Open Society Institute Research Articles

STATE AND PUBLIC MECHANISMS FOR THE DEVELOPMENT OF INCLUSIVE EDUCATION IN UKRAINE (1990–2020)

The article analyzes the state-public mechanisms for the development of inclusive education in Ukraine for the period 1990-2020. In the 1990s, there was inertia on the part of state institutions in deciding to implement inclusive education. For a long time, Ukraine was limited to implementing only state programs («Children of Ukraine», «Long-term Program for the Advancement of Women, Family, Maternal and Child Welfare», «State National Program «Education» (Ukraine of the 21st Century)», etc.. In fact, in 2011 inclusive education was introduced in Ukrainian schools when the Cabinet of Ministers of Ukraine approved Decree No. 872 of August 15, 2011. Since then, the Ministry of Education and Science of Ukraine has been pursuing an active policy of developing inclusive education, publishing educational and methodological literature on the topic. The author of the article distinguishes three periods of the development of inclusive education in Ukraine during its independence. The first (1990-2001), when there is a slowdown, moderation of the state’s actions in introducing declarative changes in the country's legislation; considerable attention is paid to the implementation of state programs to support children. The second period (2001-2010) begins with the general project work of the All-Ukrainian Fund «Step by Step», the Ministry of Education and Science of Ukraine and the Institute of Special Education of the Academy of Pedagogical Sciences of Ukraine; it concludes with the approval of the «Concept for the Development of Inclusive Education». In terms of the development of an inclusive educational environment, the work of many public organizations and foundations on the formation of philosophy of inclusion and the formation of a social ground for the introduction of inclusive education was fruitful. The third period (2011-2020) is characterized by excessive attention of the state, various institutions, teachers, the public to the problems of inclusive education for people with special needs, as well as informing the population through the media about achievements in the field of inclusive education. The implementation of inclusive education in Ukraine is supported in close cooperation with the Ministry of Education and Science of Ukraine by the International Fund «Renaissance», «Open Society Foundation», All-Ukrainian Fund «Step by Step», «Inclusion Support Network. School for All», «Poroshenko Charity Foundation», etc. Joint initiatives are aimed at introducing inclusive education and creating a positive environment for the perception of inclusion of people with impaired psychophysical development.

Associations between national development indicators and the age profile of people who inject drugs: results from a global systematic review and meta-analysis

SummaryBackgroundGlobally, an estimated 15·6 million people inject drugs. We aimed to investigate global variation in the age profile of people who inject drugs (PWID), identify country-level factors associated with age of PWID, and assess the association between injecting drug use (IDU) in young people and rates of injecting and sexual risk behaviours at the country level.MethodsWe derived data from a previously published global systematic review done in April, 2016 (and updated in June, 2017) on the percentage of young PWID, duration of IDU, average age of PWID, average age at IDU initiation, and the percentage of PWID reporting sexual and injecting risk behaviours. We also derived national development indicators from World Bank data. We estimated the percentage of young PWID for each country, using a random-effects meta-analysis (DerSimonian-Laird methodology) and generated pooled regional and global estimates for all indicators of IDU in young people. We used univariable and multivariable generalised linear models to test for associations between the age indicators and country urban population growth, youth unemployment percentage, the percentage of PWID who are female, the percentage of the general population aged 15–24 years, Gini coefficient, opioid substitution therapy coverage (per PWID per year), gross domestic product (GDP) per capita (US$1000), and sexual and injecting risk behaviours.FindingsIn the original systematic review, data on age of PWID was reported in 741 studies across 93 countries. Globally, 25·3% (95% uncertainty interval [UI] 19·6–31·8) of PWID were aged 25 years or younger. The highest percentage of young PWID resided in eastern Europe (43·4%, 95% UI 39·4–47·4), and the lowest percentage resided in the Middle East and north Africa (6·9%, 5·1–8·8). At the country level, in multivariable analysis higher GDP was associated with longer median injecting duration (0·11 years per $1000 GDP increase, 95% CI 0·04–0·18; p=0·002), and older median age of PWID (0·13 years per $1000 increase, 0·06–0·20; p<0·0001). Urban population growth was associated with higher age at IDU initiation (1·40 years per annual percentage change, 0·41–2·40). No associations were identified between indicators of IDU in young people and youth unemployment, Gini coefficient, or opioid substitution therapy coverage provision at the country level. No associations were identified between injecting and sexual risk behaviours and age of PWID.InterpretationVariation in the age profile of PWID was associated with GDP and urbanisation. Regions with the highest prevalence of young PWID (aged ≤25 years) had low coverage of interventions to prevent the spread of blood-borne viruses. Data quality highlights the need for improvements in monitoring of PWID populations.FundingAustralian National Drug and Alcohol Research Centre, Australian National Health and Medical Research Council, Open Society Foundation, WHO, the Global Fund, UNAIDS, National Institute for Health Research Health Protection Research Unit for Evaluation of Interventions, Wellcome Trust.

