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Kasia Kowalczyk: Welcome you all at our workshop on public health and harm reduction in Central Asia and the Caucasus. My name is Katarzyna Kowalczyk and I'm the organizer of this workshop. And before even I will start to introducing our great panelists and my co-chair Arkady, let me just briefly explain you the idea behind. So, with my organization, the Global Public Health Network, a couple of years ago we started to run projects in that region. And thanks to that, I met great people. Some of them are here. And I know that this part of world hasn't got a presence at GFN it deserves. Also, there are a lot of misconceptions and myths about situation there. So I thought, well, it's about time for us to discuss the region, to expose the region to you. But me, myself, I'm working in the field of public health and harm reduction, so mainly our workshop today will be dedicated to those issues. Of course, we will tackle, we'll touch upon the main focus of GFN, we will discuss smoking, but my goal and my intention is for you to learn a bit about the situation in the area of public health and harm reduction in those countries. Right, so I think we might start. And let me, one second, one more thing. So the agenda is as follows. The agenda is as follows, so Arkady will help me to introduce our guests. Then each of our guests will have a short pitch, sort of introductory pitch to describe the key, or to deliver the key messages. Then we will start initiate some discussion, but feel free to jump in. They are here for you, so feel free to ask questions, because I assume it will be interesting, and I assume you might have a lot of questions. So thank you.

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Arkadi Sharkov: Thank you, Kasia. I would say feel obliged to ask questions because where there is data, there are questions and questions arise and they have to be answered in a proper way. Good morning to you all. Hope you slept well and hope this first panel is going to be a neat, I hope and I know that it will be an interesting one. So, my name is Arkady Sharkov, but I will be last. Let me first introduce our pleasant speakers this morning. Next to me, Dr. Althea Semigulina, which is an honoured physician of the Kyrgyz Republic, Doctor of Medicine, Professor, Rector of the Bishkek International Medical Institute, former Deputy of the Sixth Coal of the Supreme Council of the Kyrgyz Republic. Next to her, Dr. Saida Umarova, doctor in medicine, associate professor, physician, has a degree, First Deputy Minister of Health and Social Protection of the Republic of Tajikistan. Next to her, Gintaldas Kantra. Dr. Gintatus Kendra, a cardiologist, deputy chairman of the council, a member of the expert council of the Densalyuk ILO in Kazakhstan. Next to him, Mr. Amir Rashidov, a drug addiction clinician in the Republic Specialized Scientific and Practical Drug Treatment Medical Center in Uzbekistan. And last on the other side, Mr. Zurab Chabrashvili, former Minister of Labour, Health and Social Affairs, a Deputy Chairperson of the Parliamentary Committee of Healthcare and Social Affairs, Governor of the Kakheti region and Mayor of Tbilisi. Ambassador Chabrashvili served as permanent representative of Georgia to Council of Europe and the UN office and the organization in Geneva. He has a rank of Ambassador of Extraordinary plenty of potential of Georgia since 2007. It is a pleasure. As you see, it is an interdisciplinary team here, we can say, from all different areas, both from the medical, from the economic, and mainly from the policymaker field, people who develop their policies in their countries, and here to share good examples and also good ideas on how to improve public health. So let's start with Dr. Samigulina, the podium is yours on the topic of public health, and you have a short time to present your idea. Thank you.

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Samigullina Alfiya Eldarovna: Good morning, good afternoon, dear participants. I would like to tell you a few words about the situation in Kyrgyzstan. And Kyrgyz Republic is a post-Soviet country, space. It became independent in 1991. And unfortunately, public health is still in its nascent stage. If we talk about the law and public health, Nowadays, at this stage, the parliament, the Dzhokhar Kukhinesh, has conducted discussions. And in the first reading, they submitted the law to be reviewed by the parliament members, but then it was returned back to be finalized. So it means that there are still many questions which were not addressed yet. And Kyrgyzstan is a very peculiar country among Central Asian countries. And those reforms which were embarked back in 1991, they are going on quite actively, and the country seems to be number one in terms of its reforms. But unfortunately, huge expenditures allocated for the health sector are not financed by the government. We have many, many projects which are still implemented at the expense of donors. So if not for the donor support, then financing for a key project is not sufficient in the country. So it turns out that Kyrgyzstan is one of the countries where the health services are paid from the pocket of our population or patients or their families. And as per capita, GDP is 6.5%. 6.5% of GDP is allocated to the health sector.

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Attendee: It's one of the lowest indicators in Central Asia after Tajikistan.

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Samigullina Alfiya Eldarovna: If you talk about the mortality rate from non-contagious diseases, then 75% of the population below 76 years old, they die because of non-contagious diseases. Why we have such a problem? First of all, because there are huge difficulties with outreach work. It's lagging behind. Prevention medicine is not developed because we don't have screenings. We don't have programs which would cover population. without paying a fee, even for prophylactics and prevention, population has to pay from their pocket. But given the fact that the living standards in our countries are low, then people focus less on prevention. So when NCDs become chronical, they have to pay more money both. for the country and for the patients so that these diseases can be treated and to maintain at least some level of health, to be able to work, to be able to feed their families. So here I would like to draw your attention to the fact that out of all risk factors of development of NCDS, Kyrgyzstan ranks number four out of 180 countries in terms of salt consumption. So, of course, we have a big number of smoking people. On average, it's 30 percent of adult population. And we also have a lot of people consuming alcohol. I think that these figures are not only figures pertaining to Kyrgyzstan, but to the neighboring countries as well. So these are the peculiarities of our country. Thank you.

