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Statements Special Procedures
31 May 2018
Bishkek, 31 May 2018
Members of the press,
Ladies and gentlemen,
I would like to begin by sincerely thanking the Government of the Kyrgyz Republic for inviting me to assess, in a spirit of dialogue and cooperation, the realisation of the right to physical and mental health in the country. During my 10-day visit, I met with high-ranking Government officials and relevant health-related authorities at the central and local levels. I also met the Ombudsman as well as representatives of the National Preventive Mechanism, international organizations and a wide range of civil society actors, including healthcare professionals. I visited various facilities, including a psychiatric hospital, two hospitals in prisons, one school, different primary health centres at the community and local levels, a psycho-neurological institution, as well as health services at a pre-trial detention centre and at a prison for women.
I take this opportunity to thank the Regional Office for Central Asia of the High Commissioner for Human Rights as well as the UN Country Team for their crucial support to my visit.
You will find in this room a short document that explains my responsibilities as the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, as well as the focus issues for this visit. I am an independent expert who reports to, and advises, the UN Human Rights Council and UN General Assembly on the realisation of the right to physical and mental health.
I was impressed by the openness of the national and local authorities and was able to learn about the good efforts that the donor community has devoted, for years, in the country’s health sector. Kyrgyzstan also underwent revision by the Committee of Racial Discrimination just prior to my visit. Against this background of openness, I was encouraged to be the first Special Rapporteur to carry out an official country visit to Kyrgyzstan in the last five years, following the last visit by a special mandate holder in 2013. I took this opportunity to follow up on some of the recommendations by Special Rapporteurs that visited the country prior to 2013.
International Legal framework
The Kyrgyz Republic is party to most international human rights treaties, but is yet to ratify the Convention on the Rights of Persons with Disabilities which it signed in 2011. According to most of the counterparts I met with, including representatives of international, national and local organizations as well as some national authorities, the ratification of the CRPD is a most needed step to continue the work already initiated to progressively remove the barriers faced by persons with various types of disabilities for the effective realization of all their rights. I appreciate clarifications provided to me by different government officials, indicating that the ratification should be joined with relevant implementation and that according to recent studies this will require significant financial resources which are currently unavailable. However, I would like to stress that ratifying the CRPD does not imply full immediate implementation but rather, it will confirm the commitment of the State towards the progressive realization of the rights of persons with disabilities. I strongly encourage the Kyrgyz Republic to ratify the CRPD.
The right to health, including particular provisions regarding its underlying determinants, are provided for by the Kyrgyz Constitution of 2010, notably articles 47, 48 and article 9. At the policy level, the national health system recently experienced its third major reform “Den Sooluk” and is currently in the process of adopting its next reform, with the view to effectively serving the health related needs of the population and ensuring the full realization of the right to physical and mental health.
During my visit, I could observe the existing political will to focus on investing in primary healthcare as well as some attempts to keep the entire healthcare system sustainable. Some achievements in this direction are shown by reductions in child mortality indicators as well as the prevention and treatment of communicable diseases, notably tuberculosis.
However, modern healthcare is more than that, and there is an urgent need to implement healthcare policies and services with a more comprehensive approach. In my report of this country visit, to be presented at the Human Rights Council in June 2019, I will elaborate further on specific challenges, opportunities and recommendations. Today, I would like to highlight some of the progress and remaining challenges that I have observed in these 10 days.
Sexual and reproductive health rights
During my visits to healthcare facilities, I could confirm the good efforts towards addressing maternal and infant health. Between 1990 and 2016 Kyrgyzstan reduced national under-5 mortality by two thirds and neonatal mortality by half. However, while making some progress on maternal mortality, the current rate is one of highest in the region, with almost 70% of preventable maternal deaths . Better quality emergency obstetric care is needed to prevent maternal deaths and provide the conditions for healthy newborn children. A relevant cause of maternal mortality is the poor quality of C-section, a procedure that has increased in recent years to the point of being the most common surgical procedure at present.
During my visits to healthcare facilities, I was also informed about many cases where pregnant women delay visits to primary care facilities which prevents the provision of proper prenatal care. I learned about the good work by village health committees at the community level and by health workers at primary care facilities involving regular visits to families to inform about, and follow up on, maternal care. In this regard, continuing to raise awareness amongst women about the importance of receiving quality health care and accessing referral services remains a key component in addressing the right to health of women.
Adolescent pregnancies and fertility rates are high in the country and access to family planning services, particularly contraceptives, are yet to become completely satisfactory. The supply of contraceptives by development partners recently stopped, and the State needs to take over this responsibility as duty bearer in the promotion and protection of sexual and reproductive rights.
