The Kyrgyz health care reform program was encompassed in a 10 year systematic plan called the “Manas National Program on Health Care Reforms 1996-2006.” The Manas program represented the Kyrgyzstan political will for reform and enabled the technical and aid organizations that worked in the health sector during this time. A driver of the reforms was the process by which Kyrgyz health partners worked seamlessly with WHO, World Bank, and USAID.
The Kyrgyz health care reform program was encompassed in a 10 year systematic plan called the “Manas National Program on Health Care Reforms 1996-2006.” The Manas program represented the Kyrgyzstan political will for reform and enabled the technical and aid organizations that worked in the health sector during this time. A driver of the reforms was the process by which Kyrgyz health partners worked seamlessly with WHO, World Bank, and USAID. These donors/agencies worked to their comparative advantages with WHO contributing to health policy and monitoring and evaluation, the World Bank establishing framework conditions and equipment/commodities, and USAID providing implementation support for the first pilot in Issyk-Kul and its expansion throughout the country. The first phase of reform from 1996 to 2000 introduced the Mandatory Health Insurance Fund (MHIF) and emphasized the strengthening of primary health care.
During the first phase of reforms, primary health care was strengthened by restructuring to create a new primary health care sector and service delivery improvements including introduction of family medicine and new clinical practice guidelines. First, primary care was separated from hospital care by establishing Family Group Practices (FGPs) to which patients would freely enroll for services. As the budget collapsed, hospitals were starving primary health care and the idea was to separate primary health care to create autonomous PHC practices in which general doctors (family practitioners as well as internists, pediatricians, and ob/gyns) could practice under one roof in a new entity with improved management and potential to increase the scope of more cost-effective primary health care services. This was an important step, since Kyrgyzstan had no family physicians prior to 1995. FGPs were supplied with equipment, improved management and health information systems, and with necessary drugs for emergency care and maternal and child health, thereby expanding the population’s access to health services in appropriate settings. Second, family medicine training was institutionalized at the undergraduate and postgraduate levels. In 1998, the first long-term training program was formed with the creation of two family medicine residencies. Continuous training programs were also put in place for practicing doctors. Approximately 65% of doctors and nurses participated in retraining programs. Finally, 162 clinical protocols were developed and introduced on the basis of evidence-based medicine in addition to the evidence-based standards introduced through WHO programs such as Integrated Management of Childhood Illnesses (IMCI). This process of institutionalizing family medicine took place with the help and expertise of several technical and aid organizations.
In 1997, the payroll tax for health was introduced along with the MHIF, which would function as an obligatory social insurance scheme. The MHIF was created as a parastatal social insurance fund under The Government of Kyrgyzstan. During the first three years of its operations, coverage increased to 30% of citizens, largely workers and former workers or pensioners. When the national government started to fund contributions for children and social welfare recipients, coverage increased up to 70% in 2000 and 83% in 2001. During this first phase of reforms, the primary benefit of the MHIF was that it led to a gradual introduction of the institutional mechanisms necessary for a full transition to output-based purchasing mechanisms in an environment that had been fundamentally input-based. The MHIF started to contract with some providers and facilities, and new reimbursement procedures (capitation based payments to primary care facilities and case-based payments to hospitals) were introduced. Initially the new provider payment systems only contained variable costs (e.g. drugs, supplies, food, and staff bonuses), in order to ensure that health facilities had time to adjust and that the small amount of payroll tax funding benefited the population most effectively, while ensuring that the reforms would be visible. The first few years of the reforms functioned primarily as a learning period for the new institutions within the health system.
The second phase of reforms from 2001 to 2004 focused on incorporating budget funds into the nascent health financing reforms. MOH and MHIF leadership recognized that conflicting financial incentives in the new payroll-tax-funded and budget-funded provider payment systems had caused the health financing reforms to hit a ceiling. The health budget input-based provider payment systems still rewarded maintaining excess capacity and there was also a growing risk of fragmenting the population by insurance status thus undermining universal coverage. The MHIF was merged under the MOH and it became the single-payer for the new State Guaranteed Benefit package, incorporating revenue from budget, payroll tax, and population copayments. This second phase was implemented in geographic areas step-by-step, beginning in two oblasts, gradually expanding to the rest of the country at the rate of two oblasts per year. The goals of the second phase were achieved through four primary mechanisms.
- Oblast, rayon, and city tax revenues allocated to health were pooled at the oblast level into oblast purchasing organizations, thereby reducing resource fragmentation. Budget funding was included in the MHIF as single-payer and the revenues were supplemented by the payroll tax collected by the MHIF. This change allowed for a cross-subsidization between city and rayon borders which had been impossible before. Furthermore, by 2006 these oblast pools were centralized into one national purchasing pool, opening the possibility for wider cross-subsidization at the national level.
- Unified output-based provider payment systems were introduced for both budget and payroll tax funding. Instead of the previous line-item payments, outpatient care would now be paid on a capitation basis and hospitals would be paid on a per-case basis. Such changes solidified and enhanced the financial incentives to restructure and downsize the excess capacity and overstretched facilities of the Soviet era initiated by the MHIF payment systems using payroll tax funding.
- The reform program established an explicit set of entitlements known as the State Guaranteed Benefit Package (SGBP). This package established free primary care for all citizens and specialized care with copayments. The copayments consist of relatively few categories and a flat fee and they vary with insurance status, exemption status, and the type of case. The copayment categories are prospective such that patients know their copayment before accessing services. An important motivation in instituting this reform was the prevalence of informal payments, which were a holdover from the Soviet health system and had expanded rapidly since independence and collapse of the health budget.
- It was necessary to downsize hospital capacity and restructure the service delivery system. Most Soviet hospitals had been built as agglomerations of 15-20 small buildings, so downsizing facilities was relatively easy. Unnecessary buildings were demolished, rented out, or transferred to alternate uses. By 2004, hospital sector real estate capacity had been reduced by approximately 46%. This downsizing took place within a cooperative arrangement whereby the MHIF, the Hospital Association, and a consulting company worked closely with hospitals in order to create successful restructuring plans. This shift in priorities from specialized/hospital care to primary care led to an important increase in primary care spending. From 2001 to 2005 the share of government spending on health care devoted to primary care increased from 11% to 25%. Corresponding reductions in utility costs were critical to the allocation of additional resources to direct patient care and became more important to the sustainability of the health system over time as the price of utilities increased rapidly.
