1. Leadership/governance

WHO determined that effective leadership and governance are one of the health system building blocks, which are focused on the policies that allows the health system to function and deliver services (WHO, 2010). These policies can be around disease-related policies or cross-cutting policy areas. Thus for this element, it is important to look at both policies regarding NCDs and PHC.

Under this building block, six publications were identified and reviewed. One group of publications focused on the implementation of the WHO’ Global Action Plan for the prevention and control of NCDs for the period of 2013–2020. Following this action plan, the CIS countries developed their own national NCD action plans with strong advocacy from WHO (WHO-Moldova, 2018; WHO-Ukraine, 2018). For example, Ukraine’s NCD action plan was designed with three main objectives: intersectoral action and partnership around NCD risk factors, prevention of NCDs in clinical and community settings, and reduction of risky behaviours influencing NCD mortality and morbidity (WHO-Ukraine, 2018). The NCD action plan of Moldova was similar to the one in Ukraine with additional plans focusing on alcohol control (WHO-Moldova, 2018).

The overall assessment of the NCD Action plan was done by WHO in Ukraine (WHO-Ukraine, 2018) and Moldova (WHO-Moldova, 2018) with these countries having elaborated several strategies around the NCD-related risk factors, but their enforcement was not assessed and documented. NCD management and control are considered as multisectoral task, and the countries developed certain intersectoral objectives. However, most of these actions remained on paper and did not materialise due to difficulties of multisectoral work.

Concerning PHC and governance in CIS countries, WHO has evaluated and reported on the PEN piloting in Moldova and Kyrgyzstan (Jill Farrington, Reference Jill Farrington2017; Collins et al., Reference Collins, Ciobanu, Laatikainen, Curocichin, Salaru, Zatic, Anisei and Farrington2019). The results of these evaluations were not very promising due to the short period of piloting during one year. In one year, the NCD management practices were changed in the PHC facilities, but time was insufficient to demonstrate improvement of health outcomes. In March 2017, WHO conducted a workshop on implementation of PEN in Eastern Europe and Central Asia (WHO-Europe, 2017), which stated that out of 12 CIS countries only five of them had piloted the PEN protocol. From the literature review, it was found that none of the CIS countries had their own vision or strategy to strengthen PHC (WHO-Europe, 2017). This is despite the fact that two global conferences on PHC were conducted in Kazakhstan one of the CIS countries (Exworthy, Reference Exworthy2008).

2. Healthcare financing

Health financing requires the system to raise sufficient resources to provide health care in parallel to protecting the population from the financial burden of paying for health services (WHO, 2010).

Eleven publications were identified that address health financing. The studies from CIS countries show that there is no clear health financing reform towards strengthening the PHC system (Rechel et al., Reference Rechel, Roberts, Richardson, Shishkin, Shkolnikov, Leon, Bobak, Karanikolos and McKee2013). Data from CIS countries describe the overall cost-effectiveness of PHC (Balashova et al., Reference Balashova, S and Karachurina2014) as well as for preventive measures and early detection of NCDs in Ukraine (Palamar and Gruzeva, Reference Palamar and Gruzeva2019).

CIS countries still prioritise hospitals versus PHC, with, for example, Russia spending more on inpatient care than outpatient: 50.3% and 33.2%, respectively (Alshamsan et al., Reference Alshamsan, Lee, Rana, Areabi and Millett2017; Sheiman et al., Reference Sheiman, Shishkin and Shevsky2018). Also, development assistance is very limited (US$ 0.34 per capita in CEE-CIS countries) and fragmented for PHC strengthening in CIS countries (Suhrcke et al., Reference Suhrcke, Rechel and Michaud2005).

The main approach applied for PHC financing is per capita payment, which is not covering all required services (Smith, Reference Smith2011; Mukeeva, Reference Mukeeva2012; Schwarz et al., Reference Schwarz, Wyss, Gulyamova and Sharipov2013). The capitation-based financing of PHC in CIS countries is very low and does not exceed 35% of overall government health expenditure (Oleszczyk et al., Reference Oleszczyk, Svab, Seifert, Krzton-Krolewiecka and Windak2012; Shvets, Reference Shvets2012). Therefore, the PHC system in CIS countries is considerably underfinanced, which increases out-of-pocket payments for the population (Rechel et al., Reference Rechel, Roberts, Richardson, Shishkin, Shkolnikov, Leon, Bobak, Karanikolos and McKee2013; Schwarz et al., Reference Schwarz, Wyss, Gulyamova and Sharipov2013; John Tayu Lee et al., Reference John Tayu Lee, Pati, Atun and Millett2015) mainly with regard to diagnostic and laboratory tests and medicines.

