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Family Medicine as a Model of 

Primary Health Services Delivery: 
A Pilot Study in Almaty, Kazakhstan 

 

 

Dilara Orynbassarova 

 
KIMEP University, MPA, Almaty, 
Kazakhstan 

 

 

Vol. 4, No. 1 (2015)   |   ISSN 2166-7403 (online)  

DOI 10.5195/cajgh.2015.209 |   http://cajgh.pitt.edu 

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Central Asian Journal of Global Health 

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Abstract 

Introduction. Advanced models of delivering primary health care are being implemented in various countries of the world. This 

is especially true for countries undergoing a healthcare transition in Central Asia, such as Kazakhstan, which obtained independence 

from Soviet Union in 1991. The Kazakhstan National Program of Health Reform, implemented between 2005-2010, aimed to 

create an effective system of primary care. One of the key directions of healthcare reform implemented in Kazakhstan included the 

development of family medicine, which has become cutting-edge agenda for Kazakhstan Health Ministry over the past 10 years. 

While many papers have been published about the importance of family medicine and primary healthcare models, few have focused 

on analyzing family medicine effectiveness in Kazakhstan and its impact on access to family doctor services and patient satisfaction. 

The key aims of this pilot investigation were 1) to assess the model’s impact on access to primary care and patients’ satisfaction, 

and 2) to explore the model’s effectiveness in some Central Asian and transitional countries in the literature.   

Methods. This pilot study was based on semi-structured interviews and questionnaires about the perception and impact of the 

primary care model to 86 respondents aged 19-51 (54% females, 46% males). The majority of respondents were Almaty city 

residents (71%), while the rest were Almaty Province rural residents (22%) and residents of other Kazakhstan regions (7%).  

Results. Respondents from rural areas associated general practitioners, or family doctors, with community clinics (also referred to 

as feldsher posts). Even though urban area respondents use family doctor services, they were more likely to get those services in 

private rather than public clinics. Rural residents appear to have better access to primary care providers than urban residents 

participating in our study. Also, respondents from rural areas were more satisfied with services provided by family doctors than 

respondents from urban areas. 

Conclusions. This pilot study helped to improve our understanding of primary health care reforms implemented in Kazakhstan, a 

topic that is not traditionally covered in international literature. This pilot study suggests that primary care is more effectively 

implemented in rural areas of Kazakhstan (Almaty Province); however, future full-scale research in this area is needed to fully 

understand the complexity of primary healthcare access in Kazakhstan. 

Keywords: Central Asia, Kazakhstan, primary health care, family medicine, access to care, general practice 

 

Family Medicine as a Model of 

Primary Health Services Delivery: 
A Pilot Study in Almaty, Kazakhstan 

Dilara Orynbassarova  

 
KIMEP University, MPA, Almaty, Kazakhstan 

Research 

Advanced models of delivering primary health 

care are being implemented in various countries around 

the world. This is especially true for countries 

undergoing a healthcare transition in Central Asia, such 

as Kazakhstan, which obtained independence from 

Soviet Union in 1991. Many international declarations 

and forums recognized the importance of implementing 

an effective primary health care system.1 Primary health 

care is an effective vehicle to “improve health care access 

and outcomes while narrowing equity gap.”2 Qualitative 

analysis of empirical evidence indicates one of the 

directions that most countries undertake while reforming 

their primary care system is the development of family 

medicine centered care, which has become a critical 

component of Western public health systems. Published 

evidence indicates that 90% of various patients in 

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CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 

 

 

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

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different countries around the world begin and end their 

medical treatment at the level of a family doctor, seeking 

help of highly specialized professionals only in 

exceptional cases.2-4 

As a country in transition, Kazakhstan is 

seeking the most appropriate model for improving public 

health practice, traditionally challenged by a focus on a 

curative medicine approach rather than prevention.5-7 

Despite the fact that several drawbacks of primary 

healthcare models have been recognized, including 

access to care, various publications recognized positive 

aspects of primary care models, including slower growth 

in healthcare spending.8  Recent publications by 

Sharman,9-11 emphasized the need for change from 

Kazakhstan’s current disease-centric healthcare 

paradigm to a new primary health and wellness-centric 

health care paradigm.11 The concept of primary care is 

not unknown in Kazakhstan, as historically, in the 

countries of the former Soviet Union, many functions of 

primary care doctors have been performed by feldshers.12 

Feldsher is a middle level healthcare provider with 

training similar to physician assistants in the US or an 

advanced nursing degree, providing primary care mainly 

in rural areas in the countries of former Soviet Union. 

Also, while it had many weaknesses, Semashko’s 

centralized model of healthcare, as was practiced during 

the Soviet period, paid particular attention to prevention, 

especially in the area of vaccinations.13 

One of the major objectives of the Kazakhstani 

Health Program 2005-2010 and part of 2020 strategic 

development plan, included the development of family 

medicine and strengthening the principles of general 

medical practice. As a part of this program’s vision, 

family doctors would gradually replace current 

healthcare providers, such as district physicians and 

pediatricians, thus unifying the primary care services 

delivery system.14,15 Family medicine-centered care in 

Kazakhstan is not new health care developmenal 

approach; it was introduced in Kazakhstan over twenty 

years ago. The history of introducing the family medicine 

model started in 1990s, when the first pilot clinic of 

mixed type (district physicians practicing with family 

doctors) was created in Alma Ata (Almaty) in 1989.16-18 

Little has been published about assessing family 

medicine practice implications for Kazakhstan, and 

almost no research has been conducted about the impact 

of the model on access to primary care services and 

satisfaction with those services by Kazakhstani citizens. 