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Arkadi Sharkov: Thank you, Dr. Samigulina. It's interesting to find so much similarities between what's happening in Kyrgyzstan and also in Bulgaria, especially in the field of medical practice and copayment, out-of-pocket payment from patients, and the topic of prevention and prophylaxis as well. So, Dr. Umarova, your point of view?

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Saida Umarzoda: Good afternoon, dear ladies and gentlemen. I am from Tajikistan. I wanted to tell a few words about the health sector status in our country. Our country is a mountainous country and 90% of the territory is covered by mountains. So you can imagine that already this factor creates problems or barriers for the population to have access to health services. In 1993, after the Republic of Tajikistan became sovereign, it adopted the family medicine health sector concept. Now we have three levels of health care in the republic and the major focus is on the PHC. So, the PHC facilities are more than two and a half thousand. In the country, however, the material and technical base leaves much to be desired. And of course, in order to enhance PHC services as a situation in Kyrgyzstan, we receive a lot of support from our development partners, such as the World Bank, the UNICEF, UNFPA on screening of ulcer for women. And ADB is also supporting us to improve infrastructure of PHC facilities. However, we have a lot of problems, these proportions in operations of PHC level and hospital facilities. The problem is mainly lack of qualified. skilled health workers, though we have two medical universities and several colleges. Nowadays, we have 20 doctors per 10,000 people. As for the middle-level health workers, 60 per 10,000 population. a greater migration outflow of health workers abroad, mainly to the Russian Federation, because the salary of doctors and the middle-level staff is very low. And health financing after the coronavirus infection increased a bit, but it still leaves much to be desired, so it has to be increased. So the country adopted the health code, which unifies more than 40 laws, and there are several national programs which are implemented to improve the situation, such as counteracting HIV infection, counteracting obesity, because obesity is increasing among young population children and women. In 2012, according to the demographic study, the obesity among women was 27 percent. Nowadays, it's already 38 percent. In some regions of the country, child obesity increased from 3 percent to 7 and 12 percent. This is an alarming sign and requires preventive work. to be able to prevent such development. There is also increase in cardiovascular diseases, diabetes too. This is as for the oncology pathology. So it's a breast cancer, which ranks number one, and among children is the malignant formations in the stomach. and intestines. Notwithstanding the fact that the number of smoking people is not that high, only 10% of the population, maybe 1% of women. And because of the tradition, many women conceal that they are smoking. And this could be business women, even health workers, as we can note, though the statistic is not very accurate. Now we are assessing the non-contagious diseases, which ends in a couple of weeks, and we expect to have new data. So, under the NCDs, the country adopted a program to fight NCDs in 2013, and it ends in 2023. So, we want to take stock of the results, to have statistics, to see the developments. And of course, we'll take all the measures to improve the situation. And I wanted to mention that among the population, we have many people who consume nasolites, like chewing tobacco. So, maybe half of the population is using this Nasvi in the country, and this is a reason why the oncological diseases in the intestine and stomach are increasing. And the scientists in Tajikistan proved the direct dependence of development of some oncology with using this Nasvi. This is indicative of the need to fight this traditional type of tobacco consumption. Of course, we assume that today the World Bank approves the new project on approval of the new project, the new strategy, and this work will be aimed at improving the preventive work, strengthening technical material base of PHC facilities so that we are able to identify pathologists on the early stage, so we don't have early screening as it was mentioned in Kyrgyzstan. Thank you.

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Arkadi Sharkov: Thank you, Dr. Romarova. From that point of view, actually, studies show that screening – it's interesting, this is for the Ministry of Economy and also Ministry of Finance – screenings increase the expenditure on healthcare for the first couple of years, but 10, 15 years into the into the game. It reduces the overall risk, which is beneficial for the health care and social and from the economic system. So policymakers tend to think, policymakers tend to think to the future, but politicians typically tend to think short wise in that term. That's why it's hard always to push such policies which are beneficial in the long term. This is from experience from my country. So, Dr. Kentra, the podium is yours.

