The interview was originally published in Jumhuriyat 4 June, 2019 (read in Tajik)
Could you please provide a brief information on the "Health Services Improvement Project"? How do you assess the implementation (i.e. outcomes) of this Project and what specific improvements you have noted in the target (pilot) district /areas?
The project has yielded really good results so far. 37 new rural health centers are being built and equipped across the country, including in Farkhor, Yavan, J. Balkhi, Dangara, Devashtich, J. Rasulov, Mastchoh, Fayzabad, and Ishkoshim districts. Over 10,000 healthcare staff have received training, including in effective care of mothers, children and adults with high blood pressure. The proportion of pregnant women who have received regular care during their pregnancy from their primary care clinician – which makes pregnancy and birth safer for mothers and children - is now nearly 100% in project districts. The average quality of care delivered in project facilities has improved by over 20% in rural health centers and over 30% in health houses. In total, more than one million people or 14% of the population of Tajikistan have benefitted from the project’s activities, particularly women and children.
The World Bank and Tajikistan have been partnering for over 25 years to strengthen healthcare for the population of Tajikistan. The “Health Services Improvement Project” is a good example of how this partnership is helping to improve service delivery in primary healthcare, particularly in rural areas of the country. It is financed by the World Bank and the Health Results Innovation Trust Fund at the amount of US$33 million and implemented by the Ministry of Health and Social Protection of the Population of Tajikistan.
By providing training to medical personnel, constructing and equipping healthcare facilities and, most importantly, by providing hands-on guidance and incentive payments to health workers for better results through an approach called “performance-based financing”, the project aims to increase both the coverage and the quality of basic primary health care services.
Given that over 75 percent of Tajikistan’s population lives in rural areas, it is important that quality health services are important in rural health facilities and people do not have to travel to the district health centers or hospitals for high quality care.
Training of Family Doctors, Regional Clinical Center for Family Medicine, Khatlon Oblast, Tajikistan
We know that the Performance Based Financing (PBF) mechanism was rolled out within the framework of the HSIP project: PBF is a unique financing mechanism successfully implemented in many countries. Could you, please, briefly tell us on the PBF?
The so called “performance-based financing” (PBF) – is designed to reward primary health care workers and facilities for their good performance – but only after it is confirmed that they have successfully met pre-agreed targets. The results reported by health care facilities are checked and verified rigorously every quarter before they can receive incentive payments.
The PBF creates incentives to improve the quality of care. It is a way to motivate clinical teams who are working exceptionally hard and providing better and greater care to their patients. This is especially important in countries where the average salary of public sector workers is relatively low.
Under this project, 450 primary care facilities in ten districts of Khatlon and Sughd regions are implementing the PBF approach, including Devashtich, J. Rasulov, Maschoh, Spitamen, J. Balkhi, Kabadiyan, Farkhor, Yavan, Dangara, and Fayzabad. 70% of the received bonuses by the facilities can be distributed as payments to clinical staff, and 30% can be used by the manager to improve conditions in the facility, e.g. for minor repairs, or buying drugs and equipment.
Counselling session, Rural health center, Yovon district, Tajikistan
Some time ago the World Bank completed an impact assessment of the PBF in Tajikistan? Would you mind sharing with us the results of this assessment?
Yes, we undertook a study that compared results in project districts in which the “Performance Based Financing” approach was piloted with project districts without PBF. districts of the country. We visited rural health centers, health houses, and families in these districts before the PBF pilot started and again after three years.
The results showed significantly improvement in many aspects of quality of care in the districts where PBF was piloted. For example, the proportion of facilities that had piped water increased by almost a fifth due to PBF. Facilities receiving PBF also had greater availability of equipment and drugs compared to facilities without PBF. Staff in facilities receiving PBF were more likely to provide better quality care, for example measuring blood pressure in patients with high blood pressure. We found primary care nurses and doctors were significantly more satisfied with their jobs. Families noticed the improvement in quality of care and were more likely to report that rural health centers work closely with the community and the staff is competent.
Overall, the results in Tajikistan are similar to other countries’ experiences with PBF: better quality of care, but mixed results on the use of care. Indeed, Tajikistan has experienced one of the strongest impacts on quality of care among countries that have introduced PBF. But additional measures are needed to encourage people to come to use primary care services.
Why has PBF been successful in improving quality of care?
PBF has been successful in improving quality of care, as it motivates health workers to use their skills and knowledge to achieve results. It also gives primary care managers autonomy over a portion of their budget to buy key inputs needed to deliver health services. Finally, as the budget allocated to primary care is low in Tajikistan, it increases the overall resources for priority health services.
In your opinion, what is the future of the PBF in Tajikistan? Will it be rolled out in other districts/rayons of the country?
At the moment, the government of Tajikistan is reforming the way primary care is funded by rolling out per capita financing. This means that instead of a fixed budget per district, now primary care facilities will have their budget adjusted for the number of people served by that facility and its location. So primary care facilities with a bigger or more remote population will have more resources to treat their patients, which is an excellent approach.
The PBF pilot has shown that the quality of primary care services can be improved for patients when performance of health workers is rewarded. We hope that these reforms to primary care funding will include a performance-based element so that teams which are delivering better quality care will continue to be rewarded.
What does the World Bank plan for the health sector in the Republic of Tajikistan?
Because of the positive results under the Health Services Improvement Project, we’re discussing an extension of the project to focus on child health specifically.
Tajikistan has the youngest and fastest growing population in Central Asia, so investments in the health of children and young people are critical.
The World Bank’s Human Capital Index shows that a child born today in Tajikistan is expected to be 53 percent as productive when he or she grows up compared to a situation in which he or she enjoyed complete education and full health. It means that a lot more needs to be done to ensure that today’s children will grow up healthy, educated and productive, able to compete and succeed in the future. There is strong evidence from countries around the world that investments in the early years of children’s lives are some of the most cost-effective a country can make for future prosperity. So, we are now working with the government of Tajikistan on a new project on early childhood development.
The World Bank Group and Tajikistan just launched a new partnership strategy for 2019-23, which will among other things focus on investments in human capital. The World Bank Group is committed to continuing its support to the country, as it strives to improve the lives and meet the aspirations of its young and growing population.