Annex T Country Tables Zdrav to ZdravPlusII UZ.pdf

2/3/2008 Response to Tina's Questions -- Uzbekistan Not start work in Uzbekistan until mid-way through ZdravReform and minimal activities 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 Tina's See ZdravPlus II Project Regonal Conceptual/Technical Overview Paper Distributed to USAID Evaluation Team for General Definition of Project Components Scale Just intended to provide a general picture, not fully specified, activities not always fit precisely across projects, generally allocated to time where most accomplished For Z+II

ZdravPlus II Remainder +R for Project Component At Independence ZdravReform ZdravPlus ZdravPlus II To Date and Beyond Roll-out Stewardship

Legal and Policy

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

No general policy dialogue, focus is on the opening created by Uzbek desire to invest in and improve rural health care

Generally same situation, broad health policy dialogue not possible but dialogue expands as initiatives expand. Environment characterized by difficult struggle to reach agreement but then move forward and not go back.

Dialogue continues to expand as initiatives and scope of reform expands but still no broad health policy dialogue or a critical mass to create a general health sector strategy. Environment remains characterized by difficult struggle to reach agreement but then move forward and not go back.

In the short-term likely to remain the same, the scope of initiatives drives dialogue rather than a broad health sector strategy driving initiatives. Not too damaging as long as scope of initiatives continues to expand, it can even be seen as positive as time is given for initiatives to develop O

Institutional Structure, Roles, Relationships

(ISRR)

MOH monopoly with complete command and control

Only related to implementation of rural PHC model

No broad approach but progress in specific institutional structure and roles including establish health purchaser, some PHC facility autonomy, establish GP Training Centers, establish EBM Center.

Some movement on forming or supporting NGOs and working with Mahalla's

Continue step-by-step establishment of institutional structure and roles. Substantial institutionalization and capacity building although how to realign the roles and increase the long-term capacity of the MOH central apparatus remains a concern.

Government shut-down NGOs and didn't allow direct linkages to community so found alternative mechanisms. Began working with Republican Institutes as well as EBM Center and merger of two medical academies created some openings.

Likely Uzbek environment remains difficult and more conducive to step-by-step establishment of overall institutional structure, roles, and relationships and capacity building rather than broad realignment. No major issues with this approach and could continue to be effective. Expect continued shut-down of NGOs and lack of access to community O

Policy Marketing Command and control, little dialogue

Minimal, Government decreeing investment in rural health care

Minimal as govern by decree and very difficult to broaden participation. Not good for long-term but effective process in short-term -- agree on policy and then implement

Minimal as govern by decree and very difficult to broaden participation, current environment more difficult than ZdravPlus I.

In short-term likely to remain the same, hopefully in longer term there is more participation in policy dialogue and greater potential and need for policy marketing O

Monitoring and Evaluation Politically driven Minimal

Developing through monitoring inherent in QI processes and special studies on health financing implementation

Developing through monitoring inherent in QI processes and special studies on health financing implementation. Generally, a growing interest from UZ partners to monitor the results of their reforms.

The Uzbeks are interested in assessing progress and potential for M&E activities should continue to increase O

Donor/Project Coordination None

Generally good and very close with WB

Generally good and very close with

WB

Generally good and very close with WB and

ADB

Unclear if more formal donor/project coordination mechanisms will develop O

Resource Use

Health Delivery System Structure Inverted pyramid

Rural PHC model:

establish independent SVPs in 1 oblast

Rural PHC model: establish independent SVPs in 3 oblasts

Rural PHC model: close to completing roll-out nationwide. Urban PHC model: pilot reorganization and restructuring. Lack of hospital restructuring troubling but inherent in Uzbek step-by-step approach

Rural PHC model -- solidify. Urban PHC model -- complete piloting and roll-out. Hospital: initiate hospital restructuring linked to financing P, R, O

Human Resources Planning None Minimal

Some HR planning linked to PHC development and ME improvement

Some HR planning linked to PHC development and ME improvement Unclear how it will develop… O

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

Health Financing

See writing on fragmented financing, no separation of purchaser/provider, wrong incentives in provider payment systems (PPS), etc.

