Public
Health Challenges and Priorities for Kazakhstan
Altyn
Aringazina1, Gabriel Gulis2,
John P. Allegrante3
1Department
of Population Health and Social
Sciences, Kazakhstan School of Public Health, Almaty, Republic of
Kazakhstan; 2Unit
for Health
Promotion Research, University of Southern Denmark, Esbjerg, Denmark;
3Department
of
Health and Behavior Studies, Teachers College, and Department of
Sociomedical
Sciences, Mailman School of Public Health, Columbia University, New
York, NY
USA
Abstract
The Republic of Kazakhstan is one of the largest
and fastest growing post-Soviet economies in Central Asia. Despite
recent
improvements in health care in response to Kazakhstan 2030
and other
state-mandated policy reforms, Kazakhstan still lags behind other
members of
the Commonwealth of Independent States of the European Region on key
indicators
of health and economic development. Although cardiovascular diseases
are the
leading cause of mortality among adults, HIV/AIDS, tuberculosis, and
blood-borne infectious diseases are of increasing public health
concern. Recent
data suggest that while Kazakhstan has improved on some measures of
population
health status, many environmental and public health challenges remain.
These
include the need to improve public health infrastructure, address the
social
determinants of health, and implement better health impact assessments
to
inform health policies and public health practice. In
addition, more than three decades after the Declaration
of Alma-Ata, which was adopted
at the International Conference on Primary Health Care
convened in
Kazakhstan in 1978, facilitating population-wide lifestyle and
behavioral
change to reduce risk factors for chronic and communicable diseases, as
well as
injuries, remains a high priority for emerging health care reforms and
the new
public health. This
paper reviews the current public health challenges in Kazakhstan and
describes
five priorities for building public health capacity that are now being
developed and undertaken at the Kazakhstan School of Public Health to
strengthen population health in the country and the Central Asian
Region.
Keywords: Central Asia, Kazakhstan, health care, health
promotion, population health, public health
Introduction
The Republic of Kazakhstan is one of the former Soviet
republics that are now part of the Commonwealth of Independent States
(CIS). It has one
of the largest and
fastest expanding economies in Central Asia, growing an estimated 9%
between
2000 and 2007. In 2011, Kazakhstan marked the 20th
anniversary of post-Soviet independence by introducing new social
policies
designed to strengthen its domestic socioeconomic standing and
political
position in the international community. In addition, the central
government of
Kazakhstan has prioritized several goals aimed at diversifying the
economy
beyond its reliance on oil, natural gas, and other extractive
industries,
decreasing dependence on the government sector, and increasing
competitiveness
of the state as a whole. A key area of the central government’s
interest is the
improvement of population health.
Despite
strong macroeconomic indicators and considerable progress in building
civil
society, efforts to democratize its system of higher education and
related
institutions and modernize infrastructure to support population health,
numerous challenges remain in delivering public health services to a
population
of over 16 million people, 59% of whom now live in the two largest
urban
centers: Almaty and the capital city of Astana. Although many health
status
measures show Kazakhstan to be ahead of most nations of the region,
Kazakhstan
continues to lag behind nations with the size of its economy on several
important health and environmental indicators.1
This
paper briefly reviews the current health status and features of health
care in
Kazakhstan and describes the current public health challenges. We also
present
five priorities for public health capacity building that are now being
developed at the Kazakhstan School of Public Health to strengthen
population
health in the country and the Central Asian Region.
Socio-demographic
and Health Status Profile
The
population of Kazakhstan is currently estimated (as of 2011) to be 16.5
million, with a growth rate of 1.235%.2 The
World Bank3 has estimated the Gross
National Product to
be $149.06 billion in 2010, with a per capita gross national income of
$6,280,
which is below the average of other European Region states.
Life
Expectancy
The
World Health Organization (WHO) health profile for Kazakhstan, which is
located
within the WHO European Region, estimates the average overall life
expectancy
at birth to be 64 years (59 years for males and 70 years for females),
which
lags behind the regional average of 75 for both genders.1
The trend
in life expectancy in Kazakhstan is similar to that observed in the
other CIS. Similar
to other nations, female life expectancy at birth exceeds that for
males by 11
years.
Causes
of
Mortality
The
WHO estimates that, with only a few exceptions, the rates of mortality
due to
the main diseases are above the averages for other regional states.