In 2005, the MOH started developing a successor program (third phase) to the initial Manas scheme. The new program, known as Manas Taalimi, aims to institutionalize the reforms that took place under the first round of reforms. It also aims to strengthen facets of the health system that were not as actively emphasized during the Manas program. More specifically, Manas Taalimi seeks to incorporate public health and medical education into the reforms; base the content of clinical practice on evidence; strengthen services for groups with worse health outcomes; enhance the capacity of the MOH in policy formation, budget planning, and monitoring and evaluation; and strengthen the quality of care for priority health interventions in MCH, CVD, TB, and HIV.
Table 1: Chronology of events and legislation in the health sector
| Date | Event |
|---|---|
| August 1991 | Declaration of independence in Kyrgyzstan |
| 1993 | Introduction of user fees |
| March 1994 | Memorandum of Understanding between WHO Regional office for Europe and the Ministry of Health of the Kyrgyz Republic to undertake the MANAS Health Care Reform Programme |
| Ministry of Health requests technical assistance from USAID for a primary health care demonstration project in Issyk-Kul oblast | |
| August 1994 | National Health Policy approved by the government |
| November 1996 | Government approves MANAS Health Care Reform Programme |
| World Bank funded Health Project (1996-2000) started in Kyrgyzstan (Bishkek and Chui oblasts) | |
| January 1997 | Introduction of the mandatory health insurance system in Kyrgyzstan |
| July 1997 | MHIF introduces case-based payment to hospitals |
| 1997-1998 | Rolling out of primary health care reforms to Chui, Jalal-Abad, and Osh oblasts and Bishkek |
| November 1998 - March 1999 | FGPs enrolment campaign in Chui oblast and Bishekek |
| Jan 1999 | Introduction of capitation payment to FGPs in Bishkek |
| April 1999 | About 55 hospitals and 290 FGPs enter into contracts with the MHIF |
| January 2001 | Government decree on introduction of a new health care financing mechanism in health facilities of Kyrgyzstan since 2001 |
| Government decree on programme of state guarantees on provision of free and exempt health care to citizens of Issyk-Kul and Chui oblasts in 2001 | |
| Government decree on population's co-payment for drugs, meals and certain types of health services rendered by health facilities besides the program of state guarantees on provision of free and exempt health care to citizens of Issyk-Kul and Chui oblasts in 2001 | |
| February 2002 | Government decree on provision of health care to citizens of Kyrgyzstan under the State Benefits Package since 2002 |
| March 2002 | Maryn and Talas oblasts join the single payer system |
| March 2003 | Batken, Jalal-Abad and Osh oblasts join the single payer system |
| November 2003 | Republican facilities join the single payer system |
| July 2004 | Law on the Single Payer System in Health Care Financing in the Kyrgyz Republic |
| March 2005 | Popular uprising and subsequently new government elected |
| February 2006 | Government approves "Manas Tallimi" Health Care Reform Programme 2006-2010 |
Source: Adapted from Falkingham, J., Akkazieva, B., and Baschieri, A.
Mandatory Health Insurance Fund (MHIF)
Program Summary
The Kyrgyz health care reform program was encompassed in a 10 year systematic plan called the “Manas National Program on Health Care Reforms 1996-2006.” The Manas program represented the Kyrgyzstan political will for reform and enabled the technical and aid organizations that worked in the health sector during this time. A driver of the reforms was the process by which Kyrgyz health partners worked seamlessly with WHO, World Bank, and USAID. These donors/agencies worked to their comparative advantages with WHO contributing to health policy and monitoring and evaluation, the World Bank establishing framework conditions and equipment/commodities, and USAID providing implementation support for the first pilot in Issyk-Kul and its expansion throughout the country. The first phase of reform from 1996 to 2000 introduced the Mandatory Health Insurance Fund (MHIF) and emphasized the strengthening of primary health care.
During the first phase of reforms, primary health care was strengthened by restructuring to create a new primary health care sector and service delivery improvements including introduction of family medicine and new clinical practice guidelines. First, primary care was separated from hospital care by establishing Family Group Practices (FGPs) to which patients would freely enroll for services. As the budget collapsed, hospitals were starving primary health care and the idea was to separate primary health care to create autonomous PHC practices in which general doctors (family practitioners as well as internists, pediatricians, and ob/gyns) could practice under one roof in a new entity with improved management and potential to increase the scope of more cost-effective primary health care services. This was an important step, since Kyrgyzstan had no family physicians prior to 1995. FGPs were supplied with equipment, improved management and health information systems, and with necessary drugs for emergency care and maternal and child health, thereby expanding the population’s access to health services in appropriate settings. Second, family medicine training was institutionalized at the undergraduate and postgraduate levels. In 1998, the first long-term training program was formed with the creation of two family medicine residencies. Continuous training programs were also put in place for practicing doctors. Approximately 65% of doctors and nurses participated in retraining programs. Finally, 162 clinical protocols were developed and introduced on the basis of evidence-based medicine in addition to the evidence-based standards introduced through WHO programs such as Integrated Management of Childhood Illnesses (IMCI). This process of institutionalizing family medicine took place with the help and expertise of several technical and aid organizations.
In 1997, the payroll tax for health was introduced along with the MHIF, which would function as an obligatory social insurance scheme. The MHIF was created as a parastatal social insurance fund under The Government of Kyrgyzstan. During the first three years of its operations, coverage increased to 30% of citizens, largely workers and former workers or pensioners. When the national government started to fund contributions for children and social welfare recipients, coverage increased up to 70% in 2000 and 83% in 2001. During this first phase of reforms, the primary benefit of the MHIF was that it led to a gradual introduction of the institutional mechanisms necessary for a full transition to output-based purchasing mechanisms in an environment that had been fundamentally input-based. The MHIF started to contract with some providers and facilities, and new reimbursement procedures (capitation based payments to primary care facilities and case-based payments to hospitals) were introduced. Initially the new provider payment systems only contained variable costs (e.g. drugs, supplies, food, and staff bonuses), in order to ensure that health facilities had time to adjust and that the small amount of payroll tax funding benefited the population most effectively, while ensuring that the reforms would be visible. The first few years of the reforms functioned primarily as a learning period for the new institutions within the health system.
