food processing industries 21.4. Support food industry in appropriate (ethical) promotion through their sales channels 21.5. Pursue enactment of laws/directives and enforcement procedures Education and 22a. Advocacy and re- 22a.1. Continue conducting advocacy on vitamin A fortification as strategic part of VAD elimination in information advocacy among national milestone events (See 18a.1) communication national leaderships takes place 22b. Critical gatekeeper 22b.1. Continue conducting information and education on VAD elimination for leading medical and public groups are being health officials (See 18b.1) informed and educated 22b.2. Develop and support information dissemination by food industry on the need and value of vitamin A-fortified food through their retail networks 22c. Broad public 22c.1. Conduct educational activities through mass media acceptance for vitamin 22c.2. Develop information and education on the need and value of vitamin A fortification for leading A-fortified food is being medical, educational, food industry, media and public health professionals stimulated 22c.3. Develop and disseminate information and education for consumers through industry retail channels 22c.4. Insert knowledge on vitamin A fortification in ongoing educational curriculums at primary and technical professional levels (See 18c.3) Monitoring and 23a. Develop monitoring 22a.1. Develop system for regular reporting by fortifying food industries of their supplies to retail shops Evaluation of vitamin A-fortified and food industry customers food supplies 22a.2. Set up system for annual reporting on results from quality control inspections in markets by SES 23b. Develop 23b.1. Develop/strengthen capacity on vitamin A status assessment and reporting among young children population-based (Center of Pediatrics & Child Surgery?) (See 19b.1) vitamin A status 23b.2. In 2010, conduct national survey to affirm attainment of national goal (See 19b.2) assessment capacity 3. Promotion Education and 24a. Advocacy and re- 22a.1. Continue conducting advocacy on dietary improvement education as a strategic part of VAD of the dietary information advocacy among elimination in national milestone events (See 18a.1 and 22a.1) habit of communication national leaderships increased takes place use of 24b. Public acceptance 24b.1. Conduct educational activities through mass media vitamin A- for inclusion of vitamin 24b.2. Develop information and education on the need and value of stimulating dietary education for rich foods A-rich foods in the leading medical, educational, food industry, media and public health professionals (See 18b.1 and 22b.1) regular diet is being 24b.4. Insert knowledge on vitamin A-rich food consumption in ongoing educational curriculums at stimulated primary and technical professional levels (See 18c.3 and 22c.4) Monitoring and 25a. Educational efforts 25a.1. Periodically assess public knowledge and practices on consumption of vitamin A-rich foods Evaluation are being monitored (including fortified foods) 25b. Insert a KAP 25.b.1 In 2010, ensure behavioral evaluation aspect as part of the national survey to affirm attainment of module as part of the national VAD goal (See 19b.1 and 23b.2) vitamin A status assessment capacity

Annex 3 6

ANNEX 4

Baby Friendly Hospital – Breastfeeding Promotion

ANNEX 4 BABY FRIENDLY HOSPITAL – BREASTFEEDING PROMOTION

1. Since 1994 the WHO/UNICEF Program “Protection, Encouragement and Support of Breast Feeding” has been introduced in the Kyrgyz Republic with the help of UNICEF. In 1996 the National Committee on Support and Encouragement of Breast Feeding was created in the republic. To change the previously existing practice of breast feeding in obstetrical institutions and to adopt WHO recommendations, the normative-legal base of this program was revised and the following orders of the Kyrgyz Republic (the KR) were issued:

(i.) №155 by 1994 «About measures on improving breast feeding in obstetrical institution of the KR» (ii.) № 19 by 1996 « About organization of maternity hospital and adoption of breast feeding only in obstetrical institutions of the KR» (iii.) №173 by 2004 «About adoption of breast feeding only in the practice of obstetrical institutions, pediatric departments and Family Medicine Centre» (iv.) №174 by 2004 «About realization of obstetrical institutions certification on the program of “Protection, Encouragement and Support of Breast feeding» (v.) №48 by 6.02.2004 «About organization of maternity-houses and further improving of obstetrical-gynecological aid quality in the KR» (vi.) Clinic protocols on neonatology. (vii.) Definite measures on adoption of breast feeding in medical educational institutions were made. Kyrgyz State Medical Academy, Medical Specialized Schools.

2. Since 1999 the initiative in the Kyrgyz Republic is called “Initiative of Benevolent Attitude to Child Hospitals”. The main aim of Hospitals with Benevolent Attitude to Child is to protect and encourage practice of breast feeding with the help of adoption of “10 principles of breast feeding” and to put an end to spreading of free and reduced deliveries of artificial breast milk by the institutions of the MOH. In the framework of this program such steps as: joint sojourn of mother and new-born baby and early breast feeding were taken everywhere; these steps contribute to improving perinatal health indicators.

3. From 2000 until 2006 31 medical institutions were conferred the name of “Baby Friendly Hospital” or “Hospital of Benevolent Attitude to Child”. In 2006 12 medical institutions confirmed this title. As a result of the adoption of this program, the situation related to breast feeding in the Kyrgyz Republic has changed radically during the last years. 47.3% of deliveries take place in Hospitals of Benevolent Attitude to Children. At present, 95.3% of infants discharged from the maternity houses are exclusively breast fed; 88.5% of infants under 3 months are on breast feeding only (according to the reports of 2000-2004); and 81.2% of infants at the age of 6 months.

4. On average the duration of infants’ breast feeding is about 12 months. According to research made in the Kyrgyz Republic, 97.3% of children under the age of 2 years have been breast-fed at a certain point of time. Out of this number 61% of infants between 0-3 months were on breast feeding only, 32% until the age of 4-6 months.

5. In the Kyrgyz Republic some interesting ways of disseminating the “10 principles of breast feeding” can be observed. In Osh oblast, different non-governmental organizations took responsibility for it working with women from large families who know their neighbors well. In Jalalabad oblast women from so-called “Mahalyas” – people’s cooperations which play a role in the Councils, the court of arbitration and which decide many social questions – took over responsibility. In Batken oblast, where religion plays a very important role, imams read suras in which they ask women to feed infants by breast as long as possible, explaining that breast milk strengthens health both for children and mothers and protects mothers from another pregnancy.

Annex 4 1

6. At present the “Groups of Mother’s Support” (GMS) work on the basis of maternal houses, maternal departments with the status of “Benevolent Attitude to Child Hospitals” and FMCs. The Group of Mother’s Support may also include other family members (fathers, grandmothers etc.). Generally a group consists of 4-6 people. 3 or 4 times a month lessons are given and anybody can attend them. The rest of the time, members of GMS give consultations over the phone or meet privately. In some districts provided with telephones there are some 24-hours “hot-line” connections. During the last years, GMS organized an enormous movement of encouragement and support of breast feeding in different regions (At-Bashy, Aksyi, Bazarkorgon, Tup and Naryn city).

7. In the Kyrgyz Republic a people’s holiday of the breast feeding week is celebrated especially bright and expressive. Thus in Bazarkorgon district there was a staged theater moving with 10 thousand participants in 2005. Everywhere the week of breast feeding is brightly illuminated in press and television. A series of IEC materials on the topic of “breast feeding is the best start of life” has been prepared, among them: calendars, brochures, booklet and posters.

Proposals for 2007 on the Program of “Benevolent Attitude to Child Hospitals”

8. Despite the fact that 31 medical institutions in the republic have the status of Benevolent Attitude to Child Hospitals and despite the MOH order #173 from 14.04.04 about “Adoption of breast feeding only in obstetrical institutions and Family Medicine Centres”, obstetrical institutions, pediatric departments of hospitals and FGPs are not protected from children’s artificial food, such as artificial breast milk (baby formula).

9. The project of the national law “International Summary of Rules on Artificial Breast Milk Sale” was worked out as an article of the Children’s Code “Protection of children’s health with the help of breast feeding and regulation of artificial breast milk sale”. It was sent to the Kyrgyz MOH in 2004, but the project was not accepted. In this connection, there started a work on preparation of another project of the national law about adoption of “International Summary of Rules on artificial breast milk sale” (plan of actions for preparation and realization of the law “about protection and propaganda of breast feeding”). Three consultants received training on breast feeding in a sub-regional training seminar on the implementation of “International Summary of Rules on Artificial Breast Milk Sale” in Baku, Azerbaijan, from 10-14 July, 2006.

10. It should be noted that medical workers in the Kyrgyz Republic are not well informed about the questions of feeding infants above 6 months of age, because there is a lack of guidelines and information about additional feeding of children elder than 6 months. To improve the knowledge of medical workers it is necessary to prepare and approve the clinical protocol on feeding of children elder than 6 months and to conduct trainings and a seminar on feeding: “complementary feeding: modern recommendations, demands and practical skills for successful adoption of complementary feeding” for Benevolent Attitude to Child Hospitals’ workers. In addition, it is necessary to continue the work of monitoring and further certification of hospitals.

Annex 4 2

ANNEX 5

PEPC Training Pilot Raions

ANNEX 5 PEPC Training Pilot Raions

Pilot raion Donor Trainees Jalalabad Oblast Bazar-Korgon HOPE Accoucheur-gynecologists, neonatologists, Aksy HOPE accoucheurs in maternity units of territorial hospitals Osh oblast Nookat ADB JFPR Accoucheur-gynecologists, neonatologists, Karakulja ADB JFPR Accoucheur in maternity units of territorial hospitals Alay ADB JFPR Chon Alay ADB JFPR Issykkul oblast Karakol city ZdravPlus Accoucheur-gynecologists, neonatologists, Balykchi city ZdravPlus accoucheurs in maternity units of territorial hospitals Cholponata city ZdravPlus

Batken oblast Leilek HOPE Accoucheur-gynecologists, neonatologists, Batken HOPE accoucheurs in maternity units of territorial hospitals Naryn oblast USAID (ZdravPlus) trained all raions

Chui oblast UNICEF trained all raions, maternity houses #1 and #2, Perinatal Center of Bishkek.

Talas oblast UNFPA will train all raions in September, October 2007

Source: Information collected by the TA team during the needs assessment and sector analysis

Annex 5 1

ANNEX 6

Integrated Management of Childhood Illnesses

ANNEX 6 INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMCI)

A. Content of IMCI

1. According to WHO “IMCI is an integrated approach to child health that focuses on the well-being of the whole child. IMCI aims to reduce death, illness and disability, and to promote improved growth and development among children under 5 years of age. IMCI includes both preventive and curative elements that are implemented by families and communities as well as by health facilities”1. IMCI focuses not only on service delivery in health facilities, but also on raising the awareness of families and improving child care in the home setting. With regard to improvement of the service delivery system, IMCI aims at (i) promoting the accurate identification of childhood illnesses in primary care facilities and outpatient departments; (ii) ensuring appropriate treatment of all major illnesses, (iii) strengthening the counselling skills of caretakers and improving health counselling; and (iv) speeding up the referral of severely ill children. With regard to its focus on families, IMCI promotes (i) appropriate care seeking behaviours; (ii) improved nutrition and preventative care; and (iii) correct implementation of prescribed care.

2. For implementation of the IMCI strategy in a country, WHO proposes a phased process involving the following main steps:

(i.) Adopting an integrated approach to child health and development in the national health policy. (ii.) Adapting the standard IMCI clinical guidelines to the country’s needs, available drugs, policies, and to the local foods and language used by the population. (iii.) Upgrading care in local clinics by training health workers in new methods to examine and treat children, and to effectively counsel parents. (iv.) Making upgraded care possible by ensuring that enough of the right low-cost medicines and simple equipment are available. (v.) Strengthening care in hospitals for those children too sick to be treated in an outpatient clinic. (vi.) Developing support mechanisms within communities for preventing disease, for helping families to care for sick children, and for getting children to clinics or hospitals when needed.

3. The IMCI strategy consist of three major components

(i.) Improving case management skills of health-care staff (ii.) Improving overall health systems (iii.) Improving family and community health practices

4. The third component, the so-called Household and Community IMCI (HH/C IMCI), was officially launched as an essential component of the IMCI strategy at the First IMCI Global Review and Coordination Meeting in September 1997. The participants of that Meeting recognized that improving the quality of care at health facilities alone would not be effective in realizing significant reductions in childhood mortality and morbidity because numerous caretakers currently do not seek care at facilities. Since that first meeting, several efforts were undertaken to strengthen interagency collaboration for promoting and implementing community approaches to child health and nutrition.

1 http://www.who.int/child-adolescent-health/integr.htm

Annex 6 1 5. At the UNICEF-led International Meeting on Health and Nutrition in Communities held in Durban, South Africa (20-23 June 2000)2, participants reached consensus on sixteen key family care practices, which are based on scientific evidence and country experience.

