Official Development Assistance
1. Development partners
According to the eligibility criteria outlined, 35 development partners were selected as eligible and invited to participate in the survey of 2017. Among these 35 development partners, 25 agencies responded to the invitation to take part in the survey. Seven (7) of these development partners reported that they did not have any active projects in 2017. Eighteen (18) organizations have implemented various projects and provided full information. It should be noted that one organization, the Global Fund, accepted the invitation to participate in the study, but the executive agency of their project was the United Nations Development Programme (UNDP).
Table 1. Development partners’ participation in the survey, 2017
Development partners | Participated in the 2015 survey | Did not participate in the 2017 survey | Participated in the 2017 survey, but did not have active projects in 2017 | Participated in the 2017 survey |
Asian Development Bank (ADB) | √ | |||
World Bank (WB) | √ | √ | ||
World Health Organization (WHO) | √ | √ | ||
United Nations Children's Fund (UNICEF) | √ | √ | ||
United Nations Development Program (UNDP) | √ | |||
United Nations Population Fund (UNFPA) | √ | √ | ||
Joint United Nations Program on HIV / AIDS (UNAIDS) | √ | √ | ||
United Nations Office on Drugs and Crime (UNODC) | √ | |||
World Food Program (WFP) | √ | √ | ||
Food and Agriculture Organization of the United Nations (FAO) | √ | |||
Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) | √ | √ | ||
Global Alliance for Vaccines and Immunization (GAVI) | √ | √ | ||
Eurasian Development Bank (EDB) | √ | |||
Islamic Development Bank (IsDB) | √ | |||
Embassy of the Federal Republic of Germany in the Kyrgyz Republic - German Development Bank (KfW) | √ | √ | ||
United States Embassy - United States Agency for International Development (USAID) | √ | √ | ||
German Society for International Cooperation (German Society for Technical Cooperation) (GIZ) | √ | √ | ||
Japan International Cooperation Agency (JICA) | √ | √ | ||
South Korean Embassy in the Kyrgyz Republic - Korean International Cooperation Agency (KOIKA) | √ | |||
Turkish Embassy in the Kyrgyz Republic - Turkish International Cooperation Agency (TIKA) | √ | |||
Kuwait Fund for Arab Economic Development (KFAER) | √ | |||
Community Development and Investment Agency (ARIS) | √ | |||
Embassy of the Swiss Confederation in the Kyrgyz Republic - SDC | √ | √ | ||
Representation of the European Union | √ | |||
Austrian embassy | √ | |||
Japanese Embassy in the Kyrgyz Republic | √ | |||
Embassy of the Russian Federation in the Kyrgyz Republic | √ | |||
Embassy of the Republic of India in the Kyrgyz Republic | √ | |||
Embassy of the Islamic Republic of Iran in the Kyrgyz Republic | √ | |||
Embassy of Israel | √ | |||
Embassy of the Kingdom of Saudi Arabia / Saudi Development Fund | √ | |||
Embassy of Qatar in the Kyrgyz Republic | √ | |||
Embassy of the People’s Republic of China in the Kyrgyz Republic | √ | |||
Embassy of Finland | √ | |||
Estonian Embassy | √ | |||
Total: | 12 | 10 | 7 | 18 |
Compared to the 2015 survey, participation was expanded. In 2015, only 22 organizations took part in the study, of which only 12 provided information on their projects. In the 2017 survey, project information was obtained from 18 donor organizations.
It should also be noted that, unlike in the first mapping round, UNDP, FAO, KFAED, and SFD joined the second round. Also, separate data from the Japanese Embassy in the Kyrgyz Republic and the Japan International Cooperation Agency were obtained.
Of the 18 development partners that provided information, ten are multilateral and eight are bilateral.
Figure 1. Bilateral and multilateral development partners, 2017
Projects covered by this study started, ran throughout, or ended in 2017. Overall, development partners reported 41 projects and programs (Fig. 2) totaling US $53 974 277. This total disbursement equals 23% of total health expenditures for 2017.
Figure 2. ODA projects or programs per donor, 2017
As can be seen from Fig.2, the largest number of projects were implemented by USAID, the KfW Development Bank (KfW) and the Swiss Embassy in the Kyrgyz Republic. They accounted for 56% of all donor projects in the health sector in 2017.
In terms of ODA allocated within the framework of bilateral and multilateral agreements, GFATM (through UNDP), KfW Development Bank, and USAID allocated the most significant financial assistance to the Kyrgyz Republic. The amount of aid provided equals US $15,797,109, US $9,772,972, and US $8,657,000, respectively. The sum of budgets of their projects equals 63.4% of the total amount of development projects in 2017.
Figure 3. Total ODA by type
Of the $53 974 277, 94% was disbursed through grant assistance and only 6% was provided in the form of a loan (Fig.3).
Regarding aid modalities, these can be divided into 3 large categories: SWAp, Project/Program aid, and Sector Budget Support.
Figure 4. SWAp/SBS/Project aid (by organizations), 2017
In 2017, the vast majority (82%) of the reported funds were allocated for program/project aid, and 18% of the funds were allocated for SWAp activities. No funds were allocated for Sector Budget Support in 2017.
Figure 5. Overall fund distribution by aid modalities.
As for the SWAp project, which is being implemented within the framework of the “Den Sooluk” National Health Reform Program, traditionally the main donors are the World Bank, KfW, and SDC.
The diagram below indicates the flow of funds to the SWAp basket from each of these organizations.
Figure 6. Funds allocated within SWAp
Geographical coverage
Development partners’ projects have been classified as projects with national coverage, regional coverage, and pilot projects
Figure 7. Geographical coverage of donor projects
Figure 7 shows that seventeen (17) donors provide support at the national level; seven (7) of them have also implemented projects at the regional level. Four (4) out of 18 surveyed organizations are implementing pilot projects in pilot sites.
2. Funding categories, components, health system priorities
The distribution of disbursements for 2017 across different funding categories is illustrated in Fig. 8. The largest share is devoted to investments (57.92%), technical assistance accounts for 38.09%, and the remaining 3.99% are administrative costs. The Global Fund (through UNDP), KfW Development Bank, and WHO provided the largest investment support - 79% of total investments. In the 2015 survey, the leaders in this category were the World Bank, KfW, and the Swiss Agency for Development and Cooperation (SDC). Compared to 2015, the share of investments increased by 17.34%.