According to WHO,
noncommunicable chronic
diseases (cardiovascular diseases, including diabetes, and cancer)
accounted
for about 85% of all deaths in Kazakhstan, injuries about 11%, and
communicable
diseases about 2%.1 Cardiovascular diseases
accounted for 57% of all
mortality.4
Infant mortality in 2010 was 29 deaths per 1,000
live births and maternal mortality was estimated in 2008 to be 25
deaths per
100,000 births.
Infectious
and Sexually Transmitted Diseases
Blood-borne diseases such as Hepatitis C and HIV, sexually
transmitted infections, and tuberculosis still constitute a challenge
for the
public health system in Kazakhstan. As
of the
end of 2010, Kazakhstan reported to the WHO Regional Office for Europe
and the
European Centre for Disease Prevention and Control a cumulative total
of 15,754
HIV and 1,242 AIDS cases, including 881 deaths due HIV/AIDS.5
For
the year 2010 alone, 1,988 HIV and 256 AIDS cases, with 165 deaths due
to
HIV/AIDS, were reported. The rate of newly diagnosed HIV infections in
2010 was
12.4 per 100,000 populations. Although
Kazakhstan currently has a relatively low prevalence rate of HIV
infection,
there are a number of factors in place that create the potential for a
dramatic
increase, including those of migration, injection drug use, commercial
sex
work, and the marginalization of vulnerable groups.6
Kazakhstan has a prevalence rate for tuberculosis (TB) of
198 per 100,000, which, when compared to 63 per 100,000 people for
other
nations in the WHO European Region, is the highest in the region. While
working on a region-wide initiative to
improve the effectiveness of the health system in response to TB,
Project HOPE
initiated an anti-TB strategy by implementing Directly Observed
Therapy-Short
Course (DOTS) in 1994. Since then, the TB program has expanded to
become a
region-wide disease management program. In 2009, Project HOPE
implemented a
five-year, USAID-funded partnership with Population Services
International
(PSI) to increase access to TB prevention and treatment among at-risk
populations in Kyrgyzstan, Tajikistan, Uzbekistan, and Kazakhstan. The
initiative provides
direct outreach
services and training to those populations most at-risk and focuses on
increasing TB and HIV knowledge and prevention as well as training for
providers on stigma reduction.
Immunizations
Kazakhstan has been officially considered a poliomyelitis
free country by the WHO since 2002, with the national immunization
coverage at
98 percent in 2010. Concerning other vaccine-preventable diseases,
coverage in
2010 for BCG was at 96%, measles-containing vaccine (MCV) at 98%, and
DTP1 and
DTP3 were at 99%. Vaccination against 21 infectious diseases is
conducted in
Kazakhstan. In accordance with the national calendar of prophylactic
vaccination, children under two years old are given vaccine treatment
against
11 infectious diseases. A National Advisory Committee on Immunization
was
established in spring 2012 with the aim of being an advisory body to
deal with
the issues of vaccination and resolve the issues of introduction and
application
of new vaccines in Kazakhstan. Vaccines certified by the WHO are
procured and,
moreover, all vaccines undergo laboratory control, tests, hospital
control to
ensure safety and effectiveness.
Population
Risk Factors
Although
the adult risk factors of blood glucose, blood pressure, and the rate
of female
obesity are higher in Kazakhstan than other countries in the region,
male
obesity and adult tobacco use is lower. In 2008, the rate of obesity
among
adult males aged 20+ was 20.2, while adult female obesity was 27.4.
According to data
collected by the National
Center for Healthy Lifestyle Development, the average smoking rate in
1998 was
28%, which had declined to 27% by 2007 and where it has remained as of
2011. Average
alcohol consumption has declined from 55% in 1998, to 41.9 % in 2007,
to 35.6
in 2011. Adult participation in physical activity was 15.3% in 1998 and
18.6%
in 2007; however, in 2011 levels of participation in physical activity
declined
slightly to 17.6%. Major efforts are now being taken to improve the
management
and control of hypertension.7
Health Care
Since
the post-Soviet era and as the result of reforms, health care in
Kazakhstan has
developed and evolved into a stable government function that is
designed to
provide high-quality medical and related pharmaceutical and
rehabilitation
services to the population. One of the main priorities of the central
government of Kazakhstan is the modernization of a high-quality health
sector
and development of an integrated health care system that utilizes high
technology.8 The State Health Development
Program calls for an
intersectoral approach to improving population health and includes
benchmarking
measures on a wide range of legislative, investment, structural,
economic, and
personnel indicators. Additionally, one of the
main goals of the
program is to introduce incentives for people to engage in
“self-keeping”
behavior and lifestyle changes that can promote and protect health.