For physical growth and mental development:

(i.) Breastfeed infants exclusively for six months (ii.) Starting at six months of age, feed children freshly prepared energy- and nutrient-rich complementary foods, while continuing to breastfeed up to two years longer (iii.) Ensure that children receive adequate amounts of micronutrients (e.g., vitamin A and iron), through diet or supplementation (iv.) Promote mental and social development by responding to children’s needs for care through talking, playing, and providing a stimulating environment

For disease prevention:

(i.) Take children as scheduled to complete the full course of immunizations (e.g., BCG (Bacilus Calmette-Guerin), DPT (Diptheria, Pertusses, and Tetanaus), OPV (Oral Polio Vaccine), and measles) before their first birthday (ii.) Dispose of feces, including child feces, safely; wash hands after defecation, before preparing meals, and before feeding (iii.) Protect children in malaria-endemic areas by ensuring sleep under insecticide- treated bednet (iv.) Adopt and sustain appropriate behaviors regarding prevention and care for HIV/AIDS-affected people, including orphans

For appropriate home care:

(i.) Continue to feed and offer more fluids, including breast milk to sick children (ii.) Give sick children appropriate home treatment for infections (iii.) Take appropriate actions to prevent and manage child injuries and accidents (iv.) Prevent child abuse and neglect and take appropriate action when it has occurred (v.) Ensure men’s active participation in providing childcare, and in the reproductive health of the family

For seeking care:

(i.) Recognize when a sick child needs treatment outside the home. Seek care from appropriate providers (ii.) Follow the health worker’s advice about treatment, follow-up, and referral (iii.) Ensure that every pregnant woman has adequate antenatal care, including at least four antenatal visits with and appropriate health care provider, Tetanus Toxoid vaccinations and support from family and community in seeking care at the time of delivery and during the postpartum and lactation period

2 Peter Winch, Karen LeBan, Barmak Kusha and Participants at the Workshop “Reaching Communities for Child Health: Advancing PVO/NGO Technical Capacity and Leadership for Household and Community Integrated Management of Childhood Illness (HH/C IMCI)” Baltimore, Maryland, January 17-19, 2001

Annex 6 2 6. Within IMCI a special focus is also put on prevention and care of neonates and infants. The basic needs of neonates identified by WHO also demand an integrated approach to neonatal care focusing not only on the skills and knowledge of health workers, but also on the health system and knowledge of mothers. The basic needs of neonates include:

During labor and delivery, mothers and newborns need3:

(i.) Skilled attendance – provide safe management of normal delivery and timely referral for complications. (ii.) Support and care – promote family support and a baby and woman-friendly environment for birth and maternal and newborn care. (iii.) Infection control – ensure clean delivery, including clean surface, hands, blade, and cord tie. (iv.) Management of complications – identify and manage complications, including bleeding, high blood pressure, prolonged labor, and fetal distress.

Following birth, newborns need:

(v.) Air - stimulate and resuscitate infants who are not breathing at birth. (vi.) Warmth – dry the baby at birth. Maintain warmth through skin-to-skin contact, warm ambient temperature, and head and body covering. Promote kangaroo care for low-birth weight infants. (vii.) Breastfeeding – breastfeed within the first hour after birth. Continue exclusive breastfeeding on demand day and night for six months. (viii.) Care – keep the newborn close to the mother, father, or other caregiver. Keep the mother healthy. (ix.) Infection control – maintain cleanliness when handling the infant. Keep the cord clean. Provide prophylactic eye care. Promote early and exclusive breastfeeding. Immunize according to schedule. Treat infections promptly. (x.) Management of complications – recognize and respond urgently to serious and life-threatening conditions.

B. Implementation of IMCI in the Kyrgyz Republic

7. IMCI is included in the Kyrgyz Republic’s National Health Reform Program “Manas Taalimi” for 2006 – 2010 and is identified as a key strategy to achieve MDG 4 and MDG 5. Manas Taalimi emphasizes that the level of skills of medical workers at the primary care level needs to be strengthened related to curative care and prevention of illnesses, timely diagnosis of difficult cases and referral. To raise the efficacy of proved interventions awareness raising and capacity building of the families in healthy styles of life, rational care for ill and healthy children, identification of danger signs in children, providing first aid and timely consultation with doctors are planned. To achieve these outputs it is planned to implement IMCI nation-wide at the primary and secondary care level.

8. IMCI has been implemented in the Kyrgyz Republic since the year 2000. In 2000 the standard IMCI clinical guidelines have been adapted to the country’s needs. Since 2001 medical workers have been trained in IMCI implementation with financial and technical support of international organizations (WHO, UNICEF, WB, ABR, USAID, Zdrav+, HOPE project Jalalabad, “For children survival”, HOPE project Batken, “Healthy family”).

3 http://www.who.int/child-adolescent-health/PREVENTION/Needs.htm

Annex 6 3 (i.) UNICEF supports training and technical provision in 5 pilot regions (Issyk kull: Jetyoguz, Tup, Chui: Jayil, Moskovski, Osh: Aravan). Doctors, assistants and some patronage nurses are being trained. (ii.) USAID (HOPE project) supports training in two regions of Jalalabad oblast: Aksyi, Bazakorgon. Doctors and assistants are trained. (iii.) WB supported the training of family doctors in all oblasts of the Republic, unfortunately, doctors of Issyk–Kul oblast are not trained in this program (with exception of 2 pilot regions of UNICEF) as at the moment of their re-training in family medicine, IMCI program was not included in the course. (iv.) ABR supported the training of assistants in 12 regions (Osh – 4 regions, Jalalabat – 3 and Naryn – 5). (v.) Since 2005 USAID/HOPE started the implementation of IMCI in Batken oblast (Batken, Leilek regions).

9. The training of non scoped assistants in other regions of the republic has been conducted since 2005 with the support of WB, thanks to which by the middle of 2006 all assistants in all regions will be trained. Since 2003 the training in IMCI is included into post diploma training of the department of family medicine, higher nurse training, and of the pediatric departments of KSMA and JASU since 2005. In medical college of Kara-Balta, Karakol, and Jalalabat IMCI is taught in separate blocks according to class topics. In 2005 13 assistants of obstetric clinics of every region were taught in training courses of IMCI in the frame of “Manas Taalimi”. Since September 2005 they are giving regional seminars in oblasts for assistants on a regular basis.

10. In 2006, WHO conducted an IMCI performance review of 121 trained medical workers working in 68 health facilities, 35 of which were maternity houses.4 Medical workers were observed treating children with high fever, coughing/difficult breathing/pneumonia (71%) or diarrhea (25%). Overall 2 or 3 times as many doctors as medical assistants or family nurses were evaluated. The report found several instances where IMCI protocols were followed but found that several areas needed strengthening including:

(i.) Lack of nutrition counseling by health care workers and medical workers don’t pay attention to the nutrition status of the child. Furthermore, medical workers frequently don’t ask about nutrition of children during illness (ii.) Over or under classification of pneumonia (iii.) Wrong classification of anemia are frequent (iv.) Some children were hospitalized who didn’t need it, some who did were not hospitalized (v.) Lack of demonstration of how to give medicines to a child (vi.) Few observed mothers giving first dose of medicine to a child (vii.) Lack of counseling on danger signs to look out for in the child in the home (viii.) Not checking to see if mothers understood the instructions there were given (ix.) Only 39% of medical workers completed all required tests before hospitalizing children (x.) Need for doctor approval before hospitalizing sick children (xi.) IMCI protocol takes an average of 18 minutes, but MOH protocols only allow 12 minutes.

4 Quality evaluation of the Integrated Management of Childhood Illnesses (IMCI) implementation and outline of barriers for ist sustainability on all levels of Primary Health Care, MOH/National Center of Pediatrics and Children’s Surgery/Health Caring Development Center of Kyrgyz Republic/WHO, Bishkek 2006.

Annex 6 4 The evaluation study concluded that the medical workers use the main principles of IMCI in their daily work, but efforts should be made to improve the work of medical workers in the fields of:

(i.) Systemic assessment of the severity of the illness (ii.) Systemic assessment for accompanying illnesses (iii.) Evaluation, classification, and recommendations in treatment of pneumonia and anemia according to WHO guidelines (iv.) Emphasis on correct child feeding practices (v.) Provision of first aid to ill children before hospitalization (vi.) Improvement of interpersonal communications skills of medical workers (vii.) Improvement of drug supply

C. Analysis of Strengths-Weaknesses-Opportunities-Constraints in IMCI-KR

Strengths the following was developed and implemented

(i.) Child registration and health card, which includes questions on child nutrition. (ii.) Child growth card (“Chart of physical development”) (iii.) Guidelines for mothers, which includes recommendations on nutrition for children when sick or healthy according to 4 age groups (iv.) There is information on IDA in the IMCI Module (for doctors) and for nurses also on Vitamin A deficiency and IDD. (v.) Information about correct way of breast feeding and recommendations for nutrition problem identification (vi.) Family nurses Module includes recommendations on child nutrition of HIV infected mother.

Concerning the IMCI program in general

(i.) A vertical structure is established (IMCI program coordinator at the level of MoH, IMCI Center at the republican level, responsible IMCI supervisors at oblast and raion levels). (ii.) More than 70% of medical doctors and feldshers are trained. (iii.) Existence of normative legal list of activities (orders) (iv.) Support from MoH (v.) Integration with primary health care (vi.) IMCI is a program area within “Manas Taalimi” (vii.) IMCI was introduced into curricula of educational institutions

Weaknesses (i.) Low motivation and stimulation of IMCI supervisors and medical workers (ii.) Lack of new adapted methods of child’s height identification (iii.) Shortage of information materials on nutrition, especially on nutrition of pregnant and lactating women, both for medical workers and for the community (iv.) Insufficient monitoring and follow up of the program (v.) Insufficient analysis of results of the program (vi.) During IMCI training of medical staff, low priority is given to practical application of knowledge in oblast Educational Family Medicine Center (vii.) Shortage of registration forms for a sick child in facilities (viii.) Mothers are not provided with a child growth card to observe the child’s growth and development

Annex 6 5 Concerning IMCI program in general

(i.) Shortage of medical staff (ii.) Shortage of funds for follow-up and monitoring (iii.) Family nurses are not trained (iv.) Weak supervision system of IMCI program at every level by MoH (v.) Inadequate design of mechanisms for the 3rd community-IMCI component implementation (vi.) Lack of support to IMCI center (vii.) Lack of phone connection with raion and oblast facilities, lack of internet connection in IMCI center

Opportunities

(i.) Training for family nurses (ii.) Improvement of monitoring and follow up observations of trained medical workers (iii.) Improvement of 3rd component of IMCI (iv.) Provision of handout information materials on nutrition to the community (v.) Stimulation of medical workers (vi.) Creation of supervision system at every level (vii.) Provision of financial incentives to IMCI center staff (viii.) Provision of all health facilities with children registration forms (ix.) Analysis of program according to conducted monitoring and follow up (x.) Conduct activities with local communities on health and nutrition, because there is a network established in the state system (xi.) Training of medical workers on work with community (xii.) Consistency of IMCI Modules with new data of WHO

Constrains

(i.) Low salaries and lack of motivation of Medical workers (ii.) Shortage of literature on work with communities and child growth (iii.) Lack of height measuring tools and weighing scales in primary health facilities (iv.) Constant depletion of trained medical workers

Annex 6 6

ANNEX 7

Donor and MoH Support for IMCI and PEPC Training

ANNEX 7 Donor and MoH Support for IMCI and PEPC Training

Maternal Newborn Target raion Child Health Training (IMCI) Training (PEPC) Jalalabad Oblast CBECDP 1st phase Toguztoro None yet CBECDP 1st phase Chatkal None yet CBECDP 1st phase Toktogul None yet CBECDP 1st phase CBECDP 2nd phase Suzak None yet Community IMCI training for 92 family nurses by HOPE. Feldshers and doctors are trained by Kyrgyz State Medical Institute of Refreshing and Retraining (KSMIoRR). A branch of the KSMIoRR exists in Jalalabad oblast Educational Family Medicine Center (EFMC) Bazar-Korgon HOPE HOPE trained family doctors and feldshers. Family nurses are being trained in IMCI at present Nooken None yet Doctors and feldshers are being trained by KSMIoRR. Family nurses are NOT trained in IMCI Aksy HOPE HOPE trained family doctors and feldshers. Family nurses are being trained in IMCI at present Osh oblast CBECDP 1st phase Nookat ADB JFPR CBECDP 1st phase Karakulja ADB JFPR CBECDP 1st phase Alay ADB JFPR CBECDP 1st phase Chon Alay ADB JFPR CBECDP 1st phase CBECDP 2nd phase Uzgen None yet KSMIoRR is training doctors and feldshers in IMCI in Osh oblast EFMC, but NOT yet family nurses Aravan None yet KSMIoRR is training doctors and feldshers in IMCI in Osh oblast EFMC, but NOT yet family nurses Batken oblast CBECDP 2nd phase Leilek preliminary HOPE trained family doctors and feldshers. implementation Family nurses are being trained in IMCI at present Batken preliminary HOPE trained family doctors and feldshers. implementation Family nurses are being trained in IMCI at present Kadamjai None yet KSMIoRR is training doctors and feldshers in IMCI in Osh oblast EFMC, but NOT yet family nurses Naryn oblast CBECDP 1st phase Has provided training in IMCI in all 5 target raions, however PEPC was NOT trained anywhere in Naryn oblast. According to information from MOH, USAID (ZdravPlus) are starting implementing PEPC Source: Information collected by the TA team during the needs assessment and sector analysis