The share of technical assistance in 2017 was 38.09%, which is 15.97% less than in 2015.
Figure 8. Total disbursements by funding category, 2017
The following figure illustrates the distribution of the 38.09% of technical assistance funds across five components: (i) policy development, (ii) capacity building, (iii) guideline and protocol development, (iv) legal and regulatory framework, and (v) other (includes communication, consulting and similar services). As can be seen from the figure, a stronger emphasis in 2017 was on capacity building (51.85%).
Figure 9. Technical assistance by components, 2017
Fig. 10 illustrates distribution of the investment quota – the 57.92% of the total ODA disbursed – across five components: (i) construction and refurbishment, (ii) medical equipment and technology, (iii) IT, (iv) medical supplies, and (v) other.
Figure 10. Investment funds by components, 2017
Fig. 11 illustrates the distribution of total disbursements among four health system functions: (i) health service delivery, (ii) resource generation, (iii) health financing, and (iv) stewardship and governance. The figure demonstrates that the main share of disbursements is allocated to health service delivery (71.7%).
However, no significant changes were observed in this category in comparison with 2015.
Figure 11. Disbursements by health system functions, 2017
The health service delivery component can be broken down into four categories: (i) primary health care, (ii) hospital care, (iii) public health services, and (iv) emergency care (Fig. 12). Hospital care remains the main area of focus. In 2017, the percentage of funds allocated for emergency care has increased compared to 2015 (15.6% vs 2.2%).
Figure 12. Distribution of health service delivery quota, 2017
Fig. 13 shows the distribution of total ODA disbursements across different health priority program areas. This clearly shows that the two areas with the largest share of financing are communicable diseases (36.55%), and maternal and child health and reproductive health (28.82%). Non-communicable diseases rank third (11.90%). Less attention is paid to adolescent health (3.22%), injuries and violence (9.2%), and other areas (11.06%).
Figure 13. ODA distribution according to health priority program areas, 2017
3. Alignment with national priorities
The alignment of aid flows with health-sector policies, strategies, and programs is shown in Table 5. Not all development partners completed this table. However, the data obtained allows to conclude that half of the development partners implement their projects in view of the objectives set forth in national strategies: National Sustainable Development Strategy of the Kyrgyz Republic for 2013-2017 (eight donors) and “Den Sooluk” National Health Reform Program of the Kyrgyz Republic for 2012-2018 (ten donors).
Table 2. Development partner alignment with national frameworks, 2017
General strategies | |
National Sustainable Development Strategy of the Kyrgyz Republic for 2013-2017 | KfW; Swiss Embassy – SDC; UNAIDS; UNFPA; WB; WFP; WHO, GIZ |
Den Sooluk National Health Reform Program of the Kyrgyz Republic for 2012-2018 | KfW; Swiss Embassy – SDC; UNAIDS; UNFPA; UNICEF; USAID; WB; WFP; WHO |
Subsectoral strategies | |
Strategy for the Protection and Promotion of Health of the Population of the Kyrgyz Republic until 2020 (Health–2020) | KfW; Swiss Embassy – SDC; USAID; WB; WHO |
Health Investment Strategy for 2016-2025 | KfW; Swiss Embassy – SDC; WB |
“Tuberculosis 5” National Program for 2013-2016 | KfW; USAID; WB |
State Program on the Stabilization of the HIV Epidemic in the Kyrgyz Republic 2017-2021 | KfW; UNAIDS; UNFPA; USAID; WB; WHO, GFATM |
State Program on the Prevention and Control of Non-communicable Diseases in the Kyrgyz Republic for 2013-2020 | KfW; Swiss Embassy – SDC; WB; WFP; WHO |
State Program on Immunoprophylaxis for 2013-2017 | WB; WHO |
Program to Prevent the Reappearance of Local Malaria Transmission in the Kyrgyz Republic for 2014-2018 | WB; WHO |
State Program on the Health Protection of Citizens of the Kyrgyz Republic against Harmful Tobacco Impact for 2008-2017 | WHO |
State Guaranteed Benefits Program that ensures health care for the citizens of the Kyrgyz Republic | KfW; Swiss Embassy – SDC; USAID; WB |
Kyrgyz Republic’s E-health Program for 2016-2020 | USAID; WB; WHO |
Concept of creating an electronic database of drugs and medical products in the Kyrgyz Republic | USAID; WB; WHO |
Kyrgyz Republic program to develop the drugs circulation sphere in the Kyrgyz Republic for 2014-2020 | WB; WHO |
Program for providing incentives for physicians working in health organizations of remote areas, small towns, and rural areas | Swiss Embassy – SDC |
4. Financial management systems
Section VI of the questionnaire requested development partner agencies to indicate their use of the country’s financial tools and/or national procurement systems. Ten (10) development partners indicated whether their ODA was recorded in the national health budget or not; eight (8) development partners did not have this information (Fig.14).
Figure 14. Was your ODA recorded in the annual 2017 sector budget?
Four (4) agencies provided a positive response to this question: KfW, World Bank, GAVI, and UNFPA.
Five (5) organizations provided data on the usage of national procedures (budget execution, financial reporting, auditing, procurement). Two (2) of these donors reported usage of national budget execution, financial reporting and auditing procedures. Among the non-SWAp partners, only UNFPA reported using national procurement system.
5. Aid predictability
This survey covered 41 projects and programs: 34 of these are ongoing, five (5) were completed by 31 December 2017, one (1) project was approved but not started, and one (1) project was suspended.
The majority of development partners (9) committed to providing support in 2018. Of these, six (6) partners intend to continue support in 2019 and four (4) in 2020. The Swiss Agency for Development and Cooperation and the World Food Programme have already committed to support the Kyrgyz health sector until 2022 (Fig.15).
Figure 15. Development partner commitment to provide future support to the Kyrgyz health sector
Among partners continuing to support the Kyrgyz health sector in 2018, seven
(7) agencies confirmed that they would be increasing their disbursements and two
(2) agencies reported plans to decrease their contributions.
