Annex D FINAL 2 Turkmenistan Country Findings.pdf

Annex D: Turkmenistan Country Findings

Background: Turkmenistan has accepted only limited external assistance in health. The government has largely retained the Soviet era model of governance since independence.

Until recently, Turkmenistan has shown little interest in a broad restructuring of the health care system. But in recent years, the President has strongly backed improvements in primary care. ZdravPlus II has been responsive and is working with the Ministry of Health and Medical Industry to implement service delivery and health information changes. The recognized success of this assistance may facilitate more extensive reforms.

Senior officials in the new government express strong support for continuing current ZdravPlus II assistance and invited the project to propose new ideas. These are encouraging signs, and we encourage ZdravPlus II to explore the potential for further reforms over the next two years.

Performance Monitoring Plan Analysis: Zdrav’s quantitative targets for 2007 for IMCI training, laboratory training, hospital HIS, Safe Motherhood , policy dialogue, and outreach were virtually met or exceeded. The major accomplishments of the project, however, are not well captured by these or other quantitative indicators. These accomplishments include: 1) Maintaining a good working relationship with the government during a difficult period for development organizations; 2) introducing evidence-based improvements in health care in clinical facilities and training institutions;

and 3) introducing an effective computerized information system that is currently being scaled up. With recognized success in these areas, ZdravPlus II is well-positioned to support additional reforms.

Stewardship: Activities in this component have been limited due to GOT restrictions.

ZdravPlus II has pursued legal and policy issues related to IMCI and maternal health through partnerships with WHO and UNICEF. A noteworthy achievement was the issuance of a policy directive (prikaz) that incorporated IMCI into medical school curricula.

Resource Use: Health care financing is an issue for Turkmenistan with funding for health at only an estimated 2.5% of GDP, including a large capital investment program.

An unusual insurance arrangement and low family incomes (despite large natural gas revenues) impede effective public sector services. ZdravPlus II has provided initial awareness training from the regional office, but the GOT has not yet requested assistance in this area. The project’s support for computerizing part hospital reporting of patient discharge information is widely recognized as a major improvement and is being scaled

up. The new reporting system currently serves largely to update established procedures, but has the potential to support reforms in financing and management. The system is discussed below.

Service Delivery: ZdravPlus II has established an exceptionally effective working relationship with the health ministry, and is the only USAID partner with a formally approved work plan. As an indication of improved relations with the new government, in

2007, an unprecedented 9 policy directives (Prikaz) were issued to authorize ZdravPlus II work.

The Deputy Minister of Health expressed his gratitude for the full range of ZdravPlus II assistance, and urged the US to continue and expand project assistance. While he expressed a willingness to consider a broad range of health reform activities, he specifically mentioned health finance and evidence based medicine, as major future needs, and agreed that Turkmenistan should conduct a survey of multi-drug-resistant tuberculosis.

USAID attributes Zdrav’s unusually good working relationships with the ministry to careful consultation with GOT counterparts and the resulting sense of GOT ownership.

Ministry officials and representatives of international agencies offered similar assessments. ZdravPlus II activities are also extensively linked with those of other international agencies, such as WHO.

ZdravPlus II has used a very small budget effectively to support the ministry’s interest in maternal-child health, introducing innovations in a highly conservative system. The ministry has requested expanded assistance, chiefly training, and USAID is considering additional funding. Providers have responded enthusiastically to technical training, which has been severely limited in recent years.

Officials at an operational level, and representatives of international agencies consistently credit ZdravPlus II for its flexibility and responsiveness in facilitating their programs. To a large degree, they view the project’s comparative advantage in terms of its depth of knowledge of program implementation in the Turkmen health system, which is unique among international partners. Counterparts offered a number of examples of how Zdrav effectively used modest funds to facilitate policy changes or donor programs. For example,

• Safe Motherhood: ZdravPlus II facilitated a presentation of Safe Motherhood results that was soon followed by a national program. To help launch the national initiative the project funded WHO expert trainers and translated technical materials into Turkmen. ZdravPlus II then developed the monitoring forms that documented the impact of the program.

• Evidence Based Medicine: Although donors shared an interest in evidence based medicine, only ZdravPlus II had the flexibility to host the first workshop on this topic, which is now of widespread interest among senior officials. Evidence-based medicine remains a new concept for the ministry, but ZdravPlus II efforts have provoked expressions of interest and requests for more information. When learning of skepticism by the Sanitary Epidemiological Service (SES), which could have blocked new EBM practices, the project quickly responded by arranging for a workshop with global experts.

