Mental Health Law of the Kyrgyz Republic and its implementation

mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation contents 1. introduction………………………………………………………………………………………………………………4 definitions………………………………………………………………………………………………………………..4 2. methodology……………………………………………………………………………………………………………..4 3. overview of the kyrgyz m………..5 4. analysis of kyrgyz mental health legislation……………7 4.1. 1999 psychiatric care law………………..7 4.1.1. lack of a ?definitions? section………………………………………………………………………….7 4.1.2. involuntary treatment/civil commitment……………………………………………………………8 4.1.3. lack of provisions mandating the reporting and investigation of allegations of patient abuse and/or neglect…………………………………………………………………………………….124.1.4. lack of judicial review or right to counsel for individuals incompetent to make care decisions………………………………………………………………………………………………………..12 4.2. criminal code of kyrgyz republic………………………..13 4.2.1 no provision for individuals who are incompetent to stand trial in forensic mental health cases……………………………………………………………………………………………………………13 5. implementation of the 1999 psychiatric care law…………………..13 5.1. lack of adequate funding to implement the law……………………14 5.2. patients? rights……………………………………………………………………………………………………..14 5.3. forced labor……………15 5.4. involuntary treatment/civil commitment………………………………………………………………..16 5.4.1. adults……………………………………………………………………………………………………………16 5.4.2. minors 15 years old and older………………………………………………………………………..17 5.5. discharge of ?voluntary patients?……………………………………………………………………………185.6. restraint……………………………………………………………………………………………………………….19 5.7. failure to establish an independent agency to investigate and monitor allegations of patient abuse, neglect, and other rights violations…………………………………………………….20 5.8. failure to supervise the implementation of the kyrgyz mental health law………………….21 5.9. criminal prosecution of people with mental health problems………….21 6. implementation of the criminal code………………………………………………………………………21 6.1. delays in completing forensic assessments…………………………………………………………….21 6.2. failure to ensure independent assessments for criminal defendants……………..22 mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation 1. introduction this report is intended to examine the extent to which the mental health law and practice in kyrgyz republic complies with international standards, to provide recommendations to the kyrgyz government. the report was prepared at the request of the office of the president of the kyrgyz republic. the report examines the system of mental health care in the kyrgyz republic, evaluates the current laws regarding the provision of mental health services and the protection of the rights of individuals receiving mental health services. the united nations general assembly resolution 46/119 ?principles for the protection of persons with mental illness and the improvement of mental health care? of 17 december 1991 (hereinafter the ?mi principles?) is the international standard against which the system is analyzed. definitions throughout this report definitions used in the mi principles will be used: ?counsel? means a legal or other qualified representative; ?mental health care? includes analysis and diagnosis of a person?s mental condition, and treatment, care and rehabilitation for a mental health problem (mental illness) or suspected mental illness; ?mental health facility? means any establishment, or any unit of an establishment, whose primary function is to provide mental health care; ?user? is a person receiving mental health care, including all persons who are admitted to a mental health facility; ?personal representative? means a person charged by law with the duty of representing a person?s interests in any specified respect or of exercising specified rights on that person?s behalf, and includes the parent or legal guardian of a minor unless otherwise provided by domestic law. 2. methodology on january 22, 2003, valentin bogatyrev, assistant to the president of the kyrgyz republic, sent a letter to the mental disability advocacy center (mdac) requesting the following: that mdac, (1) examine the system of public mental health services in the kyrgyz republic; (2) review the kyrgyz national program for mental health in accordance with the principles described in the world health organization (who) ?world health report 2001: mental health: new understanding, new hope?; and (3) evaluate the current laws of the kyrgyz republic regarding the provision of mental health services and the protection of the rights of individuals receiving mental health services in accordance with current international standards, including the mi principles. in a response to that request mdac asked lawyers from the washington protection and advocacy service (wpas) in the usa to join the investigation and co-author this report. the authors of this report are dr. arman vardanyan, deborah a. dorfman and craig awmiller. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation health of the kyrgyz republic reported that the uk?s department for international development (dfid) had pledged to the kyrgyz government that dfid it would, in concert with the world bank, work to fully fund the national mental health program. deputy minister meimanaliev stated that this funding had been withdrawn and therefore the national reform plan had been suspended. he furtherexpressed his uncertainty as to the reason that this funding had been withdrawn. despite the withdrawal of international partners, in 2001 the ministry of health merged the chim-korgon psychiatric hospital withthe rmhc. later, the children?s psychiatric facility in ivanovka village was alsomerged the rmhc. these mergers served to further centralize the nationally funded mental health service, resulting in a concentration of funding and resources at the rmhc in bishkek and shifting resources away from other facilities such as chim-korgon. the mergers have also impeded the development of community-based mental health care: the little funding that the government has allocated for mental health care has been concentrated primarily at the rmhc and has left little available for the development of community-based mental health care. all of these mental health facilities are funded, owned, and operated by the national government of the kyrgyz republic. the rmhc provides primarily inpatient mental health care, but also provides some outpatient and partial hospitalization as wellthere are also a number of psychiatric facilities operated at the district and/or regional level.these facilities, such as the issyk-kul oblast, are funded through the oblast budgets and are owned and operated by the state trough the district/regional administration. the facilities are administratively part of general medical hospitals and are funded through them. it was repeatedly reported to theauthors that the regional hospitals tend to have fewer resources than the facilities that are funded by the national government, although the authors have been provided with neither the copies of the actual budgets for the nationally-funded facilities nor those which are locally-funded. the care provided at the local level includes both inpatient care as well as outpatient care. at the raion and oblast levels, some local governments are beginning to use a co-payment system to provide mental health care. for example, according to the medical director of its psychiatric unit, the issyk-kul region is participating in a pilot project to implement a co-payment system for mental health care. this system is not being used at the national level, although some legislators are pushing for the adoption of such a requirement.the kyrgyz minister of health explained that ? in theory at least ? the kyrgyz mental health system should function on three levels: primary care provided at the raion level by general practitioners larger intermediate care facilities staffed with psychiatrists and provided at the each oblast level and long-term, tertiary care provided on the national level at the rmhc in bishkek.according to the minister, the structure of this system is in keeping with the government?s intention to provide mental health services in the most accessible, locally-based means possible. this, in turn, is in keeping with the recommendations of the who and the majority of interview on 6 june 2003. see decree of ministry of public health of the kyrgyz republic, may 4, 2000, n 138 (hereinafter ?decree n 138?). see decree n 138see also rmhc under the ministry of public health bylaws, approved by the decree n 138 of the ministry of public health of may 4, 2004 (hereinafter ?rmhc bylaws?). regions are also know as ?raions? and ?oblasts?. there are 6 regions in kyrgyz republic (osh, issuk-kul, batken, jalal-abad, naryn, talas and chuiy) and 40 districts. the co-payment system is currently utilized in the regular health care system (the government program of the kyrgyz republic on the reform of public health services ?manas?). interview on 4 june 2003. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation involuntary treatment provisions of the 1999 psychiatric care law differently and that they are frustrated by the lack of guidelines for interpretation. not only were clinicians confused about the interpretation of theinvoluntary commitment law, but lawyers and judges were also equally confused. for example, when during the interviews with judges at the october court in bishkek, there was no agreement amongst themselves as to how the law should be interpreted. an example of a term in the 1999 psychiatric care law that needs a definition to avoid inconsistent interpretation is the term ?emergency cases? as referenced in article 25, ?procedures of application and making a decision regarding the psychiatric examination of a person without his/her agreement or the agreement of his/her legal representatives?. there is no language in the statute to clearly define what constitutes an ?emergency case?. thus, it is likely that different doctors will interpret this term differently, risking the compromise of the rights of the patient. synchronization of the terminology used in 1999 psychiatric law and in the civil procedural code regarding the civil commitment is also needed. the statutes use different terms toaddress the same issue. civil commitment is referred as ?involuntary treatment? in 1999 psychiatric law and as ?compulsory treatment? in the civil procedural code. the use of different terms creates additional confusion among judges and lawyers, who are used to and more confident to work with the civil procedural code and clinicians, who are guided exclusively by 1999 psychiatric law. it is necessary to clearly to define the terms of a statute, such as the 1999 psychiatric care law, in order for judges, lawyers, clinicians and others to more consistently interpret and implement the statute. 4.1.2. involuntary treatment/civil commitment kyrgyz law provides that an individual can be detained for involuntary inpatient mental health treatment in only limited instances and pursuant to the provisions specifically set forth in the 1999 psychiatric care law. specifically, a person may be detained for involuntary treatment if that person has been determined to be: a direct danger to self or others; unable to independently provide for own care needs; or at risk of the mental health condition worsening if no psychiatric care is received the law further stipulates that anyone detained pursuant to article 29 must be given a psychiatric examination within 72 hours of admission to an inpatient psychiatric facility to determine whether continued hospitalization is necessary. where it is found that such hospitalization is inappropriate, the individual must be immediately discharged.however, where continued hospitalization is deemed clinically appropriate, an application for involuntary treatment must be made within 24 hours to the local court to determine whether the article 29, ?bases for hospitalization in a psychiatric in-patient institution on in-voluntary basis? of the 1999 psychiatric care law. article 32(1), ?examination of persons, placed in psychiatric in-patient institutions on in-voluntary basis? of the 1999 psychiatric care law. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 10the list of patients? rights in article 5 of the 1999 psychiatric care law also states that a patient has the right to ?assistance of a lawyer, legal representative or other persons in accordance with procedure set by the legislation of the kyrgyz republic.? the mandatory language of this provision appears to confer a right to counsel. however, the law does not specifically provide for a procedure for appointing counsel in involuntary civil commitment proceedings. similarly article 7(3), ?representative office of rights and legal interests of citizens who receive psychiatric care,? of the 1999 psychiatric care law also refers to the right to a lawyer, stating that the ?[p]rotection of rights and legal interests of the citizen receiving psychiatric care may be implemented by the lawyer. invitation procedure of the lawyer and payment for his/her services are provided by the legislation of kyrgyz republic.?article 5 of the 1999 psychiatric care law seems to provide for a right to counsel. however, the law is silent as to whether such counsel shall paid for by the state for those who cannot afford to pay for representation, or whether the law merely allows for counsel if the individual and/or their family have the money. similarly, article 7 of the 1999 psychiatric care law and article 40 of the constitution, while more specifically addressing the issue of payment of the lawyer for indigent persons, still do not clearly address the issue. more specific language must be added to the statutes.the right to an attorney is essential to ensure that the rights of the patient are protected in the involuntary civil commitment process. it is not enough to have legislation that allows an individual to instruct an attorney to represent them, as many are simply unable to pay for an attorney. the law should be modified to clearly state that an individual who is subject to the involuntary commitment process has a right to representation by an attorney and if they cannot afford it, an attorney will be provided to them free of charge. 4.1.2.ii) lack of clear procedures for judicial review of involuntary civil commitment applications the 1999 psychiatric care law lacks any clear procedures guiding the judicial review of involuntary civil commitment applications. accepted world-wide legal and psychiatric standards require that before an individual can be subject to involuntary civil commitment beyond the first article 40 of the constitution of the kyrgyz republic states that ?[e]very citizen in the kyrgyz republic shall be provided qualified legal assistance and defense of the rights and freedoms guaranteed by the constitution.? it should be noted that even if the language of the statute, as it currently exists, were to be interpreted to confer a right to counsel, paid for by the state, this right is not being implemented. as discussed more below, the involuntary treatment procedures are virtually never used. moreover, local attorneys informed mdac there are no free legal services provided by the state in such cases, as the only free (extremely limited) legal services provided are for criminal cases. (the legal aid society lawyers provides representation only in criminal cases). furthermore, it was reported by nurlan sudykov of the association of lawyers of the kyrgyz republic, that there is little interest in the legal community in providing pro bono (unpaid) representation to people with mental disabilities. see ?kyrgyz republic: country reports on human rights practices ? 1999?, united states department of state, bureau of democracy, human rights, and labor, february 23, 2000 discussing the impoverished conditions of the kyrgyz republic and its people. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 124.1.3. lack of provisions mandating the reporting and investigation of allegations of patient abuse and/or neglect all patients have a right to be protected from harm, including, but not limited to, abuse by other patients and staff. despite this clearly articulated right, individuals with mental disabilities are among the most vulnerable to physical and sexual abuse, particularly those individuals who are institutionalized. the heightened vulnerability of people with mental health problems requires that the staff take affirmative measures to protect patients from harm from themselves and others.a key component in ensuring such protection is the requirement that all staff working at a facility be mandated to report and investigate any allegations of patient abuse and neglect. the 1999 psychiatric care law lacks any provisions mandating the reporting and investigation of alleged patient abuse and/or neglect at psychiatric facilities. the law should be amended to include mandatory reporting and investigation of alleged patient abuse and neglect provisions. reporting and investigating allegations of patient abuse and neglect is a key element in ensuring that abusive and/or negligent staff will be identified and disciplined or have their employment terminated, as is appropriate. these requirements also serve to stop and prevent patient abuseand neglect. 4.1.4. lack of judicial review or right to counsel for individuals incompetent to make care decisions when an individual is deemed to lack the capacity to make care decisionssuch as children and individuals with intellectual or other cognitive disabilities, a legal representative should be appointed to make such decisions. however, such a decision-maker should only be appointed after there has been a ?fair hearing by an independent and impartial tribunal?. un resolution 46/119 also requires that ?[s]pecial care be given within the purposes of these principles and within the context of domestic law to the protection of minors to protect the rights of minors, including, if necessary, the appointment of a personal representative other than a family member.there are simply no provisions in the 1999 psychiatric care law for judicial review or a right to an attorney for individuals who are incompetent to make their own care decisions. rather, article 7(2) of the 1999 psychiatric care law states that such decisions shall be made by the individual?s ?legal representative?. this person is defined as ?parents, adoptive parents, guardians? and where these individuals are absent the ?administration of psychiatric institution or psycho-neurological institution for social security and special training.? the law should be modified to include specific language providing that the appointment of a legal representative for persons deemed incompetent to make care decisions should be done pursuant to judicial review with legal representation of the alleged incapacitated person or minor by an attorney. furthermore, the law should be modified to ensure that such an individual has the right to judicial review and legal representation in cases where the issue is involuntary treatment or intrusive procedures such as electro-convulsive therapy (ect) and other similar procedures and treatments. such review and legal representation are essential in order to protect the human principle 8 of the ?mi principles?. also known as developmental or learning disabilities. principle 1(6) of the ?mi principles?. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 14resolution] through appropriate legislative, judicial, administrative, educational and other measures, which they shall review periodically.? 345.1. lack of adequate funding to implement the law article 17, ?funding of psychiatric care? of the 1999 psychiatric care law states: ?funding of institutions and person providing psychiatric care is implemented from the state budget, the fund of compulsory medical insurance and other sources not forbidden by the legislation of kyrgyz republic in amounts necessary for the guaranteed level and high quality of psychiatric care?. international standards also mandate that psychiatric facilities have sufficient resources to provide the required standards of care. principle 14(1)(a)-(d) of the un resolution 46/119 of 1991 states that ?[a] mental health facility shall have access to the same level of resources as any other health establishment and in particular: qualified medical and other appropriate professional staff in sufficient numbers and with adequate space to provide each patient with privacy and a programme of appropriate and active therapy; (b)[d]iagnostic and therapeutic equipment for the patient; appropriate professional care; adequate, regular and comprehensive treatment, including supplies of medication.? the kyrgyz republic is not in compliance with international law and standards or with its own laws with regard to the provision of resources for mental health facilities. despite the mandate for funding under article 17 of the 1999 psychiatric law, and other relevant international standards, during the research of this report, the ?lack of sufficient funding? was the single most commonly cited reason for the failure to implement the 1999 psychiatric care law. virtually everyone interviewed informed of a severe lack of funding by the government as a significant cause for the lack of implementation of the law. as discussed more fully below, the lack of funding has adversely affected the conditions of care for individuals in need of mental health treatment, in both the community as well as in institutions. in some cases, the conditions of care have been so poor that the inadequate conditions have caused the patients to suffer serious and irreparable harm. a lack of funding is no justification in international law for inhuman or degrading treatment and conditions. 5.2. patients? rights article 5 of the 1999 psychiatric care law sets out the rights of individuals with mental health problems with regard to the conditions of care while at a mental health facility. these rights include, but are not limited to: the right to respectful and human treatment the right to information about illnesses the right to psychiatric care in conditions limiting their freedom to the least extent possible and if possible, at home the right to all types of care based upon what is medically necessary for the individual patient the right to psychiatric care in ?conditions satisfying basic sanitary-hygiene requirements article 23(1) of the ?mi principles?. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 16according to principle 13(4) of the same resolution ?[t]he labor of a patient in a mental health facility shall not be exploited. every such patient shall have the right to receive the same remuneration for any work, which he or she does as would, according to domestic law or custom, be paid for such work to a non-patient. every such patient shall, in any event, have the right to receive a fair share of any remuneration which is paid to the mental health facility for his or her the practice regarding forced labor at the psychiatric facilities in the kyrgyz republic are not in compliance with the laws and constitution of the kyrgyz republic and international standards. during the on-site reviews of rmhc and chim-korgon psychiatric hospital, both the patients and staff informed the authors of this report that patients were required to do work to improve the hospital, but were not compensated for this work. for example, at the rmhc, the deputy medical director stated that the patients are compelled do unpaid work as a form of ?labor therapy?. similarly at chim-korgon psychiatric hospital, the patients perform unpaid work. the most egregious example of forced unpaid labor that we observed was at the so called ?labor colony?, a ward at the chim-korgon psychiatric hospital. at the ?labor colony? patients are required to do work such as growing vegetables and other crops, as well as other types of labor, while residing at the hospital. although these patients spend all day, almost every day doing work to benefit the hospital, they receive no payment. 5.4. involuntary treatm5.4.1. adults as previously discussed, the involuntary treatment provisions of the kyrgyz mental health law restrict involuntary commitment to only those patients who have been deemed a danger to themselves or others, gravely disabled, and/or a risk of exacerbating their psychiatric symptoms pursuant to a court order. moreover, international legal and psychiatric standards recognize the substantial infringement upon human rights imposed by involuntary mental health treatment and that specific criteria and legal safeguards are necessary when imposing mental health treatment under compulsion.despite these clear legal requirements, the research for this report revealed that the involuntary treatment procedures were virtually never implemented. for example, the judges at the october district court of bishkek, reported that since the enactment of the 1999 psychiatric care law, they were only aware of 5 cases brought by the administration of the rmhc in bishkek, the facility with 700 beds. the judges further reported that families often have a family member admitted to a psychiatric facility for mental health treatment. in such cases these admissions are considered ?voluntary? and thus, the involuntary treatment court procedures are not invoked. articles 28 & 29 of the 1999 psychiatric care law; see also article 18(3) of the constitution of the kyrgyz republic (as amended october 21, 1998)(?[n]o one may be subjected to arrest or detention except on the basis of law?). see wpa statement 1989; see also principles 15, 16, 17, and 18 of the ?mi principles?. pursuant to article 4, ?voluntary referral for psychiatric care? of the mental health law of the kyrgyz republic, ?voluntary? mental health care ?is provided upon voluntary referral of the person or with his/her permission except in cases provided by the present law [sic].? similarly, under article 28(4), ?basis for hospitalization in a psychiatric in-patient institution? voluntary inpatient care is specifically based upon the request or agreement of the patient alone. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 18in another representative example, a 15-year-old orphan with a severe intellectual disability on the acute ward of the chim-korgon had been admitted to the hospital 30 days prior to mdac?s visit. before being admitted to the chim-korgon psychiatric hospital, she lived in a state-operated orphanage. she was no longer allowed to stay at the orphanage because she was too old. 5.5. discharge of ?voluntary patients? related to the problem of failing to implement the law regarding involuntary commitment is the failure to implement the law regarding the discharge of ?voluntary patients? from psychiatric hospitals. article 40(2), ?discharge from a psychiatric in-patient institution? of the 1999 psychiatric care law, states that a ?voluntary? patient can be discharged from an in-patient psychiatric facility upon his or her request, the request of his or her legal representative, or the decision of the individual?s treating physician. additionally, article 40(1) of the 1999 psychiatric care law mandates that a patient for whom there has been a clinical determination that there is no longer a need for inpatient mental health treatment should be discharged. similarly, international standards require that a patient who is admitted to a psychiatric facility on a ?voluntary? basis be discharged from the facility upon his or her request, unless he or she would constitute a danger to themselves or others and/or is gravely disabled. particularly, principle 15(3) of the ?mi principles?: ?[e]very patient not admitted involuntarily shall have the right to leave the mental health facility at any time unless the criteria for his or her retention as involuntary patient, [?] and he or she shall be informed of that right?. discharge of voluntary patients from psychiatric facilities in the kyrgyz republic is not in conformance with the kyrgyz law and international laws and standards. doctors and staff at the rmhc in bishkek, the chim-korgon psychiatric hospital, and the issyk-kul oblast repeatedly reports that patients are often admitted to the hospital on a ?voluntary? basis by their families. the patient cannot be discharged from the hospital, regardless of their clinical appropriateness for hospitalization agrees to the discharge. if the family refuses to take the patient back home, the patient remains indefinitely in the hospital. patients who are orphans or who have lost ties to their family are also often compelled to stay at the hospital, regardless of their clinical needs, until they die because they have no where to go in the community. the psychiatrists and hospital staff reported that it was a particular problem for patients coming from rural areas who were far from their families. in a representative example,in the female rehabilitative ward at chim-korgon psychiatric hospital, mdac researchers met a 28-year old patient who had no parents. she was placed at chim-korgon when she was 14 years old because she was too old to remain at the orphanage. as her doctor confirmed, she had no mental illness or mental disability, but she has remained at chim-korgon for the past 14 years. she would like to be discharged to the in cases where a ?voluntary? patient wishes to be discharged from the hospital and his or her doctor believes that he or she is a danger to themselves or others or is gravely disabled, the patient should be detained pursuant to the involuntary commitment procedures, including judicial review. article 40(5) of the 1999 psychiatric care law mandates that ?[t]he patient placed in psychiatric in-patient institution voluntarily, may be refused discharge, if bases for hospitalization on in-voluntary basis will be identified by the commission of psychiatrists of psychiatric institution, as set out in article 29 of the present law. in that case the issues of his or her stay in the psychiatric in-patient institution, prolongation of hospitalization and discharge from in-patient institution are settled in accordance with the procedure, set out in articles 32-36 and item 3 and article 40 of the present law?. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 20explained that she knew that this was ?wrong? but that she did not know what else to do. she did not have enough staff to appropriately supervise patients and therefore had to resort to restraining patients for long periods of time. such restraints appeared to be most frequently applied to patients with senile dementia and intellectual disabilities. in a representative example, a 14 year old, female patient with an intellectual disability had been admitted from an orphanage to chim-korgon approximately one month before the mdac visit. according to staff, this young woman had been restrained ? tied by her wrists and ankles to her bed ? continuously until the day of the mdac visit. according to staff, such measures were necessary because she would bite others and herself. no specialized psychological program was utilized to assist this young woman from engaging in such behavior, nor were any of the other patients with intellectual disabilities benefiting from any specialized program. 5.7. failure to establish an independent agency to investigate and monitor allegations of patient abuse, neglect, and other rights violations the 1999 psychiatric care law mandates that an entity be established to protect and enforce the rights of patients receiving psychiatric care. article 38, ?service of protection of rights of patients placed in psychiatric in-patient institutions,? of the 1999 psychiatric care law requires that ?[t[he state creates service of protection for persons that are in psychiatric in-patient institutions independent from the agencies of health protection. representatives of the service protect rights of patients who are in psychiatric in-patient institutions, receive their complaints and applications, which they solve with the administration of the given psychiatric institution or, depending on their nature, send them to the representative and executive power authorities, the prosecutor or the court?. such independent agencies are consistent with international standards and laws. principle 22 of un principles also requires that ?