Annex 7 1

ANNEX 8

Number of Health Facilities in Kyrgyz Republic in 2005

ANNEX 8 NUMBER OF HEALTH FACILITIES IN KYRGYZ REPUBLIC IN 2005

National and scientific centers of National Research Institute (NRI) 9 National hospitals 8 City hospitals 13 City child hospitals 1 Tuberculosis hospitals 12 Psychiatric and psycho-neurological hospitals 3 Territorial hospitals 47 Branch territorial hospitals 17 Other hospitals 12 Maternity houses, perinatal center 3 T.B. prophylactic center 9 Oblast center for T.B. control 6 Skin-venereologic prophylactic centers 2 Oncologic prophylactic center 2 Narcological center 2 Dental polyclinics – total 37 Family Medicine Centers (FMC) 85 Family Group Practices (FGP) within FMC 670 Feldsher Accoucher Posts (FAP) 816 FGP – private 31 FAPs - private 51 Public Health Institutes 59 Source: Republican Medical Information Center

Annex 8 1

ANNEX 9

Number of Graduates of Medical Faculties

Annex 9 Number of Graduates of Medical Faculties for the Period from 1996 to 2006:

Training of Medical Doctors and Pharmaceutics, Kyrgyz Republic, 1996-2006 State and Private-Paid Basis

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

1. Total number of graduates by higher medical 782 690 753 732 835 738 771 784 843 763 823 educational institutions: Kyrgyz State Medical Academy (general medicine) 782 690 753 640 661 547 581 556 566 439 435 Kyrgyz Russian-Slavonic University (general - - - - 24 42 36 50 49 50 48 medicine) Osh State University (general medicine) - - - 92 150 149 154 178 218 259 307

By major: Treatment medicine 357 302 398 426 526 625 631 588 634 515 535 Pediatrics 232 183 188 143 150 - - 40 40 29 23 Preventive medicine 43 57 38 17 25 25 17 23 27 33 47 Dentistry 108 109 77 73 77 61 63 78 77 85 93 Pharmaceutics 42 39 52 73 57 27 28 20 29 48 78 Higher Nursing training ------32 35 26 30 29 Health management ------10 23 18

Annex 9 2. Total number of graduates by secondary 2436 2347 2446 2494 1551 2817 2955 2888 2629 2422 2499 medical educational institutions:

Bishkek College 685 641 617 617 308 666 686 618 490 516 347 Tokmok College 127 167 137 137 66 169 142 145 135 91 100 Talas College 141 142 141 147 55 149 231 213 166 139 99 Karabalta College 195 170 185 177 130 223 239 234 208 217 205 Karakol College in the name of I.Ahunbaev 149 139 113 139 90 120 153 117 120 114 113 Naryn College 103 143 113 74 133 219 197 170 164 119 82 Kyzyl-Kiya College 248 221 193 272 156 273 310 389 338 247 280 Jalalabat College 413 385 563 533 305 540 523 483 452 366 465 Mailuusuu college 143 83 89 128 85 131 153 122 123 72 120 Osh College 232 256 295 270 223 293 311 341 269 240 300 Medical college under Kyrgyz State Medical Academy - - - - - 34 42 56 20 42 43 Medical college under Osh State University ------19 79 139 Uzgen Medical College under Osh State University ------75 59 88 Medical college under KUU ------50 121 118 By program (specialization): Nursing 1419 1388 1238 1286 - 1185 1098 954 973 795 1089 Nursing – masseur (among sight disabled) ------16 8 9 10 Medical treatment 297 259 204 262 127 267 288 185 230 248 350 Obstetrics 352 267 331 284 246 233 322 257 296 587 812 Treatment obstetrics 42 127 401 385 816 655 693 850 536 28 3 Orthopedic dentistry 75 96 91 102 120 147 178 155 138 184 27 Dentistry 25 28 25 23 29 30 32 27 42 37 68 Preventive medicine 73 78 79 68 67 66 61 62 72 28 43 Laboratory diagnostics 102 77 47 54 54 44 67 70 60 77 30 Pharmacy 51 27 30 30 92 190 248 312 274 429 67

Annex 9

ANNEX 10

Number of mid-level Graduates of Medical Colleges

ANNEX 10 Number of mid-level Graduates of Medical Colleges for the Period from 1996 to 2006:

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Total number of mid-level graduates: 2436 2347 2446 2494 1551 2817 2955 2888 2629 2422 2499 Bishkek College 685 641 617 617 308 666 686 618 490 516 347 Tokmok College 127 167 137 137 66 169 142 145 135 91 100 Talas College 141 142 141 147 55 149 231 213 166 139 99 Karabalta College 195 170 185 177 130 223 239 234 208 217 205 Karakol College in the name of I.Ahunbaev 149 139 113 139 90 120 153 117 120 114 113 Naryn College 103 143 113 74 133 219 197 170 164 119 82 Kyzyl-Kiya College 248 221 193 272 156 273 310 389 338 247 280 Jalalabat College 413 385 563 533 305 540 523 483 452 366 465 Mailuusuu college 143 83 89 128 85 131 153 122 123 72 120 Osh College 232 256 295 270 223 293 311 341 269 240 300 Medical college under Kyrgyz State Medical Academy - - - - - 34 42 56 20 42 43 Medical college under Osh State University ------19 79 139 Uzgen Medical College under Osh State University ------75 59 88 Medical college under KUU ------50 121 118

By program : Nursing 1419 1388 1238 1286 - 1185 1098 954 973 795 1089 Nursing – masseur (among sight disabled) ------16 8 9 10 Medical treatment 297 259 204 262 127 267 288 185 230 248 350 Obstetrics 352 267 331 284 246 233 322 257 296 587 812 Treatment obstetrics 42 127 401 385 816 655 693 850 536 28 3 Orthopedic dentistry 75 96 91 102 120 147 178 155 138 184 27 Dentistry 25 28 25 23 29 30 32 27 42 37 68 Preventive medicine 73 78 79 68 67 66 61 62 72 28 43 Laboratory diagnostics 102 77 47 54 54 44 67 70 60 77 30 Pharmacy 51 27 30 30 92 190 248 312 274 429 67

Annex 10

ANNEX 11

FAP’s in Need of Repair per Oblast

ANNEX 11 FAP’s in Need of Repair per Oblast (Source: MHIF)

FAPs situated at Number of Number of Number of schools, FAPs that FAPs that FAPs in Oblast administration have been need to be need of buildings and in rehabilitated rehabilitated equipment private houses etc.

Djalalabad oblast 72 59 151 20 Issykkul oblast 17 80 111 10 Naryn oblast 29 22 61 10 Batken oblast 12 17 43 14 Chui oblast 10 14 28 4 Talas oblast 6 13 32 15 Osh oblast 55 72 152 25 Total 201 277 578 98

Annex 11

ANNEX 12

External Assistance to the Kyrgyz Republic in the ECD Sector

ANNEX 12 A EXTERNAL ASSISTANCE TO THE KYRGYZ REPUBLIC IN THE EARLY CHILDHOOD DEVELOPMENT SECTOR Project Funding Subsector Project Amount Duration Activity Agency ($ millions) Health, Nutri- Community-Based 10.5 (loan) 2004 - Improving the development status of young children between birth and 8 years of age, by pro- tion, & Social Early Childhood viding holistic interventions on improving health, nutrition, and psychosocial development Protection/Early Development Childhood De- velopment Health & social Reducing Neonatal 1.0 (grant) 2004 - Reduction of neonatal mortality rate in 4 raions of Osh oblast services Mortality Health Sustainable Food 2.0 () 2004-2006 To reinforce and sustain the reduction of iodine deficiency disorder (IDD) and iron deficiency ADB Fortification in (com- anemia (IDA) among poor children and women in Central Asia through parallel attention to Central Asia and pleted) supply (production and distribution); demand (public awareness and demand creation); and Mongolia regulation (quality control, implementation of regulations and legislation, and trade facilitation). Health JFPR: Grant Assis- 6.85 (grant) 2001– Fortification of salt and flour; legislative enforcement; support for regulatory authorities; and tance to Asian 2003 social marketing and promotion Countries in Tran- (com- sition for Improv- pleted) ing Nutrition of Poor Mothers and Children Health Mother and Child 5.0 (loan) 2003-2005 Provision of equipment and training for maternal hospitals in the south of the Kyrgyz Republic Health 2.5 (grant) Kredit- Health Mother & Child 14.15 1995-2006 To improve diagnostics, prevention and treatment of typical diseases that affect pregnant anstalt fur Care Program Grant Tech- women, mothers and small children. The program includes supply of equipment for neonatal Wiederauf- I/II/IIa/III nical assis- care units, delivery rooms and children's hospitals. It also entails a substantial training program bau (KfW) tance In- to introduce more effective medical treatment and to improve the management of hospitals. vestment Loan/credit ECD Children in Difficult N.A. 1998 Training and support to a short-stay reception center for homeless children in Bishkek; support Save the Circumstances to reopen kindergartens in rural areas; integrated education projects; curriculum development; Children and capacity building (UK) Health Child Health and N.A. 1998 - Practical support for child care organizations; community involvement; and parents’ clubs Disability Swiss Health Health Reform 2.0 (grant) 2001-2004 Support to the health care reform: hospital improvement and services restructuring, hygiene Agency for Support Project and sanitation improvement, strengthening of primary health care; health care promotion and Develop- community involvement ment and Coopera- tion (SDC)

Annex 12 1 Swiss Health & Social Kyrgyz Swiss 9.159 (grant, 2006-2008 The project contributed to the improvement of basic health infrastructure in Naryn oblast Serv. Swedish Health TA) through reconstruction of raion hospitals, procurement of medical equipment and training of Coop. (SDC Infrastructure Project staff. In the current phase (2006-2008) it continues to improve infrastructure, quality of medical & State Se- services and develops national hospital hygiene measures. The main focus is on extension of cretariat for Community Action for Health (health promotion model for rural population) in Naryn and Talas Economic oblasts. In 2006, SIDA joined the project with contribution to extend the model throughout the Affairs Batken, Osh and Chui oblasts. At the same time USAID implements the model in Issyk Kul and SECO) Jalalabad oblasts, with the technical expertise of the Swiss Red Cross. Education N.A. 2000-2005 Mother and child survival, parent education and IEC campaigns; Growth and Development UNICEF Program - pilot projects in preschools; support for textbook leasing system; and support of IMCI training in 3 pilot raions Health Vaccine N.A. 2000 - The Vaccine Independence Initiative (VII) is a revolving fund working through UNICEF. UNI- Independence CEF conducts national immunization campaigns; procurement of vaccines and cold chain Initiative equipment; and supports pilot raions Health & Social CDC (TA) 2.18 (N/A) Planned (i) HIV sentinel surveillance; (ii) Blood safety (iii) Tuberculosis; laboratory diagnosis and elec- Services tronic surveillance; (iv) Definition of live birth and infant mortality; (v) applied epidemiology training program. Health & Social ZdravPlus 8.676 2005-2009 Comprehensive technical assistance to the government in the implementation of the National Services Health Reform Strategy Manas Taalimi Program, 2006-2010 Health & Social Project HOPE 2.357 2003-2009 Technical support to the national TB control program: Services (Health Opportunity 1. Training on DOT to TB specialists, primary health care workers, nurses, lab tech- ni- for People Every- cians, and prison medical staff where) 2. Monitor case reporting and tracking 3. Research on reasons for noncompliance with treatment 4. Develop patient education materials and support education campaigns USAID Health & Social Project HOPE 0.658 2003-2007 Improve child survival, health and nutrition in Batken oblast. Reduce morbidity and mortality Services rates of children under five and women of reproductive age by strengthening and improving the quality of existing local health care services and delivery systems. Health Healthy Community 0.55 (grant) 2003-2006 Grant support to the communities through NGOs and community initiative groups in the fields Grant Program of mother and child health, infectious diseases, hygiene and sanitation, health reform advocacy, mental health, healthy lifestyle promotion, and child health improvement. Health Increased Utiliza- 3.6 (grant) 2003 - Primary health care education of health professionals; support for tuberculosis control activities; tion of Quality 2005 adaptation of WHO definition of live birth and infant mortality; community and local government Primary Health (com- mobilization; and HIV/AIDS prevention and control Care in Selected pleted) Populations Health & Social Child Survival Pro- 2.2 (grant) 2002 - Improvement of the health of children under five and women of reproductive age in two pilot Services ject in Jalalabad 2006 raions (Bazar-Korgon and Aksy) in Jalalabad Oblast Human Devel- MercyCorp 2.55 2005-2008 To enable citizens and leaders in Kyrgyzstan to effectively address and peacefully manage USAID opment & De- conflict and tensions through a focus on community-based economic development. Mercy mocracy Corps

Annex 12 2 Health, Public Health and Social 15.0 2005-2011 Improvement of the health status by improving access, financial protection, efficiency, equity, Administration, Protection Project and fiduciary performance in the Kyrgyz health sector; ensuring sufficient and reliable financing Law & Justice for the health sector; and strengthening the targeting of social benefits by developing effective administration and information management systems. Support of implementation of Manas Taalimi Health Reform Programme Education, Pub- The Rural 15.5 2004-2010 Improvement of learning and learning conditions in primary and secondary schools, with priority World Bank lic Administra- Education Project attention to rural areas tion Health, Nutri- The Second Health 19.5 2001-2006 Improvement of performance and long-term financial viability of the health system by adjusting tion, Population Sector Reform Pro- (comple- the delivery system to available means and focusing on health risks and diseases. & Public Ad- ject ted) ministration Health Child Health 0.025 (grant) 2002 - Promotion of Effective Perinatal Care; IMCI 2003 WHO (completed) Health and So- PCD 0.18 2003-2005 (a) To undertake functional analysis of the clinical and support activities in the new primary cial Services (grant) (com- care centers; (b) to design nursing and assistant roles for primary care services; (c) to analyze pleted) the need for nursing out-reach services in local communities and design appropriate community nursing roles; (d) to develop a requirements planning model for primary and community DFID nursing staff; (e) to facilitate service restructuring in Bishkek and Osh Cities. Health & Social Health Policy Re- 3.26 (grant) 2000-2006 To strengthen the capacity of Kyrgyz health policy makers to use evidence on health system Services sponse to Poverty (com- performance to inform policy decisions to mitigate the effects of poverty. (TA) pleted) Health Health SWAp 13.8 2006-2010 On-budget support to the health sector to fully co-ordinate capacity-building related to strength- DFID, KfW, (grant) ening financial management, audit and procurement capacity. SDC and the World Bank Human Dev. & Poverty Alleviation 3.0 Planned Addressing social issues in the Ferghana Valley: to reduce the potential for social conflict, Democracy Programme for strengthen local economies, improve equality of wealth distribution and strengthen local gov- EU/TACIS Ferghana Valley ernments’ capacity to respond to community concerns.