Istanbul Protocol implementation in Central Asia: Bending the arc of the moral universe

In countries emerging from authoritarian rule, a major challenge is ending often widespread and systematic torture and ill-treatment practices. Between 2011 and 2019, Physicians for Human Rights (PHR), in collaboration with the Open Society Foundation (OSF), the Open Society Justice Initiative (OSJI) and regional and local partners, worked to establish effective torture investigation and documentation practices in the Central Asian countries of Kyrgyzstan, Tajikistan, and Kazakhstan. Our approach consisted of activities in three sequential phases – (1) assessment, (2) capacity building, and (3) policy reform. In this paper, we briefly describe activities during each phase and identify key lessons learned from these experiences and resulting policy and program reforms as a model for future efforts in other settings.

Islamic Garb in Public Employment in Europe and the US—From Integration to Accommodation to Anti-Discrimination

According to a recent report by the Open Society Foundation (2018), one third of EU countries have national or local “bans” on Islamic garb. The report identified five common justifications for these restrictions: the imperative to provide security and counter terrorism, the drive for equality between men and women, the desire for homogeneity, the need for integration and assimilation, as well as the pursuit of neutrality and secularity. I argue that it is upon notions of integration and neutrality that we see important differences in the approach towards Islamic garb in public employment between Europe and the US: How can we explain these differences? I attend to this question by focusing on the American public employment sector as my case study. I analyze institutional action on Islamic garb in employment from the 1990s onward through an examination of laws, policies, guidelines/regulations, court decisions, and settlement agreements. In my discussion, I contrast the European need for integration and the pursuit of neutrality to that of religious accommodation in the US. Drawing from this discussion, I make several recommendations for the implementation of an accommodation approach in Europe that is based on principles of anti-discrimination.

A Third Option: Understanding and Assessing Non-binary Gender Policies in the United States

Our fundamental understandings and treatments of gender and gender identity within the United States are evolving. Recently, a few countries and several U.S. states have moved away from the binary categories of male and female to include a non-binary gender option for official state documents. This third, gender-neutral option, is usually represented as “X” where “M” for male and “F” for female traditionally appeared. The purpose of this study is twofold; first, to utilize Iris Marion Young’s theory of oppression to help contextualize the historical oppression of non-binary gender identity recognition by the State, and second, to analyze recent efforts by U.S. states to include non-binary gender categories. Using Young’s theory for normative explanation along with the Open Society Foundations’ (OSF) practical recommendations, we present a simple administrative framework for comparing proposed, adopted, and enacted non-binary gender policies across the United States. Tying each OSF best practice to one of Young’s faces of oppression, we are able to assess each law or policies’ effectiveness in dismantling the oppressive binary constructs of society.

Conversation with Jody Raphael about "Decriminalization of Prostitution: The Soros Effect"

George Soros and Open Society Foundation are supporting the decriminalization of prostitution by funding organizations around the world to advocate for this legal change. Heather Brunskell-Evans (FiLiA podcasts, London) interviews Jody Raphael, Senior Research Fellow, Schiller DuCanto & Fleck Law Center, DePaul University College of Law, Chicago, Illinois, USA, about her research on this topic and discusses her article "Decriminalization of Prostitution: The Soros Effect."

The new global governors: Globalization, civil society, and the rise of private philanthropic foundations

ABSTRACTOne of the important drivers of change within contemporary global civil society is the growing power and influence of private philanthropic foundations (PPFs). To illustrate this argument, this article considers the cases of the Bill and Melinda Gates Foundation (BMGF) and the Open Society Foundations (OSF), the largest and fourth largest PPFs in the world today by wealth or assets, and, especially, their founders. The article considers their influence within global civil society, within the context of international development, and the consequences of their activities for a range of international actors. This is done in the context of debate within the literature on the activities of PPFs, in which the articles sides with advocates of critical scrutiny. In developing its argument, the article draws on a range of sources including the financial statements and audited accounts of PPFs, of other non-governmental organizations and of selected inter-governmental organizations. It is argued that the BMGF and OSF are engines of neoliberalism and potent symbols of a second distinct ‘gilded age’ and that their influence must be restrained through anti-trust measures and through greater taxation and regulation.

