Socially-oriented primary health care in Kyrgyzstan: Family doctors and nurses learn from Kazakhstan’s person-centred model of care
Primary health care services in Kyrgyzstan have a strong medical orientation. Inspired by the model in neighbouring Kazakhstan, family doctors and nurses in two regions are paying more attention to social determinants of health – and linking people up with appropriate services.
In early 2020, Dr Janara Toksonbaeva – the Deputy Director of the Osh Family Medicine Centre – was inspired by what she saw during a visit to Polyclinic No. 5 in Almaty, Kazakhstan.
‘In Kyrgyzstan we used to look at a person’s illness, prescribe medications and send them home,’ she recalled recently. In Kazakhstan, she saw an entirely different way of working – one that considers the whole person: ‘They have social workers, psychologists and home health visitors on their teams, which means they can consider social problems as well as physical ones. People are covered from all angles from the moment they walk through the door.’
Janara Toksonbaeva could see the benefits of this approach in both the positive health outcomes and the high levels of patient satisfaction. She left Kazakhstan confident that a similar system could be created in her country.
‘Socially vulnerable’ individuals with complex needs often slip through the cracks
Over the next three years, with support from the Promotion of Primary Health Care project – implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of Germany’s Federal Ministry for Economic Cooperation and Development (BMZ) – Janara Toksonbaeva and other Kyrgyz doctors, nurses and health managers embarked on a novel experiment: testing out elements of the person-centred integrated care model they observed in Kazakhstan at the Family Medicine Centres where they work.
Such an approach is urgently needed in Kyrgyzstan. Family doctors and nurses often see patients whose health is affected by social, psychological or legal problems they face in their daily lives: A grandmother who struggles to manage her high blood pressure, and lives in crowded conditions with her daughter and two disabled grandchildren who are not registered for social assistance. A single mother of two, anxious about an unwanted pregnancy and lacking the passport she requires to enrol in the national health insurance scheme and access free maternity care. A schoolboy whose mother frequently requests that he be written off sick from school due to stomach pains, but is unaware that he is being bullied by his classmates.
These and other ‘socially vulnerable’ individuals have complex needs which require coordinated inputs from the health system, on the one hand, and social service agencies, on the other. In practice, however, they tend to fall between the cracks. Primary health care workers are not trained or mandated to screen individuals for social vulnerability. And when they encounter patients who clearly require support – for example, for substance use disorders, homelessness or gender-based violence – they are essentially on their own.
Sometimes, if it was obvious that someone needed help, we would try to do something using our own personal contacts, but there was no system.Janara Toksonbaeva, Osh Family Medicine Centre
Kazakhstan’s integrated model of care inspires Kyrgyz visitors
Neighbouring Kazakhstan has built a primary health care system which successfully overcomes the divide between health and social services. As Janara Toksonbaeva and dozens of other Kyrgyz health officials, managers and health care practitioners have seen firsthand during German-supported visits to Kazakhstan, primary health facilities there excel at providing multi-disciplinary, integrated care.
Strengthening person-centred care is a top priority of Kyrgyzstan’s national health reform strategy, Healthy Person – Prosperous Country. ‘The Ministry of Health had already looked at primary health care systems in several different countries before we went to Kazakhstan,’ explains Sardarbek Karimov, a technical advisor with GIZ who helped to organise the first study tour, in 2019, which was hosted by the World Health Organization’s European Centre for Primary Healthcare in Almaty. ‘When we got there, we were shocked,’ he continued. ‘We realised that what we’d been looking for was right next door.’
Primary health care leaders from Kazakhstan show the way
When Kyrgyz health officials expressed interest in adapting elements of the Kazakh approach in pilot health facilities in Chuy and Osh, Dr Roza Abzalova and a team from the Kazakh National Association for Primary Health Care agreed to lend their expertise.
Working in cooperation with GOPA Worldwide Consultants, under the auspices of the Promotion of Primary Health Care project, the Kazakh experts trained more than 400 doctors and nurses from the two regions on social determinants of health. They also led workshops on socially-oriented primary health care for hundreds of local government officials, educators, social workers and NGO staff – all of whom are part of the social service ecosystem, but do not generally coordinate their work with health institutions.
Roza Abzalova and her team were impressed by the enthusiasm with which the ideas of socially-oriented primary health care were received.
