Community Action for Health in the Kyrgyz Republic

Transcription

1 Sharing Experiences in International Cooperation Issue Paper on Health Series, No. 3a Overview and results

2 Authors: Tobias Schüth 1 Tolkun Djamangulova 1 Rahat Aidaraliev 1 Gulmira Aitmurzaeva 2 Aigul Iliyazova 2 Venera Toktogonova 3 Authors affiliation 1 Community Action for Health Project, financed by the Swiss Agency for Development and Cooperation (SDC), implemented by the Swiss Red Cross (SRC) 2 Republican Centre for Health Promotion under the Ministry of Health of the Kyrgyz Republic 3 Association of Village Health Committees in Kyrgyzstan Contact: Community Action for Health Project/SDC/SRC: tolkun@src.kg; Republican Centre for Health Promotion: rchp08@mail.ru; Association of Village Health Committees: arhc@inbox.ru Tobias Schüth: tobiasschueth@gmail.com Swiss Red Cross Rainmattstrasse 10/P.O. Box CH-3001 Berne Phone Bishkek, April 2014 Pictures: Kirgistan, SRC

3 Acknowledgements Numerous actors have made the Community Action for Health programme in Kyrgyzstan (CAH) possible. Foremost of all, the enthusiasm, commitment and ideas of the countless members of the village health committees (VHCs) carried the programme further than we had ever dared to imagine. Among them, many new leaders emerged, including Taalaigul Rysalieva, chairperson of one of the first VHCs in Jumgal rayon and today chairperson of the board of the National Association of VHCs (AVHC), and the other current members of the AVHC board (Kerimbek Mukanbetov, Sagynbek Abjaparov, Maksat Abdraimova, Gulnara Teshebaeva, Artyrkul Atanova, Mairambek Koshaliev). Kubanichbek Atanov and Venera Toktogonava, the first director and first coordinator of the AVHC, contributed decisively to the establishment of the Association. The team of trainers who set up the first VHCs in Jumgal rayon in 2002 were Tolkun Djamangulova, Shaken Janykeeva and Temir Tologonov; for one long year they left their families to live and work with the communities in remote Jumgal and to learn the key lessons that would shape the development of the CAH programmes for many years to come. Tolkun Djamangulova and Rahat Aidaraliev, as coordinators of the CAH programme, led the extension of the CAH programme throughout the country and built the capacity of the Republican Centre for Health Promotion (RCHP) and of the AVHC to steer the CAH programme as partners. Within the RCHP, its director Gulmira Aitmurzaeva provided support and leadership to the CAH programme on behalf of the Ministry of Health and its health reform programme, while Aigul Iliyazova and Baktygul Toktorbaeva led the capacitybuilding of Health Promotion Units (HPUs) and the coordination between the CAH programme and family medicine centres, sanitary-epidemiological surveillance, other Ministry of Health departments and donor agencies. They also coordinated the development of health actions. Jamilia Usupova and Jumagul Borukeeva also took part in these activities. Ainura Shergalieva oversaw data collection and analysis while Anarbek Alimahunov was in charge of software development for the current data collection system using mobile phones. Special mention goes to the staff of the 180-odd Health Promotion Units (HPUs) in the country, who are direct partners of the VHCs; without their commitment and enthusiasm, their smiles of recognition and gratitude, the VHCs would not exist. Likewise, the staff of all Family Group Practices (FGPs) and the Feldsher-Accousher-Points (FAPs) greatly supported the establishment of VHCs and provided continuous support for their development and activities, notably by making available meeting rooms. Many directors of Family Medicine Centres (FMC) also lent support and offered encouragement to VHCs and their HPU staff. A number of dedicated professionals in each oblast made the implementation of the CAH programme possible throughout the country, serving as either project trainers or oblast HPU staff. They are: Shaken Janykeeva, Venera Toktogonova, Fatima Abdukarimova, Cholpon Bazarkulova, Gulzat Jumabek-kyzy (Naryn); Melis Tylobergiev, Gulipa Sheisheneva, Mairam Akishova (Talas), Asel Aitekova, Kyal Kuchkacheva, Aibek Kasemaliev (Chui), Irlan Mukashev, Anara Abdrazakova, Maksat Kurmanov (Issyk-kul), Khalima Usmanova, Islam Tursunkulov (Batken), Rysbek Isaev, Bigsat Umarov, Elnura Mamytova (Osh), Shailokan Torobekova, and Jamilia Hudaibergieva (Jalalabad). The recent development of a CAH model adapted to urban areas was headed by Ainura Mergenbaeva, Nazgul Akmatalieva, Aigul Iliyazova and Tolkun Djamangulova. The above was made possible by strong support throughout the years from the Ministry of Health, including all ministers, numerous key staff in the Ministry of Health, and the donor

4 organisations that trusted the process: foremost the Swiss Agency for Development and Cooperation (SDC), which has been funding the CAH programme since its inception and has pledged to continue to do so until It will have supported the programme for a total of 16 years. Additional support for the country-wide extension has come at different times from the Swedish International Development Agency (Sida), the United States Agency for International Development (USAID), the Liechtenstein Development Service (LED), the Department for International Development (DFID), and the World Bank. The following donor agencies contributed to the CAH programme by collaborating with VHCs on health promotion issues: UNICEF, World Food Programme, the Finnish Government, the Global Fund To Fight AIDS, Tuberculosis and Malaria, the Gesellschaft für Internationale Zusammenarbeit (GIZ), the World Bank, and others. Last but not least, the Swiss Red Cross conceptualised the CAH programme and provided all technical assistance for the project, funded by the SDC, Sida and LED. Purpose of this publication The population lacks knowledge about health issues this is a routine statement in many discussions about health in Kyrgyzstan. But to what extent is it true? Fact is, that health awareness and behaviour have been improving considerably as a result of the Community Action for Health programme (CAH programme), and the partnership for health promotion between Village Health Committees (VHCs) and the government health system. This booklet offers a short description of the programme, which began in 2002, and summarises its main results. These results demonstrate that investment in health promotion and specifically in partnering with communities can result in improved health awareness and behaviour and reduced disease burden on the one hand, and in empowered communities that address local determinants of health with own initiatives on the other. This should encourage the Ministry of Health and donor agencies to continue to invest in the CAH programme and may prompt health ministries and donors to consider this approach in other countries. It is also intended to reassure the health care staff involved in the CAH programme that their efforts bring about change, and motivate them to continue to give their best. Finally, it is hoped that the VHCs see this summary of results as a way of thanking them for their tireless efforts and commitment to improving the health of their communities and as an encouragement to persevere and keep on growing.

5 Content List of abbreviations 1 Executive Summary 2 1 Short description of the CAH programme Organisational set-up Formation of VHCs Health actions Organisational capacity building Financial Support 6 2 Results of the CAH programme Source of data Brucellosis Background Health action by VHCs Results Hypertension Background Health action by VHCs Results Mother and Child Health Danger signs in pregnancy and early childhood Nutrition in pregnancy Nutrition in early childhood Sexual and reproductive health Background Health action by VHCs Results Tuberculosis Background Health action by VHCs Results 20

6 2.7 Alcohol Background Health action Results Tobacco Background Health Action by VHCs Results Iodine deficiency disorders Background Health action by VHCs Results Addressing determinants of health Empowerment of VHCs Own initiatives Advocacy and good governance Gender 27 3 Lessons learnt and sustainability 28 References 30

7 List of abbreviations AA AVHC CAH CAH project/sdc CMR CVD CVMR DFID FAP FGP FMC GAVI GIZ HPU ICCO IMR LED MCH MMR MoH PHC PRA RHC RCHP SDC Sida SRC UNDP UNFPA UNICEF USAID VHC WHO Alcoholics Anonymous Association of Village Health Committees Community Action for Health Community Action for Health Project, financed by the Swiss Agency for Development and Cooperation (SDC) and implemented by the Swiss Red Cross (SRC). The project was formerly named Kyrgyz-Swiss Health Reform Support Project and Kyrgyz-Swiss-Swedish Health Project Child mortality rate Cardiovascular diseases Cardiovascular mortality rate Department for International Development Feldsher - Accousher Point Family Group Practice Family Medicine Centre Global Alliance for Vaccines and Immunisation Gesellschaft für Internationale Zusammenarbeit Health Promotion Unit (at the rayon level) Inter-Church Organisation for Development Cooperation Infant mortality rate Liechtenstein Development Service Mother and Child Health Maternal mortality rate Ministry of Health Primary Health Care Participatory Reflection and Action (formerly known as Participatory Rural Appraisal) Rayon Health Committee Republican Centre for Health Promotion Swiss Agency for Development and Co-operation Swedish International Development Cooperation Agency Swiss Red Cross United Nations Development Programme United Nations Family Planning Agency United Nations Children s Fund United States Agency for International Development Village Health Committee World Health Organisation 1

