Kyrgyzstan: Improving family health through telemedicine
Increasing rural access to primary health care through adapting and deploying digital health solutions
Of the 21 countries in the Europe and Central Asia region, Kyrgyzstan has the highest maternal and neonatal mortality rates. Along with out-of-pocket payments for health services, the rural population has a high and geographically imbalanced under-five mortality rate in comparison to the urban population.
With human, geographical, and financial constraints, there is a substantial need for access to quality healthcare and specialized services, mostly at the rural primary health care level. This is where digital health solutions fit in.
Needs Assessment and Advocacy
Beginning in November 2019, the first step was to conduct an analysis of the current situation in Kyrgyzstan, advocate, and build a network of national experts and representatives of developmental partners and donors. In the form of a rapid review, an analysis was completed on the current use of telemedicine services in the country.
Additionally, a foundational assessment was conducted to see whether a strong foundation exists to implement telemedicine programs nationwide. It found that 99.2% of Kyrgyzstan households had access to mobile phones, of which 79.2% had a smartphone; 76% of urban and 65.3% of rural households had access to the internet from any one device from home; and 73.7% of women surveyed had accessed the internet at least once a week in the last three months (MICS 2018). This data provided a basis for the development of telemedicine technologies.
Disability is a strong driver of inequitable realization of rights. 32,013 children, 1.3% of the child population, are registered with a disability (Data from the National Statistic Committee). In Kyrgyzstan - as in many other countries in the region – official data on the number of children with disabilities is that which corresponds to the number of children (with a disability) who receive a state benefit.
The problem of congenital malformations is real for Kyrgyzstan. In 2020, 7,375 children with congenital malformations (CHD) registered. 751 children were registered with birth defects for the first time in their lives, which amounted to 3.0 per 10 thousand children (E-Health Center, Ministry of Health, 2020). The current surveillance system (routine statistical reporting) collects data on the total number of congenital anomalies of the nervous system (including anencephaly and similar malformations, hydrocephalus), heart and vascular system, cleft palate and lip, Down syndrome and other congenital anomalies.
Several programmes were implemented to prevent folic acid preventable birth defects and other folate deficiency diseases. These include periconceptual and conception folic acid supplementation through antenatal care, counselling to maintain the healthy diet, flour fortification. However, there is no full integration of nutrition services into the health system, challenges existing with universal access to iron and folic acid supplements for pregnant women. Moreover, the outcomes of the most recent 2021 National Integrated Micronutrient and Anthropometric survey shows that only 2 per cent of flour in households is adequately fortified, 22 per cent is inadequately fortified and 76 per cent is not fortified at all. The Birth defects register is vital to monitor the impact of strategies to raise the folic acid status of women periconceptionally in order to prevent Neural Tube Defects (NTDs). Neural Tube Defects (NTD) Register allows to get on-time quality data on congenital malformation, analysis of causes and risks factors, assessment of efficiency of measures on NTD prevention, policy-makers informing, and evidence-based policy programming. Under UNICEF support and the partnership with E-Health Center the NTD Register developed and disseminated in health organizations country-wide in 2021.
This open-source solution works in low-cost and low-bandwidth settings and can be customized for use in the field. With its convenient digital assistant, Ayu, it provides the opportunity to upload national clinical protocols to ensure care provided by the local health worker is in adherence to clinically approved standards. The underlying approach is to create a provider-to-provider connection, which allows a family doctor from a remote family center to connect with a qualified health specialist at a secondary or tertiary level outpatient facility. In conjunction with the Ministry of Health (MoH) and National Telemedicine Council a lengthy process of transforming three clinical protocols from paper-based to the telemedicine platform fitting format was concluded.
Main advantages of introducing telemedicine at primary health care level:
- Resolving the unmet need at the rural primary health care level
- Strengthening the capacity of family doctors in the provision of the quality PHC service based on evidence-based recommendations and clinical standards
- Resuming and strengthening services due to the COVID-19 pandemic
- Improving access by overcoming human, geographical, and financial constraints to specialized healthcare
- Improved linkages to specialist services on the ground to tackle developmental disorders in their early stages
- Strengthening infrastructure (medical, ICT, broadband connectivity) at the PHC
- Prioritizing Digital health as part of the government agenda
Training and Deployment
In May 2021, the second phase began with trainings on the digital platform, as well as with customizing and testing the digital solution. This phase first began with thorough testing and adjustment of the app to the existing digital ecosystem using the infrastructure of the MoH. Based on the findings, the app was then customized. The second part of testing the platform was completed with the targeted end-users - the family doctors. This was the most important part of the process as the family doctors gave feedback that was immediately implemented to ensure that the platform is convenient and user-friendly for them. Following this, under the leadership of the MoH, a 2-day master training workshop was organized in October 2021 where 40 master trainers were prepared to train family doctors in the field on how to use the app.
Working in two districts (covering almost 10% of the country’s population, with 47% being children), four one-day trainings were organized for the family doctors, health specialists, and local IT experts. These trainings focused on building their capacity to use the platform as well as to prepare the infrastructure and establish networks between the family doctors and the specialized health experts.
Since then, the program has been deployed in 3 facilities, where clients have been registered and consultations are taking place. A total of 84 users are currently active on the application. As of June 30, 2022, 194 visits (117 Male and 77 Female) have been created out of which 78 (45 Male and 33 Female) consultations have been completed with a doctor’s prescription. There are also 10 clinical protocols included in the application.
The working committee group has been put in place to make recommendations for the health reimbursement financing model to include telemedicine services offered by doctors. It consists of national health reimbursement, law, health financing, local health administrators. Clinical protocol working group is working on digitizing of the next 10 clinical protocols such as autism, anemia, down syndrome, etc.
The MOH with support of partners is working on the development of the normative document that consists of the digitalization of the healthcare strategy (telemedicine) for the Kyrgyz Republic. The normative document is intended to form the basis for instituting a digital policy that will be a milestone for the digitization of health services.
Insights
Many lessons were learned throughout the rollout, such as the importance of building family doctors’ capacity to use the digital solution, the availability and bandwidth of good internet connection, and the time required to properly enter data into the platform.
The activity of transforming the clinical protocols from paper to the telemedicine platform format revealed the importance of formatting clinical protocols clearly and with a logical flow and description of all the steps that lead to the appropriate diagnosis.
It is important that the MoH leads the process in a coordinated way and bringing all partners into one team to make the process well-integrated.
This experience was featured in the Global UNICEF bulletin in March 2022. Currently, the MOH is looking into potential partners to get support in the expansion of the geographical areas and numbers of the health conditions where telemedicine consultation can be applied.
The Global Health Newsletter is a bi-monthly internal newsletter to keep UNICEF colleagues working on health issues up to date on recent developments of interest to all. March 2022. This newsletter contains regional and country stories from ESAR, Kyrgyzstan, Rwanda, Sri Lanka, and Ukraine