The main aim of this pilot investigation was to 

investigate the care given under the family medicine 

model in Kazakhstan, and observe if any disparity 

between rural and urban settings exist regarding access to 

care and satisfaction with these services.  

Results of this pilot study can serve as a 

foundation for further full-scale research studies in the 

fields of primary care, family medicine, and general 

medical practice in Kazakhstan. This research would be 

of special interest to those with interest in Central Asian 

region. 

 

Methods 

Survey development for this study was based on 

elements of Hsiao Evaluation Framework elements, 

including organizational arrangements, financing, 

resource allocation, and provision elements,which refers 

to allocation of health care goods and services.19,20 Since 

this pilot study focused on finding out the family 

medicine effectiveness in providing healthcare services, 

the service provision element was the key target for the 

analysis. Effective service provision indicators included 

access to primary care services, patient satisfaction, and 

capacity of effectively managing acute and chronic 

diseases by family doctors. 

Data were collected from November 1, 2009-

January 12, 2010. The main data collection technique 

was a survey tool composed of semi-structured 

interviews and questionnaires created for this study. The 

questionnaire was divided into five major parts as per 

effective service provision indicators. Interviews were 

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conducted by two highly trained professionals, including 

a district pediatrician and district therapist. This pilot 

study consisted of 86 respondents aged 19-51 (54% 

females, 46% males). The majority of respondents were 

Almaty city residents (71%), while the rest were Almaty 

Province rural residents (22%), and residents of other 

Kazakhstan regions (7%). Descriptive statistics have 

been conducted to report the findings.  

Convenience sampling technique was applied in 

a randomly chosen Almaty City Polyclinic #8 and 

Almaty Diagnostic Hospital. Interviews were conducted 

by specialists, who had approximately 7 years of 

experience working with the Association of Family 

Doctors of Kazakhstan, district pediatricians, who had 

roughly 15 years of experience working in the Almaty 

Child City Polyclinic #8, and district therapists, who had 

approximately 11 years of experience working in Almaty 

City Polyclinic #8 and worked part-time as a family 

doctor in the Republican Family-Doctor Center in 

Almaty. Patients who were available to complete the 

survey were surveyed.  

While no formal ethics review was conducted, 

this project was approved as thesis work by KIMEP 

University. Each questionnaire also had a heading that 

informed participants of the aims of the study in addition 

to the confidentiality of their responses. 

 

Results 

One of the key findings of this study was that 

rural area respondents associated feldshers with primary 

care doctors. It was observed that the majority of 

respondents (75%) from rural areas responded that the 

community feldsher doctor was their first contact, while 

15% of respondents had difficulties in replying to the 

survey, and 10% of respondents cited other as their 

primary contact in the case of a health issue. Even though 

urban area patients used family medicine services, they 

preferred to get those services in private clinics vs. public 

ones. Specifically, 71% of urban respondents indicated a 

preference for private clinics, 26% indicated preference 

for public clinic services, and 3% found it difficult to 

respond. Respondents reported that the reasoning for this 

may be that quality doctors are not motivated to work in 

public clinics due to low financial incentives.  Also, there 

is a lack of incentives for serving children, adults, and 

women all together by one family doctor, as district 

therapists are better reimbursed by serving mainly the 

adult population. 

Despite the small sample size, it appears that 

rural residents have higher access to family medicine 

services compared to urban residents. Almost half of 

rural respondents (49%) agreed with the statement 

“patients can contact family doctor easily by telephone to 

obtain advice.” The majority of urban respondents (55%) 

disagreed with the statement “the appointments are easy 

to make whenever I need them” compared to 45% of rural 

patients agreeing with this statement. 55% of urban 

patients indicated that the public polyclinic they visited 

did not employ a family doctor.  

Rural area respondents in this study were more 

satisfied with services provided by family doctors than 

respondents from urban areas. Overall, 51% of 

respondents were dissatisfied with the quality of services 

provided by family doctors, 2% very dissatisfied, 12% 

moderately satisfied, 31% satisfied, and 4% very 

satisfied. Groups of dissatisfied respondents (51%) and 

satisfied (31%) were targeted for selective analysis by 

their place of residence. Considerable difference in 

answers was revealed. Among 51% respondents 

dissatisfied by family doctor services, 82% were Almaty 

city residents, and among 31% respondents satisfied, 

71% of respondents were from rural areas.  

