Religious women's rights to health care
Article 43 of the Constitution of the Kyrgyz Republic guarantees every citizen the right to health care and medical insurance. To this end, the state creates conditions for the provision of medical services to everyone and takes measures to develop state, municipal, private and other healthcare organizations. Medical services, including services on preferential terms, are provided at the expense of the state to the extent of state guarantees provided for by law. The main regulatory legal act governing the issues of protecting the health of citizens in the country is the Law of the KR “On Protecting the Health of Citizens in the Kyrgyz Republic”, according to Article 1 of which “health protection” means a set of measures of a political, economic, legal, social, cultural, scientific, environmental, medical, sanitary and hygienic and anti-epidemic nature, aimed at maintaining and strengthening the physical and mental health of every person, and providing him or her with medical assistance in the event of loss of health. The above-mentioned Law also enshrines the rights of citizens to healthcare and establishes that the health of citizens is ensured, inter alia, by: a) providing all citizens with equal opportunities in exercising the right to receive health care and medical and social assistance; and b) providing citizens with health care throughout the country. It should be noted that according to the Law of the KR “On Medical Insurance of Citizens in the Kyrgyz Republic”, medical assistance is provided on the basis of compulsory medical insurance. The scope, types and conditions for the provision of health care free of charge and on preferential terms are determined by the Programme of State Guarantees for the Provision of Health Care to Citizens in the Kyrgyz Republic. Medical services that are not included in the Programme of State Guarantees shall be paid at citizens’ own expense. The Government has also adopted the Public Health and Health System Development Programme for 2019-2030 called “Healthy People - Prosperous Country”, which aims to strengthen people-centred healthcare systems and provide lifelong quality services, intended to maximise health indicators of the population, reduce health inequalities, and ensure financial protection.
- What rights of citizens are established by the Law of the KR “On protecting the health of citizens in the Kyrgyz Republic”?
- What rights of citizens are established by the Law of the Kyrgyz Republic “On Immunoprophylaxis of Infectious Diseases”?
- What challenges do healthcare professionals and religious women face in the Kyrgyz Republic?
- What does the Law of the KR “On protecting the health of citizens in the Kyrgyz Republic” say about the refusal of citizens from medical intervention?
- What does the Law of the KR “On Immunoprophylaxis of Infectious Diseases” say about the refusal of citizens from preventive vaccinations?
- What are the gaps in the proper registration of “consent / refusal”?
- What liability for citizens and healthcare professionals is established by the Criminal Code of the Kyrgyz Republic?
What rights of citizens are established by the Law of the KR “On protecting the health of citizens in the Kyrgyz Republic”?
The Law of the KК «On protecting the health of citizens in the Kyrgyz Republic” defines two terms applied to citizens: a sick person - a person who has been diagnosed with a disease, and a patient - a person who is provided with health care in healthcare organisations or by private medical practitioners with the preparation of relevant medical documentation.
With regard to the rights of citizens, the Law of the KR “On protecting the health of citizens in the Kyrgyz Republic” distinguishes between the rights of citizens and the rights of patients. Thus, according to Art. 61, citizens in the Kyrgyz Republic have an inalienable right to healthcare, which is ensured by:
- protection of the natural environment, creation of favourable conditions for work, daily life, recreation, education and training of citizens, production and sale of safe food and medicines;
- providing all citizens, regardless of gender, race, language, disability, ethnicity, religion, age, political or other beliefs, education, origin, official, property or other status, as well as other circumstances, with equal opportunities in exercising the right to receive health care and medical and social assistance;
- providing citizens with healthcare throughout the country;
- granting the right to protect one's life and health;
- giving citizens the right to freely choose a family doctor or a general practitioner;
- providing health care under the Programme of State Guarantees;
- providing information on preventive medicine, hygiene and the promotion of a healthy lifestyle.
Articles 66–71 of the Law of the KR “On protecting the health of citizens in the Kyrgyz Republic” additionally establish the rights of certain groups of the population: families, pregnant women and mothers, minors, elderly citizens, persons with disabilities, and citizens affected by emergency situations and living in environmentally disadvantaged areas.
