Improving health standards for mothers and children in the Kyrgyz Republics poorest districts

Pamposh Dhar, ADB Consultant

An Early Child Development Project also brings benefits for women and whole families An ADB-supported project in the Kyrgyz Republic has shored up once declining health standards among expectant mothers and children in the crucial first eight years of life. The Community-Based Early Childhood Development Project has also helped the country become largely self-sufficient in vaccines, ending an unhealthy dependence on foreign assistance for this crucial means of preventing diseases among children. The abrupt collapse of the Soviet Union in 1991 threatened to undermine previously high standards of public health during the transition to a market economy. With economic contraction and a decline in social services, poverty increased, and health and education became less accessible. Infant and child mortality rates soared, peaking in 2006 before the ADB project, and other development efforts, finally began to bear fruit in 2007. Pregnant women faced greater health risks as antenatal care became less accessible. Many pre-schools closed, inevitably increasing the childcare responsibilities of mothers and reducing the time available for economically productive activities. The ADB project, which began in 2004, focused on improving health and nutrition in the 12 poorest raions (districts), spread across the three oblasts (provinces) of Jalal-Abad, Naryn, and Osh. The 12 raions had staggering poverty levels above 70%. Reversing Worsening Infant and Child Mortality, Improving Health for All The project helped reverse the rise in infant and child mortality, open kindergartens in farflung villages, counter iron and iodine deficiencies among pregnant women, and make medicines accessible in remote rural areas. In two years, between 2006 and 2008, the national infant mortality rate fell 12% in JalalAbad oblast, 23% in Naryn, and fully 40% in Osh. The under-5 mortality rate fell 16% in Jalal-Abad and Osh, and 23% in Naryn. The national averages also fell during this period, but nowhere near as much as in the oblasts covered by the project. Nationwide, the infant mortality rate fell 7%, and the under-5 mortality rate declined by 9%, between 2006 and 2008. The project helped the Kyrgyz Republic reduce its dependence on foreign assistance for the supply of vaccines on the premise that this crucial health intervention should not be so dependent on unpredictable donor funding. In 2003, the Kyrgyz Republic was wholly

dependent on donor financing of vaccines. By 2008, it was financing 60% of vaccinations in the country, with ADB providing the remaining 40%.1 By 2010, over 300 community-based kindergartens had opened in the three oblasts covered by the project, benefiting more than 13,000 young children. Zeinep Mambetaeva has a daughter, Elina, in an ADB-supported village preschool, in Toktogul rayon center in JalalAbad oblast, an opportunity that was once unthinkable in a rural area. I used to be a teacher, Ms. Mambetaeva said, adding that she understands the value of early childcare. Meanwhile, with Elina in kindergarten for part of the day, she says, I have time to do other things. The project helped rehabilitate and upgrade 30 state-run kindergartens in need of major repairs. These kindergartens were then able to support community-based pre-schools. More than 40,000 parents were also trained to provide better childcare at home. Innovative Public-Private Partnership pens Village Pharmacies Women and children also benefited from an innovative sub-project to make medicines readily available, at affordable rates, in even the most remote areas. This component of the project established a partnership between the Ministry of Health, ADB, and private pharmacies to remove a major hurdle in the medical treatment of villagers, especially young children and pregnant women: the lack of access to medicines. In 1991, when all pharmacies in the Kyrgyz Republic were privatized, they closed branches in rural areas to focus on the more lucrative market in the capital city, Bishkek. In 2006, the Ministry of Health, with support from ADB, introduced a public-private partnership model to encourage companies to open pharmacies in remote rural areas. The Government provided the premises for the pharmacies. ADB trained health workers to be dispensers and financed the initial cost of medicines and equipment. The Ministry enforced price regulations for essential drugs, but allowed the pharmacies to sell other medicines and personal products so that they could make a profit. In 2005, there had been less than 100 pharmacies in all 12 raions covered by the ADB project. By the time the project closed in 2010, there were an additional 123 in nine of these raions, where 90% of the population acquired access to a pharmacy, up from just 30% five years earlier. Among the goods the pharmacies sell are iron tablets that have helped reduce iron deficiency anemia among women, particulary when they are pregnant. By the time the project closed, 84% of all pregnant women diagnosed with anemia were taking iron tablets. Combating Deficiencies The project helped build awareness of iodine and iron deficiencies and ways to counter these, including greater use of iodized salt. By 2010, about 95% of all households in the project areas were regularly using iodized salt. Advocacy by ADB and the United Nations Childrens Fund (UNICEF) played a major role in the passing of a law requiring all flour to be fortified with micronutrients to counter common deficiencies, particularly among women and children.

1 UNICEF and Institute of Strategic Analysis and Evaluation under the President of the Kyrgyz Republic. National Report Kyrgyztan. Global Study on Poverty and Child Disparities. (page. 36) http://www.unicef.org/kyrgyzstan/Child_Poverty_Report_Eng.pdf

Alihan suffered from anemia as a small child, a common ailment in his village of Josholuu, in Osh oblast. Before a private pharmacy opened in the village, Ailhans father had to skip a days work to travel to the raion hospital to buy his sons medicine. The trip cost him as much as the medicine. Not only that, but the quality of medicine was suspect too, because of poor storage conditions. Even if the medicines hadnt expired, they were usually spoiled by the sun or humidity, sighed Dr. Jarkynbai Dooronov, who was treating Alihan at the time. All these medicines need to be stored properly, said Maltavarova Zulpia, who works in the pharmacy in Josholuu. Its not like at grandmothers house, where everything is scattered on the windowsill. She learned about proper storage during the ADB-sponsored training for those wishing to run rural pharmacies. Affordable, Accessible Medicines Aiylychy Tanaeva used to buy her expensive heart medicine in the city of Osh, capital of the oblast. Now she can get it in the village and at a more affordable price because the Government subsidizes essential medicines bought against a doctors prescription. In the old days, she was never sure how much medicine she should buy because she could not predict how often she would need to take it. Sometimes she would run out of medicine before her next trip to Osh. At other times, she would end up buying too much and some of it would expire. Now, she says, she can buy it in smaller amounts. If I run out of medicine, it takes only 10 minutes to go and get some at the local pharmacy, she explained. No-one can argue against the rural pharmacies, said Oljobay Dyikanbaev, owner of the MedPharm company. But we wouldnt have opened a pharmacy in the village without ADB support. A Project for Children Helps Everyone This and other aspects of the Community-Based Early Childhood Development Project have brought renewed hope for kids in the Kyrgyz Republic by providing health and education support in the first eight years of life. It has given parents more confidence in looking after their children, especially supporting women since childcare is usually more of the mothers responsibility. At the same time, the new preschools have freed up womens time. The project has also helped reduce iodine and iron deficiencies, common during pregnancy. By giving the country financial control over vaccines, the project brought the assurance of predictable good health for children in all provinces. And finally, the project has helped rural communities in nine extremely poor raions gain easy access to affordable medicines and perhaps opened the door for other raions to follow suit.

The views expressed in this paper are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. The countries listed in this paper do not imply any view on ADB's part as to sovereignty or independent status or necessarily conform to ADB's terminology.