[s]tates shall ensure that appropriate mechanisms are in force to promote compliance with these principles, for the inspection of mental health facilities, for the submission, investigation and resolution of complaints and for the institution of appropriate disciplinary or judicial proceedings for professional misconduct or violation of the rights of a patient.? the requirement in the 1999 psychiatric care law to establish an entity to protect and advocate on behalf of patients with mental disabilities regarding their psychiatric care has not been implemented. there is currently no entity established and authorized to carry out such duties. the provisions of the 1999 psychiatric care law that allows for patients to bring complaints regarding their care to the courts for resolution are meaningless in practice. it is highly unlikely that such individuals will be able to retain an attorney to help them pursue their complaints and there is no agency established to provide such assistance. the lack of such an entity is one of the reasons that notwithstanding the legal procedure, by which patients receiving psychiatric care the kyrgyz mental health law also requires thata record be kepton the types of restraints and the time of theapplication of these restrictive measures in the patient?s medical record for each instance of seclusion and/or restraint or other restrictive intervention. it is highly unlikely that cases as one described above are properly recorded. however, if so, then it brings the broader issue of professional competency and ethical standards, which are not covered in this report. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 22under go a mental health assessment. specifically, it was reported that these evaluations are not done in a timely manner. the chief prosecutor, mr amir shagivaliev, stated that the criminal code requires that such assessments are completed within 30 days of a court order. despite this requirement, these evaluations, he reported, often take up to 6 months. this is due, at least partially, to the fact that there are not enough qualified forensic mental health evaluators and these evaluations are only available in the south of the country at the psychiatric hospital in kyzyl-djar and more recently at chim-korgon. interviews with judges at the october court and the lawyers at the legal aid societyand dr. rosa raimbekova (former medical director of the rmhc) also confirmed that the delays in completing forensic evaluations.6.2. failure to ensure independent assessments for criminal defendants as discussed above, the kyrgyz criminal code allows a court to order a forensic evaluation of a criminal defendant to determine whether the individual?s psychiatric condition influenced the defendant?s actions as they related to the alleged crime. state employed evaluators conduct these evaluations. if, after the evaluation has been completed, the defendant disagrees with the outcome of the evaluation, the defendant can either ask for a second opinion to be rendered by a panel of state appointed evaluators. alternatively, the defendant may retain an independent expert to conduct an independent forensic evaluation of the defendant to offer to the court in support of the criminal defendant?s case. although a criminal defendant is entitled under the law to a second opinion or an independent evaluation in defending his or her case, it was reported to mdac that defence attorneys virtually never seek these independent evaluations and second opinions. specifically, legal aid attorneys told mdac that they have never retained an independent expert because they have no money to do so. thus, without proper funding for independent experts, this right becomes illusory. 7. conditions of care 7.1. international and national standards a number of documents by various intergovernmental institutions and organizations have created de facto body of generally recognized set of basic international standards regarding the provision of mental health care and treatment. these documents include statements of ethics in the field of psychiatry, reports and recommendations by international health care organizations specific to the provision of mental health care, and various declarations, covenants, and conventions which describe and define certain fundamental, widely-recognized, human rights. the lawyers at the legal aid society also stated that they very rarely seek a second opinion from the panel of state appointed evaluators, although they did not explain why they do not ask for a second opinion. such key documents include, but are not limited to, the ?international covenant on civil and political (adopted into force by the general assembly of the united nations on 23 march, 1976), the ?international covenant on economic, social and cultural rights? (adopted into force by the general assembly of the of united nations on 3 january, 1976), the ?convention on the elimination of all forms of discrimination against women?(adopted by the united nations generalassembly into force on 3 september 1981)the united nations general assembly resolution 46/119 on the ?protection of persons with mental illness and the improvement of mental health care,? (adopted by the general assembly of the united nations on 17 december 1991), the world psychiatric association?s?statement and viewpoints on mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 24more inexpensive, ?generic?, forms of this drug are now widely available. while a medication similar to that of atypical anti-psychotic clozapine was said to be in occasional use, psychiatrists seemed unable to procure other atypical anti-psychotics such as respiradone or olanzapine, which do not cause the potentially lethal side effects associated with clozapine. again, this highlights the pressing need to increase not only the availability of the older generation drugs listed on the government formulary, but to also expand the formulary to include more safe and efficacious drugs that are widely available in more developed counties. it is curious to note that procurement of supplies of non-formulary drugs is apparently almost exclusively exercised by the rhmc in bishkek. this may well again be another effect of excessive centralization of resources. 7.2.4. failure to appropriately fund the mental health system the mental health system in the kyrgyz republic is so short of funds that it cannot ensure that people in its care receive even a minimal amount of human necessities such as food, clothing, and appropriate medication. therefore, if measured by these rudimentary standards alone, the kyrgyz mental health system falls well below the international standard of care ? and it shall inevitably continue to do so until funding levels are dramatically increased. mdac was told throughout our visit that this chronic state of under-funding remains the single greatest obstacle to providing appropriate mental health care. every effort should immediately be made by people of the kyrgyz republic and by the international community to increase the funding to an appropriate level. however, such under-funding cannot be used as an all-purpose excuse for failures to find more innovative and cost-effective measures of providing care. dr. sutybek nazarculov, general director of the rmhc in bishkek, acknowledged that operating large psychiatric hospitals such as the rmhc is not necessarily the most cost-effective means of providing good mental health care. given the widespread poverty in the country, mental health care practitioners are faced with an emergent and particularly critical situation. they bear the responsibility of devising and implementing an appropriate remedy in the most cost-effective and exigent means possible. moreover, mdac cannot conclude that the lack of funding serves as a justification for the various human rights violations observed by, or reported to, the authors at the psychiatric facilities. in many instances, additional safeguards that would provide more safe and humane conditions for the patients would require little or no monetary investment. however, mdac researchers noted a general and disturbing lack of interest on the part of several authorities within the kyrgyz mental health system to implement such crucial safeguards. such additional, relatively inexpensive and easily implemented safeguards will be discussed in more detail below in regard to conditions at individual psychiatric facilities. finally, it appears that the funding currently available within the mental health system is not distributed equitably. for example, the off-campus branches of the rmhc at chim-korgon and the ?ward 12? vocational program in the village of novo-pavlovka both showed signs of physical dilapidation, shortages of basic supplies, and significant treatment failures far worse than those observed by the authors at the main campus of the rmhc. again, this suggests an inequitable concentration of funding not only within the rmhc and its branches, but also within the main campus of the rmhc in bishkek. likewise, the conditions observed at chim-korgon and at ?ward 12? were much worse than the conditions observed at the oblast-level hospital in karakol. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 26linens, blankets, or mattresses. other staff members stated that most of the improvements to the physical structure of the hospital, such as paint for walls, had to be provided by the staff themselves. several staff members told the authors that, on occasion, the shortage of mattresses is so acute that patients must sometimes sleep on bare, rusted bedsteads. in regard to basic hygiene issues, the staff on two wards reported that patients were bathed approximately every ten days. one ward had no working toilets.staff also reported that there were insufficient numbers of staff members to provide adequate treatment and ensure patient safety. due to this chronic shortfall, certain higher functioning patients provide both supervision and care to patients who are in a more acute stage of their mental illness.in regard to the provision of medication, staff reported that due to the inconsistency of the medication supply, medications must be administered on a ?triage? basis. according to the rmhc triage system, patients who are the most acute and most recently admitted to the hospital are the most likely to receive medication. staff acknowledged that, on occasion, medication shortages are such that some patients who should be provided with medications do not receive any medication at all for an extended period of time. this erratic administration of psychotropic medication is less than optimal, and perhaps even dangerous. on an ?acute? male ward and an ?acute? female ward, each of the several patients interviewed reported that they were receiving the same psychotropic regimen of haloperidol and cyclodol.the authors noted that several individuals who appeared to have intellectual disabilities were interspersed among the general patient population. staff acknowledged that although patients with intellectual disabilities are sometime admitted to the rmhc, no specific treatment program has been developed that would be congruent to these patients? level of intellectual functioning. all of the patients interviewed regarding psychotropic medications stated that they were receiving the same regimen. even patients with intellectual disabilities are treated in a manner indistinguishable from the rest of the adult psychiatric population. the treatment provided to patients at the rmhc is therefore not individualized. further, except for those patients who reside on the ?neurotic? ward, no patient at the rhmc receives any form of psychotherapy. this appears to be further indication of a lack of appropriately individualized services at the rmhc.when examined in its entirety, it is obvious that the rmhc is hardly the type of small, intensive, in-patient psychiatric facility as envisioned and recommended by the who ?world health needed: (a) to improve methods of production, conservation and distribution of food by making full use of technical and scientific knowledge, by disseminating knowledge of the principles of nutrition and by developing or reforming agrarian systems in such a way as to achieve the most efficient development and utilization of natural resources; (b) taking into account the problems of both food-importing and food-exporting countries, to ensure an equitable distribution of would food supplies in relation to need.? interviews with rmhc staff, june 4 2003. principle 14 (1) of the ?mi principles? requires that psychiatric facilities shall have, inter alia?[q]ualified medical and other appropriate professional staff in sufficient numbers?. interviews in ward 9 and ward 10 of rmhc 4 july 2003. principle 9 (2) of the ?mi principles? requires, that ?[t]he treatment and care of every patient shall be based on an individually prescribed plan, discussed with the patient, reviewed regularly, revised as necessary and provided by qualified professional staff?. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 28dr. agybekov also stated that: 1) the problems at chim-korgon were ?too numerous? to describe in detail; 2) that he was certain the authors of the report would be aware of these problems by the end of their tour of the facility; 3) that the hospital at chim-korgon was chronically under-funded; and that 4) such under-funding was symptomatic of general under-funding of mental health facilities in the kyrgyz republic. the facility at chim-korgon serves three general populations: ?acute? adult psychiatric patients, geriatric patients, and patients who have been sent to the hospital as a result of a forensic assessment. the facility also contains a ?labor colony? (described in greater detail below) that reportedly provides patients with ?vocational therapy.? including the ?labor colony,? the authors visited wards representing each of these population groups. as stated above, although many of the patients at chim-korgon have been transferred from the rhmc in bishkek, the mental health practitioners at chim-korgon are unable to offer these patients any form of therapy that was not already available at the rhmc in bishkek. as in bishkek, patients at chim-korgon recited received haloperidol and cyclodol as the principle and perhaps singular form of pharmacological treatment. staff and patients at chim-korgon were more even more expressive regarding frequent shortages of medication than their counterparts in bishkek. staff members stated that they frequently could not provide patients with either appropriate neuroleptics or the appropriate ?correctives? for side effects. further, one patient stated that he felt like killing himself because he was being administered haloperidol without any ?corrective?. in regard to this particular patient, staff confirmed that they were currently unable to provide him with the appropriate medication to counteract the side-effects he was experiencing. the amount of suffering experienced by individual patients who are unable to receive appropriate psychotropic medication is troubling. the situation is illustrative of a failure of the kyrgyz mental health system on a more systemic level. rather than a ?tertiary? level facility, as described by the minister of health, the hospital at chim-korgon – which, it must be remembered, is considered to be a branch of the rmhc – should more appropriately be considered, in many cases, a ?terminal? level facility. given that many of the patients there have already exhausted all available forms of treatment – and given that a number have been also been abandoned by their families – a large number of residents at chim-korgon are likely to remain there until they die. according to one staff member at chim-korgon, the maximum length of stay for a patient was supposedly up to seven years. for those non-geriatric patients who have not yet responded to treatment and who have no family, this would seem to be a conservative estimate. in order to determine if chim-korgon was indeed fulfilling such a ?terminal? and hopelessly ?custodial? capacity, staff members were repeatedly asked if they had access to any form of treatment not available at the rmhc in bishkek. the staff reported that, to the contrary, certain drugs were occasionally available at the rmhc in bishkek that were never available in chim-korgon. the staff members at chim-korgon did not elaborate on which classes of drugs, or specific medications, were available at the