UHC Forward: Towards Universal Health Coverage

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 Aarogyasri network includes 244 private and 98 public hospitals, all of which must meet specific structural, procedural and pricing requirements. Individuals seeking care approach their nearest in-network health facility, where Aarogya Mithras guide them through the system. If a patient needs further care, they will be given a referral card to the appropriate network hospital(s). Beneficiaries may also seek care and receive referrals at health camps held by in-network hospitals.

As of January 2010, there were a total of 342 hospitals in the network. The principal reason Aarogyasri Trust decided to work with private providers was the lack of resources in the public system. The government has been unable to attract the needed specialists to public facilities, while the private sector has rapidly expanded high quality healthcare services.

A hospital or nursing home in Andhra Pradesh is eligible to be a part of the Aarogyasri network of care, established for indoor medical care and treatment of disease and injuries. The hospital should comply with the following minimum criteria:

• Have at least 50 inpatient medical beds
• Be fully equipped and engaged in providing in-patient medical and surgical facilities along with diagnostic facilities (e.g., pathological tests and X-rays, E.C.G. etc.) for the care and treatment of injured or sick persons
• Have at least one operation theater of its own where surgical operations are carried out
• Have fully qualified nursing staff under its employment 24 hours a day
• Have fully qualified specialist doctor(s) on premises 24 hours a day
• Maintain complete records as required by Aarogyasri on a daily basis and able to provide necessary insured patients’ records to the insurer or his representative as and when required
• Have sufficient experience in the specific identified field
• Agree to deliver the package of services at the rate specified for each identified intervention/surgery as approved by the Trust. The package includes consultation, medicine, diagnostics, implants, food, cost of transportation, and hospital charges, etc. The package price should cover the entire cost of treatment of the patient from date of reporting to discharge from hospital, as well as 10 days after discharge and any complications while in hospital, making the transaction truly cashless to the patient.
• Include the services of a Radiation Oncologist and Medical Oncologist if it desires to be empaneled for Chemo- and Radio-therapies
• Include services of trained ENT Surgeon(s) and Auditory Verbal Therapist(s) if it desires to be empanelled for Cochlear Implant Surgery

All hospitals that qualify to be in-network must sign a memorandum of understanding with the insurance company. This Memorandum is subject to the approval of the Trust. A provision is made in the Memorandum for non-compliance/default; all such matters are looked into by the Trust.

From the perspective of beneficiaries, the path to seeking care is made as simple as possible, as indicated in Figure 1.

• Beneficiaries approach nearby health facility (either public health clinic or area hospital) where an Aarogya Mithra is placed to help beneficiary navigate the health system. Alternatively, the beneficiary can utilize the Aarogyasri 24x7 customer care toll free number (by dialing 1800-474-7788), state’s emergency medical service (by dialing 108), or telemedicine service (by dialing 104) to reach a network hospital. Follow the links for more information on the state’s emergency medical and telemedicine services.
• Beneficiary is seen and diagnosed by a doctor with the support of an Aarogya Mithra to ensure proper care is delivered.
• If beneficiary needs to seek care elsewhere, he/she will be given a referral card to the appropriate network hospital(s)—the beneficiary can select which network hospital they would like to visit for the next step of care.
• Beneficiaries may also attend the Health Camps being conducted by a network hospital in a village and can get the referral card based on the diagnosis done at the Health Camp.