8 Executive Summary The CAH programme in Kyrgyzstan is a partnership for health promotion between the government health system and the Village Health Committees (VHCs). It began in 2002 with a pilot project in one rayon 1 and today is a country-wide programme involving some 1,700 VHCs in 84% of villages. VHCs are community-based organisations that carry out voluntary activities aimed at improving the health of their communities. As independent civil society organisations they collaborate with the government health system. At the rayon level they are organized into 58 Rayon Health Committees (RHCs), which are registered as non-profit organisations. These in turn form the national Association of VHCs (AVHC), which represents the VHCs in their dealings with the Ministry of Health and donor agencies. The Health Promotion Units (HPUs) in rayons and oblasts are the key partners of the VHCs on the health system side. They regularly visit the VHCs, providing training and support. They are part of the primary health care (PHC) system and are guided by the Republican Centre for Health Promotion (RCHP). The CAH programme has been endorsed by the Ministry of Health and has been part of the health reform programme (Manas Taalimi and Den Sooluk) since The CAH programme is coordinated by the RCHP together with the AVHC. Evidence presented in this booklet suggests that the CAH programme resulted in measurable health gains. The work of the VHCs reversed the brucellosis epidemic in Kyrgyzstan long before an effective veterinary vaccine was introduced. The VHCs screened over a million people for hypertension during the last three years ( ) and detected over 180,000 people with high blood pressure, including 57,000 who were not aware of their condition. They increased awareness of nutrition, danger signs in children and pregnant women and tuberculosis symptoms, and raised school students knowledge of HIV/AIDS prevention. They improved health and well-being in their villages through numerous own initiatives addressing local determinants of health. They also gave women a platform to take on new roles in community management. In recent years there has been a decrease in infant, child, and maternal mortality rates in Kyrgyzstan, and in the cardiovascular mortality rate. The CAH programme is likely to have contributed to this decline in mortality through improved health awareness and behaviour. The CAH programme is supported by the Ministry of Health and collaborating donor agencies. The Ministry of Health finances the yearly training for three health actions (currently on danger signs, nutrition in pregnancy and early childhood, and hypertension), and the annual assessment and planning exercise of the VHCs. A project funded by the Swiss Agency for Development and Cooperation (SDC) and implemented by the Swiss Red Cross initiated the programme (hereafter: CAH project/sdc 2 ), supported its expansion throughout the country and financed numerous health actions. Support for the expansion has also been provided at different times by Sida, LED, USAID, DFID and the World Bank. A number of other donors have been working together with VHCs on health promotion issues (UNICEF, the Global Fund, Asian Development Bank, GAVI, WHO, GIZ, World Food Programme, ICCO). In recent years the RCHP, with support from the CAH project/sdc, also developed a model for a CAH programme in urban areas, which will be introduced to all rayon centres and towns in the period The present booklet, however, is about the CAH programme in villages. 1 Rayon = districts, oblasts = regions. 2 The current name is Community Action for Health project, formerly referred to as Kyrgyz-Swiss Health Reform Support Project and Kyrgyz-Swiss-Swedish Health Project. 2

9 In conclusion, the CAH programme in Kyrgyzstan demonstrates that a partnership between community based organisations and a Government health system is possible, is beneficial to both sides (the demand and provider side of the health system) and can be scaled up to a national level. The CAH programme also shows that community empowerment processes and centrally designed health campaigns with measurable health outcomes can be combined and can mutually strengthen each other. 3

10 1 Short description of the CAH programme CAH is a country-wide partnership between voluntary Village Health Committees (VHCs) and the government health system of Kyrgyzstan. Its goals are a) to empower VHCs to improve their health in the villages and b) to enable the government health system to work in partnership with VHCs. 1.1 Organisational set-up The programme began in 2002 with a pilot project in one rayon 3 and today is carried out country-wide, involving some 1,700 VHCs in 84% of villages. The CAH programme has been endorsed by the Ministry of Health and is part of the health reform programme since While table 1 gives an overview of VHCs per oblast, its expansion throughout the country is depicted in figure 1 on the following page. Map of the Kyrgyz Republic with oblasts Table 1: Status of CAH programme per oblast, December 2013 No. of villages in oblast Villages with VHCs No. of VHCs No. of RHC Naryn % Talas % 95 4 Batken % Chui % Osh % Jalalabat % Issyk-kul % Total 1,786 1,505 84% 1, Rayon = districts, oblasts = regions. 4

11 VHCs are community-based organisations that engage in voluntary activities aimed at improving the health of their communities. As independent civil society organisations they collaborate with the government health system. They also work together with local selfgovernment structures. At the rayon level they are organised into 58 Rayon Health Committees (RHCs), which are registered as non-profit organisations. The RHCs in turn form the national Association of VHCs (AVHC), which represents the interests of VHCs in their dealings with the Ministry of Health and donors, and is the contractual agency for the cooperation of VHCs with the Ministry and donors. It supports VHCs in their organisational development and provides a forum for exchange, discussion and decision-making on guidelines and policy within the VHC movement. The Health Promotion Units (HPUs) in rayons and oblasts are the key partners of the VHCs on the health system side. They regularly visit the VHCs, providing training and support. As staff of the Family Medicine Centres (FMCs) they are part of the primary health care (PHC) system but are trained and guided by the Republican Centre for Health Promotion (RCHP). The RCHP, together with the AVHC, coordinates the CAH programme. The medical services in the villages (Family Group Practices (FGP) and the Feldsher Accousher Points (FAP), which offer obstetric care) also work closely with the VHCs. Figure 1: Expansion of CAH programme throughout Kyrgyzstan: No. of VHCs, village population covered, proportion of villages covered, Formation of VHCs PRA session In each oblast the CAH programme began with an analysis of health priorities by the people in all villages. The process was facilitated by PHC staff. It took place in neighbourhood groups; used tools designed according to the principles of Participatory Reflection and Action 4 (PRA) and involved 50-70% of households. During the analysis the neighbourhood groups elect people from their neighbourhoods as members of the future VHC. These bottom-up elections tend to produce new kinds of leaders, who enjoy the trust of their neighbourhoods and are active and community-minded. Finally, a 4 Formerly known as Participatory Rural Appraisal. 5

12 village meeting elects the board of the VHC from among these members. The HPU staff then work with the VHCs in two ways: they build their organisational capacity to help them become independent civil society organisations, and they train them to implement so-called health actions in their villages to improve the health problems identified as priorities by the communities as well as other public-health issues. 1.3 Health actions Health actions cover a broad range of issues drawn from the analysis of communities priorities and from additional public-health priorities. Health actions are designed by the RCHP in collaboration with the agency financing them, and HPUs train the VHCs to implement the health actions. The VHCs then visit people in their homes to discuss the health issue with the help of information material and tools. The VHCs involve members of school parliaments 5 in all health actions and work with other organisations as appropriate (the local primary care providers [FGP/FAPs], local self-government structures, veterinary services, etc.). VHC members receive no remuneration for the time spent on any of these health actions. In addition to these health actions, the RCHP with support of the CAH Project/SDC/LED has developed a school health education programme that was approved by the Ministry of Education. It focuses on five issues: brucellosis, personal hygiene, dental hygiene, tobacco and sexual-reproductive health. 1.4 Organisational capacity building Alongside the health actions, the organisational capacity of the VHCs is enhanced. Organisational capacity building enables VHCs to manage their affairs as independent civil society organisations, i.e. to gradually define their own agendas and take initiatives designed to tackle determinants of health beyond the suggested health actions. They learn to mobilise resources and collaborate with other organisations in the village, the rayon and beyond. The VHCs have close links with the local self-government organisations, called Ail Okmotus. Using their organisational capacities the VHCs carry out numerous own initiatives to address determinants of health in their villages. Starting in 2009, the CAH Project/SDC/LED has offered a micro grant for income generation activities to each VHC. The profit from the income generating activities adds to the resources for own initiatives and helps cover administrative expenses. 1.5 Financial Support The CAH programme is supported by the Ministry of Health and collaborating donor agencies. The Ministry of Health finances the yearly training for three health actions (currently these are nutrition in pregnancy and early childhood, and hypertension) and the annual VHC assessment and planning exercises. This amounts to one quarterly visit of HPU staff to all VHCs and ensures a basic level of collaboration and support. It also allows donor agencies to work with VHCs and HPUs on additional health issues. VHC meeting 5 School parliament is a student representation body elected in all Kyrgyz schools. 6

