12323143.Pdf

Ministry of Health and Social Protection of Population The Republic of Tajikistan

PREPARATORY SURVEY REPORT ON THE PROJECT FOR IMPROVEMENT OF AMBULANCES IN THE REPUBLIC OF TAJIKISTAN

DECEMBER, 2018

JAPAN INTERNATIONAL COOPERATION AGENCY

CONSORTIUM OF BINKO INTERNATIONAL LTD. HM AND JR KOEI RESEARCH AND CONSULTING CO.,LTD 18-063

PREFACE

Japan International Cooperation Agency (JICA) decided to conduct the preparatory survey and entrust the survey to the Consortium of Binko International Ltd. and Koei Research and Consulting co., Ltd.

The survey team held a series of discussions with the officials concerned of the Government of Tajikistan, and conducted field investigations. As a result of further studies in Japan, the present report was finalized.

I hope that this report will contribute to the promotion of the project and to the enhancement of friendly relations between our two countries.

Finally, I wish to express my sincere appreciation to the officials concerned of the Government of Tajikistan for their close cooperation extended to the survey team.

December, 2018

Ms. Mitsuko KUMAGAI Director General, Human Development Department Japan International Cooperation Agency

SUMMARY

1. Overview of the Country The Republic of Tajikistan (Tajikistan) is located in the middle of the Eurasian continent, in the northeast part of Central Asia, bordered by Uzbekistan to the west, Uzbekistan and Kyrgyzstan to the north, People's Republic of China to the east, and Afghanistan to the south. Tajikistan’s capital city is Dushanbe, its area is about 143,100 square kilometers (about 40% of the Japan), 93%1 of the land is mountainous, half of it is above 3,000m, and the eastern border with China is part of the Pamir Plateau, which reaches an elevation of 7,000m. The altitude of the capital Dushanbe is not very high around 700 - 800 m, the Fergana Basin in the northwest is the lowest in the entire region, around 300 to 500 m above sea level, bordering Uzbekistan and Kyrgyzstan. On the other hand, the altitude of Khorog, the provincial capital of the Gorno-Badakhshan Autonomous Oblast2 (GBAO) in the Pamir region exceeds 2,000m above sea level. The total extension of domestic railroad is about 680km, connecting the metropolitan area of the west part of Tajikistan and neighboring countries Uzbekistan and Turkmenistan. The main road is about 30,000km, most of which was built before 1991 during the Soviet Union period. The road connecting the northern part and the southern part, which is one of the main highways, connects Dushanbe to the northwestern Khujand beyond the mountains. The main highway extending to the east connects Dushanbe to Khorog of the GBAO and continues to the north-eastern part beyond the mountains and goes to the neighboring Kyrgyz’s Osh. Tajikistan is landlocked, the climate is continental climate, and it varies with altitude. Temperatures in urban areas such as the capital Dushanbe and Khujand rise beginning April, and in the summer, it gets hot. The average temperature in July is 32°C, sometimes over 40°C. From December to February, the temperature will be below 0°C and snow piles up. Dushanbe's average winter temperature is 9°C and daily highest temperature reaches 13°C in December-January. On the Pamir Plateau, the average temperature in January is -18°C and the average temperature in July is 14°C at an altitude of 3,600 m. The population is 8.9 million (2017: United Nations Population Fund), the ethnic composition is Tajik (84.3%), Uzbek (12.2%), Kyrgyz (0.8%), Russian (0.5%) and others (2.2%)3. The official language is Tajik, but Russian is also widely used. In 1991, the country became independent from the Soviet Union. Overall standard of living declined due to a civil war after independence. Since the civil war came to an end with Comprehensive Peace Agreement signed in June, 1997, the economy has begun to grow, but the unemployment rate is still high, and the economic situation is severe. The International Monetary Fund and the World Bank are working together to promote economic growth and development. Since the global financial crisis in October 2008, the impact of the economic recession in the economically relevant Russia and Kazakhstan reduced the remittances from overseas migrant workers and slowed the growth of Gross Domestic Product (GDP). In the primary industry, major industries are agriculture mainly in cotton cultivation, pastoralism, in the secondary industry the textile industry is relatively developed. Although small, it has mineral resources such

1 www.maff.go.jp, Japanese Ministry of Agriculture, Forestry and Fisheries, accessed in October 2018. 2 Oblast is a type of administrative division in several post-Soviet states. The word "oblast" is also translated as "region" in this text. 3 Agency for Statistics under the President of the Republic of Tajikistan

as gold, silver, copper, molybdenum and antimony. In addition, it has abundant water resources and one of the major industries is hydroelectric power generation. GDP is 7.3 billion dollars, while inflation rate is 7.3%4.

2. Background and Outline of the Project Under the "National Development Strategy (NDS) 2016-2030", Ministry of Health and Social Protection of Population (MoHSPP) formulated a national health plan, so-called "National Health Strategy (NHS) 2010- 2020". The health plan sets priority on improving the quality, access and efficiency of health services. Also, one of the priority targets is to secure effective emergency medical service accessible to all people. “Order of the Ministry of Health of the Republic of Tajikistan No.33” (MoHSPP, Order No.33)5 for the improvement of ambulances aims at the deployment of one vehicle per 10 thousand people. However, as of 2016, the deployment rate remains approximately 30% of the target which is 270 vehicles among 8.7 million people. In Tajikistan, Non-Communicable Diseases (NCDs) account for 60% of all causes of death. Among them, there is an increase in the number of deaths due to cardiovascular diseases and traffic trauma, and they require sudden and urgent measures. (From 1997 to 2005, cardiovascular disease deaths increased 41%, traffic accident death 32%). There is a growing demand for emergency medical services to carry out appropriate and prompt treatment in close proximity to patients during transportation. Although the index of maternal and child health is improving, newborn, infant and maternal mortality rates are still high (neonatal mortality rate 20/thousand live births, infant mortality rate 37/thousand live births, maternal mortality rate 32/100 thousand live birth). It is an urgent matter to strengthen the medical cooperation system to promptly provide health care services to children and pregnant women who susceptible to sudden changes in health conditions. Over 70% of existing vehicles are more than 10 years of age, and the models are mixed, 2-Wheel-Drive vehicles (2WD), and 4-Wheel-Drive vehicles (4WD) manufactured in Russia, Korea, China, Germany, and France. These vehicles are aged and failure occurs frequently. Also, due to lack of on-board equipment, there is no option but to bring hospital equipment during emergency dispatch. Most of Tajikistan’s land is mountainous with many unpaved roads, and the road surface becomes mud/frozen during the rainy season and the snowfall season. Therefore, it is urgent issues to improve and provide with 4WD that can access remote areas such as mountains and deployment of on-board equipment for emergency life-saving measures during transportation.

3. Project summary In the capital city, Dushanbe where multiple target facilities are located, emergency referral system is effectively functioning because there is a telephone system for requesting ambulances and a high ratio of paved roads. On the other hand, medical facilities in rural areas, which are mountainous and with unpaved roads, have difficulty in providing quick emergency medical service unless the vehicle type is a 4WD. Under the Project for Improvement of Ambulances (the Project), different types of vehicles and on-board equipment will be deployed taking into consideration of characteristics of emergency medical service of the target facilities such as contents, scope and scale of activities, and considering long transportation hours, bad road

4 IMF estimation, 2017 5 Order of the Ministry of Health of the Republic of Tajikistan No.33 dated January 28, 2010, “On improvement of first medical aid and emergency medical care management”

conditions, and necessity for emergency treatment during transportation. Implementation of the Project aims at improving the performance of ambulances and on-board equipment, thereby improving access to health care facilities and quality of emergency medical service. The Project plans to deploy a total 94 ambulances consisting of 83 replacement and 11 supplemental. In addition, it is planned to improve on-board equipment such as Defibrillator, Pulse Oximeter, and Suction unit etc. Thus, strengthening of emergency service system enables the provision of quick emergency treatment during transportation. The below Table i shows the specification of ambulances, the number of planned ambulances by type, and the outline of on-board equipment.

Table i Content of Plan (ambulance) Main Deployment destination Purpose of use Quantity Specification Central District Hospitals, Oblast Transportation of emergency Hospitals, etc. Ambulance, patients at city / Oblast and 4WD Rayon6 level hospitals, 86 Type A patient transport between medical facilities Oblast Hospitals Accommodation of Dushanbe city Clinical Hospital of Ambulance, emergency patients, Emergency Medical Aid 4WD / 2WD transportation of patients 8 National Medical Center Type B between medical facilities Research Institute of Obstetrics, and Sanitary aviation7 Gynecology and Perinatology, etc. Source: Survey Team

According to MoHSPP, Order No. 33, Type A ambulances are mainly deployed in Central District Hospitals and Oblast Hospitals for patient transportation. On the other hand, Type B ambulances are mainly deployed in urban areas, and are used for sanitary aviation in addition to patient transportation.

6 Rayon is a type of administrative unit of several post-Soviet states. The word "rayon" is translated as "district" in this text. 7 Depending on the patient's condition, medical specialists are to be dispatched to medical institutions that can give emergency response or transport patients to well-equipped facilities.

iii

Table ii Content of Plan (Equipment with ambulance) Ambulance Equipment Purpose of use Quant. Classification Resuscitation set Used to assist respiration to shallow spontaneous patients, 94 (manual) providing breathing assistance with oxygen inhalation etc. Ambulance Used to deliver an electric shock to rescue the patient from 94 Type A, Type B Defibrillator the lethal cardiac arrhythmia such as Ventricular fibrillation, and Cardiac failure. Ambulance Suction unit Used for suction of body fluids such as sputum. 8 Type B Used for measurement of oxygen concentration in the 8 Pulse Oximeter patient’s blood during transportation Used like a shovel to rescue the victim from an accident 8 Scoop Stretcher scene such as a slope, and transport it as a tanker ECG Used to observe the activity of a patient’s heart during 8 transportation. Ambulance Used for the observation of vital signs such as heartbeat, 1 Type B Patient Monitor ECG, body temperature, respiration of the patient during (Obstetrics and transportation. gynecology Infant Incubator Used for transportation of neonates between medical 1 institute) (for transportation) facilities.

4. Project Schedule and Cost Estimate When the Project covered here is implemented under the Japanese grant aid, it takes 4 months for detailed design and bidding and 10.0 months for procurement and construction supervision, totaling 14.0 months. In addition, it takes 0.5 months from the beginning to the end of the soft component. The total cost to be borne by the Tajikistan side is estimated at approximately 2 million yen.

5. Project Evaluation 5-1 Relevance The Project relevance for implementation under the Japanese Gant Aid Project is as follows.

