MEDICINES TRANSPARENCY ALLIANCE

KYRGYZSTAN

WORKING TOGETHERFOR BETTER ACCESS TO MEDICINES

There are many complex factors hindering access to medicines in Kyrgyzstan, but a common cause is weak systems. Monitoring medicines usage in hospitals has been near impossible because of a haphazard data entry system. Procurement law has mandated that medicines are bought on the basis of price without regard for quality. There has been little trust in the quality of medicines available in hospitals, so doctors have been known to advise patients to pay out of pocket for branded medicines. These can cost many times what they do in other countries, putting a heavy financial burden on the most vulnerable consumers. There has been a desperate need for medicines reform in Kyrgyzstan.

challengesOur

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Kyrgyzstan launched a MeTA pilot in 2008. Through the programme, a small secretariat formed an 18-member MeTA Council, made up of representatives from civil society, the private sector, development partners and government, with the support of the WHO Country Office.

The mission was to contribute to good governance, transparency and accountability across the medicines chain, through the engagement of all stakeholders with an interest in the outcome of the medicines market.

Thanks to MeTA, academics and patients were sitting around the same table as professional associations, the private sector and government for the first time. They debated problems and identified solutions. Out of this process, transparency and new rigour has been brought to the policy-making dialogue. It has led to a reorientation of medicines policy in Kyrgyzstan to the needs of the patient, and has laid the foundations for a pathway to improved access to safe and effective, quality essential medicines and their rational use. As ownership of medicines policies and programmes is now shared by all stakeholders, there is optimism that reform will not only be implemented and enforced, but also sustainable and that there will be real change for the most vulnerable.

Kyrgyzstan is one of seven countries to adopt MeTA– the programme is also active in Ghana, Jordan, Peru, the Philippines, Uganda and Zambia. It is currently funded by the UK Government through the Department for International Development.

responseOur

achievementsOur

We revised the State Medicines Policy and it was approved by Government Decree in July 2014.

We supported the Ministry of Health to establish a policy unit specializing in medicines.

We developed a new medicines codifier which will enable medicines price and usage to be monitored.

The SMP revision sparked a review of the legal framework of the pharmaceutical sector, leading to an overhaul of the framework to eliminate corruption risks and bridge gaps.

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Medicines Transparency Alliance

How MeTA Kyrgyzstan transformed medicines policyOne of MeTA’s central achievements is the revision of the State Medicine Policy (SMP), which came about in response to a request from the Ministry of Health. The revision and the final adoption of the revised policy by government decree in July 2014 involved MeTA coordinating two years of targeted consultations with stakeholders and steering the policy through the political process. The consultation process cemented MeTA as an inclusive venue where all sectors could raise concerns. “Before MeTA there was a one-sided approach to the development of regulations and laws – civil society participation was not available,” says Burkanbek Moldotashev from the Kyrgyz pharmaceutical company Biovit. “Policies have become better because it’s now possible to discuss many aspects of the supply of medicines.”

journeyOur

Key to how MeTA has worked

Robust evidence gathered and

analysed

Dissemination of evidence and

multi-stakeholder dialogue

Policy or practice recommendations Action

Advocacy and awareness raising

MeTA’s approach and contribution to revising the State Medicines Policy

• WHO Pharmaceutical Sector Country Profile;• Pharmaceutical Sector Scan to provide baseline information on medicines;• Data Disclosure Survey to assess disclosure status of information on medicines;• Legal framework of the pharmaceutical sector;• Health Policy Analysis Centre assessment and analysis of the SDP 2007–2010

implementation.

• Provided medicines input to national 2012–2016 healthcare reform programme, ‘Den Sooluk’.

• Held forums to discuss evidence gathered.• Held targeted consultations, focus groups and broad round table discussions with

stakeholders. • Circulated revised SMP draft for comment.

• Developed and proposed monitoring and evaluation system for SMP.• Recommended the establishment of a specialized medicines policy unit in the

Ministry of Health (MOH).

• Government approved the SMP by decree.• MOH established a specialized policy unit enabling the MOH to take the

lead on medicines policy formulation.

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The benefits of the multi-stakeholder approach are clear in the final product, the 2014–2020 SMP – a vastly different document to its previous editions. For the first time, the policy recognises the need to monitor and regulate the prices of medicines on the essential medicines list. It institutionalises the notion that medicines are special commodities, and that that should be recognized in business, fiscal and even national security policy and legislation. It also promotes the idea that open discussions among stakeholders lead to agreement among disparate interests over improving governance in the pharmaceutical sector.

WHO consultant on MeTA, Aygul Sydykova, says discussing the policy widely helped to resolve potential problems and balance the interests of different groups. “The different approach to revising the SMP meant the discussion was country-driven this time. The new policy includes all the recommendations of WHO for medicine policies, but they have been developed to reflect Kyrgyzstan’s situation.”