The rights of patients in the provision of health care are established by Articles 72–76 of the Law of the KR “On protecting the health of citizens in the Kyrgyz Republic”. Thus, when applying for and receiving medical assistance, a patient has the right to:
- receive affordable quality health care in healthcare organizations, as well as from private medical practitioners;
- choose an attending physician in outpatient and inpatient healthcare organizations;
- receive preferential medical, pharmaceutical, orthopaedic and other services in healthcare organizations in accordance with the procedure established by the Government of the Kyrgyz Republic;
- respectful and humane attitude on the part of medical and caretaking personnel;
- examination, prevention, treatment, medical rehabilitation and accommodation in conditions that meet sanitary and hygienic requirements;
- hold a council and consultations of other specialists;
- participate in scientific and medical experiments with his/her written consent and in accordance with the procedure established by the authorised state body of the Kyrgyz Republic in the field of health care;
- have access to a lawyer or other legal representative to protect his/her rights;
- be admitted by a clergyman, and in the hospital - to be provided with conditions for practicing religion, including the provision of a separate room, if this does not violate the internal regulations of the hospital;
- refuse the participation of students of medical educational institutions in the process of diagnosis, treatment;
- other rights stipulated by the legislation of the Kyrgyz Republic.
A patient has the right to receive, in a form accessible to him/her, the available information on his/her state of health, including information on the results of the examination, the presence of the disease, its diagnosis and prognosis, treatment methods, the risks associated with them, possible options for medical intervention, their consequences and the results of the treatment. (Article 73 of the Law of the KR “On protecting the health of citizens in the Kyrgyz Republic”).
Information on the fact of applying for medical assistance, the state of health of a citizen, the diagnosis of his/her disease and other information obtained during his/her examination and treatment, constitute a medical secret. The disclosure of information constituting a medical secret without the consent of a citizen or his/her legal representative is permitted:
- for the purpose of examination and treatment of a citizen who, due to his/her condition, is unable to express his or her will;
- in case of a threat of the spread of infectious diseases, mass poisoning and injuries;
- at the request of the bodies of inquiry and investigation, the prosecutor and the court in connection with the ongoing investigation or court proceedings;
- in case of providing assistance to a minor under the age of 16, his/her parents or legal representatives shall be informed, except for cases established by the law of the Kyrgyz Republic on HIV/AIDS;
- if there are grounds to assume that harm to the health of a citizen was caused as a result of unlawful act.
Persons who, in accordance with the procedure established by law, were provided with information constituting a medical secret, shall bear equal responsibility with medical and pharmaceutical workers, proportionally to the damage caused to the citizen, for the disclosure of medical secrets in accordance with the legislation of the KR. (Article 91 of the Law of the KR “On protecting the health of citizens in the Kyrgyz Republic”).
What rights of citizens are established by the Law of the Kyrgyz Republic “On Immunoprophylaxis of Infectious Diseases”?
According to Article 1 of the Law of the KR “On Immunoprophylaxis of Infectious Diseases”, “immunoprophylaxis of infectious diseases” is a system of measures carried out to prevent, limit the spread and eliminate infectious diseases through preventive vaccination. “Preventive vaccination” is the introduction of medical immunobiological medicines into the human body to create specific immunity to infectious diseases.
Citizens of the Kyrgyz Republic have the right:
- to receive complete and objective information on the need for preventive vaccinations, the consequences of refusal from vaccination, and possible post-vaccination complications;
- to choose the healthcare institutions;
- to receive free-of-charge preventive vaccinations in public healthcare institutions;
- to receive paid preventive vaccinations;
- for a free medical check-up, and, if necessary, a medical examination prior to preventive vaccinations in public healthcare institutions;
- for free treatment in public healthcare institutions in case of post-vaccination complications;
- for social protection in case of post-vaccination complications;
- to refuse from preventive vaccinations.
Thus, the main legislation regulating the issues of protecting the health of citizens in the Kyrgyz Republic establishes guarantees of the rights of citizens when applying for and receiving medical assistance. In addition, there are sectoral laws that regulate medical care and treatment for certain diseases (oncology, tuberculosis, HIV/AIDS, psychiatric diseases, etc.).
What challenges do healthcare professionals and religious women face in the Kyrgyz Republic?
Legislation of the Kyrgyz Republic does not distinguish between the right to health care for religious and non-religious women. Healthcare professionals, when taking an oath, swear to provide medical care to patients, regardless of nationality, social status, political views and religion, as well as to respect their human dignity. Today, the country provides access to medical services for all women, regardless of their religious affiliation. However, in practice, doctors and religious women face certain problems.
It should be noted that the Kyrgyz Republic is characterised by religious and cultural diversity. In this regard, a secular model of state-confessional relations has been developed in the country, based on the principles of equality of all citizens before the law and respect for the religious beliefs of every citizen, regardless of religion. Accordingly, representatives of practically all professions have to take into account certain religious beliefs, and doctors are no exception.