13 The CAH project funded by SDC and implemented by the Swiss Red Cross initiated the programme 6, supported its expansion throughout the country, and financed numerous health actions. Support for the expansion has also been provided at different times by Sida, Liechtenstein LED, USAID, DFID and the World Bank. A number of other donors have worked with VHCs on health promotion issues (UNICEF, the Global Fund, Asian Development Bank, GAVI, WHO, GIZ, World Food Programme, ICCO). They typically finance the training of HPU staff and VHCs on these issues and pay for working material. They contribute to the sustainability of the CAH programme by providing support to the organisational development of VHCs (for example. by financing meetings of the Rayon Health Committees) and by covering administrative expenses of AVHC. 2 Results of the CAH programme 2.1 Source of data The data presented in this booklet were obtained from two sources. From 2002 to 2012, the VHCs carried out simple surveys when starting a health action (baseline) and performed annual follow-up surveys. The data were collected and compiled by HPU staff and sent to RCHP and the CAH project for analysis. VHCs were told to interview as many people as possible for these surveys. Although these data were not based on random sampling and were collected by thousands of VHC members the large size of the sample (usually between 10,000 30,000 people) nonetheless gives a good indication of the dynamics over time. Since the process of collecting data by VHCs became too cumbersome as a result of the nationwide coverage of the CAH programme, HPU staff have been collecting data through representative cluster surveys 7 by using mobile phones that send data to a server located in the RCHP, allowing much more rapid analysis and monitoring of data collection sites by Global Positioning System. The system was introduced by the CAH project/sdc in The following chapters explain the results achieved by each health action. 2.2 Brucellosis Background The incidence of human brucellosis in Kyrgyzstan increased dramatically after 2000, and by the mid-2000s Kyrgyzstan was one of the countries with the highest incidence in the world. The underlying epidemic among animals had been spiralling out of control because of an ineffective vaccine (S-19) being used for sheep and goats. In addition, many more families were now in close contact with these animals, which in Soviet times had been cared for by professionals. Most people did not know how to protect themselves from infection by 6 The current name is Community Action for Health project, former known as the Kyrgyz-Swiss Health Reform Support Project and Kyrgyz-Swiss-Swedish Health Project. 7 The sampling procedure for surveys was two-stage cluster sampling: villages were selected using cluster sampling, while households within clusters were selected by simple random sampling from household lists (7 samples per cluster, 625 clusters). Regarding rayon centres/towns, the surveys took place in all of them. Clusters (defined as the coverage area of one FGP) were randomly selected and within clusters the households were selected randomly from lists. 7

14 animals. It therefore came as no surprise that brucellosis was identified as a top health priority in most oblasts during the initial PRA analysis Health action by VHCs As most brucellosis cases occurred in boys and young men between the ages of 13 and 35 and around the time of the lambing season, it soon became clear that infections were mostly linked to lambing. The health action therefore focused on protecting people when assisting ewes with lambing. VHCs promoted the use of gloves, having a separate lambing place, using disinfectant (lime) and, most importantly, the burying of placentas in the ground. Every autumn before lambing season the VHCs explained these measures to people with the help of information material, and school parliament members went from door to door to offer help with digging holes for the placentas. The health action was begun in Naryn oblast in 2003 and implemented in more oblasts every year as the CAH programme was expanded. In addition, the VHCs set up brucellosis committees made up of members of the local self-government structures, FGP/FAPs, the veterinary service and the police. Their task was to organise the regular testing of all cows for brucellosis and to make sure that animals which tested positive were not secretly sold but slaughtered. When an effective vaccine (Rev-1) was finally introduced by the veterinary service from 2009 onward, the VHCs discontinued these activities and instead helped to inform people about the new vaccination programme. However, as part of the school health education programme (developed by the CAH project/sdc and the RCHP) school students continue to be taught how to protect themselves against brucellosis before every lambing season. Financing: CAH project/sdc Brochure on brucellosis prevention Results In all oblasts the VHC surveys revealed substantial improvements in all four measures, especially during the first 2-3 years. As an example, figure 2 shows the results of Naryn and Batken oblasts. The oblasts where the health action was implemented later (here: Batken) serve as control group; their low baseline data demonstrate that the changes are indeed the result of the VHCs work (for example, compare the 2007 figures for Naryn and Batken). 8

15 Figure 2: Presence of four indicators of brucellosis prophylaxis in homes with sheep/goats/cows in villages of Naryn oblast (top) and Batken oblast (bottom) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Naryn oblast holes for placentas lambing place gloves disinfection 80% 70% 60% 50% 40% 30% 20% 10% 0% Batken oblast holes for placentas lambing place gloves disinfection The results obtained for the oblasts where action was taken can be compared with the situation in eight rayons in the south of Kyrgyzstan which had no VCHs before the start of the vaccination campaign with Rev-1 in the south (six rayons in Jalalabat and two rayons in Osh 8 ), and which can therefore serve as a control group. Figure 3 shows that in both areas, those with VHCs and those without, the human incidence rates rose in parallel until However, from 2007 onward the incidence in areas with VHCs stopped rising and starting in 2008 it even began to decline. At the same time the incidence rate in areas without VHCs 8 The six rayons in Jalalabat are Ak-Suy, Ala-Buka, Susak, Togyz-Toroy, Toktogul and Chatkal, (VHCs established in 2012 and 2013) and the two rayons in Osh are Alay and Chong-Alay (VHCs established in 2011). These eight rayons have a total population of about 700,000. Villages and rayon centres are included in the two areas because there are no separate data for rayon centres and villages. Excluded from the comparison are oblast centres and towns in both areas. 9

16 continued to rise dramatically until 2011, when the Rev-1 vaccination campaign was implemented in the southern oblasts, resulting in a sharp fall in case numbers the following year. It is important to note that the decrease in human incidence rates in VHC areas occurred before the start of Rev-1 vaccinations in the northern oblasts (2009 in Naryn, 2010 in Issyk- Kul, Chui) 9. The dotted line in figure 3 shows that seroprevalence in animals continued to rise until 2009 and did not begin to fall until after the start of Rev-1 vaccinations. It is therefore all the more astonishing that the human incidence rate decreased in VHC areas even though the epidemic continued to spread among sheep and goats. Figure 3: Brucellosis incidence rate in VHC areas and areas without VHCs (for definition of areas see text) Human Incidence rate per 100,000 population all country covered with vaccination incidence rate non-vhc areas (8 rayons JB+Osh) incidcene rate VHC areas (6 oblasts) Seroprevalence sheep/goat (%) 3 2,5 2 1,5 1 0,5 0 Seroprevalence sheep/goats (%) These findings strongly suggest that the participation of growing numbers of VHCs in the health action between 2003 and 2010 caused the reversal of the human incidence rate in VHC areas from 2007/2008 onward. The turning point can probably be attributed to the fact that in 2007 the population covered by VHCs almost tripled compared with that of 2006 (529,000 versus 1,392,000 villagers, see figure 1). 9 Vaccination expansion: 2009 Naryn oblast (0.1 mio animals), 2010 Issyk-kul and Chui oblasts (2.6 mio animals), 2011 Talas, Osh, Jalalabat and Batken oblasts (12.3 mio animals) 10