rmhc in bishkek that were not available to them. certainly, the heavy reliance upon haloperidol was evident among the patient population at chim-korgon. perhaps as to be expected, several patients appeared to be suffering from extrapyramidal symptoms commonly associated with haloperidol class medications. without a reasonable opportunity to provide some of their patients with the possibility of discharge ? and with such severely restricted access to common pharmacological treatment principle 8 (2) of un resolution 46/119 of 1991, ?every person shall be protected from harm, including unjustified medication, causing mental distress or physical discomfort? mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 30patients. the lighting throughout the hospital was also poor. some sections of the wards were lit by only one small, dim bulb. ?vocational programs? ? in the loosest possible sense of the phrase ? are occasionally offered to those patients who are permitted to leave the wards. one patient explained that he was a mechanic and that as such he was allowed to leave the ward in order to repair staff members? vehicles. male patients with sufficient privileges are also allowed to work in a grain mill located on the hospital grounds. this grain mill is connected to a bakery that provides bread and pasta to the patients. (a staff member overseeing the work at the bakery stated that if it were not for the grain mill and bakery, the patients would starve.) a sewing center has been constructed which is intended to provide vocational opportunities for female patients: yet because no fabric is presently available, no vocational activities are currently being offered to female patients. although all of the patients interviewed stated that they enjoyed the opportunity to work ? particularly to alleviate boredom ? none were being paid for the work. in addition, some patients reported that they were allowed to supplement their usual diet of bread and pasta by working in the vegetable fields that surround the hospital grounds. these patients stated that they were grateful for this opportunity. again, such activity was said to at least break up the boredom commonly experienced on the wards ?and by harvesting these vegetables, the patients were able to supplement their otherwise meager diets. such harvesting, however, remains problematic. bearing in mind the chronic food shortage at chim-korgon, this ?opportunity? soon resembles a form of forced labor: if a patient wishes to have a diet that consists of anything substantially more than bread, pasta, or tea, he or she must work for this food. it is disturbing that patients must comply with treatment, or directions, in order to earn sufficient privileges that in turn allow them to have a slightly more varied diet. some patients at chim-korgon are unable to earn such privileges due to a continued unstable psychiatric or behavioral condition. no newspapers, radios, televisions, or telephones were available for the use of patients. furthermore, even those patients who were allowed to leave the wards after having earned enough ?privileges? told mdac that they were not allowed to enter the nearby village. aside from their own company, rare visits from family members, and conversations with hospital staff, patients have no other occasion for social interaction. when considered as a whole, the conditions at the main campus of the chim-korgon hospital can be considered to be in violation of practically every basic principle outlined by the principle 13 of the mi principles.additionally, no educational facilities programs are being provided to the several young adults who reside at chim-korgon.7.2.5(e) the ?labor colony? at chim-korgon approximately one kilometer from the main campus of the chim-korgon hospital, down a narrow dirt road, surrounded by trees and in the middle of a field, stands a group of buildings that is collectively known by chim-korgon staff and patients as the ?labor colony.? the compound principle 13 (4) of the ?mi principles? rights and conditions in mental health facilities. ?the labor of a patient in a mental health facility shall not be exploited.? principle 13 of the ?mi principles?: rights and conditions in mental health facilities principle 13 (2b) of the ?mi principles?: the environment and living conditions in mental health facilities shall include facilities for education. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 32own rooms. they reported that those women who were more willing to engage in sexual acts were granted even more ?privileges.? they reported that male patients often took away food from them. they also stated that some of the male patients were ?sexual perverts.? when mdac asked the chief psychiatrist if some of the male patients at the labor colony had been committed to chim-korgon due to a previous sex offence, the head psychiatrist stated that this was true for ?one or two? of the male patients at the labor colony. it is true that some patients with psychosis may have delusions. however, the quantity, nature and detail of the allegations mdac received left the researchers in no doubt of the credibility of these women?s testimony. such credibility is further heightened by the fact that several of the female patients argued among themselves as to whether or not they should reveal to the authors the ?truth? about their living conditions. at least one female patient was displeased that mdac had been told about the rapes and sexual assaults. this woman concluded that as outsiders, mdac would recommend the closure of the labor colony and she would be moved back to the main campus of chim-korgon, where she ?would be hungry again?. she said that she would prefer to ?put up with? the sexual assaults and rapes that were occurring at the labor colony in exchange for having greater access to food. such careful weighing of how the disclosure of the sexual assaults and rapes would effect any recommendations made by this report, gave further credence to the impression that the issue of sexual assaults and rapes was one that the female patients at the labor colony commonly dealt with. one young woman was noted to be barefoot. when asked if she had any shoes, she stated that she and another patient shared a pair of shoes, and at the moment the other patient was wearing them. other patients described a similar lack of clothing. one young woman explained that she and another patient shared a bathrobe and a dress: when she was wearing the robe, the other woman wore the dress, and vice versanone of the patients participating in the labor colony vocational program received remuneration for their work. like the patients at the main campus, the residents of the labor colony explained that they were at least able to supplement their diets by working in the fields. the general physical conditions of the barracks were as equally squalid as the main campus. one staff member was observed shouting at a male patient who was attempting to talk to us. the staff member sternly directed the patient to return to his room. the patient was visibly frightened by the staff member and quickly obeyed the commands given to him. the conditions at the labor colony were in violation of not only international standards of psychiatric care, but of several basic international human rights standards as well. many of these violations could be avoided by implementing inexpensive or free safeguards. for example, if men and women are to be housed together at the labor colony, staff offices should be located between male and female rooms in order to provide at least a minimal degree of protection for the female patients. as discussed above, staff offices are currently at the front of the barracks and therefore provide no buffer between male and female patients. such a measure would require no additional funds. additionally, several of the female staff members at the labor colony reported that they themselves were afraid of the male patients, as many particularly aggressive males had been placed at the labor colony. a re-distribution of the patient population between the labor colony and the main campus at chim-korgon could well reduce the likelihood of further sexual mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 34two large bathtubs, unconnected to any plumbing system, sat unused in one room. according the staff, these bathtubs had been the gifts of ?an american.? the patients stated that they were given newspapers on occasion, but that they had no television, radio, or telephone. in regard to psychiatric care, both the patients and staff reported that they were unable to procure sufficient amounts of medications. each patient interviewed stated that he had been prescribed both haloperidol and cyclodol. none of the patients interviewed knew their mental health diagnosis. one patient stated, ?all i know is that the doctor says i?ve got the worst possible illness.? another patient stated, ?i?m not sure? and another, when asked why he was at ward 12, just shrugged. according to the staff, a psychiatrist visited the ward three times a week, on a part-time basis. several of the patients reported that they were originally from rural areas and that they would like to return to their homes, but did not know when this might occur. the staff stated that the ward had been last inspected and visited by the general director of the rhmc a year and a half before our visit. despite these dire conditions, the staff members of ward 12 ? who are underpaid and largely forgotten by the authorities in the kyrgyz mental health system ? expressed a great deal of sympathy of the patients in their care. these staff members should be commended for their commitment to providing all the possible care that their capacity allows. 7.2.5(g) issyk-kul oblast hospital in karakol the standards of care observed by mdac at the issyk-kul oblast hospital in karakol came as a very pleasant surprise. this small, essentially rural, 30-person hospital, at a considerable distance from the capital, was the single most well maintained facility that mdac visited. credit for this must be given to the supervisors and staff members of the karakol hospital, all of whom are seemed committed to providing their patients with the best care possible. rooms that at chim-korgon would have contained 16 beds contained a maximum of four at the karakol hospital. each patient had a table next to his or her bed as a place to store personal belongings. each patient was well clothed. each had sufficient and clean bed linen, blankets, and a mattress. the male patients were appropriately separated from the female patients and were being adequately supervised. patients had the opportunity to socialize in a common area, which included a working television set. staff members spoke to patients in a respectful manner. when asked if the staff experienced difficulty in properly feeding the patients, it was explained that because the patients at the karakol hospital were still within a reasonable distance of their families, families were able to supply the majority of the food for the patients. staff reported, however, that they would have difficulty providing the patients with an adequate level of nutrition if the patients were forced to rely exclusively upon the food provided to them by the hospital. in terms of psychiatric care, the karakol hospital was largely fulfilling the function for which it was designed. staff reported that if a patient admitted to their care did not improve within 25 days, he or she was to be transferred to chim-korgon hospital, but that, for the year of 2003, they had only been required to send 5 patients, out of an approximate 200, to chim-korgon. staff mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 36individual with a mental disability in an attempt to resolve any issues related to his or her disability. this independent service should also have the authority to conduct full investigations into any allegations ? or into probable cause beliefs ? that an individual or a group of individuals with mental disabilities had been or were abused, neglected, or had suffered any violation of rights. this authority should include, but not be limited to: reasonable access to individuals with mental disabilities, including those living in institutions; the capacity to meet privately and confidentially with such individuals; reasonable access to facilities providing mental health treatment, including but not limited to state-operated and locally-operated psychiatric hospitals; access to patient records with the appropriate consent for release of information; access to patient records in the event that the patient is incompetent to consent to a release of said records and there is probable cause to believe that said individual has been abused or neglected or is likely suffer from abuse or neglect in the future. such an agency could operate as part of ombudsman office of the kyrgyz republic. adequate funding by the government should also be made available to support this entity. 8.3. training on mental health law and procedure (civil commitment) the failure to implement this part of the 1999 psychiatric care law appears to be largely the product of a widespread and serious lack of knowledge and understanding of the involuntary commitment procedures among clinicians, lawyers, and judges. for example, when mdac interviewed the staff at the issyk-kul oblast hospital in karakol, we inquired as to whether they were familiar with the involuntary treatment provisions of the current mental health law of the kyrgyz republic. although the staff members responded by saying that they were aware of the law and its requirements, it became clear upon further discussion that they had confused civil commitment with mental health commitments through the criminal law. the law to which they were referring was actually the provision for forensic mental health commitments under kyrgyz law. similarly, during an interview with psychiatry students at the rmhc, they reported to mdac that each psychiatrist interprets the law for involuntary treatment differently. these students also expressed their frustration at the lack of clear guidelines as to when to invoke the involuntary treatment application procedures. the lack of understanding of the law was also evident during mdac?s meeting with judges in the october court. during our meeting with the court, we discussed both forensic and civil commitments. when we discussed civil commitments and the legal requirements for this process, the judges began to argue amongst themselves as to what the law required. during an interview with mdac, dr. solozhenkin, chief psychiatrist for the ministry of health of the kyrgyz republic, also stated that judges in the kyrgyz republic have been generally unwilling to participate in the involuntary commitment process. as discussed above, the pervasive failure to utilize the court procedures before admitting an individual violates the kyrgyz mental health law and violates the rights of affected individuals with mental health problems. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 38at the same time, the program should be revised in order to better implement the recommendations made in the who world health report ?2001: mental health: new understanding, new hope.? this document articulates a number of basic principles for the provision of appropriate mental health care, including such absolute necessities as providing local, community-based, psychiatric treatment, a sufficient amount of medication, and the reduction in size of large psychiatric facilities as were observed at the rhmc in bishkek and chim-korgon. perhaps more significantly, the who report describes the means by which countries with very limited resources can nevertheless make certain immediate improvements to their mental health delivery system at no greater cost. 8.7. funding to implement involuntary commitment legal procedures of the 1999 psychiatric care lawthe kyrgyz government should ensure that funding is available to pay for the costs of implementing the involuntary commitment court procedures. this should include court costs, and the costs of attorneys to represent individuals who have been detained under these involuntary treatment provisions. 