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Gintautas-Jouzas Kentra: Thank you very much. I'll continue as we started in Russian languages, because it's common languages for our regions. So, I'll continue. Kazakhstan, as a post-Soviet republic, is rather well-doing in terms of health financing. From this viewpoint, we are doing quite okay. And representing NGO Densovuk, which means health in the Kazakh language, this is the association of the concept of reducing harm from non-contagious diseases. We do not differentiate, we actually merge. or bring together all negative impacts on health in one place. So our concept works in several areas, which includes the concept of harm reduction among injection drug consumers. We implement methadone therapy approach. Then second, using nicotine-containing products, we also use harm reduction concept. The third is the harm reduction concept when consuming foodstuff. I would say that this area is the most challenging one, but on the other hand, it's also easy because, well, it's challenging because it affects the whole society, but easy because it is understood by the government, by the Ministry of Health, because food concerns everyone. Then reproductive culture. Unfortunately, we have our own traditions in the region, and the problems of reproductive culture also have to play a big role. So it turns out that many families now cannot have children, and spreading infection and chronicalization of these diseases, which happened even before the first pregnancy and the undesired pregnancy. So the national traditions in the countries of our region, the majority of population are devout and practice Islam. So we cannot follow the metrics of European countries and we have to find out our own solutions, local solutions. Why we have chosen this direction or this field out of all the areas which affect the health because non-communicable diseases globally, we have the data on the mortality prevalence in Kazakhstan the same, 90% of deaths because of NCDs take place in Kazakhstan. In future, why we have chosen this field? Because it is easier to work with the government, with the society and the government. What is the concept of harm reduction? This is a universal arrangement and mechanism, It can be used in different sectors, in health care, and security at household level. And we know 8 to 10% of non-communicable disease depend on the healthcare, and 50 to 70% depend on the individuals. And in order to decrease the burden of NCDs, we use this concept. What is the convenience of this mechanism, nicotine-containing products? Because it generates lots of negative perceptions. During the first presentation yesterday, it was told that this concern and problem is globally prevalent, and our government and the Minister of Health is following closely the recommendations of the WHO. And we know this FCTC-WHO Framework Convention, and we make reference to them when we We promote the harm reduction concept of methadone therapy among the drug users. On some side, we authorize these concepts, and on the other side, we prohibit them. and we try to unite all these approaches and concepts at the Republican conference. We have made a different proposal to include the harm reduction concept in the plan for development of the healthcare of Kazakhstan. And lately, the decree of the government was adopted, the healthcare development until 2025, which included the concept of harm reduction from NCDs on the whole. After we have included this, we have signed a memorandum with the Minister of Health Care and to provide the training workshops for the doctors in the Republic of Kazakhstan on preventive medicine for the health promotion units. And for the last year, through online Zoom trainings, we have covered the majority of health care professionals health care professionals in Kazakhstan, which included all of these areas, combating tobacco smoking, alcohol addiction, and nutrition, reproductive culture. And maybe I have missed something. These are the major areas, which includes all our training workshops. If we focus on one aspect, there would have been major issues and concerns. If we follow the evidence-based approach, all this reasoning about these approaches are strengthened. And we were able to communicate with the government and the Minister of Health. There are some impediments. If we discontinue advocacy, then Then very soon the regress will occur. And this was approved on the methadone substitution therapy. Officially, these programs are ongoing because of the COVID. We stopped advocating this area, this field. The Ministry of Health, of course, working in this direction, but they are not advocating anything. They are just implementers. And just recently, with the UN agency, Ministry of Interior, at the roundtable on promotion of this concept, the Minister of Interior was against irrespective of the legislative framework. We had the Ministry of Interior staff talking negatively about this approach and mechanism. It was scaled up in mass media. We can see these linkages. These authorities have the power. if we lower our efforts, then we can lose time. And therefore, we continue our efforts and advocate among the public associations and the new members of the newly elected members of the parliament Sometimes, some MPs stay in place, and they are well aware of these issues. Sometimes, we have newcomers. Sometimes, the social issues generate lots of noise, and, therefore, we have to At different platforms, we have to attract the new members of the parliament. The legislative framework should be supported and endorsed. These are the main areas which I wanted to share about these activities. And we have the NGOs, and we can criticize the performance of the Minister of Healthcare and the government. Thank you very much.

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Arkadi Sharkov: Thank you, Dr. Kentra. It was very interesting, especially the part of tradition and religion in harm reduction. It's an interesting topic to develop later on, if you agree upon, and also the middleman role, the role of the medical specialist in advocating the needs for such programs for prevention of usage of harmful products. So next, the podium is for Mr. Rashidov, please.

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Amir Rashidov: Good afternoon, good morning, dear participants of 10th Global Forum on Nicotine. We came together to discuss and address many issues related to public health, and I would like to share with you the current updates in the Republic of Uzbekistan. In many countries of Central Asia, one, the biggest share of mortality is to do with non-communicable diseases, from 70 to 83% of all deaths are related to this phenomenon, non-communicable diseases. And as you know, one of the leading causes of NCDs is the use of tobacco. And the Republic of Uzbekistan, we have our own peculiarities. We are very close to Republic of Tajikistan. We have this chewing tobacco, according to the latest researches and evidences implemented with the support of the World Bank and WHO steps. there is the trend of reduced small use of tobacco. However, the local academic evidences or researchers show that for the last 10 years, there is a steady increase of use of tobacco. The scientists are drawing attention to this Why these figures are so different? What is the truth? And along with this, the share of population leading the less healthy lifestyle, the increased consumption of salt, a low mobility life, using the products cooked on the animal fat and obesity and also the share of people with high blood pressure and leukemia. And we understand the importance of combating of all these issues and concerns and we are doing a lot on the part of the government and Minister of Health. We are doing a lot And we adopt different decrees and edicts of the president. And literally, we have the law recently, the law on restriction and dissemination or distribution of tobacco and alcohol products. In one month's time, this law will come into effect. And in addition, we have the program on combating tobacco smoking. and the using of tobacco and alcohol products. And we are quite confident that it requires joint efforts, and I'm very much happy We have represented from different ministries and agencies which are willing to unite their efforts to combat this problem and this concern which is of global prevalence. Thank you very much for your attention.

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Arkadi Sharkov: Thank you, Mr. Rashidov, especially the interdisciplinary approach you marked at the end, especially when it comes to, if we're speaking about raising health population, we speak about Ministry of Education, Ministry of Social Affairs, Ministry of Health Care, combined efforts of the whole country and the whole power of the state. Next, Mr. Chabrashvili. Mr. Chabrashvili, as a former Minister of Labour, Health and Social Affairs, which is the heaviest burden for every government, those are the unlikely ministries. It's a very heavy burden for everyone who takes this job because it's very, how shall I say, ungrateful. But give your perspective, especially in the field of public health.

