On the right track
How do you identify women with high-risk pregnancies and make sure they get the right care at the right time? Detecting and referring women with complicated pregnancies is one of the biggest challenges facing Kyrgyzstan as it works to improve maternal and child health and to reduce the persistently high number of maternal and neonatal deaths.
In July, the Kyrgyz Ministry of Health convened a new working group tasked with developing national standards for when and how pregnant women should be transferred from one level of care to another, or to specialists at the same level of care. This marks the first attempt to bring together experts from a wide range of backgrounds – clinicians, health officials, health economists and insurers, and representatives from medical training institutions – to discuss and agree standards and procedures for perinatal referrals across the country. The broad membership of the working group is significant, because it reflects an understanding that, on their own, technical changes to current referral practices will yield only limited results: better health outcomes will only be secured by addressing the quality of antenatal care and financing of maternal and newborn health services.
The Promotion of Perinatal Health project, which works with the Ministry of Health to strengthen the maternal and newborn referral system and to develop new models for patient-centered, integrated care for pregnant women, is providing technical support to the working group.
Functioning referral systems can mean the difference between life and death
Most pregnancies proceed uneventfully, but for those which don’t, it is essential that complications be picked up on time and managed correctly. When risk signs are missed, when women with high-risk pregnancies aren’t referred to the correct level of care, or when they don’t manage to access the facilities they’ve been referred to, the results can be fatal.
All of these are problems in Kyrgyzstan where, on average, one woman a week dies of pregnancy-related causes. The 2017 Confidential Enquiry into Maternal Deaths showed that many deaths occur among poor women and those living in remote areas – and that these deaths could have been prevented by appropriate primary health care, early referral, and greater awareness of pregnancy-related risks on the part of women and their families.
Outside urban settings there is a serious shortage of family doctors to provide antenatal care, however, and their level of training and clinical knowledge about pregnancy-related risks is limited. Moreover, procedures for transferring patients between facilities are administratively cumbersome: on average eight phone calls are required between five different parties to approve a referral. Ambulances are not readily available, and women’s families are therefore often required to pay out of pocket to cover transportation costs to distant locations. Even when a woman is successfully transferred, systems for sharing clinical records often don’t work smoothly and receiving facilities know little about the woman’s medical history.
Learning from what has worked – and what hasn’t – at the oblast level
These challenges with the perinatal referral system are not new, and in various regions of Kyrgyzstan attempts have been made in recent years to streamline referral practices to make it easier for women to receive specialist care on time. One such attempt was in Chuy oblast where, in 2017, with the support of GIZ, regional authorities introduced Directive No. 153, which specified which perinatal and gynecological services should be provided at each health facility in the region and, correspondingly, which clinical diagnoses could be treated at which facility. This provided much-needed clarity about which inpatients should be referred to which health facilities and, over the period next two years, led to a drop in maternal deaths.
While generating some clear benefits, these reforms also highlighted other problems, including how perinatal services are paid for within the health system. The current payment mechanisms for inpatient services essentially ‘punish’ hospitals for managing complex cases, as complicated deliveries are reimbursed at a lower rate than normal deliveries. This disincentivises facilities from accepting and treating women with high-risk pregnancies.
Another critical gap pertains to referral procedures for outpatients. While pregnant women with certain types risks require specialised care at higher-level institutions, others can be successfully managed at the primary level if the health care providers are properly trained. Health system reforms currently underway in Kyrgyzstan emphasise patient-centered care at the primary level, making it increasingly important to create referral systems which link doctors, nurses and midwives who provide services to outpatients at Family Health Practices with health providers in secondary- and tertiary-level hospitals. The Promotion of Perinatal Health project is working closely with the Government of Kyrgyzstan to develop for a model for integrated care in maternal and child health.
Starting a national discussion – with all the key players at the table
The idea behind the working group is to learn from the achievements from recent pilot reforms, while also tackling some of the factors which limited their success. Dr Raisa Asylbasheva, the Ministry of Health official spearheading the group, sees a clear need for national standards: ‘We’ve seen that referral system piloted in Chui and Bishkek has positively influenced health outcomes, and we need to move towards a common standard for the entire country’
The new working group is significant because of its multi-disciplinary membership. Not only are clinical specialists and maternal health coordinators involved, but officials from the Mandatory Health Insurance Fund (MHIF), the E-Health Center, and medical training institutions are as well. Moreover, the working group has truly national representation, with members from all seven provinces. ‘We were pleasantly surprised how active and engaged the discussions were at this initial meeting,’ says Sardarbek Karimov, a technical advisor with GIZ. ‘People from across the country feel this problem in their daily work and are invested in solving it.’
One of the inputs to the meeting which generated particular interest was a presentation by Marat Kaliev, the former head of the MHIF, about health financing in Kyrgyzstan. ‘Until now clinical specialists and health care providers in Kyrgyzstan haven’t thought much about how the system is financed,’ says Damira Seksenbaeva, an advisor with GIZ. ‘The presentation opened their eyes to big questions about how much Kyrgyzstan spends on health compared to other countries, where the health budget goes, and how facilities are reimbursed for the services they provide. The financing system for outpatient and inpatient maternal and newborn services needs to be reformed in Kyrgyzstan, and these discussions are therefore very important.’
Before the next meeting of the working group, the representatives from each region are expected to meet and review international referral standards in light of the available health facilities and capacities in their particular regions. The E-Health Center, for its part, will focus on formats for referral documentation and the sharing medical records, an area in which improvements are urgently required.