17 Cost-effectiveness analysis According to estimates by the Swiss Tropical and Public Health Institute, the VHCs assisted to prevent 10,192 cases between 2007 and The costs saved were calculated to be 4,827,065 USD. Out of these costs, the public health system saved 646,393 USD, the patients saved 2,788,889 USD for treatment and transport and 1,391,784 USD for loss of income 10. The costs for the brucellosis health action for information material and training of VHCs on the health action and on organizational development amounted to 300,000 USD over a period of 10 years. This is an investment of 29.4 USD per averted case which stands against avoided costs of 474 USD, resulting in a cost-savings ratio of 1: Hypertension Background Kyrgyzstan is one of the countries with the highest coronary heart disease mortality rate and has one of the highest stroke-related mortality rates in the world. One major reason is a high prevalence of hypertension (31%) and the fact that only 2.4% of those with hypertension are treated so that their blood pressure is in the normal range i. This is partly due to the fact that only 27% of those with hypertension are aware of their condition. In all oblasts people named high blood pressure among the top three health priorities during the initial PRA analysis. Therefore, VHCs were asked to help raise awareness on hypertension as part of the overall health sector strategy on hypertension Health action by VHCs Each VHC was equipped with one semi-automatic, upper-arm blood pressure cuff (semiautomatic means the pumping is done by hand, saving battery power, so that one battery lasts for about a thousand measurements). During a yearly hypertension action week in September, around World Heart Day, all VHCs throughout the country screen as many adults as they can. If they detect somebody with high blood pressure, they document the results and refer the individuals concerned to their primary care providers. They also give them a brochure with extensive information about hypertension and other cardio-vascular diseases (CVD) risk factors. Those who already know that they suffer from hypertension are reminded to take their drugs regularly. Finally, VHC members hand a sheet with the names and addresses of hypertensive individuals to FGP or FAP of the area so that they can be followed up if they fail to consult their primary care providers. In addition, VHCs measure blood pressure throughout the year if people approach them 11. In rayon centres, towns and cities, FGP personnel set up blood pressure measuring points at busy places during the hypertension action week. The growing number of health committees in urban areas also takes part in screening campaigns. Before and during the hypertensionaction week, the mass media also inform the population about the campaign. Financing: MoH (HPU visit to VHCs for yearly refresher training). CAH project/sdc/led (blood pressure cuffs, information material). 10 Unpublished communication by Joldoshbek Kasymbekov/Jakob Zinsstag (Swiss-Tropical and Public Health Institute). Assumptions for the calculations were based on information from the National Infectious Disease Hospital and on a survey of 95 brucellosis patients. According to these sources, the costs for the public health system of one human case was 63 USD and the private costs for the patient 274 USD for treatment and transport. Loss of income was 137 USD per case. The total costs per case therefore are 474 USD. It was assumed that 50% patients were treated in hospitals and that 30% became chronic cases with an average treatment of 3 years duration. 11 The Community Action for Health project will provide VHCs with more blood pressure cuffs in

18 2.3.3 Results Since 2011, VHCs in villages and FGPs in urban areas have screened about 1.2 million people and detected high blood pressure in 57,044 people who had not been aware that they suffered from hypertension. They also detected 129,362 people who knew that they suffered from hypertension but did not have their blood pressure under control due to lack of compliance or inadequate treatment regimens. Overall, around 16% of the population were diagnosed with high blood pressure (known and unknown).this figure is lower than that of the 2007 representative survey (31%), most likely because more middle-aged than old people were screened. The results of the hypertension health action for are presented in table 2. Table 2: Results of hypertension action weeks in the month of December, years , all oblasts Total Of total by VHCs No. of people screened 311, , ,273 1,197, ,744 (71%) No. of people newly detected with high blood pressure No. of people with high blood pressure and known hypertensive diseases (= uncontrolled hypertension) No. of people detected with high blood pressure, known and unknown (% of screened) 13,182 22,077 21,785 57,044 40,685 (71%) 29,842 47,462 52, ,362 93,424 (72%) 43, 024 (14%) 69, 539 (17%) 73, 843 (15%) 186,406 (16%) 134,109 (72%) VHC member measures the blood pressure during the screening action Some 40% of those screened were men, and some 60% women. Men are vastly underrepresented in the official register of hypertension and the relatively even numbers of men and women screened helped to correct this imbalance. Furthermore, screening mostly identifies individuals between the ages of 20 to 59 (73% of all screened, see figure 4 for age distribution in 2013). This is important because CVD death rates in Kyrgyzstan are increasing especially among young, ablebodied people. From 1991 to 2010, CVD mortality rates increased by 40.5% and 18.1 % in the age brackets and 40-59, respectively. ii 12

19 Aside from the improvements in the quality of primary and hospital care, the decrease in CVD mortality observed since 2010 may also be due to the increased awareness of hypertension achieved by screening campaigns (for example, CVD mortality in the year of age bracket was 51.2/100,000 in 2010 and 45.5 in In the year of age bracket it was in 2010 and in 2012). Figure 4: Age distribution of persons newly diagnosed with hypertension, VHC health action, No. screened people men women 0 < > 70 age brackets 2.4 Mother and Child Health Maternal, infant and child mortality rates all decreased from 2010 to Maternal mortality rate (MMR) decreased from , Infant mortality rate (IMR) from and Child Mortality rate (CMR) from [2012]). Many programmes of the Mother and Child health (MCH) component of the health reform programme contributed to this decline. The data presented below regarding mothers improved MCH awareness and behaviour changes suggest that the CAH programme also contributed to the drop in mortality rates Danger signs in pregnancy and early childhood Background High maternal mortality has been a major public health problem in Kyrgyzstan since the collapse of the Soviet Union. One of the reasons is late recognition of danger signs in pregnancy and therefore late admission to maternity clinics. Child mortality also rose sharply in the 1990s. The leading cause of death among children up to 5 years of age is pneumonia. The fact that many mothers are unfamiliar with the signs of pneumonia and other dangerous diseases and therefore delay taking their children to receive medical care is a major reason for the high child mortality rates. Therefore, VHCs were asked to raise mothers and families awareness of danger signs in pregnancy and early childhood. 13

20 Health action by VHCs VHC members visit the families of pregnant women and mothers with young children, talk to mothers, mothers-in-law and fathers about these danger signs and provide them with information material to which they can refer in case of doubt. Financing: MoH (HPU visit to VHCs for yearly refresher training). CAH project/sdc, UNICEF, UNFPA. Results danger signs According to VHC surveys, the percentage of mothers able to identify at least three danger signs in pregnancy doubled (from 41% to 86%) after the information campaign in The percentage of mothers able to identify at least three danger signs in early childhood also doubled from 39% to 77%, see figure 5 for details. Figure 5: Danger signs in pregnancy and early childhood before and after VHC health action, 2012 (data from the Naryn, Talas, Chui, Issyk-Kul oblasts; n=sample size) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 86% 41% 39% knows 3 danger signs of pregnancy 77% knows 3 danger signs of early childhood Baseline (June 2012, n= 1206) Monitoring (Sept 2012, n= 897) In 2011, UNICEF supported a small pilot project in three Ail Okmotus (self-government bodies) in Batken oblast. VHCs taught mothers of children <5 years of age the danger signs in small children and pregnancy. Surveys by UNICEF before and after this short campaign showed that awareness among mothers had risen steeply. At baseline in July 2011, 33% of mothers were familiar with at least three danger signs for children; at follow-up in October 2011, this figure had increased to 75%. For pregnancy-related danger signs the results were 26% at baseline and 56% at follow-up. 12 The 2013 representative cluster surveys found that pregnant women and mothers in villages (where there are VHCs) were more aware of danger signs in pregnancy and childhood than their counterparts in rayon centres/towns where there are no VHCs (see figure 6 for details). What is interesting in this respect is that both populations had been equally informed (74%) about danger signs by FGP/FAP staff but more than half of the women in villages said that they had also received information from VHCs. The VHCs are therefore very likely the reason for the greater awareness among mothers living in villages. It should also be noted that in villages many more mothers had the leaflet with danger signs in their households than in rayon centres/towns (the leaflet is given to mothers by FGP/FAP staff and VHCs). 12 Both surveys were cluster surveys with a sample size of

21 Figure 6: Mothers awareness of danger signs (DS) in pregnancy and early childhood in VHC areas (villages) and non-vhc areas (rayon centres/towns), representative cluster survey 2013 (n= sample size) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 91% 85% heard of DS 77% 74% 67% 65% knows 3 DS of pregnancy knows 3 DS for children 63% 31% leaflet about DS at home 74% 74% info from FGP/FAP 55% info from VHCs VHC areas (n=3901) non-vhc areas (n=1066) Nutrition in pregnancy Background Anaemia in pregnancy is very common in Kyrgyzstan. A 2005 iii study of Naryn oblast found that 35% - 89% of pregnant women were anaemic, depending on the stage of pregnancy. A country-wide survey carried out in 2013 found that 47% of pregnant women reported having been told by a doctor that they were anaemic iv. The reason for the high levels of anaemia is dietary iron deficiency. Many families can afford to eat meat only once a week or not at all. The widespread habit of drinking black tea further prevents iron absorption, especially in diets with little meat. The antenatal care guidelines call for iron/folate tablets to be prescribed to all pregnant women with anaemia; the tablets are available as part of the outpatient drug package. However, many pregnant women do not take these pills, partly because of side effects, and partly because they are not aware of how important they are for their own health and that of their babies. Anaemia in pregnancy and early childhood was a top health priority of people in all oblasts in the PRA analysis. Therefore, VHCs have been asked to help raise awareness among pregnant women of proper nutrition and the importance of taking iron/folate tablets if diagnosed with anaemia. Health action by VHCs The VHCs contact the FGP/FAPs regularly to obtain a list of pregnant women in their respective villages. They visit these women and, using information material, explain the detrimental effect of anaemia on their health and that of their baby. They suggest that they try eating at least a small piece of meat on as many days as possible, abstain from drinking black tea during the pregnancy so as not to impair iron absorption, and take iron/folate tablets if diagnosed with anaemia. Financing: MoH (HPU visit to VHCs for yearly refresher training). CAH project/sdc, UNICEF. 15

