Achievements in Implementation of VI MCH CARK Forum Recommendations

1. MCH CARK ForumVII Annual Meeting Achievements in implementation of VI MCH CARK Forum recommendations November 5-7, 2003, Almaty, Kazakhstan

2. Recommendations of the VI MCH CARK Forum on reduction of Infant and Child Mortality • To adopt international criteria of live birth in pilot regions, improve registration and reporting system; • Early neonatal period – to provide and ensure safe motherhood and healthy pregnancy; • Late neonatal and post-neonatal periods – to introduce IMCI program, program of micronutrients disorders prevention; • Inter-sectoral issues – to conduct a survey on accessibility and quality of health care services at primary health care level

3. The Kyrgyz MOH Decree № 338 as of 27.09.01 «On transition to WHO recommended criteria of live birth and stillbirth» is being implemented, in accordance to which, registration of the infants born is performed with the use of official criteria of live birth in parallel with WHO recommended criteria

4. Infant Mortality Rates (IMR) by official statistics and application of WHO recommended criteria, Kyrgyz Republic (9 months of 2003) IMR with application of WHOecommended criteria IMR by official statistics 21,4 Kyrgyz Rep 19,4 Bishkek City 21,3 26,5 Chui Oblast 14,8 20,1 Talas oblast 22,7 23,2 Naryn Oblast 20,7 21,1 13,7 15,9 Issyk-Kul Oblast Osh Oblast 22,2 22,9 Batken oblast 20,3 20,7 Jalal-Abad Obl 19,1 19,9

5. ·The MOH Decree №511as of 11.12.02 «On Transition to WHO recommended criteria of live births and stillbirths in pilot regions» is implemented; Chui oblast and Bishkek City are identified as pilot regions; - 8 seminars were conducted, 200 specialists were trained, including: Ob-Gyns, neonatologists, pediatricians, pat-morphologists, medical statisticians, health care system managers; -the following equipment was provided to pilot regions: electronic scales, mucus exhaust devices, Ambu bags, kits for pat anatomic autopsy of low weight newborns;

6. Perinatal Mortality Rate in Pilot Regions by official statistics and application of WHO recommended criteria of live birth, 8 months 2003 % Growth Official statistics WHO criteria Kyrgyz Republic 24,7 36,0 45,7 Bishkek City 23,8 35,3 48,3 Kyrgyz Research Institute of Obstetrics 43,2 58,5 35,4 Chui oblast 21,9 32,2 47,0

7. Nationwide transition to international definitions,related to perinatal period, is planned for January 1, 2004. • The following preparatory work is being done: • Inter-Sectoral Working Group has been established; • National Statistics Committee has reviewed Program of converting of IMR taking into account WHO recommendations; • The Ministry of Justice jointly with Ministry of Interior are implementing activities aimed at improvement of reliability and accuracy of registration of children born and died

8. The Ministry of Health (MOH) has revised the registration-reporting system, medical documentation, related to perinatal period, taking into account WHO recommendations, which are introduced in all health care facilities of the republic; seminars were conducted to train specialists in their use in practice; • Clinical Protocols on Low-Weight Babies care are being developed; • National Program on Perinatology is being initiated

9. Logistic of maternity health facilities of the republic is being upgraded: • -with support of WB, ADB, Kyrgyz-Swiss Health Reforms Support Project, repair works have been completed in 124 health care facilities, including maternity ones; • Under the «Protection of Mother’s and Child’s Health Project II», the German bankKFWhas supplied medical equipment to maternity institutions in the south of the country; • -The same project plans to supply medical equipment to maternity health facilities in the north of the country in 2003-2004.

10. The draft of the Resolution of the KR Government «On modification of national statistics due to transition to international definitions,related to perinatal period»is being discussed with ministries and agencies • On the 5th of November 2003 a Review Meeting is being held with participation of the KR Government representatives, interested Ministries and agencies, international organizations, where the results of introduction of international definitions, concerning perinatal period, in pilot regions will be discussed, as well as perspectives for their expansion nationwide will be considered

11. Provision of safe motherhood and healthy pregnancy is the main objective to reduce the level of infant mortality in early neonatal period • The work on introduction of Initiative for Promoting of Effective Perinatal Care (PEPC) is continued • At present, the Program is introduced in Chui Oblast, Bishkek City (City Perinatal Center, Maternity House # 1), trainers are trained, training sessions are conducted • Monitoring ofPEPC at maternity institutions in Chui Oblast is being conducted

12. PEPC Initiative is integrated into USAID/HOPE «For Survival of Children» program (2003 - 2006), it is planned to introduce it in 2 rayons of Jalal-Abad Oblast (Bazar-Korgon and Aksyi); • Main principles of PEPC Initiative are incorporated into the curricula of the Kyrgyz Medical Academy (KMA), Kyrgyz State Medical Institute of Training and Retraining (KSMIT&R); • 46 Clinical Protocols on Pregnancy Management, Physiological Labor and Main Types of Obstetric Pathologies have been developed and approved.

