ABSTRACT
INTRODUCTION: The Central Asian republics of the former Soviet Union gained their independence in 1991. Soon after this event, reforms in health care were planned in many of these countries. In Kyrgyzistan, the reforms included a mandatory health insurance system, a new provider payment system, licensing and accreditation, a national drug policy and rationalization of ambulatory services. Multi-profile policlinics, or family medicine group practices were established. Reforms in health care are not always accompanied by changes in medical education, and so medical knowledge may lag behind that in other countries. This is especially prominent in rural areas, where new practices and regulations may arrive late, and are often misunderstood. The reforms in Kyrgyzistan necessitated a change in undergraduate medical education. The educational reform consisted of a unification of the separate tracks for pediatrics, medicine and public health into one track of general medicine; the introduction of teaching of patho-physiology according to body systems; the establishment of clinical clerkships; and a proposal for rotating internship. METHODS: World Health Organisation sent teams to Kyrgyzistan to work with the local committees as facilitators for the implementation of the health-care reform. This paper is based on the experience of the authors in conducting two such missions directed at the synergistic reform in medical education. RESULTS: VISIT 1: Changes to the curriculum were suggested. It was decided not to recommend teaching in rural primary care settings at that stage, due to logistical difficulties. This subject was to be addressed at a later stage because medical services in rural areas were scarce. VISIT 2: Among other interventions, the encouragement of doctors to practice in rural areas was discussed in detail, but the teachers of the medical school were not receptive to the idea of sending medical students to rural clinics. This was to be addressed at some time in the future. CONCLUSION: The changes were aimed at facilitating the introduction of family medicine as a specialty and strengthenning primary care, although measures to incorporate rural practice in the reform proved difficult to achieve. Reform in medical education can only be justified if it will contribute to the improvement of the health of the population. In order to achieve this goal, the production of better physicians must be assured. In Kyrgyzistan, it was hoped that improved graduates would be the resource for the development of family medicine as a recognized specialty, with the potential to improve the health status of the whole population.
ABSTRACT
A written policy is an essential starting point for any administration. Objectives and targets should then be established and strategies to achieve these objectives should be developed. This general approach is also recognized in Turkey, but the policy formulation process is not linked to implementation. The administration does not feel obliged to work according to a plan. Another reason for not adhering to the policy could be that some of the policy principles and targets are too ideal and unrealistic. The targets and objectives are consciously set at an unachievable level to motivate the health workers, but this discourages the health administrators. Services are not evaluated routinely, and the data collected are not processed into usable information and are therefore not used in decision-making. Decisions are usually based on the previous experience of the individuals involved in the policy formulation process or on political will. The high turnover of administrators at the national and provincial levels of the Ministry of Health is another major barrier to adopting and implementing the health policy. If the core of administrators is not stable, a stable policy cannot be established. One of the obstacles to progress was the poor communication between the newly developed Project Coordination Unit and the well established general directorates of the Ministry of Health. Each directorate is autonomous: all deal with different issues. The Unit functions overlapped in many ways with those of the general directorates. This created an awkward situation for them, and sometimes they felt left out from decisions that affected them profoundly. The Unit reports to the undersecretary of state and the minister; therefore, the link with the general directorates was intended to be established through these offices, but sometimes this linkage failed, which resulted in duplication of decisions and activities. Instead of working together towards a common goal, which would strengthen their efforts, they usually work separately. The future is not easy to predict. Change is still needed, but the political environment and level of stability cannot be foreseen. The new Government is pursuing reform activities. The Grand National Assembly has not yet discussed the proposed legislation. New discussions will start at the Assembly, and the policy could be reformulated as a result. This may take some time, which will delay the process. One can hope that the achievements attained so far will be considered and built upon.