22 Results nutrition in pregnancy The 2013 representative surveys (figure 7) confirmed that in areas with VHCs (villages) fewer pregnant women drank tea than in areas without VHCs (rayon centres/towns). For the other indicators the difference is very small. However, data from the VHC survey shows that the proportion of pregnant women who ate meat the day before the survey increased from 69% in 2009 to 86% in The proportion of anaemic pregnant women who took iron/folate acid rose from 43% in 2009 to 66% in Unfortunately there are no earlier data for rayon centers or towns. In any case, the proportion of women taking treatment against anaemia is an urgent issue to improve. Figure 7: Nutrition in pregnancy in VHC areas (villages) and non-vhc areas (rayon centres/towns), representative cluster survey 2013 (n= sample size) 75% 66% 86% 80% 46% 49% 81% 84% 70% 66% 77% 79% 61% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% tea with last meal meat yesterday told to have anaemia rest yesterday ironfa today or yesterday (if anaemic) info from FGP/FAP info from VHC VHCs (n= 3349) non-vhcs (n=579) Nutrition in early childhood Iron deficiency anaemia is the most important nutritional problem in early childhood in Kyrgyzstan. Several studies of young children aged 6-36 months have shown that anaemia affects 50-80% of children in different regions of the country iii,v. A study carried out in Talas in 2010 revealed anaemia in 43.9% of children aged 6-24 months vi. Anaemia was identified as a top health priority in all oblasts in the PRA analysis. Besides anaemia, about 14% of children under 5 years of age were found to be stunted according to the Multiple Indicator Cluster Survey carried out in 2006 vii. The survey also found that only 36% of the children were exclusively breastfed during the first 6 months and that only 44% received complementary feeding in time. Therefore, VHCs were asked to help mothers provide proper nutrition for their children and to educate pregnant mothers in better nutrition for themselves. Health action by VHCs VHCs visit mothers with newborn babies after their return home from maternity clinics, and with the help of information material explain the importance of exclusive breastfeeding for the first six months of life and appropriate supplementary feeding from six months on. They also explain to mothers the importance of giving Gulazyk (micronutrient supplement 16

23 containing iron and vitamins 13 ) to children 6-24 months of age. In a pilot project in Talas oblast, Gulazyk reduced iron deficiency anaemia in children in this age group by 27% in one year; among children who took it for a full year (having been 6-12 months old at the beginning of the study) the decrease in iron-deficiency anaemia was 40%. Financing: MoH (HPU visit to VHCs for yearly refresher training). CAH project/sdc, UNICEF. The purchase of Gulazyk is financed mostly by UNICEF, with contributions from the World Bank, Soros Foundation, Swiss Red Cross, and others. Results exclusive breastfeeding Mothers were asked by VHC members what they had fed their babies the day before the interview. The percentage of mothers of children 0-6 months of age who reported having exclusively breastfed their children rose by 32% (17 percentage points) from 2009 to A further important change was that fewer mothers now give tea to children younger than 6 months of age (see table 3). Table 3: Exclusive breastfeeding before and after three years of VHC health action (Naryn, Talas, Chui, Batken, Osh 1 oblasts, data collected by VHCs) Sample size 7,356 9,300 Exclusive breastfeeding of children < 6months 53% 70% Gave tea to child < 6 months 24% 15% The 2013 representative cluster surveys confirmed that in villages 70% of infants < 6 months of age are breastfed exclusively (sample size = 3,329), which is about the same as in rayon centres/towns without VHCs (68%). The survey also found that only 31% of mothers said that VHCs had given them information about exclusive breastfeeding. Since these results were unsatisfactory, the health action has been revised to make it more interesting for VHCs to discuss exclusive breastfeeding with mothers, and now offers tools for better communication. In addition, VHCs now also include other family members (especially mothers-in-law and fathers) in the discussions. The effect can be seen in the cluster survey of March 2014, which showed that 67% mothers had received information on exclusive breastfeeding from VHCs and 82% of infants < 6 months of age were exclusively breastfed in villages. The situation improved also in rayon centres/towns without VHCs (77% exclusive breastfeeding). This indicates that a programme for improved advice on exclusive breastfeeding in maternities may also be having an effect (financed by CAH Project/SDC/LED). VHC member explains how to breastfeed 13 Gulazyk is internationally known as Sprinkles. 17

24 Results complementary feeding Data collected by VHCs about this health action showed improved feeding patterns from baseline (2009) to follow-up (2012). The proportion of mothers who reported giving black tea to children 6-11 months of age decreased by one third (from 65%, n=32,235, to 44%, n=27,575; data from Naryn, Talas, Chui, Batken oblasts, 2 rayons of Osh oblast). There was also a small increase in mothers who reported breastfeeding beyond the age of 6 months (68% to 73%). The 2013 representative cluster surveys identified better feeding practices in areas with VHCs (villages) than in urban areas without VHCs (rayon centres/towns), see figure 8. Especially noteworthy is the earlier start of complementary feeding (see 6-month figures), which is important to prevent wasting and stunting. Also, in VHC areas mothers offer more fruit and vegetables than in non-vhc areas, fewer give their children tea and more use Gulazyk. More than half of mothers (54%) said that they had received information about supplementary feeding from VHCs. Results Gulazyk Regarding Gulazyk, several studies show that the percentage of mothers with children 6-24 months of age who reported giving Gulazyk to their children is greater in villages (where there are VHCs) than in rayon centres and cities (where there are no VHCs). In a study carried out in Talas oblast in 2009 (790 participants) 85% of mothers in villages reported giving Gulazyk to their children, vs. 71% in rayon centres viii. This was five months after the beginning of the Gulazyk programme. A year after the start of the programme, a follow-up study vi (2010) found that in villages 71.2% of children still used Gulazyk while in urban areas only 29.0% were given the supplement. Figure 8 also indicates that the representative cluster surveys of 2013 found higher Gulazyk compliance in villages (with VHCs) than in urban areas (without VHCs). Figure 8: Supplementary feeding practices in VHC areas (villages) and non-vhc areas (rayon centres/towns), representative cluster survey 2013 (n= sample size) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 77% 62% solid food yesterday (6 ms) 91% 91% solid food yesterday (7 ms) 44% 32% fruit + vegetables yesterday 50% 40% tea yesterday 69% 60% gets Gulazyk 86% 81% breastfed in last 24h 68% 66% info from FGP/FAP 54% info from VHC VHCs (n=3455) non-vhcs (n= 631) 18

25 2.5 Sexual and reproductive health Background Sexually transmitted diseases greatly increased during the 1990s, and the number of HIV infections continues to rise quickly. In all oblasts the population identified reproductive tract infections as a high health priority. The VHCs were therefore asked to help raise awareness of sexually transmitted diseases Health action by VHCs Using an educational tool called Road to safety, VHC members help teachers educate their students about this topic in classes The tool consists of six lessons that are discussed with pupils with the help of posters. VHC members from the school parliaments also support this health action. It is one of six components in the health-promotion school package supported by VHCs and their school parliament members together with the teacher responsible for general education. In addition, VHCs were given DVDs with a feature film on sexual and reproductive health to be shown to adults. This film is also used in classes Financing: CAH project/sdc, GIZ Results Surveys carried out by school teachers among students before and six months after the lessons found that students were more aware of several key issues regarding the prevention of HIV infection. Surveys were conducted in five schools per rayon, with all students of class 9 participating. Table 4 shows the details. Table 4: Awareness of HIV prevention among school students (Naryn, Talas, Chui, Batken, Osh 1 oblasts, data collected by VHCs) Sexual and reproductive health (schools) Oct 2011 Feb 2012 Sample size 3,230 2,513 Knows about infection through needles 79% 90% Knows about fidelity as a means of avoiding infection 10% 31% Knows about condom use as a means of protection 22% 44% 2.6 Tuberculosis Background Since the 1990s, the incidence of tuberculosis has been increasing in Kyrgyzstan owing to deterioration in the socio-economic situation and the relevant medical services. Of special concern is the prevalence of multi-drug resistant forms of tuberculosis, which develop when treatment regimens are not completed. Prisons play an important part in spreading tuberculosis, especially the multi-drug resistant forms. Although PRA analyses found that tuberculosis was not a high priority for people, concern has grown in recent years. 19