Професионално развитие на учителите чрез подхода активно учителство

Teachers’ professional development through the “Active Teaching in Bulgaria” clubs is part of an international network on the Teacher Leadership approach. The approach was created by Professor David Frost of the University of Cambridge, UK and adapted to Bulgaria by a team of the Open Society Institute. In Bulgaria, it has been implemented since 2010. Active Learning Clubs operate in the cities of Varna, Veliko Tarnovo, Vratsa and Lyaskovets. The effectiveness of measures for teachers’ professional development and the relevance of the offered forms and content to the real needs of teachers, schools and pupils are being studied. The first results show that effective professional development takes place when teachers have the freedom to share the challenges they face in their day-to-day work and to seek solutions for them. This also contributes to the progress of the school as a whole. Improving the work of teachers requires a higher level of trust in them, enhancing internal communication within the pedagogical teams, participating in a developing professional community, research activities, describing the results in a teacher portfolio.

Introduction: Indigeneity in ‘Southeast Asia’: Challenging identities and geographies

Only a few decades ago, there was not a country in Asia that recognised the existence of specifically and legally defined ‘Indigenous Peoples’. In recent years, however, that has changed, albeit unevenly. The concept of indigeneity is being increasingly accepted, both by governments and the public, although it remains highly controversial, even in countries where it has made some ground legally. For example, in the region we now frequently refer to as ‘Southeast Asia’, the governments of the Philippines and Cambodia now define particular ethnic groups of people as Indigenous, and are providing these groups with particular rights. In other countries in the region, the concept of Indigenous Peoples is still not legally recognised, but there is increasing acceptance of the concept, or at least recognition of it amongst certain groups. Questions related to the proliferation and contested nature of the concept of Indigenous Peoples were addressed during a multidisciplinary workshop organised by the Center for Southeast Asian Studies at the University of Wisconsin-Madison in March 2015. This special issue of the Journal of Southeast Asian Studies is devoted to considering some of the conceptions of indigeneity in Southeast Asia that brought together a group of scholars and activists from various countries in Asia and the United States for the workshop, which was financially supported through a grant provided by Open Society Foundations.

University Intelligentsia in the Making of Maps: Post-university Networks and Political Change in Slovenia and Poland

The present paper is a result of research done in Slovenia and Poland while the author was a fellow of the Open Society Institute, Budapest between March 2002 and March 2003. The paper looks into the role of a section of university educated intelligentsia in the making of independent Slovenia out of communist Yugoslavia and in the transition of Poland from a one-party communist rule to a multi-party democracy.

The Millennium Villages Project: a retrospective, observational, endline evaluation.

The Millennium Villages Project (MVP) was a 10 year, multisector, rural development project, initiated in 2005, operating across ten sites in ten sub-Saharan African countries to achieve the Millennium Development Goals (MDGs). In this study, we aimed to estimate the project's impact, target attainment, and on-site spending. In this endline evaluation of the MVP, we retrospectively selected comparison villages that best matched the project villages on possible confounding variables. Cross-sectional survey data on 40 outcomes of interest were collected from both the project and the comparison villages in 2015. Using these data, as well as on-site spending data collected during the project, we estimated project impacts as differences in outcomes between the project and comparison villages; target attainment as differences between project outcomes and prespecified targets; and on-site spending as expenditures reported by communities, donors, governments, and the project. Spending data were not collected in the comparison villages. Averaged across the ten project sites, we found that impact estimates for 30 of 40 outcomes were significant (95% uncertainty intervals [UIs] for these outcomes excluded zero) and favoured the project villages. In particular, substantial effects were seen in agriculture and health, in which some outcomes were roughly one SD better in the project villages than in the comparison villages. The project was estimated to have no significant impact on the consumption-based measures of poverty, but a significant favourable impact on an index of asset ownership. Impacts on nutrition and education outcomes were often inconclusive (95% UIs included zero). Averaging across outcomes within categories, the project had significant favourable impacts on agriculture, nutrition, education, child health, maternal health, HIV and malaria, and water and sanitation. A third of the targets were met in the project sites. Total on-site spending decreased from US$132 per person in the first half of the project (of which $66 was from the MVP) to $109 per person in the second half of the project (of which $25 was from the MVP). The MVP had favourable impacts on outcomes in all MDG areas, consistent with an integrated rural development approach. The greatest effects were in agriculture and health, suggesting support for the project's emphasis on agriculture and health systems strengthening. The project conclusively met one third of its targets. The Open Society Foundations, the Islamic Development Bank, and the governments of Japan, South Korea, Mali, Senegal, and Uganda.