(1) MoHSPP aims to "secure effective emergency medical services accessible to all people" which enables them to receive medical service promptly and effectively in each area. However, many of the ambulances needed for patient transportation have become unusable due to breakdown from aging, accidents, etc. Meanwhile the demand for emergency medical services is on the increase because of increase in NCDs and the change of traffic environment. Therefore, there is urgent need for provision of ambulances in this situation. Through provision of ambulances, the Project plans to help with the establishment of the emergency medical service system. (2) The Project does not include advanced equipment. As the types of equipment to be procured are already in use in the country and the maintenance systems already established, it can be operated and managed by a minimal addition of personnel and can be used effectively for a long time. (3) The Project beneficiary areas are the whole of Tajikistan, and the beneficiary population is the general people of the country, which is approximately 8.9 million people. This means that the Project will be beneficial to Tajikistan.

(4) The goal of the Project is “securing effective emergency medical service accessible to all people” for the public. It is in line with the aim of ensuring Basic Human Needs (BHN) through “improvement of health services” stipulated under the priority area “social development” in the assistance policy of Japan. In addition, the development of a nationwide emergency medical service network through the Project is expected to ensure the rapid provision of ambulance services for inhabitants in remote areas and improve their access to the services.

5-2 Effectiveness The implementation of the Project will enhance the emergency medical service system pertaining to the transportation of emergency patients, and the following quantitative and qualitative impacts can be expected.

(1) Quantitative impacts (Indicators showing the achievement of the Project)

Table iii Quantitative Impacts Target value (2022) Baseline Indicators (3 years after the Project (Actual value as of 2016) completion) 1. Number of emergency dispatch in Rayon, City, and Oblast (case)

Target facilities under the Project*1 499,926 570,000

2. Number of emergency dispatch of the facilities where vehicles are supplemented

Khatlon Region (Kulob) 0 1,800

GBAO Region（General Hospital） 0 1,500

GBAO Region (Maternity Hospital) 0 1,500 *1 The emergency transportation cases (6,767 cases) in Sughd Oblast, Istiqlol, Buston and the emergency transportation cases (3,177 cases) in GBAO, Murghob, Roshtqala, Shughnon were excluded from the reference values, since they are not targeted facilities of the Project.

(2) Qualitative Effects 1. The scope8 and type9 of emergency medical services will be expanded and upgraded through replacement of vehicles and on-board equipment. 2. The replacement of vehicles and on-board equipment will enable medical personnel to provide safe emergency medical services. 3. Emergency medical services can be provided timely and appropriately during emergency transportation.

8 With the introduction of 4WD suitable for bad roads, it is possible to accommodate patients at mountainous emergency sites even during snowfall. 9 In some facilities, it is possible to transport premature babies and observe vital signs of patients during transporting them.

CONTENTS

PREFACE

SUMMARY

LOCATION MAP

LIST OF FIGURES & TABLES

ABBREVIATIONS

Chapter 1 Basic Concept of the Project

1-1 Background of the Project ...... 1 1-2 Situation of project site and surroundings ...... 1 1-2-1 Natural Conditions ...... 1 1-2-2 Social and Environmental Considerations ...... 2

Chapter 2 Contents of the Project

2-1 Basic Concept of the Project ...... 3 2-1-1 Overall Goals and Project Purpose ...... 3 2-1-2 Project summary ...... 3 2-2 Outline Design of the Japanese Assistance ...... 4 2-2-1 Design Policy ...... 4 2-2-2 Basic Plan (Equipment Plan)...... 6 2-2-3 Outline Design Drawing ...... 35 2-2-4 Implementation Plan ...... 36 2-2-4-1 Implementation Policy ...... 36 2-2-4-2 Implementation Conditions ...... 36 2-2-4-3 Scope of Works ...... 37 2-2-4-4 Consultant Supervision ...... 37 2-2-4-5 Quality Control Plan ...... 39 2-2-4-6 Procurement Plan ...... 39 2-2-4-7 Operational Guidance Plan ...... 40 2-2-4-8 Soft Component Plan ...... 41 2-2-4-9 Implementation Schedule ...... 42 2-3 Obligation of Recipient country ...... 44 2-4 Project Operation and Maintenance Plan ...... 45 2-5 Project Cost Estimation ...... 46

2-5-1 Initial Cost Estimation ...... 46 2-5-2 Operation and Maintenance Cost ...... 46

Chapter 3 Project Evaluation

3-1 Preconditions ...... 49 3-2 Necessary Inputs by Recipient Country...... 49 3-3 Important Assumptions ...... 49 3-4 Project Evaluation ...... 50 3-4-1 Relevance ...... 50 3-4-2 Effectiveness ...... 51

APPENDICES

1. Member List of the Survey Team 2. Survey Schedule 3. List of Parties Concerned in the Recipient Country 4. Minutes of Discussions (M/D) 5. Soft component plan 6. References 7. Other materials / information

LOCATION MAP

0 25 50km

LIST OF FIGURES & TABLES

No. Description Page Figure 1-1 Climate of Tajikistan, Dushanbe and Khorog 2 Figure 2-1 Site Map 35 Figure 2-2 Implementation Schedule 43

Table 2-1 Planned Number per Ambulance Classification of Function 7 Table 2-2 Calculation Criteria for the Number of Ambulance Deployments 11 Table 2-3 Result of Examining the Requirement 12 Table 2-4 Plan of Ambulance Type and On-board Equipment 27 Table 2-5 Ambulance Deployment Evaluation and Distribution List 30 Table 2-6 Recommended Ambulance On-board Equipment 32 Table 2-7 Main On-board Equipment 33 Table 2-8 Main Specification of Ambulance and its Purpose of Use 33 Table 2-9 Main Specifications of the Equipment to be Procured and Purpose of Use 34 (Equipment with ambulance) Table 2-10 Major Undertakings to be Taken by Japan and Tajikistan Sides 37 Table 2-11 Commissioning and Operation Training for Ambulances 40 Table 2-12 Estimated Cost to be Borne by Tajikistan side 46 Table 2-13 Estimated Costs of Operation and Maintenance (Fuel costs) 47 Table 2-14 Estimate of O&M Costs (Labor and Consumables) 47 Table 3-1 Quantitative Impacts 51

ABBREVIATIONS

Abbreviations Official Name A/P Authorization to Pay B/A Banking Arrangement BHN Basic Human Needs CT Computed Tomography DRS District of Republic Subordination E/N Exchange of Notes G/A Grant Agreement GDP Gross Domestic Product GMP Good Manufacturing Practice JICA Japan International Cooperation Agency MoHSPP Ministry of Health and Social Protection of Population MRI Magnetic Resonance Imaging NCDs Non-Communicable Diseases NDS National Development Strategy NHS National Health Strategy UHC Universal Health Coverage VAT Value Added Tax 2WD 2-Wheel-Drive vehicles 4WD 4-Wheel-Drive vehicles

CHAPTER 1 BACKGROUND OF THE PROJECT

Chapter 1 Basic Concept of the Project

1-1 Background of the Project In the Republic of Tajikistan (Tajikistan), Non-Communicable Diseases (NCDs) account for 60% of all causes of death. Among them, there is an increase in the number of deaths due to cardiovascular diseases and traffic trauma, and they require sudden and urgent measures. (From 1997 to 2005, cardiovascular disease deaths increased 41%, traffic accident death 32%). There is a growing demand for emergency medical services to carry out appropriate and prompt treatment in close proximity to patients during transportation. Although the index of maternal and child health is improving, newborn, infant and maternal mortality rates are still high (newborn mortality rate 20/thousand births, infant mortality rate 37/thousand births, maternal mortality rate 32/100 thousand birth). It is an urgent matter to strengthen the medical collaboration system to promptly provide health care services to children and pregnant women who susceptible to sudden changes in health conditions. Although the emergency service system of the Tajikistan was maintained in the former Soviet Union era, more than 80% of the domestic ambulances were lost due to the civil war after independence in 1991. The country's ambulances are used to transport patients in response to requests from citizens and to transport patients from lower medical facilities to higher medical facilities. However, due to insufficient number of ambulances, etc., it is not possible to utilize ambulances at the appropriate time, patients are forced to go to hospitals by themselves using general vehicles such as private cars and taxis, and due to insufficient onboard equipment in ambulances many cases of death prior to hospital arrival have been reported. As of 2016, there were about 270 ambulances throughout the country against the total population of 8.9 million people. The number does not meet the national standard for deployed ambulances (1/10 thousand people) as well as the standard for on-board equipment. Also, most of the existing vehicles have been in service for 10 to 20 years or more since procurement, both vehicles and onboard equipment have deteriorated due to aging and frequent failures have occurred, there is urgent need to improve the quality and quantity of ambulances. The country’s “National Health Strategy (NHS) 2010-2020” sets priorities on improving the quality, access and efficiency of health services, and focuses on securing effective emergency medical services that are accessible to everyone. The ambulance improvement plan will provide ambulances and onboard equipment such as defibrillators, ventilators, etc., to areas with few ambulances, have obsolete ambulances or areas targeting emergency medical care. It is positioned as a high priority project in the country's National Development Strategy (NDS) aiming at achieving Universal Health Coverage (UHC).

1-2 Situation of project site and surroundings 1-2-1 Natural Conditions The climate of Tajikistan 's capital, Dushanbe is similar to that of northern part of Japan. The handover of the ambulance will be done in the capital Dushanbe, and the Tajikistan side will then transport them to each site. The temperature drops to around 11°C to 13°C below zero in winter, and traffic is disrupted due to heavy snow, road freezing, etc., in mountainous areas. Hence it is best to make the delivery in spring to summer period. Develop an implementation plan with temperature conditions in mind.

The following graph shows the annual temperature change in the capital Dushanbe (left) and the state capital Khorog of Gorno-Badakhshan Autonomous Oblast1 (GBAO) (right).

(Temperature) Dushanbe (Precipitation) (Temperature) Khorog (Precipitation)

(month) (month)

Precipitation of Dushanbe Lowest temperature of Dushanbe Lowest temperature of Tokyo Precipitation of Tokyo Maximum temperature of Dushanbe Maximum temperature of Tokyo

Source: http://www2m.biglobe.ne.jp/~ZenTech/world/kion/Tajikistan/Tajikistan.htm (Accessed in April, 2018)

Figure 1-1 Climate of Tajikistan, Dushanbe and Khorog

1-2-2 Social and Environmental Considerations The ambulance vehicles planned for deployment in this case are manufactured in Japan or expected to be similar ones, which adequately satisfies the local exhaust emission regulations. So, there are no cause for environment and social impact.

1 Oblast is a type of administrative division in several post-Soviet states. The word "oblast" is also translated as "region" in this text.

CHAPTER 2 CONTENTS OF THE PROJECT

Chapter 2 Contents of the Project

2-1 Basic Concept of the Project 2-1-1 Overall Goals and Project Purpose Under the “NDS 2016-2030”, Ministry of Health and Social Protection of Population (MoHSPP) formulated a national health plan, so-called “NHS 2010-2020”. The health plan sets priority on improving the quality, access and efficiency of health services. Also, one of the priority targets is to secure effective emergency medical service accessible to all people. “Order of the Ministry of Health of the Republic of Tajikistan No.33” (MoHSPP, Order No.33)2 of the National Standards aims at the deployment of one vehicle per 10 thousand people. However, as of 2016, the deployment rate remains approximately 30% of the target which is 270 vehicles among 8.7 million people. In addition, vehicles are obsolete and frequent failures occur. Furthermore, since on-board equipment is not improved, it is required for borrowing the hospital equipment when necessary. Therefore, it is essential to improve quality and quantity of ambulances.