According to the results of the Baseline Assessment in 16 communities of the Kyrgyz Republic on “Knowledge, Awareness on Radicalisation and Access of Religious Women to Public Services”, conducted in 2017-2018, in practice, doctors face a number of challenges when serving religious women (below are excerpts from the report):
“It is widespread when a woman refuses to be examined by a male doctor. Such cases occur even when the life of a woman is threatened, for example, if the surgeon or anaesthetist is a man. For example, there was a case when a woman had severe bleeding during childbirth, and a surgery had to be urgently performed; her husband categorically refused to let the anaesthesiologist see her: “Let her better die rather than be seen by a strange man”, he said.
There are also many cases when religious women refuse contraception, ultrasound and taking gynaecological and other types of tests. Doctors also mentioned cases when religious people refused to take medicines that, in their opinion, do not meet the requirements of Islam, as well as cases of refusal to have unmarried girls examined by a gynaecologist. It was also mentioned that when refusing medical services, women refer to some religious sources.
When asked if they allow receiving medical care against the will of a person or the legal representative of a minor, all doctors said that they were against it. It was noted that any medical intervention can be carried out only with the consent of the patient or the legal representative of the child. The exception is when the patient is unconscious, then only in case of a threat to life can they provide him/her with emergency medical care without the patient’s permission”.
In addition to the issue of access to health care, there is also a tendency in the country to refuse preventive vaccinations. According to the report “An Informative Study to Analyse Reasons for Vaccine Refusals and Understanding Constraints and Barriers”, conducted in 2018 with the participation of mothers and fathers of children under five, religious leaders and healthcare professionals, the latter encounter unvaccinated or partially vaccinated children in their practice (below are excerpts from the report).
“Most parents, according to doctors, refuse to vaccinate their children on religious grounds. There are cases when parents are influenced by religious figures who oppose vaccination. When refusing vaccination, parents give the following reasons:
- The presence of prohibited substances in vaccines;
- There is no need for vaccination, because everything, including disease, depends on divine predestination.
In addition to religious reasons, parents who refuse to vaccinate their children, also indicate other reasons:
- Fears of adverse reactions;
- Vaccination kills the child's natural immunity;
- Ineffectiveness of vaccination to prevent diseases;
- Lack of confidence in the quality of vaccines.
During the study, some healthcare professionals explained that mothers are sometimes subjected to pressure from their husbands and other family members in deciding whether or not to get vaccinated. In some families, this can lead to conflicts.
Follow-up of children who have not received compulsory vaccinations is carried out at the level of the Family Doctors Group / First Aid Station (FDG/FAS). The healthcare professionals explained that each health station maintains lists of children/vaccination registers, and prepares a monthly vaccination plan. If the child does not attend a medical facility at the appointed time, healthcare professionals call the parents or visit the family. If parents refuse to vaccinate their children, awareness-raising is carried out with them. Apart from awareness-raising, healthcare professionals cannot take any measures in respect of parents who refuse to vaccinate their children”.
What does the Law of the KR “On protecting the health of citizens in the Kyrgyz Republic” say about the refusal of citizens from medical intervention?
According to Article 74 of the Law of the KR “On protecting the health of citizens in the Kyrgyz Republic”, a voluntary consent of a citizen is a prerequisite for medical intervention.
In cases where the citizen’s condition does not allow him/her to express his/her will, while medical intervention is necessary for emergency reasons, the issue of its implementation in the interests of the citizen is decided by a council, and if the council cannot be convened - directly by the attending (on duty) doctor, followed by notification of officials of the healthcare organization.
In respect of persons under the age of 16 or persons recognised as legally incapable, consent to medical intervention shall be given by their legal representatives. In case of their absence, the decision on medical intervention shall be taken by a council, and if the council cannot be convened - directly by the attending (on duty) doctor, followed by notification of officials of the healthcare organization.
A citizen's written consent is required in case of surgical intervention, blood transfusions and the use of complex invasive diagnostic methods. Consent may be withdrawn, except in cases where doctors have already begun medical intervention and its termination or return is impossible due to a threat to the life and health of the person concerned.
What does the Law of the KR “On Immunoprophylaxis of Infectious Diseases” say about the refusal of citizens from preventive vaccinations?
Unlike the Law of the KR “On protecting the health of citizens in the Kyrgyz Republic”, written consent of citizens to receive preventive vaccinations is not required. However, citizens must confirm in writing their refusal of preventive vaccinations. For the refusal of preventive vaccination, which led to the development of the disease of a minor, the responsibility shall be borne by his/her parents or legal representatives.