Figure 16. Pledged amounts for 2018
6. Coordination and complementarity
Eight (8) development partners reported that a total of 120 missions were conducted during 2017; most of them (105) were conducted by the WHO. WHO remains the most active donor in this regard, as in 2015. In addition, GIZ, SDC, UNFPA, and WHO reported on analytical works carried out in 2017. Twenty (20) analytical works were conducted in total.
Figure 17. Development partner health-sector missions and analytical works, 2017
Nine (9) of 14 development partners who rated partner coordination in the health sector reported a good level. Three (3) development partners said that coordination was at a medium level. One partner was very satisfied with the quality of coordination and marked it as excellent.
Figure 18. Rating of partner coordination in the health sector
Eleven (11) development partners provided feedback on the effectiveness of political dialogue between the Ministry of Health of the Kyrgyz Republic and their organizations. Donor opinions were different: WHO and UNDP believe that political dialogue has a great impact. Seven (7) organizations report medium impact between their organizations and the Ministry of Health. Four (4) organizations indicated only some impact of political dialogue.
Figure 19. Perceived impact of policy dialogue, 2017
1. Level of participation and total amount of ODA
An invitation for participation in 2018-2019 survey was sent to 30 organizations (in 2017 - 35; in 2015 - 35) providing assistance to the health sector of the Kyrgyz Republic, who met the OECD criteria . Since the data collection period coincided with the exacerbation of the COVID-19 pandemic in the country, and many embassies and organizations were forced to suspend their activities and switch to working online, only 20 representatives (in 2017 - 25; in 2015 - 21) of the donor community responded to the invitation to participate in the study. 6 of these development partners reported having no active projects in 2018-2019, 2 organizations had active projects only in 2019, and 12 organizations had active projects in both 2018 and 2019 and provided full information on them (in 2017 – 18 organizations; in 2015 – 12 organizations).
It should that the Japanese Agency for International Cooperation provided information on behalf of the Embassy of Japan in the Kyrgyz Republic, and the Swiss Agency for Development and Cooperation submitted information on behalf of the Embassy of the Swiss Confederation in the Kyrgyz Republic. Data on the projects of the Embassy of the Republic of Turkey were provided by the Turkish International Cooperation Agency. Information on implementation of the Global Fund grant was kindly provided by the local office of the United Nations Development Programme, as an implementing agency for this grant.
Table 1: Development partner participation in the 2018-2019 survey.
Partner organization | No active projects in 2018 | Active projects in 2018 | No active projects in 2019 | Active projects in 2019 |
Asian Development Bank (ADB) | √ | √ | ||
Embassy of the People’s Republic of China in the Kyrgyz Republic * | ||||
Eurasian Development Bank * | ||||
European Bank for Reconstruction and Development * | ||||
Food and Agriculture Organization of the United Nations (FAO) | √ | √ | ||
Global Alliance for Vaccines and Immunization (GAVI) | √ | √ | ||
German Agency for International Cooperation (GIZ) | √ | √ | ||
Islamic Development Bank (IsDB) | √ | √ | ||
Embassy of India * | ||||
Embassy of the Islamic Republic of Iran * | ||||
Embassy of Japan - Japan International Cooperation Agency (JICA) | √ | √ | ||
Kuwait Fund for Arab Economic Development* | ||||
KfW Development Bank | √ | √ | ||
Korea International Cooperation Agency (KOICA) | √ | √ | ||
Embassy of the Republic of Korea | √ | √ | ||
Embassy of the State of Qatar * | ||||
Embassy of the Russian Federation | √ | √ | ||
Russian-Kyrgyz Development Fund * | ||||
Saudi Fund for Development (SFD) | √ | √ | ||
Embassy of the Swiss Confederation - Swiss Agency for Development and Cooperation (SDC) | √ | √ | ||
Embassy of the Republic of Turkey in the Kyrgyz Republic - Turkish International Cooperation Agency (TIKA) | √ | √ | ||
Joint United Nations Program on HIV / AIDS (UNAIDS) | √ | √ | ||
Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) - United Nations Development Program (UNDP) | √ | √ | ||
United Nations Population Fund (UNFPA) | √ | √ | ||
United Nations International Children's Emergency Fund (UNICEF) | √ | √ | ||
United Nations Office on Drugs and Crime (UNODC)* | ||||
United States Agency for International Development (USAID) | √ | √ | ||
World Bank | √ | √ | ||
World Food Programme (WFP)* | ||||
World Health Organization (WHO) | √ | √ |
* - organizations highlighted in gray did not respond to the invitation to participate in this survey.
Among the 14 development partners that had active projects, seven are multilateral and seven are bilateral.
Figure 3. Bilateral and multilateral development partners
The projects covered in this survey were separated into 2 years: some started, continued, or ended in 2018 and others in 2019. Overall, development partners reported 34 projects and programs in 2018 and 40 projects in 2019. Total disbursements in 2018 were $46,739,638 and $39,546,260 in 2019, representing
22% and 19% of total health expenditures, respectively. Despite an increase in the number of projects, amount of funding from nearly the same donors decreased by 15% in 2019 compared to 2018.
Figure 4. ODA projects or programmes per donor, 2018-2019
As can be seen from the figure above, the absolute leader in terms of the number of projects in the health sector in both 2018 and 2019 is the KfW Development Bank. Looking at 2018 and 2019 separately, the KfW Development Bank, the Turkish International Cooperation Agency (TIKA), and the United Nations Population Fund (UNFPA) account for 56% of all projects in 2018 and 50% in 2019.
In terms of ODA amounts, the KfW Development Bank was also the leader in terms of disbursement with $15,139,249 in 2018 and $11,835,931 in 2019. The second by volume of disbursements in 2018 is the Turkish International Cooperation Agency with $11,273,428; and UNDP implementing the Global Fund grant owns the thrid place with $8,660,213 in disbursements.
In 2019, UNDP takes the second place with the same amount of disbursements as in 2018, and the Swiss Agency for Development and Cooperation takes the third place with $4,439,651.