The second phase of reforms from 2001 to 2004 focused on incorporating budget funds into the nascent health financing reforms. MOH and MHIF leadership recognized that conflicting financial incentives in the new payroll-tax-funded and budget-funded provider payment systems had caused the health financing reforms to hit a ceiling. The health budget input-based provider payment systems still rewarded maintaining excess capacity and there was also a growing risk of fragmenting the population by insurance status thus undermining universal coverage. The MHIF was merged under the MOH and it became the single-payer for the new State Guaranteed Benefit package, incorporating revenue from budget, payroll tax, and population copayments. This second phase was implemented in geographic areas step-by-step, beginning in two oblasts, gradually expanding to the rest of the country at the rate of two oblasts per year. The goals of the second phase were achieved through four primary mechanisms.
- Oblast, rayon, and city tax revenues allocated to health were pooled at the oblast level into oblast purchasing organizations, thereby reducing resource fragmentation. Budget funding was included in the MHIF as single-payer and the revenues were supplemented by the payroll tax collected by the MHIF. This change allowed for a cross-subsidization between city and rayon borders which had been impossible before. Furthermore, by 2006 these oblast pools were centralized into one national purchasing pool, opening the possibility for wider cross-subsidization at the national level.
- Unified output-based provider payment systems were introduced for both budget and payroll tax funding. Instead of the previous line-item payments, outpatient care would now be paid on a capitation basis and hospitals would be paid on a per-case basis. Such changes solidified and enhanced the financial incentives to restructure and downsize the excess capacity and overstretched facilities of the Soviet era initiated by the MHIF payment systems using payroll tax funding.
- The reform program established an explicit set of entitlements known as the State Guaranteed Benefit Package (SGBP). This package established free primary care for all citizens and specialized care with copayments. The copayments consist of relatively few categories and a flat fee and they vary with insurance status, exemption status, and the type of case. The copayment categories are prospective such that patients know their copayment before accessing services. An important motivation in instituting this reform was the prevalence of informal payments, which were a holdover from the Soviet health system and had expanded rapidly since independence and collapse of the health budget.
- It was necessary to downsize hospital capacity and restructure the service delivery system. Most Soviet hospitals had been built as agglomerations of 15-20 small buildings, so downsizing facilities was relatively easy. Unnecessary buildings were demolished, rented out, or transferred to alternate uses. By 2004, hospital sector real estate capacity had been reduced by approximately 46%. This downsizing took place within a cooperative arrangement whereby the MHIF, the Hospital Association, and a consulting company worked closely with hospitals in order to create successful restructuring plans. This shift in priorities from specialized/hospital care to primary care led to an important increase in primary care spending. From 2001 to 2005 the share of government spending on health care devoted to primary care increased from 11% to 25%. Corresponding reductions in utility costs were critical to the allocation of additional resources to direct patient care and became more important to the sustainability of the health system over time as the price of utilities increased rapidly.
In 2005, the MOH started developing a successor program (third phase) to the initial Manas scheme. The new program, known as Manas Taalimi, aims to institutionalize the reforms that took place under the first round of reforms. It also aims to strengthen facets of the health system that were not as actively emphasized during the Manas program. More specifically, Manas Taalimi seeks to incorporate public health and medical education into the reforms; base the content of clinical practice on evidence; strengthen services for groups with worse health outcomes; enhance the capacity of the MOH in policy formation, budget planning, and monitoring and evaluation; and strengthen the quality of care for priority health interventions in MCH, CVD, TB, and HIV.
Table 1: Chronology of events and legislation in the health sector
| Date | Event |
|---|---|
| August 1991 | Declaration of independence in Kyrgyzstan |
| 1993 | Introduction of user fees |
| March 1994 | Memorandum of Understanding between WHO Regional office for Europe and the Ministry of Health of the Kyrgyz Republic to undertake the MANAS Health Care Reform Programme |
| Ministry of Health requests technical assistance from USAID for a primary health care demonstration project in Issyk-Kul oblast | |
| August 1994 | National Health Policy approved by the government |
| November 1996 | Government approves MANAS Health Care Reform Programme |
| World Bank funded Health Project (1996-2000) started in Kyrgyzstan (Bishkek and Chui oblasts) | |
| January 1997 | Introduction of the mandatory health insurance system in Kyrgyzstan |
| July 1997 | MHIF introduces case-based payment to hospitals |
| 1997-1998 | Rolling out of primary health care reforms to Chui, Jalal-Abad, and Osh oblasts and Bishkek |
| November 1998 - March 1999 | FGPs enrolment campaign in Chui oblast and Bishekek |
| Jan 1999 | Introduction of capitation payment to FGPs in Bishkek |
| April 1999 | About 55 hospitals and 290 FGPs enter into contracts with the MHIF |
| January 2001 | Government decree on introduction of a new health care financing mechanism in health facilities of Kyrgyzstan since 2001 |
| Government decree on programme of state guarantees on provision of free and exempt health care to citizens of Issyk-Kul and Chui oblasts in 2001 | |
| Government decree on population's co-payment for drugs, meals and certain types of health services rendered by health facilities besides the program of state guarantees on provision of free and exempt health care to citizens of Issyk-Kul and Chui oblasts in 2001 | |
| February 2002 | Government decree on provision of health care to citizens of Kyrgyzstan under the State Benefits Package since 2002 |
| March 2002 | Maryn and Talas oblasts join the single payer system |
| March 2003 | Batken, Jalal-Abad and Osh oblasts join the single payer system |
| November 2003 | Republican facilities join the single payer system |
| July 2004 | Law on the Single Payer System in Health Care Financing in the Kyrgyz Republic |
| March 2005 | Popular uprising and subsequently new government elected |
| February 2006 | Government approves "Manas Tallimi" Health Care Reform Programme 2006-2010 |
Source: Adapted from Falkingham, J., Akkazieva, B., and Baschieri, A.
Premiums for the Mandatory Health Insurance Fund (MHIF) are paid by different entities depending on the status of the enrollee. The payroll tax is set at 2% for those employed and is payable by employers. Farmers pay 5% of their land tax as their contribution to the health fund. Finally, pensioners and the unemployed have their contribution paid for by the pension and unemployment insurance funds. This contribution equals 1.5 times the minimum wage. The MHIF is the sole purchasing agency for health services within the Kyrgyz health system.
Premiums for the Mandatory Health Insurance Fund (MHIF) are paid by different entities depending on the status of the enrollee. The payroll tax is set at 2% for those employed and is payable by employers. Farmers pay 5% of their land tax as their contribution to the health fund. Finally, pensioners and the unemployed have their contribution paid for by the pension and unemployment insurance funds. This contribution equals 1.5 times the minimum wage. The MHIF is the sole purchasing agency for health services within the Kyrgyz health system.
