PROCEEDINGS OF THE URBAN SEMINAR - CENTRAL ASIAN CITIES IN SEARCH OF NEW WAYS OF GOVERNANCE: THE IMPACT OF COVID-19 AND BEYOND (Part 2)

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PANEL DISCUSSION PROCEEDINGS: RESPONDING TO COVID-19 IN CENTRAL ASIA: ADJUSTING HEALTH SERVICES IN TIMES OF CRISIS

Developed by: Ilyas Yesdauletov, PhD Candidate, University of Edinburgh, i.yesdauletov@sms.ed.ac.uk
Saniya Soltybayeva, Research Fellow, Economic Research Institute, Ministry of National Economy of Kazakhstan, soltybayevas@gmail.com

Cite as: Yesdauletov, I & Soltybayeva, S (2021) Central Asian Cities in search of new ways of governance: The impact of COVID-19 and beyond. Proceedings of the Urban Seminar. The Central Asian Research Forum on Sustainable Development and Innovation of the Kazakhstan PhD Association in the UK (KPAUK). March 17-18, 2020, Nur Sultan. Available at: https://www.kpauk.org/articles/social-science/proceedings-of-the-urban-seminar---central-asian-c59/

In this session, the panellists explored Covid-19 pandemic responses in two Central Asian cities, namely Almaty and Bishkek, and compared them to other post-Soviet cities. During the discussion, the following two broad questions were pursued:
1. What were the most acute problems in administering health services in Central Asian cities during the peak of the Covid-19 crisis?
2. Compared to last year, there is now a weakening of the pandemic. How did the healthcare systems of Central Asian cities change since the peak?

The discussion revealed that the Covid-19 crisis exposed Central Asia's acute health care issues such as a shortage of medical personnel and protective equipment, opacity of the state apparatus, and inefficient bureaucratic procedures. Yet the pandemic also demonstrated the city administrations' ability to change and adapt and the power of the region's civic society. Moreover, Central Asian cities had been actively preparing for the next wave of the pandemic. However, the cities face serious issues with the supply of the Covid-19 vaccines and the reluctance of people to be vaccinated. Below are the main messages of this discussion.

Moderator: What were the most acute problems in administering health services during the peak of the COVID-19 crisis?

Discussant: Aida Alzhanova
Firstly, the Kazakh public authorities are relatively enclosed, and they began interacting with society only in recent years. The Law on Public Councils came into power in 2015. However, the councils' activity raises many questions. For example, these council members' selection is not transparent, although they now include mostly civic activists and professionals. Secondly, the problem is the centralisation of power. All medical supplies are purchased through the Akimat [city administration]. The purchase of personal protective equipment (PPE) was carried out back in January 2020, but during the crisis (March 2020), there was an acute shortage of medical supplies in hospitals. This led to the fact that 551 doctors became infected in the central state hospital of Almaty in the first days of the pandemic - this is an ordinary hospital where no special protection measures were taken. In Almaty, in the first weeks of the pandemic, more than 1000 doctors became infected.
The authorities claimed that the doctors had all the PPE, although they were given only two masks per day, according to interlocutors. In this regard, the local society and business structures gathered and provided the Almaty health department with 11 thousand PPE in a few days. However, these organisations' closed nature led to the fact that there are suspicions as there is no evidence about whether the PPE reached the hospitals, who at what level violated the procedures.
After the mass infection began, this central state hospital of Almaty was declared a provisional centre – starting from April 11, all infected doctors were included in the list of those who were to receive compensation from the state budget and those infected there before April 11 were denied compensation. Then city civic activists put pressure on the authorities so that all denied initially infected doctors received payment from the city budget - the fact that they got sick is the public health department's fault, which did not provide enough PPE. Another problem is that small and medium-sized private medical facilities were shut down due to lockdown. Only state clinics could function. People who had non-Covid19- related illnesses had limited access to medical services. Therefore, it is unclear whether deaths should be attributed to Covid-19 or other diseases.
The third problem is related to corruption - the problem of a shortage of medicines, which were later found in the warehouse of SK Pharmacy by civic activists. There have been many discussions on these issues, but they have not been resolved yet. One of the main problems is the abysmal communication of government agencies both with the population and within the medical community.
The Deputy Governor of Almaty said that rumours about queues in pharmacies were fiction, which caused a storm of indignation among the population. The people achieved his removal. Civic activists were allowed to check the warehouses for corruption. All in all, the pandemic gave a powerful impetus to the social movement. Even a special Law on Public Control was initiated.
When the Kazakhstan government introduced price controls for drugs in pharmacies, many drugs disappeared from sale.