Based on qualitative interview data, it appears 

that patients living in rural communities in Kazakhstan 

are more satisfied with services provided by family 

doctors since they have less access to specialist care, and 

urban area patients prefer directly accessing specialists in 

secondary and tertiary care specialized hospitals, since 

those are available in Almaty city. Data analysis revealed 

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that rural patients considered the family doctor as point 

of first contact for acute and some of the chronic health 

problems, while urban respondents considered the 

district therapist as doctor of first contact for acute health 

problems, and preferred narrow field specialists as a first 

contact doctor for chronic illnesses. The majority of 

urban respondents would rarely refer to family doctors 

when having chronic illness, including gastritis, allergy, 

chest pain, or ENT problems, and prefer to visit 

specialists for those. In allergy cases, the majority of 

urban respondents (52%) would refer to allergologyst, 

chest pain (63%) to cardiologist, applying plaster cast 

(66%) to surgeon, and vision problem 48% to 

ophthalmologist. However, different answers revealed 

from rural patients. The majority rural respondents would 

consider the family doctor as the doctor of first contact 

when having health problems and some chronic illnesses, 

such as gastritis and ENT problems. 

 

Discussion  

In summary, the family medicine model is being 

practiced in Kazakhstan, and appears to be accessible to 

rural residents. An interesting finding is that even though 

urban area respondents used family doctor services, they 

preferred to get those services in private clinics. 

Countries in transition, including Armenia, Russia, 

Kyrgyzstan, and Turkmenistan that inherited the Soviet-

Semashko model of health care, and characterized by a 

centrally controlled healthcare service provision, were 

found to have similarly developed levels of a family 

medicine model, with rural areas being more positively 

affected by the primary care model compared to urban 

ones. For comparison, the same trend is observed in the 

Kyrgyzstan study, where rural family doctors in Issyk 

Kul (rural area) managed the initial visit with health 

concerns 80-100% of the time more frequently than in 

Bishkek city (capital city).21  The presence of a large 

number of highly trained specialists in urban areas as an 

alternative to family doctors have adversely impacted 

family doctors’ ability to solve first-contact chronic 

health problems. A higher density of population in urban 

vs. rural areas, as well as a high concentration of 

specialists in urban areas may potentially prevent urban 

area family doctors to fully realize their potential. 

Limitation of this research includes small 

sample size, poor representatives of rural population, and 

non-randomized nature of our sampling technique. While 

these weaknesses limited the generalizability of study 

findings to the general population of Kazakhstan, these 

limitations will be addressed in future research. 

However, since there is a paucity of published research 

on primary healthcare models in Kazakhstan, this pilot 

investigation has been designed to fill this important gap. 

To generate more nationally representative samples, 

further research is suggested that would capture a wider 

variety of geographic catchment areas, with random 

selection of research participants. Future studies should 

specifically address rural-urban differences in perception 

and use of primary care. Kazakhstan is a good country to 

implement this research, as it has undergone substantial 

economic and political transition in a relatively short time 

frame.  

Family medicine model care was found to be 

effective and accessible, especially in rural areas of 

Kazakhstan. Better policies targeting primary care 

integration should be considered for furthering primary 

care in Kazakhstan. While it early to judge the overall 

effectiveness of the model, work to date clearly indicates 

that impacts and challenges of this model for Kazakhstan 

need to be assessed. Advantages and disadvantages of 

this model need to be clearly explored before further 

integration, as previous publication suggested that 

overall health expenditures were higher in countries with 

stronger primary care structures, perhaps because 

maintaining strong primary care structures is costly and 

promotes developments such as decentralization of 

services delivery.8 

As an interesting comparison, studies in 

Kyrgyzstan, Armenia, and Turkmenistan suggested that 

family care models improved rural access of those 

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residents with low income and low education.22-24 In 

Kyrgyzstan study, increased access to services positively 

impacted waiting time and out of pocket payments of 

(73%), as rural patients no longer needed to travel to 

urban centers for specialists’ care.24 Turkmenistan study 

indicated 2 fold decrease of Sayat Chardzhou rural total 

health expenditure and 3-fold decrease in patient 

hospitalization rate.25  In Moldova study, rural patients 

(68%) living in village near to Laloveni city expressed 

satisfaction with increased access to services.26 

Ukrainian study of Dneprodzerzhinsk indicated a 3-fold 

decrease in ambulatory call frequency, and patient 

hospitalizations became lower than average city level.27 

In Armenia, the proportion of self-referrals by patients to 

specialist care in rural areas decreased from 26% to 20%, 

in contrast, self-referrals rate in urban areas increased 

22% to 38%.24 

This pilot study helped to improve our 

understanding of primary health care reforms 

implemented in Kazakhstan, a topic that is not 

traditionally covered in international literature. This pilot 

study seems to suggest that primary care is more 

effectively implemented in rural areas of Kazakhstan 

(Almaty Province); however, future full-scale research in 

this area is needed to fully understand the complexity of 

primary healthcare access in Kazakhstan.   

 

Competing interests 

The author declares that they have no competing 

interests. 

 

Acknowledgment 

   The author would like to thank the College of 

Social Sciences of KIMEP University, particularly our 

honorable professors Dennis Soltys, John Dixon, John 

Couper and Aigerim Rollanovna for suggestions on 

previous versions of this paper. 

 

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