Building sustainable health systems: experiences, challenges and recommendations for EECA countries

In recent years, health issues have become key points on the agenda of many countries in Eastern Europe and Central Asia (hereinafter – EECA). The need to build strong and sustainable health systems has gained particular urgency, driven not only by current challenges, such as the COVID-19 pandemic but also by long-term public health concerns.

As part of its efforts to highlight health issues, our team conducted surveys in Georgia, Kazakhstan, Kyrgyzstan, and Moldova. Participants were representatives of civil society organizations covering a wide range of topics, from HIV and harm reduction to migration and oncology. The survey instrument was consistent with the methodology used by the Civil Society Engagement Mechanism (CSEM) and partners from civil society organizations around the world.

Key aspects of health status in the countries listed above

Georgia:

Both positive and negative aspects were identified in the context of UHC in Georgia. Limited awareness and participation in UHC policies, despite positive feedback on the Universal Health Program (UHP), require increased attention.

Positive points:

• Participation in budget planning: civil society actively allocates funds for government programs, including HIV.
• Collaboration with government agencies: LGBTQI+ organizations ensure inclusive access to health care.
• Telemedicine: online clinics provide access to health services, emphasizing technological potential.

Issues and challenges:

• Structural barriers: overcoming stigma and criminalization of drugs.
• Lack of targeted services: addressing the needs of key communities.
• Additional costs: addressing financial barriers for vulnerable groups.

Kazakhstan:

There are positive aspects of health care in Kazakhstan, including coordination with government structures. However, financial constraints, limited access to health services when income is lost, and insufficient budget monitoring pose challenges in ensuring access for various key groups. This context emphasizes the need for additional efforts to improve the health system and ensure universal coverage.

Positive points:

• Skills development of health staff: investment in education and leadership among nurses and midwives is globally recognized.
• Coordination and collaboration: structural units of government and the president’s office are actively collaborating, coordinating ministries, and engaging with parliament.

Issues and challenges:

• Inadequate funding: limited funds for diagnosis, treatment, and medicines create financial difficulties for patients.
• Monitoring and transparency: insufficient monitoring by civil society and unclear budget utilization create challenges in effective resource management.
• Gender service challenges: restrictions in access to contraceptives and lack of free services for menopausal women, as well as limited access to gender-specific services.
• Lack of services for certain groups: problems in providing medical care for cancer.

Kyrgyzstan

Despite successes in reforms, the country faces challenges such as underfunding, limited access to health care, and inadequate infrastructure.

Positive points:

• International cooperation: supports improvement of primary health care facilities.
• Community councils: linked to ministries, provide monitoring and accountability.
• Increased health awareness including HIV.
• Dedication of health staff ensures a high level of patient care.
• Increased pandemic preparedness and training improves response to health crises.

Issues and Challenges:

• Limited engagement with government agencies: makes it difficult to protect civil society rights.
• Stigma and discrimination: against marginalized groups, including HIV-positive people, limit access to health care.
• Lack of funding: limits the ability of civil society organizations to address health issues.
• Lack of participation in policy development: limits the influence of civil society.
• Political instability: creates uncertainty and disrupts the continuity of health initiatives.

Moldova

Despite improvements in overall health coverage, the main challenge remains limited funding, preventing full implementation of policies and programs to improve the quality and accessibility of health services.

Positive points:

• Collaboration with government: effective collaboration with various departments of government emphasizes a collective approach to addressing health challenges.
• Advocacy activism: participation in campaigns and policy changes demonstrates civil society’s persistence in the health sector.
• Impact monitoring: civic groups are actively monitoring the impact of changes in the health system.
• National Health Agency: its role in policy-making demonstrates a structured approach to public health initiatives.

Issues and challenges:

• Stigmatization: high levels of stigma in the community and among health personnel.
• Punitive approaches in legislation: barriers such as criminalization of drug use and HIV affect key populations.
• Lack of integration: uncoordinated health and social approaches that force people to seek services from multiple agencies.
• Discrimination in health care: barriers, including discrimination against non-binary people, make access to health care difficult, especially for people at risk of HIV.

Key recommendations in achieving UHC in the countries of the EECA region

• Identify a coordinating mechanism for UHC:

The issue of a coordinating government agency or mechanism to promote Universal Health Coverage is decided at the MOH and agency level. However, communities active in HIV may not have a clear idea of who is doing the UHC work.

• Systematic advocacy collaboration:

Advocacy collaboration with government ministries outside the health sector in all countries in the region is characterized by fragmentation.

• Priority areas for health collaboration:

Primary health and social care services and territorial dispensing offices for ARV, OST, and their analogs are the highest priority for developing further cooperation in health.

• Level of quality of health services:

All countries in the EECA region lack standards and a unified approach to regulating the quality of services. Differences in the quality of services strongly depend on nosology and population group.

• Community awareness:

In Georgia and Kazakhstan, participants noted a lack of awareness of UHC monitoring. In Moldova, only state accountability mechanisms are highlighted, and in Kyrgyzstan, they note the abolition of community councils, which used to serve as accountability mechanisms.

• Priority areas for investment:

Prevention, reduction of patients’ expenses, and staff training and retention are recognized as the most important areas for health sector development.

• Opportunities for participation of population and organizations in planning and monitoring:

In the EECA region, there are opportunities for participation in budgetary processes at both national and local levels. However, in some countries, participation is often limited by formal inclusiveness, uncertain mechanisms, and the complexity of the process, resulting in a lack of civil society engagement.

A combination of these recommendations, with the active interaction of donors, government agencies, and NGOs, can become the basis for building modern, sustainable, and inclusive health systems in EECA countries.

Also read:

• Analysis of procurement of rapid tests and test systems for HIV monitoring in Kyrgyzstan and the Republic of Moldova (2021-2022): challenges and recommendations
• The power of civil society in ensuring Universal Health Coverage: the Health for All Advocacy Toolkit