Thousands of interdependent, overlapping pieces make up Kyrgyzstan’s Community Action for Health network. It’s easiest to explain the overall system by describing its unique actors and institutions, broken into two interconnected halves. There is formal health promotion – government-run organizations embedded in the primary care system in the Kyrgyz Republic – and informal health promotion – volunteer-based, non-profit organizations located in communities throughout the country. Now, about those pieces:
Village Health Committees
A Village Health Committee, or VHC, is a community-run non-governmental entity focused on health promotion activities on a person-to-person level. Made up of mostly women, these organizations offer advice on a variety of community health concerns – everything from brucellosis to prenatal nutrition to HIV – and operate in 1700 villages throughout Kyrgyzstan. They work to engage local partners, and are the main implementers of national health initiatives, as well as locally-driven “own initiatives” determined by the community’s needs. Often, VHCs partner closely with village-level primary care facilities called FAPs.
Rayon Health Committees
A Rayon Health Committee, or RHC, is a communication platform for VHCs. RHCs consist of VHC representatives, and meet semi-regularly to discuss challenges, successes, and needs for capacity development across the rayon level. These organizations are platforms for training and best-case practice sharing, but are becoming more responsible for the implementation of rayon-wide planning and health actions.
Association of Village Health Committees of Kyrgyzstan
The Association of Village Health Committees of Kyrgyzstan, or AVHCK, is a relatively new institution in Kyrgyz Health Promotion, and is the national governing body of all 1700 VHCs. The main role of the AVHCK is to improve the capacity of VHCs, working in coordination with the Republican Centre for Health Promotion to provide organizational support and direction. Still figuring out what that means and how to do it, the AVHCK works closely with the Swiss Red Cross (the founder of the Community Action for Health) and meets annually with the General Assembly of VHCs. The AVHCK is essentially a handful of dedicated and hardworking people in Bishkek, and is one of my primary work sites where I work on organizational development, strategic planning, data analysis, and program design.
Health Promotion Units
Health Promotion Units, or HPUs, are the main local actor for the formal, government-run health promotion structure, responsible for the management and training of VHCs. HPUs are the main implementers of new health projects, based around a monthly health promotion schedule, as well as monitors and evaluators of projects. They regularly travel to the 35-50 VHCs they manage to provide resources, training, and develop VHC capacity. HPUs can be divided into two categories – Oblast HPUs and Rayon HPUs. The 130 Rayon HPUs are tasked with managing their region’s VHCs, and the 22 Oblast HPUs are responsible for managing and training the Rayon HPUs.(Kyrgyz Geography is confusing.)
Republican Centre for Health Promotion
The Republican Centre for Health Promotion, or RCHP, is the federal agency responsible for health promotion in Kyrgyzstan. It manages and monitors projects, develops health curriculum for schools, and collects data on health issues in the country. A part of Kyrgyzstan’s Ministry of Health, this organization is the primary implementing partner of any international development project focused on health education, promotion, or behavior change. The RCHP provides training, resources, pamphlets, and the financial and organizational support for HPUs (though any financial support is likely to be from international donors or projects.) This organization’s specialty is designing pamphlets and posters around health issues, with varying success. It is the RCHP’s goal to integrate health promotion into primary care facilities, so that health promotion and primary care become a set of comprehensive health services for Kyrgyzstani communities. Located in Bishkek, the RCHP is one of my primary work sites where I work on program design, training, and organizational development.
Primary Health Care in the Kyrgyz Republic
Both of these systems work with Kyrgyzstan’s primary care facilities, all funded by the State Guaranteed Healthcare Package – a tax-based budget guaranteeing basic healthcare to all citizens. Essentially, Krygyzstan has a universal, single-payer healthcare system, and like the Soviet system, primary care facilities are determined by population size.
Larger cities have hospitals, smaller cities have Family Medical Centers, or FMCs. FMCs are essentially clinic cooperatives, hosting several specialists or departments and offering retinue of basic services to citizens – anything from dentistry to physical therapy. HPUs are housed in Family Medical Centers.
In smaller cities (or large villages) are Family Group Practices, or FGPs, that are essentially less-equipped, smaller versions of FMCs, offering fewer services.
In villages and rural areas with sparser populations, there are Feldsher-Obstetrician Points, or FAPs. A feldsher is like an American Nurse Practitioner, licensed to provide some basic medical services, but is not a doctor, and they usually (but not always) work with a nurse or midwife to provide care for a village’s pregnant women or new mothers. Often, FAPs and VHCs work together, sometimes as a single organization, but there are many villages that host only FAPs or only VHCs.
In terms of accessing care, most Kyrgyzstani people will choose to go to a larger, better-staffed hospital for medical services. The Kyrgyz health system is not known for its adherence to patient confidentiality, so many people will leave their village or rayon if they are seeking care or advice for a potentially embarrassing or seemingly shameful condition. In Kyrgyzstan, that can be anything from HIV to diabetes to anemia to an abortion. People are not limited to where they can access healthcare, so it is common to travel to seek medical care. And, since the fall of the Soviet system, independent, private clinics are becoming more and more popular for those who can afford it, though prices are often far beyond the capacity for most of Kyrgyzstan.
Now, showing how all of these pieces interrelate to create a comprehensive, national system for health promotion is a more difficult task entirely, especially considering how the program is designed to act, and how it actually works.
*A quick note on Kyrgyz geography: regions of land are classified and managed using the old Soviet system. Oblasts are equivalent to American states, and rayons are comparable to counties, each with their own government. Kyrgyzstan has 7 oblasts – Batken, Osh, Jalal-Abad, Naryn, Talas, Chui, and Issyk-Kul – and two cities considered independent of the oblasts – Osh in the South, and the capital, Bishkek. Here’s a Kyrgyz map!