Problem: Kazakhstan was ranked among countries with the lowest life expectancy in the WHO European Region; health professionals were distributed inequitably across the country and geographic disparities in health status were seen between rural and urban populations.
Solution highlights: The concept of transport medicine was conceived: Using the country’s existing transportation infrastructure, a series of trains now travel to stations across the country to provide health services to rural populations; aligning the initiative with overarching health system reforms (the State Health Care Development Programme for 2011–2015 “Salamatty Kazakhstan”), and gaining cross-sector buy-in from the government, helped to support implementation of medical trains; building upon existing infrastructure helped to alleviate the burden of additional resources in the setup and rollout of the initiative; solutions for population health problems were based in a strong understanding of current challenges and were adapted to population and geographic contexts.
Description of practice
Kazakhstan faced a rural-urban health divide, with discrepancies in resources distributed across the country, particularly human resources. Many rural and remote areas experienced a general shortage of health workers. For example, the northern region of Kostanay had just 266 physicians per 100 000 population compared to a national average of 388 per 100 000 population in 2010. Persisting challenges – such as limited health infrastructure, constrained resources and poor sanitation – negatively impacted the health system’s ability to substantively reduce morbidity and mortality among the country’s rural populations.
The launch of the State Health Care Development Programme “Salamatty Kazakhstan” put focus on the health and development of the population, and set out plans to modernize and expand health services across Kazakhstan. In the context of this overarching policy, the Ministry of Health and the Committee of Emergency Situations (within the Ministry of Internal Affairs) introduced a programme for train-based health service delivery, capitalizing on the existing railway infrastructure as a means to reach rural areas. Three mobile medical trains have been established: Densaulyk, based in Almaty; Zhardem, based in Aktobe; and Salamatty Kazakhstan, based in Karaganda. The three trains serve southern, eastern-western, and northern regions of the country, respectively. Each train consists of eight wagons and 80 staff members, of which approximately half are health providers (including general practitioners, nurses, and specialists such as pediatricians, neurologists, gynaecologists, cardiologists, and dentists). The trains are equipped with modern clinical, diagnostic and radiology equipment. Advanced infrastructure and resources on board the trains allow for complex diagnosis and treatment of patients, including minor outpatient surgery and dental care. Real-time video communications are used to link onboard providers with professionals in hospital settings. Managers on board each train are responsible for ensuring a specific itinerary is followed and that trains are appropriately resourced throughout their trips. Today, medical trains continue to cover remote regions of the country, stopping according to predetermined schedules to deliver care to patients.
Implementation of practice
What stage is the practice currently in?
Fully implemented and scaled up
Who was/is responsible for the implementation of the practice?
The Ministry of Health led the introduction of medical trains as a means of tackling health disparities between rural and urban areas. With the President of the Republic of Kazakhstan’s support, cross-sector action was made possible, linking with the Ministry of Internal Affairs and partnering with the company responsible for railway transportation, Kazakhstan Termir Zholy.
Trains take approximately 20 days to cover 832 remote stations. Between 2010 and 2014 medical trains treated 56 851 people. Ongoing monitoring and registration of patients has recorded positive outcomes for the initiative, notably in terms of improved access to services. More than 30% of patients seen on each train are diagnosed during their first appointment, of which one in four are diagnosed with a serious disease requiring intervention.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Gulnara Kulkayeva
- Ministry of Healthcare and Social Development