ASSESSMENT OF THE AMERICAN 
INTERNATIONAL HEALTH ALLIANCE (AIHA) 
PROGRAM IN CENTRAL ASIA 
---------------------------------- 
MAY 2001 
USAID contract: 115-C-00-01-00010-00 
Robert C. Simpson 
e-mail:rsat7572054@hotmail.com 
TABLE OF CONTENTS 
 Page 
1. Statement of Work and Assessment Method 2 
2. Characteristics of AIHA’s Program in Central Asia 3 
 a. AIHA Partnerships 
 b. Regional Activities 
 c. AIHA Program Support Activities 
3. USAID’S Health Sector Reform Program in Central Asia 7 
4. The Context for the AIHA Program: USAID’s relationships with AIHA 8 
5. AIHA’s strengths and comparative advantages for USAID programs in 
 Central Asia 10 
 a. Innovations in Health Care Service Delivery 11 
 b. Demonstrating/Developing More Effective Health Institutions 15 
 c. Introducing Better Curricula and Teaching Methods 21 
 d. Raising Professional and Institutional Standards 22 
6. AIHA’s comparative disadvantages for USAID programs in Central Asia 23 
7. AIHA’s Management and Administrative Capacity and Structure 24 
8. Recommendations to USAID and AIHA 25 
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1. Statement of Work and Assessment Method 
a. Schedule and Team 
The assessment was commissioned by the USAID Central Asia Regional Mission, 
under the direction of Jennifer Adams, who is in charge of health and population 
programs in the region. Two investigators, an independent consultant, Robert Simpson, 
and an USAID/E&E Bureau senior public health expert, Paul Holmes, were selected to 
carry out the statement of work. The Mission provided two and a half weeks in the field 
and about one week for writing the report. Simpson has prior USAID and international 
health experience. This was Simpson’s first visit to Central Asia. The USAID staff 
member, Holmes, had played a leading role in assessing the first phase of the overall 
AIHA program and designing the current second phase. Because of family illness, 
Holmes had to leave the team at the beginning of the trip. Simpson continued the trip, 
however, and wrote this report. Holmes has reviewed the report. 
Representatives from USAID/CAR and AIHA participated in almost all the visits. Mary 
Skarie, USAID/CAR Project Officer for ZdravPlus, joined Simpson in Kyrgyzstan. 
Jennifer Adams participated in the visit to Turkmenistan. James Smith, AIHA’s Director, 
or Associate Director Don Harbick participated in most of the field visits. The visit was 
well organized and administered by USAID and AIHA. All the participants were open 
and responsive to the assessment. Dr. Zhamilya Nugmanova. the AIHA Regional 
Director, and Dr. Shulpan Makhmudova, the USAID project officer, were primary and 
indefatigable resources for the evaluation effort. Their judgments and effective 
collaboration determine to a large extent the achievements of the AIHA project in 
Central Asia. 
b. Which AIHA partnership activities demonstrate a comparative advantage in a 
technical field? How can USAID build upon and focus these activities for 
future, on-going implementation? 
The assessment was rapid and the schedule was full, with barely two weeks in mid-May 
2001 spent visiting AIHA activities in three Central Asian countries. Visits were made to 
four current partnerships in Kazakhstan, Kyrgyzstan and Turkmenistan: 
• Astana City Family Medicine Center and Mercy Health System in Pittsburgh, 
Pennsylvania; 
• Kazakhstan School of Public Health and the Virginia Commonwealth University 
(VCU) in Richmond, Virginia; 
• Kyrgyz State Medical Academy (KSMA) and the University of Nevada School of 
Medicine, at Reno, Nevada; 
• Turkmenistan Ministry of Health Primary Care Training Center in Ashgabat and 
the University of North Dakota and North Dakota State Health Department. 
The assessment visit also included five completed activities carried out by the Almaty 
City-Tucson partnership. Activities in Uzbekistan (the National Center for Emergency 
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Medicine in Tashkent and Ferghana Region and the Grady Health System in Atlanta, 
Georgia) and Tajikistan ( the Republican Education Center for Family Medicine and 
Boulder Community Hospital in Colorado) were not included in the assessment. 
The assessment mainly compares AIHA’s program capabilities with USAID’s program 
needs. The key question is not so much whether AIHA did a good job, but whether it 
was the right job strategically. How well does AIHA contribute to achievement of 
USAID’s Central Asian Strategic Objectives for health? Recognizing that the USAID 
Strategic Objectives for health have recently been revised, how can AIHA’s objectives 
be brought into closer alignment with the S.O.s? Are the chosen problems and partner 
situations importantly related to the Strategic Objectives? Are AIHA’s capabilities -- as 
determined by the nature of the AIHA organization, the nature of the partnerships, and 
the characteristics of the regional activities -- appropriate for the challenges of the 
USAID/CAR strategy and for health reform in the region. What has been learned from 
AIHA’s activities? How do the results advance health reform in the Central Asian 
countries? 
For example, the most successful partnership activity – measured against the planned 
objectives for that activity – may be the Toxicology Center in Almaty. The question for 
this assessment, however, is how this successful activity is contributing to reform of the 
health sector in Kazakhstan, particularly in line with USAID’s Strategic Objectives. 
There may be a reduction of USAID health funds in the Region soon. Because of limits 
on USAID funding, whether AIHA activities contribute significantly to health reform in 
Central Asia is an important question for the CAR Mission. The conclusions of the 
assessment are intended to inform Mission decisions about the most effective uses of 
the AIHA program in Central Asia. 
c. How can the local management and administrative capacity of the AIHA 
regional office, staff and structure, increase its overall effectiveness and 
efficiency? 
 
AIHA’s senior managers in Washington and the Central Asia Regional Office work as a 
team, so consideration of effectiveness and efficiency must be in terms of the whole 
team’s performance. Nevertheless, the report contains recommendations about how 
USAID and AIHA managers can interact for greater benefit to the USAID health 
program. AIHA’s relatively long history working in the region has produced a rich 
network of relationships with health experts and officials in each of the countries. By 
travelling with the AIHA staff, this assessment provided good opportunities to observe 
the AIHA team at work with the network of health experts and officials in the region; 
these interactions were fruitful, producing new insights for AIHA about health reform. 
Some of the observed interactions were between AIHA managers and USAID staff; 
these interactions were less fruitful, with relatively limited exchanges of information and 
few examples of consensus about strategic action. More effort is needed by USAID and 
AIHA senior managers to achieve productive levels of communication. The 
opportunities to observe routine AIHA management and administration were limited; 
judgments in this area must be by inference from interviews and documentation. 
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2. Characteristics of AIHA’s Program in Central Asia 
AIHA accounts for about 20% of the USAID budget for health and population activities 
in Central Asia. AIHA is an important USAID resource for clinically-related service 
delivery activities and medical education. USAID’s main health project, ZdravPlus, 
concentrates on policy, planning and regulation of health reform, which involves 
reducing the number of clinical sites and shifting resources towards primary health care. 
The emphasis of the ZdravPlus consortium led by Abt Associates is at the macro-level, 
together with extensive service-delivery activities in Kyrgyzstan, in Kazakhstan, and with 
imminent expansion in Uzbekistan. Project Hope has the lead with tuberculosis control, 
and the Centers for Disease Control with clinically-based infectious disease control and 
sexually transmitted diseases. 
 a. AIHA Partnerships 
AIHA Partnerships are formed between Central Asian health institutions and consortia 
of U.S. health organizations. For example, the Turkmenistan Ministry of Health’s 
Primary Care Training Center is in partnership with five U.S. organizations under the 
leadership of the University of North Dakota. Sometimes one U.S. consortium will work 
with multiple Central Asian partners. In Almaty City, the Tucson partnership worked 
with the Women’s Wellness Center, the Toxicology Center, the Kazakhstan Medical 
Academy, Emergency Medical Services and with Nursing academies. Partnership 
purposes are well defined, and translated into work plans organized around activities 
and interactions among the partners – training, curriculum development, workshops – 
that bring about an exchange of ideas and the professional support for implementing the 
ideas, usually with some funds for local costs and equipment. About 45% of the AIHA 
Central Asia planned budget were allocated for Partnership Packages, 31% for 
management, and 24% for regional and program support activates that are directly 
managed by AIHA. The financial value of the Partnerships is understated because the 
salary and related costs of the experts are not included. 
The first notable fact about the partnerships is that the U.S. partners commit their 
institutions with the understanding that the staff time from their organizations is a 
contribution to the partnerships; the U.S. staff is paid by their U.S. organization without 
reimbursement from USAID. The U.S. staff members typically report that their personal 
initiative was an important factor in motivating their employing organization to work in an 
international, cross-cultural project. Often the Partnership is the first international work 
experience for them; they are not yet in the ranks of international experts. For the 
project to be successful, high personal commitment must often compensate for lack of 
international experience. The volunteers have a steep learning curve, and their 
motivation enables them to overcome obstacles, often big obstacles such as frustrating 
bureaucracies. The age and backgrounds of partners suggests that the ‘volunteers’ are 
high performers seeking additional challenges. Because the U.S. team is drawn from 
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U.S. domestic organizations, recruiting specific skills and personality types that will be 
effective across cultures is not an easy task. The lead U.S. partner’s recruitment of 
consortium organizations and individuals is a key determinant of project success. 