Table 2: Population coverage and funding sources
| Population group | Payroll tax rate, base and source | Comment |
|---|---|---|
| Employed population groups | ||
| Employees in formal sector | 2% payroll contribution by employer | There is an upper limit on contribution payments: earnings exceeding 120-times the monthly minimum wage are not subject to payroll tax payments (i.e., earnings portions above 12,000 soms) |
| Civil servants and public enterprises | 2% payroll contribution by employer | |
| Self-employed | 2% of total enterprise income | |
| Private farmers | 5% of land tax (only after 2001) | |
| Non-employed population groups | ||
| Pensioners | 1.5x minimum wage from pension fun to MHIF | |
| Registered unemployed | 1.5x minimum wage from unemployment fund | |
| Children under 16 and students under 18 | Republican budget | |
| Persons receiving social benefits | Republican budget |
Source: Jakab, M.
Copayments are regulated in the State Guaranteed Benefits Package (SGBP). The SGBP was the primary instrument used to address the problem of informal payments. Copayments were introduced in two oblasts starting in 2001 and were henceforth expanded gradually to the entire country through 2004, when all oblasts conformed to the same system. The destination of the copayment revenues is regulated; 20% can go toward complementing personnel salaries and 80% must go towards inputs such as medicines, supplies, and food. The majority of copayments are used for the purchase of medicines and supplies, functioning as additional revenue for hospitals to fund their variable costs. Copayments vary with insurance status, exemption status, case type (delivery, surgery, medicine), and referral status.
Populations with high expected use of the health care system qualify for two copayment exemptions. The first is based on social characteristics and was intended to target vulnerable groups such as war veterans, the elderly, and the disabled. The second is based on groups with certain medical conditions with high externalities such as tuberculosis, AIDS, syphilis, and polio. Both of these groups are exempt from any fees. Hospitals are also required to set aside 10% of all copayment funds in order to cover services for the very poor that are uninsured. This process was initiated voluntarily by health providers to support the most vulnerable populations.
Mandatory Health Insurance Fund (MHIF)
Funding
Premiums for the Mandatory Health Insurance Fund (MHIF) are paid by different entities depending on the status of the enrollee. The payroll tax is set at 2% for those employed and is payable by employers. Farmers pay 5% of their land tax as their contribution to the health fund. Finally, pensioners and the unemployed have their contribution paid for by the pension and unemployment insurance funds. This contribution equals 1.5 times the minimum wage. The MHIF is the sole purchasing agency for health services within the Kyrgyz health system.
Table 2: Population coverage and funding sources
| Population group | Payroll tax rate, base and source | Comment |
|---|---|---|
| Employed population groups | ||
| Employees in formal sector | 2% payroll contribution by employer | There is an upper limit on contribution payments: earnings exceeding 120-times the monthly minimum wage are not subject to payroll tax payments (i.e., earnings portions above 12,000 soms) |
| Civil servants and public enterprises | 2% payroll contribution by employer | |
| Self-employed | 2% of total enterprise income | |
| Private farmers | 5% of land tax (only after 2001) | |
| Non-employed population groups | ||
| Pensioners | 1.5x minimum wage from pension fun to MHIF | |
| Registered unemployed | 1.5x minimum wage from unemployment fund | |
| Children under 16 and students under 18 | Republican budget | |
| Persons receiving social benefits | Republican budget |
Source: Jakab, M.
Copayments are regulated in the State Guaranteed Benefits Package (SGBP). The SGBP was the primary instrument used to address the problem of informal payments. Copayments were introduced in two oblasts starting in 2001 and were henceforth expanded gradually to the entire country through 2004, when all oblasts conformed to the same system. The destination of the copayment revenues is regulated; 20% can go toward complementing personnel salaries and 80% must go towards inputs such as medicines, supplies, and food. The majority of copayments are used for the purchase of medicines and supplies, functioning as additional revenue for hospitals to fund their variable costs. Copayments vary with insurance status, exemption status, case type (delivery, surgery, medicine), and referral status.
Populations with high expected use of the health care system qualify for two copayment exemptions. The first is based on social characteristics and was intended to target vulnerable groups such as war veterans, the elderly, and the disabled. The second is based on groups with certain medical conditions with high externalities such as tuberculosis, AIDS, syphilis, and polio. Both of these groups are exempt from any fees. Hospitals are also required to set aside 10% of all copayment funds in order to cover services for the very poor that are uninsured. This process was initiated voluntarily by health providers to support the most vulnerable populations.
Kyrgyzstan offers free primary health care services to all citizens through the State Guaranteed Benefits Package (SGPB) regardless of insurance status. By 2003, 98% of the population was enrolled with a Family Group Practice (FGP) for their primary health care needs.
Kyrgyzstan offers free primary health care services to all citizens through the State Guaranteed Benefits Package (SGPB) regardless of insurance status. By 2003, 98% of the population was enrolled with a Family Group Practice (FGP) for their primary health care needs. Enrollees choose a FGP of their choice and are free to move between FGPs once per year during the annual registration period.
Population groups covered by the MHIF include formal sector employees, civil servants, pensioners, the registered unemployed, children and students under age 21, welfare benefit recipients, farmers, and the self-employed. In 2001, over 80% of the population was covered by the MHIF.