Health Vaccine 1.26 (grant) 2000– Financing of vaccines procurement for the Vaccine Independence Initiative Independence 2004 JICA Initiative Funding (completed)

Annex 12 3 ANNEX 12 B EXTERNAL ASSISTANCE IN THE CHILD HEALTH AND NUTRITION SECTOR

Table 1: MCH and MCN Projects in the Kyrgyz Republic by Donor Agency Funding agency Subsector Project & location Duration

1. Food fortification: nationwide 2000-2006 ADB Health 2. Iodization of salt: nationwide 3. IMCI (training) for 12 pilot rayons 2004 1. Food fortification: nationwide 2000-2006 2. Iodization salt: nationwide 1993 UNICEF Health 3. Supplementation vit A, nationwide From 2004 4. IMCI (training) for 5 pilot rayons 2000 IMCI - organized seminar, adaptation of 2000 WHO modules World Bank Health IMCI (training) 27 raions 2005-now US-AID/ IMCI 2 raions, Jalalabad oblast 2003-6 Health Hope 2 raion in Batken oblast 2005-now Naryn oblast, Village Health Committees 2001 Scaled up to Talas oblast, 2005 Swiss Red Cross Health Scaled up half Chui oblast, Batken oblast 2006 2nd half Chui oblast and Osh oblast 2007 VHC in Issykul oblast 2005 USAID/ZdravPlus Health 2 raions in Jallabad oblast 2006 6 other raions, Jalalabd oblast 2007-8

Table 2: MCH and MCN Projects in Selected Raions

Supported by Oblast Raion ADB US-AID World Bank CB- UNICEF ECD2 (HOPE) (US-AID) Baby Friendly Hospitals/BF Aravan IMCI - Osh IMCI Uzgen Baby Friendly Hospitals/BF

IMCI Batken Baby Friendly Hospitals/BF

IMCI Batken Kadamjai Baby Friendly Hospitals/BF

IMCI Leilek Baby Friendly Hospitals/BF

IMCI Suzak Baby Friendly Hospitals/BF

IMCI Nooken Baby Friendly Hospitals/BF

Jalalabad IMCI Bazarkorgon Baby Friendly Hospitals/BF 2002-06 IMCI Aksy Baby Friendly Hospitals/BF 2002-06

Annex 12 4

ANNEX 13

Global Prevalence and Trends in Nutritional Status

ANNEX 13 GLOBAL PREVALENCE AND TRENDS IN NUTRITIONAL STATUS AND NUTRITION AT A GLANCE IN THE KYRGYZ REPUBLIC

1. Food insecurity of households1, Protein-Energy Malnutrition (PEM) among children under five years of age, chronic energy deficiency (CED) among adults, particularly women of reproductive age (WRA), and micronutrients deficiencies (MND) still remain a challenge for developing countries. While these traditional public health concerns still dominate, there is an emerging problem of overweight2.

2. In most subregions of the developing world the percent of undernourished is declining but far too slowly to reach the target of halving the 1990 proportion (20% of developing world) by 2015. PEM occurs characteristically in children under 5 years and peaks during the period when children are gradually taken off breast-milk and introduced to complementary foods. Stunting3 usually peaks between 12 and 24 months, primarily due to poor feeding practices resulting in a diet inadequate in energy and micronutrients. Wasting4 is due to coinciding increases in the occurrence of infectious disease5. Overall stunting remains prevalent in all subregions with a slow progress in decline and a worsening situation in the Sub-Saharan subregion. Among adults, chronic energy deficiency (CED6) is common, particularly among WRA, without a significant decline across subregions. Overweight and obesity7 are rapidly growing in all regions, affecting children as well as adults (Table 1).

3. The most important micronutrient deficiencies (MND) of public health importance are vitamin A deficiency (VAD), anemia due to dietary iron deficiency (IDA) and iodine deficiency disorders (IDD). Of all supplementation programs that against iodine deficiency was the most successfull with 67% households in Sub-Saharan Afria consuming iodized salt in 1997-2002. The corresponding firgures are 53% in South Asia, 80% in South East Asia and 81% in Latin America and the Caribbean. Despite these achievements nearly 2 billion individuals worldwide are iodine deficient. Iron deficiency is one of the most prevalent nutritional disorders without a trend in decline in all subregions. Extrapolation from the best available data indicate that 140 million under-five children and over 7 million pregnant women suffer of Vitamin A deficiency each year – about half occurring in South and South-East Asia. The decline in clinical cases (xerophthalmia) is most likely attributable to the bi-annual vitamin A capsule distribution. Less or no improvements are reported for moderate and mild VAD. Zinc deficiency is thought to be common in children and pregnant women but no population-based data are as yet available8 (Table 2).

4. In 2002 the World Bank produced a report Prospects for Improving Nutrition in Eastern Europe and Central Asia, which provides an overview of the critical nutrition issues and problems in the region. The summary for the Kyrgyz Republic is shown in Table 3.

1 Energy intake less than daily requirement for an active and healthy life. The FAO measure of food insecurity or undernourishment tales into account the amount of food available per person nationally, (derived from food balance sheets) and the extent of inequality in access to food 2 Ending Malnutrition by 2020. An Agenda for Change in the Millennium. Fd Nutr Bull 2000 supplement 3 to volume 21 and 5th Report on the World Nutrition Situation, UN- Standing Committee on Nutrition: March 2004 3 HAZ = height-for-age Z-score < - 2 4 WHZ = weight-for-height Z-score < - 2 5 Tomkins A, Watson F. Malnutrition and Infection; a Review. ACC/SCN State of the Art Series, Nutrition Policy Discussion Paper, 1989 No. 5 6 CED = chronic energy deficiency = Body Mass Index (BMI) < 18.5 7 Overweight = BMI ≥ 25; obesity BMI ≥ 30 8 Zinc Nutrition and Public Health. ACC-SCN News 1995,no.12: 24

Annex 13 1 Table 1: Global Prevalence of Malnutrition 1999-2001 and Trends 1980-2005

1999-2001 GLOBAL TREND VARIABLE PERCENT MILLIONS 1980-2005 FOOD INSECURE 17.0 800 Reduced 20% - Sub-Saharan Africa 33 198 - South Asia 22 293 - South-East Asia 13 66 - Latin America & Caribbean 10 53

WOMEN: Chronic Energy Deficiency Stagnant - Sub-Saharan Africa 5-40 198 - South Asia 27-45 293 - South-East Asia 12-25 63 - Latin America & Caribbean < 10 33 Stagnant LOW BIRTH WEIGHT - Sub-Saharan Africa 14 - South Asia 30 - South-East Asia 12 - Latin America 10 - INDUSTRIALIZED COUNTRIES 7 UNDER-FIVES • Underweight 22.2 121 Reduced 12% • Stunted 27.5 150 Reduced 20% • Wasted 7.3 40 Stagnant

Sources: State of Food Insecurity in the World Food and Agriculture Organization, FAO, 2002,2003 and 5th Report on the World Nutrition Situation, 5th Report on the World Nutrition Situation, UN- Standing Committee on Nutrition: March 2004

Table 2: Global Prevalence and Trends of micronutrient deficiencies 1997 – 2003

MICRONUTRIENT DEFICIENCY PERCENT MILLIONS IODINE DEFICIENCY DISORDERS (IDD) • general population 35 1,988 • children 6-12 years 36 285 significant reduction VITAMIN A DEFICIENCY (VAD) • Under-Fives - deficient serum levels 25 127 - xerophthalmia (eye lesions) 0.88 4,4 • Pregnant or lactating mothers - night blindness 5.8 6.2 - deficient serum levels 18.4 19.8 significant reduction of clinical cases IRON DEFICIENCY ANEMIA (IDA) • children - 0 to 4 years 34 no - 5 to 14 years 53 measurable • women, 15-59 years: - all 43 difference - pregnant 56 in 40 years ! • men, 15-59 years 34

Source: 5th Report on the World Nutrition Situation, UN- Standing Committee on Nutrition: March 2004

Annex 13 2 Table 3: Nutrition at a Glance, the Kyrgyz Republic (selected indicators)

Average in Eastern Europe- Basic Data Kyrgyz Republic Central Asia (EE-CA) or in selected countries Infant Mortality Rate 66 EE-CA: 23 Under-Five Mortality rate 76 Russian Federation (RF): 21.7

Child Malnutrition

Stunting (chronic malnutrition) 24.8% RF: 13% - Lowest quintile 33.9% - Highest quintile 14.3% Wasting (acute malnutrition) 3.4% RF: 4% Underweight 11% RF: 4% Low birth weight (< 2,500g) 6.3% RF: 6%

Adults

Overweight and obesity 8.6% women, age 15-49 years EE-CA: 12.1% adults BMI>30 RF: 28% adults overweight 24% adults obese 21% Under-Fives > =2 SD (1993)

Micronutrient Deficiencies

Iron Deficiency Anemia EE-CA: - children < 3 years 50% - children < 4 years: 22% - women, 15-49 years 38% - pregnant women: 24% Iodine Deficiency Disorders EE-CA: Total Goiter Rate - goiter in school-aged children 20% 18% Vitamin A Deficiency No data EE-CA: No data

Child Feeding Practices, 1997 data

Breastfeeding RF: - 0-3 months 98% (of which 31% exclusive) - 45% at 3 months - 8-11 months 81% - 32% at 6 months Introduction of Weaning Foods Median age 5 months RF: early introduction

Access to Food

Daily Energy Supply per Capita 1994: 2,069 kcal EE-CA: 2,850 kcal

Economic context

Population below Poverty Line 40% RF: 50% GNP per Capita (1998US$) 350 EE-CA: 2,310 Source: C.Rokx, R.Galloway, L.Brown. Prospect for Improving Nutrition in Eastern Europe and Central Asia. Human Development Network. Health, Nutrition and Population Series. the World Bank, Washington DC 2002

Annex 13 3

ANNEX 14

Nutrition in Pre-service Training of Medical Doctors, Nurses and Midwives

ANNEX 14 NUTRITION IN PRE-SERVICE TRAINING OF MEDICAL DOCTORS, NURSES AND MIDWIVES

Institution Curriculum 2nd year Nutrition is taught within the subject of propadeutics of child illnesses Kyrgyz State Medical Academy (KSMA) - 2 hours lectures - 6 academic hours of practical classes (breast feeding of children 0- 6 months, complementary feeding, artificial and combined feeding) 3rd year Child nutrition is taught only to students of paediatric program – 16 hours practical classes, 2 hours – lectures. 4th year

2 hours neonatal feeding of preterm and full term babies 6th year IMCI program is taught, which includes nutrition of healthy and sick children < 5 years Clinical residents specializing in “Family Medicine” are taught

child nutrition within IMCI training Nutrition of pregnant women is taught within subject of

Antenatal Care Nutrition is taught within IMCI and separately by special Medical College topics: pediatrics etc.

Doctors and Feldshers are trained nutrition within IMCI - - 8 Kyrgyz State Medical Institute of hours. Refreshing and Retraining (KSMIoRR) Nutrition of pregnant and lactating women is within the subject of Antenatal Care.

Annex 14 1

ANNEX 15

Nutrition Goals in UN SubCommittee and Nutrition in the Millennium Development Goals

ANNEX 15 NUTRITION GOALS IN UN SUBCOMMITTEE ON NUTRITION (SCN) AND NUTRITION IN THE MILLENNIUM DEVELOPMENT GOALS (MDG)

1. The Commission on the Nutrition Challenges of the 21st Century, in its report to the UN Subcommittee on Nutrition1 stated that the following goals endorsed at the 1990 World Summit for Children2 (box 1), should be maintained as an unfinished agenda in the new millennium.

(i.) 50% reduction of 1990 levels in severe and moderate malnutrition among Under- Fives (ii.) Reduction of the rate of low birth weight to less than 10% (iii.) Reduction of IDA among women by one-third of 1990 level (iv.) Virtual elimination of IDD (v.) Virtual elimination of blindness and other consequences of VAD

Key strategies to achieve these goals:

(i.) Enable women to breastfeed their children exclusively for 4-6 months and to continue breastfeeding with (adequate in quantity and quality) complementary foods well into the second year (ii.) Institutionalize growth monitoring and promotion as the center piece in Primary Health Care (and tool for nutrition improvement) (iii.) Disseminate knowledge and supporting services to increase food production and ensure household food security.

