Annex T Country Tables Zdrav to ZdravPlusII TJ.pdf

2/3/2008 Response to Tina's Questions -- Tajikistan Not start work in Tajikistan until ZdravPlus Most activities done in collaboration with other donors/projects, documented elsewhere, not included due to space constraints Same situation at independence for all countries although level of health financing collapse varied See ZdravPlus II Project Regonal Conceptual/Technical Overview Paper Distributed to USAID Evaluation Team for General Definition of Project Components Tina's Just intended to provide a general picture, not fully specified, activities not always fit precisely across projects, generally allocated to time where most accomplished Scale

For Z+II ZdravPlus II Remainder +R for

Project Component At Independence ZdravPlus ZdravPlus II To Date and Beyond Roll-out Stewardship

Legal and Policy

No comprehensive policies, patchwork of laws/regulations, governing done by decree

Supported by WHO created Somoni Master Plan, generally good plan but created a semi-parallel MOH and a lot of conflict. Broad policy dialogue difficult.

Started productive health financing reform dialogue with a multi-sectoral working group. Dialogue about family medicine also contentious.

Health Financing Strategy approved by the President. Approval of regulations to start PHC per capita payment. Significant conflict over nature of BBP and copayments but ultimately approval of good policy. General service delivery and family medicine dialogue more productive although issues with approval of international consultants for SM.

Surprisingly good openings for dialogue in EBM and ME.

Continue to strengthen policy dialogue processes and legal/regulatory base. Is talk of SWAp or at least development of Health Sector Strategy. O

Institutional Structure, Roles, Relationships (ISRR)

MOH monopoly with complete command and control

Substantial conflict over who has the leading role in introducing family medicine and retraining (PGI or new Republican Family Medicine Center) demonstrates problems with duplicative roles. Clear that building capacity in MOH will be long-term and difficult challenge.

Initiate productive dialogue on establishing a oblast-level health purchaser. Family medicine institutional conflict somewhat mitigated. It appears DIC and EBM Center in good institutional home in TSMU.

Creation of Family Medicine Association.

Center of Excellence (COE) model established.

Establish and solidify health purchaser and define health provider autonomy and public/private relationships. In service delivery, continue separating and decentralizing functions and establishing and clarifying roles and relationships O

Policy Marketing Command and control, little dialogue

Very controlled and politized environment and not broad dialogue

Dialogue broadening but still very politicized. Try to support MOH in advocating and showing results to the Government to obtain more time and space for reform implementation

Priority to enhance dialogue and broaden participation. O

Monitoring and Evaluation Politically driven Minimal

WB project and WHO working with Tajik partners to establish a Health Policy Analysis Unit similar to Kyrgyzstan

Objective data and analysis of reform implementation needed to depoliticize environment and move toward evidence-based policy-making O

Donor/Project Coordination None

Contentious at times. Possible some underlying tension due to who there during the war vs. who not and relationship humanitarian assistance and development.

ZdravPlus contributed to donor coordination process.

Still difficult at times. Nature of Tajikistan does contribute to a divide and conquer mentality.

A major issue requiring a lot of effort.

Unpredictable whether moving toward SWAp will improve or worsen in the short-term although likely good for the long-term. O

Resource Use

Project Component At Independence ZdravPlus ZdravPlus II To Date and Beyond Roll-out

Health Delivery System Structure Inverted pyramid

Loss of time during war years really hampered development of bottom-up pilots and restructuring which was generally happening in other CAR countries.

Decision on rural PHC model -- Rural Health Centers reporting to PHC Network Manager under the CRH, working on establishing specific roles and relationships now. Cities mixed polyclinics which enables COE development. Minimal hospital level restructuring and given low level of funding the system continues to collapse under its own weight.

Expand PHC reorganization and restructuring. Hospital level restructuring needs to start and critical to long-term sustainability of health sector. O

Human Resources Planning None None None Definitely a future priority

Health Financing

See writing on fragmented financing, no separation of purchaser/provider, wrong incentives in provider payment systems (PPS), etc. Initiated productive, multi-sectoral dialogue

Hard to agree upon first implementation step after National Health Financing Strategy approved. After long dialogue and development of multiple implementation strategies and plans, implementation of pilot PHC per capita payment started in 2007. Approval and pilot implementation of BBP with formal copayments. Most CAR countries generally improved pooling and purchasing arrangements first and then solidified BBP after payments could be matched to benefits. Tajikistan is introducing BBP and then will need to back down the chain to improve pooling and purchasing arrangements to realize the BBP, dialogue in process.

Just starting health financing implementation, substantial support needed in the future to continue to develop and implement TJ health financing model. P, O

Health Information Systems

(HIS)

Excessive but data poor, politicized and not used

Initiated automated hospital database and

HIS

Expand automated hospital database and HIS. Currently working on module to attach to hospital HIS to enable better planning and management of formal copayments

Continue implementation and expansion linked to health financing implementation P, O

Health Management Command and control, politics equated with management

Provided training to health providers on general health management principles and communicating the objectives of the health reforms.