26 2.6.2 Health action by VHCs When tuberculosis became one of the priorities of the Den Sooluk programme, a health action was developed for VHCs to raise awareness of the main symptoms to facilitate early detection and of the need to complete the treatment regimen so that relatives and neighbours can persuade patients to take their drugs regularly and until the end of treatment. Information to prevent discrimination was also handed out. VHCs distribute leaflets with this information and talk to people about it. The health action was piloted in Issyk-Kul and Chui oblasts in Since 2013, the health action is being implemented yearly in all oblasts. Financing: CAH project/sdc, Quality Health Care Project/USAID Results In 2013, the randomised cluster surveys in the pilot area (Chui and Issyk-Kul oblasts) showed greater knowledge of all indicators related to tuberculosis in areas with VHCs (in villages) compared with rayon centres/towns (without VHCs), see figure 9. Figure 9: Knowledge about tuberculosis in VHC areas (villages) and non-vhc areas (rayon centres/towns), representative cluster survey 2013 (n= sample size, survey done among pregnant women and mothers of children aged 0-11 months, pilot study in Issyk-Kul and Chui oblasts) 100% 95% 90% 80% 70% 81% 73% 82% 68% 67% 60% 50% 40% 48% 47% 47% 53% 43% 43% 30% 20% 23% 19% 10% 0% no danger if treated air transm. 3 symptoms TB treatable send to medic remind of drugs avoid contact VHCs (n= 607) non-vhcs (n=517) 2.7 Alcohol Background Alcohol consumption in Kyrgyzstan is lower than the average consumption in the WHO European region (5 litres of pure alcohol per person and year versus 12 litres in the WHO European region, data from 2004). Nonetheless, the effects and the costs associated with alcohol consumption and alcohol dependency are a strain for many families and society as a whole. 20

27 2.7.2 Health action Excessive alcohol consumption was identified as a health priority by the people of Naryn, Issyk-Kul, Chui, and Batken oblasts. When asked why this was so important, those surveyed mentioned the high number of people addicted to alcohol and the toll this takes on the health and well-being of whole families. However, they also mentioned that normal families without alcoholics spend too much money on alcohol because of social pressures and traditions. The health action was therefore designed to change communities attitudes to alcohol. VHCs asked every family how much they spent on alcohol per year and on what occasions. Most families were surprised by the amount of money spent on alcohol. VHC members then asked what they would do if they had these amounts available for other expenditures. The most frequent answers were clothes for the children, food, school books, etc. VHCs reached between 50-70% of families with this exercise. Initially, VHCs staff were often told not to put their noses in other people s private affairs. However, by politely explaining the purpose of the survey helping people save money they were able to persuade most families to cooperate. At the end they calculated from the family data how much the village as a whole spends on alcohol per year and presented their findings at a village meeting. Again, people were shocked to see their village spend so much on alcohol: in some cases, the amounts reached thousands of US dollars a year. The VHCs then presented the most frequent occasions at which people drank alcohol and asked the participants of the meeting whether the village was willing to agree on changing some of these traditions, and in what way. Most villages agreed, for example, that there should be no alcohol at funerals that it should be acceptable not to bring alcohol as a gift when visiting other families that nobody should be forced to drink at banquets. These new traditions were written out on posters and in leaflets that also showed the amount the village was spending on alcohol every year. The VHCs distributed the leaflets to influential people and asked their support for making these new traditions known and acceptable in the village. The VHCs also talked to people about them. Regarding alcohol dependency, it was explained to the VHCs that alcoholism is a disease that has to be treated and that any forced measures, like prohibiting the sale of alcohol in the village, would not be constructive in the long term. Instead, they were asked to identify alcoholics who were willing to undergo rehabilitation and afterwards participate in groups of Alcoholics Anonymous (AA). After a four-week rehabilitation period in rayon centres, successful participants were asked to establish AA groups in their villages. For several years, these groups were regularly visited by AA group members in the rayon centres for support. This was done in Naryn and Talas oblasts and in a few places in Chui oblast. Financing: CAH Project/SDC, Sida, LED Results In yearly surveys the VHCs asked people about their alcohol-related habits. As shown in figure 10 (using data from Naryn oblast as example) people did to some extent drop harmful traditions and changed to the new traditions instead (the yearly survey by VHCs was stopped after 2009 to avoid overburdening the committees). During a parliamentary election, the VHCs of Naryn oblast wrote an open letter to all candidates, calling on them not to hand out vodka during their campaigns. At the end of 2013 there were some 100 AA groups in Naryn, Talas and Chui oblasts, with about 1,000 abstinent alcoholics. The obvious health-benefits aside, a gender study ix also found that violence within the family had decreased considerably. 21

28 Figure 10: Traditions around alcohol consumption, Naryn oblast, VHC surveys 60% 50% 40% 30% 20% 10% 0% brought alcohol as a guest present received alcohol as a guest present were offered alcohol at funeral were offered alcohol for "small occasion" offered alcohol for "small occasion" were forced to drink alcohol at a party offered alcohol as payment for small works 2.8 Tobacco Background Smoking is highly prevalent among Kyrgyz men (> 50%) and on the increase among women. It is one reason for the high CVD, cancer, and chronic obstructive pulmonary disease morbidity and mortality rates. As strokes and heart attacks were among the priorities identified in the PRA analyses, it was explained to VHCs that tobacco use was one of the main risk factors for these and other diseases, and a health action on tobacco was drawn up Health Action by VHCs A pilot health action on tobacco use was carried out in Chui oblast in VHCs were provided with information material for use during house visits and in public meetings and campaigns. They were also given breath analysers that measure the carbon monoxide content in exhaled breath and can therefore indicate whether and how much somebody smokes. Seeing a test that shows that their blood contains a toxin resulting from smoking is a very useful educational tool and motivates many smokers to try and stop. Special emphasis was put on school sessions to prevent students from taking up smoking. In addition, the project trained FGP/FAP staff in counselling smokers and giving them advice on how to stop. Starting in 2014, this health action will be expanded to the rest of the country 14 and include a special component on nasvai 15. Financing: Kyrgyz - Finnish Project on Tobacco prophylaxis. 14 Expansion to be supported by MoH (Non-communicable disease project WHO), Kyrgyz - Finnish Project on Tobacco prophylaxis and CAH Project/SDC. 15 Nasvai is a paste containing tobacco that is placed between the lips and gums. 22

29 2.8.3 Results Surveys among school students revealed encouraging improvements for many indicators. A number of these are shown in table 5. Table 5: Tobacco-related knowledge and behaviour before and after one year of VHC health action, Chui oblast pilot project with data taken from surveys by the Kyrgyz-Finnish Project on tobacco prophylaxis in 16 schools. School students classes Sample size Knows smoking is bad for health 74% 99% Knows passive smoking is unhealthy 71% 96% Knows tobacco creates dependency 25% 66% Has a friend who smokes 29% 17% Has a family member who smokes 65% 60% Has a family member who smokes inside the house 35% 25% Has tried smoking (school students) 31% 23% 2.9 Iodine deficiency disorders Background The incidence of iodine deficiency disorders has increased greatly since the early 1990s, when salt was no longer universally iodised as in Soviet times. In the mid-1990s, several studies found some 50% of school students to suffer from goitre x xi (see figure 11). During the PRA analysis, goitre was identified as an important health concern by the people of most oblasts Health action by VHCs The iodised-salt health action began with VHCs checking salt in all households using test kits. This has a powerful educational effect: seeing one s kitchen salt turn blue or stay white when tested and being explained the significance of the change leaves a lasting impression. It also helps identify the brands of salt that are typically not iodised. During testing, in addition to being explained the importance of iodised salt, people are also encouraged to ask for iodised salt at the retailers. Most importantly, all retailers are given a test kit and asked to use it at the wholesale market when buying salt to make sure they bring only iodised salt to the village. VHCs periodically check samples of salt to keep up the pressure on retailers to provide only iodised salt; they also renew the test kits of Testing salt for iodine in a small shop 23