Decriminalization of Prostitution: The Soros Effect

This article explores the activities of George Soros and his charitable organization, Open Society Foundations (OSF), in advocating for the full decriminalization of the sex trade industry. Research finds that OSF spends only a small amount of money on grass roots “sex worker” groups around the world advocating for full decriminalization, but the foundation awards larger amounts of funds to large human rights groups whose reports and policies have a wider reach. OSF’s rationale for full decriminalization fails to consider violence and coercion in the sex trade industry, misreads research, and does not include research from venues where full decriminalization of prostitution has occurred. Thus OSF and its grantees have created a partial view on prostitution that they advocate to the public. Those concerned with trafficking for sexual exploitation, violence, coercion, and abuse in prostitution should be cognizant of these strategies used by decriminalization advocates funded by OSF and be prepared to point out the unsupported assumptions and meet OSF’s allegations with proven facts.

Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review.

SummaryBackgroundSharing of equipment used for injecting drug use (IDU) is a substantial cause of disease burden and a contributor to blood-borne virus transmission. We did a global multistage systematic review to identify the prevalence of IDU among people aged 15–64 years; sociodemographic characteristics of and risk factors for people who inject drugs (PWID); and the prevalence of HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) among PWID.MethodsConsistent with the GATHER and PRISMA guidelines and without language restrictions, we systematically searched peer-reviewed databases (MEDLINE, Embase, and PsycINFO; articles published since 2008, latest searches in June, 2017), searched the grey literature (websites and databases, searches between April and August, 2016), and disseminated data requests to international experts and agencies (requests sent in October, 2016). We searched for data on IDU prevalence, characteristics of PWID, including gender, age, and sociodemographic and risk characteristics, and the prevalence of HIV, HCV, and HBV among PWID. Eligible data on prevalence of IDU, HIV antibody, HBsAg, and HCV antibody among PWID were selected and, where multiple estimates were available, pooled for each country via random effects meta-analysis. So too were eligible data on percentage of PWID who were female; younger than 25 years; recently homeless; ever arrested; ever incarcerated; who had recently engaged in sex work, sexual risk, or injecting risk; and whose main drugs injected were opioids or stimulants. We generated regional and global estimates in line with previous global reviews.FindingsWe reviewed 55 671 papers and reports, and extracted data from 1147 eligible records. Evidence of IDU was recorded in 179 of 206 countries or territories, which cover 99% of the population aged 15–64 years, an increase of 31 countries (mostly in sub-Saharan Africa and the Pacific Islands) since a review in 2008. IDU prevalence estimates were identified in 83 countries. We estimate that there are 15·6 million (95% uncertainty interval [UI] 10·2–23·7 million) PWID aged 15–64 years globally, with 3·2 million (1·6–5·1 million) women and 12·5 million (7·5–18·4 million) men. Gender composition varied by location: women were estimated to comprise 30·0% (95% UI 28·5–31·5) of PWID in North America and 33·4% (31·0–35·6) in Australasia, compared with 3·1% (2·1–4·1) in south Asia. Globally, we estimate that 17·8% (10·8–24·8) of PWID are living with HIV, 52·3% (42·4–62·1) are HCV-antibody positive, and 9·0% (5·1–13·2) are HBV surface antigen positive; there is substantial geographic variation in these levels. Globally, we estimate 82·9% (76·6–88·9) of PWID mainly inject opioids and 33·0% (24·3–42·0) mainly inject stimulants. We estimate that 27·9% (20·9–36·8) of PWID globally are younger than 25 years, 21·7% (15·8–27·9) had recently (within the past year) experienced homelessness or unstable housing, and 57·9% (50·5–65·2) had a history of incarceration.InterpretationWe identified evidence of IDU in more countries than in 2008, with the new countries largely consisting of low-income and middle-income countries in Africa. Across all countries, a substantial number of PWID are living with HIV and HCV and are exposed to multiple adverse risk environments that increase health harms.FundingAustralian National Drug and Alcohol Research Centre, Australian National Health and Medical Research Council, Open Society Foundation, World Health Organization, the Global Fund, and UNAIDS.