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Zurab Tchiaberashvili: Thank you, Arkady. Colleagues already touched some of the important issues, I think, and I'll dwell on some of them in my short introduction. The first is reliability of data and data collection in general. Some of the percentage is being named already concerning prevalence of tobacco use in our countries presented here. In Georgia, it's around 30, but it's very difficult to correctly name now the exact number of prevalence due to the lack of the reliable data. We conducted steps in 2010, then 2016, next had to be in 2022. but is missing still, and that's why there is a discrepancy between the various surveys showing the prevalence of tobacco use in Georgia. So my first message would be to have reliable, comparable data. Because even if you have the data from various surveys, sometimes the methodology differs, and comparison is absolutely necessary. Second, what I would say is that how the policies are drafted and implemented in countries in general, and in particular in Georgia. The one way is what the advanced countries in harm reduction do, like UK, New Zealand, and others, that they rely on science. And science means they collect data, they analyze, and they see what is the best way to address the issues in a particular field. But scientific method includes discussion as well. Meaning that the open discussion, not only within scientists, but within society is important. For first, understanding the problem, understanding the issue. Second, to find the best solution for society. And importantly, to overcome the certain stereotypes existing in our society. When we are talking about the stereotypes, it's already mentioned about Kazakhstan, the methadone program, which exists in Georgia already more than 15 years. And I remember what kind of barriers been there to implement the program. The barriers were not only organizational or financial. mainly it was the stereotypes in society. It was not easy to overcome. The same what I observe now concerning the use, the harm reduction understanding in tobacco consumption control is almost the same as we observed concerning the harm reduction in drug abuse. So that's very important, that data and then discussion. What happens in our countries? Okay, this forum is a very good forum to see what are the, of course, some of the scientific data are still coming. This is still the new field, the harm reduction in tobacco. But there are already success stories in these fields. I already named some of the advanced countries. And maybe sometimes there is a dilemma. What do you prefer to follow? You follow those who are in the front or just to wait before the disunderstanding seeds into every... mind of the international bureaucracy. I will not name the specific organizations. And for politicians, safer is to wait for the international bureaucracy because if the prime minister asks the health minister that why you do this, it's always easier to point at the international bureaucracy rather than to name the few countries who are riskier in applying the scientific data and method in drafting their policies in their countries. So we have to understand the motivation of politicians, why they choose this kind of safer for their own political career path rather than safer path for the public health and the society. What I want also to say about the few words about resources and the primary care was named here by several colleagues as an important one. When we are talking about the harm reduction, of course, the first advice what the doctor has to give a patient is to quit smoking, of course, right? But then, this is just, one is to say they quit smoking, another is to help actually them. how to do that. And that's why it's important to have a well-organized, well-coordinated system in the healthcare where anybody who wants to quit smoking can apply to. And it was not easy, as I've said, in Georgia we have more than 15 years, the methadone program, and it was not easy to set up the system. So in harm reduction in tobacco, the primary care doctors are very important to have The first to overcome certain stereotypes. The second is to actually help the patients to get results. So question of resources is very important. But still, we had a discussion on Tuesday on these issues concerning Ukraine, Georgia, and Kazakhstan. And Dmitry, who is in audience here, asked me that if you would be a minister now, what you would do. And I continue saying that public debate, public discussion, providing data and overcoming stereotypes, that's the key. Thank you.

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Arkadi Sharkov: Thank you, Zurab. And if Kasi would allow me just to give a short example from Bulgaria and then I'm returning Thank you very much. From what I heard until now there are actually a lot of those problems that are still occurring in Bulgaria, although Bulgaria is part of the European Union since 2007. Healthcare everywhere is a troublesome area, especially when it comes to different interests. For instance, I can give a short example. In Bulgaria, because we have a National Health Insurance Fund, which is the main payer for services, 50% of the budget of the National Health Insurance Fund goes for hospital care, 50-5-0, and only 22-23 goes to primary and secondary. care. When we speak about medicines, around 33-34% go there. So there are interests in these fields which are pushing against prevention of prophylaxis. Thankfully, for the past year, we adopted the national cancer plan, which is part of the European one, which is We have to do screening programs for the next seven years in order to see what's the actual situation with cancer, because the main problem is vulgarity, that cancer is caught at a very late stage when it's very expensive to treat it, and the outcomes are very, how should I say, sad at the end. And another topic which is interesting and might be interesting to you, as an advisor to the Minister, with the new government that now was voted, there will be an accent on excise taxes as a method from which How should I say, policies could be made, especially in the field of harm reduction, or people can be pushed towards less harmful ways of using such substances. So it's a topic that is also from the economic and also from the social sphere to be, how should I say, viewed upon with interest. So thank you. And Kasia, I'm returning the word to you.

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Kasia Kowalczyk: I wouldn't say it's only Bulgaria. We all represent Eastern Europe, Central Asia countries. I'm myself Polish, which means that we all unfortunately have the unpleasant experience of Soviet times, and this is heavily still observed in the way our public system works, or actually not works. So, and thank you so much. And I have so much questions, so many questions, but before we'll jump into this, just to summarize what you have said, I would like to show some data summarizing the key public health and harm reduction problems. I'm just looking at Kamil to help me to bring on the presentation. It just showed that, so first of all, this is what I wanted to start with so that you know where are we from. So we should have started with this. I hope it's accurate. You can find our guest here. But following up, so basically, So what I did is I collected key public health indicators, and as you could see, we do not differ that much, especially one of which I found particularly interesting is healthy life expectancy. And let me just jump, I, into, into the site, it shows that, well, the region itself maybe has higher life expectancy than an average, but still much is to be done and much is to be improved. And then because in almost all the presentations there was this issue of non-communicable diseases. This is not only typical for this region, I think in general this is the highest problem in public health. And that would be actually my first question, because even though we share a similar history, there are some differences, and some of you mentioned diets, and I'm referring to diets because diet in your countries is quite specific and is related to also the history of your countries. This is what I've learned. As a nomad country, you were sort of forced by the Soviets to sit down. And some of the problems are linked with this and also with the past. Could you please elaborate more on this? Because I found it absolutely interesting.

