A/HRC/41/34/Add.1 26. The Ministry of Health is the primary body responsible for policies on health protection, including policy formulation, implementation and evaluation, in the areas of health care and health promotion, sanitary and epidemiological welfare, health financing and economics, staffing in the health-care system, the provision of medicines to the population, medical science and education, and compulsory medical insurance. The Ministry participates in the planning process, taking into account socioeconomic, demographic, epidemiological and other data. Although the health-care system is a funding priority, it is still underfunded, health-care infrastructure is underdeveloped, and facilities are ageing, characterized also by a lack of modern equipment and fixed assets depreciating in value. Furthermore, the implementation, monitoring and accountability mechanisms in health-related policies are not appropriately developed. C. National health-care system 27. Kyrgyzstan inherited a centralized health-care system from the Soviet Union that guaranteed free medical care and access to a range of services for the population. It also inherited, however, a system that prioritized hospital care and curative rather than preventive services, and significant geographical imbalances in terms of access and quality. Since Kyrgyzstan became independent, the health-care system has undergone three main reform programmes: Manas (1996–2005), Manas Taalimi (2006–2010) and Den Sooluk (2012–2016, later extended to 2018). The Special Rapporteur was informed that, at the time of the visit, the State was working towards a fourth generation health sector strategy that would address the new challenges posed by the increasing prevalence of noncommunicable diseases, while accelerating progress towards universal health coverage. 28. In the recent past, Kyrgyzstan has been depicted as a pioneer in health reforms for its early establishment of a single payer system (the mandatory health insurance fund), its establishment of a basic benefit package (the State-guaranteed benefits package), its promotion of family medicine and the priority given by the State to the health sector in terms of funding. 29. The health reforms have shifted the focus from hospital care to outpatient care, and to primary health-care services in particular. Family medicine centres have been created and family physician groups established as the first point of contact with the health-care system. Many hospitals have also been restructured. As a result, inpatient care discharges per 100 persons, for example, dropped from 25.8 in 1988 to 14.1 in 2015. 13 Child hospitalization and overtreatment are still, however, issues of concern that require further action. 30. The reforms also introduced a mandatory health insurance contribution, the mandatory health insurance fund and a single-payer system. In 2001, Kyrgyzstan introduced a State-guaranteed benefits package to clarify health-care entitlements, copayment for particular services and tests, and an exemption mechanism. The mechanism currently covers 16 medical categories, including HIV, tuberculosis and maternal care, and 30 socially vulnerable groups, including children under the age of 5 and persons over 70, households with a “social passport”, 14 recipients of State benefits and beneficiaries of monthly cash payments. More transparency is needed in order for citizens to be more aware of their entitlements. 31. The health reforms initially reduced out-of-pocket expenditure on health-care services. After 2009, however, out-of-pocket spending began to grow at an increased rate and faster than the growth of the total household budget per capita. The main driver of outof-pocket expenditure is medicine for outpatients. Moreover, informal payments made 13 14 OECD, 2018 Development Pathways, p. 54. A document issued to a low-income family to demonstrate that it meets guidelines with regard to poverty. The passport also contains a range of demographic information about the holder, including general financial status (income and property), educational status, gender, age, physical status (noting any disability hindering income generation) and social mobility potential (i.e., the ability to move to a higher social level). 7