as discussed below some procedures are performed very infrequently in kazakhstan implying that access to them is likely to be uneven referred patients have a higher likelihood of being admitted than those who arrive by ambulance or through selfreferral the most common reason for patients being refused admission including those with referrals is lack of medical necessity unplanned procedures also represent the bulk of surgical activity in most kazakh hospitals unplanned admissions occupy beds intended for planned activities can lead to the postponement of necessary care thereby becoming in effect a barrier to access while waiting times appear short given the low volumes of surgical procedures performed comparisons should be made with caution