2-1-2 Project summary The Project for Improvement of Ambulances (the Project) plans to deploy a total 94 ambulances consisting of 83 replacement and 11 supplemental. In addition, it is planned to improve ambulances on- board equipment such as Defibrillator, Pulse Oximeter, and Suction unit etc. Thus, strengthening of emergency service system enables the provision of quick emergency treatment during transportation. In the former Soviet Union, the deployment plan for ambulances was established for the purpose of transferring traffic trauma patients and seriously ill patients from lower level medical facilities to higher level medical facilities. In formulating the Project, special characteristic of Tajikistan such as geographical situation, length of transportation time for patients, contents of emergency medical service were taken into consideration. In the capital city, Dushanbe where multiple target facilities are located, emergency referral system is effectively functioning because there is a telephone system for requesting ambulances and a high ratio of paved roads. On the other hand, medical facilities in rural areas, which are mountainous and with unpaved roads, have difficulty in providing quick emergency medical service unless the vehicle type is a 4-Wheel- Drive vehicles (4WD). Under the Project, different types of vehicles and on-board equipment will be deployed taking into consideration of the characteristics of emergency medical service of the target facilities such as contents, scope and scale of activities, and considering long transportation hours, bad road conditions, and necessity for emergency treatment during transportation. Implementation of the Project aims at improving the performance of ambulances and on-board equipment, thereby improving access to health care facilities and quality of emergency medical service.

2 Order of the Ministry of Health of the Republic of Tajikistan No.33 dated January 28, 2010, “On improvement of first medical aid and emergency medical care management”

2-2 Outline Design of the Japanese Assistance 2-2-1 Design Policy (1) Basic Plan Under the Project, it is planned to procure ambulances, which are equivalent to the existing ones, and on- board equipment. The emergency service system will be improved and strengthened through replacement of aged vehicles and supplemental vehicles for the facilities with inadequate number of vehicles. Types of ambulance are to be maintained by manufacturer’s agents or car repair dealers in Tajikistan. Grade of on-board equipment is decided by technical level of ambulance medical personnel in current emergency service system and necessity for emergency treatment during transportation. However, equipment which cannot be maintained by own budget is excluded. Grade of equipment shall be the same as equipment currently being used in emergency medical service.

(2) Policy on Natural Conditions Since 93% of the land is mountainous and there is long-lasting rain during the rainy season, unpaved roads in the mountainous area become muddy and the muddy ruts hinder the passage of the vehicles. For this reason, the Project plans to procure 4WD vehicles or equivalent for driving on rough roads. In addition, since during winter the temperature drops to -5 to -8°C in the highlands and to -17°C in the suburbs of Khorog city3, ambulances specially designed for cold weather shall be selected. Provision of roofed garages is a condition for procurement of ambulances to protect engine parts in such areas4. Diesel fuel, which is distributed in this region, has been set to be used in temperature conditions of up to 15°C below zero. It is confirmed that it can be used in a temperature environment lower than the setting condition by adding commercially available additives.

(3) Policy on Socioeconomic Conditions In Tajikistan, imported vehicles from Japan, Western countries, South Korea, and China etc. are distributed. Since vehicle market in Tajikistan is relatively small, there are few manufacturer’s dealers, and most of sales and maintenance activities are done through local contractors from neighboring countries5. Therefore, repair parts markets are available in capital of each Oblast and private car dealers provide maintenance services by procuring repair parts from those markets. Considering such economical activities in the market, the location of manufacturer’s agent shall be in Tajikistan or in neighboring countries.

(4) Policy on Procurement Conditions The ambulances and on-board equipment shall be procured from Japan or third countries since they are not manufactured in Tajikistan. The procurement condition is summarized as follows.

3 The southeast part of Tajikistan, the capital city of GBAO 4 From December to January, the lowest temperature become minus 17 °C in GBAO and Khatlon Region..http://hikersbay.com/climate/tajikistan?lang=ja (Accessed on September 7, 2018) 5 Turkey, Russia, Uzbekistan, Kazakhstan etc.

Policy on Ambulance procurement 1. Chassis, the base frame of the ambulance shall be manufactured the same as the product line on the market, and fabrication of the ambulance shall be done at a certified factory of the vehicle manufacturer. 2. Maintenance and repair service shall be organized by authorized dealer of the vehicle manufacturer located in Tajikistan or neighboring countries in order to supply periodical replacement spare parts and consumables etc.

Policy on On-board equipment procurement Considering the economic efficiency of transportation costs, though on-board equipment shall be basically procured in Japan, However, some products may include Europe and the U.S.A. etc. in addition to Japan as procurement target taking into consideration superiority of quality.

(5) Policy on Operation and Maintenance Maintenance and major repair for ambulance is conducted by manufacturer’s authorized dealers or private repair factory, but since the targeted facilities are located in remote areas, small repairs are fixed by repair technician or driver belonging to the facility. Considering current situation, initial operational guidance, simple operation and management skills are taught by manufacturer’s local technician to driver or responsible personnel of vehicles (A). The on-board equipment will be procured based on the type and grade currently used in Tajikistan. However, in order to promote long-term effective use of the equipment, soft components, i.e., operation guidance by emergency physicians of Japan shall be planned since personnel may be inexperienced with operation during life-saving procedures and maintenance of some of the on-board equipment such as Defibrillator (B). Since there is no experience with the maintenance methods of these equipment at the facilities, technical guidance for maintenance including the initial operation training of the equipment shall be given by the manufacture’s local agent. In order to maintain the effectiveness of guidance, preparing the manual in Russian for maintenance of the on-board equipment, and providing guidance on soft components shall be given. (C) The technical guidance of (A), (B) and (C) shall be implemented immediately after the delivery of the equipment. in 5 areas such as Dushanbe city, Khujand city in Sughd, Bokhtar city (Qurghonteppa city) in Khatlon, Kulob city in Khatlon, and Khorog city in GBAO. The guidance of (A) will be conducted in forms of seminars to drivers and responsible personnel of vehicles, the guidance (B) and (C) to emergency physicians and nurses.

(6) Policy on Grades and Specifications of Equipment The specification of the equipment shall be based on the grade of the ambulances and on-board equipment that are currently being used in Tajikistan.

(7) Policy on Overall Implementation Schedule The term of the Project shall be 14 months after signing the Exchange of Notes (E/N) and the Grant Agreement (G/A). In order to avoid the Project delays due to landslides and main road traffic closures caused by heavy rain and bad weather, procurement is planned to be completed before the rainy season (from May to September).

(8) Policy on Procurement of Consumables/Spare Parts The oxygen for on-board oxygen cylinders will be filled by the hospitals in each region after handover of ambulances. Consumables for ambulances are not included under the Project.

2-2-2 Basic Plan (Equipment Plan) (1) Overview of the Project A total of 94 ambulances will be procured under the Project, 83 replacement vehicles for 55 medical facilities and 11 supplemental vehicles for 8 medical facilities. One set of on-board equipment will also be procured for each ambulance. Technical specifications of ambulances and on-board equipment are either 4WD, two boxes type or 2-Wheel-Drive vehicles (2WD), one box type depending on the emergency activities of target medical facilities.

1) Confirmation of Request 1. Number of ambulances deployed More than one year has been passed since Tajikistan submitted the original request, and the survey for the Project was conducted in August 2017. Then, Tajikistan submitted a new request list of ambulances during the survey. The reason for the submission of the new request is the changes in the operational condition of existing ambulances in the original request, and urgent need to strengthen emergency service system in addition to the survey results. Ambulances are used to transport emergency patients within the service coverage area and to transport serious patients to higher medical facilities. In addition, while strengthening the emergency service system is ongoing, there is urgent need to secure the provision of prompt and appropriate emergency medical service. In order to achieve the goal declared in health policy of Tajikistan "Securing accessible and effective emergency medical service for all people", it is considered an important factor to procure ambulances and on-board equipment. Therefore, implementation of the Project will contribute to the acceleration of the national plan of Tajikistan. The new request required the deployment of 98 ambulances to 67 facilities. The breakdown is 98 vehicles in total, replacement 89 vehicles and 9 supplemental vehicles. Based on the results of survey analysis, it was found that some medical facilities can continue to use the existing ambulances, while some facilities have insufficient ambulances. Therefore, the number of ambulances in procurement plan was changed and adjusted according to the above mentioned "Overview of the Project". For the result of examination of the number of procured ambulances for each facility, refer to Table 2-3 below.

2. Standard of Ambulance (Type) Type of ambulance is classified into 3 grades A, B and C in accordance with "the classification of function of ambulance" (MoHSPP, Order No.33, 2010). The classification is divided by functions of on-board equipment. Type A6 is Basic (for transportation), Type B7 is Basic Life Support, and Type C 8 is Advanced Life Support. Basic life-saving equipment such as suction unit and blood pressure monitor is mounted on Type A. In addition to the same equipment as in Type A, Medical Electronics (ME) equipment such as ECG, Defibrillator and ventilator is mounted on Type B and C, to enable provision of urgent life support during transportation. The initial request for the Project in 2017 is to procure 56 Type B vehicles for facilities located in rural areas and 18 Type C vehicles for facilities located in urban areas, and also to procure for additional 10 facilities. Type C ambulance is requested for medical facilities located in Dushanbe city and rural capitals, while Type B ambulance is requested for medical facilities located in Oblast or Rayon9 level. With MoHSPP Budget and support from other donors, a considerable number of Type B and C, advanced life support ambulances, have already been procured in urban areas such as Dushanbe city. On the other hand, at the Oblast and Rayon levels, even the number of Type A is inadequate, and the existing ambulances are aged and require frequently repairs. While number of procurement demand for Type C ambulances is relatively small and possible to procure through own budget or support from other donors, it seems financially difficult for Tajikistan to procure various ambulances for facilities in rural areas all over the country with only its budget. The results of survey in rural areas, show that the number of existing ambulances is inadequate, and confirmed that Tajikistan side desires to procure more Type A ambulances equipped with basic life support features and their price is lower than Type B life support ambulances. Based on these survey results, procurement of type A ambulance will be the center of the Project and as many Type A ambulances as possible can be procured. As for Maternity Hospitals, Oblast hospitals and Central District Hospital that are requested Type C, Type B ambulances (on-board equipment is similar to Type A) actually exist, so Type B ambulances will be procured.