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Gintautas-Jouzas Kentra: Thank you, Kasia. In fact, we have common history, that's true. And if you take some data, international data, average European indicators, if you take a diet or nutritional habits, that's different from European and American, these habits, And therefore, different diseases related to these disorders also can be seen. But to take this as a base and extrapolate a certain region will be a wrong thing to do, what happened to us a couple of years ago. Or we have public debate about soft drinks containing sugar, that this is very bad and body mass index is growing. And our organization decided to go into detail and we did our research, small research. in the biggest city, in Almaty, in our polyclinic, and we covered a certain number of population and we found out that use this soft drink containing sugar Only young people use those soft drinks containing sugar. As people grow older, they use them less and less, but traditional people use. People traditionally in Kazakhstan have tea with milk, similar to English people, all age group, regardless of their age group. Every Kazakh citizen, in average, use two cups of tea with milk, put in two spoons of sugar. all age groups. And if we look at the data of other countries where those other countries that don't have this tradition, drink tea with sugar, many countries people drink water, we don't have another tradition, usually with tea, we have something, baked cake or something containing sugar and get additional calories and some light sugars. And if you look in details, what is, what are the habits, different regions. And besides that, according to WHO, we have 17 grams of salt consumption. So, you can imagine, this exceeds in many times. And all cardiovascular diseases and blood pressure is a result of this high usage of salt. Because all our traditional dishes, they contain a lot of salt. If we start to prohibit salt, we know it doesn't work. We know, like with alcohol, if we ban tobacco, there will be some clandestine production of tobacco. Those bans don't work. If we start banning eating traditional food, we will be the number one enemy. It will cause resistance. And this harm reduction concept is not prohibited. It provides explanation and gives... The right direction for people to follow, this is supposed to… And family upbringing is very important to start with children, where you build this immune system against bad habits. And if a child sees that he needs to do certain things in school, explain that this is a very bad thing, they will look and see how grandmothers and parents are eating some fat food. And another aspect, they will do this, explain this to parents. So we need to continue to work. And we said yesterday that it is a very easy way for the government to prohibit. You just adopt the law and prohibit, and it means it's done. But what happens in the actual situation? The prohibitions, we know they don't work because it is dependence, physical, psychological, and dependence is a medical issue. Just to prohibit dependence, it would be easy to treat all drug addicts, all tobacco addicts, but unfortunately, it's not realistic, it's impossible. So, therefore, the harm reduction concept proposes that it should be done step by step, and it's working. And we were able to convince people with the methadone therapy, and the nicotine-reducing program also works. Unfortunately, we still have to do a lot of work because of misunderstanding and because our government is looking for easy ways to prohibit. For example, in Kazakhstan, they prohibited selling alcohol and nicotine products. for people aged under 21, but the average age when they start smoking and drinking is 17 and a half years old. Then how do they get it? So it means that the laws do not work and they won't work. Thank you.

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Saida Umarzoda: As for the meals, Tajikistan is such a country that in all regions, people have their own traditions, their own customs related to food. For example, in Gorny Badakhshan autonomous region, there are too many problems, unfortunately. Probably people have healthy foods there, then they don't consume a lot of fried and fatty food. But if we talk about the northern part of the country, which is Sardiska Oblast, people like to eat a lot there. And mainly the way they cook their food is frying with like animal fats. And we can observe that the level of obesity among children and women is high there. And the studies which were conducted in 2016 in the country, they indicated the problem which exists in the region and that people consume a lot of salt. And this actually results in development of non-contagious diseases and heart-related pathology and diabetes. And the children consume a lot of drinks containing sugar. And the tea, by all means, should be very sweet, and it should be accompanied by other sweet cookies. So, like, cakes and bakery is available all the time on the table in the family, so we have to work with mothers, with families regarding increasing the awareness about the future of their younger generations. And I wanted to emphasize one good decision made by our government prohibiting marriages among close relatives when they were not prohibited, we had many children with inborn defects or deficiencies. So, when the government resolution was parsed, it means that we can prevent these situations, and we have to start thinking about enhancing the health of genes. So, when women start thinking what kind of diseases had her relatives, such as grandmothers, grandfathers, and parents, they'll start educating their children properly. So, knowing which diseases can be inherited, they will work on preventing the diseases. So, mother and father knows They will inform the child that there is a risk of developing such a pathology because they have some similar diseases among relatives. And the southern regions of Tajikistan are very different as compared to the northern part of the country. Of course, women also have obesity, but children are born with hypertrophy because there is a high level of anemia among pregnant women. This is an issue which is often discussed. And we do our best so that the pregnant women can have enough food, proper food, not to affect the development of the fetus. And our donors also work on hypertrophy among children. And every five years, we conduct a medical demographic study. to study the deficiency of microelements in the food for children of early age. So, here we have to enhance the culture and focus on the national specificities. Thank you.

