What did the Kyrgyz Republic do?

During the final years of the Soviet regime, approximately 500 collective and state farms controlled 98 percent of the arable land in the Kyrgyz Republic.¹ These centrally managed enterprises focused on a few priorities, especially raising sheep for wool and growing fodder crops like alfalfa to support the flocks. Much of the food Kyrgyz ate was grown or raised in other Soviet republics.

With independence, these agricultural enterprises, deprived of the subsidies and markets in other Soviet republics they had depended on for survival, started to fail. Nevertheless, the Kyrgyz government tried to prop them up by continuing the subsidies on a smaller scale, and the agricultural sector continued to be dominated by socialist modes of production for a few years. At the end of 1994, only 12 percent of land was cultivated by individual farmers. By then, value added in agricultural production had decreased by one quarter. As a result of this decline in local production and a spike in food prices caused by deregulation, food insecurity had increased by one half relative to pre-independence levels.

In 1994, however, the government initiated land reform policies in earnest, with the vast majority of the collective and state farms (190 collective farms and 262 state farms) dismantled and distributed on an egalitarian basis to individuals. The changeover happened region by region and was largely complete by 2002.

The result was a total transformation in Kyrgyz society. In 1994, there were only 20,000 individual farms, and the average Kyrgyz farm encompassed 15 hectares. By 2001-2002, there were 250,000 individual farms with an average size of just three hectares. At the time, these farms employed more than half of Kyrgyz citizens and accounted for 37 percent of GDP.

With this new agricultural model based on small family farms, the agricultural sector recovered relatively quickly. By 2001, the sector’s output equaled output in 1990, the last full year of the Soviet regime.

However, the crop mix had changed significantly. Given the trauma of the transition, family farmers initially focused on subsistence, which in practice meant a pronounced shift from livestock to wheat. After a few years, however, farmers regained confidence in their basic food security and started to transition to more commercial production, including fruit and vegetables, kidney beans, and, eventually, livestock (although less for wool and more for dairy and meat).

According to the World Bank, this sequence of events - “sweeping land reform and subsequent accumulation of livestock assets by peasant farms, along with their increasing commercial orientation” - was responsible for rapid overall agricultural growth, rural poverty reduction, and increased food security.²

In 1997, the average Kyrgyz consumed just 1,873 calories per day. By 2002, that number was up to 2,111 per day. By 2006, the year when the DHS measured stunting prevalence at 18 percent, daily calorie intake was 2,274, a 20 percent improvement in less than a decade. Similarly, rural poverty, which stayed high through the Russian financial crisis in 1998, started a steady decline in 2000, dropping by nearly half by 2008.

Though agriculture played a pivotal role in stabilizing the country during the transition, its relative importance has declined since then.

In 2016, agriculture employed 27 percent of the population and accounted for 13 percent of the country’s GDP. Globally, those are still relatively large percentages, but they are one half and one third, respectively, of what they were at the turn of the millennium. Now, rural Kyrgyz increasingly find employment in other sectors or abroad, and food is increasingly imported. The value of imports increased from just under $150 million in 2004 to more than $850 million in 2014.^3, 4, 5

According to a recent article on Kyrgyz agriculture, “The small size of the majority of farms seems to be simultaneously a blessing and a curse for Kyrgyz agriculture.” On the one hand, because farmers work land that they own, they can respond very quickly to market signals and are incentivized to manage their farms carefully. “It would not be an exaggeration to say that self-reliance of farmers is a major source of extreme poverty reduction and basic food security … despite the harsh conditions of transition,” wrote the authors.⁵

However, they also argue that because the farms are so small, farmers have tended to adopt risk-averse strategies, have not benefited from economies of scale, and lack the capital to make investments in technology.⁶ These challenges are compounded by a lack of technical expertise among the farmers, many of whom were trained as laborers on large farms. With donor funding, the Kyrgyz Republic started to build up an extension service to train farmers in modern techniques, but since the donor funding ran out the government has been unable or unwilling to sustain the program.