A competitive selection process, organized for all partnerships on the same time cycle, 
allows AIHA headquarters management to select the most appropriate U.S. partner 
from the group of bidders. To guide the selection process, the AIHA headquarters 
managers’ understanding of the specific requirements for a particular partnership, on 
both the U.S. and Central Asian sides, is another important determinant of partnership 
success. The frequent, relatively intimate discussions that AIHA regional and 
headquarters managers have with Central Asian participants, in the U.S. or in the 
region, talking about current problems, anticipating future needs, divining trends in both 
donor and national policies, trying out regional ideas, are important inputs to the 
partnership brokering process. The fact that these conversations have been going on 
with the same small team of AIHA managers for almost a decade is obviously a 
significant asset for AIHA and USAID. 
The second notable fact about the partnerships is that they are for relatively brief time 
periods, generally three years, with possible extensions, but only up to a total of five 
years. Part of the explanation for the short periods is the relatively tight rein that the 
USAID procurement process imposes. Some of the explanation comes from the short 
planning time periods common in USAID a decade ago in developing the programs for 
Eastern Europe and the former Soviet Union, when the AIHA program was designed. 
Perhaps another factor is the recognition that volunteers and their organizations working 
in difficult circumstances should not be held to long-term commitments. A significant 
consequence of the short time periods, in a project where most of the planning process 
is internal, is tailoring of partnerships to short term results. The information in the 
balance of this report will indicate that AIHA has been remarkably successful working 
within the constraints of very short time periods. Given the short time periods, what 
program objectives are being foregone, or more likely not even considered, because of 
the pressure for quickly accomplished objectives. Perhaps the longer-term strategic 
planning that occurs in USAID could compensate for short-term project thinking, by 
helping AIHA see how their activities fit into USAID’s longer-term strategy. The 
interaction between USAID and AIHA on longer term planning issues has not been 
substantial nor very fruitful as yet. 
 
The third notable fact about the Partnerships is the relative insulation of the partners 
themselves from the USAID programming process. The AIHA staff handles interactions 
with USAID, so the U.S. partners’ staff are not drawn into the USAID programming 
process and diverted from the Partnership activities. Nevertheless, the Partners are 
developing valuable insights about health reform through their Partnership activities. 
USAID and AIHA should consider ways to introduce the Partners’ insight and 
experience into the USAID planning process. 
 b. Regional Activities 
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About 24% of the planned budget for the Central Asia Health Partnership Program is 
programmed by the AIHA regional and headquarters offices, rather than by the 
Partnerships. Of this amount: 
• 42% (10% of the CAR total) is for collaborative regional initiatives such as 
infection control activities and nursing, 
• 29% (7% of the CAR total) is for program support activities such as conferences, 
and 
• 29% (7% of the CAR total) is for continuing activities from the prior partnerships 
such as Sustainability Grants and support for learning resource centers and 
internet connections. 
Nine Central Asian regional initiatives were included in the five-year budget forecast, 
from FY 1999 through FY 2003, anticipating that one or two initiatives would be 
emphasized every year, as follows ($thousands): 
Initiative_____ Emphasis Years in bold 5yr.Budget 
 __99_ _00_ _01_ _02_ _03_ 
 Emergency Medical Services 126 9 134 
 Infection Control/WHONET 25 101 105 15 15 261 
 Health Professions Education 7 93 20 20 140 
 Nursing 28 74 50 25 177 
 Primary Health Care 8 91 100 60 258 
 Women’s Health 22 5 23 25 10 86 
 Neonatal Resuscitation 12 12 
Each of the initiative areas is related to programs at the country level. The work plan 
does not document well the criteria for selecting these particular initiatives. The AIHA 
practice is to vet informally and systematically possibilities with host country officials and 
U.S. Partners and subsequently to propose priorities to USAID. The Emergency 
Medical Services initiative relates to the Uzbekistan Ferghana Valley activity launched 
in FY 1999 on a fast track, and to the EMS activity in Almaty under the prior cooperative 
agreement. The education items correspond to the region-wide interest in reforming the 
medical and nursing schools, for example, joining with Zdravplus to support leadership 
at the regional Rectors’ Council. As rationale for supporting these initiatives, AIHA cites 
linking country efforts to get regional support, e.g., for regional professional associations 
which can affiliate with U.S. professional groups. During the assessment, the Rectors’ 
Council and the nursing associations were credited with effectively reinforcing country￾specific efforts. 
The largest regional initiative, infection control, was addressed through the 
Almaty/Tucson Partnership, one of the previous set of Partnerships. Although infection 
control is not prominent in the current partnerships, hospital deaths due to infection are 
an important issue in the region. To continue this effort, AIHA supports technical 
contributions from CDC and WHO to reduce infections in hospitals (nosocomial 
infection). The residual infection control activity in Kazakhstan, supported by the earlier 
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Tucson partnership, is struggling and needs stronger leadership and support within the 
bureaucracy. 
 c. AIHA Program Support Activities 
Regional Program Support activities are mainly administered by AIHA staff to 
supplement resources available through the partnerships, mainly for two purposes: (i.) 
when centralizing of functions is cost-effective, e.g., for translation of documents, or (ii.) 
when strategic use of funds by AIHA managers can gain support for the program, e.g., 
by inviting officials to events that may open their eyes to the benefits of AIHA programs. 
The largest item, travel costs for conference participants not covered by specific 
partnerships, accounts for about 6% of AIHA’s total budget for Central Asia. USAID 
country level officers noted the long lists of invitees for AIHA conferences, and 
expressed difficulty in judging the value of such extensive participation. During the 
assessment, Central Asian officials cited the trips to U.S. partnership sites and to 
specific U.S. organizations, such as the U.S. medical school accrediting organization as 
very valuable. The more general conferences were not cited, perhaps because the 
purposes were less specific, although still influential. Tracing the developmental benefits 
of bringing decision-makers to the annual AIHA conference would require extensive 
detailed analysis. AIHA’s senior managers have well-developed, keen judgments about 
the roles of key decision-makers in Central Asia. Perhaps the questions for USAID are 
(1.) whether the political capital accrued at these events leads to decisions that are 
developmentally sound and consistent with the USAID regional and country strategies, 
and (2.) whether the portion of the budget is reasonable. 
Sustainability Grants, about $324,000 committed in FY 1999 and FY 2000, for 
completing activities started by the previous set of Partnerships were specifically 
looked at in this assessment only for the Almaty City - Tucson partnerships. 
3. USAID’S Health Sector Reform Program in Central Asia 
 
USAID/Central Asia Strategic Objective 3.2 encompasses a primary outcome of health 
reform, targeted at Kazakhstan, Kyrgyzstan and Uzbekistan: “Increased utilization of 
quality primary health care in select populations.” The Zdrav Reform discussion of 
transforming primary health care (Conceptual Foundations for Central Asian Republics 
Health Reform Model, September 1999) outlines the challenge presented in the cities 
by resistance to Family Group Practices by well-entrenched polyclinic managers. The 
Zdravplus document expresses concern that a lag in improving the quality of primary 
health care is threatening the restructuring of the delivery system. If the clients lose 
confidence in the quality of primary care, the support for health reform will erode. The 
document urges testing of new models of primary care, and notes “The family group 
practice is the key institutional change needed to accomplish integrated reform of the 
health financing and delivery system.” 
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During the assessment in each country, the resistance of health professionals to the 
shift to family medicine was a prominent topic, for example, explaining the lack of 
momentum for health sector reform in Kazakhstan. In Kyrgyzstan health reform is 
moving more quickly with strong direction from the Minister of Health, despite 
ambivalence among senior professionals in the system. Even though policy decisions to 
pursue health sector reform were made four or five years ago, there is no consensus 
about a clinical model or example of how to organize health services around family 
group practices. The problem is mainly in the urban areas. The questions are about 
quality of care and about use of the existing experts and staff. This lack of momentum 
for reform, uncertainty about the right clinical model and how to proceed towards it has 
motivated AIHA to give top priority to supporting the shift towards primary health care. 
The priority for primary health care was also mandated by USAID’s request for 
applications. ZdravPlus has been supporting pilot service delivery activities in 
Kyrgyzstan, mainly through STLI. Both ZdravPlus and AIHA are supporting the 
education and retraining of health professionals to prepare them to deliver primary 
health care using the family medicine approach. Project Hope is focused on 
tuberculosis control. Success of future USAID disease control programs, including 
tuberculosis and AIDS, will depend on the effectiveness of the primary health care 
system. 