2. At the Millennium Summit in September 2000 the participating nations (from 191 countries) agreed upon a set of goals to which countries and the international donor community have committed themselves to reaching by 2015, the so-called Millennium Development Goals (MDG). Nutrition is not mentioned as a specific MDG, but there is a concensus that good nutrition is essential for the progress towards reaching at least six MDG3 (box 24)

Goal 1: Eradicate extreme poverty and hunger Malnutrition erodes human capital, reduces productivity Goal 2: Achieve universal primary education Malnourished children are more likely to have impaired school performance Goal 3: Promote gender equality and empower women Better nourished girls are more likely to stay in school and to have more control over future choices

1 Ending Malnutrition by 2020. An Agenda for Change in the Millennium. Fd Nutr Bull 2000 supplement 3 to volume 21 2 Development goals and strategies for children in the 1990s. A UNICEF Policy Review, August 1990 pg 26. UNICEF New York 3 UN-SCN, SCN News July 2004: Nutrition and the Millennium Development Goals and (b) Repositioning Nutrition as Central to Development, a Strategy for Large-scale Action. Directions in Development, IBRDevelopment/ the World Bank, Washington DC 2006 4 Summarized from 5th Report on the World Nutrition Situation. Nutrition for Improved Development Outcomes. UN Standing Committee on Nutrition (SCN) March 2004, Secretariat c/o WHO Geneva

Annex 15 1

Goal 4: Reduce child mortality Malnutrition is directly and indirectly associated with more than 50% of all child mortality. Goal 5: Improve maternal health Chronic energy deficiency and micronutrient deficiencies are associated with most major causes of maternal mortality Goal 6: Combat HIV/AIDS, malaria and other diseases Malnutrition speed up the onset of AIDS among HIV-positive, weakens resistance to infections and reduces malaria survival rates.

Goal 1: Eradicate extreme Poverty and Hunger

3. Malnutrition erodes human capital, reduces productivity and undermines development and poverty reduction. Macro- and micronutrient deficiencies are a manifestation of poverty as the degree of poverty limits the quantity and quality of food intake5. But malnutrition is not only an outcome of poverty, it also contributes to poverty. Adults suffering from IDA, who are of small stature and underweight, have lower work outputs than better-nourished adults. Horton found that the aggregated costs of low birth weight, malnutrition in young childhood, late school enrollment and reduced cognitive ability due to malnutrition and/or IDA can be as high as 3% in gross domestic product (GDP)6. These costs are even underestimates of the true costs as they do not include the cost of vitamin A deficiency or diet-related chronic disease costs, which for China for example have been estimated at 2.4 percent of GDP7. This self-reinforcing cycle of poverty and hunger (malnutrition) means that the beneficial effects of an intervention are related to the impact of each main element: nutrition, health and productivity8 (Figure 1-2)

Goal 2: Achieve universal Primary Education

4. The capacity to learn is negatively affected by chronic malnutrition and short term hunger as well as iron deficiency is – all leading to paying less attention in class9. Also, malnourished children may receive less schooling because of their height, which often is used as an indicator by parents for readiness for school. Late enrollment leads to lower expected lifetime earnings. Glewwe and Jacoby10 illustrate that for each year of delay in entry to primary school in Ghana a child loses 3 percent of lifetime wealth. Besides the obvious human costs, there is an economic cost to government; higher repetition rates among malnourished children reduce the effectiveness of public resources spent on education.

5 Berhman J., H Alderman and J. Hoddinott (2004) Malnutrition and Hunger Published in Lomborg B. (ed) Global crisis, global solutions. Copenhagen Consensus 2004 Cambridge: Cambridge University Press 6 Horton S. Opportunities for Investment in nutrition in low-income Asia Asian Development Review 1999, 17 (1, 2):246-273 7 Haddad L., et al. Reducing Child Malnutrition; How Far Does Income Growth Take Us? The World Bank Economic Review 2003; 17 (1):107-131 8 Joffe M. Health, livelihoods, and nutrition in low-income rural systems.In: C.Hawkes, M.Ruel, S.Babu, editors. Linkages between agriculture and health in science, policy and practice. Fd Nutr Bull. 2007, 28 (2) suppl 9 (a) Grantham-McGregor S. Assessments of the Effects of Nutrition on Mental Development and Behavior in Jamaican Studies Am.J.Clin Nut 1993; 57 (supplement):303S-9S; (b) Pollitt E. et al. Early Supplementary Feeding and Cognition: Effects over Two Decades. Society for Research in Child Development Monograph, 1993: 235 Chicago: University of Chicago Press; (c) Del Rosso J.M.., T. Marek Class Action. Improving School Performance in the Developing World through Better Health and Nutrition World Bank, Washington DC 1996 10 Glewwe P., and H. Jacoby An Economic Analysis of Delayed Primary School Enrollment and Childhood Malnutrition in a Low Income Country. Review of Economics and Statistics 1995; 77:1 February:156-69.

Annex 15 2

Goal 3: Promote Gender Equality and empower Women

5. Better nourished girls are more likely to stay in school and to have more control over future choices. Gender equality is good for child nutritional status. Improvement in women’s education relative to men’s contribute to a reduction of child malnutrition of more than 50% from 1970 to 199511. Further, women’s decision-making power relative to men’s was significantly associated with nutritional status of their children12 .

Goal 4: Reduce Child Mortality

6. Malnourished children tend to be having a higher incidence of infectious diseases. Childhood illnesses reduce the absorption of nutrients (diarrhea), increase requirements (fevers) resulting in a downward spiral of infections – malnutrition - reduced immunity - more frequently and severely ill, the well-known synergism of malnutrition-infections13. There is a very strong association between underweight and child mortality14. It has been estimated that out of 11.6 million deaths that occurred in 1995 among children under 5 in developing countries, 6.3 million (54%) were associated with low weight-for-age15. This is mostly due to moderate malnutrition and not the more commonly monitored severe malnutrition, like marasmus and kwashiorkor. Also micronutrient deficiencies, notably VAD, IDA and zinc deficiency are linked with increased morbidity and mortality16 ( Figure 3)

Goal 5: Improve Maternal Health

7. Poor maternal nutritional health also contributes to at least four of the five major causes of maternal mortality17. Blood loss during delivery has much more serious consequences in anemic women and the risk to die is far greater18. Iron deficiency is the major cause of anemia but folate deficiency contributes to anemia, (and preterm deliveries and low birth weight) and therefore is associated with risk of maternal death. Maternal infection may be exacerbated by even mild vitamin A deficiencies, which lead to reduced immuno-competence, is associated with increased risk to die19. Sepsis is also attributable to prolonged labor due to chronic energy deficiency. Small stature as a result of childhood malnutrition is a recognized risk for obstructed labor. The nutritional link with eclampsia is still

11 Smith L. & Haddad L. Explaining child malnutrition in developing countries: A cross-country analysis. IFPRI Research Report 111, IFPRI Washington DC 1999 12 Smith L et al. The importance of Women’s Status for Child Nutrition in Developing Countries. IFPRI Washington DC 2003 13 Tomkins A, Watson F. Malnutrition and Infection; a Review. ACC/SCN State of the Art Series, Nutrition Policy Discussion Paper, 1989 No. 5 14 Pelletier D.I., Frongillo E.A.Changes in child survival are strongly associated with changes in malnutrition in developing countries. J.Nutr 2003;133:107 15 Pelletier D.I., Frongillo E.A. and J.P. Habicht. Epidemiological evidence for a potentiating effect of malnutrition on child mortality American Journal of Public Health 1993; 83(8):1130-1133. 16 (a) Beatonet al. Vitamin A supplementation and and morbidity and mortality in developing countries. Fd Nutr Bull. 1994; 15 (4); (b) Jones G et al. How many child deaths can we prevent this year? Lancet 362; 65:71; (c) Mason J, Rivers J, Helwig C guest editors Recent trends in malnutrition in developing regions: Vitamin A deficiency, anemia, iodine deficiency and child underweight. Fd Nutr Bull 2005, 26-162; Ossendarp SJ, West CE, Black RE. The need for maternal zinc supplementation in developing countries: an unresolved issue. J. Nutr 133;(3): 817S 17 Leslie J: Improving Nutrition of Women in the Third World; In: Pinstrup-Andersen P; Pelletier d, Alderman D, editors; Child Growth and Nutrition in Developing Countries 1995; pp 117-138, Cornell University Press, Ithaca, USA; 18 Stolfzfus RJ, Mullany L, Black RE. Iron deficiency anemia in public health terms. In: Comparative Qualification of Health Risks: the Global Burden of Disease due to 25 selected major risk factors, Harvard University Press, Cambridge 2003 19 West KP Jr. et al. Low dose vitamin A or beta-carotene supplementation reduces pregnancy-related mortality: A double-masked, cluster randomised trial in Nepal. BMJ 1999; 318:570

Annex 15 3

tentative. Almost all dietary surveys report extremely low calcium intakes in poor communities who cannot afford milk and milk products. There is compelling evidence that high calcium intake is associated with less hypertension and reduced the likelihood of developing eclampsia20.

8. There are even more pertinent reasons to improve maternal health and nutrition. Malnutrition affects generations. Poor communities are confronted with the intergenerational cycle of undernourished mothers, who are more likely to give birth to low birth weight babies – who in turn become stunted children21 and small adults with impaired physical development and higher risks for high blood pressure, type 2 diabetes mellitus, coronary heart disease and stroke22. From a health perspective the negative consequences of common energy deficiency in adults are most obvious among women, notably during pregnancy and lactation. Maternal under-nutrition is a major cause of low birth weight in their offspring, which in turn increases early infant mortality23. Figure 4 provides an overview of the causal links between maternal malnutrition and consequences throughout life.

Goal 6: Combat HIV/AIDS, Malaria and Tuberculosis

9. Malnutrition weakens the immune system and increases the risk of infection. Providing undernourished HIV/AIDS mothers with multivitamin supplements reduces child mortality and HIV transmission through breastfeeding24, estimated to be 10-20%25. Underweight, VAD and zinc deficiency are major contributing factor to malaria26. There is also good epidemiological and clinical evidence that malnutrition contributes to the incidence and severity of tuberculosis and that those with the „triple trouble“ of HIV, TB and malnutrition are at greater risk than those having the single health problem27 .

10. In conclusion, international evidence is sufficiently robust to promote Nutrition in the context of the MDG in particular and overall development in general. Improving the nutritional status of the population, specifically women of reproductive age and children, is an investment with high returns in survival and quality of life, poverty reduction and sustainable (health) sector reforms.

20 (a) Bucher, H.C., et al. Effects of a dietary calcium supplementation on blood pressure: a meta-analysis of randomized controlled trials. JAMA 1996a; 275:1006-1012; (b) Bucher, H.C. et al. Effect of calcium supplementation on pregnancy-induced hypertension and eclampsia: a meta-analysis of randomized controlled trials. JAMA 1996b: 275:1113-1117; (c) Villar J et al. Nutritional interventions during pregnancy for prevention or treatment of maternal morbidity and preterm delivery: an overview of randomised controlled trials. J.Nutr 2003; 133:1606S 21 Grantham-McGregor SM (1998) Small for gestational age, term babies, in the first six years of life. Eur J Clin Nutr 1998; 52 (Suppl 1): S59-64.:S59-S64. Martorell R, Kettle Khan L, Schroeder DG (1994) Reversibility of stunting: epidemiological findings in children from developing countries. Eur J Clin Nut 48:S45-S57 22 Barker DJP Mothers, Babies and Health in Adult Life 1998, Edinburgh: Livingstone. 23 World Health Organization. Maternal Anthropometry and Pregnancy Outcomes. A WHO Collaborative Study. Bulletin of the World Health Organization, 1995,. Suppl. to Volume 73; (b) Jones G et al. How Many Child Deaths can we Prevent this Year? Lancet, 2003, 362:65-71; (c) Susan P Walker, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet 2007,369: 145-57 24 Fawzi WW et al. Randomised trial of vitamin supplements in relation to transmission of HIV-1 through breast feeding and early child mortality. AIDS, 2002; 16: 1935 25 DeCock KM et al. Prevention of mother-to-child HIV transmission in resource-poor countries. JAMA 2000; 283:1175 26 (a) Ezzati M et al. Estimates of global and regional potential health gains from reducing multiple major risk factors Comparative Risk Assessment Collaborating Group. Lancet 2003; 362; 9380:271 27 VanLettow M et al. Triple Trouble; The Role of Malnutrition in Tuberculosis and Human Immunodeficiency Virus Co-Infection. Nutrition Reviews 2003;61 (3):81

Annex 15 4

Figure 1: The Core Nexus and Cross-Cutting Derminants

Figure 2: The Importance of Health to Labor Productivity

Annex 15 5

Figure 3: Causes of Malnutrition

Child

nutritional

status

Child's Child's dietary health Immediate intake status Determinants

Household Care for Health, food security mothers environment and children and services

Underlying Determinants Resources for Resources for Resources for food quality care health

- Food production - Caregiver control - Safe water supply - cash income - adequate sanitation of resources and - transfers of food autonomy - health care in-kind - caregiver physical availability and mental status - environmental - caregiver know- safely/shelter ledge and beliefs

POVERTY

Political and economic structure

Basic Socio-cultural Determinant environment

Potential resources: Environment, technology, people

Source: Adapted from UNICEF, 1990 & 1998; and Engle, Menon, and Haddad, 1990, UNICEF (1998) State of the World's Children; Oxford University Press

Annex 15 6

Figure 4: Nutrition throughout the life cycle

Annex 15 7

ANNEX 16

Linkages Between Nutrition, Health, Labor Productivity and Causes of Malnutrition

ANNEX 16 LINKAGES BETWEEN NUTRITION, HEALTH, LABOR PRODUCTIVIY AND CAUSES OF MALNUTRITION

Figure 1: The Core Nexus and Cross-Cutting Determinants

Figure 2: The Importance of Health to Labor Productivity

Annex 16 1

Figure 3: Causes of Malnutrition

Child

nutritional

status

Child's Child's dietary health Immediate intake status Determinants

Household Care for Health, food security mothers environment and children and services

Underlying Determinants Resources for Resources for Resources for food quality care health

POVERTY

Political and economic structure

Basic Socio-cultural Determinant environment

Potential resources: Environment, technology, people

Source: Adapted from UNICEF, 1990 & 1998; and Engle, Menon, and Haddad, 1990, UNICEF (1998) State of the World's Children; Oxford University Press

Annex 16 2

Figure 4: Nutrition throughout the life cycle

Annex 16 3

ANNEX 17

How Thailand tackled Undernutrition

ANNEX 17 HOW THAILAND TACKLED UNDERNUTRITION1

1. In 1982 more than half of Thai preschool children were underweight. Over the next eight years severe and moderate underweight as well as severe vitamin A deficiency were virtually eliminated. Mild underweight was significantly reduced till 10%. Maternal mortality declined from 230 in 1992 till 17 per 100,000 live births in 1996.