Taking a longer term view, Kyrgyz agriculture is no longer the key to economic growth it was in the 1990s, when it drove poverty reduction, increased food security, and spurred stunting reduction in the immediate post-independence period. As currently constituted, the Kyrgyz Republic's agriculture sector has a relatively low ceiling due to the lack of scalability and associated benefits.⁷ However, in 1995, the Kyrgyz Republic needed a higher floor of production, which land reform provided.

In the Soviet era, the Kyrgyz Republic ran on a complicated matrix of social benefits that amounted to 18 percent of the Kyrgyz Republic’s GDP.⁸ Like the health system, the Soviet-era social protection system was expensive, inefficient, and impossible for the Kyrgyz Republic’s government to maintain.⁹

Beginning in 1995, then, the Kyrgyz Republic started to reform its social protection system to make it cheaper and more efficient. The government started with the creation of the Universal Monthly Benefit (UMB), a means-tested cash benefit for the poorest families with children between the ages of 18 months and 16 years. This was an unconditional cash transfer program - that is, families that qualified did not need to do anything to “earn” the benefit.

The UMB was and is a small program, initially covering about ten percent of the population (583,000 people in 1998) and providing very limited benefits (about 50 soms, or less than $1 per month, in 1998).¹⁰  However, because the program was well-targeted, it reached the poorest families and provided a cushion against total destitution - and therefore against the conditions that tended to lead to stunting. Not only that, but since it specifically targeted families with children, it reached children most at risk of stunting.

Moreover, many families in the Kyrgyz Republic, especially in the early transition period, were subsistence farmers, and since the UMB was paid in cash it provided some flexibility in the event of an emergency, especially as the majority of income was in-kind. Although its formula has been updated since its creation in 1995, the UMB is still the main anti-poverty cash transfer program in the Kyrgyz Republic.

It is also worth noting that the country's pension program, by far the largest social insurance program in the Kyrgyz Republic, may have had an impact on stunting during the 1990s. Although by definition pensions target the elderly, our interviews suggest that many families chose to live in multigenerational households during the worst of the economic crisis, in which case some young children may have benefitted from the cash their grandparents or great grandparents were receiving from the government.

Social benefits and social insurance did not eliminate poverty in the Kyrgyz Republic, but they provided a safety net for the poorest during very lean years and kept the Kyrgyz Republic’s crisis from being even more damaging to people’s health and well-being.

The Kyrgyz Republic is widely recognized for successfully rebuilding its health system, for doing so much earlier than the other Central Asian republics, and for doing so in a way that met the needs of its citizens.

The Soviet era health care system was input-based, designed to reflect what planners in Moscow deemed appropriate. As a result, the Kyrgyz Republic was left with a very expensive health system focused on specialized curative care. For example, the Soviet government determined that the optimal number of doctors per 1,000 population was 3.2, even though the average in OECD countries was 2.1.

After 1991, independent the Kyrgyz Republic did not have the money to fund the existing system. Government spending on health was cut by a third between 1991 and 1998. To receive basic care, already impoverished citizens were being forced to pay out of pocket.

The Kyrgyz Republic needed a new health system that could provide for its people’s health needs at a reasonable cost. Though many international and bilateral organizations were working to improve the Kyrgyz health sector in the immediate post-independence years, they were not coordinated. Finally, in 1994, the Ministry of Health asked the WHO Regional Office for Europe for help in designing, funding, and implementing a plan for reform. With support from the WHO and other donors, the Ministry of Health launched Manas in 1996. Manas focused on making preventive care for mothers and children accessible to all. The impact of these reforms can be seen in a steady decline not only in stunting but also in newborn and child mortality.¹¹

Manas, which ran for eight years, was implemented in phases, with different aspects of the new health system being pilot tested in various regions over time and gradually extended to cover the whole country.

In 1996, following earlier pilot tests funded by USAID in Issyk-Kul Oblast, the Kyrgyz Republic created equitably distributed Family Medicine Group Practices and Family Medicine Centers to be the new “front door” to the Kyrgyz health system.¹² The Soviet system was geared toward providing inpatient care in hospitals. The new Kyrgyz system was geared toward providing as much outpatient care as possible at family practices and centers, including pre- and post-natal care, routine immunization, and childhood disease management. To staff these practices and centers, the Kyrgyz Republic retrained thousands of doctors and nurses in family medicine. It also updated clinical guidelines based on evidence-based principles, introducing approximately 200 new protocols.