AIHA can reasonably argue that its programs are on target, consistent with and 
supportive of the PHC objective: virtually all of its’ partnerships and regional activities 
are attempting to improve the quality and cost-effectiveness of primary health care, 
either directly at the service delivery level or indirectly through training and education of 
health professionals. The emphasis of AIHA activities is on clinical care rather than 
health financing or macro-level analysis, although health management is an important 
educational area for AIHA. Partnerships in the previous phase introduced new delivery 
approaches in special areas of primary care medicine, emergency medicine and 
toxicology. The current Astana partnership is grappling with delivery of comprehensive 
family medicine at a community clinic, a more difficult task. Given the breadth and 
depth of clinical issues surrounding the transformation of the health system, AIHA’s 
emphasis on clinical care is critically needed for the reform effort. (Although the 
purpose of this report is not to assess the overall USAID health sector program in 
Central Asia, the comments of interviewees suggest that clinical issues have not 
received enough attention given their complexity and importance for health reform.) 
In the assessment below, the author explores AIHA’s contribution towards achieving 
Strategic Objective 3.2, attempting to determine: 
• the extent to which AIHA and USAID have chosen strategically useful 
activities, 
• the extent to which the AIHA project is appropriate for the tasks, 
• the extent to which the experience from the AIHA activities will help to 
resolve important issues about reform, 
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• the extent to which the education and training institutions supported by 
AIHA will give health professionals the skills needed to move reform 
forward. 
4. The Context for the AIHA Program: USAID’s relationships with AIHA 
The cooperative agreement between USAID and AIHA for Central Asia was initially 
negotiated and approved in Washington based on the USAID/CAR Mission’s statement 
of health sector objectives at that time. This agreement was one of a set of five 
agreements with the Europe and Eurasia Bureau defining AIHA’s role in the New 
Independent States. The complexity of managing this set of agreements would be a 
challenge for any organization. Because USAID is a decentralized organization, 
authority for funding and managing Central Asian programs is delegated to 
USAID/CAR. In the case of AIHA, however, through definition of the terms of the 
regional agreements, USAID Washington has retained responsibility for ensuring that 
various sub-regional agreements reinforced each other and contributed to Eurasian 
regional objectives. USAID Washington also oversees AIHA’s performance in 
organizing a total effort that meets USAID’s needs expressed in the five agreements. 
Furthermore, the network of U.S. partners, representing many States, comprise an 
important constituency for USAID/Washington in meeting the needs of the Bureau’s 
many programs. As a result, there is some tension between the Agency’s management 
objectives. Washington created the overall program with the presumption that Missions 
will use health partnerships to implement the regional and country programs. Missions 
are accustomed, however, to deciding what organizations will be selected to achieve 
program objectives, because the Mission provides the funding for field programs. 
Furthermore, USAID/Washington holds Missions accountable for achievement of 
regional or country program objectives. Because of Washington’s responsibility for 
overall partnerships program, the Missions are a little unsure of their authority vis-à-vis 
AIHA. Not surprisingly, therefore, Missions are sensitive to any actions by AIHA that 
may suggest AIHA does not recognize the Mission as its guide for setting the direction 
of the program. AIHA, on the other hand, believes that changes in Mission staff can 
bring abrupt changes in program direction, leaving AIHA’s programs at odds with the 
Mission strategy. 
USAID has given to AIHA substantial discretion in directing the program, consistent with 
the terms of a Cooperative Agreement. Under a cooperative agreement, responsibility 
for determining the course of action within USAID’s broad scopes of work is left with the 
grantee. Nevertheless, for AIHA, managing the five cooperative agreements involves 
active, if not day-to-day, relationships with many USAID offices and individuals. In 
addition, of course, AIHA maintains relationships with many U.S. partners and with the 
country officials and partner institutions where programs are being implemented. One 
of the challenging tasks for AIHA’s small management team each day, is how to satisfy 
the needs of so many clients and partners. 
Complexities arise when the many USAID clients, in Washington, in Regional Offices 
such as Almaty, and in the individual countries are all working with AIHA directly and 
9
perhaps concurrently. (In most countries, U.S. Ambassadors are also interested and 
active clients.) There are bound to be differing, maybe contradictory, ideas about 
program directions coming from USAID. USAID has considerable experience with this 
management issue; it is handled by constant effort to communicate horizontally and 
vertically within the organization. 
AIHA has a small, very experienced team of managers at headquarters and in the 
regions, so communications and coordination within AIHA are more easily handled than 
in USAID. Moreover, within AIHA authority for most programming and financial 
decisions is retained at headquarters, so the question of how to deal with USAID on 
particular matters is mainly determined at AIHA headquarters. There is an incentive for 
AIHA to limit communication with Missions about program strategy: fear that Missons 
will raise new and unforeseen demands can arise under the Cooperative Agreement’s 
broad scope of work. To limit this risk, it is not surprising that AIHA concentrates on 
communications with U.S. and Central Asian partners where AIHA has control over 
resources and implementation actions. 
In addition, when the client -- USAID -- has multiple representatives, it is tempting to 
choose the most compatible voice among them. That AIHA has not done so, but openly 
engages with USAID at all levels, is a tribute to the confidence and skill of the 
organization and its managers. Nevertheless, the fact that this assessment was 
commissioned suggests that AIHA and the USAID/CAR Mission are not in complete 
agreement about the strategic and/or programmatic choices in the Central Asian 
Region. A central purpose of this assessment is to suggest ways that AIHA and 
USAID/CAR can come to a better understanding about program direction and can 
sustain that understanding, even if there are changes in staff or shifts in USAID program 
strategies. The common ground for USAID and AIHA is a clear and realistic view 
of the needs for health sector reform in Central Asia. 
Because USAID and AIHA operate very differently, it is difficult to mesh USAID and 
AIHA at the strategic level. The centralization of authority at AIHA contrasts with 
decentralization in USAID. In addition, USAID as an organization has an exceptionally 
complex system of program planning and management, as those involved with defining 
strategic objectives and results will attest. AIHA has a very informal planning process 
that occurs in an incremental way, typically in relatively frequent discussions with 
country officials,. USAID seeks the most effective investment opportunities through 
macro-level analysis of the health sector. AIHA draws on the experience of government 
officials whose analysis of the health sector has occurred over a lifetime, seeking 
energy and vision. USAID also engages these officials, as well as other donors, but 
relies substantially on quantitative and qualitative information, often analyzed by 
independent experts. Both USAID and AIHA are trying to understand what is the reality 
of the development environments in each country, and to develop a vision of what could 
be. Both organizations know the risks of playing to the local officials, who talk reform 
but are protecting political interests. USAID must also be mindful that AIHA is part of a 
Strategic Objective team of implementing organizations that are also potential 
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competitors, with financial and institutional interests. USAID seeks to be even-handed 
and promote cooperation. 
5. AIHA’s strengths and comparative advantages for USAID programs in Central 
Asia 
AIHA has nearly a decade of experience in Central Asia. From the perspective of 
AIHA’s managers, AIHA seeks to capture the energy/combustion of experience and 
ideas, and to define programs that have “traction”, that have prospects for forward 
movement. AIHA relies on the wisdom of experienced leaders and uses observation 
visits to the U.S. to enable these leaders to envision change. AIHA seeks situations 
where there are good prospects for movement in the health system, where determined 
health professionals can manage change in positive directions. The Almaty Toxicology 
Center is an example, with copies spreading nationally. Sometimes political interests 
create momentum and bring support; AIHA is alert to opportunities such as the Health 
Minister’s desire for Emergency Medical Services in the Ferghana Valley in Uzbekistan 
and an emerging interest in a similar program in adjoining Kyrgyz portion of the Valley. 
At the same time, AIHA is mindful that countries rather than donors determine the pace 
of change. In general, AIHA believes health sector reform in Central Asia is going about 
as fast it can now; sustainable change requires an orderly process. 
In the following discussion of AIHA’s program, activities are grouped in categories that 
represent important outcomes of AIHA programs that contribute to health reform. A 
particular partnership activity may appear in more than one category. A partnership 
with a Medical Academy could be included in two categories: “better teaching and 
clinical methods” or “raising professional standards”. 
The outcomes that AIHA produces with comparative advantage arise from the nature of 
AIHA’s program: 
• Improved health care service delivery: by seeing delivery of primary 
health care in the U.S., AIHA partners can select and adapt improvements 
in health service delivery, such as community outreach; 
• More effective health institutions: by seeing health organizations in the 
U.S., AIHA partners can improve the structure and functions of community 
clinics or teaching institutions as models for national health system reform 
(however, basic reform or building capacity in complex institutions is 
beyond the capability of AIHA’s limited inputs); 
• Better teaching and clinical methods: by transferring and adapting 
curricula, teaching methods and clinical algorithms; 
• Raising standards of health professionals: by seeing the functions of 
U.S. workers, new standards or roles can be developed and introduced for 
physicians and nurses. 