Table 3: Coverage additions (1997-2001): Population groups, sources of financing and benefits
| Population group | Year | Source of financing | Services provided (depth of coverage) |
|---|---|---|---|
| Formal sector employees, except civil servants | 1997 | 2% from the wage bill administered by the Social Fund (SF) | Drugs at hospital level, salary bonuses |
| 1998 | Emergency care at the primary level | ||
| 2000 | Additional/outpatient drug package | ||
| Civil servants | 1998 | 2% from the wage bill administered by the SF | Drugs at hospital level, salary bonuses |
| 2000 | Additional/outpatient drug package | ||
| Pensioners | 1997 | Value of 1.5x minimum salary administered by the SF (Pension Fund) | Drugs at hospital level, salary bonuses |
| 1998 | Emergency care at primary level | ||
| 2000 | Additional/outpatient drug package | ||
| 2003 | Republican budget | Coverage unchanged | |
| Registered unemployed | 1997 | Value of 1.5x minimum salary administered by SF (Unemployment Fund) | Drugs at hospital level, salary bonuses |
| 1998 | Republican budget | Emergency care at primary level | |
| 2000 | Additional/outpatient drug package | ||
| 2002 | Effectively not covered: no funding provided this group by Republican budget | ||
| Children and students under 21 | 2000 | Value of 1.5x minimum salary | Drugs at hospital level, salary bonuses |
| Republican budget | Emergency care at the primary level | ||
| Additional/outpatient drug package | |||
| Welfare benefits recipients | 2000 | Value of 1.5 minimum salary | Drugs at hospital level, salary bonuses |
| Republican budget | Emergency care at the primary level | ||
| Additional/outpatient drug package | |||
| Farmers | 1997 | 2% of the land tax administered by SF (5% in 2000, 6% in 2003) | Drugs at hospital level, salary bonuses |
| Emergency care at primary level | |||
| 2002 | Health insurance policies (400 KGS = US $10/year) administered by MHIF | Coverage unchanged | |
| Self-employed | 1998 | 2% of the value of 3x minimum salary | Drugs at hospital level, salary bonuses |
| Emergency care at primary level | |||
| 2000 | Additional/outpatient drug package | ||
| 2002 | Health insurance policies (400 KGS = US$10/year) administered by the MHIF | Coverage unchanged |
Source: Jakab, M., and Manjieva, E.
Mandatory Health Insurance Fund (MHIF)
Population covered
Kyrgyzstan offers free primary health care services to all citizens through the State Guaranteed Benefits Package (SGPB) regardless of insurance status. By 2003, 98% of the population was enrolled with a Family Group Practice (FGP) for their primary health care needs. Enrollees choose a FGP of their choice and are free to move between FGPs once per year during the annual registration period.
Population groups covered by the MHIF include formal sector employees, civil servants, pensioners, the registered unemployed, children and students under age 21, welfare benefit recipients, farmers, and the self-employed. In 2001, over 80% of the population was covered by the MHIF.
Table 3: Coverage additions (1997-2001): Population groups, sources of financing and benefits
| Population group | Year | Source of financing | Services provided (depth of coverage) |
|---|---|---|---|
| Formal sector employees, except civil servants | 1997 | 2% from the wage bill administered by the Social Fund (SF) | Drugs at hospital level, salary bonuses |
| 1998 | Emergency care at the primary level | ||
| 2000 | Additional/outpatient drug package | ||
| Civil servants | 1998 | 2% from the wage bill administered by the SF | Drugs at hospital level, salary bonuses |
| 2000 | Additional/outpatient drug package | ||
| Pensioners | 1997 | Value of 1.5x minimum salary administered by the SF (Pension Fund) | Drugs at hospital level, salary bonuses |
| 1998 | Emergency care at primary level | ||
| 2000 | Additional/outpatient drug package | ||
| 2003 | Republican budget | Coverage unchanged | |
| Registered unemployed | 1997 | Value of 1.5x minimum salary administered by SF (Unemployment Fund) | Drugs at hospital level, salary bonuses |
| 1998 | Republican budget | Emergency care at primary level | |
| 2000 | Additional/outpatient drug package | ||
| 2002 | Effectively not covered: no funding provided this group by Republican budget | ||
| Children and students under 21 | 2000 | Value of 1.5x minimum salary | Drugs at hospital level, salary bonuses |
| Republican budget | Emergency care at the primary level | ||
| Additional/outpatient drug package | |||
| Welfare benefits recipients | 2000 | Value of 1.5 minimum salary | Drugs at hospital level, salary bonuses |
| Republican budget | Emergency care at the primary level | ||
| Additional/outpatient drug package | |||
| Farmers | 1997 | 2% of the land tax administered by SF (5% in 2000, 6% in 2003) | Drugs at hospital level, salary bonuses |
| Emergency care at primary level | |||
| 2002 | Health insurance policies (400 KGS = US $10/year) administered by MHIF | Coverage unchanged | |
| Self-employed | 1998 | 2% of the value of 3x minimum salary | Drugs at hospital level, salary bonuses |
| Emergency care at primary level | |||
| 2000 | Additional/outpatient drug package | ||
| 2002 | Health insurance policies (400 KGS = US$10/year) administered by the MHIF | Coverage unchanged |
Source: Jakab, M., and Manjieva, E.
Entitlements of coverage under the MHIF were introduced under the State Guarantee Benefits Package (SGBP). The specifications of the SGBP are the following:
- Primary care is provided free of charge for the entire population with certain lab and diagnostic tests against copayment.
- Hospital care is provided against formal copayment.
Entitlements of coverage under the MHIF were introduced under the State Guarantee Benefits Package (SGBP). The specifications of the SGBP are the following:
- Primary care is provided free of charge for the entire population with certain lab and diagnostic tests against copayment.
- Hospital care is provided against formal copayment. Copayment is a flat fee payable upon admission.
- Exemption categories were designed based on categorical targeting and disease types to protect populations with high expected health care use. Providers receive a higher payment for treating exempt patients to prevent selection bias.
- An additional outpatient drug benefit was also introduced to subsidize the price of medicines for primary care sensitive conditions in order to reduce unnecessary hospitalizations (e.g., anemia, ulcers, pneumonia, and hypertension).
The Additional Drug Package (ADP) was introduced in 2000 as a way of reinforcing the importance of primary care. It started in seven pharmacies and was slowly rolled out to the entire country by 2003. The ADP is an outpatient drug benefit for those insured with the MHIF, which initially included 37 generic drugs but has expanded since. To purchase drugs through the ADP, the patient pays a discounted price at the pharmacy and the MHIF reimburses the pharmacy for the difference. The subsidy amount is based on a reference price and is approximately 50% of the reference price.
Mandatory Health Insurance Fund (MHIF)
Benefits package
Entitlements of coverage under the MHIF were introduced under the State Guarantee Benefits Package (SGBP). The specifications of the SGBP are the following:
- Primary care is provided free of charge for the entire population with certain lab and diagnostic tests against copayment.
- Hospital care is provided against formal copayment. Copayment is a flat fee payable upon admission.
- Exemption categories were designed based on categorical targeting and disease types to protect populations with high expected health care use. Providers receive a higher payment for treating exempt patients to prevent selection bias.
- An additional outpatient drug benefit was also introduced to subsidize the price of medicines for primary care sensitive conditions in order to reduce unnecessary hospitalizations (e.g., anemia, ulcers, pneumonia, and hypertension).