Figure 5 shows that only 4% of the total 2018 ODA covered in this report has been received in the form of loan. In fact, only World Bank support for the SWAp project was received in the form of a concessional loan.As for 2019, the loan element was only 1% - these were the disbursements under the Saudi Development Fund project for construction and equipping the Public Pediatric Emergency Hospital.
Figure 5. Total ODA by types.
Compared to 2015 and 2017 surveys, the loan element has significantly decreased. For example, in 2015 it was 10% of total ODA, and in 2017 - 6%7.
2. Geographic coverage
Information on the geographic coverage of partners’ projects is presented in Figure 6.
Figure 6. Development partners by geographic coverage, 2018-2019
2018: All twelve organizations indicated that they provided support at the national level; of those, two organizations indicated that they worked at both the national and regional levels, and two partners had national level projects with pilot sites.
2019: Thirteen organizations implemented projects at the national level; of those, five organizations worked at both the national and regional levels, two partners had national coverage projects with pilots, and only one partner, the Saudi Fund for Development, had a project without national coverage, focusing only on Bishkek city.
Table 2: Development partners by geographic coverage, 2018-2019
Geographic coverage | Donor agencies | |
National | GAVI, GIZ, JICA, KfW, SDC, TIKA, UNAIDS, UNDP, UNFPA, UNICEF, USAID, WB, WHO | |
Regional | Bishkek city | GAVI, GIZ, KfW, SFD, UNAIDS, UNFPA, USAID, WHO |
Osh city | GIZ, KfW, SDC, UNAIDS, USAID | |
Batken oblast | SDC, UNAIDS, USAID | |
Jalal-Abad oblast | GAVI, KfW, SDC, UNAIDS, USAID | |
Issyk-Kul oblast | GAVI, SDC, UNAIDS | |
Naryn oblast | GAVI, GIZ, SDC, UNAIDS | |
Osh oblast | GAVI, GIZ, KfW, SDC, UNAIDS, USAID | |
Talas oblast | GAVI, SDC, USAID | |
Chui oblast | GAVI, GIZ, SDC, UNAIDS, USAID |
According to the table, it can be concluded that in general all regions of the country are covered by the projects of development partners.
3. Funding categories, components, health system priorities
Distribution of disbursements for 2018 and 2019 by three funding categories is shown in Figure 7. In 2018, the largest share are investments (69.0%); technical assistance accounts for 21.7%; and the remaining 9.3% of ODA are administrative costs. In 2019, the share of investments decreases to 54.9% and technical assistance increases up to 30.9%. As for administrative costs, they have also increased by almost 5% (14.1%) compared to 2018. In percentage terms, the difference seems small, but in monetary terms, the amount of investments, for example, dropped by $10.5 million.
Figure 7. Total disbursements by funding categories, 2018-2019
The following figure illustrates the distribution of technical assistance funds across five components: (i) policy development; (ii) capacity building; (iii) development of guidelines and protocols; (iv) regulatory framework; and (v) other (including communications, consulting, etc). The largest share of technical assistance in both 2018 and 2019 is for capacity building (73.5% and 48.6%, respectively)
Figure 8. Technical Assistance by components, 2018-2019
Figure 9 demonstrates the distribution of the investment quota of total ODA by five components: (i) construction and refurbishment; (ii) medical supplies; (iii) information technology; (iv) medical equipment and technology; and (v) other. The largest share of investment in 2018 was provided for construction and refurbishment (56.7%), but things have changed in 2019 and investment in medical equipment and technology is predominant. This results from the completion of construction on major projects in 2018 and start of their equipment in 2019. As can be seen from the diagram, investments in information technology remain at a rather low level in both years.
Investments by components
Figure 9. Distribution of investment quota, 2018-2019
Figure 10 illustrates the distribution of total disbursements across four health system functions: (i) health services delivery; (ii) resource generation; (iii) health financing; b (iv) leadership and governance. The figure clearly demonstrates that the main priority of most partners is in the area of health services delivery. Resource generation and Leadership and governance also have some share of support. The lowest disbursement numbers were allocated for the function of health financing.
Figure 10. Disbursements by health system functions, 2018 – 2019
The area of Health Services Delivery can be divided into four main categories: (i) primary care; (ii) hospitals; (iii) public health services; and (iv) emergency care (Figure 11). Public health services remain the primary focus area (52% in 2018 and 42.6% in 2019). Nearly similar numbers are observed for the primary care component (37.1% in 2018 and 40.6% in 2019). The most neglected area is emergency care.
Figure 11. Distribution of health service delivery quota, 2018 – 2019
Figure 12 shows the distribution of all ODA disbursements across the various priority areas of health programs. In 2018, the breakdown is as follows: communicable diseases (46.72%), non-communicable diseases (20.46%), and maternal and child health and reproductive health (8.92%). Less attention is given to health areas such as adolescent health (4.49%) and injury and violence (4.38%). A fairly significant share of funding (15.04%) was allocated to areas not covered by the above-mentioned classification ("other")
In 2019 the picture is slightly but different: the area with the highest funding remains the same - communicable diseases - 58.75%. The emphasis in 2019 shifted slightly toward Maternal and child health and Reproductive health - funding increased by almost 11%. Adolescent health received the smallest funding - 3.16% of the total allocated funds.
Figure 12. Distribution of ODA according to priority health areas, 2018-2019
4. Alignment with national and international priorities
This section outlines the commitment of development partners towards the implementation of certain health sector policies, strategies and programs, as well as the achievement of particular Sustainable Development Goals. Almost all of the development partners interviewed are implementing their projects in line with the objectives outlined in the national strategies: "Den Sooluk" National Health Reform Programme of the Kyrgyz Republic for 2012 - 2018, the National Development Strategy of the Kyrgyz Republic for the period of 2018 - 2040, and the Programme of the Government of the Kyrgyz Republic on health protection and health system development “Healthy person – prosperous country” for 2019-2030. The only difference is that in 2018 the "Den Sooluk" National Health Reform Programme was active national programme in health sector, while in 2019 it was replaced by the Programme of the Government of the Kyrgyz Republic on health protection and health system development “Healthy person – prosperous country” for 2019-2030.