Thus,
the overall goal of the program is to improve
health for all citizens of Kazakhstan in an effort to ensure
sustainable social and economic
development.
The program is also intended to promote dynamic development
of the health care system by creating conditions for economic reforms
that can
improve access to high-quality medical and social services and the
provision of
prevention
programs. This has included development of a new system of social
insurance as part
of reforms that replaced the Soviet system and are designed to improve
access,
especially among those in the rural areas where access to care has been
problematic,9-11 and reduce the problem
of informal payments to medical personnel that often has been a feature
of
reimbursement in the provision of medical care.12
In addition, the program aims
to elevate the professional personnel qualifications of medical
specialists and
foster development of an equitable health care system that is capable
of
adapting to
market conditions of society. Recent
developments along these lines
include the creation of a health care legal base, significant increases
in
health care funding that have allowed for the construction of new,
state-of-the-art clinics and hospital facilities, capital repairs and
improvement of the technical infrastructure of health facilities, and
the
introduction of new medical technologies for diagnosis and treatment.
As a
result of improving the quality and accessibility of health care, some
positive
trends in the health status of the population related to infectious and
other
diseases have been achieved. However, the majority of public health
parameters
remain unsatisfactory.
The State Program’s specific goals for improvement of key
indicators by 2015 include:
- increasing
life expectancy at birth from 68.4 to 70
years;
- decreasing
maternal mortality per 100,000 births from 28.1 to 24.5; and
- decreasing
infant mortality per 1,000 births from 16.5
deaths to 12.3.
As in other middle-income countries, the increase in life
expectancy is expected to be accompanied by an increase in the number
of people
living with chronic disease and thus a significant increase in the
demand for
primary health care is likely to occur.13
Even with key elements of the most recent State Program
reforms for health care now in place, the health care system continues
to be in
transition6 and significant barriers to
implementation have
remained.14 Kazakhstan’s difficult economic
context, lack of
resources, the legacy of Soviet-era policies, and the complex and often
corrupt
political arrangements between national and local authorities are among
the
challenges that remain to be overcome.15
However, there are some
positive changes in the health status and health care system of
Kazakhstan. For
example, health care indicators have continued to improve on most
measures as
the health care system has modernized. Moreover, the birth rate has
increased,
together with years of life expectancy, and although the rates of some
noncommunicable diseases have risen, the mortality due to
cardiovascular
diseases has decreased by 1.7%.
Public
Health Challenges
Public
health in Kazakhstan
is under the direction of the Ministry of Health. Public health efforts
are
organized and undertaken through a coordinated system of central,
regional, and
local entities.16 There are
several key elements of this system. The Committee on
Sanitary-Epidemiological
Surveillance of the Ministry oversees the “Sanepid”
(sanitary-epidemiological) Service, which has organized a
network of
subdivisions whose role is to conduct disease surveillance, prevent the
transmission of communicable diseases, and enact quarantine and other
control
measures in the event of epidemic outbreaks. The National
Program of
Health Reform and Development for 2005-201017
outlined an ambitious set of
goals for the reduction of infectious diseases through programs that
are now
being implemented at the national, regional, and local levels. An
Interministerial Coordination Committee on AIDS
coordinates an inter-agency system of HIV/AIDS centers that are
implementing a National Strategic Program on HIV/AIDS
Prevention to address the HIV/AIDS epidemic and related diseases.
Finally, a
National Centre for Healthy Lifestyles focuses on health promotion and
disease
prevention, including drug abuse and trafficking, alcohol and tobacco
use,
maternal and child health, nutrition, and environmental health. In
addition,
primary health care providers, nongovernmental organizations (NGOs) and
several
international agencies, including USAID, the U.S. Centers for Disease
Control
and Prevention (CDC), the World Bank, and WHO, provide a range of
consultative,
programmatic, and other public health services that support domestic
public
health efforts in Kazakhstan and throughout the region.16
Among the most significant public health challenges is the
legacy of poor environmental management that has led to two
catastrophic
environmental health disasters, the effects of which continue to
unfold. In the
case of the first, a population of approximately 200,000 Kazakhs living
in the
vicinity of the Semipalatinsk Test Site, located in the steppe region
of
northeast Kazakhstan, was exposed to large doses of radiation when,
starting in
the 1940s, the Soviet Union conducted over 400 nuclear weapons tests
over the
course of four decades. The health and environmental impacts of these
tests and
the subsequent radiation exposure have become evident in recent decades
with the
increase in the incidence of cancers and other related diseases.18
The second was the
environmental disaster that resulted from the draining of the Aral Sea
during
the 1960s, when Soviet irrigation projects destroyed what was then the
fourth
largest lake in the world. The destruction of the lake has left the
lake bed
and surrounding land polluted and the region economically depressed.