One study highlighted how in Kazakhstan the Government’s financing for PHC was increased in 2014 from USD 1.69 billion to USD 2.61 billion, but did not improve the gatekeeping and prevention functions of PHC (Birtanov, Reference Birtanov2016). Other studies show that the salaries of the PHC workers are fixed salaries without incentives based on performance (Mukeeva, Reference Mukeeva2012). This results in low motivation of doctors and nurses to work more and cover health promotion and counselling on NCD-related risk factors and might explain why additional funding without addressing human resource issues results in little change.

3. Health workforce

A key component of any health system is the health workforce delivering care and services to the population.

In 1978, the Alma-Ata declaration on PHC was adopted by the USSR together with other countries and was considered as an action towards structural reforms from the Soviet policlinics to PHC centres (Exworthy, Reference Exworthy2008). The reorganisation of policlinics to the primary healthcare centres was declared in 1990 in Russia, but without clear vision or strategy to strengthen PHC. This resulted in functioning of Soviet policlinics as they used to work before. One of the main reasons was the absence of comprehensive training for general practitioners. A study in 2016 shows that only 20% of the universities had general practice as a subject in pregraduate medical education (Gruzeva et al., Reference Gruzeva, V and Zamkevich2016a, Reference Gruzeva, P, Simyanov and Galienko2016b). Medical education systems in CIS countries were continuously training specialists instead of generalists (Parfitt, Reference Parfitt2009; Mukeeva, Reference Mukeeva2012; Brimkulov, Reference Brimkulov2015). This resulted in the PHC system that mainly functioning as an outpatient facility where healthcare services are provided by specialists.

During the last five years, in some CIS countries the health system has tried to introduce family medicine practice by retraining specialists (Barton, Reference Barton2011; Kolesnyk and Svab, Reference Kolesnyk and Svab2013; Voronenko and Shekera, Reference Voronenko and Shekera2013; Alikhanova et al., Reference Alikhanova, Аsenova, Такirova and Omarkulov2017). This resulted in gradual increasing family doctors, but with very low competence. A study conducted in 5 CIS countries to evaluate the quality of care through the clinical performance and value vignettes (CPV) demonstrated very low knowledge of the general practitioners about NCD management and its risk factors (Hrytsko et al., Reference Hrytsko, Furtak and Parobets’ka2014; Peabody et al., Reference Peabody, Demaria, Smith, Hoth, Dragoti and Luck2017; Matiukha et al., Reference Matiukha, Medvedovska, Bukhanovska and Dikhtiarenko2020). Coexistence of specialists in PHC facilities does not motivate family doctors to learn more, because it is easier to refer them to specialists (Asadov and Aripov, Reference Asadov and Aripov2009; Oleszczyk et al., Reference Oleszczyk, Svab, Seifert, Krzton-Krolewiecka and Windak2012). Therefore, it is important to prepare health professionals for PHC with a focus on prevention and early detection of diseases at undergraduate, postgraduate, and continuous medical education levels (Lilit Khachatryan, Reference Lilit Khachatryan2013; Krzton-Krolewiecka et al., Reference Krzton-Krolewiecka, Svab, Oleszczyk, Seifert, Smithson and Windak2013; Gruzeva et al., Reference Gruzeva, V and Zamkevich2016a, Reference Gruzeva, P, Simyanov and Galienko2016b). A study conducted in 30 European countries and some CIS countries confirmed that building General Practice/Family Medicine in academic discipline comprising teaching and research was essential to strengthen the PHC system (Zarbailov et al., Reference Zarbailov, Wilm, Tandeter, Carelli and Brekke2017; Kasimova, Reference Kasimova2018; Akhmedov and Jarylkasynova, Reference Akhmedov and Jarylkasynova2010). However, the interest of students to become general practitioners in Russia was ≤5% in 2009 (Krzton-Krolewiecka et al., Reference Krzton-Krolewiecka, Svab, Oleszczyk, Seifert, Smithson and Windak2013). This situation is even worsened by globalisation when migration is increasingly present among medical personnel.

4. Medical products, technologies

Medicines and supplies need to be provided within the health system and are an essential pillar of the health system. Only one publication was identified as relevant to this building block.

This study aimed to assess the availability, prices, and affordability of four essential medicines used to treat diabetes in private primary care pharmacies in seventeen countries including Russia (Babar et al., Reference Babar, Ramzan, El-Dahiyat, Tachmazidis, Adebisi and Hasan2019). From this study, availability of some diabetes medicines was poor, but affordability was better than in the other countries included in this study.

