This post was co-authored with Wezi Marianne Msisha, Senior Health Specialist, World Bank.
In Tajikistan, primary health care (PHC) accounts for just 27 percent of public health spending and yet PHC accounts for over 70 percent of all referrals and health visits across the country.
Given this imbalance, in April 2014 the country launched the pre-pilot of a new PHC financing mechanism, using a Performance-Based Financing (PBF) approach, which should significantly improve the quality and coverage of PHC services. The pre-pilot phase focuses primarily on the prevention and early detection of maternal and child health (MCH) related diseases and non-communicable diseases.
The PBF pilot started with 17 health facilities of Spitamen district of Sughd Region of Tajikistan, covering over 104,000 people, in April 2014.
Less than a year since it launched, Spitamen District is already reporting success. The new mechanism encourages health workers to proactively conduct preventive activities in the community, plan and analyze their work more accurately and follow clinical protocols closely.
According to Ms. Qaromat Niyozalieva, Deputy Manager of the Spitamen District Health Centre, the new financing mechanism has already brought systemic changes both to the operation of health facilities in general and to the behavior of each of their workers in particular.
“Home visits have improved: doctors and nurses now communicate more with their patients at patients’ homes, learn households’ environment and atmosphere in the family, and this impacted the quality of periodical health screening. The performance has improved against all indicators: more patients have been detected and registered, preventive measures are being taken. And the health workers themselves are different now—they became well groomed and careful,”—she notes.
On average, the pre-pilot health facilities have demonstrated a 75 percent improvement in performance against the quality indicators. The quantity of services delivered in the second quarter of the pilot have also improved significantly compared to the first quarter, resulting in a four-fold increase in the amount of incentives earned by the facilities in the second quarter.
Mr. Hasanboy Karimov, Director of one of the pre-pilot Rural Health Centres, says that though not much time has passed to be able to accurately estimate the new system’s impact on health outcomes, some data do indicate that such impact will be positive.
“We have improved the periodical health screening, postpartum care, detection of hypertension patients and malnourished children. A benefit is that we now can purchase equipment to further improve our work, buy reagents for our laboratories, carry out repairs when needed, and, which is also important, PBF gives rise to healthy competition, passion among health workers—this means they strive to enhance their abilities.”
A similar opinion was expressed by Ms. Sabiha Normatova, a family doctor from another Rural Health Centre.
“I am happy to have PBF introduced in our facility; this is a positive moment in health workers’ activity. We have increased the number of adults detected with hypertension, and diabetes, as well as catching malnutrition in children early. . We have intensified our family planning activities, introduced new contraception registries, and increased visits to postpartum women and newborns.”
Ms. Normatova also notes that for her as a doctor and for colleagues who directly work with the community, this system is more convenient as it potentially brings more income for their effort.
“We are happy that PBF will do away with wage-levelling. Thanks to this system, we now can fully demonstrate our capabilities and potential. And this will not be in vain as this will affect our salaries.”
Tajikistan is pinning its hopes on this new mechanism. The PBF pilot was scaled up in January 2015 to cover another seven districts, in Sughd and Khatlon Regions, serving roughly 25 percent of Tajikistan’s population. Among other things, there are hopes in the country that PBF will in future change the current situation where the level of PHC spending is proportionate to the financial position of a district—the poorer the district, the less it spends on PHC—to one where spending is better aligned with what the people need, regardless of where they live.
The Ministry of Health of Tajikistan is optimistic that every single person in the nation’s population of 8 million will feel the impact of the reform very soon.