2. Thailand achieved these results through a programme of accelerated action that focused on nutrition and improved Human Poverty Index from 34% in 1970 to 12% in 1990.

(i.) Underweight was identified as the most important nutritional problem and for the first time the National Economic and Social Development Plan included a separate national plan for food and nutrition. The plan set explicit goals to eliminate severe, moderate and mild underweight. (ii.) Comprehensive surveillance was instituted through growth monitoring. All preschool children were weighed and checked every three months at community weighing posts. Those with severe underweight were given food supplements. (iii.) Nutrition was incorporated into relevant health, education and agriculture policies at national, regional, local and community levels. (iv.) Costs were minimized by retraining existing staff, using volunteers at village level and allocating funds to selective measures with maximum impact. Each group of about 10 households close to chose a suitable volunteer to engage in a national training programme and then monitor both mothers and children in their communities. (v.) A programme of nutrition education and communication encouraged breast feeding and timely incorporation of complementary foods and proper hygiene. Information was disseminated about food beliefs and taboos. (vi.) School lunch programmes were established in schools in poor areas (vii.) Salt was iodized. (viii.) Household and community food security was strengthened by promoting home gardening, fruit trees, fish ponds, and preventing infectious diseases in poultry.

The dramatic progress in Thailand shows:

(i) The need to establish broad-ranging, integrated food and nutrition programmes as part of poverty reduction. (ii) The need for some form of local organization through which village-level workers or volunteers encourage and support families of children who are lagging behind. (iii) The need to address undernutrition in the context of a poverty alleviation plan.

1 Ending Malnutrition by 2020. An Agenda for Change in the Millennium. Fd Nutr Bull 2000; volume 21, supplement 3, pg. 15

Annex 17 1

ANNEX 18

Number of State Kindergartens and Number of Preschool Age Children in all Oblasts

ANNEX 18 Number of State Kindergartens and Number of Preschool Age Children in all Oblasts

Number of Number of Number of Oblast preschools children preschool teachers

Kyrgyz Republic 448 54365 2388 Batken oblast 17 2671 121 Jalalabad oblast 131 11224 474 Issyk Kol oblast 36 3872 146 Naryn oblast 25 1811 84 Osh oblast 39 3988 181 Talas oblast 18 1893 73 Chui oblast 57 6029 36 Bishkek city 95 17561 813 Osh city 30 5316 236

Source: National Statistics Committee of Kyrgyz Republic. 2006. Education and Science in Kyrgyz Republic. Statistics Collection, Bishkek. P. 37 Note: Data for 2005

Annex 18

ANNEX 19

Public Financial Management Action Plan for 2006

ANNEX 19 PUBLIC FINANCIAL MANAGEMENT (PFM) ACTION PLAN FOR 2006 Approved by the Presidential Decree # 337 on June 29, 2006

Time- Objective Activities Responsible Expected output frame I. Preparation and execution of realistic annual budget - Immediate actions I. A. Improvement of the budget process - Enhancement of the budget realism and avoiding the introduction of amendments to the budget without a relevant support from revenues 1.A.1 Improvement of the 1.A.1.1. Conduct an analysis of the existing process of Ministry of Economy Q3, 2006 The MEF has an improved process of system of functional and budget preparation and develop recommendations on and Finance, budget preparation and the information informational interaction its improvement. Improve current system of Central Treasury system enabling to improve the quality of among subdivisions of the information flows in the MEF and create a database the budget MEF and the CT for budget preparation. 1.A.2. Improvement of the 1.A.2.1. Improve institutional mechanisms on Ministry of Economy Q3, 2006 The budget quarterly allocation realistically legal framework on the improvement of in-year planning and decision making and Finance, reflects the need of budget agencies in budget, including on introducing changes to the budget during the year. Central Treasury, budget resources and provides them more establishment of a Develop the instruction/manual on a new scheme of Ministry of Justice freedom in reallocating funds among normative mechanism to preparing a quarterly allocation and approval in-year subordinated institutions. reduce the introduction of changes, ensuring the consistency between changed frequent changes into the expenditures and available resources. budget and additional expenditures of the budget 1.A.2.2. In order to avoid duplicating actions between without a resource support. MEF and CT and to effectively use budget resources, MEF should sign resource agreements with ministries. Define a list of pilot projects. 1.A.2.3. Prepare a draft statutory act of the Ministry of Economy Q3, 2006 A decrease in the number of changes government limiting the introduction of changes and and Finance, introduced to the budget. An improved increasing the responsibility for taking such decisions Central Treasury, predictability in receiving quarterly and the transparency of the process. line ministries and allocations by budget agencies. agencies, Ministry of Justice

1.A.3. Preparation of a 1.A.3.1 Improve the quality of macroeconomic Ministry of Economy Q4, 2006 A more accurate macroeconomic forecast, realistic budget, including forecast; elaborate and introduce the model of and Finance including the definition of the revenue part costing of budget activities macroeconomic forecasting. of the budget

Annex 19 1 1.A.3.2 Analyze the system of wages of budget Ministry of Economy Q3, 2006 The MEF has its own information base for employees; Based on the results to prepare an and Finance, a more accurate forecast of the needed improved methodology for calculation of the wages Ministry of Labor funds for this item in short- and mid-term fund. and Social period. Protection 1.A.3.3. Analyze mechanisms of expenditures Ministry of Economy Q3, 2006 The forecast of the needs in expenditures financing for utility services and develop and Finance, for utility services is improved, the recommendations on improvement of planning of this Central Treasury, consumption of services by budget item and mechanisms to streamline these Energy companies agencies is streamlined, financing expenditures. To develop the Instructions/Guidelines. (to be agreed) mechanisms are improved and more transparent.

I.A.3.4 Develop a methodology for calculation of Ministry of Economy Q3, 2006 More accurate forecasts of operational operational costs. Conduct an inventory of normative and Finance, line costs on the basis of improved normatives. expenditures and propose recommendations on their ministries and improvement. agencies

I. B Establishment of a new consolidated chart of accounts - Improvement of the budget and operational classification (given future needs), including integration of current and capital costs classifications - Establishment of a uniform classification of budget ministries compatible with the updated budget classification 2.1 Establishment of a new I.B.1.1. To develop a new budget classification Ministry of Economy Q4, 2006 A new budget classification is established consolidated Chart of corresponding to the GFS 2001 principles. and Finance, enabling to obtain complete information on accounts in accordance with Central Treasury financial resources and flows at the level of international standards the MEF/CT for budget preparation and I.B.1.2. To develop a plan for switching into National execution, and compliant with international standards of financial reporting. standards. I.B.1.3. Analyze relevant legislation and introduce Ministry of Economy Q4, 2006 amendments to put it in line with the new budget and Finance, classification. Central Treasury

I.C. Improvement of the budget execution process - Improvement of cash management to minimize the uncertainty of budget process execution - Increase the coverage of budget operations within the Treasury I.C.1. Improvement of cash 1.C.1.1 To improve the process of financial plan Ministry of Economy Q3, 2006 New mechanisms imply a significant management for timely and formation, approval and execution. Introduce and Finance, reduction in movements/changes, and a predictable financing of improved methods of short-term cash forecasting Central Treasury direct dependence of approved budgetary institutions and based on the experience of other countries. Enhance expenditures on available resources. The introduce a recording responsibility of the Ministry of Economy and Finance accuracy of cash forecasting is improving. system of commitments for and the Central Treasury for timely financing based on monitoring of arrears to approved assignations or resourced agreements spending units

Annex 19 2 I.C.1.2. Develop mechanisms to improve management Central Treasury Q4, 2006 Central Treasury is fully using internal of cash on the government accounts to finance short- reserves to finance short-term deficits term deficits to ensure an efficient use of resources and reduce the needs for borrowings. I.C.1.3. Develop mechanisms enabling the Treasury to Central Treasury Q4, 2006 Central Treasury executes control over register commitments of budgetary institutions. liabilities, efficiency of cash planning is Develop instructions on principles and mechanisms of increased, arrears preventing mechanisms contract registration. Introduce amendments to are improved relevant legal acts. I.C.2. Strengthening the I.C.2.1 Improve the procedures of control over proper Ministry of Economy Q4, 2006 The Central Treasury controls proper Treasury’s role in controlling execution of procedures established in regional offices and Finance, execution of established treasury proper execution of of the Treasury. Central Treasury procedures by regional treasury offices and procedures established by takes corresponding measures to prevent the Treasury to improve the violations. efficiency of budget execution.

I. D Financial management improvement - Initial improvements of controlling functions in budget agencies; pilots of introduction of enhanced internal audit. - Development of the Guidelines on internal control I.D.1 Establish normative I.D.1.1. To conduct a Round Table on elaboration and Ministry of Economy Q3, 2006 Basic conceptual principles of financial (legal) basis for internal agreeing basic concepts of financial control and and Finance control and internal audit identified. audit internal audit.

I.D.1.2. Prepare a strategic document describing Ministry of Economy Q3, 2006 Major directions of internal audit internal audit development in the public sector to and Finance development are identified. ensure a uniform basis for legislation reform, training and donors’ support. I.D.1.3. Elaborate basic standards for conducting Ministry of Economy During Functional responsibilities of the internal internal audit. and Finance 2007 audit unit are identified I.E Improvement of the mid-term planning process - Creation of conditions for intergration of the policy choices into budget process

I.E.1. Carry out pilot 1.E.1.1. Improvement of sectoral analysis and Ministry of Economy 2006 - The document on mid-term budget clearly activities in order to preparation of the quality-improved sectoral mid-term and Finance, 2007 reflects mid-term budget prospects both at establish a basis for better strategies of the pilot ministries and ensurance of the MAWPI, MT&C, macro-level and at pilot sectors' level. integration of sectoral close linkage with the annual budgeting process. Ministry of MTBF process is a part of the annual strategies into the budget. Education, MLSP budget preparation process. I.F. Strengthening the legal basis - Legal basis clearly defines rights and duties of the budget process particpants and increases responsibility for issuing legal acts that are not supported by financial resources.

Annex 19 3 I.F.1.1. Take an inventory of the budget acts in order Ministry of Economy 2007 Budget legislation clearly defines main to clearly identify principles of the budget rights and to and Finance budget principles as well as the roles and improve transparency of the budget management responsibility of state institutions in budget process preparation and implementation processes I.F.1.2. Take an inventory of statutory and legal acts to Ministry of Economy 2007 Improvement of implementation of statutory ensure their support with financial resources. Prepare and Finance and legal acts related to financing of concrete proposals and recommendations. budget organizations.

I.G. Organizational changes I.G.1. Increase the Central I.G.1.1. Establish a subdivision of internal control in Ministry of Economy Q4, 2006 The division executing the specified Treasury’s role in control the Central Treasury that executes control over proper and Finance, functions is established over internal treasury implementation of established treasury procedures by Central Treasury procedures regional treasury offices I.G.2. Strengthen I.G.2.1 Changes in the structures of the Internal Audit Ministry of Economy Q3, 2006 The unit responsible for internal audit institutional basis for internal Department to establish the unit and Finance development is established audit development (i) responsible for establishment and monitoring of internal audit standards in the public sector (ii) with a clear role in improving internal standards

I.H. Capacity building I.H.1. Increase the capacity I.H.1.1.To conduct a series of training workshops and Ministry of Economy During Advanced PEM methods are introduced in of MEF and line ministries’ other activities to build up staff capacity in reform and Finance 2006 practice. staff by training and areas using both internal resources and international studying international experts under the framework of technical assistance. experience.