These transfers from the U.S. to Central Asia are most successful when there is an 
easily grasped, underlying concept which fits well into the Central Asian Partner’s vision 
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of health reform. It is more difficult to transfer the underlying management principles or 
strategies that produced the improvements in the U.S., although when the 
improvements begin to be replicated throughout a national system, this is evidence of 
more fundamental changes in management thinking. 
a. Improved Health Care Service Delivery 
The introduction of improved emergency medical services and a toxicology control 
center in Almaty and the introduction of community outreach for primary health care in 
Astana are AIHA’s most exciting innovations in service delivery. Each innovation 
appears to provide cost-effective improvements in the quality of health care. All the 
activities are in Kazakhstan. Unfortunately, AIHA has not documented their lessons in 
an analytic way, so the results are less useful than they might be at the policy level and 
with donors. Nevertheless, in each case there is evidence of policy-level influence. 
Determining the importance of these innovations as contributions to national health 
sector reform will require careful analysis; however, such effective innovations in 
primary care are inherently interesting for the architects of health reform. How can 
improvements in specialized care, for emergency cases, traumas or drug abusers, be 
incorporated into a reformed health system? Can community outreach that educates 
families about how to manage chronic diseases reduce need for treatment in hospitals, 
and thereby reduce overall costs in the health system? 
 (1.) Emergency Medical Services (EMS) in Almaty 
The Tucson partnership introduced an EMS system, an innovation that has been 
common in AIHA’s programs elsewhere. This need was probably identified before 
health reform was a central topic in the USAID-AIHA discussions. The transfer of ideas, 
systems and standards has taken root and the changes are being sustained; the 
management systems for responding to calls, with constant medical monitoring, 
adherence to performance norms and follow-up supervision are evident. Because an 
EMS stands apart from the rest of the health system, is less integrated, changing the 
entire system is easier than reforming a polyclinic. Transferring a self-contained system 
where management control can be complete may be a relatively safe bet using 
Partnerships. The EMS service established during the partnership has been expanded 
substantially by the City with its own resources for equipment and staff, suggesting 
more than satisfaction with the results. Supplementary funds are being earned: the EMS 
includes a training team that is successfully charging for its courses. The day that I 
visited, the team was returning from training at an oil corporation facility paid for by the 
corporation. As a successful innovation, the EMS stands on its own, and is worthy of 
some analysis of the results to guide decisions about replication. Comparison with the 
Uzbek experience in Ferghana Valley would be useful in connection with any planning 
for Kyrgyzstan. Does an effective EMS become an important contribution to health 
reform, with what results in terms of reduced costs for the whole system and improved 
health outcomes for their clients. Interestingly, in-hospital emergency services in 
Uzbekistan are being linked with the intensive care services. As the Mission thinks 
about what innovations will further reform, an EMS might not be the first item on the list, 
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but it may be producing some surprising cost-savings and benefits, including benefits 
that lend themselves to marketing with the public. 
 (2.) Toxicology Center in Almaty 
This Tucson activity had the most vivid success among the Partnerships visited. 
Selecting the outstanding manager, who has vision, determination, and discipline was 
the essential inspiration. The Learning Resource Center is the engine of the system; it 
is linked to an on-line/hotline emergency information service and to an emergency 
clinical facility. Although the Center is located in a City Hospital, the information on 
toxins is provided to requestors from throughout Kazakhstan. Almost half of the calls to 
the Center request on-line consultations for treatment. An effective laboratory was 
established under the Partnership to analyze poisons and to identify the chemical 
structure. A data base on patients with poisoning, that increasingly are alcohol and drug 
abuse patients as drug trafficking through Kazakhstan increases, already covers two 
oblasts and is slated for national coverage. Most cases are treated at home – 80%; 
nevertheless, the number of patients hospitalized has tripled since 1995. 
Beyond providing emergency information and treatment, the Center defines its functions 
as teaching, research and prevention. The Center provides a one-month training 
course for health professionals – half lectures and half clinical experience – that is the 
region’s alternative to training in Moscow. The training fee is modest. Training staff for 
replications of the center elsewhere is an important priority. The Almaty Center has 
taken on the responsibility of creating a national network of Toxicology Centers. Two 
have been established with the Almaty Center playing the technical assistance role that 
Tucson used in transferring the system from the Arizona Drug and Poison Information 
Center. The daily rounds at the clinic for practitioners culminate in a weekly 
presentation. The mortality rate at the Center and the length of stay have been steadily 
decreasing. The staff has produced 20 publications, including the Journal of Clinical 
Toxicology. The Center took the lead in establishing an Association of Toxicologists in 
Kazakhstan. Prevention is accomplished through public education. The Center has 
used social marketing concepts to develop broadcast material for television. The Soros 
Foundation has provided three grants for the prevention program. The Center also 
monitors labeling of pharmaceutical products for safety. 
The Center was established as an Almaty City clinical site; however, it has become a 
national center. Every document prepared by the Center is sent to the Ministry of 
Health at the national level for review. The Center drafts national policies and was 
instrumental in the national directive to establish a network of centers. Support for the 
Center has been strengthened by good documentation of costs and effectiveness. The 
energetic Director did his Ph.D. dissertation on the cost savings from fewer admissions 
and less time in the hospital for admitted patients. The annual savings in the hospital 
system are double the City’s cost for operating the Center. Information about costs and 
efficacy of treatment methods identified the relative ineffectiveness of expensive hema￾dialysis. Better training of ambulance service staff allows them to determine that 30% of 
cases don’t require immediate admission. 
13
The Director of the Center cites “understanding and development of poison control in 
Kazakhstan” as the essential ingredient needed for the Center. He credits the Tucson 
Partnership with transferring and establishing the concept of poison control. The Center 
is using management methods learned from Tucson, as well as methods for working 
with media, public officials and staff. The Director states that he can’t implement all his 
ideas, but Tucson taught him how to realize those ideas that he chooses to implement. 
Like EMS, the Almaty Toxicology Center and the emerging national system are 
relatively self-contained with considerable internal management control of functions and 
directions for development. The poison control concept has been grafted onto the 
existing health system without much disruption of that system. The costs and benefits 
are relatively easily documented. (This is an example of ‘evidence-based’ programming 
that has persuaded government officials and donors to provide funding for expansion of 
services and functions.) From the perspective of health sector reform, how can this new 
system be incorporated into the scheme of primary care? Among the benefits might be 
growing public confidence in a health system that effectively handles drug abuse and 
poison emergencies. 
 (3.) Primary Health Care: Community Outreach 
The Astana-Pittsburgh Partnership has adopted aggressive methods of community 
outreach to improve the health status of the catchment population for the newly opened 
Family Medicine Center (FMC) supported by the City of Astana. Other aspects of the 
Astana Partnership are also important and will be discussed below. The purpose of this 
section is to describe the successful transfer of community outreach strategies from 
Pittsburgh to Astana. Aggressive community outreach was not envisioned when the 
Partnership was first formulated. Visits of Astana City officials to Pittsburgh clarified 
understanding of how health problems are linked to the social environment. 
Professionals from Astana that are working in the community, notably a visionary school 
principal and the FMC Director, saw in Pittsburgh and understood how community 
action outside the clinic can prevent problems that might end up in the clinic. 
The incentives underlying the rapid development of community outreach activities in 
Astana must be powerful because the scope of activity is large and dramatic. For the 
FMC, capitation payments give the health care provider incentive to keep the entire 
community of individuals healthy. In a community like Astana or Pittsburgh which 
experiences economic distress due to unemployment or social disruption due to a 
migrant labor force, illness and the threat of illness in families moves to a high position 
on the family agenda of concerns. For a school principal interested in developing 
leadership skills and preparing the life skills of students, maintaining good health is a 
strong motivator for introducing student responsibilities and instigating student action in 
the community. 
The Pittsburgh Partnership Coordinator invited to visit Pittsburgh with an Astana team 
the Principal of the school in the FMC’s catchment area. After observation of school￾14
based health programs in Pittsburgh, the school activities developed in Astana this year 
are of two types: promotion of health for students through education and immunizations, 
and community involvement by teens working with target groups with likely health risks. 