Officials from international organizations also consistently observed that ZdravPlus II’s institutional capacity will become dramatically more valuable if, as many expect, the ministry continues to expand its health reform initiatives in areas such as health financing, HIV/AIDS, and clinical guidelines.

ZdravPlus II training evaluations document substantial knowledge gains from this training, suggesting that it is of good quality. Limited efforts to monitor the impact of child health (IMCI) training on provider performance found an impressive 80% level of compliance with the IMCI clinical guideline, exceeding expected levels. ZdravPlus II surveys at the initial pilot Etrap (district) show a noteworthy decline in under-5 child mortality from 42/1000 in 2002 to 28/1000 in 2006.

ZdravPlus II supported the MCH Institute in developing a monitoring system with 27 quantitative indicators of the quality of care for pregnancy, labor & delivery, newborn care, and postpartum family planning, based on chart reviews and patient surveys.

By 2008, ZdravPlus II had trained 47 IMCI trainers and 15 medical school teachers as part of an effort to scale up and institutionalize this child health approach. In turn, 1000 family physicians and 520 have completed IMCI training. More recently, steps to introduce IMCI in hospitals have begun on a small scale.

Zdrav supports training for the most peripheral laboratories as part of a nascent strategy to support family medicine. Trainees include both family physicians, who often conduct their own lab tests, and physicians who specialize in this area. This strategy complements CDC’s training program in referral laboratories. The impact of ZdravPlus II training is not well documented.

ZdravPlus II assistance in Tuberculosis directly observed therapy (DOTS) is minimal.

Starting in 2004, Zdrav conducted a series of policy level workshops on health information systems and health financing topics. In 2007, ZdravPlus II responded to a ministry request to pilot test a computerized patient discharge summary in 7 hospitals.

The software is a modified version of one developed by Zdrav for other CAR applications. While the HIS has potential for application to a case-based hospital reimbursement system, its current application is chiefly on reporting. Officials were stunned to find that a core hospital report that required a week under the old paper-based system could be completed—with greater accuracy—in about 2 minutes. The ministry is currently scaling up the system, with one-third of all hospital statisticians currently trained at the State Medical Institute Health Management Training Center.

Based on this experience, the Rector of the Institute, which provides most of the continuing medical education in the country, expressed interest in expanding cooperation with ZdravPlus II. In particular, the Rector proposed institutionalizing EBM training in the Institute’s program, which has national coverage. Incorporation of IMCI into the Institute’s program is in its initial phase, with Zdrav support.

Community and Population: Community/population interventions have focused on a Keeping Children Healthy campaigns in 11 Etraps, starting in 2002. This initiative was based on ministry Family Nurses, who reached over 50,000 mothers of young children with educational messages and materials. Before/after tests of relevant knowledge showed an overall increase from 54% to 88% in these areas.

Conclusions: The ZdravPlus II staff in Turkmenistan has skillfully supported health system improvements in a restrictive policy environment. Multiple signs point toward increasing openness by the government with regard to further reform of the Soviet era model, but this may be ultimately a Presidential level decision. Nevertheless, managers and providers that we interviewed were consistently enthusiastic about the project’s assistance and clearly would like more. The basic resources potentially available for health are impressive, including an expanding infrastructure and the country’s substantial financial reserves. At the same time, limited health information suggests a large unmet need for health services. If the policy environment for reform improves, ZdravPlus II is well-positioned to play a critical supporting role. The impressive potential health benefits of such an initiative justify continued assistance.

In the short term, ZdravPlus II can facilitate supportive policy changes while working within its current mandate. Direct evidence of improvement, chiefly in service delivery, is relatively modest, but it has made a strong impression in the officials we interviewed at all levels. The project should invest more in measuring the impact of reforms and in disseminating this information. This approach applies to ZdravPlus II support for laboratories and health information. In new areas, such as financing and management, the project should explore the Ministry’s openness to baseline assessments of current systems. New areas where officials have already expressed interest, such as expanding evidence-based medicine, are also worthy of support. ZdravPlus II should also review its comparative advantage in addressing tuberculosis (including drug resistant varieties) and

HIV/AIDS.