13. The Program of Initiative Baby Friendly Hospitals is being implemented (IBFH): • 14 maternity health institutions were certified in the republic, 5 more maternity departments are prepared for internal certification and 1 – for re-certification in the year of 2003; • The issues of Breastfeeding are incorporated into training and retraining of Family Doctors, Curricula of the KMA and KSMIT&R; • 4 Clinical Protocols on Basic Care of Newborns and Intensive Therapy have been developed on WHO standards and approved; • Normative-Legal framework of maternity health facilities is being reviewed to meet WHO recommendations

14. As a result of activities, conducted in the area of safe motherhood and healthy pregnancy, the overview of the year 2002 has indicated that in the republic and especially in Bishkek City and Chui oblast, almost no purulent-septic cases in women in childbirth are registered;the rate of infections among newborns, specific for perinatal period, has decreased almost by 2 times. The Maternity Mortality Rate has stabilized in the republic and for 9 months of 2003 it comprised – 52,0 (9 months of last year – 52,8)

15. 9 months 2003 9 months 2002 Kyrgyz Republic 52,0 52,8 Bishkek 53,4 24,0 Chui oblast 54,7 58,5 Talas Oblast 149,6 117,5 Naryn Oblast 19,7 62,0 Issyk-Kul Oblast 102,4 81,0 Osh Oblast 29,7 35,1 Batken Oblast 42,0 73,7 Jalal-Abad Oblast 51,9 49,9 Maternal Mortality Rate, Kyrgyz Republic, 9 months of 2003 (per 1000 livebirths)

16. IMCI Program in the republic is recognized as the main component of the National Policy for Reduction of Infant Mortality level in neonatal and post-neonatal periods and Child Mortality: • Since 2000 the Program has being implemented 3 pilot rayons (Aravan, Jail, Jety-Oguz), results of implementation were discussed at Review Meeting in April 2003 with participation of UNICEF, WHO/EURO. The results of the program implementation are evaluated as successful and since 2003 the program has been expanded to 2 more rayons (Moskovskyi and Tyupskyi);

17. Coordination Centre under the Research Institute of Obstetrics and Pediatrics for Monitoring and Evaluation of IMCI Program implementation has been established; • IMCI Coordinators and trainers of pilot rayons are trained in IMCI master course in Child’s Care; a Plan of Actions is developed in introduction of this course in five pilot rayons; • IMCI Program is integrated in USAID/HOPE Project «For Children’s Survival» (2003-2006), introduction of the IMCI program has been started in Bazar-Korgon and Aksyi Rayons of Jalal-Abad oblast;

18. In pilot IMCI rayonsmedicinesare supplied by different projects; • At the national level medicines, used for IMCI, are included into the Essential Drug List; • IMCI issues are incorporated into the program of training and retraining of Family Doctors, paramedical staff, curricula of Kyrgyz State Medical Academy, Kyrgyz State Medical Institute of Training and Retraining; • Training and retraining of Family Doctors and Paramedical Staff from pilot rayons is given priority

19. IMCI program implementation has considerably affected the general structure of IMR in the republic: • - In 2003 Morbidity of Respiratory Organs Diseases has dropped by 21,4% compared to 2000, and Infectious and Parasitic diseases – by 40,2%; • For the given period,mortality of children of the first year of life of Pneumonia has decreased: • in Jayil rayon - by 9,3% (2000 -3,2; 2002 – 2,9), • in Aravan rayon – by 4 times (2000- 7,5; 2002- 1,9); • in Jety-Oguz – by 41% (2000 –4,4, 2002 – 2,6)

20. Causes of Infant Mortality in Kyrgyz Republic, 2000-2002, (%) 2000 2002 +\- Respiratory Organs Diseases 34,6 27,2 -21,4 Perinatal Conditions 33,1 46,4 40,1 13,9 8,3 -40,2 Infectious and Parasitic Diseases Congenital Anomalies 8,9 9,7 9,0 Other 9,5 8,4 -11,5

21. Immunization coverage rate against vaccine manageable infections has reached the level of 95-98%. Supply of vaccines from the Republican (National) budget in 2003 has comprised 18,2% (2001- only 10,9%). To achieve the National Vaccine Independence in future, the Kyrgyz Republic has developed the Financial Sustainability Plan of the National Immunization Program (NIP) for the Years of 2003-2008, which envisages participation of local budgets, incorporation of part of the NIP funding into the budget of National Strategy for Poverty Alleviation, toughening of control of vaccine stocks and immunization activities.