The Additional Drug Package (ADP) was introduced in 2000 as a way of reinforcing the importance of primary care. It started in seven pharmacies and was slowly rolled out to the entire country by 2003. The ADP is an outpatient drug benefit for those insured with the MHIF, which initially included 37 generic drugs but has expanded since. To purchase drugs through the ADP, the patient pays a discounted price at the pharmacy and the MHIF reimburses the pharmacy for the difference. The subsidy amount is based on a reference price and is approximately 50% of the reference price.
The reforms restructured the health delivery system to form a completely new PHC sector and introduced retraining mechanisms for physicians in order to establish a cadre of autonomous primary care providers across the country. From 2000 to 2003 alone, the share of primary care expenditures in total health spending increased from 17% to 31%.
The reforms restructured the health delivery system to form a completely new PHC sector and introduced retraining mechanisms for physicians in order to establish a cadre of autonomous primary care providers across the country. From 2000 to 2003 alone, the share of primary care expenditures in total health spending increased from 17% to 31%.
Enrollees are free to choose a family group practice for their primary care and they can switch once per year during the annual registration period. In large urban settings, practices that offer higher quality services will attract a larger number of patients, leading to higher capitation payments for the practice. Rural areas, however, have too few providers in order to create this type of quality incentive.
After the primary care reforms created the undergraduate, postgraduate, and continuing education curricula, the number of primary care physicians rose significantly from 5.8 per 1,000 population in 2001 to 8.2 per 1,000 population in 2005. Furthermore, by the end of 2004, 75 percent of primary care physicians and nurses had been retrained as family physicians and family medicine nurses.
Kyrgyzstan has three types of primary care providers. First, the core of the old rural health system, Feldsher-Obstetric Ambulatory Points (FAPs) are facilities in the most remote reaches of the country that offer basic services such as neonatal care, immunizations, and health education. As of 2006 there were 875 FAPs across Kyrgyzstan, each serving between 500 and 2,000 people. Second, Family Group Practices (FGPs) are the major providers of primary care in Kyrgyzstan. FGPs are normally made up of three to five doctors. They can be freestanding and autonomous entities or units within large hospital polyclinics. Finally, Family Medicine Centers (FMCs) are large outpatient facilities staffed by varying numbers of specialists, often 10 to 20 health care professionals in addition to their affiliated FGPs. Their service offerings range from primary care to specialized care, including instrumental diagnostics. In 2006, approximately 93% of FAPs and 96% of FGPs were part of Family Medicine Centers.
Secondary care is provided by hospitals at the oblast level (generally one oblast merged hospital in each oblast), and by territorial hospitals in rayons and cities (51 hospitals nationally). The main difference between these two types of hospitals lies in the variety and complexity of conditions that they can handle. Tertiary care that provides highly specialized services is conducted in eight central-level hospitals. In terms of legal organization, most health care organizations tend to be public. The exceptions are optic, dental, urologic, and gynecological services, which tend to be private facilities and are mostly concentrated in the capital city of Bishkek.
Mandatory Health Insurance Fund (MHIF)
Service delivery system
The reforms restructured the health delivery system to form a completely new PHC sector and introduced retraining mechanisms for physicians in order to establish a cadre of autonomous primary care providers across the country. From 2000 to 2003 alone, the share of primary care expenditures in total health spending increased from 17% to 31%.
Enrollees are free to choose a family group practice for their primary care and they can switch once per year during the annual registration period. In large urban settings, practices that offer higher quality services will attract a larger number of patients, leading to higher capitation payments for the practice. Rural areas, however, have too few providers in order to create this type of quality incentive.
After the primary care reforms created the undergraduate, postgraduate, and continuing education curricula, the number of primary care physicians rose significantly from 5.8 per 1,000 population in 2001 to 8.2 per 1,000 population in 2005. Furthermore, by the end of 2004, 75 percent of primary care physicians and nurses had been retrained as family physicians and family medicine nurses.
Kyrgyzstan has three types of primary care providers. First, the core of the old rural health system, Feldsher-Obstetric Ambulatory Points (FAPs) are facilities in the most remote reaches of the country that offer basic services such as neonatal care, immunizations, and health education. As of 2006 there were 875 FAPs across Kyrgyzstan, each serving between 500 and 2,000 people. Second, Family Group Practices (FGPs) are the major providers of primary care in Kyrgyzstan. FGPs are normally made up of three to five doctors. They can be freestanding and autonomous entities or units within large hospital polyclinics. Finally, Family Medicine Centers (FMCs) are large outpatient facilities staffed by varying numbers of specialists, often 10 to 20 health care professionals in addition to their affiliated FGPs. Their service offerings range from primary care to specialized care, including instrumental diagnostics. In 2006, approximately 93% of FAPs and 96% of FGPs were part of Family Medicine Centers.
Secondary care is provided by hospitals at the oblast level (generally one oblast merged hospital in each oblast), and by territorial hospitals in rayons and cities (51 hospitals nationally). The main difference between these two types of hospitals lies in the variety and complexity of conditions that they can handle. Tertiary care that provides highly specialized services is conducted in eight central-level hospitals. In terms of legal organization, most health care organizations tend to be public. The exceptions are optic, dental, urologic, and gynecological services, which tend to be private facilities and are mostly concentrated in the capital city of Bishkek.
The Kyrgyz health system is centralized at the national level. The Ministry of Health is responsible for health policy, regulation and the oversight of the health care system. Funds collection, pooling, and health purchasing is managed by the Mandatory Health Insurance Fund (MHIF) in the capital city of Bishkek. The MHIF is also responsible for the operations of the financing system, as it is the sole purchasing agency for health services within the Kyrgyz health system.
The Kyrgyz health system is centralized at the national level. The Ministry of Health is responsible for health policy, regulation and the oversight of the health care system. Funds collection, pooling, and health purchasing is managed by the Mandatory Health Insurance Fund (MHIF) in the capital city of Bishkek. The MHIF is also responsible for the operations of the financing system, as it is the sole purchasing agency for health services within the Kyrgyz health system.
The MHIF is an agency of the MOH responsible for collecting premiums and for funding individual health services in the SGBP and the Additional Outpatient Drug Benefit. The MHIF is responsible for contracting with primary health care providers and hospitals and for paying them for services they provide to enrollees.
The Ministry of Health is responsible for creating a unified state policy for the health sector, functioning as the steward of health care in Kyrgyzstan. Under this banner, the MOH has the following responsibilities:
- Develop the State Guarantee Benefits Package (SGBP).