The school has 2800 students in eleven grades, covering almost the entire catchment 
area. Health promotion for students done in cooperation with the FMC includes 
immunizations in the first grade and health exams in the 3rd, 6th and 9th grades. Health 
education includes a special class on safety, especially traffic safety, and classes under 
the guidance of the FMC gynecologist on pre- and post-natal care, sexually transmitted 
diseases and AIDS. (Other Pittsburgh-inspired changes in the school are elections of 
school leaders with active political campaigns, experience in conflict resolution and 
introduction of school uniforms.) Teen groups are formed in the 10th grade to work in the 
community with four high-risk groups: elderly citizens living alone, families with invalid 
children, single mothers and mothers with many children. Before launching, student 
leaders received training in the U.S. with conferences in Washington and Philadelphia 
to learn about teenage problems in the U.S., how they are solved, and who in the 
community solves them. This experience led to formation of a teenage club for health 
lifestyles, organized with the help of the FMC pediatrician. The student leaders were 
also given the skills to carry out community surveys in Astana, gathering information 
about traumas/accidents, family discord, infectious diseases like TB, sexual deviance 
and violence. In developing the program for elderly citizens, they solicited help from 40 
organizations working with elderly. These initiatives involved education of parents 
about the value of uncustomary openness with children on topics of family welfare and 
sexual responsibility. 
Another type of community outreach in Astana originates in the FMC, bringing large 
groups from the community to the clinic for education and aid with disease 
management. I observed a meeting of the Cardiology Club. The Director of the FMC is 
a cardiologist, so the clinic itself happens to have a well-qualified specialist for this 
program. The Club began in December 2000 to inform cardiac patients how to monitor 
and manage their heart disease. About 30 middle-aged or elderly citizens attended, 
80% women, for a two-hour session. The Club meets on Saturday, a convenient time 
for the clients. An important incentive was free medicine for cardiac problems. The 
FMC had received a small grant to look at the question of whether the regular use of 
free medication would reduce needs for hospitalization (and costs?). Some people 
came from other catchment areas. A flyer on angina was distributed and explained, to 
give information about prevention of heart attacks. Blood pressure was checked and 
monitored in a personal record book, and often health management skills such as 
massage were taught. Participants with long-term cardiac problems attested that the 
health management skills learned at the Club had reversed the steady deterioration of 
their health condition. The FMC objectives for the Club included giving clients more 
ability to be responsible for their health, to prevent health crises and to reduce hospital 
admissions for cardiac problems. 
The examples of community outreach have only begun, within the last five months, so it 
is early to judge their value. The important point is that these activities arose directly 
from the Partnership, and they provide robust examples of disease prevention and 
15
health promotion in the community, in a population-based rather than clinic-based 
program. Both activities are locally developed and managed, so this kind of opportunity 
fits well into the Partnership model. Inspiration from the U.S. was a powerful motivator 
and generated an abundance of ideas which are being applied. Unfortunately the scale 
of community outreach was not envisioned in setting up the Partnership. There is not 
yet an organized effort to look at costs, benefits and effectiveness of these programs. 
Whether or not the Astana FMC becomes a viable model clinic for replication, the 
community outreach needs analysis to determine its usefulness in health reform. The 
Director of the Center and a key Partnership member from Pittsburgh thought it would 
not be too difficult for them to devise a modest data collection effort. 
b. Demonstrating/Developing More Effective Health Institutions 
Introducing new or redesigning existing institutional models is tricky business and to do 
so in a complete way is a long-term effort. There is certainly need for long-term 
institution building in the health sectors of Central Asian countries, but USAID ‘s current 
program time-frames don’t permit this approach. Is it possible then to improve 
institutional forms, or introduce new institutional functions in the three-to-five year time 
frame for AIHA’s programs or the standard five-year time-frame of any USAID project? 
Can such institutional changes contribute significantly to health reform? 
In Central Asia, AIHA is working with two basic institutional forms: community 
organizations/clinics that deliver health services, and schools for health professionals. 
Service delivery institutions are responsible for the innovations discussed in the 
previous section. This section will consider institutional and organizational issues of 
delivery systems, without regard to the particular kind of services (toxicology) being 
delivered or to any particular aspect of delivery (outreach). In looking at AIHA’s 
partnerships with schools, this section will again look at institutional functions and 
organization, rather than curriculum or teaching methods that will be discussed later. 
The question here is whether AIHA is effective in helping institutions structure 
themselves or in defining new institutional functions in order to significantly benefit 
health reform. 
 (1.) Family Medicine Center in Astana 
The FMC in Astana is dealing with the Gordian knot of health reform in Central Asia, 
how to organize clinical services at the community level by using the Family Group 
Practice model. In this situation, the AIHA Partnership is not restructuring or cutting an 
existing knot, the Polyclinic; it is creating a new structure beneath the Polyclinic. Is a 
clinic providing family medicine for a sub-population within a polyclinic’s catchment area 
-- but relatively self-reliant and independent of the polyclinic -- an appropriate model for 
urban primary health care? A key question for USAID, perhaps not fully analyzed when 
the Astana partnership was defined, is whether the scale of the FMC and the population 
it serves is a likely form to be considered in Kazakhstan’s health reform. It is not clear. 
The Abt Concept Paper on health reform argues that family group practices must be 
formed away from the direct control of Polyclinic managers, like the rural clinics. On the 
16
other hand, there is a strong argument for tackling the reform of Polyclinics directly, 
accepting that reform may not occur until it happens at the Polyclinic level. All of the 
structural and functional innovations resulting from the Partnership that are listed below 
might be used at a Polyclinic level as well as at a sub-clinic like the FMC. How these 
innovations work, how they play out, however, in a Polyclinic may be quite different from 
how they work in the FMC. 
• Citizen Involvement: FMC Board 
The concept of a Community Board to guide and to support the FMC comes from 
the Partnership. The Board has been functioning since 1999, so it is battle￾tested. The Board sees its main purpose as gaining the authorization of the 
community and giving the community a strong role in guiding the FMC, a clear 
departure from the top down direction used in the former Soviet Union. 
Understanding of the community’s role came from observing a Community Board 
in Pittsburgh. The membership noted that the style of management and 
approach to problem-solving used by the president changed following visits to 
Pittsburgh. Community institutions, such as the school principal, are active on 
the Board. Other resources, such as medical institutions and directors of 
government health programs, are active. The Board’s important responsibility to 
advocate for funding from the Municipal Government has been effective, through 
facilitation by a Board Member who also sits on the Municipal Governing Council. 
The Board is prominent in the development of the FMC. This is an innovative 
organizational structure that has been effectively transferred and adapted 
through the Partnership. 
• Policy-Level Influence 
The FMC was resisted at the policy-level in the National Health Agency, and by 
senior officials in the Municipality. The clinical reforms, based on Family Group 
Practice, and the community involvement were not supported. Visits to 
Pittsburgh by Municipal Officials persuaded them that many health problems 
arise from the society, had their roots in families and the community, and they 
changed their position. The city decided to use per capita financing to reinforce 
the preventive/health promotion approach. The Municipal Government support, 
including financial support and provision of a site, was strong enough to counter 
the resistance at the National Health Agency. The demonstration effect of the 
Partnership’s sponsored visits allowed the program to get started. Through this 
process, the Board learned how to be effective at the policy/political level. Both 
the Board and the City see the real test needed to sustain this support as the 
satisfaction of the FMC clients from the community. Whether effectiveness in 
influencing policy by demonstration can be transferred to possible future 
replications of the FMC or use of a Board, without trips to the U.S., can only be 
determined by trying to do so. Astana’s strong, well-financed Municipal 
Government is an important factor. On the other hand, a well-documented and 
carefully analyzed success in Astana might make the advocacy process easier in 
17
the future. Fortuitously because this model is being developed in the national 
Capitol, a member of the Board works at the national Health Care Agency on 
primary health care, and the Municipal Director of Health who has become a 
strong advocate for the FMC and community outreach sits on the National Health 
Agency Council. 
• Importance of Education/Information 
The fledgling Learning Resource Center is playing a very effective, surprisingly 
active role: providing clinical information from the Web for practitioners and 
clients, preparing educational materials for the patient groups and helping with 
data collection and processing. The physicians and the nurses see education of 
families about health care as high priority, as indicated by their interest in 
information about community/client needs, by the materials they are preparing 
and by the way they are handling patient visits. The effectiveness of effort in this 
area is an indication of the high motivation and capability of the staff, who for the 
most part had been selected through a competitive process. The staff is certainly 
above average, so their adoption of new concepts will be better than average. 
Nevertheless, Pittsburgh’s efforts in this area have had rapid and promising 
effect. 
• Physician-Nurse Teams 
FMC physicians have made radical changes in the use of Nurses, reflecting a 
substantial upgrading of nursing roles and responsibilities. This change seems 
to be substantially attributable to the partnership. Nurses are screening patients 
as the first step in visits, handling routine functions, triaging cases as needed, 
and advising the physician on the patient’s condition. This demonstration of 
Nurse capabilities seems to be a solid achievement that can reinforce the region￾wide Nursing reform effort. 
I was not able to review planning, administration and financial management at the FMC 
to assess the influence of the Partnership. Clearly, the rapid start-up indicates 
substantial planning, organization and training efforts. All the entire Astana FMC team 
members are strong, articulate advocates for family medicine. How to generate 
revenue is at the top of the agenda as a return for high quality care. The Municipality is 
committed to free health services, reflecting the retrenchment on this issue since the 
1998 financial crisis. There are many issues ahead, and it is clear that getting this far 
has been a tremendous struggle. 