I. I. Motivational changes I.I.1 I.I.1.1. To study the experience of other countries and Ministry of Economy During Motivation of government bodies in introduce the practice of increasing motivation of and Finance 2006 conducting reformed is increased public bodies in conducting reforms

II. A. Improvement of the inter-government finance system - Establishment of the basis for local budget preparation under the new inter-government finance (IGF) conditions

II.1 Increase level of II.1.1 Develop and approve the list of indictors Ministry of Economy During Statutory and legal framework is prepared information provision in area reflecting the level of demographic and financial data, and Finance, 2006 for LSG bodies on functions to be of IGF and the quality of management of local self- National Agency for executed, principles for formation of own government (LSG) finance needed to make Local Self- resource base and the principles for calculations on inter-budget transfers and a revenue Governance (ALSG) calculation of equalizing grants. potential forecast. To establish a electronic database by LSG bodies.

Annex 19 4 II.2 Defining optimal sharing II.2.1 Define the most optimal sharing rates of state Ministry of Economy Q3, 2006 Established sharing rate create incentives rates of state taxes for taxes for local budgets aimed at minimization of and Finance, ALSG for LSGs to increase tax collections in their different levels of the budget counter financial flows, and increase of LSGs territories and are established at a level incentives in economic development of municipalities. that minimizes counter financial flows. Approve them by relevant statutory acts. II.3 Improving of the system II.3.1 Improve the formula of equalization grants Ministry of Economy Q 3, 2006 The equalization grant formula takes into of intergovernmental allocation. and Finance account the potential of LSGs in generating transfers allocation own revenues and represents a II.3.2. Form revenue and expenditure parts of 2007 Ministry of Economy transparent mechanism for equalizing budget by LSGs based on the provisions of the Law and Finance, LSGs transfers calculation. on Financial and Economic Fundamentals of Local Self-Government. II.4. Conducting a pilot II.4.1. Finance pilot LSGs directly from republican Ministry of Economy By end of Prior to the process of preparation of local project on transferring to budget avoiding oblast and rayon levels and Finance, ALSG 2006 budgets for 2007 all LSG bodies have the two-tier budget system approved MEF Guidelines on the budget (republican budget - budget process specifying the timelines, of LSG) responsibility of various bodies in the process of budget formation and execution and specific amounts of transfers from the republican budget. II.5 Provide relevant II.5.1 Prepare the Guidelines/Instructions on Ministry of Economy Q3, 2006 Prior to the process of preparation of local methodological basis for preparation of the budget for LSGs for 2007. and Finance, ALSG budgets for 2007 all LSG bodies have the finance staff of LSG bodies approved MEF Guidelines on the budget in budget process. process specifying the timelines, responsibility of various bodies in the process of budget formation and execution and specific amounts of transfers from the republican budget. II. B Capacity building II.B.1 Capacity building II.B.1.1 Training workshops for LSGs staff. Ministry of Economy 2006 Finance staff of LSGs obtained basis and Finance, ALSG knowledge on budget preparation. III. A. Improvement of the revenue management process - Fiscal reform strategy - Tax legislation improvement III.A.1. Improvement of the III.A.1.1. Development and adoption of instructions Ministry of Economy 2006-2007 Predictability in budget preparation tax legislation system and and regulations on application of the Tax Code. and Finance, STI, process. evaluation of the impact of SCI changes. III.A.1.2. In case a new edition of the Tax Code is approved, to conduct trainings on new version of the Tax Code.

Annex 19 5 III.A.1.3 Economic evaluation and financial analysis of consequences of amendments introduced to legislation. III.A.2. Introduction of the III.A.2.1. Establishment of the real estate value Ministry of Economy 2006 Strengthening the revenue part of the local property tax threshold and its approval by a Governmental and Finance, State budget resolution. Register, STI III.A.2.2. Development of a regulation on the procedure of application of adjustment coefficient to determine the amount of deductions. III.A.2.3 Development of instructions (regulation) on the procedure of calculation and payment of the property tax to the budget. III.A.2.4 Identify the list of real estate objects which are not subject to taxation.

III. B Capacity building III.B.1 Capacity building III.B.1.1 Study the experience of taxation for small and Ministry of Economy 2006 medium businesses and the experience of VAT and Finance calculation and administration in other countries.

Annex 19 6

ANNEX 20

PEO Budget

ADB Technical Assistance Annex 20: PEO Budget Kyrgyz Republic: Preparing the Second Community-Based Early Childhood Development Prepared by Lina Nijelskaia - Economist, financial specialist based on materials presented by Larisa Gagarina - Domestic ECE Specialist in accodance with Rie Hiraoka task. Calculation of Monthly and Annual Budgets for different models of Pre-school Educational Organizations Exchange rate: 21 working days per month 1USD= 38 KG Som Quantities Salary& Food Monthly costs calculation (KG Som) Total annual costs (KG Som) 10 Total annual costs ('000 USD) Percent Share Full day group Half day group Two shifts groups 50 Unit costs Full day group Half day group Two shifts groups 50 Full daby group h f PEOHalf day g iroup Two shifts groups 50 Full day group Half day group Two shifts groups 50 Full day group Half day group Two shifts groups 50 # Budget line Unit 25 children 25 children (3 children (6 (KG Som) 25 children 25 children children (6 25 children 25 children (3 children (6 25 children 25 children children (6 25 children 25 children (3 children (6 (6 hours in a day) hours in a day) hours in a day) (6 hours in a day) (3 hours in a day) hours in a day) (6 hours in a day) hours in a day) hours in a day) (6 hours in a day) (3 hours in a day) hours in a day) (6 hours in a day) hours in a day) hours in a day)

I. Recurrent Costs 1 Salary 4.075 2.269 4.087 48.895 27.223 49.046 1,287 0,716 1,291 6610 1.1. Teacher Salary month 1.940 1.184 2.369 23.285 14.213 28.426 0,613 0,374 0,748 1.1.1. Care component hour in a month 126 63 126 4 504 252 504 6.048 3.024 6.048 0,159 0,080 0,159 1.1.2. Education component learning activity (15 minutes) 155 113 227 6 932 680 1.361 11.189 8.165 16.330 0,294 0,215 0,430 times in a month

1.1.3. Teacher Assistant hour in a month 126 63 126 4 504 252 504 6.048 3.024 6.048 0,159 0,080 0,159 1.2. Administrative staff staff month 718 466 932 8.618 5.594 11.189 0,227 0,147 0,294 1.3. Junior service staff month 1.416 618 786 16.992 7.416 9.432 0,447 0,195 0,248 1.3.1. Cleaning times in a month 42 21 42 8 336 168 336 4.032 2.016 4.032 0,106 0,053 0,106 1.3.2. Cooking days in a month 21 30 630 7.560 0,199 1.3.3. Watching days in a month 30 30 30 15 450 450 450 5.400 5.400 5.400 0,142 0,142 0,142 2 Allocations to the Social Fund 21% of wage fund 856 476 858 10.268 5.717 10.300 0,270 0,150 0,271 112 3 Travel allowance 30.128 30.128 30.128 0,793 0,793 0,793 466 3.1. Transportation 2.128 2.128 2.128 0,056 0,056 0,056 3.1.1. Roundtrip in raion center (100 km) times in a year 4 4 4 304 1.216 1.216 1.216 0,032 0,032 0,032 3.1.2. Roundtrip to oblast center (150 km) times in a year 2 2 2 456 912 912 912 0,024 0,024 0,024 3.2. Accomodation person day in a year 40 40 40 600 24.000 24.000 24.000 0,632 0,632 0,632 3.3. Per diam (travel to raion and oblast center) person day in a year 40 40 40 100 4.000 4.000 4.000 0,105 0,105 0,105 4 Public Utilities 23.867 16.391 19.195 0,628 0,431 0,505 344 4.1. Water supply charge lump sum in a year 1 0,2 0,5 4.615 4.615 923 2.308 0,121 0,024 0,061 4.2. Electricity charge lump sum in a year 1 0,2 0,5 4.728 4.728 946 2.364 0,124 0,025 0,062 4.3. Heating charge lump sum in a year 1 1 1 11.751 11.751 11.751 11.751 0,309 0,309 0,309 4.4. Telephone and fax service lump sum in a year 1 1 1 1.800 1.800 1.800 1.800 0,047 0,047 0,047 4.5. Mail service lump sum in a year 1 1 1 720 720 720 720 0,019 0,019 0,019 4.6. Other connection service lump sum in a year 1 1 1 252 252 252 252 0,007 0,007 0,007 5 Other service purchase 190.725 32.025 38.400 5,019 0,843 1,011 23 7 8 5.1. Current repairs of buildings and rooms lump sum in a year 1 1 1 2.000 2.000 2.000 2.000 0,053 0,053 0,053 5.2. Current repairs of construction 0,000 0,000 0,000 5.3. Current repairs of equipment and inventary lump sum in a year 1 0,5 1 1.000 1.000 500 1.000 0,026 0,013 0,026 5.4. Medicaments and dressing purchase set per year 1 1 1 500 500 500 500 0,013 0,013 0,013 5.5. Food purchase child-day in a month 525 30 15.750 157.500 4,145 5.6. Equipment purchase 20.850 23.688 27.875 0,549 0,623 0,734 5.6.1.Books item in a year 10 10 10 100 1.000 1.000 1.000 0,026 0,026 0,026 5.6.2. Aids set in a year 75 75 75 50 3.750 3.750 3.750 0,099 0,099 0,099 5.6.3. Painting things and plasticine lump sum in a year 1 0,5 1 5.000 5.000 2.500 5.000 0,132 0,066 0,132 5.6.4. Learning Toys lump sum in a year 11.100 11.100 11.100 0,292 0,292 0,292 Rocking-toy lump sum in a year 1 1 1 900 900 900 900 0,024 0,024 0,024 Balls, baskets lump sum in a year 5 5 5 100 500 500 500 0,013 0,013 0,013 Table meccano lump sum in a year 3 3 3 300 900 900 900 0,024 0,024 0,024 Floor meccano lump sum in a year 3 3 3 400 1.200 1.200 1.200 0,032 0,032 0,032 Puppet show lump sum in a year 4 4 4 200 800 800 800 0,021 0,021 0,021 Pyramid lump sum in a year 5 5 5 100 500 500 500 0,013 0,013 0,013 Set of geometric figures lump sum in a year 5 5 5 150 750 750 750 0,020 0,020 0,020 Mosaic lump sum in a year 5 5 5 300 1.500 1.500 1.500 0,039 0,039 0,039 Dolls and enimals lump sum in a year 10 10 10 150 1.500 1.500 1.500 0,039 0,039 0,039 Set of tea-things, set of plaster lump sum in a year 400 400 400 0,011 0,011 0,011 vegetables and fruits 2 2 2 200 Child buckets and shapes lump sum in a year 5 5 5 100 500 500 500 0,013 0,013 0,013 Doll's cupboard lump sum in a year 3 3 3 100 300 300 300 0,008 0,008 0,008 Doll's table and chairs lump sum in a year 2 2 2 200 400 400 400 0,011 0,011 0,011 Doll's bad lump sum in a year 5 5 5 100 500 500 500 0,013 0,013 0,013 Child kitchen cabinet for play lump sum in a year 1 1 1 150 150 150 150 0,004 0,004 0,004 Toy kitchen-range lump sum in a year 1 1 1 300 300 300 300 0,008 0,008 0,008 5.7. Other household equipment and materials lump sum in a year 8.875 5.338 7.025 0,234 0,140 0,185 Uniform set per staff in a year 5 4 4 100 500 400 400 0,013 0,011 0,011 Towel per cild in a year 25 25 50 30 750 750 1.500 0,020 0,020 0,039 Glass per cild in a year 25 25 25 20 500 500 500 0,013 0,013 0,013 Plates and dishes set per child in a year 25 100 2.500 0,066 0,000 0,000 Toilet paper lump sum in a year 1 0,5 1 625 625 313 625 0,016 0,008 0,016 Chamber-pot per cild in a year 10 10 10 120 1.200 1.200 1.200 0,032 0,032 0,032 Soap lump sum in a year 1 0,5 1 1.250 1.250 625 1.250 0,033 0,016 0,033 Cleaner set per cild in a year 25 25 25 40 1.000 1.000 1.000 0,026 0,026 0,026 Wash-basin for toys cleaning set in a year 111200 200 200 200 0,005 0,005 0,005 Cleaning inventory set in a year 111200 200 200 200 0,005 0,005 0,005 Flowerpot unit 5 5 5 30 150 150 150 0,004 0,004 0,004 5.8. Other current costs 0,000 0,000 0,000 Total Recurrent Costs 303.883 111.484 147.069 7,997 2,934 3,870 36 24 29 II. Capital investments 6 Buildings and constructions 201.400 201.400 201.400 5,300 5,300 5,300 24 43 40 6.1. Major repairs of kindergarten buildings lump sum 1 1 1 201.400 201.400 201.400 201.400 5,300 5,300 5,300 6.1.1. Repair of study room, roof, floor, and of lump sum 1 1 1 87.400 87.400 87.400 87.400 2,300 2,300 2,300 pre-school service facilities. 6.1.2. Boilers, pipes and heating radiator lump sum 1 1 1 114.000 114.000 114.000 114.000 3,000 3,000 3,000 repairs in small schools. 7 Equipment and mechanisms 334.234 152.222 152.222 8,796 4,006 4,006 40 33 30 7.1.Out-door equipment for physical development 1 1 1 9.002 9.002 9.002 9.002 0,237 0,237 0,237

