Health challenges in Kazakhstan and Central Asia Shalkar Adambekov, 1 Aiym Kaiyrlykyzy, 1 Nurbek Igissinov, 2 Faina Linkov 3,4 1 Center for Life Sciences, Nazarbayev University, Astana, Kazakhstan 2 Central Asian Cancer Institute, Astana, Kazakhstan 3 Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA 4 Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Women’s Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA Correspondence to Dr Faina Linkov, University of Pittsburgh School of Medicine, 3380 Blvd of Allies, Room 307, Pittsburgh, PA 15213, USA, linkfy@mail.magee.edu Received 22 June 2015 Revised 10 July 2015 Accepted 14 July 2015 To cite: Adambekov S, Kaiyrlykyzy A, Igissinov N, et al. J Epidemiol Community Health Published Online First: [ please include Day Month Year] doi:10.1136/jech-2015- 206251 ABSTRACT The Central Asian region, which encompasses Kazakhstan, Uzbekistan, Tajikistan, Turkmenistan and Kyrgyzstan, is an interesting geographic region with a rich history dating back to the Silk Road, Mongol conquests and expansion of the Russian Empire. However, from a public health viewpoint, the Central Asian region is under-investigated, and many public health challenges exist, as countries of Central Asia inherited the centralised medical systems practiced in the Soviet Union, and are currently undergoing rapid transitions. A large number of low and middle-income countries around the world, including countries of Central Asia, face a double burden of chronic and infectious disease. This essay focuses on the exploration of the most important public health challenges in the Central Asian region, including limited scientific productivity, the double burden of chronic and infectious disease, the need for healthcare reform and the reduction in care variation. Central Asia has a large number of medical schools, medical centres, and emerging research institutes that can be used to foster a change in medical and public health practice in the region. INTRODUCTION The Central Asian region, which encompasses Kazakhstan, Uzbekistan, Tajikistan, Turkmenistan and Kyrgyzstan, is an interesting and under- investigated geographic area from a public health point of view. The region has a rich cultural and scientific heritage dating back to the Silk Road, Mongol conquests and the expansion of the Russian Empire ( figure 1, Map of Central Asia). Interesting genetic variations in populations living in the centre of the Eurasian continent make these populations highly unique for public health risk factor research. It is a multiethnic and multicultural region, which has dramatic implications for health practices. 1 The Central Asian region is endemic ter- ritory for many infectious diseases, including viral hepatitis (conditions that increase the risk of liver cirrhosis and cancer), haemorrhagic fevers, and nosocomial and blood-borne infections. An add- itional public health challenge in Central Asia is the uncontrolled use of and self-medication with anti- biotics, 2 potentially leading to antibiotic resistance for conditions such as tuberculosis (TB). Maternal and child health continues to be an ongoing public health concern in this region, with many women of reproductive age suffering from anaemia and not receiving regular healthcare prior to becoming pregnant. 3 Central Asia also has intriguing challenges when it comes to environmental health, including climate change, nuclear testing, water allocation and urban- isation, which makes it a unique site of research for multiple disciplines. 4 Along with geographical and ethnical diversity, the region is interesting from a medical system infrastructure point, as it has been undergoing economic transition from the Soviet era central planning system to more modern approaches to healthcare infrastructure, which has direct impact on healthcare systems and the health of the population. While there is a network of ‘feldsters’, or middle primary healthcare providers, the system is very cumbersome, needs restructuring, and is not always efficient in the use of existing resources. Evidence-based medicine is not always practiced due to the slow transition of scientific medicine into day to day medical and public health practice. Many of the public health challenges continue to exist in this region, as countries of Central Asia inherited the centralised medical system practiced in the Soviet Union. It must be noted that health- care reforms occurring since the breakup of the Soviet Union in 1991 had different rates of success across the Central Asian region. The degree of success was largely dependent on the consistency of government policy and the state of economic devel- opment. Most countries of Central Asia started to embark on wide-ranging reforms in the second half of the 1990s; however, the pace has varied, with Kazakhstan only adopting a systematic approach after 2004, while reforms in Tajikistan were delayed by the civil war. 5 While the public health challenges outlined in this essay can present themselves in any developing country, problems experienced in Central Asian health systems partially result from the collapse of the Semashko centralised healthcare system of the Soviet Union, and are associated with the subse- quent transition period and the global restructuring of healthcare systems in these countries. In general, health facilities are still funded according to rigid budget line items, which reinforce excess hospital capacity and offer little opportunity for innovation by managers or staff, while potentially encouraging wasteful patterns of treatment. 6 During the past two decades, countries of Central Asia attempted to transform their centrally planned, supply-driven healthcare systems and implemented many interest- ing innovations. 7 For instance, since gaining inde- pendence, Kazakhstan has undertaken major efforts to reduce expenditures on the hospital sector and to focus on primary healthcare. 8 However, devel- opments from the region receive little attention in English language biomedical literature, as the majority of Central Asian scientists tend to publish in local journals. Moreover, renovations in healthcare systems in Central Asia must cope with the old problems that have never been resolved, as well as to rapidly adapt to the newly emerging challenges. Chronic Adambekov S, et al. J Epidemiol Community Health 2015;0:1–5. doi:10.1136/jech-2015-206251 1 Essay JECH Online First, published on August 7, 2015 as 10.1136/jech-2015-206251 Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.