Table 3: Alignment of partners with national programs and strategies for 2018-2019
General (national) strategies | |
The National Development Strategy of the Kyrgyz Republic for the period of 2018 - 2040 | GIZ, JICA, KfW, SFD, UNAIDS, UNFPA, UNICEF, USAID, WHO |
"Den Sooluk" National Health Reform Programme of the Kyrgyz Republic for 2012 - 2018 | GIZ, KfW, SDC, UNAIDS, UNFPA, UNICEF, USAID, WHO |
Programme of the Government of the Kyrgyz Republic on health protection and health system development “Healthy person – prosperous country” for 2019-2030 | GAVI, GIZ, JICA, KfW, SFD, SDC, UNDP, UNFPA, UNICEF, USAID, WHO |
Sub-sectorial strategies | |
Health Sector Investment Strategy for 2016-2025 | KfW |
«Tuberculosis-V» National program | KfW, UNDP, USAID, WHO |
The State program on stabilization of the HIV epidemic in the Kyrgyz Republic for 2017-2021 | KfW, UNAIDS, UNDP, UNFPA, UNICEF, USAID, WHO |
The State program on prevention and control of non-communicable diseases in the Kyrgyz Republic for 2013-2020 | KfW, SDC, UNAIDS, UNFPA, UNICEF, WHO |
Programme of the Government of the Kyrgyz Republic for Mental Health Protection for 2018-2030 | WHO |
State Guaranteed Benefits Programme to ensure health care for the citizens of the Kyrgyz Republic | GAVI, KfW, UNFPA, USAID, WHO |
The concept of creating an electronic database of drugs and medical products in the Kyrgyz Republic | UNAID, UNFPA, USAID, WHO |
Kyrgyz Republic program to develop the sphere of drug circulation in the Kyrgyz Republic for 20142020 | UNAIDS, WHO |
Program for provision of additional incentives to physicians working in health facilities of small towns and remote and rural areas | USAID |
Regulations on the sanitary protection of the territory of the Kyrgyz Republic and the Comprehensive Plan of Anti-Epidemic Measures for the sanitary protection of the territory of the Kyrgyz Republic against the importation and spread of quarantined, highly dangerous infectious diseases that pose a danger to public health and population health for 2018-2022 | GAVI, USAID, WHO |
Table 4 summarizes the contributions of donors in support of the health-related Sustainable Development Goals. The table shows that most donors contribute to reducing maternal mortality (SDG 3.1), preventing newborn and under-5 mortality (SDG 3.2), eliminating AIDS, tuberculosis, and malaria (SDG 3.3), and achieving universal health coverage (SDG 3.8). None of the SDGs has been neglected, and WHO, as the leading and coordinating agency for international health within the UN system, seeks to cover all of the health-related SDGs in its activities.
Table 4: Contribution of partners to the Sustainable Development Goals.
1 | 3.1. By 2030 reduce the global maternal mortality ratio to less than 70 per 100,000 live births | GIZ, SDC, UNFPA, UNICEF, WHO |
2 | 3.2. By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births | GAVI, GIZ, SFD, SDC, UNFPA, UNICEF, WHO |
3 | 3.3. By 2030 end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases | UNAIDS, UNDP, UNFPA, USAID, WHO |
4 | 3.4. By 2030 reduce by one-third pre-mature mortality from non-communicable diseases (NCDs) through prevention and treatment, and promote mental health and wellbeing | SDC, UNFPA, WHO |
5 | 3.5. Strengthen prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol | WHO |
6 | 3.6. By 2030 halve global deaths from road traffic accidents | WHO |
7 | 3.7. By 2030 ensure universal access to sexual and reproductive health care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programs | GIZ, UNFPA, WHO |
8 | 3.8. Achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all | GAVI, GIZ, UNFPA, USAID, WHO |
9 | 3.9. By 2030 substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination | WHO |
10 | 3.a. Strengthen the implementation of the WHO Framework Convention on Tobacco Control in all countries, as appropriate | SDC, WHO |
11 | 3.b. Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all | WHO |
12 | 3.c. Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States | JICA, SDC, WHO |
13 | 3.d. Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks | SDC, WHO |
14 | Other SDG targets related to health | JICA, UNFPA, WHO |
A more schematic coverage of the SDGs is shown in Figure 13.
Figure 13. Contribution of partners to SDGs (coverage)
5. Financial management systems
Section VI of the questionnaire requested Development partners to indicate what national financial instruments, accounting systems, and/or national procurement systems they utilize. In 2018, 6 of 12 development partners indicated their recording of their ODA in the national health budget, six development partners did not have this information. In 2019, 9 of 14 donors answered this question; 5 partners had no information in this regard.
Figure 14. ODA recorded in the annual budget for 2018-2019
6. Aid Predictability
Figure 15 shows the commitments of the development partner community to support Kyrgyz health sector in the upcoming years up to 2024.
10 organizations planned to provide support in 2019 - based on the fact that their projects were present in the analysis for 2019, we can conclude that they have fulfilled their commitment. Only two organizations have long-term plans for support - the Saudi Fund for Development and WHO. They plan to support the health sector until 2024.
it should be separately noted the PHC Quality Improvement Program will soon be launched within the framework of the Programme of the Government of the Kyrgyz Republic on health protection and health system development “Healthy person – prosperous country” for 2019-2030, which will become the successor of SWAp project. This Program will be supported by Joint Financiers - the World Bank, the KfW Development Bank and the Swiss Agency for Development and Cooperation (SDC). The total amount of funding commitments to the Program for the five-year period up to 2024 is estimated at $37 million.
The World Bank has allocated $20 million for the project including $10 million grant and $10 million loan. Swiss Agency for Development and Cooperation pledged $9 million, and KfW Bank - €9 million. All financing agreements have passed the ratification procedures.
Figure 15. Commitment of the development partner community to support Kyrgyz health sector in future.
7. Coordination and Complementarity
Nine development partners reported a total of 35 missions during 2019. In addition, GAVI, UNAIDS, UNFPA, USAID, and WHO reported a total of 16 analytical works undertaken in 2019.