As opposed to tuberculosis incidence, which has gone down, there has been a rapid increase of sexually transmitted HIV cases. The State has addressed this challenge through a new Program that ambitiously seeks to overcome HIV Infection for 2017-2021. The implementation of this programme will unquestionably require to strengthen sexuality education. In this connection, I welcome the introduction of sexuality education as part of the “healthy lifestyle” curriculum, optional in the school program and mandatory in the vocational education system. However, in my visit to a school, I could observe that sexuality education continues to be a sensitive item, linked to existing misconceptions, a prevailing patriarchal system and conservative societal attitudes, which are yet to be overcome. While the school was strong in the implementation of classic approaches to promote physical health and healthy food, much remains to be done regarding broader approaches to new challenges, including sexual education, integration of children with disabilities and addressing bulling, to mention only few on them.
Regarding the increased rates of sexually transmitted HIV infection, quality integrated sexual, reproductive and HIV services must be ensured, free from stigma and discrimination with a focus on primary care.
Groups in vulnerable situation
Overall, any healthcare system should address discrimination as a crucial element in the full realization of the right to physical and mental health. Regrettably, during my visit in Kyrgyzstan, I learned about many cases of stigma and discriminatory attitudes based on different grounds by the society at large, and healthcare practitioners in particular. One acute example of discrimination relates to sexual orientation and gender identity. Lesbian, gay, bisexual and transgender persons are subject to psychological violence, sexual abuse and physical harm by family members, law enforcement officials and healthcare practitioners, which significantly affect their physical and mental integrity.
In 2017, Kyrgyzstan made a commendable step forward by issuing the “Guidelines on providing medical and social assistance to transgender, transsexual and gender nonconforming people for medical professionals of all levels of healthcare and other departments of the Kyrgyz Republic”, one of the most progressive standards in the Central Asian region. Nonetheless, these Guidelines are yet to be fully disseminated throughout healthcare practitioners and are yet to be effectively implemented. Testimony indicates that informal payments may sometimes help remove barriers faced by the trans community in healthcare facilities, but the high prices demanded are only rarely affordable.
I trust that the anti-discrimination law currently under discussion in the country will be adopted soon and that it will include safeguards against discrimination on any grounds.
Additional groups in particularly vulnerable situation to access healthcare services are refugees and minority groups. While refugees with a valid State identity may access healthcare services through health insurance at ten times the price paid by citizens, refugees holding certificates issued by the Office of the United Nations High Commissioner for Refugees cannot access health insurance policies due to the lack of State documents. On the other hand, some ethnic Uzbeks, despite having been born in Kyrgyzstan, may have to pay ten-times more for foreigners’ health insurance in order to access health services. The lack of documents amongst Uighurs and Mugats communities (Central Asian Roma) also prevents them from accessing healthcare. Populations with no State documents may potentially be provided certain health services but only through informal costlier payments.
Transparency in the healthcare system
This leads me to the next pending challenge I would like to stress here today. Throughout my visits to health facilities and in most of my meetings, I was informed that informal payments in exchange of health services unfortunately continue to be a common practice, Addressing remaining corrupt practices and improving transparency at all levels of health policies and services is key for the full realization of the right to physical and mental health. The lack of transparency, compounded with unclear rules in the provision of services, diminishes trust among healthcare users, healthcare providers and policy-makers, and groups in vulnerable situations are the ones who suffer the most from this.
In this connection, the need to invest substantially more in human resources is evident and should be a first priority. The salaries of physicians and other healthcare workers are unacceptably low, and this factor has i) a negative impact on the quality of services, ii) provides incentives for informal payments and iii) contributes to the brain drain of medical personnel not only to other countries but from the public to the private sector, including the pharmacy industry. Equally important would be to strengthen mechanisms of self-governance within the medical profession, so that physicians and other healthcare workers develop ownership over their profession and monitor ethical standards in providing healthcare services.
The right to mental health
Ladies and gentlemen,
Healthcare services in Kyrgyzstan are still based on a rather narrow biomedical model, where the health insurance coverage includes mainly biomedical interventions. It should be reminded that modern healthcare has incorporated new priorities, such as mental health, services for children and adults with disabilities, services for older persons, medical and psychosocial rehabilitation and palliative care. It is important to make this change real in the country’s healthcare system so that resources are used not only for medications and hospital treatment, but also for other types of health related interventions which may not necessarily be only biomedical. This is particularly important when conducting research on mental health issues, an area which is becoming nowadays a global priority.