5. Information and research

Another building block proposed by the WHO is the information and research that is produced by the health system. In the literature review, seventeen publications described the information and research building block.

These articles identified for this building block can be divided into two groups: firstly, articles describing the intentions of CIS countries to develop family medicine (Asadov and Aripov, Reference Asadov and Aripov2009; Akhmedov and Jarylkasynova, Reference Akhmedov and Jarylkasynova2010; Balabanova et al., Reference Balabanova, Roberts, Richardson, Haerpfer and McKee2012; Peabody et al., Reference Peabody, Demaria, Smith, Hoth, Dragoti and Luck2017; Blake et al., Reference Blake, Bohle, Rotaru, Zarbailov, Sava, Secula, Prytherch and Curteanu2019). In most of these articles, authors are documenting shift from soviet system of polyclinics to family medicine/general practice without appropriate financing and human resources reforms (Gazizov, Reference Gazizov2010; Balabanova et al., Reference Balabanova, Roberts, Richardson, Haerpfer and McKee2012).

The second group of articles are studies done by academic institutions on the management of chronic diseases at the PHC facilities and NCD burden in different CIS countries (Gazizov, Reference Gazizov2010; Ryngach and Vlasyk, Reference Ryngach and Vlasyk2018; Blanche Greene-Cramer et al. Reference Blanche Greene-Cramer, Lopes-Cardozo, Husain, Couture and Bilukha2020). These include studies on management of hypertension and diabetes at the PHC level (Lysenko, Reference Lysenko2011; Codreanu et al., Reference Codreanu, Sali, Gaibu, Suveica, Popa, Perico, Ene-Iordache, Carminati, Feehally and Remuzzi2012; Ahmedov et al., Reference Ahmedov, Green, Azimov, Avezova, Inakov and Mamatkulov2013; Basu and Millett, Reference Basu and Millett2013; Chizova and Oshchepkova, Reference Chizova and Oshchepkova2013; Shinbolatova et al., Reference Shinbolatova, Kulzhanov, Aringazina and Nurbakhyt2014; Zhdan et al., Reference Zhdan, Holovanova, Filatova and Khorosh2017; Bikbov et al., Reference Bikbov, Fayzrakhmanov, Kazakbaeva, Zainullin, Arslangareeva, Gilmanshin, Salavatova, Nikitin, Mukhamadieva, Yakupova, Khikmatullin, Zaynetdinov, Uzianbaeva, Aminev, Nuriev and Jonas2019). Many of these studies confirm the effectiveness and affordability of the PHC system in the management of chronic diseases (Ahmedov et al., Reference Ahmedov, Green, Azimov, Avezova, Inakov and Mamatkulov2013; Barbazza et al., Reference Barbazza, Yegeubayeva, Akkazieva, Tsoyi, Zheleznyakov and Tello2019; Collins et al., Reference Collins, Ciobanu, Laatikainen, Curocichin, Salaru, Zatic, Anisei and Farrington2019). One of the main reasons of effectiveness of the PHC system reported in these studies is the focus on prevention of NCD-related risk factors (Rahmonov et al., Reference Rahmonov, R, Nozirov and DjurVaev2012; Avdeeva, Reference Avdeeva and Luchkevich2013; Polyanskaya, Reference Polyanskaya2013; Palamar and Gruzeva, Reference Palamar and Gruzeva2018; Gruzieva et al., Reference Gruzieva, Galiienko, Pelo, Omelchuk and Antonuk2018).

6. Service delivery

Service delivery is the health system providing quality, accessible, and safe services to the population. In the reviewed literature, 41 identified documents discuss this component of the health system.