The chair of NGOs Alliance for transparency in the pharmaceutical sector, Dr Burul Makenbaeva, says NGOs now feel equipped to demand transparency throughout the supply chain. “Before MeTA, my organization knew nothing about medicines policy,” she says. “When we joined MeTA we were helped to understand how policy is formulated. MeTA has made a big improvement in helping the NGO sector advocate.”

The revision of the SMP is already delivering change. It sparked a review of the legal framework of the pharmaceutical sector, leading to reform to eliminate corruption risks and bridge gaps. It has also shed light on the ability of consumers to buy all but narcotic and psychotropic medicines without a prescription. The head of the professional association NGO, the Family Group Practitioners Association, Suiumjan Mukeeva, says among other problems, it contributes to irresponsible antibiotic use. “Self-medication and self-administration of antibiotics have increased because antibiotics have been available so freely,” she says. MeTA facilitated discussions with donor projects to assess the scale of the problem and has provided technical advice to the Ministry of Health to revise legislation on medicine dispensing.

MeTA has also helped the Ministry of Health establish a unit dedicated to medicines policy, which had previously been the domain of the Drug Regulatory Authority. It has been pioneering on the issue of antimicrobial resistance in Kyrgyzstan, supporting the first research on antibiotics use in the country. It has supported the introduction of stronger anti-corruption provisions in pharmaceutical legislation.

MeTA’s approach and contribution to tackling corruption

Vulnerabilities to corruption in the legal framework of pharmaceutical sector.

• Anti-corruption survey results presented at anti-corruption forum.• All stakeholders discussed draft of revised pharmaceutical legislation.

Recommended MOH revise pharmaceutical legislation to strengthen anti-corruption provisions; supported the revision of the legislation.

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Medicines Transparency Alliance

MeTA’s approach and contribution to tackling antimicrobial resistance

• Gaps and barriers for establishing practices of rational use of antibiotics; • Antibiotic consumption and use.

• Presented survey on antibiotics at international AMR conferences.• Lancet Infectious published results of antibiotic use surveys.

CSOs campaigned to raise awareness of AMR.

Lobbied policymakers and MOH on AMR.

Kyrgyzstan joined the European Surveillance of Antimicrobial Consumption Network for New Independent State countries.

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Improving procurementUnder Kyrgyz national procurement policy, public authorities were once forced to buy everything at the lowest possible price – including medicines. There has been problematic, particularly amidst widespread belief that cheaper medicines are less effective than their more expensive branded counterparts. “Doctors tell patients to buy the more expensive versions of medicines out of their own pocket, rather than use the medicines available on the state benefits package. Patients will often refuse to have the hospitals’ intravenous medicines,” says Baktygul Toktobaeva, Program specialist of the MeTA Secretariat.

MeTA seized the chance to change this when the Minister of Finance invited it to contribute to a review of Kyrgyzstan’s procurement policies. “We managed to introduce a new clause in the law as it applied to pharmaceutical procurement,” says Mariam Djankorozova, Head of MeTA Secretariat. “It says that, first of all, procurement should be based on the medicine’s efficiency, quality and safety – and only then should price be considered.” The new law has now taken effect and MeTA stakeholders hope it will restore trust in medicines procured by hospitals and improve affordability.

In addition, MeTA recognized that changing the law would be futile if those responsible for procurement were ill-trained for the role. Ideally, medicines should be bought by professional procurement officers but in Kyrgyz hospitals, doctors and nurses have often been responsible for tendering for medicines. MeTA has sought to assist them by producing new standard bidding documents harmonized with World Bank procedures, which provide detailed procedures on purchasing medicines.

MeTA’s approach and contribution to improving procurement

Reviewed existing laws and standard tender documents.

Disseminated existing law on public procurement and the standard bidding documents to stakeholders.

Organized round table discussions with representatives from government, civil society organizations, development partners, hospitals, the pharmaceutical sector and members of the MeTA Council to discuss revisions to the law on public procurement and standard bidding documents for medicines.

• Supported Ministry of Finance to harmonize standard bidding documents with World Bank procedures.

• Law on public procurement was changed to include the clause on medicines procurement developed and recommended by MeTA.

• Medicines codifier piloted in health organizations and at Ministry of Finance public procurement website.

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Medicines Transparency Alliance

MeTA’s approach and contribution to improving quality

• Desk survey of quality of medicines procured by government (in collaboration with the Drug Regulatory Authority);

• Desk survey of assessment of regulatory system; • Medicines Quality Assessment from retail market using minilab kits.

The quality of medicine was raised as a cross-cutting issue during SMP discussions and during joint donors/government reviews of health Sector-Wide Approach (SWAp) reforms.

• Launched counterfeit medicines awareness campaign with demonstration of video “Attention! Counterfeit Medicines!”.

• CSO coalition campaigned in rural areas to raise awareness of right to access to quality medicines.

There are plans to change law on medicines to encourage registration of medicines already subject to stringent foreign regulation and for medicines pre-qualified by WHO.