8.8. training for patients and family members on rights and self advocacy it is important that training be provided to individuals with mental disabilities and their family members with regard to legal rights, how to obtain assistance with patients? rights violations, and self-advocacy skills. this training should be conducted on an ongoing basis by a qualified, independent entity knowledgeable in the area of mental health treatment, the 1999 psychiatric care law, and other relevant law and standards. ideally, this training would be conducted by the independent agency designated to protect human rights of psychiatric in-patients as recommended above in this section. the training should be provided on an ongoing basis throughout the country as part of a regular outreach effort to patients with mental disabilities. such training should be provided to patients who are residing in state-operated or locally-based psychiatric facilities, as well as to individuals who are residing in care homes or in other community placements, and to individuals who reside in their own homes with their families. additionally, the training must be made accessible at the broadest level possible to accommodate cultural and language differences among different populations residing in the kyrgyz republic. it should also be accessible to individuals with limited cognitive abilities, such as individuals who are diagnosed with borderline intellectual functioning and more severe intellectual disabilities. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 40ismailoc bekmursa turnsunbay bakir uulu, the ombudsman of the kyrgyz republic staff at ?ward 12? of the rmhc staff at the issyk-kul oblast hospital in karakol legal aid foundation tilek s. meimanaliev, first deputy minister, ministry of health of the kyrgyz republic documents reviewed ?law of kyrgyz republic on psychiatric care and guaranteeing the rights of persons receiving such care,? enacted in 1999. ?principles for the protection of persons with mental illness and the improvement of mental health care? adopted by the general assembly of the united nations in general assembly resolution 46/119 of 17 december 1991 (?the mi principles?) ?monitoring the human rights in psychiatric institutions,? office for democratic institutions and human rights osce helsinki foundation for human rights, warsaw, poland. rmhc under the ministry of public health bylaws, approved by the decree n 138 of the ministry of public health of the kyrgyz republic of may 4, 2000. decree of the ministry of public health of the kyrgyz republic on establishment of the rmhc under the ministry of public health of the kyrgyz republic, city of bishkek, may 4, 2000, n 138. ?mental health system users in bishkek, kyrgyzstan: their rights to information,? by linda light, vancouver, british columbia, canada, april, 2003. biennial collaborative agreement between the ministry of health of kyrgyzstan and the regional office for europe of the world health organization 2002/2003. world psychiatric association statement and viewpoints on the rights and legal safeguards of the mentally ill, adopted by the world psychiatric association general assembly in athens, 17 october 1989. world psychiatric association declaration of hawaii/ii as approved by the general assembly of the world psychiatric association in vienna, austria, on 10 july 1983. world psychiatric association madrid declaration on ethical standards for psychiatric practice (approved by the general assembly on august 25, 1996 and amended by the general assembly in yokohama, japan, august 2002.) mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 432. all persons with a mental illness, or who are being treated as such persons, shall be treated with humanity and respect for the inherent dignity of the human person. ?principle 1(3) all persons with a mental illness, or who are being treated as such persons, have the right to protection from economic, sexual and other forms of exploitation, physical or other abuse and degrading treatment.? ?principle 7. role of community and culture. every person shall have the right to be treated and cared for, as far as possible, in the community in which he or she lives. where treatment takes place in a mental health facility, a patient shall have the right, whenever possible, to be treated near his or her home or the home of his or her relatives or friends and shall have the right to return to the community as soon as possible. 3. every patient shall have the right to treatment suited to his or her cultural background.? ?principle 8. standards of care. 1. every person shall have the right to receive such health and social care as if appropriate to his or her health needs, and is entitled to care and treatment in accordance with the same standards as other ill persons. 2. every person shall be protected from harm, including unjustified medication, abuse by other patients, staff or others or other acts causing mental distress or physical discomfort.? ?principle 13. rights and conditions in mental health facilities. 1. every patient in a mental health facility shall, in particular, have the right to full respect for his or her: (a) recognition everywhere as a person before the law; (b) privacy; (c) freedom of communication, which includes freedom to communicate with other persons in the facility; freedom to send and receive uncensored private communications; freedom to receive, in private, visits from a counsel or personal representative and, at all reasonable times, from other visitors; and freedom of access to postal and telephone services and to newspapers, radio, and television; (d) freedom of religion or belief. 2. the environment and living conditions in mental health facilities shall be as close as possible to those of the normal life of persons of similar age and in particular shall include: (a) facilities for recreational and leisure activities; (b) facilities for education; (c) facilities to purchase or receive items for daily living, recreation and communication; (d) facilities, and encouragement to use such facilities, for a patient?s engagement in active occupation suited to his or her social and cultural background, and for appropriate vocational rehabilitation measures to promote reintegration into the community. these measures should include vocational guidance, vocational training and placement services to enable patients to secure or to retain employment in the community. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 45?the psychiatrist should inform the patients of the nature of their condition, therapeutic procedures, including possible alternatives, and of the possible outcome.? ?as soon as the conditions for compulsory treatment no longer apply, the psychiatrist should release the patient from the compulsory nature of the treatment and if further therapy is necessary should obtain voluntary consent.? from the world health organization?s fifty-fourth world health assembly, agenda item 10, 19 may, 2001, ?mental health round table: report by the secretariat?: ?ministers unanimously agreed that mental health problems are significant contributors to the global disease burden, have huge economic and social costs, and cause human suffering. the fact that countries have to face other health problems and that their health budgets are limited can no longer be deterrents to actions. new developments persuasively indicate that cost-effective solutions are possible in all contexts. many strategies, approaches, and interventions have been identified and are being used in numerous small projects around the world. these need to be evaluated and the results disseminated widely so that they may be included in national mental health programs. ministers repeatedly made urgent calls for action to reduce further stigmatization, discrimination and the violations of rights of persons with mental illness, since these affect the whole continuum of care. for instance, the stigma of mental disorders feeds the discrimination practiced by health insurance schemes in the coverage of mental illness compared with that of physical illness. there is a need to address the institutionalized stigmatization of persons with mental illness, a process exacerbated by the placement of psychiatric hospitals far away from public regard. shifting mental health services to general hospitals and community services had helped to bring mental health into the mainstream of health. efficiency can be gained by making use of former mental hospitals for general health care purposes. enforcing minimum standards in infrastructure and in the provision of high quality care, with the backing of updated legislation, is a critical step in protecting the rights of people with mental illness. most importantly, stigmatization, by all health professionals including mental health workers needs to be overcome. ministers discussed strategies to advance mental health care beyond the level of acceptance of parity between care for physical and mental disorders. they agreed that mental health care should be integrated into the general health care system. they repeatedly noted the significant role of primary health care in the delivery of mental health services, even in countries with highly specialized care. integration into primary health care is in line with the global movement, in which many nations are engaged, to transfer the provision of mental health care from psychiatric hospitals to the community. for this shift to occur budgets must be maintained or even increased; mental health teams, with multidisciplinary representation, must be developed; the needs of especially vulnerable groups must be met through supervised care; communities must have access to crisis centers for the management of acute conditions; and broad public support for community care must be secured. shifting the location of care also facilitates collaboration with nongovernmental organizations, social services and community agents, many of which are motivated to fill some of the service gaps. mental health treatments should be affordable to all those in need. given that poverty is a risk factor for mental disorders, the principle of equitable treatment for the poor must be preserved. mental disability advocacy center, 2004 mental health law of the kyrgyz republic and its implementation page 47from ?law of kyrgyz republic: on psychiatric care and guaranteeing the rights of persons receiving such care?: ?article 5. rights of persons having mental disorders. 1. persons having mental disorders have all the rights and freedom provided by the constitution of the kyrgyz republic. limitations of rights and freedom related to psychiatric care are permitted only in cases provided by the legislation of the kyrgyz republic. 2. all persons having mental disorders and receiving psychiatric care have rights for: respectful and humane treatment excluding humiliation of human dignity; receiving information about their rights, the nature of mental disorders and treatment methods applied in a comprehensible manner and taking into account their medical condition; psychiatric care in conditions limiting their freedom to the least possible extent and if possible at home; to be kept in in-patient psychiatric institutions only for a period necessary for examination and treatment; all kinds of care (including resorts) based on medical indications in the absence of contraindications; psychiatric care in conditions satisfying basic sanitary-hygiene requirements; prior permission or rejection at any stage regarding usage as objects of experiments of medical means and methods, scientific research of training process, photo/video/film recording; invitation of any specialist participating in the provision of psychiatric care to engage in activities of medical committee regarding matters specified in the present law; assistance of a lawyer, legal representative or other persons in accordance with procedures set by the legislation of the kyrgyz republic.? ?article 16. types of psychiatric care and social protection guaranteed by the state. 1. the state guarantees: emergency psychiatric care; consultative-diagnostic, treatment, preventive and rehabilitation care in out-patient and in-patient institutions; all types of psychiatric assessment, identification of temporary inability to work; social and legal assistance and support in finding employment for person having mental disorders; guardianship issues; consultations on legal matters and other kinds of legal assistance in psychiatric and psycho-neurological institutions; provision of social assistance for the disabled and elderly having mental disorders as well as provision of care; training of disabled and minors having mental disorders; psychiatric care during disasters and emergencies. 2. for the provision of psychiatric care and social protection for persons having mental disorders, the state: establishes all kinds of institutions providing out-patient and in-patient care, if possible near the residence of the patients; organizes mainstream and vocational education for minors having mental disorders;? ??? ??????????????? ?????? ????????? ??? ? ???????????? ?????????????? (mdac) (mdac) ??????? ??????, ??????? ?????????? ????? ? ????????. ????? mdac ???????? ????????? ???????????????? ? ????????, ???????? ? ????????? ????? ????????. mdac ????? ??????????????? ?????? ??????? ????????? ?????????? ? mdac ???????????? ??: www31.????????……………………………………………………………….5???????????………………………………………………………………………………………………………………………………………………………………52.???????????…………………………………………………………53.????? ??????? ???????????? ??????????????????………………………………………………………………………………………………………………………………….74.???????????????? ? ??????????? ????????……………………………………………………………………………………………94.1.????? ?????????? ?????????? ? ??????????????? ??????? ???????? ???? ??????? ??? ?? ???????? (1999 ?.)………………………………………………………………………….94.1.1.?????????? ??????? ??????????????……………………………..94.1.2.?????????????? ??????????????/ ?????????????? ??????????………………………………………….104.1.2.i)?????????? ????? ? ?????????? ?????????,…………………………………………………………………………………………………114.1.2.ii)?????????? ??????? ??????? ????????? ???????????? ?????????……………………………………………………………………………..134.1.2.iii)???????? ???????????? ???? ? ?????????????? ??????????????4.1.3.?????????? ?????????, ????????????????? ???????????? ?????/??? ??????????? ??????????…………………………………………………………………………………………………………………144.1.4.?????????? ????????? ???????????? ??? ????? ??????????????????????? ?? ????????………………………………………………………………………………………………………………………………………154.2.????????? ?????? ?????????? ??????????……………………………………………………………………………………….154.2.1.?????????? ????????? ? ?????????????? ?????, ??????? ?? ??????????????……………………………………………………………………..5.????????????? ????????? ?????????1999 ????…………………………………………………………………………………….165.1.?????????? ??????????? ?????????????? ??? ?????????? ??????………………………………………175.2.????? ?????????…………………………………………………………………………………………………………………………………………………..175.3.?????????????? ????……………………………………………………………………………………………………………………………………….185.4.?????????????? ??????????????/?????????????? ????…………………………………………………………195.4.1.????????????????………………………………………………..195.4.2.?????????????????? ? ???????? ?????? 15 ??? ? ??????…………………………………………………………205.5.??????? ???????????? ??????????????????? ?????????………………………………………………………215.6.???? ??????????? ?????????………………………………………………………………………………………………………………………235.7.????????????? ???????? ??????????? ????? ???????? ??? ?????????????????????…………………………………………………………………………………………………………..245.8.????????????? ?????????????? ?????????? ????????????………………………………………………………………………………………………………………………….255.9.????????? ????????????? ??????, ??????????? ?????? ???,??????????????……………………………………………………………………………………..256.????????????? ????????? ????????? ????????? ??????…………………………………………………………….266.1.????????????????? ?????????? ???????? ??????????………………………………………………………………..26.2.????????????? ?????????? ??????????? ?????????? ??? ???,?????????? ?? ????????? ?????………………………………………………………………………………………………………………267.??????? ?????………………………………………………………………………………………………………………………………………………………….277.1.????????????? ? ???????????? ?????????……………………………………………………………………………………..277.2.????? ?????? ???????????? ???? ?????……………………………………………………………………………………………277.2.1.?????????? ?????????????……………………………………………………………………………………………………………………………277.2.2.???????????? ??????? ???????????? ??????