00:54:05 --> 00:57:58

Samigullina Alfiya Eldarovna: And so, if you allow me, I'll just say a few words. If we talk about the Central Asian countries, we have to mention that the key issue here is imbalanced food. So, there are huge gaps, and we know that we like meat very much, especially fatty meat. So, not a single norm can exist in such food, and this is already defined genetically. At the same time, our countries enjoying huge volumes of different fruit and vegetables. But unfortunately, the majority of population do not eat them. And our pregnant women, maybe 70-80% of them, as our colleague from Tajikistan mentioned, have anemia. In addition to that, they have chronic epilepsy. So it's a double diagnosis, which affects the child, which is properly born, but the fetus is not mature in this case. And the culture of meals is aggravated by inactive style of life. So in addition to imbalanced food, the people are not active. So mainly they're active when they work in the office or do some work, but they do not work In the city, they don't visit gyms. Maybe it became a trend among younger generation who are, so to say, more successful. But the younger people of middle age who have no access to sports clubs or gyms, and they are not doing any exercises. And we do not have small facilities with proper equipment in the parks, for example, where people can do some exercising. So, this comprehensive or the lack of comprehensive work results into the fact that the level of obesity, the number of people with obesity is increasing in the country. And in addition, I also mentioned in my statement that non-contagious diseases mean a very long chronical process, and people got accustomed to it. They stopped noticing that something is wrong, and they don't have, so to say, a warning sign which indicates that they have to start prophylactics. So, for example, population doesn't measure blood pressure. have blood tests for sugar, so they do not have those tests which we want them to have more often. And of course, we want people to be more active in this area. And as for public health sector, they approve and introduce a lot of programs, but financing is not sufficient for this program, and therefore all activity is to be the responsibility of the population per se. So, all these activities are to be paid by the population from the pocket. So, it's a vicious circle. And of course, we could break it, and the concept of harm reduction is very essential in this area because if we, in terms of prophylactics, indicate the alternative ways how to reduce the harm, how to switch to less harmful attitudes, this culture can be developed further in the years to come and people become more responsible for their health.

00:57:58 --> 00:58:13

Kasia Kowalczyk: So I'm curious to hear Is the concept of harm reduction well understood in your countries or at work? Do you practice this? Do you work with it?

00:58:18 --> 01:00:06

Samigullina Alfiya Eldarovna: So the harm reduction concept is at the initial stage of being introduced in our countries. If you talk about Kyrgyzstan, we started talking about it actively from October 2021. We had a roundtable, a big meeting, and the resolution was adopted at this roundtable with participation of parliament members. Ministry of Education, Ministry of Health, our academic circles, and the civil society. So, this meeting adopted the resolution with a number of instructions for the government. At this stage, the harm reduction concept is introduced at the initial stage. So, I would say the step-by-step introduction. For example, in our Bishkek Medical International Institute, which educates future doctors, we focus on non-contagious diseases. And the harm reduction concept of NCD is the topic of studies of our institute and professors and teachers and students focus on this particular topic. Last year we conducted five surveys disseminating questionnaires among students of five universities not only medical students, and we ask them about the risk factors of NCVs. So, this work is slowly progressing, but I would say that we don't feel any large-scale support from the Ministry of Health in this area, in our country.

01:00:07 --> 01:01:47

Saida Umarzoda: Tajikistan was much later working on the harm reduction concept. The methadone replacement program, as in all former Soviet Union countries, was launched much later. But at the same time, we also face some barriers in implementing it, but now it's successfully being implemented in the Republic of Tajikistan. As for the UNWHO Framework Convention, it was signed, and in 2018, the country adopted the law on restricting the sales of tobacco products. Thus, the country demonstrates that they can work using the harm reduction concept. As of now, the working group of the Ministry of Health developed the national program to fight oncological diseases till 2030. And under this national program, we included one of the global objectives to develop a harm reduction concept, which is to be approved at the level of the government. And in fact, this national program and the concept will be comprehensive, covering all areas such as fighting obesity, alcohol and tobacco, and environmental safety. So I think If we adopt such documents in the Republic of Tajikistan, then the harm reduction concept can be implemented in the country successfully.

01:01:49 --> 01:05:03

Gintautas-Jouzas Kentra: As for Kazakhstan, we started this work earlier than our neighbors, therefore we have some experience, we have some developments, but at the same time we do not rely only on the government in this area, because the government are officials. Officials are the same people, the same people who come as elected. They are promoted to different positions, but they have similar knowledge as just common citizens. So, therefore, we are trying to work in several areas. By all means, the legal framework is very important. It's the work you do with the Parliament. Then the PHC level is mandatory work because the first thing is a patient comes to see his doctor. So, these recommendations are not prohibitive, but related to reducing harm. That's most important. And another very important area, which requires a lot of course, because we have very targeted interventions there, is working with the whole society. For this purpose, we use social networks, internet, we publish in newspapers, we participate in TV debates, we work through journalists, through the society, and this work is important, including bloggers who are important. So this work should continue. So when you have the opponents to your concept related to methadone, to nicotine program, the opponents are ready to prohibit everything, to ban everything, especially when it comes to protection of children. Yesterday, it was told that the children, adolescents start using something. something harmful, we forget about the category who is already ill with some chronic diseases or the habits of the adult population. This is about awareness and human rights. We have, from the legal perspective, we have to protect the entire society and we have to raise the awareness of the public. This is our top priority on our agenda. And it should not go only in one direction. This is a multidimensional activity. We have to work in many areas at once. And very important to engage with the society with the public and these debates on the harm on one-time vapes and some flavored vapes. We have different debates, but there is a lot of negative narrative, but we provide the line of reasoning the evidence-based opinion, this is not about emotions, my kid is smoking and I want to prohibit, this is not about emotions, this is about evidences, and then it generates the positive outcome.

01:05:03 --> 01:05:53

Amir Rashidov: Very briefly about the situation in Uzbekistan, the harm reduction program in Uzbekistan is about to be considered as for the substitution therapy, opioid substitution therapy. We had the pilot implementation. It was stopped, and it is no longer in place in Uzbekistan. There are some areas of fields for, for example, a syringe exchange and distribution of condoms, but we are at the face of reforms, and we use different concepts and programs, and from this perspective, we hope for there will be the harm reduction program also adopted in the country.