Table 2-1 Planned Number per Ambulance Classification of Function Requested Planned Function of ambulance classification number number (original) Basic Type A 0 86 Basic life support Type B 56 8 Advanced life support Type C 18 0 Total 74 94

6 It is used for accommodation of emergency patients / transportation of patients to upper hospitals (urban hospitals) at hospitals at Rayon level. 7 It is used for providing for specialized medical service support (sanitary aviation service) to other Oblast hospitals and for patient transportation 8 It is used for providing for advanced specialized medical service support (sanitary aviation service). 9 Rayon is a type of administrative unit of several post-Soviet states. The word "rayon" is translated as "district" in this text.

In addition, the Type B and Type C ambulances were requested from the National Medical Center in Dushanbe City / Maternity Hospital / some Oblast hospital / some Central District Hospital / for the provision of highly specialized medical services (sanitary aviation service)10 to other hospitals. However, Type C were excluded under the Project because there is an ongoing improvement plan for Type C funded by Tajikistan and the priority for improvement under the Project is low.

2) Current status of emergency medical service in planned facilities The current status of target facilities in emergency medical service is shown in Appendix 7-1. The target facilities have 2 to 14 ambulances, although they are mostly decrepit vehicles. Some facilities have multiple branches 11 working with emergency teams. The request for emergency dispatch varies depending on the area of the facility and the size of the medical service, but it ranges from 200 to 2,500 cases in Dushanbe city Clinical Hospital of Emergency Medical Aid (Dushanbe Emergency Hospital). On average, the dispatch requests per facility vehicle are estimated to be around 9 to 12 cases. According to a questionnaire survey, the emergency dispatch requests to patients with cardiac diseases, high blood pressure and abnormal delivery and trauma patients due to traffic accidents etc. are the highest.

3) Status of emergency medical service activity at planned facilities Overview of activities of target facilities in emergency medical service is shown in Appendix 7-2. The target facilities are medical facilities engaged in the provision of emergency medical service that are located nationwide in Dushanbe City and District of Republic Subordination (DRS), Khatlon Sughd and GBAO. The service cover population of each facility varies from 20 thousand to 400 thousand, except for the “Shifobakhsh” National Medical Center, which is the nation's highest medical facility with nationwide service coverage area. There are significant differences in placement of medical personnel depending on the medical service contents of the target areas and facilities, 3 to 259 doctors, 6 to 944 nurses, the number of beds also from 12 to 994 beds. In addition, the annual maintenance costs of the ambulances are from 2,800 to 48 thousand Tajikistan Somoni (TJS) (from JPY33,852 to JPY580,320), fuel costs from 1,400 to 150 thousand TJS (from JPY16,926 to JPY1,813,500), depending on the number of existing vehicles and the scope of activities. However, these costs are paid for by government agencies, and the shortfall is supplemented by a special budget for income earned from paid medical care.

4) Examination of requested equipment In principle, procurement of ambulance is either replacement or supplementation of existing vehicles based on the current operational status, demand, placement status of medical personnel and driver, maintenance systems, etc. Target facilities and procurement quantities are shown in Table 2-5 "Ambulance Deployment Evaluation and Distribution List".

10 Provision of medical services by dispatching medical specialists to medical facilities requested for emergency dispatch, and by patient transportation according to the patient's condition to well-equipped facilities. 11 In order to cover a wide service coverage area, branch offices are located in areas distant from some facilities.

1. Policy of priority determination of ambulance improvement (i) Priority is given to Dushanbe Emergency Hospital, which provides advanced emergency medical care in the metropolitan area, “Shifobakhsh” National Medical Center and Maternity Hospitals providing tertiary medical services, Oblast hospitals providing specialized medical services as the top referral hospital of the Oblast to enhancing emergency medical service. (ii) Priority is given to Central District Hospitals that cannot respond to ambulance call due to insufficient number of vehicles although they receive a lot of ambulance dispatch calls as regional core dispatch center, (iii) Priority is given to facilities where it is impossible to maintain current emergency service system without replacement of obsolete ambulances. (iv) Regarding ambulance maintenance at the Rayon-level, priority is given to facilities where access to major cities is difficult and ambulances are the only means of transport. (v) Facilities that can sufficiently provide emergency medical service with existing ambulances in view of the population of the service coverage area, number of emergency dispatch request and scale of emergency activities are excluded from the Project (vi) In case emergency medical service for which the facility is planning to provide are already covered by neighboring emergency medical service facilities, the facilities shall be excluded or have low priority under the Project. (vii) Facilities where the number of ambulances necessary for emergency medical service has been provided from 2016 to 2018 regardless of brand-new or second-hand ambulances, shall have low priority under the Project. (viii) Facilities that are likely to receive assistance for ambulance improvement from other donors etc., shall have low priority.

2. Setting condition of procurement quantity The estimated number of existing ambulances in the country is 270 units. With a population of 8.7 million people, the ratio is 1 ambulance per 32 thousand people which is far below the national standard of 1 per 10 thousand people. In addition, the shortage of ambulances at the target facilities is remarkable, and many cases of failure to respond to dispatch requests have been reported. The main reasons for dispatch failure are that many existing vehicles are damaged or under repair, and immediate dispatch is not possible with available ambulances. It is important to analyze the population in service coverage area per target facility, road condition of the area, emergency patient transportation distance, number of existing ambulances and their operational status, number of operations per vehicle etc. since the time required to transport emergency patients varies depending on the content of the request. To formulate ambulance improvement plan for the Project, the quantity to be procured by the target facility is calculated using the following conditions.

 Planning conditions for calculating the number of dispatches per ambulance

Considering the location of target facilities, position of health service system, access route to higher level medical facilities, it is classified as 3 dispatch types, Short-distance, Middle-distance and Long-distance. Thereby, required number of ambulances for target facility is shown in Table 2- 2 according to the number of dispatch requests, dispatch distance and time of dispatch. The definition of the classification of the target facilities which is the basis of the calculation of the estimated required number is as follows.

i. Short-distance dispatch (within 5 km one way) is estimated about 1 hour. Located in urban areas with large population such as the capital city, and relatively short distance emergency dispatch. Mileage per dispatch is estimated 50 to 65 km in average. (one vehicle per day) ⅱ. In the middle distance, mountain unpaved road (within 5-15 km one way) is estimated about 5 hours. Located in a medium-sized city such as a Rayon and having referral transfer from a facility to the upper facilities etc. Mileage per dispatch is estimated 65 to 80 km in average. (one vehicle per day) iii. Transportation of patients to other medical facilities at a long distance (15 km to 50 km one way) is estimated about 8 hours. Located in a small town in the mountain area, transportation to the upper facilities accounts for about 65%. Mileage per dispatch is estimated 80 to 95 km in average. (one vehicle per day)

Table 2-2 Calculation Criteria for the Number of Ambulance Deployments Tendency of Emergency dispatch at target Number of dispatch request per Estimated required facilities month number of vehicles a. Short -distance dispatch type (Urban-type population distribution area) 250,000 people more ① 200～ 400 0.7～1.3 vehicles Short-distance dispatch :60% ② 401～ 600 1.3～2.0 vehicles Middle-distance dispatch:35% ③ 601～ 900 2.0～3.0 vehicles Long-distance dispatch :5% ④ 901～1200 3.0～4.0 vehicles ⑤ 1201～1500 4.0～5.0 vehicles ⑥ 1501～1800 5.0～6.0 vehicles b. Middle-distance dispatch type (Medium size city type population distribution area) from 100,000 to 250,000 people ① 200～ 400 0.8～1.6 vehicles Short-distance dispatch :55% ② 401～ 600 1.6～2.5 vehicles Middle-distance dispatch:30% ③ 601～ 900 2.5～3.7 vehicles Long-distance dispatch :15% ④ 901～1200 3.7～5.0 vehicles ⑤ 1201～1500 5.0～6.2 vehicles ⑥ 1501～1800 6.2～7.4 vehicles c. Long-distance dispatch type （Small city type population distribution area from 25,000 to 100,000 people ① 200～ 400 1.0～2.0 vehicles Short-distance dispatch :35% ② 401～ 600 2.0～3.1 vehicles Middle-distance dispatch:45% ③ 601～ 900 3.1～4.6 vehicles Long-distance dispatch :20% ④ 901～1200 4.6～6.3 vehicles ⑤ 1201～1500 6.3～7.8 vehicles ⑥ 1501～1800 7.8～9.4 vehicles Source: Result of analysis by Survey Team Precondition：・Ambulance operation shift is calculated based on 24 hour system. ・To calculate, it is assumed that the ambulance will be returned base without staying at the transport destination even if it is long distance transportation. ・The operation schedule is adjusted on the assumption that the dispatch requests do not overlap

3. Consideration of activity status of existing equipment and required number for improvement Based on the activity of the target facility and the existing vehicle operational status, the emergency medical service demand is determined from the above "2-2-2 4) 1. Policy of priority determination of ambulance improvement" and "2-2-2 4) 2. Setting condition of procurement quantity", and the number of ambulances needed for emergency medical service is determined. In addition, even if the existing vehicle malfunctions, vehicles less than 10 years old, which can be repaired and continue to be used, are counted as existing vehicles capable of operating at 40 to 80% depending on their degree of deterioration. The planned quantity is determined by subtracting the number of existing vehicles evaluated from the number of ambulances required for the facility. The following table shows the operational status of the existing equipment at each target facility and the examination result of the required procurement quantity.

Table 2-3 Result of Examining the Requirement

Adjust ed Number of MD Calculation Sit e City, Rayon, Site Deployment quantity after agreement criteria for Replacement Supplementation number requested Number and state of existing ambulances Review of ambulance deployment plan reason domest ic (former name) quant it y deployment vehicle analysis

Number of existing vehicles: 2 It is a facility located in the mountains near the border of Uzbekistan in the southeastern · Manufactured year 2007, China, Haifei Changen, Mileage 110,000 km, bad part of Tajikistan. Although there are a lot of dispatch demand for emergency services, it condition but operable is not possible to dispatch all the time due to malfunctions by aging. Deployment of at · Manufactured year 2007, China, Haifei Changen, Mileage 100,000 km, bad least two dispatchable vehicles is an urgent issue according to the large number of 1 Rudaki 2 1 condition, frequent failure ②③ ㋐-③ 1 0 1 dispatch requests. Based on calculation that two Chinese vehicles manufactured in 2007 is There are approximately 20 cases a month that patients are transported by taxi or 60% - 70% due to repair, it is equivalent to 1.2 - 1.4 vehicles. Under the Project, it is private vehicles or requests to another facility since it is impossible to dispatch in planned to supplement one vehicle to secure emergency medical system by two or more some cases. vehicles together with existing two vehicles.