22. Iodine Deficiency Prevention: • The Kyrgyz Government Resolution № 836 as of 26.12.02 has ratified the National Program for reduction of Iodine Deficiency Disorders (IDD) level in population of the Kyrgyz Republic for the Years of 2003-2007; • The draft of the Government Resolution on establishment of Department of Fortified Food Products is currently being reviewed; • Association of Salt Producers of the Kyrgyz republic has been organized;

23. Control of content of iodine in imported, produced and sold salt is conducted: • -The joint MOH and State Custom Inspection Decree was issued on enforcement of control of imported salt quality; • - Normative–technical documents concerning salt productionhave been standardized; since 2002 a unified standard for Iodine concentration at the level of 40 mkg/kgfor fortified salt is introduced; • 50 labs of State SES are equipped with one wave spectrophotometers to do rapid test of quantitative content of iodine in salt

24. Prevention of Iron Deficiency and Vitamin A Disorders • Studies on assessment of spread of Vitamin A Deficiency (VAD) in the republic were conducted, which detected the problemof VAD in women and children under 5; • -The National Program for Prevention of Iron Deficiency Anemia and VAD among the Kyrgyz Republic population for the years of 2003-2007 has been developed and is to be approved soon; • - The issues of prevention of Iron Deficiency Disorders are incorporated into Curricula and training programs of KMA, KSMIT&R; • - Clinical Protocols on Prevention and Treatment of Iron Deficiency Anemias are currently reviewed

25. With support of ADB and UNICEF, the Kyrgyz Republic Government has implemented the following activities in the area of iron fortification of wheat flour: • At present, 10 flour-grinding enterprises are functional in the republic (in all oblasts, except Naryn and Issyk-Kul), producing iron fortified flour; • Due to small production capacity, flour-grinding enterprises manage to supply only 10% of the population with fortified flour instead of 33% planned for the year of 2003;

26. Work with medical community and general population to increase the level of awareness about methods of micronutrients disorders prevention: • Seminars for Family Doctors and SES Specialists are being conducted in all regions of the republic on issues of Iodine and Iron Deficiency Disorders prevention and Lab control of quality of food salt and fortified flour; • In March-April last year, the MOH jointly with ADB, UNICEF, Kyrgyz-Swiss Health Project and USAID, with support of the Ministry of Education and Culture, TV and Radio, has conducted Informational campaign aimed at increase of the of population’s awareness level about methods of micronutrients disorders prevention.

27. During the Campaign the following activities were conducted: • Sessions and programs on TV and radio; • Competition for the best session on TV, radio, and best article in newspaper; • Theater performances for schoolchildren population; • Dictations, expositions for schoolchildren; • Methodical recommendations for School teachers were developed;

28. Huge work is being performed in the area of social mobilization of population with support of local authorities and communities; • The following organizations are involved in education and training of population in methods of Micronutrients disorders prevention: • Health Committees, established at the community level (experience of the Jumgal Rayon, Naryn oblast under the Kyrgyz - Swiss Health Project); • Initiative Groups in rural areas, organized under the DFID/Rural Hygiene and Sanitation Project (Naryn, Issyk-Kul and Talas Oblasts); • NGOs and Public Organizations (Jalal-Abad, Chui, Talas Oblasts)

29. Results of monitoring of the activities, performed in the area of Micronutrients Disorders Prevention, have shown: - Analysis of more than 16 thous. samples of salt has demonstrated that % of deviation from the norm has dropped down to 17% (in 2001 – this indicator was 48%); - The amount of salt which does not meet GOST standard and is consumed by the population dropped down to 30 thous. tons (2001- 150 thous.tons); - Thanks to local salt production, the % of supply of the population with quality salt has increased up to 35-37% versus 12-17% in 2001;

30. In June – August 2003survey on accessibility and quality of Primary Health Care (PHC) services for mothers and children was conducted in the Kyrgyz Republic. Findings of the survey will be used by the MOH when developing Program for Improvement of PHC Accessibility and Quality for the population of the Kyrgyz Republic.

31. HIV/AIDS spread is a topical issue for the republic. As of today, 470 infected cases are registered, there are 3 cases of birth of children to HIV infected mothers. However, there are no developed Clinical protocols in the republic, medications necessary for HIV infected treatment are not registered in the republic yet. Specialists were trained in Vertical transmission in Odessa City, Ukraine;Working Groups is established to develop National Program;Clinical Protocols are being adapted.

32. Recommendations of the VIannual meeting of CARK ОЗМиР were taken into consideration when activities related to MCH for 2003 were planned and implemented in the Kyrgyz Republic. However, such factors as low social – economic status of the population, scantiness of financial resources, inadequate quality of medical care impede implementation of activities aimed at protection of mothers and children’s health to the full extend.