…………………………………………………………………………………287.2.3.???????????? ??????????? ???????????? ???????????…………………………………………………………..287.2.4.????????????? ????????? ????????????? ???????………………………………..287.2.5.????????? ??????????????? ??????????…………………………………………………………………………………………….297.2.5.i)???? ? ???????……………………………..307.2.5.ii)??????????????? ???????? ? ??????????…………………………………………………………………………………..327.2.5. iii)????????? ???????? ? ??????????……………………………………………………………………………………………………….367.2.5. iv)???????????????? ????????? (?????????? 12?)…………………………………………………………………..397.2.5.v)???????????????????? ????????? ??? ?????-???????? ?????????…………………..408.????????????…………………………………………………….428.1.?????? ?????????? ????????? ???? ????????…………………………………………………………………………………..428.2.???????? ??????????? ?????? ?? ?????? ???? ???????????????????????? ??????????……………………………………………………………………………………………………………………..428.3.?????????? ???????? ? ???????????? ????????????????? ??????????………………………………………………………………………………………………………………………………………………………….438.4.???????? ???????????? ???????-??????????????? ??????????…………………………………………..438.5.?????????? ???????? ?????????????? ??????????????…………………………………………………………8.6.??????????? ??????? ?????????????? ??? ??????????……………………………………………………………………………………………………………………………………………………..448.7.?????????????? ????????? ?????????? ?????????????????? ??????????……………………………………………………………………………………………………………………..458.8.?????????? ????????? ??? ????????? ? …………………………………………………………45?????????? a……………………………………………………………………………………………………………………………………………………46……………………………………………………………..46?????????? b……………………………………………………………………………………………………………………………………………………49……………………………………………………………………..4951.????????????????? ???????, ??????? ????????? ????????? 46/119 ??????????? ????????? ??????????? ?????? ?? 17 ??????? 1991 ?. (?????: ??????????).2.???????????????, ???????? ?????? ??????? ?????? ?????????, ??????????????? ????????? ?????? ???????? ????????? ??? ? ???????????? ?????????????? (mdac), ? ???????? (1) ??????? ???-??????? ????????? ???????????? ??????????????? (???) ? ????? ??????? ?? 2001???:???????????? ?????????? ?????????? ?? ????? ???????? ??????????????? ???????????? ????? ?? ???, mdac ????????? ? ???????????? ??????????? ??????????? ???????????? ??? ? ???????????? ?????????????? ????? ????????? ? ??? (wpas) ????????????????? ????????? ? ?????? ????? ????????, ?????? ??????? ? ????? ????????, ? ??????????? ?? ??????????????? ?????? ? ???????? ???? ??????? ??? ?? ???????? 1999 ?. (??????????? ? ??????????????? ?????? 1999 ?.????????? ???????? ????????? ?????????? ?????????? ?? 2001?2010 ??.? ? ?????? ???????-????? ?????????? ??? ?????????? ?12?, ?????????????? ???????? ?? ???????, ? ???? ????-????? ??? ?????-???????? ????????? ??????????????? ???????? ? ?????? ???????.???, ????????? ? ???????? ? ???????????? ?????????? ?? ???? ???????, ????????????? ???????????? ? ?????, ? ?????????? ????? ???? ??????????? ??-?? ?????????? ???????.?????????? ???????????? ??????????, ??? ?? ??? ???, ???? ?? ????? ??????????? ????-????? ???? ??? ???????? ?????????? ?????? ? ??????????????? ??????, ????????? ? 1999?.,???????????????????, ?? ??? ???? ???????? ????? ?????????? ??????????. ? ?????????????????? ????? ??????????, ? ???????????? ?????? ????????????? ?????????? ? ??????????1??. ?????????? 1: ?????? ????????? ??????????.2??. ?????????? 1: ?????? ?????????? ?????????? ? ???, ? ???????? ??????????? ????????.3.????? ??????? ???????????? ?????????????????? ? ???????? ????????? ???????????????? ??????? ? ????????? ???????? ??????-???????? ???????? ?? ????????? ????. ? 1999 ????, ? ?????? ??????? ????????????? ????????????? ??????. ????? ?????, ? 2000 ????, ????????????? ????????? ???????????? ???????????????????? ???????? ????????? ?????????? ?????????? ?? 2001?2010 ??.???????? ??????????????? ?????? ? ???????, ??? ??????????, ???????????? ?????? ?????????????????, ?????????? ????????? ???? ????????. ?? ?????? ??????? ?????? ???????-????? ? ????????? ????? ??????????????, ? ?????????? ????????????? ???????????, ??????- ?????? ??????????? ?????, ??????? ??????????????? ???????? ? ???? ??????-????? ????? ???????????? ????????, ????????????? ?? ???????????????? ???????. ? ??-????????, ??? ??????? ? ???????????? ??????? ? ???????? ? ????, ? ???????, ???, ? ???????????, ???????? ?? ?????????? ?????????????? ?????? ??????????, ????? ??? ???????- ???? ? ??????????. ????????????? ???????????? ??????????????? ?? ?? 4 ??? 2000 ?., n 138 (????? ? ?????: ?????????-????? ???? ??? ???????????? ??????????????? ??, ???????????? ?????-????????? n 138 ?? ?? ?? 4 ??? 2000 ?. (????? ? ?????: ?????? ???ǔ).?????????? ??? ??????????????? ??????????, ??????? ???????? ?? ?????????/???- ??? ??????????, ????? ??? ?????-???????? ????????? ????????, ???????- ? ??????? ????????? ??????? ????????????? ????? ???- ?????-???, ?? ?????? ??????????? ????????? ???????????????, ?????-???????? ??????? ????????? ?????? ??????? ????? ??????- ????- ?? ?????? ????????, ??????????? ???????? ??? ????????? ??????, ? ?????????? ????, ???? ??????????? ? ?????????? ????-??? ?????? ?????????, ??????? ??????????? ????????????. ?????? ?????, ????? ????????????????? ?????????? ?? ???????????? ??????? ? ????. ????? ????????????? ????????????-??????????????? -?????????????? ?????????? ?????????? ??????? ??: 6 ???????? (??????, ?????-????-????, ??????-????????, ?????????, ????????? ? ???????) ? 40 ???????.??????? ??????????????? ?????????????? ? ????????? ????? ????????? ? ??? ?????? ??????? (????-??????????? ????????? ?? ?????????????? ??????? ???????????????? ??????????????? ?????є).???????? ?? ????? ????????????? ??????????? ???????? ??????? ???????? ???????????????????? ????????? ?????????? ?????????? ?? 2001?2010??.?, ???????? ?? ????????.4.???????????????? ? ??????????? ????????4.1.????? ?????????? ?????????? ? ??????????????? ??????? ???????? ???? ??????? ??? ?? ???????? (1999 ?.)????? ? ??????????????? ?????? 1999 ?.??????????????? ????????? ?? 25 ??? 1999 ???? ? ??????????? ??????????? ??, ? ???-???????? ??????????????? ???, ??????? ?????????? ??????????? ??? ??????? ???????? ???- ??????????? ?? ??????????? ??????-?????, ????? ????????????? ????????? 46/119 ??????????? ????????? ??? ????????? ??-4.1.1. ?????????? ??????? ???????????????????? ???????????, ??????? ??????????? ? ??????????? ???????????????? ? ???????-????????? ????????? ? ?????????????? ??????? ?????? ? ??????????????? ?????? 1999 ?.? ?????? ?? ??????????????? ??????? ???????? ??????????, ?? ??? ?????????? ? ????????? ??????? ??.??????? ? ?????????? ?????????????? ??? ???????????? ????????? ????? ???????? ? ??????????-?????????????? ??????? ??.?????????? ???????? ??????????? ? ?????? ? ??????????????? ?????? 1999 ?. ??????????????? ??????, ? ????? ?? ?????????. ????? ???????, ?????????? ??????????? ????, ????????? ????? ???????? ???? ?????? ??-???????, ?????? ??????? ????? ?????????.???? ? ??????????????? ?????? 1999 ????, ? ????????????? ??????????-??????????????????????? ?????? 1999 ?. ????????????? ??? ??????????????? ???????, ? ? ??????????-???-?????? ??????????-?????????????? ???????? ? ???????, ??????? ??????????????? ?????-???????? ??????? ? ??????????????? ?????? 1999 ?.????? ? ??????????????? ?????? 1999 ?., ??? ????, ????? ????????? ??????????? ????? ??-4.1.2. ?????????????? ??????????????/ ?????????????? ?????????????????? ??????????, ???????? ?????????? ? ?????? ? ??????????????? ?????? 1999 ?., ????? ???????????, ??? ?? ??? ???:????? ????? ???????????, ??? ????? ??????????? ?? ????????? ????????? ?????? 29,??????, ????? ?????????? ?????????????? ?????????? ?????????? ????????????, ?? ? ??? ?????? ??????????? ?????? ? ?????????? ???????-?????? ? ??????????????? ?????? 1999 ?.??????? ?????? ? ??????????????? ?????? 1999 ?.??????? ?????? ? ??????????????? ?????? 1999 ?. ????? ??????? ????? ??- ??? ?????? ??????-???? ??? ????????????, ??? ?????????????? ?????????????? ??????????, ?? ? ??????? ????? ?????????? ??????? 6-????????? ???????, ? ??????????, ????????????? ?????????????????? ?? ??, ??? ??? ????????? ?????? ? ??????????????? ?????? 1999 ?. ? ???????-?????????? ?????? 1999 ?. ??? ???????????? ????????? ????????? ? ?????????, ? ??????:????????????? ????? ? ????? ???????, ????? ??????? ??? ??????????? ????????????????????? ??????????, ?????????? ? ?????? ? ??????????????? ?????? 1999 ?., ???????????????? ?????? 1999 ?.??? ??.?????? 34(2) ?????? ? ??????????????? ?????? 1999 ?.?????? 34(3) ?????? ? ??????????????? ?????? 1999 ?.?? 1999 ?.?? 1999 ?.?? 1999 ?.??????? 18(1) ????????? ??? 46/119 1991 ?.?????? ?? ???????? ????????, ??? ???????? ??????????????? ??????? ??? ????????????? ?? ???????????????? ??? ?????? ????????, ????? ?????? ?????? ???? ????????????? ???? ?????????.?????????? ?????? 1999 ?. ?????? ???????? ?????? ?? ????????? ????????????? ????????,1999 ?., ??????? ????? ???????????????, ??? ??????? ????? ????? ?? ??????? ????????, ??-???????? ??????????????? ??????? ?????? ? ??????????????? ?????? 1999 ?. ????? ????-???? ???????????? ?????????. ??????? ??????????? ???????? ? ?????? ???/?? ????? ??????-???????? ?? ??, ??? ?????? 5 ?????? ? ??????????????? ?????? 1999 ?., ??-????????,??? ??????????????? ????? ?? ????????, ?????? ???? ???? ??? ???/?? ????? ????? ???????-?????? 1999 ?. ? ?????? 40 ??????????? ?? ????????????? ?????? ??????, ???? ????? ????-????? ????????????? ??????? ?????? ????? ???????? ? ?????? ? ????????? ??????. ????? ?????????? ?????? ????????? ? ?????, ????? ? ??? ???? ??????????? 40 ??????????? ?? ????? ???????????????, ??? ??????? ????????? ?? ????? ????? ?? ???????-????????, ? ????? ????, ??, ? ????????, ?????, ?? ??????? ???? ?????? ????????? ? ?????????????????????? ??????????????, ????????????? ????? ?? ????????, ?????? ???????? ???????????? ????????????,?? ?? ????????, ??? ????? ?? ???????????. ??? ???????? ??????????????? ????, ??????? ???????????-??? ?????????????? ? ???????? ??????? ??????????? ??????? ?? ??????????. ????? ????, ??????? ???-??? ????????, ??? ??????????? ?? ????????????? ?? ????? ????? ?????????? ??????????? ?????. ??????? ??????????? ?????? ?????? ????????? ?????? ????????????????? ? ????????? ?????.). ????? ????,?????? ???????, ?????????????? ?????????? ??????? ????????????, ???????, ??? ???????? ?? ???-) ????????????????? ????? ?????, ???????-??. kyrgyz republic: country reports on human rights practices ? 1999 // united states department of state.bureau of democracy, human rights, and labor. (february 23, 2000). ? ??????? ??????????? ????????? ????-???, ? ??????? ????????? ???????? ??.????????, ?????? ???????? ?????? ???? ????????????? ?????????.? ?????? ? ??????????????? ?????? 1999 ?. ??????????? ???????? ??????? ???????, ????????? ??????????????? ?????????? ????-?? 1989 ?.?).??. ???????? 16,17, 18 ????????? ??? 46/119 1991 ?.; ??. ????? ?????? ??? ? ?????? ?????? ?? ?????? ???????? ???????? ???, ?????????? ???????????? ??????????????, ???????? ??????????? ??????-???? ??? ? ??????, 17 ??????? 1989 ?. (????? ? ?????: ??????? ??? 1989 ?.?).??????? 18 ????????? ??? 46/119 1991 ?.?????? ??? ??????? ??????????? ?????????? ???, ?????, 17 ??????? 1989 ?.????????????? ????? ?????????????, ??? ??????? ? ?????????????? ???????????????????? ????????? ???????????????? ? ????????????? ????????? ??????? (????????, ?? ????? ? ??????????????? ?????? ?????????? ??????-???? 1999 ?. ??????????????? ?????? ????????? ????????? ???????????? ??????? ? ????-?????????? ?????????????? ????? ???????????????? ????????????? ?? ?????????????? ?6 ??????????? ??????? ??? ?????????? ????????????? ?????????? ??????????????. ?????4.1.3. ?????????? ?????????, ????????????????? ???????????? ?????/??? ??????????? ??????????????????? ????????, ?? ?? ?????????????? ????????????????? ?? ??????? ?????? ??????- ???????? ?? ??????, ????? ??????????? ?????, ????, ?????????? ???-?????? ?????????????, ????? ???????? ??????????????? ? ?????? ??????????, ?????????????????????? ????? ? ??????????????? ?????? 1999 ?. ?? ???????? ????????? ????. ?????? ??? 1989 ?.??????? 8 ????????? ??? 46/119 1991 ?.4.1.4. ?????????? ????????? ???????????? ??? ????? ??????????????????????? ?? ???????? ???? ??????? ??????????? ??????????????, ??? ???????? ?????? ????- ????????? ??? 46/119 ????? ????-?????????, ??? ?? ???????????? ? ?????? ????????? ????????? ? ? ????????? ??????????-? ?????? ?? ? ??????????????? ?????? 1999 ?. ??????????? ????????? ? ?????????-? ????, ??????? ?????????? ????????????. ????? ????, ? ?????? 7(2) ?????? 1999 ?. ???????-?????? ????????? ? ???? ???????. ????? ??????? ???????????? ? ????? ?? ???????? ? ????4.2.????????? ?????? ?????????? ??????????????, ? ??????, ? ??? ??????????? ????????? ? ??????? ?????????? ?????? ????????-??????? 1(6) ????????? ??? 46/119 ?? 1991 ?.??????????? ? ???????-??????????????? ?????????? ????????? ??????? ?? ?? ?????????? ????????? ? ????????? ???????? ???????- ????? ???????, ????? ???????? ?????-???????? ?????????? ??????????, ??? ??? ???? ???????? ??????????????, ????? ????????? ? ????? ???????, ?????????????????????? ???????????? ????????? ?????? ?? ? ????? ????????? ?????????, ????-5.????????????? ????????? ?????????????? ? ??????????????? ?????? 1999 ???????? ?????????? ?????? ? ??????????????? ?????? ? ????? ????????????? ???????-??????, ????? ??? ??????????????? ????? 1999 ?., ?? ??????????? ??????? ??????? ?????????????? ??????? ???????. ? ????????? ??? 46/119 1991 ?. ?????????, ??? ????????-??? ??? ???????????? ??????????????.??????? ?????? ??? ?????? ??????? ???????????? ????????? ???? ?. ??????. ??? ??? ????????, ??? ???????????, ????????????????? ??????? ??????? ?????????????? ??? ?? ????.jackson v. indiana, 406 u.s. 715 (1972 ?.)).?????? 23(1) ????????? ??? 46/119 1991 ?.5.1.?????????? ??????????? ?????????????? ??? ?????????? ???????????? 1999 ?. ?????????: ??????????????? ???????????? ?????????? ? ???, ?????????????? 14(1)(a)-(d) ????????? 46/119 ??? 1991 ?. ?????????????, ??? ???????????????? ??-???????? ?????? ????? ?????? ? ??? ?? ????????, ??? ? ????? ?????? ???????? ??????????,(a)??????????? ?????????? ?????????????????? ???????????? ????????? ? ?????? ???-(b)??????????????? ? ??????????????? ???????????? ??? ????????;(c)?????????? ???????????? ?????????????;(d)??????????, ??????????, ? ??????????? ???????, ??????? ??????????? ??????????????? ?????? 1999 ?., ? ????? ?????? ??????????????? ????????????? ??????????, ???? ???????-1999 ?. ?????????? ??????????? ?????????????? ???????? ????? ?? ????? ???????????? ???????????????? ?? ???????? ???????? ?????? ?????, ??????????? ? ??????????????? ????-5.2.????? ?????????? ?????? 5 ?????? ? ??????????????? ?????? 1999 ?. ????????????? ???????????? ???????? ? ???????????? ?????????????? ?????????? ??????? ?????????? ??? ??????????? ??-????? ? ??????????????? ??????????. ????? ???? ?????? ????, ??? ????? ????????, ?? ???????? ?? ??????????????? ?????? ?? ????????, ?????????? ?????????-??????????-??????????, ????????????? ??????????????? ? ??????????????? ????????? ? ????????????? ????????? ??????????, ??????????????? ?????????????????. ????? ???????, ??-????? ?? ?????????? ? ?????? ???? ???????????? ??????? ??????????, ???????????? ??????, ? ??????? ????? ???????? ????????? ?12. ? ???????????? ??????????????? ???-????????? ?????????? ? ??????? ??????????? ??? ???????????? ??? ?????????? ?????????????? ????????????? ??????, ??????? ?????????? ????????????? ??????.19 ???? 2003 ?. mdac ???????? ??????? ??????????? ???????? ??????????????? ????-??? ???????, ??? ? ????????? ????? ????? ??????????? ??????????? ???? ?? ??????????? ??????????? ? ???????????? ??????? ?? ??????? ?????????-??????, ? ???????? ????? ????????????? ?-?? ?.?. ????????????, ??????? ??????????? ???????? ????????????-5.3.?????????????? ??????. ?????? ??? 1989 ?., ??. ????? ???????? 11, 12,13 ????????? ??? 46/119 1991 ?. ????????????? ????? ????? ????????? ?????????????? ????? ???????, ????? ????? ????, ??????????? ?????????? ??????????????? ????????, ??????-???????? ??????? ???????. ??????? 13(3) ????????? 46/119 ??? 1991?. ?????????????, ?????? ??????? 13(4) ????????? 46/119 ??? 1991?. ??????, ??? ????? ???????? ? ?????????????????????? ???????? ?????? ? ??????????? ??, ? ????? ????????????? ?????????. ?? ???????????????????? ????????, ?? ???? ???? ?? ????????????. ????????, ? ???? ????????????????? ???????, ? ????? ?????? ???? ?????, ?? ????? ?????????? ? ????????. ???? ??? ????-???????? ?????????????? ?? ????? ??????.5.4.?????????????? ??????????????