Case Study on Piloting Complex Health Reforms in ... - PHRplus

1. Introduction
The purpose of this case study is to contribute to greater understanding of the process of piloting
health reform initiatives as part of broader health system reform efforts. The USAID-funded Partners
for Health Reform Plus (PHRplus) Project seeks to advance knowledge of health reforms and their
impact, as well as to promote the exchange of information on critical health reform issues. A recent
PHRplus review of experience on piloting heath systems reform finds that the process of piloting
complex health reform has been poorly documented, providing little guidance on when pilots may be
an appropriate strategy to test new initiatives, or how pilots should be designed to meet the needs of
different contexts (Bennett and Paterson, 2003). The review paper suggests a framework for
improving the documentation of pilots, so that valuable information on pilot design and
implementation might be collected and shared. This case study attempts to document the use of a pilot
approach to implement health reform in Kyrgyzstan.
The concept of piloting has been used effectively in implementing health sector reform
throughout the former Soviet Union. One of the first pilots in Central Asia, established in 1994 in
Issyk-Kul oblast (province or state) in Kyrgyzstan (Figure 1), continues to provide valuable
information on the process of piloting complex health reforms. The initial objective of the pilot was to
provide the Kyrgyz government with a demonstration of a planned social health insurance model.
During the design phase, the pilot quickly evolved into a broader health reform effort aimed at
strengthening the primary care sector and downsizing an inefficient hospital sector to increase health
system efficiency given existing resources, while simultaneously improving capacity at local and
national levels to implement complex health reforms and introduce social health insurance.
Some early experiences and lessons learned from the Issyk-Kul pilot site fed into the concurrent
development of a national health reform strategy (the MANAS Program). Over time, the development
of the national strategy provided the top-down political support necessary for continuing,
strengthening, and rolling out pilot activities in Issyk-Kul oblast. Even though the Issyk-Kul pilot
project was never rigorously evaluated, the model that was tested was modified and refined based on
implementation experience, rolled out to two additional oblasts after two years with assistance from a
World Bank loan project, and eventually rolled out nationally. Experience and lessons learned in
Issyk-Kul oblast with establishing a health insurance fund were used to establish a national health
insurance fund in late 1996 and early 1997.
An achievement greater than national roll-out, however, may be the Ministry of Health’s
sophisticated appreciation for the role and use of pilots in developing and refining its policies. This
appreciation can be attributed to a cadre of capable and progressive reform stakeholders at oblast and
national levels, rigorous national-level capacity building by the World Health Organization (WHO),
USAID, and other donors, and hands-on experience implementing and evaluating the Issyk-Kul pilot
in stages. Recently, the Ministry of Health (MOH) has piloted continuous quality improvement
processes, a single-payer financing model, an outpatient drug benefit for the insured, and new models
of providing emergency care and ambulance services, with great success. In contrast to the Issyk-Kul
oblast pilot, these pilots aimed to test and refine more specific and narrow health reform interventions
and they have been more rigorously evaluated by the MOH and the Mandatory Health Insurance Fund
1. Introduction 1