For 2018, the partners reported much fewer of both joint missions and analytical works - 17 and 6, respectively.
Figure 16. Missions and analytical works of development partners in health sector, 2018-2019
All organizations provided their feedback onpartner coordination in health sector for 2018 and 2019. Six of twelve development partners in 2018 reported a good level of coordination. Nine of the fourteen partners in 2019 also rated the level of coordination as good. One partner was very satisfied with the quality of coordination and rated it as excellent.
Figure 17. Partners' opinions on coordination in the health sector
Opinions regarding the effectiveness of the policy dialogue between the Ministry of Health of the Kyrgyz Republic and partner organization were provided by ten partners for 2018 and 11 partners for 2019. Overall, development partners believe that policy dialogue has a medium to high impact on the effectiveness of collaboration between the Ministry of Health and their organization.
Figure 18. Perceived impact of the policy dialogue in 2018 - 2019
According to partners, the main problems that prevent full alignment and harmonization with health sector priorities are:
• Peculiarity of the cooperation schemes of each development partner and the peculiarities of the public system;
• Decreasing capacity to implement the health sector reforms and activities at national and local levels as well as staff reshuffling including the senior management positions;
• Poor political vision on the sectoral reforms and weak capacities of policy makers;
• Different interests of the donor countries and agencies;
• Weak capacity of the Government to coordinate and provide technical and data inputs, which makes it heavily reliant on the active contributions of development partners;
• Limited capacity and resources at the national and local levels do not allow to further implement successful programmes;
• Outbreaks and overall vulnerability of the country to disasters;
• Unaligned investment strategies and technical assistance package.
Resolution of these problems, especially in terms of capacity building, would allow the Ministry of Health to ensure more effective implementation of projects and programs of the donor community for the benefit of the country.
This publication represents a common effort – by the Government of the Kyrgyz Republic and the development partner community committed to the country's health sector – to improve information sharing and strengthen efforts towards better aid coordination and effectiveness. This exercise represents a useful tool to enable both parties to adjust their work plans towards common goals and shared priorities in both the short and the medium term.
The strategic documents for the Kyrgyz health sector are: the Strategy for the protection and promotion of public health of the Kyrgyz Republic 2020 (Health-2020), approved by Government Resolution No.306, 4 June 2014; and the Den Sooluk National Health Reform Programme of the Kyrgyz Republic for 2012–2016, approved by Government Resolution No.309, 24 May 2012. The Health-2020 strategy includes the strategic vision for improvement of the health sector based on a cross-sectoral approach to the protection and promotion of public health. The principles of the strategy fully align with the principles of the National Sustainable Development Strategy of the Kyrgyz Republic for 2013–2017, and with the principles of the Den Sooluk programme.
The Den Sooluk programme was developed on the basis of experience of previous health reform programmes. It is focused on achieving specific goals in four priority areas: (i) cardiovascular diseases; (ii) maternal and child health; (iii) TB; and (iv) HIV, through provision of extended coverage of key services, improving quality of care and elimination of barriers in the health system that have not been eliminated in the framework of previous programmes.
As a Member State of the WHO European Region, Kyrgyzstan supports the objectives adopted within the framework of a WHO Health 2020 regional strategy. Health 2020 aims at significant improvement in the health and well-being of the population, reduction of health inequalities and strengthening of public health. It also aims at ensuring the sustainability of health systems focusing on the needs of the people and at a high quality of care in compliance with the principles of universal health coverage, social equity and sustainability.
This document is the first report on official development assistance (ODA) to the Kyrgyz health sector. It aims to:
• share information and present a picture of external assistance to the health sector across the priorities set out in the strategic policy documents;
• provide evidence in support of the policy dialogues and development of coordination mechanisms at national and international levels;
• generate evidence that may help to strengthen development partner coordination in support of the ongoing reforms in the Kyrgyz health sector;
• provide forecasts of future external assistance from both short- and medium-term perspectives; and
• inform future national strategic plans and development partners’ strategies to support the Government of the Kyrgyz Republic both financially and technically.
This publication provides a picture of external assistance channeled to the health sector, highlighting not only well-supported areas of intervention but also relatively overlooked categories. Its main purpose is to provide an overall picture of external assistance to the health sector which may inform strategic planning by development partners and national authorities over the next years.
In order to implement the overall coordination and consistent decision-making on the use and planning of external assistance, Government Resolution No. 592 of 30 August 2012 established a Coordination Council between the Government of the Kyrgyz Republic and the development partners.
This section describes the design of the study, data collection and data analysis processes for the survey. The design of the study envisioned two phases:
(i) identification of eligibility criteria;
(ii) development of a questionnaire.
These processes were inspired by the successful experience of the Ministry of Health of the Republic of Moldova in previous years. Data collection was conducted through an online interface and strengthened through face-to-face validation interviews. Data analysis was conducted by the research team in close collaboration with the IT specialist.
The research team comprised mainly Ministry of Health – Health Policy Analysis staff. Inputs such as the description and structure of the mid-term budgetary framework (MTBF) categories, as well as revisions to the general analysis, were provided by other relevant departments of the Ministry of Health.
1. Study design
1.1. Eligibility criteria
The Ministry of Health of the Kyrgyz Republic and the WHO Country Office conducted this research based on inputs collected from the development partners disbursing ODA.
Under the definition in the Organisation for Economic Co-operation and Development (OECD) Statistical Directives, para. 35, ODA includes all official transactions that:
1. are administered with the promotion of economic development and welfare of
• developing countries as its main objective; and
• are concessional in character;
2. and convey a grant element of at least 25%.
The report does not include any humanitarian or philanthropic assistance or sponsorship implemented in the health sector.
Development partners that met the criteria but did not disburse funds to the Kyrgyz health sector in 2015 are listed in Annex 1 but not included in this survey. To avoid double counting, when one development partner disbursed ODA funds on behalf of another, the development partner that carried out the final disbursement to the country is the one that reported for that project.
1.2 Questionnaire development and pilot
The research team developed a questionnaire to collect information on each development partner committed to the Kyrgyz health sector that had disbursed funds in 2015. During the pilot phase a draft version of the questionnaire was sent to several technical representatives of the development partner community providing ODA to the Kyrgyz health sector. The pilot phase and further consultations enabled the final version of the questionnaire to be refined and finalized at the end of June 2016.