01:05:53 --> 01:09:58

Zurab Tchiaberashvili: The question of harm reduction in a society is linked, in my view, with the risk perception in societies. How we perceive risks, risks associated with our life, health, etc. So this is what we have to start with. And therefore, for me, it's always important to set the healthcare system in a way which motivates the public. And I concur here with our colleague from Kazakhstan that we have to we have to take into account not only national bureaucracies and the politicians and decision makers, but wide public. The important thing is that the health care system motivates them to understand risks and to practice prevention measures in general. And that's why what Arkady mentioned about Bulgaria the low utilization of the primary care in all our countries. It's a sign that there is a different kind of risk perception in our societies. There are, of course, the countries with successful single payer systems where the prevention works. But in the countries with the Soviet past, International bureaucracy pushes for the single payer healthcare systems, and without having a risk understanding in our societies, this leads to the low utilization of the prevention measures. And there is no understanding of risks, and there is no understanding of harm reduction. That's why maybe I started answering from too far about the healthcare systems, but how healthcare system motivates us and leads us to prevention, that's also important aspect, whether that healthcare system includes harm reduction measures in various aspects or not. That's very important to take into account. And of course it's correlated, the perception of risk correlated also with poverty and GDP per capita. The higher GDP per capita, the more society is inclined to to tackle with risks. The lower the GDP per capita, people abandon risks. They think that they will not get disease, they will not get into the hospital, et cetera, et cetera. And that's why we have to also talking about the harm reduction in tobacco. If we take countries where the harm reduction policies are well adopted, but take the lowest decile or quintile of the society in terms of the GDP per capita and compare it with the countries with the entirely same GDP per capita, we see that tobacco use prevalence increases in the lower income deciles and quintiles. So the perception of risks which leads to harm reduction also is very much, I think, correlated with income. And that's why it's important that more advanced our countries become in terms of economic development more this sort of thinking will come into our mind and in our societies.

01:09:58 --> 01:10:14

Kasia Kowalczyk: Thank you. I'm just looking at the watch. And I would assume that there are questions from the audience. So if I could ask for a mic. It's coming.

01:10:24 --> 01:11:44

Nadia Bedrichuk: My name is Nadia Bedrichuk. I work for Healthy Initiative. We work, operate in Ukraine and post-Soviet countries. I cannot say about Kyrgyzstan, Uzbekistan and Tajikistan, but we have conducted the researches representative researchers in Ukraine and Georgia. And we have done many of this two years ago. We could see that there are no changes in terms of perception of the harmfulness of nicotine and tobacco smoking. And many smokers and the major part of population believe that the most harmful agent in smoking is nicotine. And there are no changes in particular in Georgia and Ukraine. And among the spokes, they have misconception that electronic cigarettes, they don't contain nicotine. They're even more harmful than common traditional cigarettes. I have a question to our experts. If we have the conservative scenario and this attitude, How many years your countries will need to reduce the tobacco smoking by 80%?

01:11:44 --> 01:13:47

Zurab Tchiaberashvili: Long time. But the longer answer would be the following. What we see now is that the consumption of the combustible tobacco goes down in developed countries, in advanced societies, and the use of alternatives go up. This is part of the harm reduction policies. Of course, our societies will mimic the trend also. In five years, ten years, the same will happen in our society because through social media and the internet, people get information who are interested in. And then only after 20 years, our society may start thinking, aha, If that's happening now, we have to think about how to deal with the alternatives. While data already is there, and the successful policies are already there to take it into account, but this approach What I mentioned, Nadia, that the governments usually prefer to follow what the majority of countries does, not the outliers. And UK and New Zealand or US and others, they are outliers for the moment. But this will be the trend in a decade. This is the next decade, right? And then we will start catching up while there is a moment to catch up right now.

01:13:47 --> 01:16:46

Gintautas-Jouzas Kentra: In terms of the... In terms of the time frames, it is impossible to predict, but there are two scenarios. If we don't do anything, we will be left with the same figures and numbers. If we prohibit, prohibition don't work much. They will generate very minimum outcomes. Only the harm reduction will generate the maximum effect and outcomes. We have to start with the healthy ones, not with the sick ones. If here, if we continue these efforts, and the more population is aware, is outreached, because this population includes the members of the parliament, and this is not one year of work. the information which is accumulated in the minds of people, and it will create the gradual transition or a very sharp or a kind of leapfrogging effect. We can compare with WHO, which denies the concept of harm reduction and making reference to the Framework Convention. Will they change their policy in the future? And when will this happen? Sooner or later it will happen. Maybe some other scholars will come, some evidences. We don't know about these timeframes. If this happens to the WHO, then it would be much easier for us to use this data. And even the government officials will be more open-minded and more perceptive. And all of this are interrelated and interlinked. And we cannot be separated from the rest of the world. unfortunately or fortunately. And of course, they will have to look into the issues which are of good interest to the Minister of Health only. But the issues of interest to the public, they don't pay attention. Of course, we have to accelerate our efforts in terms of awareness raising.

01:17:01 --> 01:17:59

Attendee: Non-governmental organization from Georgia. So, my question is regarding preventive medicine because all the speakers mentioned the importance of preventive medicine and considering the high rates of non-communicable diseases in all our countries, including my country, I have a question. So how can the system stimulate people to address medical institutions for preventive reasons, prophylactic reasons? And I do not mean here only existence of state-financed screening programs, because as we witness in my country, there are many state-financed screening programs, but just existence of these programs is not helping. So that's my question.