I visited a pilot outpatient mental health centre in Jalal-Abad that is providing mental health services in compliance with WHO recommendations. This is a promising initiative based on a modern approach to healthcare and is about to become part of the national strategy. These types of initiatives need to be funded and supported by the Government so that their integration in the general healthcare system is sustainable.
Furthermore, the effective realization of the right to mental health requires that strategic changes are made to the entire system. Primary care needs to take mental health as seriously as physical health. However, I could observe that child mental health care is almost non-existent and needs to be therefore developed. In addition, services for children and adults with intellectual and psychosocial disabilities need to be developed at the community level considering that predominantly non-biomedical interventions are needed for them. The case of autism is an excellent example in this regard; autism cannot continue to be considered a disease that will be effectively addressed through the biomedical model. Rather, children and adults with autism are persons facing barriers that should be removed through broader approaches, which includes at least health, education and social services.
A comprehensive long-term health strategy needs to be developed in order to decrease and eventually eliminate reliance on large segregated institutions, including psychiatric hospitals and residential institutions. At this moment, the health system in Kyrgyzstan does not seem ready to undergo a full closure of all such institutions and this is why these institutions should at least provide the minimum conditions that protect the dignity and human rights of the people placed therein. Independent mechanisms should continue to monitor these institutions to ensure the provision of decent conditions that allow for children and adults to live in dignity, with no space for abuses or violations.
However, it should be emphatically stressed that national and international healthcare investments should start to be directed at the establishment and strengthening of community-based outpatient services that effectively serve the particular mental health needs of persons in the communities where they live. I learned about two investment projects to improve premises at two psycho-neurological institutions, one of which I visited. While the management at the Belovodsk psycho-neurological institution is doing a good job in better addressing the needs of the children through improved facilities and qualified and committed staff, the ultimate responsibility of promoting and protecting the rights of persons with mental and psychosocial disabilities is of the State.
In this regard, a long-term vision requires to start investing, as a priority, in community-based services, with family-focused approaches to services for children in need. This will include efforts in the healthcare, social welfare and education sectors, to develop early intervention services for children with disabilities and their families, inclusive education in schools and child mental health services at the community level. The same principle applies to the development of mental health services to adult population, including older persons. This long-term vision also requires to move away from the excessive reliance on institutional care and treatment with psychotropic medications, and to include in the mandatory health insurance coverage psychosocial interventions as they are equally needed and effective as medications.
The right to health in detention
I had the opportunity to visit health facilities at pre-trial detention centres and various prisons. The hospital at colony 31 is unquestionably an exemplary practice in terms of control and treatment of tuberculosis, but also in terms of treatment and rehabilitation of drug users, through Atlantis programme. The hospital at this colony was built with strong financial support and substantive cooperation from the International Committee of the Red Cross, which plans to withdraw support by 2020. Sustainability becomes therefore an issue of concern, and therefore efforts and investments in the area should be continued by the Government. I learned that not only the ICRC but also other international cooperation entities are planning to withdraw support since Kyrgyzstan has became a middle-income country. In this connection, authorities must take ownership of the projects initiated through international cooperation to ensure their sustainability.
I also observed the ongoing establishment of the Atlantis programme in colony number 2 for women, as well as the improvements in health services and facilities at the pre-trial detention centre SIZO number 5. My visit to colony number 42 revealed the contrast between the detention facilities that have benefited from international cooperation, and those which have not. I also visited the psychiatric hospital in Kyzyl Jar that host persons with mental and psychosocial disabilities with and without a court sentence. In general, I was encouraged to learn that most doctors have received training about the Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol). However, the new forms to report on potential cases of torture and ill treatment to be filled by physicians remains impractical, as it is long and time-consuming to fill.
Overall, medical personnel and relevant authorities agreed that the jurisdiction of healthcare workers at detention facilities should be transferred to the Ministry of Health. I not only agree with this approach, but strongly recommend to find suitable ways of, and effective incentives to, integrating penitentiary healthcare services into the national health system under the Ministry of Health.
Members of the press,
Ladies and gentlemen,
As final remarks, I would like to highlight that with strong political will, solid legal and policy developments and good pilot practices, the main challenge for the full realization of the right to physical and mental health in Kyrgyzstan seems to be effective implementation. This is linked to the promotion of transparent practices, the abandonment of remaining corrupt ones and a sustainable long-term strategy where the Government takes ownership of the programmes developed with international cooperation.
The role of national and local civil society must be encouraged in this process and they should be taken as equal partners not only in the formulation of guidelines and policy measures but also in the implementation of such measures, which in many cases have proved to be better instrumented through civil society partnerships.