Rural PHC model:

develop methodology for per capita payment system

Establish oblast pooling of funds and OHD as health purchaser.

Rural PHC model: implement per capita payment system in 3 oblasts

Solidify oblast pooling of funds and OHD as health purchaser. Rural PHC model: close to completing roll-out of per capita payment system nationwide. Urban PHC model: pilot per capita payment system. Hospital:

initiate design of case-based hospital payment system.

Rural PHC model: solidify. Urban PHC model: complete pilot and roll-out.

Hospital: implement new hospital payment system. Solidify oblast pooling, continue strengthen OHD as health purchaser, ensure harmonization with Treasury System, strengthen linkage to BBP P, R, O

Health Information Systems (HIS)

Excessive but data poor, politicized and not used

Rural PHC model:

design financial and HIS

Rural PHC model: implement financial and HIS in 3 oblasts

Rural PHC model: close to completing roll-out of financial and HIS nationwide. Urban PHC model: pilot financial and HIS.

Hospital: implementation of automated HIS in pilot oblast of Ferghana

Continue consistent with country implementation strategy -- solidify national roll-out of rural PHC model, continue piloting and plan roll-out of urban PHC model, and initiate pilot of case-based hospital payment system.

Over time, integration and improvement of overall country HIS. P, R, O

Health Management

Command and control, politics equated with management

Rural PHC model:

design practical health management training and systems linked to health financing

Rural PHC model: implement practical health management training and systems linked to health financing in 3 oblasts

Rural PHC model: close to completing institutionalization and roll-out of health management training and systems nationwide. Urban PHC model: pilot health management training and systems.

Hospital: develop health management training and systems. All health management training continues to be linked to health financing implementation

Continue consistent with country implementation strategy -- solidify national roll-out of rural PHC model, continue piloting and plan roll-out of urban PHC model, and initiate pilot of case-based hospital payment system.

Over time, develop long-term health management education. P, R, O

Service Delivery General Health System Functions

Postgraduate Medical Education Old system collapsed

Modular training courses in Ferghana to fill time gap while GP training process developed

GP trainer TOT, establishment of GPTCs, initiation of GP retraining for PHC doctors

GP trainer or faculty development, improvement of GP training curriculum including incorporation of priority or vertical programs, integration into medical education, dialogue on CME

Continue support GP faculty development and GP retraining, convert to a long-term CME system linked to licensing O

Graduate Medical Education

Not based on EBM, no outpatient clinical bases None

Minimal movement although general practice introduction extends across education levels in Uzbekistan better than other CAR countries so linkages established

Strengthen linkages related to general practice introduction

Solidify linkages in general practice introduction and continue broad strengthening of medical education O

Undergraduate Medical Education

Not based on EBM, theoretical with little practical clinical training or patient contact None

Link with TashME I and TashME II on general practice introduction, dialogue through Regional Council of Rectors, TashME I and TashME II merge into TSMA, work with TSMA and TashPeds to unify the curriculum across the two institutes to gradually produce general doctors capable of serving adults and children, link to regional medical education accreditation dialogue and detailed specification and adaptation of WFME standards to CAR

Continue broad strengthening of medical education O

EBM/CPGs

Nature of clinical practice not based on evidence None

Begin promoting EBM, establish EBM Center

Continue promoting EBM, support EBM Center but also support broader participation in CPG development by involving Republican Institutes

Continue promote EBM, solidify CPG development process, obtain further recognition of facility level QI as CPG implementation process O

Quality Assurance Punishment None None Establishment of health professional licensing

Unclear, broader strategy needed on licensing and accreditation and determination of linkages to health purchasing O

Pharmaceuticals

Pharmatsiya (some different names across country) monopoly Minimal

Drug Information Center in Ferghana

Dialogue on how to ensure accessibility ot drugs in PHC models, link drug-related information to EBM/CPG and service delivery priorities, minimal support for contraceptive logistics system

Unclear, broader strategy needed, sensitiviites related to Dori Dorman and central procurement remain O

Infrastructure

All owned by state, massive and deteriorating

Contribute to specification of WB equipment and SVP renovations

Contribute to specification of WB equipment. Uzbeks renovate or built SVPs.