The various models of Family Medicine in Pittsburgh had been carefully analyzed, with 
clear statements about how the Kazakhstan situation is different, leading to judgments 
about what could not be transferred. This is a micro-level investment, but the lessons, 
whether it is successful or not, are going to be valuable for decision-makers about 
health reform. Some achievements, such as Pittsburgh’s success in getting a change in 
the definition of infant mortality, have much broader significance, for the entire health 
18
system, suggesting that some of the achievements at the institutional level of 
Partnerships need to be carried, by USAID or perhaps AIHA itself, to a higher level in 
the system. 
The main disappointment with this activity is that AIHA’s and the partners’ achievements 
are not being documented in analytical, quantitative ways that would allow judgments 
about cost-effectiveness and cost-benefits for applications elsewhere; in short there is 
need for evidence-based programming. Dr. Akanov, leading the Deputy Prime 
Minister’s Task Force on Health Reform, expressed strong interest in the results from 
this model. Because this is a very intensive investment by USAID, the marginal cost to 
measure change may be relatively modest. The Director of the FMC, Dr. Abzalova, 
expresses personal interest in documenting the experience. A key member of the 
Pittsburgh Team, Jerry Baron, has the skills and interest to assist. USAID should confer 
with Abt and AIHA about how to document this experience, especially because there 
are few efforts dealing with the nitty-gritty issues of family medicine. Because the 
Partnership is clinically oriented, the concerns about quality of care and clinical cost￾effectiveness are appropriately driving the decisions about organizational structure and 
functions. 
 (2.) Professional Schools 
Two of the four current Partnerships are improving teaching quality at powerful 
institutions: the Kazakhstan School of Public Health (KSPH) and the Kyrgyzstan State 
Medical Academy (KSMA). In the U.S. and many countries where Universities and their 
faculties are involved in teaching, research and extension/application, professional 
schools play leading roles in debates about policy and in leading reform efforts. The 
donors (WHO, the World Bank, DFID, USAID) seem to foresee similarly broad roles for 
these institutions, certainly for KSPH, in the Central Asian Region and in their respective 
countries. In the former Soviet Union in general, professional medical or health 
teaching was didactic rather than clinical, university research was basic rather than 
operational or applied, and involvement in extension or application was limited. These 
characteristics suggest lack of preparation for a strong policy role. This leads to 
questions about the expectations for AIHA’s Partnerships at these two important 
institutions. 
Both Virginia Commonwealth University and the University of Nevada give first priority 
to improved teaching, which is in line with USAID’s support for “developing and 
institutionalizing medical/nursing education (LRR 3.2.2.2)”. Introducing new curricula 
and new teaching methods is generally consistent with AIHA’s limited resources; these 
are tangible products that can be incorporated into the teaching programs of existing 
institutions. I will comment further about training in the following section. 
 (a.) Kazakhstan School of Public Health 
Let me caveat my comments by saying that my opportunity to learn about KSPH was 
very limited: (i.) a rapid briefing in Almaty, for less than two hours, by the Dean and 
19
faculty chairpersons with the entire faculty present, and (ii.) a telephone conversation 
prior to my trip with Dr. Ozcan at VCU, that was basically a review of the work plan. My 
knowledge of KSPH is superficial, so I am loathe to comment about the value and 
effectiveness of the Partnership program. 
KSPH is obviously important to USAID’s health reform strategy, as indicated by the 
Mission’s decision to request AIHA to develop a Partnership for KSPH. The School was 
established only four years ago, in 1997, at the initiative of WHO. It is the first and only 
School of Public Health in the Region. Funding for faculty and facilities has been 
meager. Many of the staff are part-time, in addition to full time jobs elsewhere. The 
Dean is determined and resourceful, seeking financial resources to keep the institution 
afloat. Tuition for training health professionals in certificate courses is becoming a 
significant source of revenue. 
VCU’s Partnership began in 1999. The work plan provides only a modest level of 
resources given KSPH’s financial needs and given the obvious needs in the region for 
the kinds of teaching, research and application (expert consultancies) anticipated from 
KSPH. At the same time, the VCU/KSPH work plan is very ambitious, particularly 
development of new degree programs, including a Ph.D. program in health services 
research. Many outputs have been achieved, including: 
• A new Masters program (Health Administration/Public Health) has been 
designed. 26 courses are already on the schedule for next year; 
• Simultaneously the faculty for these courses have been helped, not only 
with teaching, but with preparation for research and consulting activities. 
• The Learning Resource Center, a professional public health association 
and a new regional journal on Health Services Research have been 
established. 
Development of the new Ph.D. program is underway, with a curriculum to be designed 
by September 2001. Dr. Ozcan guesstimates that 70% of the progress towards work 
plan objectives is achieved by VCU faculty visiting Almaty and the remaining 30% by 
KSPH faculty visits to Richmond. 
Please take into account the superficial assessment of this Partnership, and the 
author’s limited credentials in the development of academic institutions; however, I 
would urge caution about KSPH capability to pick up these tools and to deliver 
international quality graduate teaching and research programs. Skepticism about the 
possibility of achieving substantial improvements in teaching and research capacity 
does not contradict that VCU faculty have done an outstanding and under-appreciated 
job, and that the KSPH staff are very determined and able. Their ability to come so far 
so fast is remarkable. It seems to me that the institutional development task facing this 
Partnership is daunting. There is no evidence of a multi-donor strategy in the available 
documents. Perhaps a team of experts representing the donors could be 
commissioned to review possibilities for supplementary resources. { I am mindful of 
other USAID projects to build international quality institutions, for example recent 
20
commitments to the American University of Bulgaria ($35 million).} Alternatively, an 
independent expert should be asked to look at the quality of the Master’s program that 
is now emerging, and to advise about how to proceed with the further development of 
the Ph.D. program. 
(However this situation is handled, perhaps VCU and AIHA could explore possibilities 
for fellowships (Muskie?) for graduate training in the U.S., if faculty can be identified 
who have high probability of returning to work at KSPH. Additionally, there is need for 
researchers to set up measurement of progress in field projects, such as the Astana 
FMC and outreach program. Do other projects have small grant funds that would 
enable KSPH faculty and students to take on this kind of operations research, with 
technical guidance from VCU?) 
 (b.) Kyrgyz State Medical Academy 
In Bishkek, there was more time to spend with the KSMA leadership and the programs. 
Mary Skarie joined us for this portion of the assessment.. Subsequent to the trip, Dr. 
Conoboy at the University of Nevada was interviewed. 
The Partnership’s work plan concentrates on improving teaching methods and 
upgrading curriculum content, particularly for family practitioners and nurses at KSMA, 
emphasizing evidence-based medicine, and for management of health institutions. The 
KSMA/Reno work plan seems more carefully crafted to avoid overly ambitious tasks. 
The establishment of a residency program for family medicine is a major step forward. 
The recent Abt/Reno agreement to deal with disparities between faculties for in-service 
and KSMA training eliminates a problem and establishes a nice precedent for problem￾solving between two USAID activities. 
Reviewing the situation at KSMA, USAID’s strategic purposes in providing support 
appears uncertain. In the meeting with Minister Meimanaliev, he gave KSMA high 
importance. If the purpose is to produce leaders for health sector reform, as Dr. 
Meimanaliev seem s to desire, a longer term effort will be needed. KSMA is another 
example of a complex institution that will require long-term assistance in order to 
function similarly to Western counterparts. At KSMA, there appear to be no Ph.D. 
graduates from Western universities. USAID’s past experience with graduate schools 
suggests that a combination of (1.) U.S. degree training for young faculty and (2.) long￾term assignment of U.S. faculty, to have substantial effect on teaching and research 
standards and methods, is essential. 
The Center for Health Care Research at KSMA made a very effective presentation. 
This is a very strong team with a clear vision of their objectives. The skills that Reno 
has given them to do Community Assessments are being put to good use in Southern 
Kyrgyzstan. The specific research agenda indicates the Center’s intention to be useful 
for policy makers; however, they need additional formal training and education to use 
their potential. Nevertheless, the progress already made by the team at the Center 
suggests that they can become the experts that the Minister desires, as leaders of 
21
reform. One of the objectives of Ph.D. programs is to rewire your thinking circuits, so 
questions about the real world are approached in a disciplined way, different from our 
intuitive processes. Perhaps the needs of the team for structured Western training can 
be meet through some creative thinking about finding supplementary resources. The 
Partners in Reno are working on this issue. In the meantime, they could be helpful in 
documenting lessons from innovative field programs in the region. 