Perhaps the most pressing
challenges for public health are of organizational, political, and
philosophical nature. According to the WHO, the “biggest challenge of
the
country’s health sector in the domain of public health lies in
clarifying,
coordinating and streamlining the roles and responsibilities of
different
agencies responsible for public health and health promotion activities.”16
Moreover, related to
this is
making the promotion of health a core responsibility for all of the
government
ministries.19
The new policy argues for
“whole-of-government” and “whole-of-society” approaches that will
consolidate
the ideas encompassed in Health in All
policies. This concept emphasizes the need to improve the integration
of
government activities with health and to reach out beyond government to
engage
patients and citizens, developing a responsive and inclusive approach
to
governance for health.20
Thus, policy integration
across government functions and in intersectoral partnership with the
agricultural, education, housing, and transportation sectors will be
critical
to achieving the goals of public health in Kazakhstan.
Finally, despite
recent
reforms, young scholars in public health still face significant
barriers to
mounting successful programs of research that could contribute to
improving
population health in Kazakhstan and the region. The relative lack of
investment
in research, the institutional infrastructure necessary to support
grants and
contracts, and a culture of competitive, peer-reviewed investigational
public
health science hampers Kazakhstan from achieving breakthroughs in the
improvement of population health in a region where the public health
needs are
critical to advancing the goals of civil society, further economic
development,
and regional security. The recent attention given to
population health
and evidence-based practice has catalyzed interest in the region to
build the
necessary research culture and institutional infrastructure that can
support
multidisciplinary research to inform policies and practice, not only in
Kazakhstan but also across institutions in the region. Such a culture
and
infrastructure exists in Western Europe, North America, and the United
Kingdom,
where the benefits of robust national mechanisms for funding research
and
institutional infrastructures to support competitive procurement of
funds is
evident in the history of research discoveries that have altered the
course of
the human condition for the better.
Priorities
for Building Public Health Capacity
Against this backdrop and despite negative trends in many
lifestyle indicators and the apparent lack of resources for public
health, much
has been achieved in the last decade to provide a foundation for the
improvement of population health going forward. The establishment of
various
state programs and many organizations in the field of public health,
such as
the Kazakhstan School of Public Health (KSPH), has created the
essential
conditions for the development of a post-Soviet, modern public health
movement
in the Republic of Kazakhstan.
The central government of Kazakhstan has created a National
Coordination Council on Health Protection, the aim of which is the
development
and maintenance of interactions between central and local executive
bodies and
international and other organizations for conducting research and
programmatic
activities on health protection. The Council is a consultative body
governed by
the Minister of Health, comprising 32 representatives from various
ministries,
departments, non-governmental scientific institutions, and other
organizations
that meet quarterly. The main objectives of the Council include the
preparation
of recommendations and suggestions regarding: 1) performance and
maintenance of
actions assigned by the programs; 2) improvement of the state policy
and
normative legislative documents in the area of health protection; and
3) definition of guidelines for health
protection of
the citizens of Kazakhstan. Thus, the Council is an example of one of
the many
innovations in public health capacity that is supporting integration of
a state
health care policy that promotes multi-level, intersectoral
decision-making
processes concerning the main determinants of health.
The Kazakhstan School of Public Health was established in
1997 in accordance with an agreement with the WHO European Regional
office and
the Kazakhstan Ministry of Health. The
mission of KSPH is to: 1)
provide
postgraduate education for health care managers, physicians, and other
medical
specialists; 2) conduct research in public health; and 3) provide
expertise and
consulting services. One
of the
objectives of the KSPH academic program is to train public health
specialists
in a two-year Master’s degree program. Since 2005, 224 students have
been
prepared with the degree of Master of Science in Public Health;
currently, 56
Master of Science students and 15 PhD students are studying at KSPH.
KSPH also
conducts continuing education for public health specialists with short-
and mid-term
programs of five- to ten-month durations. More than 12,000
professionals have
received professional preparation in public health since 1998.