Contribute to specification of WB equipment.

Uzbeks renovate or built SVPs. Although tougher for local governments due to tightening budgets, has resulted in creating new rural PHC sector

Solidify PHC infrastructure, where possible provide TA on hospital level equipment and renovations O

Service Delivery Priority Programs

General Practice/Hypertensio n

Problems inherent in system including weak

PHC

Modular courses in Ferghana

Piloted hypertension quality improvement (QI) projects

Roll-out hypertension QI projects including within Ferghana Oblast, through links to GP training, through links to other donors/projects

Evolve into long-term, sustainable linkages and synergies between system level EBM promotion and CPG development and facility level QI and CPG implementation P, R, O

Maternal (Safe Motherhood) and family planning

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

Modular courses in Ferghana

Piloted anemia quality improvement (QI) projects. Piloted and rolled-out midife/IUD program. Developed and implemented contraceptives logistics system in Ferghana.

Roll-out anemia QI projects including within Ferghana Oblast, through links to GP training, through links to other donors/projects. Dialogue and initial activities for Safe Motherhood implementation. Continued limied support for midwife/IUD program and contraceptives logistic system.

Further support and solidify Ferghana Safe Motherhood site as Center of Excellence, collaborate and guide development of donor consortium supporting expansion of Safe Motherhood, link Safe Motherhood and FP, possibly expand FP. P, O

Child Health

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

Modular courses in Ferghana

Piloted IMCI quality improvement (QI) projects

Roll-out IMCI QI projects including within Ferghana Oblast, through links to GP training, through links to other donors/projects. Link closely with Navoii Oblast child survival project to expand QI.

Evolve into long-term, sustainable linkages and synergies between system level EBM promotion and CPG development and facility level QI and CPG implementation P, R, O

TB

Excess capacity in vertical system, not evidence-based treatment, reach of vertical system no longer able to control all TB-related issues None Minimal

Not comprehensive activities initiating integration of general health system and vertical TB system due to strength of vertical system. Activities focused on integration into medical education, incorporation of IPCS, and health promotion

As Uzbekistan moves to Phase III of the reforms with a greater focus on hospital restructuring, the vertical health systems and their relationship to the general health system will likely become a higher priority issue. O

HIV/AIDS Not yet emerge None Minimal

Link to Safe Motherhood, link to GP training, include as priority health promotion topic in patronage nurse program

Many constaints and challenges but a comprehensive strategy needed on the relationship between the general health system and the vertical HIV/AIDS system O

Population and Community Health

Marketing the Reforms

Population role not seen as important Minimal

Activiites marketing the reforms through NGOs and CBOs such as Mahallas

Due to crack-down on NGOs, the mechanism changed from direct work with NGOs to reaching out from SVPS which are government entities to communities through town meetings and other activities

Need will grow, nature and scale of activities dependent on country environment O

Health Promotion -- Government Not yet emerge None

Limited support for Institute of Health in their health promotion campaigns

Limited support for Institute of Health in their health promotion campaigns

Limited support for Institute of Health in their health promotion campaigns O

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

General health promotion activities in pilot oblast of Ferghana

Expand health promotion activities by establishing SVPs as community resource centers

Strengthen linkage between health promotion activiites and service delivery priority programs. Initiate national patronage nurse program where nurses become a channel for informing the population.

Continue patronage nurse program and strengthen linkage with service delivery priority programs. O

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

Establish Mahalla Initiative Groups (MIGs) and work with them to empower the population and involve the community in health.

Due to crack-down on foreign firms, activities are more limited and the mechanism changed from direct linkages to MIGs to reaching out to Mahallas from SVPs

Nature and scale of activiites dependent on country environment O