PHC in the most CIS countries is disease-centric and does not include a patient-centred approaches (Birn and Krementsov, Reference Birn and Krementsov2018; Beran et al., Reference Beran, Perel and Miranda2019). Prevention-centric approaches are missing in PHC in all CIS countries (Luck et al., Reference Luck, Peabody, Demaria, Alvarado and Menon2014). The state system is still promoting disease management at PHC and forgetting the key role of disease prevention and early detection, which is an essential component of PHC (Dzhakeli et al., Reference Dzhakeli, Edzhibadze and Gerzmava2009; Efremov, Reference Efremov2011; Sharman, Reference Sharman2014; Mirzikashvili and Baramidze, Reference Mirzikashvili and Baramidze2017). A study on the NCD-related risk factors conducted in 27 countries, including CIS countries, confirmed that addressing the risk factors plays a key role in preventing most of NCDs (Kotseva, Reference Kotseva2019). At the same time, most of the services at PHC are provided by specialists (Konysbaeva, Reference Konysbaeva2017) and very little by family doctors (Boitsov and Vylegzhanin, Reference Boitsov and Vylegzhanin2015; Boitsov and Fleck, Reference Boitsov and Fleck2015; Smiianov et al., Reference Smiianov, Dryha, Smiianova, Obodyak and Zudina2018; Kononov et al., Reference Kononov, Klymenko, Batsiura, Matiukha, Protsiuk, Klymenko, Trishinska and Pogorila2019). In some countries, some specialists (therapist, gynaecologist, and paediatrician) were retrained as family group practitioners to replace specialist-based care with family medicine approach (Verulava et al., Reference Verulava, Jorbenadze and Barkalaia2017). However, this approach did not change the specialised care towards family medicine approach (Palamar and Gruzeva, Reference Palamar and Gruzeva2018). In particular, the PHC facilities in urban areas function as Soviet policlinics with specialist-based care (Znatchkova, Reference Znatchkova2016; Vialkov et al., Reference Vialkov, Skvirskaia, Son, Senenko, Kupeieva, Rosanov, Leonov, Bilalov, Gajeva, Evdakov and Kravtchenko2017). Here care is delivered for adults by therapists and for children by paediatricians, working alongside other specialists (Ohanyan et al., Reference Ohanyan, Danielyan, Hopayian and Mash2015). This factor has adversely impacted family doctors’ ability to solve first-contact chronic health problems (Orynbassarova, Reference Orynbassarova2015; Sh. Adilov, Reference Sh. Adilov2016). As for rural areas, due to the shortage of specialists, family doctors deliver NCD care (Mohir Ahmedov et al., Reference Mohir Ahmedov, Mutalova, Huseynov and Observatory2013). Some studies also discuss the roles nurses could play in CIS countries (Volodina, Reference Volodina2017, Mashpanina, Reference Mashpanina2017; Blake et al., Reference Blake, Bohle, Rotaru, Zarbailov, Sava, Secula, Prytherch and Curteanu2019). Another weakness is that there is a lack of continuum of care for people with NCDs (Mashpanina, Reference Mashpanina2017; Beran et al., Reference Beran, Perel and Miranda2019; Tolokonskaya et al., Reference Tolokonskaya, Gorenkov and Agafonov2020).

Family doctors at PHC facilities are also overloaded with administrative and paperwork, which prevents them from allocating more time for patients’ counselling (Mukeeva, Reference Mukeeva2012). The appointment system, which was used in Soviet time, is no longer in place, and the flow of patients is unpredictable and not regulated (Hardison et al., Reference Hardison, Fonken, Chew and Smith2007; Smith, Reference Smith2011, Zhdan et al., Reference Zhdan, Holovanova, Filatova and Khorosh2017). Some of the CIS countries (Kazakhstan, Kyrgyzstan) have introduced mobile communication systems and e-cards for patients, but these have not reduced the workload of the family doctors, because the paper version was not discontinued (Zhdan et al., Reference Zhdan, Holovanova, Filatova and Khorosh2017; Smiianov et al., Reference Smiianov, Dryha, Smiianova, Obodyak and Zudina2018). Kyrgyzstan is known as one of the first countries among CIS countries to introduce family medicine (Hardison et al., Reference Hardison, Fonken, Chew and Smith2007; Smith, Reference Smith2011). However, attempts to integrate vertical services (tuberculosis care, endocrinology and oncology) in the PHC system in Kyrgyzstan and in other CIS countries resulted in increased workload of PHC (Ikeda et al., Reference Ikeda, Sapienza, Guerrero, Aekplakorn, Naghavi, Mokdad, Lozano, Murray and Lim2014; John Tayu Lee et al., Reference John Tayu Lee, Pati, Atun and Millett2015; Skordis-Worrall et al., Reference Skordis-Worrall, Round, Arnold, Abdraimova, Akkazieva and Beran2017; Bikbov et al., Reference Bikbov, Fayzrakhmanov, Kazakbaeva, Zainullin, Arslangareeva, Gilmanshin, Salavatova, Nikitin, Mukhamadieva, Yakupova, Khikmatullin, Zaynetdinov, Uzianbaeva, Aminev, Nuriev and Jonas2019).

