Photo Credit: World Bank
Over the years, Tajikistan has made much progress in maternal health outcomes. Notably, 79 percent of pregnant women attend at least one antenatal care visit and 87 percent deliver with a skilled provider (DHS, 2012). However, access to and utilization of the coverage of maternal and reproductive health services remains limited in rural areas as rural households face considerably greater transportation costs and other costs associated with reaching health facilities. Conversely, child malnutrition persists with 26 percent of children under five being stunted and 53 percent of children aged 6-59 months being iodine deficient (DHS, 2012). In addition, acute respiratory illness, pneumonia, and acute diarrhea still account for more than 50 percent of reported child deaths within the first year of life - a pattern that remains unchanged since 2004.
Further, despite the many efforts to improve the financing, capacity and physical infrastructure of primary health care (PHC), critical gaps persist in the quality of care. A recent study on the quality of child health services in Tajikistan found that the quality of PHC services provided to children is lacking in many areas, irrespective of providers' training. For instance, only 46 percent of sick children were assessed as per the recommendations of the Integrated Management of Childhood Illness (IMCI). Additionally, at least 60 percent of surveyed PHC facilities did not have the recommended supplies and equipment, and a significant proportion did not have essential antibiotics to treat common childhood illnesses (World Bank, 2013). All these factors contribute towards the poor health outcomes seen in Tajikistan particularly for women and children.
RBF AT A GLANCE
The Health Service Improvement Project uses performance based financing (PBF) to improve the coverage and quality of basic primary health care (PHC) services in rural health facilities in ten districts in the Rayons under Republican Subordination (RRS), Khatlon and Sogd regions of Tajikistan. The Project includes 449 health facilities (Rural Health Centers and Health Houses), roughly covering 15 percent of the country’s population. Under this supply-side scheme, the Ministry of Health (MOH) contracts Rural Health Centers and their subsidiary Health Houses to enhance both the quantity and the quality of maternal and child health and non-communicable disease services. Related PBF payments are disbursed quarterly by the Ministry of Finance, and are supplementary to the funds routinely received from public sector budgets. These payments can be used to provide staff bonuses as well as to purchase supplies and minor equipment. Throughout 2015-2016 a total number of 2180 health workers have received PBF bonuses in the project districts.
The ex-ante RBF verification (i.e. prior to payment) is led by the State Health Activities Supervision Service (SHASS) and implemented by District PBF Verification Teams. This verification is carried out quarterly in all PBF facilities to assess the accuracy of reported performance: it reviews facility registries and reports as well as administers a quality checklist.
The ex-post RBF verification (i.e. after payment) is led by UNICEF who carries out semi-annual independent assessments in a sample of PBF facilities. This verification seeks to ensure accurate reporting, as well as accurate incentivization and, if necessary, penalization. It includes home visits and phone calls to ascertain services have been delivered as reported; reviews of facility records/registers, and the implementation of a quality checklist.
Status and achievements
The Health Service Improvement Project piloted PBF in one district from April to December 2014. This piloting experience indicated improvements in ten of the PBF quantity indicators, including contraceptive use, number of children fully vaccinated, and number of postnatal visits.
The supply-side PBF scheme was rolled out in seven additional project districts starting January 2015. In April 2015, an additional financing for HSIP of US$10 from IDA credit was negotiated with the government to finance expansion of the PBF scheme to additional two districts. The AF was approved by the Board in June 2015 and two new districts were enrolled in the PBF scheme as of January 2016.
Throughout the implementation period, the project pays a close attention to continuous learning and improvement. After two years, a revised manual and accompanying revised database were launch, in January 2017. Among the changes instituted by the revised manual are: (i) higher weights on clinical quality sub-categories; (ii) replacing “malnutrition detected” with “growth monitoring” to preempt the potential perverse incentive in over reporting malnutrition; and (iii) revision in the family planning indicators to capture both new and current users of contraceptive. The revised manual and its accompanying revised database also force SHASS to apply careful and elaborate attention in its verification.
- Engagement at all levels of the health system is necessary to ensure buy-in into the design and institutional setup of RBF. Early engagement is vital, especially to foster commitment from the Ministry of Finance.
- Conducting a stakeholder analysis at the onset provides critical insights on existing dynamics and on the ways to mobilize stakeholders throughout the PBF process.
Continuous learning and adjusting is key for improvement.
EVALUATION AT A GLANCE
The impact evaluation will focus on assessing the impact of PBF on health service coverage, the quality of care and health outcomes in rural health centers.
The baseline survey was completed and results were shared with the Ministry of Health in April 2016.