Gender disparities in child development in the east Asia-Pacific region: a cross-sectional, population-based, multicountry observational study

Gender differences in child development have been extensively studied in high-income countries, but few data are available from low-income and middle-income countries. Our objective was to assess gender disparities in child development that might arise from differential investment in child health, nutrition, and education in six countries across the east Asia-Pacific region. In this cross-sectional, population-based study we quantified the magnitude of gender differences in child development using the East Asia-Pacific Early Child Development Scales (EAP-ECDS) in six countries (Cambodia, China, Mongolia, Papua New Guinea, Timor-Leste, and Vanuatu). We used stratified random sampling (according to age, residence [urban vs rural], and sex) in all countries to recruit eligible children aged 3-5 years from non-ethnic minority populations with no identified or suspected special educational needs for whom EAP-ECDS scores for five or more of seven domains and urban-rural residence information were available. Gender differences in development associated with four national indicators of gender equality (sex ratio at birth, Gender Development Index, Gender Inequality Index, and Gender Parity Index for primary school enrolment) were also examined. We used generalised estimating equation regression to study moderation of differences by family socioeconomic status and wealth, and structural equation models with maximum likelihood to test mediation through health, nutrition, and education. Between June 1, 2013, and Dec 13, 2013, 7582 eligible children were included from Cambodia (n=1189), China (n=1618), Mongolia (n=1230), Papua New Guinea (n=1639), Timor-Leste (n=1176), and Vanuatu (n=730). Girls had significantly higher development scores than boys in Cambodia (difference in composite score: β=1·87 points, 95% CI 0·29 to 3·45; p=0·747), China (2·66 points, 1·20 to 4·13; p=0·0004), Vanuatu (3·10 points, 1·65 to 4·55; p<0·0001), and Mongolia (3·94 points, 2·67 to 5·21; p<0·0001), but not Papua New Guinea (-0·43 points, -1·19 to 0·33; p=0·272) or Timor-Leste (0·09 points, -0·96 to 1·14; p=0·861). Differences in favour of girls were the largest for language skills in Mongolia (5·30 points, 95% CI 4·45 to 6·15); differences in language skills were smallest in the two poorest countries, Timor-Leste (-0·07 points, -1·03 to 0·88) and Papua New Guinea (0·05 points, -1·02 to 1·12). Greater differences in composite scores for girls compared with boys-in favour of girls-were associated with higher national Gender Development Index values (R2=0·790). In Mongolia, smaller gender differences in development were associated with increased household wealth (6·07 points [95% CI 3·22 to 8·92] in the lowest wealth quartile vs 2·27 points [1·38 to 3·15] in the highest wealth quartile), whereas in Timor-Leste, girls only outperformed boys when living in households with higher socioeconomic status (2·87 points [0·27 to 5·47] in the highest wealth quartile and 3·74 points [2·17 to 5·31] in the highest quartile of parental socioeconomic status). Mediating pathways explained up to 37% (in Vanuatu) of the association between gender and development, controlling for family socioeconomic status. Girls aged 3-5 years generally outperformed boys on tests of development, and increasing levels of gender equality across six countries in the east Asia-Pacific region were associated with improved performance of young girls relative to boys. Greater opportunities for economic development are anticipated to result from improvements in gender equality and in the development of girls. Further study is warranted to understand family-level processes and societal norms that lead to gender differences in child development in the early years. UNICEF, the Asia-Pacific Regional Network for Early Childhood, and the Open Society Foundations.

Palliative Care—Albania

Sixty percent of cancer patients are diagnosed with advanced stages of disease and those diagnosed in early stages face challenges to receive adequate treatment. Palliative care has had significant developments in recent years in Albania because of a close partnership with the Ministry of Health, local nonprofit organizations, and the Open Society Foundation Albania. In 2011, a five-year action plan for palliative care as one of four parts of the National Cancer Control Plan was approved. At the end of 2014, the first palliative care law was approved by Parliament. Palliative care by-laws, documents, standards, clinical protocols, and guidelines for adults and children have been developed. Training and education are being provided to primary care professionals. Curricula on palliative care have been developed for the faculty of medicine, nursing high schools, and social work. About 80% of essential medications used in palliative care are available in Albania, 50% of these are paid for and have some access restrictions, and meanwhile the opiophobia still remains an enormous barrier. In the last three years, significant progress has been made in service provision. From only one public palliative care service in 2013, there are now eight palliative care services in eight of the 11 regional hospitals. By the end of 2016, it is expected that palliative care services will be available in all regional hospitals in the country.