Discussant: Ainagul Kerimkulova
Bishkek faced the same problems as other countries.
• shortage of PPE, medical equipment and medicines;
• increased prices for masks;
• in the early days of public procurement, there were no bids from potential suppliers. Often private business and humanitarian aid helped to resolve the PPE and mask supply problems;
• the crisis has exposed health care issues such as a shortage of medical personnel, especially in primary health care due to low salaries;
• the "Black July" in Kyrgyzstan - shortage of infectious beds, when the beds of all other medical institutions and hospitals had to be redesigned, and hospitals stopped accepting non-Covid patients unless in extreme cases;
• at the very initial stage, there was not enough knowledge about the virus itself. In time, the Ministry of Health approved clinical protocols and standard operating procedures to treat Covid-19 patient;
• another issue was a shortage of ambulance crews, and not all patients with suspected coronavirus symptoms could be hospitalised due to the shortage of hospital beds.
On March 25, an emergency regime was introduced in Bishkek and certain districts of the Osh and Jalal-Abad regions. The entire businesses, including private clinics, were closed during the quarantine period from March 25 to June 2020. After that, some large private clinics that provided inpatient care began to work, but the cost of their services was high.

Follow up question from the moderator: To speed up the provision of medical supplies, was the procurement process changed? How did it happen?

Discussant: Ainagul Kerimkulova
The Kyrgyzstan government expedited the purchase of PPE by relying on direct contracting.
Also, in the case of pharmacies, prices have jumped on drugs. The government worked with pharmaceutical companies to limit price increases on medicines.

Discussant: Aida Alzhanova
In some cases, direct import (without licensing and permission) of PPE and other necessary medicines was allowed - a one-time import. However, these measures were put in place only after the death rate had already risen sharply. There were also long queues at pharmacies, where all the medicines disappeared. People bought in reserve, and those who needed them the most suffered. Prices have inflated a hundredfold. People took out loans to buy the necessary medicines.

Moderator: Giorgi, as we can see, during the pandemic's peak, Central Asian cities experienced issues with hospitalisation, accessibility of drugs, corruption, bureaucratic obstacles. Did you observe similar problems in other post-Soviet countries? What is the story in the cities that you have researched?

Discussant: Dr. Giorgi Khishtovani
Our project idea was to collect best practices in dealing with Covid-19, including health and business issues. We covered countries globally but also post-Soviet countries.
General issues that the health system and municipal government faced were as follows.
• The major problem was a scarcity of relevant medical and human resources. The percentage of doctors that got infected was high during the first months of the pandemic. There were specific training and retraining for retired staff as well as support from medical students.
• Intersectoral municipal coordination was also relatively low.
• Another issue was about mental health. For example, some cities in Moldova have provided a special guidance programme on mental health.
• Also, the problem with bureaucratic procurement procedures to buy PPE was almost everywhere in post-soviet countries. Moreover, the supply of essential medical services that not related to Covid-19 was scarce.
• However, the cities' primary challenge was linked with the level of independence, where local governments' capacity was different in different countries. For example, in Azerbaijan, everything was decided by the central government, while other levels of governments just followed it. The Director of the health department in Vilnius reported a permanent fight between central and local governments as the latter insisted that they knew better what needs to be done at the local level. Deputy Mayor of Tartu (Estonia) stated that the local governments' level of independence also affected their resilience. Estonia's higher decentralisation level allowed local governments to discuss more with the central government rather than in Belarus and Azerbaijan. In Tbilisi, a coordination council was established on the central level. The council incorporated ideas and suggestions from city governments.
• There was also a digital inequality issue. The younger population was more capable of following the rules, whereas the older people struggled more with digital services. There were some initiatives on the municipal level to help older people to become more e-friendly.

Moderator: Compared to last year, there is now a weakening of the pandemic. What is happening now after the peak of the crisis? What is the focus? For example, in the United Kingdom, the main priority is vaccination of the population. What about the Central Asian cities?

Discussant: Aida Alzhanova
Vaccines are not yet available. They were purchased in small quantities for medical personnel, teachers and police, while some of them refused to be vaccinated. People are also reluctant to be vaccinated. There is also a lack of trust in the Kazakhstan authorities in general and in the Kazakh vaccine. A lot of work is needed to educate people about the benefits of vaccination, a need for an effective communication campaign. So when vaccines become available, there is a risk that people will not vaccinate due to mistrust towards the vaccines. High levels of mistrust of vaccine benefit and concerns about future unforeseen side effects are the most critical determinants of uncertainty and unwillingness to vaccinate against COVID-19.
Almaty is in the red zone, but there is no longer a complete lockdown. Everyone understood that with the observance of precautions, you could work. However, many wear masks incorrectly. People do not realise the seriousness of the situation.
The health services are also more prepared now. Special mobile teams have been organised and equipped. Patients with moderate to high severity are hospitalised. Medicines for treatment are provided free of charge. However, the rise in the infection rate is worrying.
During the peak of the pandemic last year, treatment protocols were not clear. For that reason, many doctors refused to work. This issue is now resolved, and the doctors demonstrate a greater willingness to treat Covid cases. Medical personnel that deal with infection gets additional payment.
Moreover, the past year demonstrated the strength of civil society. Young scientists from Kazakhstan and PhD students studying abroad organised the translation of the best medical resources about the virus into Russian and Kazakh languages available for all people and posted them on social networks.

