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Tajikistan : Tajikistan Health Profile 2012

2012/04/05

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Tajikistan Health Profile 2012

Tajikistan is the poorest of the former Soviet republics. It declared its independence on 9 September 1991, and has not yet fully recovered from the civil war of the 1990s. In 2007, about 74% of its 6.7 million population lived in rural areas. Tajikistan has a very young population. In 2007, 38% were below 15 years of age. Outmigration has been considerable: it is believed that up to 2 million Tajik citizens are currently working abroad, mostly in the
Russian Federation.
Although Tajikistan was always one of the poorest countries in the Soviet Union, the country suffered a particularly severe economic decline and collapse of social infrastructure when the Soviet Union dissolved, which was followed by several years of civil war. Tajikistan is one of the few countries that have quickly moved from civil war to internal stability and economic growth. As in the Soviet period, cotton and aluminium production continue to dominate Tajikistan’s economy. Poverty levels remain high. Tajikistan’s population faces a double burden of both high noncommunicable and communicable disease rates. Infant and maternal mortality rates are among the highest in the WHO European Region and malnutrition is a major public health concern. In the latest stage of health reform, many policy documents were adopted by the Government in the context of poverty reduction and attempts to reach the Millennium Development Goals.

Organizational structure
Tajikistan’s health system has evolved from the Soviet model of health care, with so far few structural changes. The Ministry of Health is responsible for national health policy, but has no control over the overall health budget, and directly manages only (most) health facilities at the national level. Local authorities are responsible for most social services, including health and education. The oblast health departments (Gorno-Badakshan Autonomous Oblast (GBAO), Khatlon and Sughd) are responsible for the health care provision of oblast-owned health care facilities and, together with the executive local authorities (khukumats) of cities and rayons, the activities of city and rayon health facilities within the respective oblasts. Although professional associations have no major role in health policy-making, physicians influence national health policy in more informal ways. Although growing, the number of private health care providers is still low.

Financing
So far, the state remains the main public funder and provider of health care services in Tajikistan. Private out-of-pocket payments, however, are believed  to be far larger than public sources of revenue, accounting for an estimated 76.2% of total health care expenditure in 2007, one of the highest percentages in the WHO European Region. In 2008, the total public budget for the health sector was equivalent to only US$ 10.6 per capita. External sources of funds contributed to about 10% of total health funding in 2007. The use of health care funds has traditionally been biased towards hospital services. Health financing reform started in 2005. The focus has been on diversifying sources of funding, such as through introducing formal co-payments, defining a guaranteed package of health services to align commitments to free health care with available resources, and introducing population and activitybased health budget formation. A first basic benefit package was introduced in 2005, but then suspended after two months. A new basic benefit package was introduced in 2007 in four pilot rayons and has since been extended to eight rayons. In another pilot scheme, fee-for-service payments have been introduced
in six hospitals of the country. In 2009, the average monthly salary for health care workers was US$ 38, compared with a workforce average of US$ 65.

Regulation and planning
Since Tajikistan’s independence in 1991, the Tajik Government has taken over the role of developing and implementing national health policies. While private medical practice has been permitted, the growth of the private sector has been slow and it has been largely confined to pharmacies, dental care and small diagnostic facilities. While the Government remains the main provider of health care services, most health expenditure is covered through private out-ofpocket payments. Tajikistan has a hospital-centred service management structure, and the central management of most health services is located in hospitals. In pilot districts, however, the Government has devolved administrative functions to primary health care providers and has established new channels of financing. Health planning in Tajikistan remains focused on the budgetary process. The process of budget formation in Tajikistan continues to follow mechanisms inherited from the Soviet period, with an emphasis on inputs and staffing rather than on quality and outputs.

Physical and human resources
Tajikistan has inherited a health system from the former Soviet Union that is comprehensive but inefficient. It is highly specialized, with an emphasis on curative and inpatient care, while primary care has been neglected until recently. There is a serious misbalance in the distribution of health facilities and the allocation of budgetary funds between primary health care and hospital care, with the bulk of funding going to secondary health care, while the services provided there are expensive and out of reach for the poor. The ratio of acute care hospital beds has declined since independence, but still remains above the level seen in western Europe. Most health facilities in Tajikistan were constructed in the period 1938–1980, and their condition has deteriorated sharply since the country’s independence, through the almost complete lack of investments in refurbishments or the purchase of new equipment. Tajikistan has less health care professionals per capita than other countries in central Asia. Physicians are mainly specialized, but more and more are being retrained to become family physicians. The intention is to also upgrade and expand nurse training. There has been a major brain drain, with health care workers moving abroad. Staff are unequally distributed, both functionally and geographically. Physicians are concentrated in the capital, Dushanbe, while the density of all staff categories (except feldshers) is lowest in Khatlon oblast and the rayons of republican subordination.
 
Principle health care reforms
Health reform in Tajikistan has fallen behind reforms in other central Asian countries. The country has now embraced a comprehensive reform agenda, aiming to strengthen primary health care, reform health care financing, develop human resources, rationalize the hospital sector, improve quality of care, strengthen management capacity and foster personal responsibility for health. Major financial, structural and institutional changes will be needed to achieve these aims.
The introduction of the basic benefit package and co-payments signalled a change from an input-based finance system towards a financing mechanism based on capitation and cases. Pilots of primary care reform, introducing
per capita financing, are under way in three of the country’s oblasts.
 
Assessment of the health system
There are marked inequities in Tajikistan’s health system with regard to both finance and the distribution of services and resources. The costs of health care place a major economic burden on the population, and poverty presents a significant barrier to accessing health services. Physical barriers play an important role in remote mountainous regions, where road conditions are poor, means of transport limited and many communities cut off for months during the winter season.
There is a serious imbalance in the distribution of the material base and budget funds between primary health care and hospital services, as a result of which the bulk of funding still goes to hospitals. Plans to increase the budget allocation to the primary care sector have still to be implemented. Quality of care is another major concern, which is affected by the lack of investment in health facilities and technologies, an insufficient supply of pharmaceuticals, poorly trained health care workers, and a lack of medical protocols and systems for quality improvement.
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