01:18:04 --> 01:20:15

Zurab Tchiaberashvili: Thank you, Shorina. Though I touched the issue of the healthcare system, this question also gives me an opportunity to dwell a little bit on that. We had a system in Georgia till 2013 when healthcare system was organized through the private insurance companies. And we saw in those years before 13, we saw the increase in utilization of the primary care and the prevention. While when we went back to the single payer in 2013, the public money on healthcare increased and out-of-pocket payments being reduced, but almost 95% of that money went to hospitals, not to primary care, not to prevention, but hospitals. That's why when I've said that single payer, it just sucks the money public provides. The more you give them, the more the system will use it. I mean hospital side. But what we talk here and what is your question is about how to motivate public. And public is motivated when the financing of healthcare is based on addressing risks, meaning on insurance. As simple as that.

01:20:17 --> 01:22:02

Arkadi Sharkov: May I add, Zorub? Zorub said it perfectly, especially in the field. Of course, the main idea of the private health insurance is not to pay you for expenses at hospital care, mainly for you to remain healthier more years in order for them to have lower expenses. So this is one. Another thing for the stimuli, I believe in Germany there is, with all the cranking cases, there is this type of stimuli which was if your GP tells you what you have to achieve until the end of the year as outcomes in order to lower your blood pressure, stop eating unhealthy foods, walk more, et cetera, et cetera. If you achieve these outcomes, and there are clear measurements for them, like, for instance, cholesterol levels and also hypertension levels, then part of your insurance input is taken out. So this is another type of stimuli. And more or less, the best way, I think, to follow if there is a single payer, and to follow through if someone goes to preventive care is through voucher schemes. Voucher schemes, not giving money by hand, not giving stimuli only to the doctor, but giving through vouchers for you, for patients to go visit the doctor for the certain idea the voucher is offering in this preventive care. So this is a type of innovation that we're trying to put in Bulgaria for the past year.

01:22:02 --> 01:22:55

Saida Umarzoda: I can here, in Tajikistan under the World Bank project, project for improvement of health services at primary care level, introduce result-based financing. This is motivation of family doctor, family physician to detect in a timely manner patients with diabetes mellitus with high blood pressure or any other pathology. There are special indicators for that and now we've been discussing whether we need to change some of those indicators to be able to identify this pathology at early stages. So the family doctor need to be motivated to do that. If this motivation is in place, we can achieve really great results at the primary care level.

01:22:55 --> 01:25:01

Samigullina Alfiya Eldarovna: However, I would like to approach from a different side in our countries, Central Asia. The public health institute is very poorly developed. We don't have a risk assessment system. We don't have a risk management system. on all the system like single payer and 70 percent as our colleague from Bulgaria said goes to the secondary or hospital care treatment of patients and remaining amounts go to pay salary and preventive health care doesn't have any money and indicated that our colleagues also have special indicators for family medicine they assess are faster and provide additional bonuses to doctors. But people still don't have, don't develop yet culture for health promotion or health saving. And people don't seek care in any hospital when they have first signs because they have to pay. And patients usually go to polyclinic when everything goes bad. And to change this tradition of post-Soviet era is very difficult. It's extremely difficult. And this information is extremely important because we do this information work on a continuous basis at all level. It is very difficult to reach out to people because we have very few people who are responsible for their health. They usually rely on doctors. Doctors rely that a patient got sick or died and didn't get healthcare in time. General aggression against doctors, on one hand, it can be beneficial to the state because the state finance health services to a full extent. For example, we've been introducing neonatal screening for three years. This is a very important great impediment because we have a lot of problems we have an endemic zone of iodine deficiency. And to understand why we need such important investments in neonatal screening was very difficult to communicate to people. However, when we were able to introduce that and when we detect up to 40% of patients with thyroid gland disorders, treat this in time and do substitution therapy, it will be a normal person. And this program is very important for our countries. And in the future, these 40 children we detect in time and that they receive substitution hormonal therapy, they became normal. becoming normal members of society. They won't be disabled. And it's a great burden. And we're able to save a lot of money and burden the health sector, because otherwise they will have to be treated in the future. And this type of risk assessment and risk management, unfortunately, is not done properly in our country. And therefore, we would like our public health to become stronger. And this home reduction concept that's only being initiated in our countries is one of the instruments that will allow to communicate to decision-makers and communicate to our people the need to make step-by-step or some important steps to improve their health. Because we have many teenagers that smoke and use drugs, and all these are manipulations related to the fact that we're being distracted from the main problem, the problem that we have to prevent. But habits need to start this in family. Family need to establish basics of healthy lifestyle. If this doesn't happen, obviously, our countries will have their high mortality and high indicators.

01:27:43 --> 01:27:52

Kasia Kowalczyk: I'm afraid we are running out of time. I don't think we can hear you.

01:27:55 --> 01:28:54

Attendee: Just, I know it's late, but just this point is important. FCTC provision for harm reduction exists. It's just that various interest groups and governments hide it. If I remember correctly, Article 1D, if I remember, says all measures, appropriate measures to reduce supply, demand, and harm reduction to make people's life healthier. So I think there is a general tendency to hide this harm reduction part from. It is integral part there. And I think, I mean, I keep convincing my government, which is, of course, in South Asia. that, no, it exists, because harm reduction is also part of medical care itself. And the FCTC does provide for it, just for information. Thank you.

01:28:54 --> 01:29:10

Kasia Kowalczyk: Thank you very much. Unfortunately, we really ran out of time, so I would like to thank you to our panelists, to Arkady, and to all of you, and I encourage you to find our guests, or if you have questions, just ask them during the coffee break. Thank you.