Number of existing vehicles: 8 Because it is close to the metropolitan area, nearly 20 cases a day are counted when the · Manufactured year 2011, China, 2 vehicles of Foton, bad condition with engine number of traffic accidents are large. When requested for long distance dispatch, it is but operable limited to 2 or 3 times a day for the dispatch. Therefore, four operable ambulances are 2 Vahdat 2 2 There are also four emergency vehicles such as wagon type manufactured in 1998- ①②③ ㋐-④ 2 2 0 required. It is planned to replace 2 small ambulances aged more than 15 years old with new 2003 and light truck type. However, they are in a state of old age and of waiting for one in order to secure emergency medical system by two or more vehicles together with disposal. These vehicles are also acting when vehicles run short. It may not be existing two vehicles. possible to dispatch approximately 5-7 cases per month due to repair .

Number of existing vehicles: 2 · Manufactured year 1970s, USA, Chevrolet, Mileage 400,000 km or more, unable to drive In order to maintain current emergency services in the area, at least one operable - Manufactured year 1994, Germany, Mercedes, Mileage 200,000 km or more, bad ambulance is required. However, the average dispatch rate is less than 30% so that 3 Hissor city 2 1 ③ ㋐-① 1 1 0 condition existing vehicles are in bad shape. Under the Project, it is planned to replace one Vehicle manufactured in Germany are frequently out of order, and Vehicle unrepairable ambulance and strengthen the emergency medical system. manufactured in US are waiting for disposal. There are many cases that one dispatchable vehicle is available only 6 to 10 days a month due to repair.

It is located in the area adjacent to the Uzbekistan border approximately 30 km west of the Number of existing vehicles: 4 main road from the capital Dushanbe. In the point of transportation, emergency dispatch · Manufactured year 1998, Russia, Mileage 300,000 km, 2 vehicles, engine failure, by traffic accident is rapidly increasing in recent years. Currently, the number of operable unrepairable vehicles is two and the age of cars exceeds 10 years. Failure has occurred frequently due 4 Tursunzoda city 2 2 · Manufactured year 2005, 2006, each one unit, bad condition but operable ②③ ㋑-④ 2 2 0 to aging, then the actual operation is about 60% of one vehicle. It is necessary to deploy Although there are two vehicles for dispatch requests, they are frequently out of at least three ambulances considering the scale, content and are of emergency service order due to aging. For that reason, the target facility depends on private vehicles activities at this facility. Under the Project, it is planned to replace two Russian-made since there are more than 15 non-dispatch cases on a monthly basis. vehicles into at least two new ambulances to secure dispatch systems.

Number of existing vehicles: 2 · Manufactured year 2007, China, Haifei Changen, Mileage 310,000 km, bad It is located in the mountain area 80 km northeast of the capital Dushanbe. There is only condition but operable one malfunctioning ambulance that can operate. However, in order to support current · Manufactured year 2007, China, Haifei Changen, Mileage 40000 km, operable, 5 Rasht 2 1 emergency service demand, at least one vehicles that are always operational are required. ③④ ㋑-② 1 1 0 frequent failure Therefore, it is planned to replace one existing vehicle in malfunctioning condition with Emergency vehicles are available. However, repair costs a lot since both of them new one and plan to improve the emergency medical service. have become old age, and repairs are frequent. The number of non-dispatch days is on average 7 to 10 days a month due to vehicle maintenance.

Number of existing vehicles: 3 · Manufactured year 2000, 2003, each one vehicle, bad condition · Manufactured year 2014, China, Mileage 160,000 km, bad condition but operable, It is core medical facility located 35 km west of Dushanbe city. Considering the number of frequent repair dispatch requests and the service coverage area, at least two vehicles that are always 6 Shahrinav 2 2 There is the only one dispatchable vehicle at this facility, and the other two operational are required for improvement. Although one aged Chinese vehicle is currently ③④ ㋑-③ 2 1 1 vehicles reach the limit for repair due to aging. Since it is shortage of vehicles, operable, the vehicle is in the timing of replacement. Therefore, it is planned to replace one there are approximately 15 cases a month which is not able to respond to dispatch existing vehicle and replenish one new vehicle. requests. Therefore, the facility depends on private vehicles for transportation currently.

Number of existing vehicles: 5 · Manufactured year 2001, South Korea, Hyundai Strarex, Mileage 100,000 km, bad condition but operable · Manufactured year 2004, Russia, UAZ, 2 vehicles, Mileage 400,000 km, bad It is a medium-range dispatching facility located 35 km east of Dushanbe. Although three condition, malfunctioning vehicles are in charge of emergency services these days, the actual operation status is · Manufactured year 2007, China, Haifei, 2 vehicles, Mileage 150,000 km, frequent 7 Faizobod 1 1 corresponding to approximately 0.5 units by the vehicles in a bad condition. Since it is ②③ ㋒-② 2 2 0 failure, bad condition necessary to maintain at least two vehicles that can be operated at all times, it is planned Since Russian vehicle and Chinese vehicle become old age remarkably, the number to replace two Russian cars manufactured in 2004 for new vehicles. of times which is not able to dispatch has increased due to repair. In practice, there is only dispatchable vehicle manufactured in Korea and China. Since there are approximately 30 non-dispatch cases a month and operation rate is about 60% , it requests support from other facilities and private vehicles.

Number of existing vehicles: 3 · Manufactured year 1994, Germany, Opel, Mileage 300,000 km or more, bad It is a long-range dispatching facility located on the main road that passes from Dushanbe condition city to Dalfords. An operational 1994 model vehicle has a car age of over 20 years. This · Manufactured year China, (Model year unknown), 2 vehicles, unrepairable 8 Nurobod 1 1 exceeds the limit of the useful life considerably. However, in order to meet emergency ③⑥ ㋒-① 1 1 0 It is not in good condition, but German vehicle is available. However, it is service demand, at least one vehicle that are always operational are required. Therefore, it impossible to transport an emergency patient in a lying state, since it is a sedan is planned to replace one existing vehicle with new one. type. There are 7 to 10 non-dispatching cases and some cases depend on private vehicles.

Number of existing vehicles: 3 · Manufactured year 2014, Korea, Hyundai, Mileage 50,000 km, bad condition, frequent repair It is a medium-range dispatching facility located 40 km north of Dushanbe. Deployment of · Manufactured year 2014, Korea, Hyundai, Mileage 50,000 km, bad condition but at least two or three vehicles that can always be driven is required, since the number of operable dispatch requests, and the population in the service coverage area is large. At present, · Manufactured year 2015, France, Peugeot, Mileage 40,000 km, frequent failure, 9 Varzo b 2 1 there are two vehicles that can be dispatched, and the utilization rate is estimated to be ①② ㋒-② 2 2 0 bad condition around 70%. Under the Project, it is planned to aim to restore the emergency medical One of the two vehicles manufactured in 2014 is not in good condition but service by replacing two vehicles including unavailable vehicles even if "engine operable. Although the other one replaced the engine, it has not recovered. Since replacement" is done. it is difficult to obtain repair parts for the vehicle manufactured in 2015, failure frequently occurs. Therefore, it will be limited to approximately 6 times a day for dispatch.

Number of existing vehicles: 2 It is a long-range dispatching facility located 90 km from Dushanbe city to the east-north · Manufactured year 1960s, Russia, UAZ, Mileage 450,000 km or more, east. Currently, one existing vehicle is not able to meet the demand for emergency services malfunctioning due to the broad range of the service coverage area. It is reported for patients to become · Manufactured year 2017, China, 2WD, 1 vehicle, Mileage 5,500 km, good severe condition during transportation because they are transported by a carriage to a flat 10 Lakhsh (Jirgatol) 1 2 condition ③④ ㋒-① 1 1 0 relay point for a long time. Therefore, it is necessary to deploy 4WD vehicles responding Russian vehicles manufactured in the 1960s are inoperable since repair parts are quickly even on rough roads such as mountain roads. Under the Project at the target not available. Also the emergency site locates at remote place, and it takes time to facility, it is planned to replace one old Russian car to establish a rapid emergency accommodate. Therefore, it is not able to respond to many requests for dispatch. dispatch system considering necessity of two ambulance. There are approximately 10 to 14 cases a month which is not able to dispatch.

Number of existing vehicles: 2 · Manufactured year 2007, China, Mileage 80,000 km or more, frequent breakdown, This facility is located two days away from the tertiary medical facility of the capital, bad condition deployment of multiple vehicles is necessary. In 2020, it becomes difficult to maintain 11 Tojikobod 1 2 · Manufactured year 2007, China, Mileage 50,000 km or more, bad condition but ③④ ㋒-② 2 2 0 existing vehicles due to aging considering the durability of the existing vehicle. Under the operable Project, it is desirable to replace two existing vehicle aged over 11 years old. There are approximately 50 to 60 cases a month which is not able to dispatch vehicles in a month. In case that patients are transported by private vehicles.

Number of existing vehicles: 4 · Manufactured year 1998, 2003, Russia, each one vehicle, UAZ, engine failure, It is a long-range dispatching facility located on the main road that passes from Dushanbe unrepairable city to Dalfords. It is necessary to deploy two dispatchable vehicle at all times from · Manufactured year 2006, China, Mileage 120,000 km, frequent failure population of service coverage area. Currently, only one operable vehicle is in good 12 Roghun city 1 1 ②③ ㋒-① 1 1 0 · Manufactured year 2014, China, Mileage 70,000 km, good condition shape, and the age of other vehicles become 14 years old or more in 2020. Therefore, at Vehicles manufactured in Russia are running over 400,000 km and their aging is least one replacement is necessary. Under the Project, it is planned to replace one vehicle remarkable. There is the only one dispatchable vehicle, and 7 to 9 cases will be not manufactured in 1998. able to dispatch a month due to shortage of vehicles.

It is a long-range dispatching facility located 140 km east of Dushanbe. Since there are Number of existing vehicles: 3 dispatch request about 6 to 8 cases / day, and long distance transportation also has 5 to 7 · Manufactured year 2000, 2 vehicles, China, Mileage 220,000 km, vehicle aging is cases / month, at least two dispatchable vehicle are necessary in order to meet demand for intense emergency dispatch request. As the car age of both existing vehicles are high, and the · Manufactured year 2008, 1 vehicle, China, Mileage 120,000 km, bad condition but 13 Sangvor (Tavildara) 1 1 number of non-dispatching cases has been increasing year by year due to repair and ③④ ㋒-① 2 2 0 operable meintenance, also multiple vehicles break down at the same time. So renewal of vehicles is Parts are frequently exchanged including various large and small repairs, and it required. It is planned to replace two inadequate vehicles manufactured in 2000, and hinders dispatch and transportation. There are approximately 15 cases a month improve the non-dispatch status due to malfunctions and attempt to restore the which is not able to dispatch due to breakdown. emergency medical service.

This facility is located in densely populated areas, and there are many transports to tertiary medical facility of Dushanbe. It is a close-range dispatching facility but has a large Number of existing vehicles: 2 population in service coverage area. There are 5 to 7 cases / month transports to the · Manufactured year 2012, China, 2 vehicles, Mileage 30,000 km, bad condition but metropolitan area, and it has high demand ( about 10 to 14 cases / day) for emergency Kushoniyon operable 14 1 2 services. Also due to duplication of existing vehicls malfunction, it is difficult to respond ④ ㋑-② 2 2 0 (Bokhtar) Two existing vehicles are 6 years old, and there are problems with durability and to plural request for dispatch Therefore, it is necessary to deploy at least two some parts such as engines, suspensions. Therefore, there are 10 days a month dispatchable vehicle. It is planned to replace two existing malfunctioning vehicles and that only one vehicle is able to dispatch. plan to reestablish the quick dispatch system.