Discussant: Ainagul Kerimkulova
When the pandemic began, mobile teams were created, which consisted of a doctor, a nurse and an epidemiologist. They monitored the health of contact persons and patients with mild and no symptoms. At the peak of the pandemic, the number of mobile teams was brought to 40; currently, due to the decrease of patients, eight teams are working. But in the case of further increases in the number of infected persons, the number of mobile teams will be increased. By the decree of the Government of the Kyrgyz Republic, additional wages were established for medical workers working in the "red zone", including workers of mobile teams.
In addition, a hotline (call centre) was organised to provide prompt medical advice to the population on self-diagnosis of coronavirus. In cases with suspected coronavirus, the applicant's data was transferred to mobile teams to assess the applicant's condition and take a smear for a PCR test. During the peak of the pandemic, the hotline received up to 4 thousand calls a day, while another 10 thousand were not dialled. In this regard, the number of hotlines was increased to 40, for which a school gym was used.
In July 2020, due to the increase in the number of patients and the shortage of hospital beds in Bishkek, inpatient organisations (day and night hospitals) were opened to provide outpatient medical care to patients with moderate to severe cases. These inpatient facilities were placed in large gyms, schools and other organisations with large indoor spaces. From July 4 to August 27, 2020, more than 100 thousand patients have been treated at day and night hospitals.
At the moment, measures are being taken to prepare for the third wave, and a response plan has been developed. Preparations have begun for mass vaccination against Covid-19. Vaccination rooms have been deployed, training seminars for medical workers have been held. Also, methodological recommendations for organising and conducting immunisation, a pre-vaccination questionnaire, a memo on possible immunisation side effects, an informed consent/refusal form for the Covid -19 vaccination, Covid-19 immunisation card-badge, and Covid -19 vaccine administration algorithms have been developed.
Vaccines have been obtained from China as humanitarian aid. Vaccination starts tomorrow.
People from the high-risk groups will be vaccinated first: medical workers, teachers, people over 65, the Ministry of Internal Affairs, Ministry of Emergency Situations, etc.
A daily morbidity screening is being carried out - a medical examination of students.

Moderator: How are other cities preparing to fight Covid today?

Discussant: Dr. Giorgi Khishtovani
The majority of former Soviet Union states and Eastern European countries are struggling a lot with a weak communication campaign. Many of them already started vaccination. In Georgia, the vaccination target is 60% of citizens. However, the current situation in Georgia is difficult – physicians were vaccinated first. Still, the amount of vaccines is limited, and we have no guarantee that we will have enough vaccines for all population. At the same time, the majority of people are against vaccination, including many physicians. It also creates an economic problem as the speed of vaccination is highly correlated with economic recovery.
Now we are opening up our economy; restrictions are lifted in Georgia. However, with this low speed of vaccination, we will have the third wave. It's a big problem in all post-Soviet countries.
This problem is complex because not only supplies are missing but also demand is not available. People refuse, and antivaccination campaigns are powerful. Strategic communication is a new sector of government activity. It can be a very long-standing problem.

Follow up question from the moderator: Do governments realise that the third wave is coming?

Discussant: Dr. Giorgi Khishtovani
It's the case. At the city level, they are much more prepared for the crisis. Now the level of stress is less than during the first months of the pandemic. Almost everybody expects the third wave. The recovery may start only in 2022. First, we need a sufficient supply of vaccines, and then we need to persuade people to vaccinate.

Discussant: Aida Alzhanova
In this regard, the situation in Kazakhstan differs from other post-Soviet countries. We have developed and started producing our own vaccine and the Russian one. It will be available from April. However, there is no proper communication for the population from the governmental side, while Covid dissidents widely use it.

Question from the audience: In Ukraine, the logistics issue of vaccination has arisen. Are the logistics and distribution ready when the vaccines arrive?

Discussant: Aida Alzhanova
There are no problems with this in Kazakhstan. "SK Pharmacia" has been building logistics for the supply of essential drugs for ten years. The same logistic routes can be used. But now, they are not doing informational work on vaccines. There is a risk when vaccines appear; there will be a shortage of them, and their price will triple.

Discussant: Dr. Giorgi Khishtovani
Logistics is the least problematic area in the post-Soviet countries. The most pressing issue is the supply of vaccines. Countries struggle to obtain a sufficient number of them. Then there is the people's resistance to be vaccinated. So, logistics comes after these two issues.

The seminar proceedings were prepared by:
Saniya Soltybayeva, Research Fellow, Economic Research Institute, Ministry of National Economy of Kazakhstan

Reviewed by the moderator and discussants:
Ilyas Yesdauletov, PhD Candidate, University of Edinburgh (moderator)
Ainagul Kerimkulova, Deputy Head, Health Department of Bishkek City Administration (discussant)
Aida Alzhanova, Civic Activist, Independent Director, National Center for Obstetrics, Gynecology and Perinatology (discussant)
Dr. Giorgi Khishtovani, Research Director, Policy and Management Consulting Group, Investigator of the Research of Good Practices and Moderation of Virtual Events at Municipal Level in Times of COVID-19 (discussant)

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