/?????????????? ??????? ??? ?????????? ????, ????????? ?????? ? ??????????????? ?????? ?? ? ????- ????? ????, ????????????? ???????????????? ? ????????? ???-?????, ??? ??? ?????????????? ?????????????? ????? ????? ????? ???????????? ??????-1998 ?.) ? ?????? 37? ??????????????? ?????? 1999 ?. (2), ??????? ?????? ????????? ??????? ? ??????? ?????????? ???-??????????? ?? ???? ? ???????????? ? ??? ??????????? ? ?????????, ???? ??????? ????????? ? ?????????-1998 ?.).??. ?????? 28 ? 29 ?????? ? ??????????????? ?????? 1999 ?.; ??. ????? ?????? 18(3) ??????????? ??(????? ???????? 21 ??????? 1998 ?.) ? ?????? ?? ???????? ?????? ??? ?????????? ????? ??? ?? ?????-??. ?????? ??? 1989 ?.; ??. ????? ???????? 15, 16, 17, ?18 ????????? ??? 46/119 1991 ?.???????? ?? ?????? ??????????? ?????????? ? ????????????? ?????????, ? ????????-?????????? ????????? ??????? ?? ??????????. ????????, ????? ???????????? ?????? ?. ???-????, ? ??????? ???????? ?????? ? ??????????????? ?????? 1999 ?., ???? ??????????? ??????700 ????. ????? ????????, ??? ????? ???????? ???????? ???????????? ????????? ????? ?????????????, ??????? ?????-???????? ? ?????????? ????????? ?? ????? ? ???????? ? ?????????????? ? ????? ???????-??? ????????????? ???????. ??????????, ?????????? ?????-????????? ?????????????????-???????????? ?????? ???????, ??? ???? ????? ????????? ?? ? ??????????????? ????????,???????? ????????? ??????????????? ???????? ? ???? ????????? ???????? ?????? ?????? ????????? ????, ??? ??? ???????? ?? ?????.????? ???????? ???????? ?????????? ?????????? ????????? ?????? 4(2) ? 28 ??????? ??????????????? ?????? 1999 ?., ??? ???????????????, ??? ?????????????? ???????????-? ???? ?????? ???????????? ???? ???????????, ??? ????????? ?????? ? ?????????-?????? ?????? 1999 ?. ? ????? ?????????????? ?????????????? ? ??????????????? ??????-?????, ? ???? ????????????, ???????? ??????????, ??? ????? ????? ??? ? ?????? ??????? 1999 ?, ????????????? ??????????????? ??????? ??????????? ???? ???????????? ????????????? ?/??? ? ??? ????????, ?? ??????????? ???????, ??????????????? ????????? ???????[sic.]? ?????,? ?????? 28(4) ?????????? ??? ?????????????? ? ??????????????? ????????? ???????????????, ??? ???-???? ?????? ???????????? ??????????? ?????? 28 (4) ?????? 1999 ?., ? ??????: ?[??] ????????????????15 ??? ?????????? ? ??????????????? ????????? ?? ??????? ??? ? ???????? ??? ??-?????? 15 ???, ????????????? ???????????? ????????? ? ???????? ??????? ??? ???????-?????? ? ???????? ?? 15 ??? ? ??????, ??????? ??????????? ?????? ? ????????? ????????-??????? ?? ?????????????. ????? ???????, ??? ?????????????? ??????????? ??????? ???-?????????? ?????? ???????????, ???? ? ???????, ???? ???? ?? ???????? ???????????? ???-????????????? ??????: ?? ?????????? ???? ??? 16-?????? ????????? ??????????? ????????? ??????? ? ??????????????? ????????, ??? ??????????????? ??? ????-???? ?? ????????), ?? ???????? ? ??????????????? ????????.5.5.??????? ???????????? ??????????????????? ???????????? ?????? ? ??????????????? ?????? ???????????????, ??? ???????? ????, ????????????????? 40(1) ?????? ? ??????????????? ?????? 1999 ?. ???????????? ??????? ???????? ?????????????????? ?????????? ????? ???????????? ????????????, ? ?????????? ???????? ???-???. ?? ?????? ????????????? ??????????, ???????, ??????????????????? ? ?????????-???????? ?????????? ??????????????? ???????? ? ?[??] ????????????????? ? ???????? ?? 15 ???, ? ????? ????, ???????-??? ? ????????????? ??????? ??????? ??????????????, ??????????????? ?????? ??????????? ?? ?????????? ? ???????? ?? ???????? ?????????????? ? ???????, ??????????????? ????????? ???????). ? ?????????, ? ?????? 15(3) ????????? 46/199 ??? 1991?.?????????, ??? ??????? ???????, ??????????????????? ?? ? ?????????????? ??????? ????????????? ??? ???/?? ??????????????? ??????????, ??????????????? ? ???????? 16, ????,??????????????, ????????????? ??????? ? ??????. ????? ? ??????????? ???????? ????,???-???????? ????????? ??????????????? ???????? ???????????? ????????, ??? ???????????? ?? ????????? ?? ???????? ?? ??????????? ?????? ??????, ??? ?? ???????? ?????? ????????? ? ????????? ??? ???. ????? ???????, ??????? ???????? ??????? ???? ????? ????? ??-????? ?????, ?????? ??? ?? ????? ?????? ?? ?????, ????? ??? ???????????? ?????. ??? ???-?? ???????? ????, ?????? ?????? ????????? ?????????, ? ?????????? ???? ?? ????? ?? ???-? ???????, ????? ???????????? ??????????????????? ??????? ????? ?????????? ?? ????????, ?? ??????? ???/?? ???? ???????, ??? ??/??? ???????????? ????????? ??? ???? ??? ??? ??????????, ?? ????????????????, ??? ?????????, ??????????? ? ??????????????? ???????? ???????????, ????? ???? ??????-?? ? ???????, ???? ???????? ??????-?????????? ???????????????? ?????????? ????????? ???????????? ?????????????? ? ?????????????? ???????, ??????????????? ??????? 29 ?????????? ??????. ? ??-??????? ?? ?????????? ???????? ? ???????, ????????????? ???????? 32-36 ? ??????? 3 ?????? 40 ??- ????????????? ??????: ?? ????? ????????? ????????????? ??????????????? ????-5.6.???? ??????????? ???????????????????? ?????? ? ??? ???????, ?????? ? ?? ??? ?????? ???????, ?????, ?? ?????? ???- ?? ?????????? ?????-???? ???-????, ??? ???? ????, ?????????? ???????????? ??????????????, ??? ???????? ?? ???????- ?, ??? ? ?????? ???? ????????? ? ?????? ?????????-???????? ??????, ????? ??? ????? ??????? ? ??????. ????? ???? ???????? ????????? ????????? ? ??????? ?????????? ?????????, ??? ?? ??????? ?? ?????? ?????????, ??? ??? ????-????, ??? ??? ?????? ?????? ?, ???? ???????????, ?? ??? ?? ?????, ??? ??????. ? ????????????????? ?????????? ???????? ???????? ?????????????????? ?????????, ? ??????? ???-???????????? ?????? 1999 ?.1999 ?.??. ?? ????????, ????? ???? ??????????? ????????? ????? ??????????? ? ????????? ???,????????????? ??????: ????????? 14 ???, ?????????? ?????????? ???????????,???? ????????????????? ? ??????????????? ???????? ?????????? ?? ???????? ??-???? ???? ?????????? ??????, ??? ????????? ?????? ???? ? ??????????. ??????5.7.????????????? ???????? ??????????? ????? ???????? ??? ????????????????????? ? ???????????????? ? ??????????? ??????????, ? ??????. ?????????????, ??? ??????????? ??????? ??????? ??????? ?????? ?????????, ??????????? ????????? ????? ??????????? ??????? ????????????? ????????????? ?????? ? ????-???. ???????? ???????? 22 ????????? ??? 46/119 1991 ?. ???????????? ???????????? ??-?????????????? ??????? ????????? ????????? ???????????? ??? ???? ?????????.?????????? ?????? ? ??????????????? ?????? 1999 ?. ? ???????? ?????? ?????? ??????-???????????? ?????? ?? ???????????. ? ????????? ????? ?? ?????????? ??????, ???????????-1999 ?., ????????????????? ???????????? ????? ?????????? ? ????????? ?? ??????? ? ?????-????????, ??? ????? ???? ??? ??????????? ????? ???????? ?????? ???????? ? ???????? ?????-????? ?? ? ??????????????? ?????? ????? ??????? ????? ? ?????????? ??????? ?????????? ??? ????-?????, ???????? ?? ??, ??? ????? ????? ?????????? ?????????, ??????? ??????????? ?????????? ????? ?????? ?? ????????????? ?, ??? ???????, ?? ???????????????.5.8.????????????? ?????????????? ?????????? ??????? ??????????????? ???????????? ?????? ?? ? ??????????????? ?????? 1999 ?., ?? ???????????? ????????? ??????-??? ?????? ??.???????? ? ????? ?? ??? ??????. ?? ????? ???????, ?-? ?????????? ???????, ??? ?? ? ???5.9.????????? ????????????? ??????, ??????????? ?????? ???,???????? ???????????????? ??, ??????, ??????????? ????????????, ?????? ????, ????- ???????? ?? ???????????? ?????????? ????????? ? ?????? ?????-?????? ? ???????????. ?? ????? ???????, ??? ??? ????, ????? ??????? ???????????? ????? ????????????????. ???????? ??????????? ?? ????? ??????????? ??????????????? ????????? ????49 ???????? ???????????? ?????? ? ??????????? ?????? (??????????? ??????????? ?????)??????? ? ??????????????? ?????? 1999 ?.?????? 46(3) ?????? ? ??????????????? ?????? 1999 ?.1999 ?.6.????????????? ?????????????????? ????????? ??????6.1.????????????????? ?????????? ???????? ?????????????????? ?????????? ??????? ??, ???????-??????????????? ??????????????????????????? ????? ?????????? ?????????? ??????? ? ?????????? ???????-??????????????????????, ??? ???????? ?????????? ??????? ????????? ?????????? ????? ????????????????????????????? ???????? ?????????-??????????. ????? ?????????? ?????????? ???????? ??? ??????, ? ??????????????? ???????? ?????-???, ? ?????? ??????? ?????????????, ????? ??????????? ??? ?????????? ???????????? ???????? ?????????? ????????6.2.????????????? ?????????? ??? ??? ??????????????? ????, ????????? ?????? ?? ??????????????? ??????? ?????-???? ????????????, ??? ???????????? ??????????? ???/?? ???????????? ????????? ?? ???-????? ????? ???? ? ????? ? ?????????? ?????????????. ????? ?????????? ?????????? ????-???????????? ??????????. ???? ?????????? ?? ???????? ? ???????????? ?????????? ????-?????? ???????? ? ??????? ??????????????? ?????????. ?????, ? ???????? ????????????, ??-???, ????? ????? ?? ????????? ?????????? ??? ??????????? ?????????? ? ????? ??????,??????????? ??????????????. ???, ?? ????? ?????? ??????, ?????? ????? ??????????? ????? ???????, ??? ???????????????? ?????????????? ??????????? ???-?????????? ????????? ?????????? ????????? ? ??????? ??????????????? ?????????, ???? ?? ???????????????.277.??????? ?????7.1.????????????? ? ???????????? ????????????????? ? ????????? ??????????? ? ????????????? ?????????? ????????????????, ??-? ?????????? ?????????? ????? ? ??????????????? ?????? 1999 ?. ???????? ????-???? ???????? ??????????????? ??????. ????? ??? ?????? ? ?????????? ????? ????????-??????? ??????????? ??? ?????? ????????????. ???????, ?? ????????? ?????? ???????????????? ?? ???????????? ??????? ? ?????????? ? ? ??????? ??????.7.2.????? ?????? ???????????? ???? ????????????? ?????????? ???????, ?, ? ?????????, ??? ??????????? ????. ????? ????????????????????????? ?????? ? ????????, ??????????? ???????????? ? ????? ????????????? ???????? ????????? ????????, ?? ?? ?????????????? ?????????? ???????????: ?????????????? ????(?????? ??????????? ?????????? ???? 23 ????? 1976 ?.), ????????-?????? ???? ?? ?????????????, ?????????? ? ?????????? ??????? (?????? ??????????? ?????????? ????3 ?????? 1976 ?.), ?????????? ?? ?????????? ???? ???? ????????????? ??????(??????? ????????????????????? ???? 3 ???????? 1981 ?.), ????????? ??????????? ????????? ??? 46/119 ?? ?????? ???, ??????-???? ???????????? ?????????????? ? ????????? ???????? ??????????????? ?????? (??????? ????????-??? ?????????? ???? 17 ??????? 1991 ?.), ????????? ??????????????? ??????????: ??????? ?????? ???????? ????? ? ???????? ???????? ??? ? ???????????? ?????????????? (?????? ??????????? ?????????? ???-?????? ??????????????? ??????????? ? ??????, ??????, 17 ??????? 1989 ?.), ?????????? ??????????? ???-?????? ??????????????? ?????????? (??????? ????????? ??????????????? ??????????? ? ????, ???????,10 ???? 1983 ?.), ?????? ??? ???????????? ? ??????? ????? ?? ???? ???????????? ????????, ????????????????? 19 ??? 2001 ?., ????? ??? ???????????? ???????????? ???????? ????????? ?? ?????? ? ????????? ?? 11?????? 2002 ?. ? ?????? ??? ?? 2001 ?. ??????????? ????????: ????? ?????????, ????? ????????.7.2.2. ???????????? ??????? ???????????? ?????????????? ?. ????????. ????????, ??? ??????????? ?????????? ?????? ?????????? ???????,7.2.3. ???????????? ??????????? ???????????? ???????????????? ??????????? ?????????? ??????????????? ????????????? ???????. ????? ???????? ??-????, ??? ????? ?? ??????? ???????? ????????? ???????????? ??? ?????????? ??????????-????. ???? ?? ?????, ?????????, ?? ????? ???????? ?????? ???? ?????????? ?????????????-??? ????????? ? ???????? ????? ?????????? ? ??????????? ?????????, ??????? ??????7.2.4. ????????????? ????????? ????????????? ?????????????????????? ????????. ???????, ???????? ??????? ???????????? ???????? ? ??????????? ?? ??????? ???????-????, ??? ??????????? ???????? ??????? ???????? ????????????, ????? ???????????? ???-???????. ??????????, ???????? ?? ? ????????????? ?????????? ?????? ?????????? ????-??? ?? ?????, ??? ??????????? ??????? ??? ?? 54 ??????????? ????????? ???, ?????????-??? ???????????? ????????? ?????? ????? ???????? ????? ????????, ????? ??? ???? ? ?????-????? ????, mdac ?? ????? ??????? ?????, ??? ????????? ???????? ?????????????? ????????????? ????????, ??????? ???????? ?????????? ????? ?????????? ? ???????? ????-?????, ?? ????? ?????? ?????? ???? ? ???????. ??????? ????? ? ?????????? ? ? ????????? ????? ? ?. ????????. ??? ????? ??????????????? ? ???, ??? ???????? ?????????????? ??????????-7.2.5. ????????? ??????????????? ???????????????, ???????? ???????? ????????????? ????? ? ????????? ??????? ???????? ??????.??????????? ? 1956 ????, ???? ???????? ???????????, ??????? ???????? ??????????-?????? ????, ?? ?????? ???????? ??????????????? ??, ???? ????????? ??????? ?????-????? ??? ??????? ?????????????? ? ???????? ?????????? ??? ??????????? ???????? ??,????? ??. ??? ??????? ??? ??????????? ????????????? ???????????????? ?????????? ? ??-???, ???????????????? ?????????, ??????? ??????????, ?????? ?? ??????? ????????? ????-??????????????; ???????? ????????? ??? ??????????? ??????????? ??? ?????? ? ?????;????); ???? ?????????, ??????????? ???????????? ?????? ??? ????????? ?????????; ? ???????? ?? 14 ?? 16 ????????, ?, ??? ?????????, ????? ???? ???????????? ??? ?????????? ????- ??????????????? ??????????? ?????????,??????, ?????? ?????????, ??????? ?????????? ??????????????, ?????? ? ???????. ?????????????? ???????? 13 ????????? ??? 46/119 1991 ?., ?????? ???????, ??????????? ? ????????????-??? ?????????? ????? ?????, ? ?????????, ?? ?????? ???????? ??? ??? ?? ?(b) ????? ?? ?????????.?????? 11(2) ?????????????? ????? ?? ?????????????, ?????????? ? ?????????? ??????? (?????? ????-??????? ?????????? ???? 3 ?????? 1976 ?.) ??????: ???????????? ? ????????? ????? ???????????, ???-??????? ? ?????????????????? ??? ??????? ???????? ?????? ????? ???????, ????? ?????????? ?????-?????? ? ???, ??? ????????? ????????? ?????? ???????? ????????, ? ?????????? ????, ????-???? ???, ??? ????????? ??????, ? ???????, ?????? 10 ????. ? ????? ????????? ?? ?????? ??????????? ????????. ???????? ????? ????????, ????????, ??????? ????????? ? ???-??????????? ??????? ???????. ????? ?????????, ??????????? ?????????? ?????????????????????? ??????????, ??? ????????, ????? ??? ???????????, ? ??????, ???? ??????? ??-????????? ??? ???????????? ? ?????????.??? ???????? ?????? ????????? ?? ?????????? ?????????????? ??????.??????? ? ?????????? ???? ?? 4 ???? 2003 ?.???????? ???????? 14 (1) ????????? ??? 46/119 1991 ?., ??????????????? ?????????? ?????? ??????????? 9 (2) ????????? ??? 46/119 ?? 1991 ?. ?????????????: ????? ? ??????? ??????? ???????? ???-??????? ?? ????????????? ????????????? ?????, ??????? ??????????? ? ?????????, ????????? ????-???? ? ????????????? ? ??????? ????????? ??????????? ??????????????? ?? 2001 ?.?. ??-?????? ????? ?????????, ???????????? ?????? ????????? ????? ??????????????? ????????-??????????????????? ? ???????? ????, ????? ?? ????? ????????????? ???????? ?? ??????????????? ????? ???????????? ?????? ??????.??? ?????????? ??? ? ????? ????????, ??? ???????????.???????? ? ??????????, ???? ?????, ?? ?????????? ???????? ???????, ???????????, ??? ??????? ???????? ? ?????? ? ?????????? ????, ??? ???? ??????????? ?? ???????. ?? ????????,???????? ? ??.? ?????????? ?????? ??????????? ??????? ?????????? ?????????, ????? ????? ??????????????????? ? ????????? ????? ? ???????? ???????? 300 ???????????, ???? ?? ???????? ???-??????? ???????? ?????????? ????? 550 ???????????. ????? ?????????????? ??? ????????,???????? ??????? ?? ????????; 2) ?? ??????, ??? ????????? ????? ??????? ??? ???????? ?????? ?? ??????? ??????????; 3) ???????? ? ?????????? ?????????? ??????????? ??????-???? ?????????????? ? ??????? ??????; ???????? ????????? ?????????; ? ????????, ? ??-????? ???? ????????? ?????????????? ???? ???????????? ????????? ?? ??????????? ??-?????? ?? ????????? ? ?? ????????? ? ???????. ?????????? ????????, ??? ???????? ??? ???????????????? ???????????? ??? ?????????? ???????? ????????. ????? ????, ???? ????-?? ???????, ? ????? ???????? ??? ????, ??? ???????????? ????????? ????????? ???????-57?????????, ??? ?? ???????? ????????????? ?????????? ?????????? ? ?????????, ??????????? ???-?????? ???????????? ?????? ????????/ ???????????? ????????? ?? ?????????? ???????? ?????-???: .kg/en/donors/techhelp_idb.htm ????????????, ??? ????????????? ????? ?????? ??????,??. ??????? 14(1) ????????? ??? 