Data from the first phase of the research showed that the GFATM had a positive impact on capacity building for human resources (HR) involved HIV/AIDS activities32. Appropriation of grant funds contributed significantly to increasing the total number of personnel working in the field of HIV/AIDS, particularly in the nongovernmental (NGO) sector. New categories of staff such as “social workers” and “outreach workers” emerged and started to deliver services. Both the GFATM and CAAP grants have also been used to provide training for HIV/AIDS workers. The data suggest that training provided with GFATM funds improved knowledge and professional skills of staff in various AIDS-service organizations.
This Chapter presents an analysis of data collected since 2007, identifying new trends and factors that are facilitating/hindering further development of HR for effective delivery of HIV/AIDS services.
8.1 The human resources context in the Kyrgyz health system
Human resources (HR) for health in the Kyrgyz Republic have exhibited the following characteristics since 2003-2004:
Decrease in the total supply of health personnel that reinforces a geographic imbalance. In 2003-2004, staff supply was characterized by a decrease in the total number of doctors and nurses in the country. This process was associated with external economic factors: some doctors left the health care sector in search of higher earnings, whilst others practised private medicine and continued a second job in public health organizations. At the same time, growing internal migration was also observed as health specialists started to migrate to Bishkek capital and adjacent Chui oblast, and
occasionally other oblast centers. This reinforced an imbalance in regional distribution of HR33
Prior to 2003, the supply of doctors and nurses in the KR as well as other CIS countries was high, and so the subsequent decrease in total numbers of personnel did not cause serious concern. Additionally, within the framework of the current health system reforms (where one of the goals was improved efficiency of health organizations‟ performance) some small planned reductions/redistributions of working (predominately, middle-level and junior) health personnel were undertaken34. Based on 2006 data, in all oblasts except Bishkek and Osh, the supply of doctors was below the average (19.9 per 10,000 population) – 12.7 to 16.9 per 10,000 population, and in some rural areas as low as 6.8 – 9.1 per 10,000 population.35
Substantial growth of external migration of health professionals. Since 2004, annual HR outflow from the healthcare system has exceeded inflow. The situation escalated dramatically because of the rapid growth of external labor migration of health
32
See Interim Report, April 2008.
http://chsd.studionew.com/index.php?option=com_content&task=view&id=73&Itemid=96&lang=english
33
Joint annual review of the Manas Taalimi Health Sector Reform Program, Human Resources Component, September 20-29, 2006.
34
Policy Research Paper #30. Evaluating Manas Health Sector Reforms (1996-2005): Focus on Restructuring. http://chsd.studionew.com/index.php?option=com_content&task=view&id=73&Itemid=96&lang=english
35
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professionals (doctors: 2004 – 3%, 2005 – 8%; nurses: 2004 – 2,9%, 2005 – 5,6%)36. In2007, 1,086 doctors left the healthcare system, including 225 doctors who left the
republic37. In part, this process started to happen because of changes in the HR policy of neighboring countries such as Russia and Kazakhstan. These countries have increased their salaries, especially for doctors and nurses; and they have a more beneficial social package and working conditions. Furthermore, migration of doctors is highest in southern regions of Kyrgyzstan (Osh, Jalalabat and Batken oblasts), and in the north of the
country (Issyk-Kul oblast). A survey of 243 doctors38 countrywide demonstrated dissatisfaction in respect to such factors of labor activity as salary size (82,7% of
respondents) and incentive systems (63,8%). Of particular concern was the high level of readiness by health workers to migrate outside the republic. For example, 62,1% of young doctors and 44,6% of middle-age doctors planned to leave the country in the 12 months period following the survey.
Lack of doctors at PHC level. Kyrgyzstan has been implementing systematic health care reform that focuses on family medicine development, and integration of separate services that used to be delivered by vertical, specialized services at PHC level (including HIV/AIDS services). These reforms have increased the demand for HR. In 2009, there is a HR shortage in PHC, particularly in the regions, and the continuing migration of health personnel is increasing the workload of PHC doctors. For example, the percentage of PHC doctors caring for 2,000+ people increased from 58% in 2004 to 81% in 200739 (in some cases the workload per doctor is as high as 5-7,000 people). Inevitably, this has a negative impact on accessibility and quality of healthcare.
Inadequate salary scales for health personnel. Salaries in the health sector are some of the lowest compared to other economy sectors in the country. Although health reforms have increased salaries several times, the overall level remains very low. For example, the average monthly salary of a doctor is 3,040 som (US$77) – below the minimum consumption level of 3,364.66 som (US$85) per capita per month40. To meet the needs of their families, health professionals usually have to take on a second job, often in a non-medical profession. In rural areas, the majority of doctors try to maintain a plot of land that in itself demands considerable costs.
One of the additional income sources for health personnel are informal payments made by patients. In Kyrgyzstan, as well as in many other countries with transition economies, the level of informal payments in the health sector is quite high. Research has shown that health-financing reforms have in recent years reduced informal payments,
particularly for drugs and medical supplies41. However, the volume of payments to health personnel increased by 18%, particularly in oblast centers and Bishkek city. This fact highlights the need to make further political reform at the national level.
36
Express analysis of medical personnel migration for the period 2004-2006. Prepared by HR Department of the MoH, September, 2006.
37
Data of the MOH, KR
38
Kojokeev K., Murzalieva G., Manjieva E. Policy Research Paper #51 «Exploring reasons for doctors outflow from the Kyrgyz health care system», 2008, http://chsd.med.kg
39Report on Mid-Term Review of the Kyrgyz National “Manas Taalimi” Health Care Reform Program, May 7,
2008.
40
Data from National Statistics Committee for the 1st quarter of 2008.
41 Jakab and Kutzin. Policy Research Paper «Trends in informal payments for 2001 – 2006 years», 2008,