- Develop draft laws and other regulations in the health sector and submit them for consideration to the Government.
- Organize and implement the registration, licensing, and accounting of medical and pharmaceutical personnel.
- Supervise and coordinate the quality of medical education within the country.
- Provide for continuous operation of high-tech medical equipment and introduce new technologies at the tertiary level.
- Coordinate the activities of the Mandatory Health Insurance Fund (MHIF) although the relationship between the MOH and MHIF is further evolving due to the recent separation of the MHIF.
- Serve as the purchaser for some of the health program budgets including public health, medical education, and high-technology services.
- Coordinate public health activities.
- Support the charitable and humanitarian activities of NGOs, associations, movements and individuals within the health sector.
- Conduct internal audits of compliance with procurement procedures, financial operations, accounting systems in health organizations and their subordinate institutions.
Mandatory Health Insurance Fund (MHIF)
Institutional structures
The Kyrgyz health system is centralized at the national level. The Ministry of Health is responsible for health policy, regulation and the oversight of the health care system. Funds collection, pooling, and health purchasing is managed by the Mandatory Health Insurance Fund (MHIF) in the capital city of Bishkek. The MHIF is also responsible for the operations of the financing system, as it is the sole purchasing agency for health services within the Kyrgyz health system.
The MHIF is an agency of the MOH responsible for collecting premiums and for funding individual health services in the SGBP and the Additional Outpatient Drug Benefit. The MHIF is responsible for contracting with primary health care providers and hospitals and for paying them for services they provide to enrollees.
The Ministry of Health is responsible for creating a unified state policy for the health sector, functioning as the steward of health care in Kyrgyzstan. Under this banner, the MOH has the following responsibilities:
- Develop the State Guarantee Benefits Package (SGBP).
- Develop draft laws and other regulations in the health sector and submit them for consideration to the Government.
- Organize and implement the registration, licensing, and accounting of medical and pharmaceutical personnel.
- Supervise and coordinate the quality of medical education within the country.
- Provide for continuous operation of high-tech medical equipment and introduce new technologies at the tertiary level.
- Coordinate the activities of the Mandatory Health Insurance Fund (MHIF) although the relationship between the MOH and MHIF is further evolving due to the recent separation of the MHIF.
- Serve as the purchaser for some of the health program budgets including public health, medical education, and high-technology services.
- Coordinate public health activities.
- Support the charitable and humanitarian activities of NGOs, associations, movements and individuals within the health sector.
- Conduct internal audits of compliance with procurement procedures, financial operations, accounting systems in health organizations and their subordinate institutions.
Outpatient care is funded through capitation-based payments while hospital services are funded through case-based payments. The capitation formula for primary care is adjusted by coefficients for rural, small towns, and mountainous areas. This leads to cross-subsidization across geographical boundaries.
Outpatient care is funded through capitation-based payments while hospital services are funded through case-based payments. The capitation formula for primary care is adjusted by coefficients for rural, small towns, and mountainous areas. This leads to cross-subsidization across geographical boundaries. The base primary care capitation rate (before adjustment coefficients) is based on two variables, the estimated number of enrollees that are expected to be enrolled in a family group practice over the coming year, and the size of the budget. The case-based payments for hospital services introduced the idea of output-based payments to the Kyrgyz health system. The system for grouping cases, generally called clinical statistical groups, was based on American diagnosis-related-groups, but was created with Kyrgyz utilization and cost data. This new system enabled an expansion of the budget management autonomy of hospital administrators, although hospital autonomy and management capacity is still an issue on the reform agenda.
The republican MHIF and its territorial branches administer the national pool of funds for the SGBP and are responsible for making all case- and capitation-based payments. Per-case payment rates are defined prospectively but payments are made on a monthly basis. In order to avoid provider selection, providers receive higher payments for treating exempt patients and those with lower copayments. A key to the success of the MHIF as the single-payer for the SGBP has been the continuous development and refinement of financial and clinical information systems to operate the provider payment systems and ensure good financial reporting and fiduciary risk mitigation.
Mandatory Health Insurance Fund (MHIF)
Provider payment mechanisms
Outpatient care is funded through capitation-based payments while hospital services are funded through case-based payments. The capitation formula for primary care is adjusted by coefficients for rural, small towns, and mountainous areas. This leads to cross-subsidization across geographical boundaries. The base primary care capitation rate (before adjustment coefficients) is based on two variables, the estimated number of enrollees that are expected to be enrolled in a family group practice over the coming year, and the size of the budget. The case-based payments for hospital services introduced the idea of output-based payments to the Kyrgyz health system. The system for grouping cases, generally called clinical statistical groups, was based on American diagnosis-related-groups, but was created with Kyrgyz utilization and cost data. This new system enabled an expansion of the budget management autonomy of hospital administrators, although hospital autonomy and management capacity is still an issue on the reform agenda.
The republican MHIF and its territorial branches administer the national pool of funds for the SGBP and are responsible for making all case- and capitation-based payments. Per-case payment rates are defined prospectively but payments are made on a monthly basis. In order to avoid provider selection, providers receive higher payments for treating exempt patients and those with lower copayments. A key to the success of the MHIF as the single-payer for the SGBP has been the continuous development and refinement of financial and clinical information systems to operate the provider payment systems and ensure good financial reporting and fiduciary risk mitigation.
The regulation of the health system is the responsibility of the Government, MOH and the MHIF. The general legal framework regarding the roles and responsibilities of state bodies involved in health care provision is encompassed in the 2005 Law on Health Protection. A series of other laws and regulations constitute the remainder of the legal and regulatory framework.
The regulation of the health system is the responsibility of the Government, MOH and the MHIF. The general legal framework regarding the roles and responsibilities of state bodies involved in health care provision is encompassed in the 2005 Law on Health Protection. A series of other laws and regulations constitute the remainder of the legal and regulatory framework.
Mandatory Health Insurance Fund (MHIF)
Regulation
The regulation of the health system is the responsibility of the Government, MOH and the MHIF. The general legal framework regarding the roles and responsibilities of state bodies involved in health care provision is encompassed in the 2005 Law on Health Protection. A series of other laws and regulations constitute the remainder of the legal and regulatory framework.
Monitoring and Evaluation is conducted through the health information system, which is relatively advanced for a country of Kyrgyzstan’s income level.