The issue of quality of the services delivered at PHC in CIS countries was discussed in several studies (Peabody et al., Reference Peabody, Luck, Demaria and Menon2014; Sharman, Reference Sharman2014; Shinbolatova et al., Reference Shinbolatova, Kulzhanov, Aringazina and Nurbakhyt2014; Orynbassarova, Reference Orynbassarova2015; Peabody et al., Reference Peabody, Demaria, Smith, Hoth, Dragoti and Luck2017). The studies conducted in Kazakhstan and Kyrgyzstan on CVD and hypertension confirmed that screening programmes and increasing awareness of patients about early detection of hypertension could contribute to the improvement of population’s health (Shinbolatova et al., Reference Shinbolatova, Kulzhanov, Aringazina and Nurbakhyt2014; Kutlu et al., Reference Kutlu, Murataliev and Memetoglu2014; Barbazza et al., Reference Barbazza, Yegeubayeva, Akkazieva, Tsoyi, Zheleznyakov and Tello2019). In Ukraine and Kyrgyzstan, studies showed that outcome of the ambulance services was improved in the regions with the strong PHC system (Nasirdin Kyzy and Baatyrova, Reference Nasirdin Kyzy and Baatyrova2013; Voronenko and Shekera, Reference Voronenko and Shekera2013; Abanto Reference Abanto2018; Shekera, Reference Shekera2019). After 2010, Russia and Ukraine started reforms of the PHC system with patient-centric approach, by strengthening gatekeeping function and by introducing counselling for prevention NCD risk factors (Boitsov et al., Reference Boitsov, Gileva, Gulin, Ipatov, Kalinina, Linchak and Ponomareva2013a, Reference Boitsov, Kalinina and Ipatov2013b; Peabody et al., Reference Peabody, Luck, Demaria and Menon2014; Gruzeva et al., Reference Gruzeva, V and Zamkevich2016b; Znatchkova, Reference Znatchkova2016; Volodina, Reference Volodina2017). In Uzbekistan, an evaluation of the quality of treatment of chronic heart failure at the PHC level find that the clinical protocols were very complicated to apply and follow by the family doctors (Ahmedov et al., Reference Ahmedov, Green, Azimov, Avezova, Inakov and Mamatkulov2013). Another finding from Tajikistan showed that the introduction of citizen report cards improved quality of care by defining problems, setting priorities, and monitoring healthcare providers (Bauhoff et al., Reference Bauhoff, Rabinovich and Mayer2017). Another intervention inherited from soviet period is screening of population to detect chronic diseases, including NCDs, and to register them for continuous care at the PHC facilities (Boitsov et al., Reference Boitsov, Gileva, Gulin, Ipatov, Kalinina, Linchak and Ponomareva2013b; Balashova et al., Reference Balashova, S and Karachurina2014).

To address the systemic issues such as excessive workload, shortage of human resources, poor quality of care, some CIS countries, Moldova (Codreanu et al., Reference Codreanu, Sali, Gaibu, Suveica, Popa, Perico, Ene-Iordache, Carminati, Feehally and Remuzzi2012; Collins et al., Reference Collins, Ciobanu, Laatikainen, Curocichin, Salaru, Zatic, Anisei and Farrington2019; Collins et al., Reference Collins, Inglin, Laatikainen, Ciobanu, Curocichin, Salaru, Zatic, Anisei, Chiosa, Munteanu, Alexa and Farrington2020) and Kyrgyzstan (Jill Farrington, Reference Jill Farrington2017) have piloted the WHO PEN protocol. The PEN pilot in Moldova was evaluated after two years of implementation and confirmed sustainable improvements in NCD risk factor control in primary health care conditioned to clinical training and support within two years (Collins et al., Reference Collins, Inglin, Laatikainen, Ciobanu, Curocichin, Salaru, Zatic, Anisei, Chiosa, Munteanu, Alexa and Farrington2020). In case of possible scaling up to a national level, this model could significantly reduce premature mortality from NCDs.

One of the studies in the Central Asian countries about gender gap of PHC services utilisation showed that children and women consume the overwhelming majority of PHC resources. Given the excess morbidity and mortality among men in the region it is required to redirect the PHC resources to address men’s health issues. This was also confirmed in a study done in Russia, which confirmed that the level of untreated hypertension was 28% higher among men (Petersen et al., Reference Petersen, Kontsevaya, McKee, Kudryavtsev, Malyutina, Cook and Leon2020). This issue could be addressed through specific outreach programmes at the PHC level, which was a basis for incentives to family doctors and nurses (Cashin et al., Reference Cashin, Borowitz and Zuess2002). As for the specific targeted activities to fight the NCDs, Russia started to establish a partnership with other CIS countries to address the NCD-related risk factors (Boitsov and Fleck, Reference Boitsov and Fleck2015).

Figure 1. Summary of the publications selection in the study.