Health financing and management training provided in pilot PHC per capita payment system sites. Dialogue on coordinating with health management training under WB project

Short-term -- capacity building training linked to health financing implementation Long-term -- health management education needed P, O

Service Delivery General Health System Functions

Postgraduate Medical Education Old system collapsed

With expatriate doctors, started FM TOT, collaborated on formation of oblast FMTCs and starting PHC retraining process

Expatriate doctors continued FM TOT, ongoing faculty development, strengthened FMTCs/COE, supported retraining, and initiated short CME conferences very popular with doctors

Continue support faculty development, PHC retraining, and CME O

Graduate Medical Education Not based on EBM, no outpatient clinical bases Minimal

FM trainers graduating from FM TOT go to polyclinic affiliated with TSMU to start FM residency, mixed results in short-term largely due to personalities but structure in place and we expect it to progress

Continue development of FM residency, link graduate medical education improvement to general medical education reform O

Project Component At Independence ZdravPlus ZdravPlus II To Date and Beyond Roll-out

Undergraduate Medical Education

Not based on EBM, theoretical with little practical clinical training or patient contact

Early on it appeared that productive dialogue with TSMU on medical education improvement could be established earlier in the process than other CAR countries, dialogue through Regional Council of Rectors

Assessment of TSMU by international consultants, ongoing technical assistance to TSMU to develop Medical Education Reform concept and implement some early steps, work on medical education accreditation and adapting WFME standards

Expand medical education reform and improvement O

EBM/CPGs Nature of clinical practice not based on evidence Minimal

EBM Center established in TSMU, productive dialogue and capacity building in EBM, started developing new CPGs. Continue to expand activities O

Quality Assurance Punishment Minimal Some dialogue about facility accreditation Possibly initiate facility accreditation and maybe QA linked to health purchasing

Pharmaceuticals

Pharmatsiya (some different names across country) monopoly

A strength of initial donor inputs due to strong WHO pharmaceutical team and humanitarian assistance focused on drugs.

Relatively strong MOH capacity. Drug Information Center (DIC) established in TSMU and provided objective evidence-based information to health providers and population

National Drug Policy developed and approved. DIC continue sustantial activiites on rational drug use. Broad picture confusing as working to reestablish central procurement of drugs. Donor commitment to provide drugs more uncertain. Should link to health financing reform but how not yet clear.

A broad strategy on financing mechanisms for drugs needed and ongoing rational drug use activities O

Infrastructure All owned by state, massive and deteriorating

Major issue as system substantially decayed. Hasn't been major investments in infrastructure expecially for PHC as in other CAR countries.

Z+ limited investment in COEs. Some investment under WB and ADB projects but still major issue.

Infrastructure needs more upgrading to realize health system improvement O

Service Delivery Priority Programs General Practice/Hypertension

Problems inherent in system including weak PHC General family medicine introduction Initiated pilots in COEs

More investment in pilots and eventual roll-out P

Maternal (Safe Motherhood) and family planning

Problems inherent in system including weak PHC and not evidence-based Minimal

Initiated pilots in COEs and working to solidify and start roll-out Continue to solidify pilots and roll-out P

Child Health

Problems inherent in system including weak PHC and not evidence-based

Incorporated into general family medicine introduction

Incorporated into general family medicine introduction

Continue to solidify in general family medicine introduction O

TB

Excess capacity in vertical system, not evidence-based treatment, reach of vertical system no longer able to control all TB-related issues Minimal

See other writing -- generally, policy dialogue, integrate TB DOTS into ME, integrate TB DOTS into PHC, link civilian and prison TB systems, health promotion.

All activities in collaboration with Project

HOPE.

Continue integrating into medical education and PHC. Gradually create more health system linkages including financing and vertical system restructuring P, O

HIV/AIDS Not yet emerge Minimal Incorporate into Safe Motherhood, some links to PHC training and health promotion

General strategy needed including addressing role of vertical system O

Population and Community Health

Marketing the Reforms Population role not seen as important Minimal

Established MOH Press Center but not yet mature and seems part of country environment is increasing desire to control information

Should be expanded if country environment allows O

Health Promotion -- Government Not yet emerge

Supported Somoni Team and Republican Center in health promotion Limited support for Republican Center Continue limited support…. O

Health Promotion -- Providers Linked to Service Delivery Not yet emerge Minimal

More intense and focused health promotion at health provider level for service delivery priority programs

Enhance and expand in concert with COEs and service delivery priority programs P, O

Health Promotion -- Community-Based Entities Not yet emerge Minimal

Initial linkages with mahallas and other community-based entities

Should be expanded if country environment allows O