Monitoring and Evaluation is conducted through the health information system, which is relatively advanced for a country of Kyrgyzstan’s income level. The system is composed of five databases: The MHIF database on the insured population, the enrollment database that enables primary care facilities to make capitation-based payments, the hospital admission database with case-coding that enables case-based payments, the outpatient care utilization registry, and the Additional Drug Package database. In addition, due to long-standing WHO support, a relatively mature operations research and policy analysis function exists in Kyrgyzstan where a series of policy analyses developed each year contribute to evidence-based policy decisions.
Mandatory Health Insurance Fund (MHIF)
Monitoring and evaluation
Monitoring and Evaluation is conducted through the health information system, which is relatively advanced for a country of Kyrgyzstan’s income level. The system is composed of five databases: The MHIF database on the insured population, the enrollment database that enables primary care facilities to make capitation-based payments, the hospital admission database with case-coding that enables case-based payments, the outpatient care utilization registry, and the Additional Drug Package database. In addition, due to long-standing WHO support, a relatively mature operations research and policy analysis function exists in Kyrgyzstan where a series of policy analyses developed each year contribute to evidence-based policy decisions.
The 2008 Review Report of the Manas Taalimi Health Sector Strategy highlights several achievements of Manas Taalimi in regards to progress towards its objectives . They include the following:
- Patient financial burden has decreased, particularly for the poorest two quintiles. For the poorest quintile, out-of-pocket health expenditures declined from 7.1% of the annual household budget in 2004 to 4.9% in 2006 (30%), and for the second poorest quintile from 5.5% to 4.2% (24%).
The 2008 Review Report of the Manas Taalimi Health Sector Strategy highlights several achievements of Manas Taalimi in regards to progress towards its objectives . They include the following:
- Patient financial burden has decreased, particularly for the poorest two quintiles. For the poorest quintile, out-of-pocket health expenditures declined from 7.1% of the annual household budget in 2004 to 4.9% in 2006 (30%), and for the second poorest quintile from 5.5% to 4.2% (24%).
- The share of patients making informal payment has significantly reduced for all categories of patient expenditures. To medical personnel, 70% of hospitalized patients paid in 2001 and 52% in 2006. For medicines, 81% of hospitalized patients paid in 2001, and 51% in 2006. For medical supplies, 72% of hospitalized patients paid in 2001, and 35% in 2006. For food, 91% of hospitalized patients paid in 2001, and 76% in 2006.
- Regional distribution of expenditures has become more equal under the State Guaranteed Benefit Package and the Additional Drug benefit allowing an increase of funding to more distant and hard-to-reach areas where delivering care is more costly.
- Financial and geographic access barriers have declined. Of those who needed but did not seek care in the past 30 days, 11.2% reported in 2001 that this decision was because care was “too expensive” or “too far”. This indicator declined to 3.1% by 2006 as reported in nationally representative household surveys.
- Utilization of primary health care and hospital care is increasing. Between 2005 and 2007, the visit rate to FGP’s increased by 36% and the hospitalization rate by 18%.
- Availability of the Additional Drug Benefit in rural areas is improving. This is indicated by a decline in the number of villages without pharmacies but with FGP’s contracted under the ADB from 142 in 2005 to 102 in 2007 (28%).
- Primary care continues to receive an increasing share of the SGBP increasing from 26.4% in 2004 to 37.9% in 2007.
- Hospitals increased the share of resources allocated directly to patients (e.g. medicines, medical supplies, food) rather than to the maintenance of infrastructure. Direct medical expenditures increased from 20.4% of hospital expenditures (in the SGBP) in 2004 to 32.7% in 2007.
- Patients continue to provide high scores for various service aspects of hospital care including cleanliness of facilities, experiencing care and respect from medical professionals, explanation of diagnosis and treatment to patients, and allocating time for patient questions.
- Good progress has been made in tuberculosis control. Tuberculosis incidence has reduced from 116 per 100,000 inhabitants in 2005 to 109 in 2007 and mortality has reduced 11 per 100,000 in 2005 to 9.6 in 2007.
Mandatory Health Insurance Fund (MHIF)
Results of the reform
The 2008 Review Report of the Manas Taalimi Health Sector Strategy highlights several achievements of Manas Taalimi in regards to progress towards its objectives . They include the following:
- Patient financial burden has decreased, particularly for the poorest two quintiles. For the poorest quintile, out-of-pocket health expenditures declined from 7.1% of the annual household budget in 2004 to 4.9% in 2006 (30%), and for the second poorest quintile from 5.5% to 4.2% (24%).
- The share of patients making informal payment has significantly reduced for all categories of patient expenditures. To medical personnel, 70% of hospitalized patients paid in 2001 and 52% in 2006. For medicines, 81% of hospitalized patients paid in 2001, and 51% in 2006. For medical supplies, 72% of hospitalized patients paid in 2001, and 35% in 2006. For food, 91% of hospitalized patients paid in 2001, and 76% in 2006.
- Regional distribution of expenditures has become more equal under the State Guaranteed Benefit Package and the Additional Drug benefit allowing an increase of funding to more distant and hard-to-reach areas where delivering care is more costly.
- Financial and geographic access barriers have declined. Of those who needed but did not seek care in the past 30 days, 11.2% reported in 2001 that this decision was because care was “too expensive” or “too far”. This indicator declined to 3.1% by 2006 as reported in nationally representative household surveys.
- Utilization of primary health care and hospital care is increasing. Between 2005 and 2007, the visit rate to FGP’s increased by 36% and the hospitalization rate by 18%.
- Availability of the Additional Drug Benefit in rural areas is improving. This is indicated by a decline in the number of villages without pharmacies but with FGP’s contracted under the ADB from 142 in 2005 to 102 in 2007 (28%).
- Primary care continues to receive an increasing share of the SGBP increasing from 26.4% in 2004 to 37.9% in 2007.
- Hospitals increased the share of resources allocated directly to patients (e.g. medicines, medical supplies, food) rather than to the maintenance of infrastructure. Direct medical expenditures increased from 20.4% of hospital expenditures (in the SGBP) in 2004 to 32.7% in 2007.
- Patients continue to provide high scores for various service aspects of hospital care including cleanliness of facilities, experiencing care and respect from medical professionals, explanation of diagnosis and treatment to patients, and allocating time for patient questions.
- Good progress has been made in tuberculosis control. Tuberculosis incidence has reduced from 116 per 100,000 inhabitants in 2005 to 109 in 2007 and mortality has reduced 11 per 100,000 in 2005 to 9.6 in 2007.
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