We observed a great desire to introduce new approaches and social work practices, particularly among doctors and nurses. They grasped very quickly the practical benefits which would result.Roza Abzalova, Kazakh National Association for Primary Health Care
Getting the basics in place: Screen, assess and refer
After the initial trainings, the team from Kazakhstan coached groups of family doctors and nurses at the pilot facilities to introduce elements of social work into their daily practice.
They taught nurses how to screen individuals for signs of social vulnerability during routine consultations, and how and when to undertake home visits to assess people’s living conditions and family circumstances firsthand. They introduced ‘eco-maps’ – a popular social work tool for visualising a person’s key relationships and influences – and showed how these can be used to create individual plans for addressing people’s needs.
The Kazakh experts also helped staff at Family Medicine Centres to determine when it is feasible for them to manage and follow-up a person’s case themselves, working as a multi-disciplinary team, and when more specialised assistance is required. They worked with staff from the pilot health facilities to develop local referral pathways for different categories of socially vulnerable individuals. These ‘algorithms’ were created in cooperation with representatives of local government, social welfare departments, law enforcement agencies, education departments and NGOs. For the first time, they make transparent what types of cases should be handled where and contribute to better intersectoral cooperation at the local level.
These standard procedures quickly proved their worth: in September 2022, several thousand displaced residents from the Batken region of Kyrgyzstan descended on Osh following border clashes. The staff at the Family Medicine Centre provided medical and social services in a coordinated manner. Thanks to the initial work which had been done, Janara Toksonbaeva and her colleagues had the tools they needed to screen, assess and refer large numbers of people. They knew exactly which types of services were available where, had the names and numbers of the relevant contact people, and could efficiently direct people to the right places for help.
Whose job is it? Two regions, two different approaches to the organisation of social care
The idea of socially-oriented primary health care is compelling, but the question of how it should be coordinated, and by whom, is complicated. Family doctors and nurses in Kyrgyzstan have heavy workloads and low salaries; their formal job descriptions are limited to clinical tasks. Thanks to a directive from the Ministry of Health, which allowed for a revision to job descriptions, the pilot facilities had the flexibility to think about how best to ‘staff’ this new area of work.
The management of the Chuy Regional Family Medicine Centre, in northern Kyrgyzstan, decided to bring in expertise from outside. It hired two social workers and a psychologist to join a multi-disciplinary team alongside the family doctors and nurses. Following a case management approach, they provide counselling to patients identified as needing support, make home visits, and accompany individuals to appointments, where necessary. Since earlier this year, 40 cases have already been opened.
‘It was not easy at first,’ admits Svetlana Byrda, one of the social workers. ‘Not all the health staff understood why social workers were needed. It has taken time to establish teamwork and mutual cooperation.’ Despite teething pains, Dr Rufina Kozhobekova, the Deputy Director of the FMC, regards the social workers as a big advantage for the health facility – and notes that feedback from patients has been positive.
I would like to see social services remain at the primary health care level and the number of social workers increase. With sustained work over time, I am sure we will achieve very good results from this model.Rufina Kozhobekova, Chuy Regional Family Medicine Centre
The Family Medicine Centre in Osh took a different approach. Here, the managers created a new position – a Social Coordinator, designated from among the existing medical staff – whose role it is to act as the interface between the health facility and social service providers in the community. When doctors and nurses identify someone in need of help, they bring the case to the attention of the Social Coordinator, who then handles the referral process. Since May 2022 the Social Coordinator in Osh has referred nearly 400 individuals to local organisations and agencies. Follow-up takes place during regular meetings of an intersectoral coordination committees, which the Social Coordinator also attends.
Seeing the whole person © GIZ/Maxime Fossat
A novel effort has born first fruit. Political support is needed to continue the journey.
Bringing social work concepts into primary health care settings is something quite new for Kyrgyzstan. While not without its challenges, the pilot effort was largely embraced by doctors, nurses, local government officials and social workers who recognise the potentials of closer integration – and have now had an opportunity to try it out in practice.
These initial experiences have been documented and shared with the Ministry of Health, whose political support will be essential for taking the approach forward. ‘This model can provide a lot of benefits in terms of quality of services and optimisation of human and financial resources,’ says Cholpon Asambaeva, who heads the Promotion of Primary Health Care project. ‘We have shown this at a small scale, and are convinced that it can be built upon in the future.’