At the same time that Manas built a new infrastructure, it downsized the old one. The Ministry of Health closed 40 percent of hospital buildings, redirecting the savings to pay for primary care. In 1994, when planning for Manas began, just seven percent of the total health care budget was allocated to primary health care. By 2003, that share had increased to almost 25 percent.

Once these changes were underway, Manas initiated a second phase, focused on how to pay for the new system.

In 1997, the government created the Mandatory Health Insurance Fund (MHIF). The MHIF collected health insurance premiums through a two percent payroll deduction from all formally employed people, although this did not come close to funding the health system. Co-payments, donor funding, and general government revenue filled (and still fill) the gap.¹³

Raising money was only part of the challenge. The other part was controlling costs. Unlike the Soviet system, Manas was based on rationing care. In 2001, the State Guaranteed Benefits Package was introduced, delineating the care to which people were entitled: primary care was free and specialist outpatient or inpatient services required co-payment on a sliding scale, depending on a number of factors. The insured population - that is, workers in the formal sector who received wages and paid into the Mandatory Health Insurance Fund - also received the Additional Drug Package to help cover the cost of basic medicines.

In 2004, the Ministry requested technical support from the WHO to create the next iteration of health reform, which was launched in 2006 as Manas Taalimi, or “Lessons of Manas.” As the name suggests, the goal was not to change the direction of the health system but to build on the foundation that was now in place.

Manas Taalimi aimed to adjust the financing details to limit out-of-pocket spending and the inequities in care that came along with it. It also sought to find new ways to reach more people with more services. It did this in two ways. First, it expanded the definition of primary care. While Manas focused on creating family group practices, Manas Taalimi added birth centers and emergency care facilities to the mix of what was considered primary care. By 2010, 39 percent of the health budget was spent on primary care, up from 25 percent in 2004.¹⁴  Manas Taalimi also sought to connect these primary health care facilities to secondary and tertiary care, so that patients could begin to receive the advanced care that had been stripped out of the system by necessity in the mid-1990s.

The second way Manas Taalimi tried to extend the reach of the health system was by investing in community-based health care, specifically by investing in village health committees (VHC). The VHCs did not provide clinical care. Instead, they focused on raising awareness and promoting healthy practices. VHCs were piloted in 2001 but scaled up after 2006 under Manas Taalimi. By 2011, the country had established VHCs in 60 percent of the country’s villages. According to our qualitative research, the VHCs were important in at least one respect that relates to stunting: working with mothers to improve breastfeeding practices.¹⁵ 

The most innovative thing about Manas Taalimi was how it was funded - by what was known as a sector-wide approach, or SWAp. Under the SWAp, more than 12 donors engaged in a single planning process with the Kyrgyz government and then funded different aspects of the plan’s execution. Five donors put their money in what was called a basket fund that was administered jointly with the government. The other donors continued to provide bilateral aid, but that aid was tightly aligned with the government’s plan. Ultimately, the SWAp was an important instrument for harmonizing donor assistance, and it helped to increase coherence and reduce transaction costs because the Kyrgyz government did not have to address the concerns of a dozen different donors but were instead getting buy-in from all donors for a single strategy.¹⁶

Roles and responsibilities were clear. The Kyrgyz government implemented the Manas Taalimi program and agreed to abide by two budget rules - to increase the health budget every year and to spend at least 95 percent of the health budget every year. The donors provided technical support and financial oversight to the Kyrgyz government.

Under Manas Taalimi, health care in the Kyrgyz Republic continued to improve. For example, the average length of hospital stays - an indicator of the health system’s efficiency - dropped by 30 percent, continuing a trend that had started with Manas. While the length of hospital stays has nothing directly to do with stunting, it is a sign of the successful ongoing transition to a primary care system. The effectiveness of that system is captured by the fact that child and infant mortality rates continued to drop during the four years of Manas Taalimi.