7.2. Kitchen equipment 56.662 1,491 7.2.1. Kitchen equipment and furniture Annex 20: PEO Budget 48.262 1,270 Kitchen-range unit 1 11.970 11.970 0,315 Refrigerator unit 1 13.490 13.490 0,355 Dish-washing sink unit 1 4.201 4.201 0,111 Cupboard unit 1 5.700 5.700 0,150 Сook-table unit 1 2.940 2.940 0,077 Shelves unit 1 9.961 9.961 0,262 7.2.2. Kitchen inventory 8.400 0,221 Electric teakettle unit 1 1.900 1.900 0,050 Pan unit 5 900 4.500 0,118 Frying pan unit 2 1.000 2.000 0,053 7.3. Furniture 268.570 143.220 143.220 7,068 3,769 3,769 7.3.1. Child Furniture 246.272 120.922 120.922 6,481 3,182 3,182 Table unit 25 25 25 1.806 45.150 45.150 45.150 1,188 1,188 1,188 Chair unit 25 25 25 557 13.930 13.930 13.930 0,367 0,367 0,367 Box for toys unit 1 1 1 3.724 3.724 3.724 3.724 0,098 0,098 0,098 Gymnastic bench unit 1 1 1 1.719 1.719 1.719 1.719 0,045 0,045 0,045 Rocking-bridge unit 1 1 1 3.784 3.784 3.784 3.784 0,100 0,100 0,100 Gymnastic wall with horizontal bar unit 1 1 1 3.507 3.507 3.507 3.507 0,092 0,092 0,092 Child -chute unit 1 1 1 7.567 7.567 7.567 7.567 0,199 0,199 0,199 Case for clothes (4 sections) unit 6 6 6 5.967 35.801 35.801 35.801 0,942 0,942 0,942 Towel rack (5 pegs) unit 5 5 5 1.148 5.740 5.740 5.740 0,151 0,151 0,151 Bed unit 25 2.506 62.650 1,649 Bed linen & bedding set per chlid 25 2.508 62.700 1,650 7.3.2. Other furniture unit 22.297 22.297 22.297 0,587 0,587 0,587 Table for teacher unit 1 1 1 4.598 4.598 4.598 4.598 0,121 0,121 0,121 Chair for teacher unit 1 1 1 1.064 1.064 1.064 1.064 0,028 0,028 0,028 Box for training aids unit 1 1 1 7.334 7.334 7.334 7.334 0,193 0,193 0,193 Carpet unit 1 1 1 5.700 5.700 5.700 5.700 0,150 0,150 0,150 Curtains unit 1 1 1 450 450 450 450 0,012 0,012 0,012 Mirror unit 1 1 1 3.151 3.151 3.151 3.151 0,083 0,083 0,083 Total Capital Investment 535.634 353.622 353.622 14,096 9,306 9,306 64 76 71 TOTAL COSTS 839.517 465.106 500.690 22,093 12,240 13,176 100 100 100

Average Unit Cost per child in a year Exchange rate: 1USD= 38 KG Som # Budget line Annual Unit Costs (KG Som) Annual Unit Costs (USD) Existing State PEO Full day Half day Two shifts isting State PE Full day Half day group Two shifts I. Recurrent Unit Costs 12.155 4.459 2.941 320 117 77 II. Capital Unit Costs 21.425 14.145 7.072 564 372 186 TOTAL UNIT COSTS 5.592 33.581 18.604 10.014 147 884 490 264

Current Unit Costs for State PEO Average annual unit costs per child for different models of PEO

40.000 Capital Unit Costs 35.000 Recurrent Unit Costs

30.000

25.000

20.000

KG Som 15.000

10.000

5.000

0 Full day Half day Two shifts PEO Models ADB Technical Assistance ECONOMIC EXPENSE ITEMS INTERPRETATION Kyrgyz Republic: Preparing the Second Community-Based Early Childhood Development Project KG Som Model 1 Model 2 Model 3

Two shifts groups Full day group Half day group on 25 children 25 children 25 children (total - 50)

Item code Expense items sum by items, KG Som COMPARISON OF ANNUAL BUDGETS FOR DIFFERENT COMMUNITY BASED PEO MODELS 2111 Salary 48.895,20 27.223,20 49.046,40 21111100 Basic Salary KG Som 21111200 Rise in wages 21111300 Salary supplements and indemnity Model 1 Model 2 Model 3 2121 Allocations to the Social Fund 10.267,99 5.716,87 10.299,74

Full day Half day Two shifts groups Item code Expense items group group 25 on 25 children 21211100 Allocation to the Pension fund 25 children children (total - 50) KG Som 21211200 Allocation to the Medical insurance fund 2111 Salary 48.895,20 27.223,20 49.046,40 2211 Travel allowance 30.128,00 30.128,00 30.128,00 2121 Allocations to the Social Fund 10.267,99 5.716,87 10.299,74 22111100 Transportation 2.128,00 2.128,00 2.128,00 2211 Travel allowance 30.128,00 30.128,00 30.128,00 22111200 Accomodation 24.000,00 24.000,00 24.000,00 2212 Public utilities 23.866,55 16.391,41 19.194,58 22111300 Per diam 4.000,00 4.000,00 4.000,00 2213 Rent 0,00 0,00 0,00 2212 Public utilities 23.866,55 16.391,41 19.194,58 2214 Transport service 0,00 0,00 0,00 22121100 Water supply charge 4.615,47 923,09 2.307,73 2215 Other service purchase 190.725,00 32.025,00 38.400,00 22121200 Electricity charge 4.728,46 945,69 2.364,23 2821 Other current costs 0,00 0,00 0,00 22121300 Heating charge 11.750,62 11.750,62 11.750,62 3111 Buildings and constructions 201.400,00 201.400,00 201.400,00 22121400 Gas charge 3112 Equipment and mechanisms 334.234,00 152.221,60 152.221,60 22122100 Telephone and fax service 1.800,00 1.800,00 1.800,00 3113 Other capital assets 0,00 0,00 0,00 22122200 Cellular connection service TOTAL: 839.516,70 465.106,10 500.690,30 22122400 Maile service 720,00 720,00 720,00 22122900 Other connection service 252,00 252,00 252,00 2213 Rent 2214 Transport service 22141100 Benzine, diesel and other fuel 22141200 Spares purchase 22141300 Vehicle maintenance 22141900 Other transport service 2215 Other service purchase 190.725,00 32.025,00 38.400,00 22152100 Current repairs of buildings and rooms 2.000,00 2.000,00 2.000,00 22152200 Current repairs of construction 22152300 ТCurrent repairs of equipment and inventary 1.000,00 500,00 1.000,00 22155100 Medicaments and dressing purchase 500,00 500,00 500,00 22155200 Food purchase 157.500,00 0,00 0,00 22155300 Equipment purchase 20.850,00 23.687,50 27.875,00 22155900 Other household equipment and materials 8.875,00 5.337,50 7.025,00 22156200 Forms and letterhead production charges 22156900 Other costs for other service purchase 2821 Other current costs 28211100 Scholarships 3111 Buildings and constructions 201.400,00 201.400,00 201.400,00 31112310 Major repairs of production buildings 201.400,00 201.400,00 201.400,00 3112 Equipment and mechanisms 334.234,00 152.221,60 152.221,60 3113 Other capital assets

TOTAL 839.516,74 465.106,08 500.690,33

ANNEX 21

Books/Publications on ECCE and Preschool Education published in the Kyrgyz Republic

ANNEX 21 AVAILABLE BOOKS/PUBLICATIONS ON ECCE AND PRESCHOOL EDUCATION PUBLISHED IN THE KYRGYZ REPUBLIC (SELECTED ITEMS FEBRUARY 2007).

Target № Author/Organization Title Price for one group 1. President’s Office “Resource book for preschool Product of preschool & ADB teacher” the first teacher CBECDP of Kyrgyz and Russian versions in ADB one book 2. “Training program for parents” Product of CFC for the first support of Kyrgyz and Russian versions in CBECDP of parent one book ADB training groups 3. “Training program for Product of preschool preschool teacher” the first teacher CBECDP of Kyrgyz and Russian versions in ADB one book 4. Kyrgyz Academy of “Interesting math” No Preschool Education information children with Educational aid for children available support of teacher In Kyrgyz 5. “Preparation for school” No Preschool information children with In Kyrgyz available support of teacher

6. “Me and world around” No Preschool information children with Educational aid for children available support of teacher In Kyrgyz and Russian 7. No Preschool ”Nature of Kyrgyzstan” information children with available support of In Kyrgyz and Russian teacher

8. “Step by step play activity No preschool development” information teacher available Aid for preschool teacher

In Russian

9. “I’m a painter. Application in No preschool kindergarten” information teacher available Aid for preschool teacher

In Russian

Annex 21 1 Target № Author/Organization Title Price for one group 10. “Art and hand work” No preschool information teacher Aid for preschool teacher available

In Russian

11. “Monitoring of psychological No preschool and physical development of information teacher preschool children” available

Aid for preschool teacher

In Russian 12. “Enhancement of step by step No preschool play activity development” information teacher available Aid for preschool teacher

In Russian 13. “ABC book” No Preschool information children with In Kyrgyz available support of teacher 14. Kyrgyz Arabaev State “Theory and methodics of No preschool University language development of information teacher preschool children” available

Aid for lecturers and students

In Kyrgyz 15. “Technology of language No preschool development” information teacher available Aid for preschool teacher

In Kyrgyz 16. No preschool “Kindergarten” information teacher available Educational aid for preschool children

In Russian and Kyrgyz

Annex 21 2 Target № Author/Organization Title Price for one group 17. Public Fund „Step by «Do yourself» Preschool step“ (Judith Rotshild Stolberg and teachers and Hellen R. Daniels). parents Methodical aid for pedagogues and parents (creation of didactic and play materials for different centers(math, science etc.))

* in Kyrgyz $3,24 (Attention: * in Russian copyright) $3,06

18. Preschool project «Step by $3,5 Preschool Step». children with Methodical aid for preschool support of children teacher

Kyrgyz, English and Russian (Attention: versions in one book copyright)

19. «Grandmother’s watch». $ 2 Preschool (Zakaeva G.) children Poem/story

Kyrgyz, English and Russian versions in one book

20. «Dorothi and glasses». $2 Preschool (Brezina I.) children Poem/story

Kyrgyz, English and Russian versions in one book

21. «Nose for doll». $2 Preschool (Haksia Mirada) children Poem/story

Kyrgyz, English and Russian versions in one book

22. «Icicle» $2 Preschool (Voskoboinikov V.) children Poem/story

Kyrgyz, English and Russian versions in one book 23. «Busunsul and Paskualina. $2 Preschool Story about two children» children (Tavadse O.) Poem/story

Kyrgyz, English and Russian versions in one book

Annex 21 3 Target № Author/Organization Title Price for one group 24. «Hanna in wheelchair» $2 Preschool (Hisenni K.) children Poem/story

Kyrgyz, English and Russian versions in one book 25. UNICEF $1.94 Preschool “I learn the world” children with «Дүйнөнү таануудагы алгачкы support of кадамдарым» teacher

Educational aid for children for preparation for school (forms, colors, time, seasons etc.)

In Kyrgyz 26. $0.33 Preschool “Magic of daily moments” children «Күнүмдүк көнүгүүлөрдүн сыйкырдуу сыры»

5 booklets

Educational aid for parents (of children 0-15 months) Psyscho/social/emotional development

In Kyrgyz 27. “Preparation for school starts from $0.33 Preschool birth” teachers and «Мектепке даярдык parents төрөлгоөдөн башталат»

Educational aid for adults to help to develop children (0-3 years)

In Kyrgyz 28. UNICEF Poster-calendar (2006-2007) $1.44 parents

Child gives recommendations about children needs for each age period (0-2 years) (skin-to skin, role of father, protection from agression)

In Kyrgyz 29. Karla-Maria Shelike Alternative humanistic pedagogy. No Preschool (Rehabilitation Center Its role in education of preschool information teachers “Nadeshda”) children available

Educational aid for teachers.

In Russian

Annex 21 4 Target № Author/Organization Title Price for one group 30. Role of music in preschool groups No Preschool in kindergarten information teachers available In Russian 31. NGO «Learning through play» No Preschool Multilanguage information teachers and education Collection of collective play available parents „Til-Dil“ activity description for children development

In Russian and Kyrgyz 32. Red Halfmoon «First medical aid» No Preschool Organization information teachers and Instructions with photos available parents

In Russian 33. «Traffic regulations for children» No Preschool information children Educational aid for children - book available for coloring

In Russian 34. Save the children No Parents of (Denmark) „I’m with you” information children with Мен Сенин жаныңдамын available cerebral palsy Practical aid for parents of children with cerebral palsy

In Kyrgyz 35. Save the children “Future of our children is in our No Preschool (Denmark) hands” information teachers and „Балдардын келечеги биздин available parents of колубузда“ children with special needs Practical guidelines for parents of children with special needs 36. „Methodical guidelines for No Preschool preschool teachers and parents of information teachers and children with special needs“ available parents

In Russian 37. ISPCAN „Violence in relation to No Preschool children: diagnosis, information teachers, intervention, prevention“. available social workers Methodical aid for pedagogues, social workers and students

Annex 21 5