30 retailers every six months. This health action was always implemented in the first year of introduction of the CAH programme in an oblast. Financing: CAH Project/SDC Results Table 6 shows the results of VHC salt testing in households in the first year (baseline) and after one year (follow-up). In all oblasts a clear increase in household coverage with iodised salt was observed. In conjunction with efforts by UNICEF and the Asian Development Bank to introduce laws on universal salt iodisation and to build the capacity of salt producers, this VHC health action is highly likely to have contributed to the great decrease in goitre seen xii xiii xiv xv xvi xvii xviii among students (see figure 11). Table 6: Effect of iodised-salt health action on household coverage with iodised salt (data from VHC surveys using test kits; n = number households covered by VHCs during the surveys) Oblast Baseline - follow-up Baseline 1 year follow-up Naryn % (n= 24,961) 98% (n= 28,142) Talas % (n= 29,617) 97% (n= 27,425) Issyk-Kul % (n= 26,794) 90% (n= 27,112) Batken % (n= 41,798) 94% (n= 45,238) Chui West % (n= 34,041) 97% (n= 37,729) Figure 11: Goitre prevalence among school students (age 6-11). Palpation surveys in various regions of Kyrgyzstan, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Bishkek Issyk-kul Osh Jalalabat Naryn Talas Batken Kyrgyzstan 24

31 2.10 Addressing determinants of health A number of donor agencies have collaborated with the CAH programme to address determinants of health, mainly to improve nutrition and the overall economic situation of poor families. During 12 years, the CAH Project SDC/LED has collaborated with VHCs to construct or repair over 200 health related social infrastructure objects, mostly FAPs and bathhouses, but also sport places (outdoor and indoor) and drinking water systems. The World Bank financed one time the distribution of seed potatoes to poor families through VHCs and the World Food Programme has been collaborating with VHCs for several years on their food aid programme. ICCO collaborates with VHCs in Osh on a programme to inform future migrants and those returning for holidays on important matters of health. This includes the information on HIV/AIDS, tuberculosis and about the right of migrants to get treatment at any FGP/FAP at their place of residence. In , the Swiss Red Cross financed a project where VHCs gave 10 hens and a rooster to the poorest female-headed household in each village, as well as material to build a hen house. VHCs contributed by organising the construction of the hen house free of cost. The household heads received training in keeping chicken. VHC members took part in this training to be able to assist where needed. The project resulted in improved nutrition and overall economic situation of these families. After one year, the average number of chicken per household had doubled to 20 and households ate in average 17 eggs per week (3.2 eggs per household member). In addition, about half of households sold eggs for a cash income of about 600 Som 16 per month. About 20% of households also bartered eggs for other goods, such as meat or milk. When egg laying decreased during winter, the consumption and sale of chicken helped to the families to get over these months. Although this temporarily decreased their number of chicken, the following spring they still had in average 40% more chicken than what they had started with. The additional cash income from selling eggs was mostly used for clothes for school, other school items and for food. Moreover, by inviting these women to become members of the VHCs, they often could overcome a certain social isolation, one of them even becoming the VHC leader a year later. These examples show that, aside from addressing defined health issues, the CAH programme offers potential to address broader determinants of health Empowerment of VHCs Own initiatives The organisational capacity and empowerment of VHCs is assessed once yearly by the VHCs themselves (self assessment) as well as by the HPUs (external assessment) using a range of indicators. An important measure of empowerment are own initiatives i.e. activities that are identified, planned and implemented without prompting by an outside agency. The number of own initiatives by VHCs has been rising constantly. Figure 12 shows this for the four regions with the oldest VHCs, for which the oldest data are available. In 2013, the average was 2 initiatives per VHC in these regions. In 2013, all the VHCs from all oblasts combined carried out 2,572 own initiatives, which is about 1.5 per VHC per year USD = SOM on 1 June 2014 (OANDA) 25

32 Figure 12: Number of own initiatives by 699 VHCs in 4 oblasts (Naryn, Talas, Chui, Batken) Number of own initiatives Examples of own initiatives include arranging a meeting room, income-generating measures (for example, growing vegetables on a piece of land provided by the local self-government body, whose proceeds go to the VHC health fund), organising collective work in their villages (for example, picking up litter in streets or planting trees, cleaning water canals), paying for a poor pregnant woman s emergency transport to the maternity clinic, organising a nursery school, celebrating the oldest women in the village by giving them presents, organising the first-ever New Year s party in the village, etc. Such own initiatives address determinants of health and well-being and are therefore an important component of health promotion. The following stories from VHCs give an impression of the range of own initiatives. Monitoring public services A VHC in Batken oblast noticed that the government welfare assistance for poor families was not reaching the poorest families in their village. They confronted the head of the local self-government structure until he agreed to have the list of recipients reviewed by a commission. Now the poorest families are actually on this list. Changing harmful traditions One VHC in Batken was concerned about the huge sums spent on funerals and weddings, as it caused families to fall into debt and become impoverished. The VHC began a discussion about this in the community and over time brought about clearly defined and accepted limits to these expenditures publicly supported by village elders (so-called Ak-Sakals) and local self-government bodies. This spares poorer families the shame of not spending more than they can afford. By sharing this story in meetings with other VHCs, many more VHCs in several oblasts have been able to bring about similar changes. Yr-Kese (singing contest) One VHC had the idea of starting an Yr-Kese in Panfilov rayon of Chui oblast. The Yr-Kese, or singing cup, was passed from VHC to VHC with great joy and success and support from the local self-government bodies and akimiats (district administration). The cup was then handed over to a neighbouring rayon. Within one year the Yr-Kese had passed through all oblasts, bringing together different ethnic 26

33 groups, raising awareness of the VHCs and strengthening their cohesion and collaboration with local authorities. One VHC member described an event in the Den Sooluk gazeta, the VHC newsletter: Representatives of different ethnicities live in our village, Syrt. Various activities are strengthening interethnic harmony. Recently we arranged a Yr-Kese contest. Representatives of the Kyrgyz, Uzbek, Tajik, Russian and Uighur ethnicities all took part in the festival. Even though many different ethnicities participated in the festivities, the participants were able to put on small performances reflecting people s customs and traditions and sang songs in the Kyrgyz language and the anthem of the Kyrgyz Republic to show that they were all citizens of one country. They also sang songs in the language of other participants. The Yr-Kese festival was bright and cheerful and everyone wished for peace and harmony. We have handed Yr-Kese over to the village of Naiman. (A. Joroeva, Too Moyun Village Municipality, Syrt Village) Sport events Sport events organised by the communities also had a positive effect on social cohesion and inclusion in the villages: A sports competition between school students from the villages of Kerme- Too and Communist was recently held by Kyzyl-Kyshtak Ail Okmotu of Kara-Suu Rayon. This fostered interethnic harmony and unity and was also lots of fun. The school administrative bodies helped organize and run the competition. The VHC members and Ail Okmotu prepared prizes for the contestants. More sports events of this kind will facilitate interethnic friendship and help the country live in peace and harmony (Dinara Mamayunusova, VHC of Kerme-Too Village, Kara-Suu Rayon) Advocacy and good governance Most VHCs enjoy a good working relationship with the local self-government bodies. They support many VHC initiatives by providing organisational assistance and resources or funding. In 2014, a project funded by the World Bank will start to involve VHCs in participatory budgeting with their local self-government bodies. This will further increase possibilities for addressing health determinants at the village level. The RHCs are in regular contact with the Family Medicine Centres and the Akimiat to discuss concerns or ask for support. In many rayons the RHC is already a member of the rayon medical council. The AVHC will propose to all RHCs to apply for membership of the rayon medical councils. The AVHC is already a member of the supervisory council of the Ministry of Health. This potential for advocacy by VHCs, RHCs, and AVHC will be strengthened further in the coming years Gender Most VHC members are women (about 90%). There are countless stories of female members who left the confinement of the home for the sake of being engaged in the community. The experience of working with the VHCs taught the women to speak and act in public more self-confidently. Many of these women have become respected leaders in their villages. A gender study by the CAH programme ix found that the programme provides a platform for women to seek and gain new roles in community management. 27