KSPH is an institutional member of the Asian Pacific
Academic Consortium for Public Health (APACPH), the Association of
Schools of
Public Health in the European Region (ASPHER), and the International
Union for
Health Promotion and Health Education (IUHPE). Although in recent years
new
faculties and departments of public health have been established in the
country, KSPH remains the flagship professional preparation program in
the
field of public health in the Central Asian region. As the only well
recognized school of public
health in the Central Asian Region, KSPH is now pursuing the
development of
public health capacity in five key priority areas that are critical to
advancing public health knowledge and practice in Kazakhstan and the
region.
1. Implementing the
New Public Health
Kazakhstan is implementing a new public health strategy that
is guided by a set of core
values and principles.21-22 Health promotion is
the cutting edge of this
new public health strategy
and its theoretical approach and methods are grounded in an ecologic
model of
health that takes into account cultural, economic, and social
determinants and
makes a commitment to equity, civil society, and social justice. In
1997, the President of Kazakhstan set out a 30-year
welfare strategy for the country in an address titled Kazakhstan
2030.23
In the address, the President emphasized the
importance of public health and health promotion as long-term national
priories. The strategy includes the promotion of health and prevention
of
disease by reducing alcohol, drug, and tobacco use, and improving
maternal and
child health, nutrition, and the environment. Nevertheless, the current
public health model in
Kazakhstan is still
largely grounded in a biomedical orientation. Key players and decision
makers
continue to underestimate the importance of public health while they
make investments
in curative medicine. Thus, there is an urgent need to support the
development
of public health programs at the local level and encourage an
interdisciplinary
and intersectoral approach to public health policy and program
development. In
addition, there is a need to facilitate the increase of knowledge and
skills of
health promotion specialists in the country and cultivate social
responsibility
for health.
2. Addressing Social Determinants
Recent attention
to the social determinants of health24
has stimulated a renewed
interest in Kazakhstan to improve the social circumstances that are
necessary
for improved health. Consistent with the WHO’s
expectation that Member States in the European Region focus on reducing
health
inequities that are socially determined, Kazakhstan is currently making
progress to improve education, employment, and housing conditions.
Efforts to prevent diseases related to poor nutrition, poor sanitation,
and
poor water supplies also continue to be a priority.25
However,
more than three
decades after the Declaration of Alma-Ata, which was adopted at
the International Conference
on Primary Health Care convened in Kazakhstan in 1978,
improving social
circumstances remains a priority that has not fully matured. The
newly reconstituted Department of Population Health and
Social Sciences at KSPH has been leading the development of work
on health economics, health impact assessment, and social determinants
of
health. Recent Master Classes sponsored with the support of the
Ministry of
Health have focused on basic principles of public health
policy-making, the role of behavioral
and social
determinants in population health, and the use of economic methods and
health
impact assessment in evaluating national public health programs. Such
activity
is designed to convene specialists with different backgrounds from
different
organizations in order to foster cooperation in finding common ways to
solve
public health problems that arise from or are related to social
determinants.
3. Conducting Health Impact Assessment
A third critical priority of
KSPH is improving the use of health impact assessment (HIA) to inform
policy
and benchmark progress.26 The
powerful hygiene and sanitary system established during the Soviet era
provided
a good foundation for the introduction of practices like health impact
assessment. Yet, the lack of democracy has hindered the full-scale use
of the
method due to many of same reasons as in other countries of the former
Soviet
bloc.27
HIA is one of the main tools
available to public health leaders to implement the Heath
in All policy approach and is especially relevant for the
rapidly developing countries with a high level of economic activity,
such as
Kazakhstan. Concepts and methods of HIA were first introduced in
Kazakhstan in
2005 when KSPH organized and conducted the first summer workshop on the
topic
for medical and public health professionals. The workshop led to the
introduction
of a course on HIA into the regular MPH curriculum at KSPH. A second
workshop
on HIA was conducted in May 2012. An existing Memorandum of
Understanding
between KSPH and the University of Southern Denmark, Esbjerg, currently
provides for ongoing teaching and consultative support in HIA,
including the
use of HIA in research and as a tool for benchmarking that can inform
public
health policy and practice. The National Coordination Council on Health
Protection seems to be a promising infrastructure within which to
situate
capacity for HIA, not only at the project level but also the policy
level in
Kazakhstan.
4.