Demand for emergency dispatch request is about 20 to 23 cases / day. From the scale of Number of existing vehicles: 7 the emergency service activity, it is required to secure at least three all-time dispatchable · Manufactured year 2002, Russia, 2 vehicles, bad condition, frequent failure vehicle. The utilization rate of the 4 vehicles manufactured in 2003 and one vehicle in 2008 · Manufactured year 2003, Russia, Gazelle, 4 vehicles, repair frequently 15 Kulob city 1 1 is estimated to be around 60%, since there is maintenance period. Based on calculations ②③ ㋑-③ 1 1 0 · Manufactured year 2008, China, 1 vehicle, frequent maintenance that the current 4 vehicles can covere the amount of two vehicle for the service, it is Existing vehicles are remarkably aged overall, and there are approximately 15 to 20 planned to replace one of the oldest manufactured in 2002 and reestablish emergency cases a month which is not able to dispatch vehicles due to repair. medical service by 3 dispatchable vehicle in total.

The target facilities are located in the main points of transportation facing the national Number of existing vehicles: 5 highway to Darvoz. Since there are many requests for emergency due to traffic accidents · Manufactured year 2008, China, 2 vehicles, difficult to procure maintenance parts etc., deployment of at least 2-3 dispatchable vehicles are required. Due to maintenance 16 Vo s e 1 1 · Manufactured year 2013, South Korea, 3 vehicles, frequent maintenance and other reasons, three existing vehicles manufactured in Korea have been operating at ③ ㋑-③ 1 1 0 There are approximately 20 cases a month which is not able to dispatch vehicles amount of 70% compared to normal vehicle and corresponds to two cars. Under the due to repair. Therefore, it is required for support from nearby facilities. Project, it is planned to replace one of the aged vehicles manufactured in 2008, and secure three dispatch vehicles systems in accordance with the number of existing vehicles.

Number of existing vehicles: 2 · Manufactured year 2000, Russia, UAZ, Mileage 380,000 km or more, malfunctioning, waiting for disposal It is a medium-range dispatching facility for emergency service located in the northern · Manufactured year 2005, Korea, Hyundai Strarex, Mileage 270,000 km, bad part of the Khatlon oblast. Considering the number of dispatch requests, it is necessary to 17 Yovon 1 2 condition, frequent repair maintain two all-time dispatchable vehicles. However, the two existing vehicles become ③④ ㋑-② 2 2 0 There are some cases that it will be impossible to dispatch vehicles due to old and it is difficult to continue to use. Under the Project, it is planned to replace two of repeated repair such as engine exchange. Non-dispatch is approximately 10-15 existing vehicles. days on average a month. In case of that, transportation is requested by a private vehicle or an individual vehicle.

Number of existing vehicles: 2 · Manufactured year 2004, China, IFI, Mileage 300,000 km or more, breakdown, It is a medium-range dispatching facility located in the central mountain area of the unrepairable Khatlon oblast. It is necessary to deploy at least one permanent vehicle according to 18 J. Balkhi (J. Rumi) 1 1 · Manufactured year 2005, Russia, UAZ, Mileage 300,000 km or more, bad emergency request. Both of the existing vehicles exceed the age of 13 years, and it is ③④ ㋑-① 1 1 0 condition, frequent failure expected that procurement of repair parts will be impossible at the time for implementation. There are 5-8 times a month which is not able to dispatch. In case of that, it Therefore, it is planned to replace one vehicle under the Project. corresponds by private vehicles.

Number of existing vehicles: 2 It is a middle-range dispatching facility located in the central mountain area of the Khatlon · Manufactured year 1987, Russia, Rafik, breakdown, unrepairable oblast. Since the number of requests for dispatch is large, deployment of at least two 19 Vakh s h 1 2 · Manufactured year 2006, China, Dams, bad condition, frequent failure dispatchable vehicles is necessary to respond to rapid emergency services. One of the ③④ ㋑-③ 2 2 0 There are 5-7 times a month which is not able to dispatch. In case of that, it exiting cars which is barely able to operate is also 12 years old. In other words, it is time to responds by individual vehicles. replace. It is planned to replace two aged vehicles under the Project.

Number of existing vehicles: 2 It is a facility located in the mountains near the border of Afghanistan in the southwest, · Manufactured year 2000, Russia, UAZ, Mileage 400,000 km or more, and the only medical facility that neighborhood residents is able to rely on. However, malfunctioning, waiting for disposal 20 Qabodiyon 1 1 emergency vehicles are becoming old, and it is difficult to respond promptly. According to ③④ ㋑-① 1 1 0 · Manufactured year 2005, Russia, UAZ, Mileage 230,000 km, frequent failure the number of dispatch requests, it is judged that at least one vehicle maintenance is It is not able to dispatch vehicles out of half a month, and depends on individual necessary, and it is planned to replace one existing vehicle. and private vehicles for transportation.

Number of existing vehicles: 2 · Manufactured year 1987, Russia, Rafik, breakdown, unrepairable, waiting for Along the national highway from Dushanbe city to Qurghonteppa, it is a facility located in disposal the main points of transportation and accommodates many patients by traffic accidents. 21 A . Jomi 1 1 · Manufactured year 2012, China, Haifei Changen, bad condition, frequent failure Since only one dispatchable vehicle is deployed, the situation continues to be unable to ③④ ㋑-② 1 1 0 There are approximately 20 cases that it is not able to dispatch vehicles due to respond to emergency dispatch requests. It is planned to replace one inoperable old repair. Some cases are replied on other facilities. However, it depends on private vehicle within existing vehicles and establish emergency medical services by two vehicles. vehicles due to the absence in some cases.

Number of existing vehicles: 5 · Manufactured year 2011, China, Kinglong, 3 vehicles, Mileage 9 to 100,000 km It is a site along the national highway facing the Afghan border, 80 km down south from · Manufactured year 2011, China, Kinglong, 2 vehicles, Mileage 50,000 to 90,000 Kulob city. There are also many emergency dispatches due to traffic accidents. Since 22 Farkhor 1 1 km there are many requests, it is desirable that at least four dispatchable vehicles are ②③ ㋑-④ 2 2 0 Regarding car age, it is seven years and not so high. However, their durability is maintained. Under the Project, it is planned to replace two vehicles to compensate for low, breakdowns are frequent, and there are many non-dispatching due to repair. failing vehicles. In practice, the system for dispatch is only equivalent to 2.5 vehicles.

Number of existing vehicles: 3 · Manufactured year 2000, 2005, Russia, each one vehicle, Mileage 15-250,000 km, It is a mountainous facility located near the border of the southern part of Afghanistan. bad condition Ambulance is the only means of transport for emergency patients and it is indispensable Mir Said Ali 23 1 1 · Manufactured year 2015, China, Kinglong, 1 vehicle, good condition to deploy at least two dispatchable vehicles according to the number of dispatch ③④ ㋑-③ 1 1 0 Hamadoni Failures frequently occurred in vehicles manufactured in Russia, and it reaches the requests. Under the Project, it is planned to replace one old vehicle manufactured in 2000 limit on the maintenance of vehicles. Therefore, there may be over 15 cases which to restore the emergency medical service. are not able to dispatch per month due to the operation by one vehicle.

Number of existing vehicles: 5 · Manufactured year 2007, Korea, 1 vehicle, Mileage 120,000 km, bad condition, frequent failure, replacement required The target facility is a middle-range dispatching facility located at the junction of the · Manufactured year 2012, China, 1 vehicle, Mileage 70,000 km, bad condition but national highway. Deployment of urban type vehicles such as high standard ambulance is operable necessary for patient transportation to neighboring critical care medical facilities. On the · Manufactured year 2016, Germany, Mercedes, 3 high-standard type vehicles, other hand, since many service coverage areas are mountainous areas, deployment of 24 Danghara 1 1 good condition ③④ ㋑-④ 1 1 0 four-wheel drive vehicles which is able to cope with rough roads is also necessary. Existing vehicles such as large type and 2WD one box are not suitable for dispatch According to the service target population, the size of the area, and the number of in mountain paths and mountainous areas, since those vehicles are used for urban requests for dispatch, it is necessary to deploy at least 3 to 4 dispatchable vehicles. Under emergency transport. In cases where access is difficult, emergency patients are the Project, it is planned to replace one old vehicle manufactured in 2007. transported by private vehicles. However, it is also time consuming and some cases are too late to respond. There are approximately 25 non-dispatch cases a month due to repair.

Number of existing vehicles: 2 It is located near the border of the southern part of Afghanistan and accepts emergency · Manufactured year 2000, China, Tangen, Mileage 260,000 km, operating while patients from Afghanistan. It is about 100 km away from the higher medical facility and it repairing takes 2.5 hours or more to transport the patient one way. It is necessary to deploy 4WD 25 Jayhun (Qamsangir) 1 1 · Manufactured year 2000, Korea, Hyundai Strarex, Mileage 320,000 km, bad vehicles which is able to run smoothly even on bad roads in the mountains. Since there ④ ㋑-① 1 1 0 condition, frequent failure are many non-dispatching due to repair of existing vehicles, availability rate is 50% or less, There are approximately 10 to 12 non-dispatch cases due to repair correspondence and it is equivalent to 0.7 vehicle. Under the Project, it is planned to replace one existing on two vehicles. vehicle.

Number of existing vehicles: 2 · Manufactured year 2000, China, Mileage 350,000 km, engine failure, unrepairable, It has three branch offices and responds to support requests from the branch office. waiting for disposal Therefore, existing one vehicle is not able to respond adequately to the dispatch requests. 26 Shahrituz 1 2 · Manufactured year 2017, China, Mileage 3300 km, good condition ②④ ㋑-② 1 0 1 It is planned to supplement one vehicle which can accommodate patient transportation in For two vehicles, there are approximately 15 to 20 non-dispatch cases due to no mountainous areas. arrangement of vehicles. In case that it depends on private vehicles for transportation.

Number of existing vehicles: 2 The facility is located along the main road near the border of the southern part of · Manufactured year 1998, Korea, Hyundai Strarex, Mileage 260,000 km, bad Afghanistan, and accommodation of emergency patients by traffic accidents is also condition increasing. Although the number of dispatch requests is large, the maintenance of the · Manufactured year 2000, Korea, Hyundai Strarex, Mileage 220,000 km, bad 27 Panj 1 1 vehicle is not sufficient, and non-dispatch is 2-3% against the request. Therefore, it is ④ ㋑-① 1 1 0 condition necessary to deploy at least one all-time dispatchable vehicle. Under the Project, it is The failure of existing vehicles is frequent, and the car body exceeds the durability planned to replace one vehicle manufactured in 1998 and strengthen the emergency limit. There are approximately 6 to 8 non-dispatch cases due to bad condition on medical service. the vehicles.