 (c.) The Rectors’ Council 
The Rectors’ Council is a fine example of AIHA’s creativity in fashioning a useful 
solution, an institutional mechanism, to a particular problem, and doing so in a way that 
will have long-term benefits. The problem was the variation among countries in the 
region in the educational programs for health professionals: differing curricula, different 
years of required education, different standards of achievement. Rather than wade into 
the morass of unifying accreditation rules for curricula and length of education, AIHA 
with Abt and USAID to devise the Rectors’ Council to lead out of the morass with 
common examination or achievement standards, a topic where agreement could 
feasibly be reached. Once established, the Rectors’ Council is a ready-made 
continuing vehicle for collaboration on university policy or cooperation among countries 
in the region. 
c. Introducing Better Curricula and Teaching Methods 
Training was an important element of every partnership activity. Every U.S. partner had 
experts to draw upon for curricula development, upgrading teaching methods, skills 
based training, case simulation for clinical experiential training, or training of trainers. 
These capabilities have become the bread and butter of programs for health 
professionals in the U.S. U.S. partners know how to do it, and Central Asian partners 
all have staff that have become experts for their own countries. This is clearly a growth 
industry. 
The Astana project has trained their own staff and has already planned the training 
program to pass on their skills to other organizations. KSPH and KSMA are adopting 
U.S. teaching and training methodologies; however, complete adoption in these 
organizations may not happen fast. KSPH has the advantage of being a new institution, 
buy the older faculty may nevertheless be resistant. The EMS and Toxicology units 
have training among their basic skills for propagating their systems of care. The 
Aschgabad Family Medicine Training Center and the North Dakota Partners have 
earned the award for overcoming the most daunting obstacles. The Aschgabad training 
team, even those who hadn’t been allowed to travel to North Dakota for training of 
trainers, did a fine job during the inaugural training demonstration for the assessment 
team. I was particularly impressed with the nurse/trainer who had grasped the 
principles so well. 
The Ashgabat Family Practice Center has become one of the beachheads for health 
reform in Turkmenistan, and perhaps as significant, one of the few beachheads for U.S. 
22
development assistance. It was not so clear to me how the Ministry would incorporate 
the Center into planning for health reform, but the survival skills developed by the 
Center Director and her staff will undoubtedly enable them to find a way. There was 
some concern about whether the North Dakota team had made use of other available 
training materials prepared in Russian, specifically the materials from Tajikistan. AIHA 
assured me that the Tajik materials had been reviewed to ensure that no duplication of 
effort occurred. Given the difficulty encountered by the North Dakota team in getting 
their materials translated in time, I suspect they would have welcomed a ready version 
from elsewhere. 
Training and related functions are clearly within AIHA’s comparative advantage 
category. 
d. Raising Professional and Institutional Standards 
AIHA has been a catalyst throughout the region in changing the role of nurses, raising 
their professional opportunities and their educational options. The teaming of doctors 
and nurses in the Astana Family Medicine Center has been described, where nurses 
have an important role in handling patients with important judgments to make about 
responding to the patient’s needs. Similar changes were made in Almaty City’s 
Women’s Wellness Center. The Tucson Partnership was also instrumental in raising 
the educational opportunities for nurses, assisting a private nursing college to offer a 
four year baccalaureate degree to nurses. Perhaps the most significant advances have 
been made at the Kyrgyz State Medical Academy where a new curriculum has been 
developed for nurses working in family group practices. Similarly, in Turkmenistan, 
nurses are full-fledged instructors along with physicians at the Family Medicine Center. 
Through the Partnerships’ visits to the United States, Central Asian nurses and 
physicians have observed the professional roles of nurses in management and in 
clinical care; these observations have been taken back to Central Asia to stimulate 
reform. AIHA has supported a regional nursing association, reinforcing these changes 
in attitudes and opportunities for nurses at AIHA sponsored conferences. Similar 
upgrading of professional standards have occurred for family physicians, toxicologists 
and emergency medical staff, again stimulated by observing the roles of these 
professions in the U.S. AIHA’s comparative advantage in raising standards arises also 
from the broad involvement in health institutions where these professions are 
trained/educated and employed. 
The same factors operate to raise standards of care in institutions, for example through 
observation in the U.S. of client-oriented health services, and standards of infectious 
disease control in clinical facilities. The quality of care and rapid action by the Almaty 
Emergency Medical Services is another apt example. 
6. AIHA’s comparative disadvantages for USAID programs in Central Asia 
23
a. AIHA Lacks Documented Strategic Analysis for Central Asia that might be 
 utilized in USAID 
Both AIHA and USAID do careful strategic planning, but as described above in Section 
4, the planning processes are entirely different in nature. The continual incremental 
strategic planning that occurs within AIHA, usually when AIHA headquarters and 
regional managers are talking with senior government officials, is dynamic. Options and 
alternatives are continuously being considered. Problems and needs in the country are 
being explored for understanding and to identify program opportunities. These informal 
strategic planning discussions are seldom documented until final program plans 
emerge, and the underlying fact-finding and reasoning process is relatively invisible. 
AIHA has a small group of officers at the policy and planning level, so current thinking 
circulates easily, probably orally for the most part. To draw the obvious contrasts with 
the USAID bureaucracy, nothing exists as a USAID program until it is in readable text 
that can be circulated among sometimes distant offices, among reviewers comprised of 
generalists and technical experts, until consistency between budgets is determined and 
predictions of program results carefully considered, until a procurement plan is carried 
out. The strategic thinking in AIHA would be valuable for USAID and the more formal 
strategic planning carried out by USAID and Abt would enlighten AIHA’s thinking. A 
mechanism or event is needed to link the two planning processes that would not 
undermine the integrity of either planning system. 
 b. The AIHA program has been designed to assist institutions and is not well- 
 suited to address broad strategic problems above the institutional level. 
AIHA’s programs, particularly the Partnerships, are designed to be effective at the 
institutional level. Less formally, AIHA managers often operate at the policy level above 
the Partnerships. At times, because of AIHA’s relationships of confidence with policy 
makers, AIHA can take action to facilitate the policy process. For example, AIHA 
convened a January 2001 workshop on training and human resource needs in Central 
Asia by the year 2010. The specter of unemployed medical specialists probably 
animates much of the resistance to health sector reform. AIHA’s initiative created an 
opportunity for policy makers to begin addressing this problem. Even though AIHA’s 
Partnerships are not directly involved in broad strategic questions, AIHA’s access and 
sometimes long relationships with policy makers could make AIHA an effective 
participant with USAID in shaping solutions at the policy level. During the assessment, 
the Kyrgyz Minister of Health asked AIHA to consider convening the donors for a 
meeting in the Summer of 2001. Devising a response to the Minister could be a useful 
opportunity for AIHA and USAID to work together in supporting open consideration of 
policy-level problems in the health sector. 
 c. AIHA’s short-term inputs are not well-suited for long-term institutional 
 development 
The limitations of AIHA’s short-term training, short-term visits and short-term technical 
assistance together with the relatively brief 3 to 5 year project life span allowed by 
24
USAID are most apparent, for example, in considering the long-term institution building 
tasks ahead for the Kazakhstan School of Public Health, discussed above. USAID and 
AIHA should take another look at what options are available within USAID’s overall 
project guidance to fashion longer duration assistance where institution building is the 
objective 
7. AIHA’s Management and Administrative Capacity and Structure 
The functions of the Regional Office addressed in the statement of work for the 
assessment concern the ability of the small staff to keep on top of the many partnership 
and AIHA Regional Activities. 
• Does the Regional Office have adequate capability to monitor achievement of 
program objectives, including the technical and programmatic content of the 
Partnership programs? 
• When technical or management problems arise, does the Regional Office 
communicate effectively to ensure the problems are resolved in a timely and 
satisfactory way? 
• Do the AIHA Regional Activities, such as conferences and workshops, that are 
organized by the Regional Office detract from the capability of the staff to monitor 
the Partnership activities? 
As noted above, AIHA’s senior managers in Washington and the Central Asia Regional 
Office work as a team, so consideration of effectiveness and efficiency must be in terms 
of the whole team’s performance. The Washington headquarters office is organized for 
the purposes of program and financial management and administration, and not for 
technical direction. Because AIHA relies on the U.S. partners for technical leadership, 
there is no unit for technical program strategy or direction in Washington. AIHA’s 
technical experts are in the Regional Offices, and it is the Regional Office that 
formulates technical strategies and monitors the technical performance of the 
Partnerships. The AIHA Regional Office for Central Asia is fortunate to be managed by 
a senior physician with involvement in AIHA’s Central Asian program from the 
beginning. There are also two health professionals on the staff, a finance manager and 
a communications technology expert. This is a small team, the smallest among AIHA’s 
Regional Offices. 