An online version of the questionnaire was made available to all eligible development partners, with secure access through individual logins and passwords. The development partners’ questionnaire is available in Annex 2. A glossary of all the terms used in the questionnaire was also provided (see Annex 3). The completed versions of the questionnaire are available in Annex 4.
1.3 Questionnaire structure
Each section of the questionnaire was developed in cooperation with all the relevant departments and units of the Ministry of Health and in consultation with the WHO Country Office and independent consultants in order to accommodate multiple needs. As a result of these multiple inputs the questionnaire comprises ten sections.
Section I requests general information about the development partner agencies: their goals and key achievements; and the total amount of ODA they disbursed to the Kyrgyz health sector in 2015 classified by four different aid modalities – programme/project aid, sector budget support (SBS), pooled funds under SWAp, and other pooled funding.
Sections II, III, IV and V collate information about every programme and/or project run by each different development partner: date of start and completion; programme/project manager; mode of project implementation (through development partner office, public sector or other mode); and status of implementation as of 31 December 2015.
In addition, the questionnaire required the description of project/programme goals; current progress (target value – actual value); type of financing; and total budgets.
Financial efforts were quantified according to type of funding (i.e. technical assistance, investments and administrative costs) and further classified by delivering facilities, disease areas and risk factors. Appropriate filters were introduced in order to avoid mistakes and double counting. Section IV also asked development partners to reframe the project according to health-sector priority areas: health service delivery, resource generation, health financing, leadership and governance.
Information was also requested on the geographical coverage of each project/programme.
Sections VI, VII, and VIII focused on assessing alignment of aid with national policies and strategies; distribution of support by MTBF and other financial tools; use of public financial systems and procurement systems; mid-term (2016–2020) aid predictability within the MTBF subprogrammes; and development partners’ multiyear plans. These sections are intended to help the Ministry of Health to assess development partners’ alignment and harmonization.
The final sections of the questionnaire assessed donor coordination for joint missions and analytical work (Section IX); and development partners’ opinions and levels of satisfaction relating to coordination mechanisms and policy dialogue in the Kyrgyz health sector (Section X).
At the end of the questionnaire, participants were asked to provide their feedback on its structure and the appropriateness of the questions. This feedback will contribute to further development of the data collection system and improvement of future reports.
2 Data collection
2.1 Online data entry model
Data were entered through a web-based platform. The platform was adopted from the similar survey in the Moldovan health sector in 2011–2013, taking account of all the aspects and features of the health system of the Kyrgyz Republic.
The database was placed on the server of the Ministry of Health of the Kyrgyz Republic. Development partners were given a three-week timeframe for data entry starting from the beginning of September 2016. The online platform had advantages for both the development partners interviewed and the research team. Development partners could access the online questionnaire to enter and upload data at convenient times and resume the task without losing previous inputs. Development partners also had access to automatically generated PDF files – summary texts intended to enable easy visualization of the information provided and facilitate the data validation process. The system also avoided the difficulties associated with tracking reviews and comments that arise when different people work simultaneously on a questionnaire. The research team was able to monitor progress on data entry and (where necessary) send timely reminders; validate data more easily and quickly; and generate text files and update the database automatically.
2.2 Interviews
All development partners that met the criteria (see 3.1.1) were invited for interviews. These were conducted by the research team after the completion of data collection through the web-based platform at the end of September 2016 – either face to face or via e-mail. Interviews were held only after development partners had accessed the online questionnaire. The validation interviews had five aims:
1. to present the goal of the study, questionnaire and glossary;
2. to collect general comments and reactions relating to the overall process undertaken, and the difficulties encountered;
3. to go through all sections of the questionnaire and the respective definitions provided in order to achieve a good standard of data homogeneity;
4. to note relevant details that did not fit into the existing questionnaire in order to record where and how the design might be improved for future surveys;
5. to obtain extra information on specific issues that could not be recorded/standardized within the questionnaire, owing to their lack of homogeneity across development partners.
2.3 Data analysis
Data analysis comprised several methods, focusing on: (i) generating aggregate analysis for all development partners, their projects and their financial disbursements; (ii) providing qualitative analysis of development partners’ feedback on coordination processes; and (iii) listing key information for each development partner.
To standardize the financial information provided, development partners were asked to enter data in the original currency used for disbursements. When the database was generated the software automatically converted all currencies to United States dollars (US$), the reporting currency that the Paris Declaration used for all aid harmonization exercises. The software used the annual average exchange rate reported by the National Bank of the Kyrgyz Republic for 2015.
The IT specialist added two additional modules – one to generate individual questionnaires (text files) for each donor covered by the survey, the other to generate a database for the numeric variables inserted. The numeric variables were generated and analysed using Microsoft Excel®. Frequencies and cross-tabulations were used for data analysis and presentation.
2.4 Data quality
Data quality was ensured by several methods. During the design stage, the questionnaire passed through five rounds of reviews by the extended research team, along with a pilot process. During the data collection phase, the online web platform included several internal control mechanisms that prompted users to avoid common data entry mistakes. In addition, provision of a link to a glossary aimed to standardize interpretation of definitions and questions (see Annex 3). The data presented are those provided officially by the organizations covered by this report. Development partners also underwent a validation process, during which all the data were reviewed in order to avoid discrepancies caused by misinterpretations of the questionnaire or the glossary. Misinterpretations were a possibility because the questions have been formulated to accommodate two distinct needs – accurate enough to avoid misconceptions while allowing all development partners (with different vocabularies, reporting and accounting methods) to match the questions to their own purposes and to feel comfortable providing official answers. On completion of the validation processes, the relevant representatives had approved all the changes to the first version of the questionnaire submitted by individual development partners.
The joint effort of development partners and the research team during the validation processes enabled most development partners to complete all parts of the questionnaire. This guaranteed further homogeneity of the results. During the data analysis process all questionnaires were subject to a third level of data quality checking, using both exploratory analysis and further data cleaning to remove inconsistencies.