Number of existing vehicles: 1 It is a middle-range dispatching facility located in the southern part of the Khatlon oblast. · Manufactured year 2014, China, Haifei Changen, Mileage 67,000 km, repair 3 to 4 Since it responds to dispatch requests for three branch offices under the jurisdiction, it is times per year impossible to respond to all emergency dispatch requests by one existing vehicle due to 28 Dusti (Jilikul) 1 2 ②④ ㋒-① 1 0 1 Oil change and tire change are carried out appropriately, and the operation and this current situation. Therefore, another vehicle deployment is required in addition to maintenance system is firmly established. There are approximately 10 to 15 non- existing vehicles. Under the Project, it is planned to supplement one vehicle and dispatch cases due to lack of vehicles. strengthen the emergency medical service by two vehicles.

Number of existing vehicles: 2 Since there are also dispatch requests from three branch offices under the jurisdiction, it is · Manufactured year 1990s, China, one box car, good condition, waiting for difficult to respond to all emergency dispatch requests by the current one vehicle. disposal Although the area of the service coverage area is relatively narrow compared to other · Manufactured year 2014, Nissan Urban, good condition 29 Khuroson 1 2 facilities, demand for dispatch requests is large, and deployment of at least three ②④ ㋒-② 2 1 1 Nissan vehicles have breakdowns 1 to 2 times a year. Although Nissan agencies dispatchable vehicles is required. Under the Project, it is planned to replace one vehicle, are not set up, they are requesting maintenance at the local repair factory. There supplement one vehicle, and build emergency dispatch systems by three vehicles are approximately 15 non-dispatch cases annually due to repair. In addition, there together with one existing vehicle in good shape. are about 15 cases that is no dispatch vehicles due to lack of vehicles.

Number of existing vehicles: 3 The target facility is located in the mountain range 30 km from the main road in the · Manufactured year 2005, 1 vehicle, bad condition, malfunctioning direction of the mountain. It is a key facility which has two branch offices in the area of · Manufactured year 2008, 2 vehicles, bad condition, frequent failure jurisdiction, and the service coverage area population exceeds 80,000 people. Since there 30 Muminobod 1 1 ③ ㋒-① 1 1 0 Only two vehicles out of three vehicles are barely able to run, and it is equivalent are many patients transported to Dushanbe city and Kulob city, it is necessary to deploy to one vehicle in activity. Since responding to dispatch requests is about 85%, at least two all-time dispatchable vehicles. Under the Project, it is planned to replace one there are approximately 40 cases which are not able to dispatch per month. aged vehicle manufactured in 2005.

Number of existing vehicles: 7 · Manufactured year 1997, Germany, Mercedes, breakdown, malfunctioning · Manufactured year 2001, Italy, Fiat, Mileage 200,000 km or more, malfunctioning · Manufactured year 2001 Manufactured year China, Mileage 200,000 km or more, At present, there are only two all-time dispatchable vehicles. The target facility is located malfunctioning in the core city of Khatlon, has many emergency service target population. Also there are · Manufactured year 2002, Germany, Mercedes, Mileage 180,000 km, bad condition Bokhtar city approximately 1,200 dispatch requests per month. Considering evaluation for the demand 31 1 3 · Manufactured year 2004, China, Mileage 250,000 km, frequent failure, replacement ①② ㋒-④ 3 3 0 (Qurghonteppa city) of dispatch requests and the distance to the destination, it is necessary to deploy at least required five dispatchable vehicles. Under the Project, it is planned to replace three older vehicles · Manufactured year 2007, China, 2 vehicles, Mileage 150,000 km or more, operable, manufactured before 2004 and to restore and strengthen the emergency medical service. frequent failure Since existing vehicles are used one in higher hospitals, the condition is generally bad. High repair costs squeeze hospital financial management and there are approximately 18 to 23 non-dispatch cases for repair.

Number of existing vehicles: 2 Currently, emergency services is responded by one existing vehicle which is not in good · Manufactured year 2012, Russia, UAZ, unrepairable, planned for disposal shape. However, vehicle is aging remarkably, and it is becoming difficult to obtain repair · Manufactured year 2012, Russia, UAZ, frequent repair 32 Temurmalik 1 2 parts. Also there is a shortage in number. Deployment of at least two vehicles is required ③④ ㋒-① 2 2 0 Although the precise manufactured year is unclear. However, it is likely used according to the size of the service area and the number of dispatch requests. Under the vehicle since aging is remarkable for six years old. There are approximately 10 to 13 Project, it is planned to replace two existing vehicles. non-dispatch cases due to repair.

It is a long-range dispatching facility located in the area adjacent to the Afghanistan Number of existing vehicles: 1 border in the southern part of the Khatlon oblast. Deployment of at least two dispatchable · Manufactured year 2007, Russia, UAZ, Mileage 400,000 km, frequent repair emergency vehicles is necessary according to dispatch demands, service coverage area Existing vehicles are 11 years of age, and frequently out of order. Replacement has 33 S.Shohin 1 3 population. The existing vehicle age exceeds 11 years. Therefore, it is difficult to keep ③④ ㋒-① 2 1 1 been carried such as gearboxes and fuel pumps in 2016, engine cases and starting good running condition even if repair parts are available. Since four branch offices are motors in 2017. Repair costs are high, and it is pressing down finances. There are also subject to emergency service activities, it is planned to deploy two vehicles (1 unit approximately 8 to 12 non-dispatch cases due to engine trouble. replacement, 1 unit supplementation) as a replacement of existing vehicles.

Number of existing vehicles: 3 It is located in the middle of the capital Dushanbe and Kulob city. Emergency patients due · Manufactured year 2004, Russia, UAZ, Mileage 350,000 km, bad condition, to traffic accidents are increasing since trunk road is near. The dispatch demand is 16 to 19 malfunctioning cases / day, and so, at least deployment of two vehicles are required. Currently, one made 34 Norak city 1 2 · Manufactured year 2007, Russia, UAZ, 2 vehicles, Mileage 310,000 km or more, in 2004 is unrepairable, both of the 2007 vehicles age exceeds 11 years, so it is difficult to ①② ㋑-② 2 2 0 frequent failures, replacement required keep good running condition even if repair parts are available. Aiming to rebuild the Repair such as engine replacement is repeated. There are approximately 10 non- emergency medical service which is able to handle the current dispatch requests promptly, dispatch cases due to bad condition and breakdown. it is planned to replace two old vehicles manufactured in 2007.

Number of existing vehicles: 2 · Manufactured year 1995, Russia, UAZ, bad condition, difficulty in driving and The number of cases which is not able to deal with dispatch requests is increasing, since continuing to use existing vehicles exceed the age of 12 years, the durability of parts declines, and 35 Khovaling 1 1 ③④ ㋒-① 1 1 0 · Manufactured year 2006, China, Haifei Changen, Mileage 43,000 km, frequent breakdowns occur frequently. Under the Project, it is planned to replace one vehicle repair manufactured in 2006. There are approximately 15 to 20 non-dispatch cases a month on average.

Number of existing vehicles: 2 It's a long-range dispatching facility located 40 km east of Kulob city. Currently, available · Manufactured year 1996, Russia, UAZ, Mileage 400,000 km, bad condition vehicles manufactured in 2009 are poor in durability. Therefore, there many cases which is Levakant city · Manufactured year 2009, Russia, UAZ, Mileage 150,000 km, bad condition but 36 1 1 not able to respond to emergency dispatches since breakdown frequently occurs, and it ③④ ㋒-① 1 1 0 （Sarband city） operable takes a lot of time. Under the Project, it is planned to replace one old vehicle manufactured There are approximately 7 to 9 non-dispatch cases a month due to repair in 1996, and restore the system which has one all-time dispatchable vehicle. correspondence.

Number of existing vehicles: 1 It is located in the frontier where the border of Afghanistan is at the southeast end of · Manufactured year 2003, Russia, UAZ, Mileage 350,000 km or more, bad Tajikistan. Surrounded by steep mountains, ambulances are a means of transportation to condition, frequent repair, required replacement local medical facilities. As service coverage area spreads, at least two vehicles There are over 10 non-dispatch cases a month on average due to various failures deployments are necessary according to the demand for dispatch requests. Currently, due 37 N.Khusrav 1 2 ②④ ㋒-① 2 1 1 of several times a month. In case of that, it requests to nearby facilities located 50 to the aging of deployed vehicles, it is difficult to say that emergency services activities to 60 km apart. However, some cases are too late to respond. Regarding long are fulfilling their roles. Under the Project, it is planned to replace one existing aging distance transportation, there are some cases that it requests to private vehicles or vehicle and to replenish new one to meet the current emergency demand since it is individual vehicles. However, it costs a lot for patients and causes a problem. necessary to deploy an emergency vehicle urgently.

Number of existing vehicles: 2 It is a planned facility located in mountainous areas far from core cities such as Kulob city · Manufactured year 1990, Russia, UAZ, breakdown, malfunctioning and Danghara, and the transportation infrastructure is not satisfactory. Ambulances are · Manufactured year 2012, China, Haifei Changen, bad condition, frequent failure, emergency services that local residents rely on. However, it is not possible to respond replacement required 38 Baljuvon 1 1 adequately to emergency dispatch requests of 200cases/month, and covers 50% only, in ④ ㋒-① 1 1 0 Although engine replacement has been carried out three times, it has reached the the current situation, The deployment of ambulance vehicles is an urgent issue. Under the limit of durability. There are over 100 non-dispatch cases a month due to lack of Project, it is planned to replace one aging vehicle and strengthen the emergency medical vehicles and breakdown, and transportation responds by private vehicles. There service. are approximately 20 to 30 non-dispatch cases a month due to breakdown.

Number of existing vehicles: 4 Under the Project, it is planned to replace one aging vehicle and strengthen the · Manufactured year 1988, Russia, UAZ, bad condition, difficulty in running emergency medical service. There are about 900 requests for headquarters and branch · Manufactured year 2008, Russia, UAZ, frequent breakdown, operable offices in total, but only two all-time dispatchable vehicles are available. Since the facility · Manufactured year 2018, Korea, Hyundai, 2 vehicles, good condition 39 Bobojon Ghafurov 1 2 has jurisdiction over 13 branch offices, it is necessary to deploy at least four emergency ①② ㋐-④ 2 2 0 The vehicles deployed in the branch are Manufactured year China and Russia with vehicles according to population in the service coverage area. Under the Project, it is a car age of 15 to 20 years, the condition is not good.There are over 60 non- planned to replace two vehicles as a replacement of two old vehicles manufactured in dispatch cases a month due to lack of vehicles. There are approximately 15 to 20 Russian. non-dispatch cases a month due to breakdown.