All information about preventive vaccinations, post-vaccination complications and cases of refusal of preventive vaccinations are subject to state statistical records, as well as registration in medical documents and preventive vaccination certificates.
The consequences of the lack of preventive vaccinations are:
- prohibition for citizens to travel to countries requiring specific preventive vaccinations;
- temporary refusal to admit citizens to educational institutions and healthcare institutions in the event of mass infectious diseases or the threat of epidemics;
- refusal to hire or suspension of citizens from works involving a high risk of contracting infectious diseases (see the List of works involving a high risk of contracting infectious diseases and requiring compulsory preventive vaccinations).
What are the gaps in the proper registration of “consent / refusal”?
The legislation of the Kyrgyz Republic does not allow healthcare professionals to properly register a patient’s choice due to the imperfection of the legislative provisions. If the doctor decides not to resort to medical intervention due to the patient’s refusal, then such a refusal must be secured with as many documents as possible: a statement from the patient himself/herself, from the relatives who accompany him/her, the conclusion of a council of doctors, which will confirm the fact of a voluntary and conscious refusal of medical intervention. This is also important because the legislation establishes criminal liability for failure to provide medical assistance to a patient without good reason by a healthcare professional who was obliged to and was able to provide such assistance.
If we refer again to the legislation, there is currently no approved documentary form of consent or refusal of the patient. Article 74 of the Law of the KR “On Protecting the Health of Citizens in the Kyrgyz Republic” contains only the provision that a citizen’s written consent is required for surgical intervention, blood transfusion and the use of complex invasive diagnostic methods. There is no mention of refusing medical intervention. It turns out that if there is no written consent, the patient is considered to have refused medical intervention, which cannot be regarded as correct. If there is a requirement for a written consent, then there must be a requirement for a written refusal. The situation is similar for preventive vaccinations, thus, only the refusal to be vaccinated is subject to written confirmation, there is no mention of written confirmation of consent to receive vaccination.
A legally capable citizen who is able to understand and control his or her actions shall have the right to consent or refuse medical intervention, including on the issue of vaccinations for his/her children. However, consent or refusal must be documented on a case-by-case basis, and the formatting requirements must go beyond a mere statement or act.
A unified form should therefore be developed and used to inform the patient about the disease and the proposed treatment. This form can then be used for recording both consent and refusal of medical intervention, as the patient is provided with the same information regardless of what decision he/she makes.
The process of expressing the will of the patient about consent or refusal should be meaningful and balanced, which means that it should be reflected in the documents as detailed as possible. The patient should be informed about the diagnosis, course and prognosis of the development of the disease, plans, goals, approximate duration of the proposed treatment, possible risks and complications, the likelihood of their occurrence, and the consequences of refusing the proposed intervention. The fact that the patient has been informed should be specified in the patient's written consent or refusal.
Another important aspect in the procedure for issuing a refusal of medical intervention is the confirmation of the fact of refusal by witnesses. It’s worth noting that the legislation of the KR does not mention witnesses at all. However, it is advisable to involve as witnesses persons who directly, due to their official duties, may be aware of the patient's state of health, or persons invited by the patient him/herself (for example, family members or close relatives).
What liability for citizens and healthcare professionals is established by the Criminal Code of the Kyrgyz Republic?
According to Article 146 of the Criminal Code of the KR, a healthcare professional can be held criminally liable and punished for “failure to provide medical assistance to a patient without good reason by a healthcare professional who was obliged to and was able to provide such assistance, as well as failure or improper performance, due to carelessness or negligence, of professional duties by a medical or pharmaceutical worker, which has resulted in significant or serious harm through negligence”.
Article 143 of the Criminal Code of the KR provides for the liability of citizens for infecting another person with a venereal or incurable infectious disease.
- “deliberate abandoning of a person without assistance, whose life or health is endangered and who is unable to take measures for self-preservation due to infancy (under the age of fourteen), old age, illness or helplessness, if the perpetrator him/herself has placed the person in a state that endangers his/her life, including as a result of a road traffic accident, or for other reasons, he/she was obliged to take care of the victim and could have provided him/her with assistance”.
- “failure to provide assistance to a person whose life or health is endangered and who is unable to take measures for self-preservation due to infancy (under the age of fourteen), old age, illness or helplessness, if the perpetrator could have provided assistance to the victim, or failure to inform the appropriate authorities or persons, of the victim's condition, which has resulted in serious harm through negligence”.