Monitoring price, quality and availabilityMeTA stakeholders shared concerns about the regulation of medicines. “Our national regulatory agency is very weak, because it depends on the money it earns from pharmaceutical businesses,” says Dr Makenbaeva. She says there is pressure to register unsafe and ineffective medicines, which exposes the agency to corruption. The revised SMP calls for the government to take responsibility for funding the regulator.

Kyrgyzstan has not had a unified system of monitoring of medicine use, price and quality. In hospitals, medicines are recorded under a multiplicity of names, making the tracking of usage virtually impossible. MeTA has responded by producing a ‘medicine codifier’ – software designed to allow operators to enter data using consistent names.

Developing the software was a painstaking process which took two years. Six-thousand-five-hundred names on the list of licensed medicines in Kyrgyzstan for the period 2009 to 2014 had to be standardized. The project illustrates MeTA’s value as a shepherd of good policies and programmes at risk of failing because of lack of political will. The codifier faced resistance from some quarters, but MeTA’s strong reputation and lobbying helped it win vital political support to overcome the opposition. The head of oncology NGO Ergene, Taalaigul Sabyrbekova, says it is a tangible demonstration of MeTA’s goal: transparency. “The government purchases medicines but it has been very difficult to find out what kinds and quantities because of the software that they have been using,” she says. “The codifier will help us to see what is being bought in hospitals by making their purchases more transparent. It shows how MeTA has helped to revolutionise the medicines supply chain in Kyrgyzstan.”

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Building trust and cooperation between civil society, the private sector and government leads to strong and efficient policy making.

Gaps in knowledge are quickly highlighted when everyone is around the same table.

The multi-stakeholder approach improves transparency.

Well-informed stakeholders are better able to hold decision makers to account.

Sustainable change is more likely when all sectors have a stake in a policy.

learnedWhat we’ve

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Medicines Transparency Alliance

MeTA Kyrgyzstan MembersGovernmentMinistry of Health: Saltanat Moldoisaeva, Chief Specialist of Medicine PolicyDrug Regulatory Authority: Rustam Kurmanov, Director-General and Djanyl Djusupova, Deputy Director-GeneralMandatory Health Insurance Fund: Jipara Azizbekova, Head of the Implementation of Health Insurance Programs Department

Civil society sectorFamily Group Practitioners Association: Suiumjan Mukeeva, Executive DirectorMental Health and Society: Burul Makenbaeva, Executive DirectorKeeping Health: Galina Ignatovskaya, DirectorErgene: Taalaigul Sabyrbekova, DirectorDiabetic Association of Kyrgyzstan: Svetlana Mamutova, Director

Business sectorLLC Biovit: Burkanbek Moldotashev, Head of Quality Control DepartmentAdilet Pharmacists’ Association: Turdubek Batirov, ChairmanOsh-Pharm-KA: Almaz Toktorov, Chairman

AcademyKyrgyz State Medical Academy: Nurlan Brimkulov, Provost and Nurila Davletalieva, Chairman of MeTA CouncilPublic Foundation Health Policy Analysis Center: Aida Abdraimova, ConsultantDepartment of Pharmacy of KSMI of Improving Qualification: Gulmira Mambetova, Lecturer

Development partnersUNICEF: Cholpon Imanalieva, Health and Nutrition SpecialistSoros Fund of Kyrgyzstan: Aibek Mukambetov, Health Programme Officer

WHO/EMP/PAU/2015.2

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KYRGYZSTAN

The Medicines Transparency Alliance (MeTA) initiative is grounded in the theory that shining a light on an often opaque system will illuminate problems, improve efficiencies and empower stakeholders to hold decision makers accountable. The hypothesis is that making information transparent and bringing stakeholders together to discuss it will improve access to quality medicines for those who need them.

The global initiative began as a pilot in 2008 in seven countries, with the aim of establishing the multi-stakeholder platforms and collecting baseline data. The current phase, Phase 2, has focussed on making information transparent and using evidence to make policy recommendations. This document is one in a series of brochures that has been produced to share the highlights from the first three years of the second phase of the MeTA programme in each of the seven countries.

The project has been funded by the UK Department for International Development. WHO, in collaboration with Health Action International, has managed the global programme and provided in-country support.

As Phase 2 comes to an end in 2015, countries are considering options for long term programme sustainability. To contribute, to get involved or for more information, contact:

MEDICINES TRANSPARENCY ALLIANCE

Oscon MoldokulovWHO Country OfficeKyrgyzstan

+996 312 611 242moldokulovo@who.int

www.metakg.orgwww.medicinestransparency.org

Gilles ForteWHO Essential Medicines and Health Products DepartmentSwitzerland

+41 22 791 4652forteg@who.int

www.who.int/medicines

Hanne Bak PedersenWHO Regional Office for Europe Denmark

+45 45 33 70 00pedersenh@who.int

www.euro.who.int/en/home