Getting Kyrgyz women the antenatal care they’re entitled to: Closing the gap between paper and practice
Pregnant women in Kyrgyzstan are entitled to a basic package of antenatal care services through the country’s national social health insurance. Yet accessing these services can be like navigating an obstacle course. A German-supported project is raising women’s awareness of their rights and making it easier for pregnant women who are uninsured to get covered.
Dr Rufina Kozhobekova is thrilled that she no longer needs to send patients away empty-handed. Many of the pregnant women she sees at the Chuy Regional Family Medicine Center are anemic, but until recently only some of them left her office with prescriptions for discounted iron supplements and folic acid. The others, who were not yet enrolled in Kyrgyzstan’s national social health insurance, had to wait – sometimes for a month, or even longer, until paperwork made its way from the Family Medicine Center to the local office of the Mandatory Health Insurance Fund (MHIF) and then back again. Given how important micronutrient supplements are for healthy pregnancies, especially in the early stages, these lost weeks could have critical consequences.
Now when Dr Kozhobekova and her colleagues see uninsured pregnant women, they can enroll them directly with the MHIF through a new digital registration software. ‘Literally the same day we can write an e-prescription for folic acid or iron supplements and the woman can get it filled, using her new policy number,’ she explains. ‘We used to spend a lot of time, energy and resources on paperwork. Now we don’t have to print anything, we don’t have to drive anywhere, and there is no more waiting.’ Even more importantly, removing this barrier builds women’s trust in the health system and makes it more likely that they will return for further antenatal visits.
Barriers to antenatal care can be deadly for mothers and babies
Speeding up the insurance enrolment process is just one of several interventions which the Promotion of Primary Healthcare in Kyrgyzstan project has been supporting in the Chuy and Osh regions of Kyrgyzstan to connect pregnant women with timely, good quality antenatal care. Implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ), the project seeks to improve the quality of clinical services at the primary health care level and to improve pregnant women’s access to the basic package of services to which they are legally entitled.
This is urgently needed. Kyrgyzstan has one of the highest maternal mortality rates in Central Asia and, despite years of health system reforms and investments in maternal and child health, maternal deaths have declined much more slowly in Kyrgyzstan than in neighbouring countries. Many of the factors contributing to maternal deaths – as well as to high stillborn rates and to the large proportion of neonatal deaths linked to prematurity – can be traced back to the primary care level. These include poor nutrition among adolescent girls and women of reproductive age, a lack of systematic family planning interventions, low prevalence of contraceptive use, antenatal care services of inadequate quality, and weak referral systems for pregnant women experiencing complications.
In Osh region, where the German-supported project has been working for several years to strengthen patient-centered integrated care for pregnant women, an analysis of recent maternal death cases was revealing. ‘We saw that most deaths occurred among vulnerable pregnant women who did not register with a health provider on time, who came late for antenatal care, or for some other reason did not get the standard eight antenatal visits,’ says Sadarbek Karimov, a technical advisor with the project. ‘Different types of barriers in the community and in health facilities are preventing women from getting the full package of care. We are trying to remove these and to close the gap between what exists on paper and what happens in practice.’
Outreach workers inform pregnant women about their rights and link them to care
All pregnant women in Kyrgyzstan are entitled to a package of maternity services and benefits – including antenatal visits, assisted delivery, postnatal care and discounted supplements and medications – as part of the so-called State Guaranteed Benefit Package. However not all women are aware of this – or know how to go about claiming these services. At the Family Medicine Center in Chuy, for example, a survey found that nearly one-quarter of Dr Kozhobekova’s pregnant patients did not know that women in Kyrgyzstan were entitled to free maternity benefits.
The problem is particularly acute among adolescents and among women who do not work outside the home and are therefore not enrolled with the Mandatory Health Insurance Fund, as people employed in the formal sector automatically are.
To address this gap the Promotion of Primary Healthcare project has been working with the Kyrgyz Family Planning Alliance (KFPA) to inform pregnant women about their rights to care. The KFPA has designed and mounted an information campaign via both traditional and social media to raise awareness of the maternity services covered under the State Guaranteed Benefit Package. It has also trained six outreach workers to provide direct counselling and advice to pregnant women in four districts of Chuy and Osh region where there are high proportions of vulnerable women. Since July 2022 these outreach workers have met individually and in small groups with more than 2,200 women, providing them vouchers which they can take to their primary health facility to become registered for antenatal care.
The outreach workers not only explain what services they are entitled to and when, but why these are important for both mother and baby. They take women and their family members through the different checks and tests which will be done when and clarify what these can show and the types of risks they can identify.
‘Overall the work of the outreach workers has shown good results,’ said Baktygul Bozgorpoeva, the head of the Kyrgyz Family Planning Alliance. ‘This is partly because they already had experience working as health care providers or members of Village Health Committee and are comfortable engaging with members of the community.’