Palliative Care in South Africa

The Hospice Palliative Care Association (HPCA) was established in 1987 by hospices in South Africa who felt the need for a national body to share best practices and to promote palliative care services in South Africa. HPCA supports member hospices in providing palliative care to people of any age with a life-limiting condition. HPCA has the further aim to ensure access to palliative care in settings other than member hospices. Many projects were launched over the years to influence policy, and to educate medical practitioners, nurses, social workers, theologians, and community caregiver; and to develop services. A key initiative was the development of a mentorship program to assist organizations to develop accredited palliative care services in South Africa. This article highlights some of the HPCA projects funded over the years by the Open Society Foundations' International Palliative Care Initiative.

Palliative Care Development in Kyrgyzstan

Palliative care began in Kyrgyzstan in 2005 as a pilot home-based care program in Osh Cancer Center and was supported by a small group of nurses and one physician from Scotland. In 2010, the Soros Foundation-Kyrgyzstan and the Open Society Foundation's International Palliative Care Initiative began supporting work on palliative care policy, legislation, essential medicine availability, education, advocacy, and implementation. A Ministry of Health working group was established to lead this initiative, and technical assistance was provided by an international palliative care consultant. Work began with a national needs assessment, which identified the existing barriers to the provision of quality palliative care, and recommendations were made to the working group to address these challenges. Today, palliative care is included in many national health care policies and laws, a national palliative care association has been established, undergraduate medical and nursing education include elements of palliative care, oral morphine and fentanyl patches are now available in parts of the country, inpatient services exist in the National Cancer Center in Osh and Bishkek, two tuberculosis hospitals with multidrug resistant/extensively drug resistant, and home care services in Osh and Bishkek. Public information campaigns and advocacy activities continue to increase public awareness about palliative care and press government action.

The International Palliative Care Initiative

This journal series describes the Open Society Foundation's International Palliative Care Initiative (IPCI) and the work of its national, regional, and international foundations and grantees to advance and develop palliative care globally. It provides examples of funding initiatives of IPCI honoring both grass roots and elite strategies of IPCI to integrate palliative care into national and international health policy based on a human rights approach.

World Health Organization Public Health Model: A Roadmap for Palliative Care Development

The Open Society Foundation's International Palliative Care Initiative (IPCI) began to support palliative care development in Central and Eastern Europe and the Former Soviet Union in 1999. Twenty-five country representatives were invited to discuss the need for palliative care in their countries and to identify key areas that should be addressed to improve the care of adults and children with life-limiting illnesses. As a public health concern, progress in palliative care requires integration into health policy, education and training of health care professionals, availability of essential pain relieving medications, and health care services. IPCI created the Palliative Care Roadmap to serve as a model for government and/or nongovernment organizations to use to frame the necessary elements and steps for palliative care integration. The roadmap includes the creation of multiple Ministry of Health–approved working groups to address: palliative care inclusion in national health policy, legislation, and finance; availability of essential palliative care medications, especially oral opioids; education and training of health care professionals; and the implementation of palliative care services at home or in inpatient settings for adults and children. Each working group is tasked with developing a pathway with multiple signposts as indicators of progress made. The roadmap may be entered at different signposts depending upon the state of palliative care development in the country. The progress of the working groups often takes place simultaneously but at variable rates. Based on our experience, the IPCI Roadmap is one possible framework for palliative care development in resource constrained countries but requires both health care professional engagement and political will for progress to be made.

Palliative Care in Kazakhstan

In Kazakhstan, like most ex-Soviet Union countries palliative care began in the late 1990s with the opening of the Almaty Hospice in 1999. Since that time, several palliative care services have opened in urban centers, but there is little coverage in rural areas. Palliative care has grown because of the collaborative work of Parliament leaders, Ministry of Health, local governments officials, Public Health Higher School, National Center for Health Development, academic medical institutions, oncology and palliative care experts, NGOs, Soros Foundation Kazakhstan, and international experts. A National Palliative Care Strategy provides the legislative framework that mandates the components of palliative that must be available at no cost for patients living with cancer. Palliative care courses are provided in several of the medical universities and nursing schools with practical training in local hospices who also offer seminars each year to practicing health care professionals. There is no “palliative care” or “palliative medicine” specialty in the national classifier of specialties. There are a number of palliative care specialists who participated in various training courses outside Kazakhstan. Oral morphine is not registered or available in the country, and patients must depend on injectable opioids or patches. Going forward, additional policies, increased public awareness, education of health care professionals, access to oral opioids, and more inpatient, home care, and day care services are needed.