Strengthening Scientific Communication and
Exchange
A fourth
priority is improving public health through scientific communication
and
exchange. KSPH is focusing on this priority by doing two things. The
first
involves emphasizing the importance of professional development and,
specifically, the value of English as a second language for all of its
faculty
and students. Fluency in English will be critical to the future
development of
the public health profession in Kazakhstan. Because the next generation
of
public health professionals will have to be proficient in conducting
searches
of the global evidence-base, exchanging knowledge and ideas with
colleagues
from different countries, and sharing the results of scientific
findings and
practice in international peer-reviewed journals, English as a second
language
must become a priority for all professional education in public health.
The
second involves revitalizing the Central
Asian Journal of Health Service (CAJHS)
as a key scientific journal of the region for public health research
and
practice. CAJHS provides many
medical
professionals from the region a peer-reviewed outlet for publication in
the
health services. The journal has recently established an online
presence and
manuscripts are translated into and published in Russian, Kazakh, and
English. Expanding
the range of published content to include more reports of public health
research
and commentary, and strengthening the editorial board and peer review
capacity
of the journal, are key priorities for KSPH, the home of the journal
editorial
offices.
5. Building Public Health Workforce Capacity
in
Education and
Training
The final critical priority is capacity-building in public
health professional education and training. KSPH is cooperating with
international organizations such as the American International Health
Alliance
(AIHA), the European Union TACIS Project on Strengthening Environmental
Information and Observation Capacity in the Commonwealth Independent
States,
and other organizations, such as UNICEF, the USAID ZdravPlus Project,
and WHO,
to achieve institutional reforms and training and education for
improving
teaching programs on public health and health promotion. In addition,
it is
working on collaborative research and education projects with the
British
Council, Council on Health Research for Development (COHRED),
Environmental
Resources Management (ERM), and the CDC Central Asia Regional Office.
KSPH also
currently collaborates with several academic institutions, including
the
Columbia University Global Research Center of Central Asia and the
Columbia
University schools of education, public health and social work; Ohio
University;
Semmelweiss University (Hungary); the University at Albany of the State
University of New York; and the University of Southern Denmark. KSPH is
at the
vanguard of efforts to strengthen public health professional education
and
training and bring its public health curriculum into line with current
international standards, including the integration of European and
global core
competencies and quality assurance standards for health promotion and
health
education28-29
and other areas of public
health. These efforts include, for example, participating in a program
of
curriculum reform that is being supported by the Soros Open Society
Foundations
(Soros Europe Foundation) Higher Education Support Program’s Academic
Fellowship Program, and voluntarily undergoing accreditation with the
Associations of Schools of Public Health (ASPHER) during 2012-2013.
These and
other efforts now underway should further the development of
educational
resources at KSPH and deepen the capacity and professional skills of
its
academic faculty to conduct scientific research, training courses, and
other
vital public health functions and services.
Conclusion
The
Republic of Kazakhstan faces many public health
challenges. These
include the need to improve public health infrastructure, address the
social
determinants of health, and implement better health impact assessments
to
better inform health policies and public health practice. In addition,
the
threats to health created by the unfortunate legacy of Soviet nuclear
testing
and poor environmental management of natural water resources have
continued to
endure. In the context of national policy reforms that have placed a
high
priority on improving the health of the population, the Ministry of
Health, the
Kazakhstan School of Public Health, and other government and
non-governmental
entities are responding and making progress with new and
fast-developing public
health policies and programs to meet the challenges. However, improving
public
health capacity is critical and will require new incentives and new
investments
in the system of public health education and training and public health
research, if further improvement of population health in Kazakhstan is
to be
achieved. Continued interest and support of the global public health
community—particularly
that of WHO—in developing and sustaining international collaborative
research
and training efforts will be critical and promises to accelerate the
process of
public health capacity building that is so critical to the future of
Kazakhstan
and the region.
Acknowledgements
The work on this paper was supported, in part, by the
Ministry of Health of the Republic of Kazakhstan (Allegrante,
Aringazina, and
Gulis) and the Soros Open Society Foundations (OSF Europe Foundation)
Higher
Education Support Program, Academic Fellowship Program (Allegrante). We
thank
Rector Zhanna Kalmatayeva and Kalissa Dosbayeva, Assyl
Nurbayev, Aigul Shinbolatova, Gainel Ussatayeva, and
others
at the Kazakhstan School of Public Health, whose assistance and
participation
in the May 2012 Master Classes conducted by Professors Allegrante and
Gulis
generated ideas that helped inform the preparation of this manuscript.
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