Since independence in 1991, the Republic of Tajikistan was exposed to civil war, natural disasters, and economic failure. Results are the Republic being economically the poorest of the former Soviet states, with increasingly poor health outcomes. Although no definitive numbers exist, infant mortality rate, under-five mortality rate, and maternal mortality rate are very high and worse than in other countries of Central Asia. These are due principally to the high incidence of acute respiratory infections (ARI), diarrhoeae and parasitic diseases among children, as well as haemorrhage and eclampsia around delivery (a majority of women deliver at home without assistance through a formally trained health care provider). These indicators hide huge differences between rural and urban areas, with worse conditions in rural settings.
The health sector in Tajikistan puts emphasis on in-patient care with an important number of hospitals and doctors. In principle, services are being provided free, and are thought to be easily accessible through a network consisting of over 3,000 facilities. However, in reality most of the patients have to pay, be it through the purchase of their drugs and dressings in hospital, or through tipping of doctors. With a public expenditure of around US$ 2 per capita and per year corresponding to about 2% of the Gross Domestic Product, the health sector is completely under funded and of poor quality. It is generally acknowledged that health workers have an extremely low pay, are not well trained, and that there is a lack of medical equipment and drugs.
Supporting the health sector reform
Health sector reform is seen as a priority of the Government of Tajikistan. To achieve the reform, a comprehensive plan, the SOMONI plan, has been elaborated with the support of World Health Organization. Important elements of the reform are the strengthening of Primary Health Care (PHC) through the promotion of family practice models, a shift in budgeting and allocation of public resources towards more regional equities and the rationalisation of services through a reduction in the number of facilities and hospital beds as well as the number of specialist doctors being trained in medical universities.
In the area of Health Sector Reform and family medicine, the Tajik Ministry of Health (MoH) is assisted by a series of bi- and multilateral donors and NGOs, among them, the Swiss Agency for Development and Cooperation (SDC) and the World Bank (WB). Activities funded by these two agencies assist Tajik efforts in carrying forward the health sector reform. Both agencies recognise that the combination of rapid economic change, resulting in a substantial decline in living standards, and the far-reaching changes resulting form the process of transition from a planned to a market economy, has highlighted the deficiencies of the existing health services at rayon (district) level. Particularly noticeable are the absence of efficient first contact services, and problems of access for poor people. A key challenge is to help to improve the equity of health services and their accessibility by developing PHC and family medicine services at district level.
The World Bank financed ”PHC reform project” began its activity in August 2000 and is planned to last four years. There are four main components of the project:
(1) PHC development and staff training, including the development of curricula for family practitioners and nurses, the establishment of disease management protocols, the upgrading of teaching facilities and the retraining of physicians and medical personnel;
(2) Rationalization and development of health facilities, including the construction of around 30 new PHC facilities in the two pilot regions and the infrastructural strengthening of the cold chain for the vaccination program;
(3) Development of a methodology for funding health care at the oblast (regional) level, using a capitation system adjusted for age, sex and disease incidence; and
(4) Improvement in project management, consisting of training of staff in health sector management, and improvements in the health management information system. Project management is being handled by a Project Implementation Unit which assists the Ministry of Health in carrying forward the reform process.
The SDC supported ”Health Sector Reform and Family Medicine Support Project” started in 2003 and has three objectives, which are:
(1) access to high quality PHC services is improved and tested models for health promotion are available;
(2) tuberculosis control using the DOTS strategy is designed and implemented in selected pilot areas
(3) skills needed to plan, manage, monitor and evaluate health services are improved.
The project supports activities on both demand and supply sides and at various levels of government. On the supply side, the project works with the Ministry of Health to improve the way in which PHC services are delivered, by supporting the improvement of the skills of the providers, and by improved supervision and management. On the demand side, the project aims to work with communities and user groups to address the problem from the users’ perspective. Community participation and the mainstreaming of HIV/AIDS and gender concerns are addressed as cross-cutting issues.
World Bank, SDC and Ministry of Health: Collaboration and complementarity
The World Bank and SDC supported projects collaborate closely with the Ministry of Health and especially with its Department for Planning, Coordination and Implementation (”Somoni group”). The tripartite agreement (SDC-MoH; WB-MoH; SDC-WB) stipulates that activities are, whenever possible, harmonised between the two projects. Joint half year monitoring and supervision missions involving the World Bank, SDC, the Swiss Tropical Institute as implementing agency on behalf of SDC, and the Tajik Ministry of Health are carried out.
Both projects concentrate activities on the same two pilot districts which are Dangara and Varzob. Furthermore, they closely collaborate at the level of the ”Project Implementation Unit” on planning, managerial and administrative aspects of the projects.
While World Bank assisted activities having started earlier, the SDC funded project is designed to complement the on-going World Bank supported PHC reform project and other projects focusing on the strengthening of family medicine services. SDC assisted activities are also introducing new components in the area of the promotion of healthy lifestyle, monitoring and evaluation skills, TB control and DOTS, and mainstreaming HIV/AIDS and quality management into the Tajik reform process.
But more importantly: World Bank support are mostly used for investments in the health sector infrastructure, through the construction of new PHC facilities and a cold chain for vaccines, as well as PHC equipment including vehicles and computers. Based on this background, SDC assistance primarily focuses on investments in human resources (”humanware”) and not hardware in order to ensure that Tajik health workers are skilled managers, administrators and health providers.
*Mouazamma Djamalova is trained physician with a post-graduate diploma in management and planning of health service delivery. Currently she is National Programme Officer at the Swiss Cooperation Office in Tajikistan. Kaspar Wyss is epidemiologist and public health specialist at the Swiss Centre for International Health of the Swiss Tropical Institute. He is coordinator of the ”Tajik-Swiss Health Sector Reform and Family Medicine Project”. Contacts: mouazam@swisscoop.tojikiston.com or kaspar.wyss@unibas.ch.
More on health sector reform in Tajikistan: European Observatory on Health Care Systems. Tajikistan – Health care systems in transition. European Observatory on Health Care Systems, 2000: 69 pages, download at www.who.dk/document/e69820.pdf