Decisions at headquarters are made by a small team of management executives: the 
Executive Director, the Chief Financial Officer and the Associate Director for 
Partnership Programs. With decision-making authority held within such a small group, 
administration of the program is vulnerable to bottlenecks at the top. Among the 
Partnerships, there was some evidence that decisions can be delayed. There are also 
advantages to centralized decision-making. Communications about what is going on in 
the field are shared among a fairly small group at headquarters. Perhaps most 
important, because decisions on programs, finance and procurement are referred to 
headquarters, the Regional Office is not under direct pressure for approvals or 
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allocations of resources. The Regional Office can concentrate on coordination of 
AIHA’s activities in the region and on monitoring AIHA programs. 
During the assessment, it was possible to observe in detail only the work of the 
Regional Office Director, and not the staff. (The administration of the assessment itself 
was shared by the USAID Mission and by the AIHA Regional Office. Despite some 
problems caused by canceling of flights, the assessment occurred smoothly and 
efficiently, giving evidence that the USAID and AIHA staffs worked effectively together.) 
Throughout the assessment, it was clear that Dr. Nugmanova had a keen appreciation 
of all the technical and managerial aspects of the AIHA program. Moreover, she has a 
clear vision of the problems and the potential of health reform in Central Asia that 
guides the strategic thinking of AIHA’s Executive team. She is clear and constructive in 
identifying problems and communicating them to AIHA’s Executive team. She is a 
skilful diplomat and problem-solver. Because of her excellent judgment and experience, 
she is able to contribute usefully to the USAID strategic planning process. 
The Regional Office provides technical support for communications technology, a 
service designed for the Learning Resource Centers. This assessment has identified 
another area where technical support might benefit the Partnership programs: evidence￾based programming, i.e., design of program evaluation systems that would collect 
baseline and follow-up data. The main purpose would be to learn about the costs, the 
benefits, and the effectiveness of programs, particularly service delivery programs, in 
order to provide evidence of the outcomes for policy makers. The technical capability 
for design of program evaluation systems could be provided from medical school 
faculties, such as KSPH and KSMA, perhaps through small contracts from the AIHA 
Regional Office or from the Partnerships. Having this kind of capability available under 
Dr. Nugmanova’s guidance would greatly strengthen the program monitoring capability 
of the AIHA Regional Office. Involvement of the Regional Office in this new approach to 
program evaluation may require augmentation of administrative capability in the office. 
8. Recommendations to USAID and AIHA
With some trepidation, because of the superficial nature of the assessment, this report 
will make some recommendations about how the USAID and AIHA organizations can 
mesh more effectively at the level of strategic decisions. 
a. The main recommendation to USAID and AIHA is to seek an appropriate 
way to link the strategic planning processes between the two 
organizations. 
The following two suggestions are intended to stimulate the search for linking 
mechanisms: 
• AIHA should make more effort to document the choices for future partnerships in 
a strategic way, identifying the significance of a proposed partnership for health 
reform, outlining how the partnership can move health reform forward. This will 
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happen most effectively if USAID and AIHA are in continuing dialogue about the 
health reform process, exchanging observations and ideas. When AIHA is 
approaching the point of proposing partnerships, special effort should be made to 
engage USAID in the thinking process. The earlier the better. The thinking 
should also be documented, with reference to health reform, so that future 
changes in staff or strategies in either organization will have as a reference the 
strategic rationale for selection of partnerships. 
 
• USAID should consider establishing a forum for its implementing projects (Abt, 
AIHA, Project Hope, etc.) to engage in strategic discussion about health reform in 
Central Asia. For example, a semi-annual meeting with an agenda of one or two 
issues related to health reform would give all USAID’s implementing partners a 
way to share their insights and wisdom about health reform. Responsibility for 
organizing the meeting could be taken by USAID or rotated among the 
implementing partners. USAID should discuss with AIHA the possibility of inviting 
one representative from each of the current U.S. Partnerships. Hopefully, the 
semi-annual meetings would stimulate more frequent informal strategic 
discussions about health reform between USAID and individual implementing 
partners. 
b. With regard to AIHA’s areas of comparative advantage, USAID should 
consider the following steps to increase the usefulness of AIHA programs 
for health sector reform: 
• Improved health care service delivery
USAID should request AIHA to develop capability for evidence-based 
programming, to document for policy makers and donors the cost-effectiveness 
and cost-benefit ratios of AIHA partners’ improvements in health service 
delivery, such as community outreach. With capability for evidence-based 
programming, innovations in health care service delivery could be given higher 
priority in selecting future partnerships. 
• More effective health institutions
For development or reform of complex institutions such as medical schools or 
schools of public health, USAID should undertake careful evaluation of the 
effectiveness of AIHA’s partnerships programs, with their relatively limited short￾term inputs, especially where the expectations of donors are for these institutions 
to play leadership roles in reform of the health sector through a combination of 
teaching, research and extension. Creative supplementation of Partnership 
inputs, for example with long-term fellowships for U.S. academic training or 
faculty sabbatical exchanges, should be explored. 
For less complex institutions, including teaching institutions without research and 
application functions, or single-purpose organizations such as emergency 
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services, USAID and AIHA should analyze more carefully the contributions these 
institutions can make to health reform, expecially to understand how these 
institutions will fit into a system emphasizing primary health care. Partnerships 
have been more successful with organizations which are somewhat independent 
in the health system, such as the toxicology centers, and less successful with 
organizations embedded in complex bureaucracies, such as the no-socomial 
infection control unit in Almaty. 
• Better teaching and clinical methods
• Raising standards of health professionals
USAID can confidently support partnerships that have these purposes. U.S. 
partners are highly skilled in transferring teaching methods and use of improved 
clinical algorithms. By seeing the functions of U.S. workers, Central Asian 
partners can be inspired to adapt and introduce new standards or roles health 
professionals. At this stage, change is occurring slowly; for example only a 
small portion of Kazakhstan’s 100,000 nurses have been affected by 
Partenership programs. 
Nevertheless, USAID and AIHA have to consider carefully the contribution these 
improvements will make to health sector reform. For example, there seems to 
have been no clear analysis or strategy for effectively using the over-supply of 
health specialists on government payrolls. Without overall plans for reducing 
government payrolls, changing roles within health professions may exacerbate 
the overall problem of oversupply. 
c. With regard to AIHA’s areas of comparative disadvantage, USAID should 
consider the following steps to increase the usefulness of AIHA programs 
for health sector reform: 
• lack of documented strategic analysis
USAID should request AIHA to do a better job of making AIHA’s strategic 
analyses accessible to USAID/CAR and to other USAID-funded organizations 
pursuing the same Strategic Objectives. By documenting these strategic 
analyses for discussion with USAID, AIHA may reduce the risk of USAID 
changing program priorities without regard to AIHA’s continuing programs. 
• difficulty of using AIHA’s institutional-level partnerships for broader 
systemic changes 
Both USAID and AIHA should make greater effort to select partnerships that 
directly contribute to health sector reform, situating the partnerships so results 
are accessible to policy makers and documenting results so achievements can 
be considered for broader applications. 
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AIHA’s regional programs have often been very effective in promoting reforms at 
the policy level; the annual conferences in Washington are useful forums for this 
purpose. AIHA should make greater effort to engage USAID/CAR and other 
USAID-funded organizations in orchestrating these kinds of events to move 
forward USAID’s health reform efforts. 
• difficulty of pursuing long-term development objectives with USAID’s short 
project time-frames and AIHA’s short-term inputs 
Despite the short project time-frames and short-term inputs, USAID should 
engage AIHA in considering long-term health reform objectives and in analyzing 
how the long-term objectives can be achieved with the AIHA program’s 
limitations. 
d. To enable AIHA management to be more effective in supporting health 
sector reform in the region, USAID/CAR and AIHA should consider the 
following possibilities: 
• a common agenda of health reform issues, developed by AIHA based on 
the continuing dialogue with health officials in the region. 
The AIHA Regional Office, in consultation with AIHA headquarters, should 
develop an agenda of issues important for health reform. The agenda should be 
used with USAID/CAR as a guide for continuing, periodic dialogue between 
USAID and AIHA about obstacles to health sector reform. AIHA should modify 
the agenda as the reform process unfolds, scheduling regular (bi-monthly?) 
discussions with USAID. AIHA headquarters staff should arrange to participate 
in these meetings during their normal visits. (This suggestion is separate from 
the recommendation at the beginning of this section for AIHA’s participation in 
USAID’s strategic planning. The objective here is to put the agenda for regular 
meetings with USAID staff in the hands of AIHA’s Regional Office.) 
• allocation of additional staff and financial resources to the AIHA Regional 
Office in order to organize evidence-based programming in Partnership 
programs. 
The AIHA Regional Office should be given the resources to mobilize an 
evidence-based programming capability, i.e., the technical expertise from the 
region that can help AIHA partners document their achievements, including 
quantitative information about cost-effectiveness and cost-benefits of AIHA 
innovations. The technical experts could be hired as AIHA Regional Office staff 
or acquired through small contracts with medical schools or KSPH. U.S. 
Partners could provide their own experts to contribute to this endeavor. 
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Attachment: Schedule of Meetings with Contacts 
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