46/119 1991?. ???????? 55???? ???. ??? ???, ??????? ?? ???????? ?????????? ????????? ?????????, ? ??????? ??? ??????????? ????????? ?? ???????, ? ??? ?????? ?????????? ?????, ???? ????, ??-????????,??? ????, ????? ?????????? ????????????? ?? ???????? ? ?????????? ????????? ???- ? ?????????? ?????? ???? ???????,??????? ?? ???????????? ? ???? ? ???????. ?????????? ????????, ???, ????????, ? ???? ???, ??-????????, ???????? ?? ??????- ????????????? ?????????, ?????? ????????????????, ??? ????? ????? ?????????, ???????????-??????????? ???????????? ????? ???????-???????? ??????????, ??? ??????????????? ??????????? ?????????? ??????, ??????????-?????? ?????????? ? ???????. ??? ????????? ???? ???????????; ? ????? ?????? ?????????-?? ?? 16 ????. ? ???????? ???????????? ??????????????? ????? ?????????? ?????????????????? ???????? 8 (2) ????????? ??? 46/119 1991?., ??????? ??????? ?????? ???? ??????? ???? ???????, ??? ??? ?????????? ????? ???? ?????? ? ???????? ?????? ?????????. ?????????-??, ??? ??? ????????? ???? ?????? ? ??????? ????????? ???? ??????. ??????? ??????????????? ????, ?? ?????? ??????? ?????????, ? ????????? ?????????, ?? ?????????? ???????.?? ?????, ???????, ??????? ??? ? ??????????? ??????????, ?????? ????????? ????????? ?????????, ??????? ??????: ???? ??? ??????. ?????? ?????????? ????? ???????? ??? ? ????????????????. ???? ? ???, ??? ????????? ?????? ?????? ?? ?? ???????? ? ??????? ???????????????????? ??????? ??????? ? ???????? ??????????, ???????? ???????? ??, ??? ?????? ??????????? ???????? ????????? ????????? ?? ???????? ??? ??????????? ? ????,???????? ?????? ????? ????????? ??????? ??????.??? ?????????, ??????? ??????????? ???????? ??????? ?????????, ?????? ????????-???????? ?? ??????.???. ????? ???????? ? ??????? ???????????? ???????? ?? ?????? ??????????????????????? ??????, ??????? ???, ?? ??????? ????, ????????? ?? ?? ?????, ??????? ????? ? ??????-????????, ?? ????? ????, ?? ?????????????? ????. ????? ???????, ??????????, ??? ???? ??-???????? ?? ????? ??????? ??????????? ?????? ??????, ??????? ?????, ???????? ??-? ?????, ????????????? ? ????????? ??? ????????? ? ???????? ?????? ?????????-?? ????? ????????? ?????????? ???? ???????? ?????????, ??????????? ? ????????13????????? 46/119??? 1991 ?.7.2.5. iii) ????????? ???????? ? ??????????????. ????? ???????? ?????????? ???????? ???????? ???? ???????, ?? ???????? ?????, ??????????? ? ????????? ??????? ????? ??????????????, ??? ?? ??????. ??????, ??? ?????????,???? ? ????, ??? ????????? ??????????? ???? ???????? ?? ?????, ???? ?????????? ? ?????????????? 13 ????????? ??? 146/119 ?? 1991 ???? ????? ? ??????? ? ??????? ???????????? ????????.??????? 13 (2?) ????????? ??? 146/119 ?? 1991 ????: ?????? ? ??????? ?????????? ? ??????? ?????-????????, ?? ???? ???????? ??????????? ? ???????? ??????? ???? ????????, ????? ???????????? ??????? ????????.?????. ?? ????????? ????????? ? ??????????? ?????? ?????? ??????. ????? ???????????? ?????? ??????? ??????? ? ???????? ???? ???????? ? ???? ?? ???? ??????, ?????????-? ???????? ????? ??????. ????? ???????, ??????? ??? ?????? ????????? ? ?????????????-??? ???????? ? ?????????? ??? ?????? ? ?? ????? ??????. ??? ? ????????? ???????? ???-???????? ?, ? ??????????, ?? ?????? ?????, ? ??????? ?????? ???????? ??????????, ??? ????????? ????? ?????????. ??? ?? ????????? ???????, ??? ??? ?????????? ?????????? ????????-?????? ? ???????? ?????????? ???. ????? ?????????????? ???????????, ??? ????????? ???-?? ????? ?????? ?????? ?? ???????? ???????? ?? ???? ????? ??????? ???????. ??? ?????? ????????? ????? ?????? ????? ? ?????? ?? ?????: ????? ??? ????? ?????, ????????????? ????? ??????, ? ????????.???????? ????????? ? ????????? ???????, ?? ???????? ?????????????? ?? ???? ????. ???????? ???????? ? ??????? ??????? ????????, ???????? ????????? ??????? ?????????, ???,???????. ??????? ??? ???? ??????? ??????????? ? ?????? ??????????? ???????.????????? ????????, ??? ??????? ??? ????????? ? ????????? ??????? ??????????????????, ?? ????? ? ?????? ???????? ????????????? ????? ? ????? ???? ????????. ??????-?? ???????? ??? ????, ??? ?????? ?? ???? ????????? ????? ???? ?? ???????? ????? ????-?????????? ??????? ???????? ????? ???????? ? ???????? ????????. ????? ???? ?? ?????????????? ?????????????? ??????. ? ???? ??, ????????? ?????????? ? ????????? ?????????? ????????? ????? ????????? ???????? ? ??????? ???????? ???????? ? ?????????? ????? ???-??????? ??????, ?? ????? ???????? ???????? ??? ?????????.?????? ???????????? ????????? ??????? ?????? ??????????? ????????????? ????-?????????, ??????? ??? ?????? ?? ?????. ????????? ???????? ??? ????????? ???????????-??? ???????? ????? ???????????? ???????? ?? ?? ???????, ? ??????? ????????? ????????.??? ?? ?????, ??????????? ???????? ? ?????????? ???????????, ??? ????????????? ??????? ?? ?????, ???? ??? ?????-?? ?????? ??????? ???????? ??? ???? ?????????? ?????. ???????? ? ? ??????????, ? ?????????? 12? ?????? ???????? ??????? ?????????? ?????, ??? ??-???????, ???-?? ???? ???????? ?? ????? ? ??? ??? ?????? ? ???????. ?? ?????????? ??????-??????????, ? ??? ???????? ??????? ??? ??????? ????????? ??????, ??? ?? ????? ??????.??????. ???? ?????? ????????? ??? ????????????? ???? ????????? ???????, ??????? ??????-??? ???? ???????? ??????? ?????????????, ???????? ? ???????? ???????, ??? ??????????? ????????-???, ?? ????? ?????? ???????, ??? ?????????? ????????????? ????????????? ? ?? ??????????? ???????, ??? ?? ?????? ???? ??????, ?? ? ??? ??? ?? ???????????, ?? ?????,????????, ?????? ?? ? ????????? ? 12, ?????? ????? ???????. ?? ?????? ????????????,???????????? ?????, ?? ?? ?????, ????? ??? ????? ????? ???????.?????????? ????????? ???????, ??? ??????????? ???????? ???? ??????? ? ????????-???????? ?? ??? ??????? ???????, ??????????? ?????????? 12? ????????? ? ???????7.2.5.v) ???????????????????? ????????? ??? ?????-???????? ????????? ???????????????? ????????????, ??????? ?? ??????? ? ?????-???????? ????????? ????????,??????? ??????? ???. ???????? ??? ?????????? ???? ? ?????????? ? ????, ??????????, ??? ???????? ?? ?????? ? ?????????????? ????????????????. ???????? ????? ???????????????????????, ?????????? ??? ??????? ????????? ???????????, ???????, ?????????????, ??-??? ????????????? ???????, ??????? ???????????? ?? ??????? ? ????. ?????? ??????????428.????????????8.1.?????? ?????????? ????????? ???? ?????????????????? ?????????? ??????????? ??? ??????????? ?????? ? ????? ??????????8.2.???????? ??????????? ?????? ?? ?????? ???? ???????????????????????? ???????????????? ????? ?????? ????????????? ??????? 38 ?????? ? ??????????????? ?????? 1999????. ????? ?????? ?????? ????? ?????????? ??????, ????????, ???????????? ????????? ?????? ?? ?????????, ??? ????? ???? ????????. ????? ?????? ?????? ???? ??????????????????? ???????????? ??? ???????????? ??????????????, ?????? ??? ?????? ????????-??????????? ????????, ????????? ? ?? ??????????. ????? ?????? ?????? ????? ???????-??? ????? ? ???????????; ?????????????? ??????? ??? ??????? ? ????????????????????? ?????? ????? ?? ??????????????? ??? ????? ?????????? ?????????? ????????-???????????? ????.8.3.?????????? ???????? ? ???????????? ??????????????????? ??? ?? ???????? 1999 ???? ??????????? ?????? ??? ????????? ????????????????? ? ??-???? ???????? ??????????????? ??????????? ?????-???????? ????????? ???????? ? ??-????????? ???? ???????????? ?????????, ??? ??? ??????????????? ????????? ????????. ??-????. ???????? ????? ???????? ???? ?????????????? ??-?? ?????????? ????? ???????????????? ????? ???????????? ????, ??? ????????? ????????????? ?? ??????.????? ???????, ???????????? ????????????????? ???????? ????????? ??? ???????-?????, ????????? ?????? ???????? ?? ???????????? ???????? ?????????? ?????????? ???-????? ???????? ??????? ?????????, ????????? ?????????????????, ??????????? ?????-8.4.???????? ???????????? ???????-??????????????? ???????????????????? ?????? ???? ???????????? ? ????, ?? ?????? ??? ??? ??????, ?? ????????????? ??????????? ?????? ???????, ??? ??? ?????? ?? ?????, ? ????? ????????? ????????????? ???????? ????? ??????????. ???? ??????????, ???????? ??, ? ??? ????????????, ?????? ?????, ?????????, ? ?????? ???????????? ???????? ???? ??? ?????????? ???????-???-???????????? ?????????? ???????? ???????????. ???????? ?????? ??????????? ???????-8.5.?????????? ???????? ?????????????? ????????????????. ??????????? ????? ?????? ????? ??????????? ??????????? ? ??????? ???????, ?????-8.6.??????????? ??????? ?????????????? ??? ???????????????? ? ??????????????? ?????? ? ???????????? ??????????? 2001?2010 ??.??? ? ??????????? ?????????????? ?? ??????? ?????? ???????????? ????????. ????? ??-????? ???????????? ?????????, ? ????? ?????????? ????? ? ??????????? ?????????????,?????? ??? ??????? ??????.8.7.?????????????? ????????? ?????????? ?????????????????? ???????????????????, ????????? ? ????, ????????? ?? ???????????? ??????????????? ????? ??? ???-??????? ?????????????? ??? ???????????? ????????? ? ???????????? ??? ???, ? ???????8.8.?????????? ????????? ??? ????????? ? ?????? ?? ???????????????? ??????????? ???????, ?????? ????????????? ? ??????? ?????? ????????-???? ????????, ?????? ? ??????????????? ?????? 1999 ?., ? ?????? ??????????????? ????-????? ??????? ???? ???????? ? ??????????????? ?????????, ??? ????????????? ???? ? ???????????. ???????? ?????? ??????????? ????????? ? ??????????? ? ??????????, ??? ?????-???????? ?????????? ????? ? ?????????? ? ???????????? ??????????????. ????? ???????????????? ??????? ????????? ??????? ? ?????, ??????? ? ?????????? ??????????, ? ?????46c????? ???????????????????? ???, ????????????? ??????????? ??????????, ?????????? ?? ????? ?????? ?????????a)?????? ???????????????????? ????????? ??????????, ???????? ????????????? ??????????? ???????????? ???????? ? ??-???????? ??????, ???????? ?????????-????????????? ???? ?? ?????? ???????? ? ???-????????? ? ????? ?????? ????????????? ? ?. ?????????????? ?????????, ???????? ?????????? ?????????? ??????????, ???????? ???-?t??????? ?????????, ???????????? ???????? ?? ???????????????, ????????? ?ж???? ??????????, ???? ???????? ?? ???????????????, ????????? ?ж???????? ??????????, ????, ??????????? ???????? ???ǖ??????? ?.??????????, ?????????, ??????? ???????? ???????????? ????????????-?????????? ???ǖ???????? ?????????? ? ???ǖ??????? ???????? ???ǖ??????? ?????????, ????????? ????????? ?? ????????? ????? ? ????????? ??????????, ?????? ??????? ???? ???ė??????? ???????, ?????????, ??????? ??????????????? ?ж???????? ?????????, ??????? ???? ??????????????? ???????? ? ???? ?????????.???????? ???????????, ??????????? ?? ??????????? ???? ???????? ? ?????????????????????????? ?????????? ??????????, ?????????? ????????????? ????????????? ???????, ???????, ?????????? ??????? ????????????????? ??????????, ????????? ?????? ?? ??????? ?? ??????????? ???? ???????? ????-?????? o??????????? ?????? ?????? ?????????????? ?????, ????? ???? ? ??????????????? ????????, ????????, ?????? ??????? ????????????????????????? ????? ????, ????????? ?ж???????? ?????????? ? 12? ???ǖ???????? ????? -???????? ????????? ???????? ? ?????? ????????????? ????? ??????????? ??????????? ?. ???????????, ?????????, ?????? ??????????? ????????, ???????????? ????-??????????? ??.?????? ??????????, ???????? ?????????? ?????????? ??????????.b)?????? ????????????? ????????????? ?????????? ? ????? ???????, ???? ??????????? ????????? ?????????:?????? ?????????? ?????????? ?? ??????????????? ?????? ? ????????? ???? ????-??? ??? ?? ????????, ???????? ? 1999 ?.????????? ??????? ?????????? ??????? ??? ? ????????? ??????????????? ????????????? ??????????? ?????????? ??????????? ???????????? ????? ????????? 46/???????????? ???? ???????? ? ??????????????? ??????????? ?? ??? ????????????????????????? ???????????? ??????????????? ?????????? ?????????? ? 138 ?? ??-2000????.?????????????? ??????? ?????? ???????????? ???????? ? ?????? ??????, ??????????:????? ?? ??????????, ????? ????, ????????, ?????? ????????, ??????, ?????? 2003.????????????? ?????????? ?????????? ????? ????????????? ??????????????? ???-?????????? ??????????????? ??????????, ????????? ? ??????? ????????? ???????-??????????? ?????????? ????????? ??????????????? ?????????? ? ??????, 17 ??-????? 1989 ?.?????????? ??????????????? ??????????, ????????? ??????????/ii ???????? ????????-??? ?????????? ????????? ??????????????? ??????????? ? ????, ???????, 10 ????1983 ?.?????????? ??????????????? 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(? ?????????? ?? 21 ??????? 1998 ???????? ??-???? ??, ?134).??????? ??? 2001, ???????????? ????????: ????? ?????????, ????? ????????, ??????-??? ??????????? ???????????????, 2001 ?.????????? ????: ??????????? ????????. ????? ?????????????, ???, 54-?? ????????? ??-????????????? ????????: ????? ? ??????? ? ????????. ????? ????????????, ????, 55-??????????? ????????? ????????, 11 ?????? 2002 ?.??????????????? ???? ? ??????????? ? ???????????? ???????, ?????? ???????? ????-????? ??????????? ????????? ??????????? ???????????? ????? 2200a (xxi) ??16??????? 1966, ???????? ? ???? 23 ????? 1976 ?.??????????????? ???? ?? ?????????????, ?????????? ? ?????????? ???????, ?????????????? ????????? ??????????? ????????? ??????????? ???????????? ????? 2200a(xxi) ?? 16 ??????? 1966, ???????? ? ???? 3 ?????? 1976 ?.??????????? ?? ?????????? ???? ???? ????????????? ?????? ??????, ??????? ??-????????? ?????????? ??????????? ???????????? ?????c)?????? ??????????, ?????????? ? ???? ?????????????????????? ????? ???????????? ???????? ???? ? ?. ????????????????????? ???????? ? ???? ????????? 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(18)?? ?????????? ?????????? ????????? ??????????????? ??????????:??? ??????????????? ? ??????????????? ??????????, ??????? ? ????????? ????????????,??? ?????? ?????????, ????????? ????????????? ??????????????? ???????, ???????,?? ?????????? ????????? ????????? ???, ?????? ???????? ??? 10, 19 ??? 2001, ????????????????? ???????, ? ????????? ???????????? ?????????. ????, ??? ?????? ?????????????????. ????? ??????? ??????????? ?????????, ??? ???????????? ??????? ???????? ?? ???????????? ?????? ???? ?????? ?????????????? ???, ????? ??? ????? ???? ???????? ? ??-????, ??? ??? ??? ??????????? ????? ????????? 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(? ??? ????? ?????????-?????????) ?? ??????????? ??????????6.?? ???????? ??????????????? ?????? ? ????????, ??????????????? ?????????-????-7.?? ??????????????? ???????? ? ????? ?? ????? ?????? ?? ????????????? ? ????????8.?? ??????????? ?? ?? ?????????? ?????? ???????????, ???????????? ? ???????? ???-????????, ???????????? ????????? ???????;9.?? ?????? ????????, ????????? ????????????? ??? ????? ???? ? ???????, ??????????-?????? 16. ???? ??????????????? ?????? ? ?????????? ??????, ????????????? ????-????????. 1. ???????????? ?????????????:????????????? ??????????????? ??????;10.??????????????-???????????????, ???????????????? ?????? ?? ????????????? ? ???-????????? ???????? ?? ??????? ???????????, ????????????? ?????????????? ???-11.??? ???? ??????????????? ??????????, ??????????? ????????? ??????????????????:12.?????????? ? ???????? ?????? ? ?????????? ? ??????????????? ??? ?????????? ???-13.??????? ???????? ?????;14.???????????? ?? ???????? ???????? ? ?????? ???? ??????????? ?????? ? ???????-15.?????????-??????? ?????????? ????????? ? ???????????, ?????????? ????????????16.???????? ????????? ? ??????????????????, ?????????? ???????????? ????????????-17.??????????????? ?????? ??? ????????? ????????? ? ???????????.2.??? ??????????? ???, ?????????? ???????????? ??????????????, ???????????????18.??????? ??? ???? ??????????, ??????????? ????????????? ? ???????????? ?????-19.?????????? ??????????????????? ? ???????????????? ??????????? ???????????????-20.??????? ???????-???????????????? ??????????? ??? ???????? ???????, ???????? ??-??? ??????? ? ???????????? ????????? ????? ??? ????? ???;21.???????? ?? ??????? ????????? ????????? ?????? ? ??????????? ?????????? ? ??-22.????????????? ???????????? ????? ??????? ???? ?? ????????????, ? ??????????? ?23.????????? ?????? ?????????????? ?????????????? ??? ???????????, ?????????? ?24.??????? ????????? ??? ???, ?????????? ???????????? ??????????????, ??????????25.????????? ???? ????, ??????????? ??? ?????????? ????????? ?????, ??????????3.??????????? ????? ?????? ??????????????? ?????? ? ?????????? ?????? ??? ???,?????????? ?.?.. ?????? ????????. ????????? ?????????.3,5 ???. ???. ?., 3,26 ???. ???. ?. ????? ____ ???.