34 3 Lessons learnt and sustainability Enabling circumstances for the development and expansion of the CAH programme in Kyrgyzstan are: A supportive Ministry of Health. All ministers and key staff of the Ministry of Health recognised the need for health promotion and the importance of investing in it. They also, importantly, supported the idea of involving communities in health promotion, although this was different from the traditional health propaganda or sanitaryhygienic education of Soviet times. When the pilot projects proved successful, the Ministry of Health included the programme s expansion in the health reform plan and established the necessary HPUs in all oblasts. The support and financing by the Ministry attracted the support of further donor agencies. The progressive health reform strategy, supported by the government, the Ministry of Health and donor agencies, with an emphasis on strengthening primary health care, created an environment highly supportive of health promotion and new ideas. Within the health reform, the establishment of the RCHP as a separate entity from the Department of Sanitary-Epidemiological Surveillance (SES) was probably helpful by creating the space needed for a new understanding of health promotion to take hold and for strong ownership to develop. The early policy of decentralisation embarked on by Kyrgyz governments, and the general desire of the Kyrgyz people to build a democracy encouraged attempts to build and strengthen civil society. The CAH programme s approach of setting up independent groups in each village was a good fit for this framework. A very flexible main donor agency (SDC), allowing for experimentation and allocation of resources according to people s priorities. Elements of the CAH programme design that seem important for its success are: Starting with people s priorities: instead of establishing people s priorities on the basis of a sample survey, a broad participatory PRA exercise was conducted, involving a large part of the population (several thousand sessions per oblast). This left people with the feeling that they were being listened to (often expressed with astonishment and gratitude after the PRA sessions). It also, as importantly, changed the perceptions of FGP/FAP staff, who realised that often lay-people are perfectly capable of correctly analysing the relative importance of different diseases and their determinants; for the first time, staff learned to see people not as passive objects who need to be taught what is good for them, but as active subjects who are a resource and partner in the fight to improve health. Designing health actions according to the priorities identified by people gave the programme credibility and increased volunteers readiness to become involved, as they felt the programme took their opinions seriously. As this booklet shows, most of the priorities identified by ordinary people were also the main priorities for the public health system. However, basing health actions on people s priorities opened the door and created goodwill to start health actions not identified by the people but by the Ministry of Health. Early results of these health actions won support from donors and the health system for longer-term investments. 28

35 The above health actions aside, the CAH programme also put great emphasis on organisational capacity building to help VHCs become independent civil society organizations. This convinced the VHCs that the programme actually wanted them to be capable of pursuing their own agendas, which increased their interest and sustainability. It also boosted their motivation to carry out health actions. And implementing the health actions and receiving positive feed-back and recognition, enhanced the organisational strength of VHCs. Thus, the two components mutually enhanced each other. Encouraging the VHCs to seek support from and collaborate with the local selfgovernment bodies meant that they had another local partner besides the FGP/FAPs and HPUs. This relationship, and the link between the RHCs and the akimiats, will be increasingly important for addressing determinants of health. Using Appreciative Inquiry in various ways helped with learning from best practices, harnessing new ideas developed anywhere in the system and incorporating a strength-based approach into the continuous development of the CAH programme. Especially the sharing of good ideas, experiences and success stories among VHCs and HPU staff is greatly facilitated by the story-telling approach of Appreciative Inquiry. Finally, the CAH programme s heavy emphasis on non-dominant behaviour by staff vis-à-vis VHCs has been crucial to establishing a relationship of equal partners with the VHCs; it gives the VHC members the respect, confidence and recognition needed to take on new tasks, grow into new roles, and develop leadership capacities. It is one of the many reasons why these volunteers are motivated to offer their time and effort for the benefit of the community. The CAH project, funded mainly by SDC, will end in March SDC was the initiator and main supporter of the CAH programme. It has put in place the main building blocks needed to ensure the programme s sustainability: a high level of institutionalisation in the health system, with the capacity at all levels to cooperate with VHCs (HPUs in rayons and oblasts, and RCHP); a country-wide network of VHCs that are strong, community-based civil society organisations, united at the rayon and national levels and recognised as valuable partners by local self-government bodies, rayon administrations and international donor agencies. On this basis the AVHC now needs to continue expanding its capacity to attract partners and sustain itself. The RCHP needs to find ways to preserve the experience and know-how gained among HPU staff and in the RCHP itself. In addition to continuing to finance quarterly training sessions for VHCs by HPUs, the Ministry of Health should broaden its support to include the financing of information material for those health actions that are of highest priority of the Den Sooluk health reform programme, which are not yet supported by donor agencies. In conclusion, the CAH programme in Kyrgyzstan demonstrates that a partnership between community based organisations and a governmental health system is possible, is beneficial to both sides, and can be scaled up to a national level. The CAH Programme also shows that community empowerment processes and centrally designed health campaigns with measurable health outcomes can be combined and can mutually strengthen each other. 29

36 References i ii iii iv v vi vii viii ix x xi xii xiii Melitta Jakab, Elizabeth Lundeen, Batkygul Akkazieva (2007). Health System Effectiveness in Hypertension Control in Kyrgyzstan, Policy Research Paper 44, Center for Health System Development, Ryskul B. Kydyralieva (2013). The State of Cardiovascular Disease in the Kyrgyz Republic, Central Asian Journal of Global Health, Vol. 2, No. 1 (2013) Tobias Schueth, Ziauddin Hyder, Melody Tondeur (2007). Report on a study with weekly dosage of sprinkles for 6 months in Kyrgyzstan, 2005, Kyrgyz-Swiss Health Reform Support Project, 2007 Republican Centre for Health Promotion/Community Action for Health Project, representative cluster survey in all oblasts, 2013 Elizabeth Lundeen, Tobias Schueth, Nurjan Toktobaev, Zlotkin S., Hyder S.M.Z., Houser R., (2010). Daily use of Sprinkles micronutrient powder for 2 months reduces anemia among children 6 to 36 months of age in the Kyrgyz Republic: A cluster-randomized trial, Food and Nutrition Bulletin, 2010, (31)3 UNICEF/CDC/Kyrgyz-Swiss-Swedish Health Project (2010). Follow-up survey of nutritional status of children 6-24 months of age, Talas oblast, Kyrgyz Republic, 2010 UNICEF (2006). Monitoring the Situation of Children and Findings from the Multiple Indicator Cluster Survey, Kyrgyz Republic, National Statistical Commitee of the Kyrgyz Republic; Elizabeth Lundeen, Master Thesis Nutrition Scientist Program, 2010, Kyrgyz-Swiss- Swedish Health Project Julian Walker, Gender Analysis of the CAH Programme, University College of London, 2010 Sultanalieva RB, S. Mamutova (1998). Endemic goitre in Kyrgyzstan. Materials of International Symposium on Iodine Deficiency Conditions, Tashkent 1998 Housten R, B. Rashid, H. Kalanzi (1994). Rapid assessment of iodine deficiency in Kyrgyzstan: Report of consultative visit. Bishkek, Kyrgyzstan: UNICEF, 1994 Rosa Sultanalieva (2006a). Iodine Deficiency Diseases in Kyrgyzstan. Dissertation. Kyrgyz-Russian-Slavian University Bishkek. (original Russian title: Ioddefitsitnye zabolevaniya v Kyrgyzstane) Rosa Sultanalieva (2006b). Prevalence of goitre among school students in Issyk-kul, Kyrgyz-Swiss-Swedish Health Project. Project Document xiv Rosa Sultanalieva (2007). Prevalence of goitre among school students in Issyk-kul, Kyrgyz-Swiss-Swedish Health Project. Project Document. xv xvi Rosa Sultanalieva (2008). Report on provision of iodine to children and pregnant women in Kyrgyzstan. UNICEF Kyrgyzstan Project Document. Tobias Schueth, Rosa Sultanalieva (2006). The effect of test kits in the hands of communities and retailers on urinary iodine excretion. Prospective study among 1800 school students in Jalal-abad and Talas oblasts. Kyrgyz-Swiss Health Reform Support Project. Project Document

37 xvii Tobias Schueth (2008). Power from below test kits in the hands of Kyrgyzstan retailers pressure producers to iodize salt; IDD newsletter 29, August 2008: xviii Tobias Schueth, Tolkun Jumanalieva, Shaken Janikeeva, and Temir Tologonov (2005). Power from below: Enabling communities to ensure provision of iodated salt in Kyrgyzstan, Food and Nutrition Bulletin 26 (4): ;

38

39

40