Landlocked, largely mountainous and with a population of just under 6 million in 2015, the Kyrgyz Republic is a vibrant democracy that adopted a parliamentary system in 2011. Since gaining independence, the country has undergone a complex phase of transition to a market economy, with macroeconomic adjustments and structural reforms. Kyrgyzstan scored 0.586 on the Human Development Index (HDI) in 2014 and 0.655 in 2010. Yet, despite the positive trend, this still ranges below the average for the Europe and Central Asia region (0.709) in which it is clustered, classifying Kyrgyzstan among the Medium Human Development countries.3
Gross national income (GNI) per capita has been calculated at $ 1553 in 2015, positioning the country among the lower middle income category of the World Bank (WB) lending group ranking.
Table 1. Economic indicators 2015, 2014
GDP growth (annual %) | 3.5 |
GNI per capita, Atlas method, US$ | 1 553 |
Population (total) | 5 990 006 |
Landlocked developing country | Yes |
HDI value | 0.655 |
WB country classification | Lower middle income |
WB geographical region | Europe and Central Asia |
The health sector
Along with other sectors, after independence the health sector needed fundamental restructuring. There was an urgent need to achieve health equity; ensure state guaranteed benefits in health-care delivery; and develop primary health care and family medicine. In fact, both the prevalence of the hospital sector and excessive specialization of health services inherited from the Soviet period were strongly overstressing the system. For these reasons and other reasons, the Kyrgyz health system has undergone different stages of reform: the Manas reform from 1996 to 2005, the Manas Taalimi reform from 2006 to 2011 and the Den Sooluk programme covering 2012 to 2016. Both the Manas Taalimi and the Den Sooluk reforms foresaw a sector-wide approach (SWAp) mechanism (see Box 1), with development partners topping up state pledges over reform goals.
The main achievements of the reforms include the introduction of mandatory health insurance; introduction of a system for progressive results-based financing methods and the single-payer system; creation of family medicine centres and of family physician groups as first contact points with the health system; restructuring of many hospitals; introduction of a state guaranteed benefits package (SGBP) and the copayment; and a first phase of additional drug provision for all insured persons at primary health care level.
As a percentage of total government expenditure, health expenditure increased from 10.3% in 2005 to 13.2% in 2015 – achieving the 13% target value set by the Den Sooluk reform programme. Costs per capita increased from a baseline 353.3 Kyrgyz soms in 2004 to 2450 Kyrgyz soms in 2014. As a percentage of gross domestic product (GDP), public health expenditures increased from 1.9% in 2004 to 3.2% in 2014.
Table 2. Health financing in the Kyrgyz Republic, 2011–2015
2011 | 2012 | 2013 | 2014 | 2015 | |
GDP growth (annual %) | 6.0 | -0.1 | 10.9 | 4.0 | 3.5 |
Health expenditure, total (% of GDP) | 6.2 | 7.0 | 6.7 | 6.5 | - |
GDP per capita growth (annual %) | 4.7 | -1.7 | 8.7 | 2.0 | 1.4 |
Health expenditure per capita (current US$) | 69.1 | 81.7 | 85.3 | 81.6 | - |
Health expenditure, private (% of GDP) | 2.5 | 2.8 | 2.8 | 2.8 | - |
Health expenditure, public (% of GDP) | 3.7 | 4.2 | 3.9 | 3.6 | - |
Health expenditure, public (% of total health expenditure) | 11.6 | 12.2 | 13.2 | 11.9 | - |
Out-of-pocket health expenditure (% of total expenditure on health) | 34.5 | 35.2 | 37.3 | 39.4 | - |
External resources for health (% of total expenditure on health) | 11.1 | 12.4 | 8.7 | 8.6 | - |
Table 3. Public allocations to the health system, 2011–2015
Indicators | 2011 | 2012 | 2013 | 2014 | 2015 |
Total public expenditure (billion KGZ soms) | 62.7354 | 81.711 | 99.7368 | 103.0035 | 109.245 |
Total expenditure on health (billion KGZ soms) | 9.0155 | 11.249 | 13.5642 | 14.1179 | 14.3963 |
Public health expenditure as % of public expenditure | 14.4 | 13.8 | 13.6 | 13.7 | 13.2 |
Demographic situation
The resident population of the Kyrgyz Republic increased by 124.4 thousand (2.1%) in 2015 and by January 2016 had reached 6 020 000 people.
The maternal mortality rate shows a significant reduction: decreasing by 24% (50.7 per 100 000 live births) between 2015 and 2014.
Table 4. Health at a glance, 2015
Indicator | Kyrgyz Republic | Republic of Moldova | Republic of Kazakhstan |
Birth rate (per 1000 population) | 27.4 | 10.9 | 22.69 |
Natural population growth (per 1000 population) | 21.6 | -0.3 | 15.24 |
Mortality rate (per 1000 population) | 5.8 | 11.2 | 7.45 |
Infant mortality(per 1000 live births) | 19.0 | 13.6 | 12.6 |
Maternal mortality rate (per 100 000 live births) | 38.5 | 23 | 12 |
In December 2015, there were 29 000 registered cases of infectious and parasitic diseases. Within this category, acute respiratory viral infections (65%) still dominate. At the same time, the epidemiological situation in 2015 was characterized by significant increases in rubella morbidity (3.4 times), whooping cough (2.4 times) and bacterial meningitis (1.4 times). High levels of measles cases remain – 299 cases per 100 000 population.
Between the periods January–December 2014 and January–December 2015, there were significant reductions in the incidence rates (per 100 000 population) of parotitis (1.6 times), syphilis (1.6 times), gonorrhoea (1.6 times), echinococcosis (6.7%) and brucellosis (20.6%). Intestinal infections showed a 3.8% reduction in the overall incidence rate – from 30 200 to 29 700 registered cases. Intensive indicators per 100 000 population were equal to 498.6 and 518.1, respectively. However, the incidence rate of bacillary dysentery grew by 15.4% – from 1809 cases (31.0) to 2131 cases (35.8). The incidence rate of bacterial meningitis increased by 41.4% – from 273 cases (4.7) to 394 cases (6.6).