In just over six months, more than 7000 women get faster access to insurance coverage
It is one thing to get women to come to health facilities for care, and another thing to make sure they get what they are coming for – without paying for it out of pocket. This is where the new electronic registration system comes in.
In the past, if an uninsured woman was confirmed to be pregnant, the doctor or nurse would fill out a special application form and attach a copy of the woman’s passport to it. When enough applications had piled up, a nurse would make a special trip to the closest MHIF office to submit the paperwork. A week or two later, they would get a call to return and pick up the insurance cards. In rural areas this procedure was particularly onerous, given the longer distance that needed to be travelled to reach the MHIF office.
‘Quality antenatal care depends on the timely registration of pregnant women and on mandatory medical insurance,’ says Klara Oskonbaeva, Deputy Chairperson of the MHIF. ‘We saw than an online registration system could make this process quicker and easier.’
The new software – developed in cooperation with MHIF, with support from the project and GOPA – was introduced on a pilot basis in four facilities in Chuy and the 12 branches of the Osh Family Medicine Center in November 2022. Since that time, more than 7000 uninsured women have been directly enrolled with the MHIF. The experiment has been so successful that the MHIF has decided to introduce it countrywide, starting in August 2023 – not only for pregnant women, but for other uninsured individuals as well.
The on-site registration has immediate and very concrete consequences in terms of women’s access to discounted micronutrient supplements, which have been identified in a recent systemic review as the single intervention which could save the most maternal lives and prevent the most stillbirths in Kyrgyzstan. However the benefits go far beyond this to include blood tests, urine tests and ultrasounds at key stages of pregnancy. Without an MHIF policy number, women are required to pay for these services out-of-pocket – something many women in Kyrgyzstan, where one-third of the population lives under the national poverty line, are not in a position to do.
Not only does the new registration system improve pregnant women’s access to care, but it also enhances communication and data management within the MHIF. ‘The online registration module is integrated with other MHIF information systems,’ explains Klara Oskonbaeva. ‘This makes it easier for us to produce reports about the coverage of pregnant women, for example, and to generate data which MHIF working groups can use to improve the mandatory insurance for pregnant women.’
Important progress, but challenges remain within health facilities themselves
While the project was quite successful in mobilising pregnant women to seek care, it is clear that more needs to be done within health facilities themselves to clarify the provisions of the benefit package among those who are responsible for delivering it. ‘We realised that health workers themselves are poorly informed about which services are supposed to be covered,’ Baktygul Bozgorpoeva explains. ‘As a result they cannot adequately counsel pregnant women about the services to which they are entitled.’
Antenatal visit at Osh FMC
© GIZ/Maxime Fossat
Together with the KFPA, the project has started bringing together representatives of the regional MHIF offices in Chuy and Osh with representatives of the regional departments of health and the heads of Family Medicine Centers to address these questions at the local level. They arranged, for example, for MHIF staff to visit FMCs and speak directly with doctors and nurses to better understand the context in which they are providing maternity services. They also organised trainings and information sessions for doctors and nurses to familiarise them with the provisions of the State Guaranteed Benefit Package so that the information being provided to women in the community is mirrored in the health facilities themselves.
Revisions to the benefit package are underway – and a joint communication campaign is in the works
In a relatively short time, the project has notched some important achievements in motivating women to seek care and in easing their way into insurance coverage. However much remains to be done until this coverage is translated into universal access to antenatal services at low cost.
One dimension relates to the quality of care. Here, the project is supporting quality improvement committees in FMCs, developing clinical protocols for antenatal care, training doctors and nurses in counselling skills, and helping to revise job descriptions so that basic antenatal care checks can be performed by nurses as well as doctors.
Another area of focus is the revision of the State Guaranteed Benefit Package – a process currently underway with support from the World Bank and the World Health Organization. A revised package is expected to be approved by the end of 2023. ‘It will specify the services which should be provided for pregnant women, mothers and newborns at every level of the health system,’ explains Damira Seksenbaeva, a technical advisor with GIZ who is contributing to the revision process. ‘It will then be up to health facilities to procure the equipment and supplies needed to deliver them, or to enter into contracts with other health organisations to so on their behalf.’
Once the new package is agreed, there is an urgent need for up-to-date, accessible information for both health service users and health service providers about the package’s contents. Materials aimed at patients need to be written in simple, understandable language; dense, official language is another barrier to care which needs to be dismantled.
In a positive development, a national-level working group of communications officers from the MHIF, the Ministry of Health and the Ministry of Labor and Social Protection is already planning integrated communications activities. Health promotion materials, social media posts and other information products will be cross-checked and cross-promoted to ensure consistency in messaging and content. The Promotion of Primary Health project is part of this effort, too.
An improved registration process, direct outreach to pregnant women, and a revised maternity benefit package – these are just some of the ways in which German development cooperation is helping to untangle Kyrgyz women’s pathways into antenatal care and supporting them to claim their rights.