In 1989, the WHO and UNICEF published a joint statement on “protecting, promoting, and supporting breastfeeding,” kicking off a global public health advocacy campaign. In 1991, the organizations launched the Baby Friendly Hospital Initiative (BFHI), based on the 10 Steps to Successful Breastfeeding, which is now implemented in more than 150 countries. The Kyrgyz government, looking to improve outcomes while cutting costs, responded by issuing a national law endorsing exclusive breastfeeding, Order N. 19, in 1996 and implementing BFHI in 2000. The BFHI outlines key clinical and management procedures to encourage proper breastfeeding and certifies facilities that comply with them.¹⁷

The results of the initiative have been noteworthy. Although the rate of children ever breastfed has always been high - it was 96 percent in 1997 - the quality of breastfeeding has improved significantly since then. Between 1997 and 2012, the number of infants breastfed within one hour of birth improved from 44 to 84 percent, and the number of infants breastfed within one day of birth improved from 67 percent to 95 percent. Similarly, the median duration of exclusive breastfeeding increased from less than one month to almost three months, and the median duration of predominant breastfeeding from less than one month to almost six months. This data helps explain the growth curves shown earlier. In 1997, children’s growth started to falter almost immediately after birth, whereas in 2014, faltering began in earnest around six months. This pattern is consistent with the data that reflects when most mothers stopped exclusive and predominant breastfeeding in both years.

Nevertheless, there are still challenges when it comes to breastfeeding in the Kyrgyz Republic. Breast milk substitutes are very popular in the country. In the mid-2000s, when remittances started coming in and families had access to more disposable income, imports of infant formula spiked from about 100,000 kg in 2002 to more than two million kg in 2012.

In response, the government passed a Law on the Protection of Breastfeeding of Children and the Regulation of the Marketing of Infant Food in 2008.¹⁸ Under the law, formula makers are prohibited from including images as part of their marketing strategy and must state the benefits of breastfeeding, the expiration date, and their name on the label. In 2009, the Kyrgyz Republic also added an 11th step to the BFHI’s 10 Steps to Successful Breastfeeding aimed at preventing the use of breast milk substitutes.

Breastfeeding has been an advocacy and policy priority in the Kyrgyz Republic for the entire period of its stunting decline. The data shows that the advocacy and policies vastly improved the quality of breastfeeding throughout the country, despite the popularity of infant formula, and the quantitative analysis suggests that these improvements contributed significantly to the decline in stunting.

Fresh off their success launching BFHI, WHO and UNICEF launched the Integrated Management of Childhood Illness (IMCI) in 1995. IMCI is intended to improve treatment of major child disease by training health care providers, strengthening health systems, and educating families and communities. Repeated infection is an established explanation for stunting, so efforts to manage those infections more effectively may have contributed to the continued stunting decline after 2006.

The Kyrgyz Republic endorsed IMCI in 2000 but scaled up very slowly until 2006, when UNICEF, USAID, and other donors provided an influx of funding. Implementation has been mixed. On the one hand, the community education component has lagged, specialists (as opposed to family doctors) have rejected the initiative, medical schools have been reluctant to incorporate IMCI into their standard curriculum, and funding cuts have shortened the length of the pre-service training and ended the in-service trainings. On the other hand, the basic one- or two-week special training course in IMCI has become a staple of medical education in the Kyrgyz Republic: almost 90 percent of family doctors and paramedics have been trained.

The limited evidence suggests that the impact has been positive, if incremental. In interviews with the WHO, doctors say they feel more confident treating sick children after the trainings. The data backs up these qualitative findings.¹⁹ In one district, hospital referrals for cases of pneumonia for children under five went down from 100 percent to 24 percent because family doctors knew what to do when a sick child came in. Most impressively, according to a 2018 review of IMCI, the proportion of under-five deaths due to acute respiratory illnesses in the Kyrgyz Republic has decreased from 54 to nine percent.

The total number of infections has decreased, too. The percentage of children that suffered from acute respiratory infection over the past two weeks dropped from 16 to six percent between 1997 and 2012. Over the same span, the percentage of children that suffered from diarrhea over the past two weeks dropped from 18 to seven percent. Overall, child mortality has dropped by more than 40 percent since IMCI was implemented, but that trend had begun in the 1990s, so it is difficult to attribute the progress to IMCI alone.²⁰