Number of existing vehicles: 5 · Manufactured year 2004, Russia, UAZ, frequent repair It is a facility to the south is the Kyrgyzstan border, the number of requests for dispatch is · Manufactured year 2006, China, Tangen, frequent repair as many as 800 cases / month. However, one new ambulance was replenished in 2016, and 40 Isfara city 1 0 ⑦ ㋐－③ 0 0 0 · Manufactured year 2007, China, Haifei, operable four existing vehicles are able to respond to emergency services. Therefore, it is not · Manufactured year 2011, Russia, UAZ, frequent repair planned to replace under the Project. · Manufactured year 2016, China, KingLong, Mileage 16,000 km, good condition

Number of existing vehicles: 5 It is a facility located in a remote area near the border of Uzbekistan at the westernmost · Manufactured year 1996, Korea, Hyundai, 2 vehicles, frequent failures, point of Tajikistan. There is no facility that provides emergency services nearby, it is an replacement required important emergency medical service facility relied upon by local residents. Since there is · Manufactured year 2006, Russia, UAZ, bad condition, repair frequent, difficulty only one deployment of an all-time dispatchable vehicle, it causes impeding the provision 41 Panjakent city 1 2 in use of rapid emergency services. It is necessary to deploy at least three dispatchable vehicle ②④ ㋐－③ 2 2 0 · Manufactured year 2008, China, Haifei, 2 vehicles, damaged drive, unrepairable according to calculation of the population and the number of requests in the service One of the five vehicles is available, the remaining four frequently break down. coverage area. Under the Project, it is planned to replace two aged vehicles manufactured Therefore, it is impossible to dispatch all the time. There are over 20 to 30 non- in 1996, and plan to improve the emergency medical service systems by three vehicles dispatch cases a month due to breakdown of vehicles. together with current one.

Number of existing vehicles: 6 Since it is a facility located in the main road from the capital Dushanbe city to Sughd, · Manufactured year 1980s, Russia, malfunctioning emergency service requests due to traffic accidents are increasing. Although four · Manufactured year 2000, South Korea, Hyundai, 3 vehicles, bad condition but emergency vehicles are deployed, the number of dispatchable vehicles is approximately operable two due to repair correspondence. It is necessary to deploy at least four dispatchable 42 Istaravshan city 1 2 · Manufactured year 2001, Russia, UAZ, one vehicle, Korea, Hyundai, one vehicle, ②③ ㋐－④ 2 2 0 vehicles to respond quickly to emergency services. Under the Project, it is planned to frequent failure replace two vehicles and to strengthen the emergency medical service by replacing two Out of six vehicles, one manufactured in 1980s and one manufactured in 2000 are vehicles; one Russian unit manufactured in 1980s and one Korean unit manufactured in not available due to aging remarkably. The remaining four are repeatedly repaired, 2001. and there are approximately 35 non-dispatch cases a month due to lack of vehicles.

Number of existing vehicles: 7 Since it is a facility located on the key points of main road leading to Uzbekistan in the · Manufactured year 2005, China, Haifei, 1 vehicles, Mileage 350,000 km, bad neighboring country, there are many emergency dispatches by traffic accidents. which condition makes it difficult to continue operation. It is necessary to deploy at least 6 dispatchable · Manufactured year 2007, Germany, Opel, 2 vehicles, Mileage 230,000 km, operable vehicles, since it has three branch offices under the jurisdiction and there are more than 43 Konibodom 1 2 · Manufactured year 2008, Russia, UAZ, 3 vehicles, Mileage 470,000 km, bad ②③ ㋑-⑥ 2 2 0 1,500 dispatch requests per month. One vehicle made in 2005 and two vehicles made in condition but operable 2008 have a mileage exceeding 350,000 km. Under the Project, it is planned to replace two · Manufactured year 2010, China, Tangen, 1 vehicle, Mileage 200,000 km, operable aged vehicles manufactured before 2008, and aim to restore and strengthen the rapid Out of seven vehicles, four vehicles are not in good condition, but operable. There emergency medical service. are approximately 25 non-dispatch cases a month due to repair.

Number of existing vehicles: 11 · Manufactured year 2000, Russia, UAZ, 7 vehicles, bad condition, malfunctioning It is a medical facility in the provincial capital, and the number of service coverage area · Manufactured year 2007, Toyota Japan, 1 vehicle, Mileage 300,000 km, good population and emergency dispatch requests is large. Therefore, deployment of at least 7 condition all-time dispatchable vehicles is required. However, currently there are four dispatchable · Manufactured year 2007, China, 3 vehicles, Mileage 250,000 km, bad condition emergency vehicles, three of which are likely to fail. In practice, there are about three 44 Khujand city 1 4 ②③ ㋑-⑥ 4 4 0 but operable operable vehicles. Under the Project, it is aimed to deploy the number of vehicles There are only four dispatchable vehicles and the non-dispatch rate is as high as according to the emergency service demand in the area, and plan to replace four vehicles 10% of the dispatch requests. When necessary, it depends on individual and as renewal of aged vehicles in additon to three current vehicles. In total, seven vehicles private vehicles for emergency services. During a month, there are approximately will be secured. 30 non-dispach days in total by 4 operable vehicles due to repair.

Number of existing vehicles: 3 The target facility is located in a mountainous area about 3 hours away from the capital · Manufactured year 1998, Korea, Hyundai, Mileage 320,000 km, bad condition but Khujand city by car. Although four-wheel drive vehicles suitable for mountain running are operable also deployed, the aging is remarkable and is not able to respond to emergency dispatch Devashtich · Manufactured year 2005, Russia, UAZ, 2 vehicles, Mileage 320,000 km, 4WD 45 1 1 requests. Also, vehicles deployed in 1988 have a car age of 20 years, and it is difficult to ③④ ㋑-① 1 1 0 (Ghonchi) (One vehicle is bad condition but operable, one vehicle is malfunctioning) procure parts. In order to restore the emergency medical service, it is planned to replace A vehicle manufactured in 1998 was transferred from other facilities in January one vehicle with 4WD specification suitable under the Project for driving in the 2018. There are approximately 10 non-dispatch cases a month due to repair. In case mountainous region as a replacement of vehicle manufactured in 2005. of that, transportation depends on private vehicles.

Number of existing vehicles: 3 · Manufactured year 2012, China, Wuling, 3 vehicles, Mileage 36,000 to 40,000 km, The state of the existing vehicle is good, the mileage is not large. In additon to that, the 46 Asht 1 1 good condition provision of one ambulance from the Indian Government is planned. Therefore, it is not ⑧ ㋑-④ 0 0 0 Three vehicles were gifted by president. There are 10 to 12 non-dispatch cases a considered an update of vehicles under the Project. month due to lack of medical teams.

Number of existing vehicles: 5 · Manufactured year 1998, Russia, Gazelle, second hand vehicle, bad condition, malfunctioning · Manufactured year 2000, South Korea, Hyundai, Mileage 200,000 km, bad condition but operable In order to respond quickly to emergency requests at the facility, deployment of at least · Manufactured year 2002, Korea, Damas, Mileage 200,000 km, bad condition but four ambulance vehicles is necessary. Currently, there are only three dispatchable operable vehicles manufactured in Korea although they are not in good shape. There are some 47 Spitamen 1 1 ②③ ㋑-④ 1 1 0 · Manufactured year 2004, South Korea, Hyundai, Mileage 180,000 km, bad cases to be delayed due to lack of vehicles. Under the Project, it is planned to replace one condition but operable emergency vehicle, build a system of emergency service by four vehicles, and strengthen · Manufactured year 2008, Russia, UAZ, Mileage 300,000 km, frequent breakdown, and respond to emergency dispatches. bad condition Vehicles manufactured in Russia are frequently out of order, difficult to obtain repair parts, and unavaiable to run. Also even by vehicles manufactured in Korea, there are approximately 20 non-dispatch cases a month due to repair.

Number of existing vehicles: 4 · Manufactured year 1991, Russia, Gazelle, second hand vehicle, bad condition, malfunctioning · Manufactured year 1998, Korea, Hyundai, Mileage 410,000 km, second hand Although four ambulance vehicles including vehicles older than 25 years of age are vehicle, bad condition deployed currently, there are times when it is impossible to dispatch due to repair · Manufactured year 2002, Korea, Damas, Mileage 200,000 km, bad condition but correspondence. This deployment is equivalent to 1.5 vehicle.It is necessary to deploy at 48 J.Rasulov 1 1 operable ②③ ㋑-② 1 1 0 least two or more dispatchable vehicles according to the activity scale (population, · Manufactured year 2008, Russia, UAZ, Mileage 330,000 km, frequent breakdown, request for dispatch) of the facility. Under the Project, it is planned to replace one vehicle bad condition manufactured in Russia to improve and strengthen emergency services in the area. It was transported for an used vehicle manufactured in 1990s from another facility. Two vehicles manufactured in 2000s are available by being repaired sometimes.There are approximately 18 non-dispatch cases a month due to lack of vehicles.

Number of existing vehicles: 8 · Manufactured year 1998, Russia, UAZ, 2 vehicles, bad condition, malfunctioning · Manufactured year 1998, Korea, Hyundai, Mileage 410,000 km, second hand Dispatchable vehicles for emergency requests are two vehicles manufactured in Korea vehicle, bad condition and some manufactured in Russia are close to age 20 years. When these vehicles are · Manufactured year 2000, South Korea, Hyundai, Mileage 200,000 km, bad calculated into a substantially operable vehicle, it is estimated to two or less vehicles. 49 Mastchoh 1 2 ②③ ㋑-④ 2 2 0 condition but operable Under the Project, since deployment of four vehicles is necessary for the emergency · Manufactured year 2008, Russia, UAZ, Mileage 300,000 km, 4 vehicles, frequent system, it is planned to replace two emergency vehicles according to the scale of current failure emergency service activities. Since six vehicles manufactured in Russia are remarkably in bad condition, there are approximately 15 non-dispatch cases a month due to lack of vehicles.

It is a planned facility located near the middle point of the main road going from Dushanbe Number of existing vehicles: 4 city to Sughd. It is also a key point of transportation, and there are many emergency · Manufactured year 2008, Russia, UAZ, Mileage 250,000 km, 2 vehicles, frequent services dispatch by traffic accidents. It has five branch offices under the jurisdiction, and failure demand for dispatchment requests is 18 to 22 cases / day, spreading emergency services. 50 Ayni ★ 2 · Manufactured year 2017, China, Mileage 60,000 km, 2 vehicles ②③ ㋒-③ 2 2 0 There is a need for deployment of at least four dispatchable vehicles. However, failure Since there are only two dispatchable vehicles for dispatch requests, frequently occurs due to aging Rossian vehicles deployed in the branch office, and it is there are approximately 20 non-dispatch cases a month due to overlapping of the difficult to respond to the prompt emergency services. Under the Project, it is planned to requests. replace two aged vehicles and to improve and strengthen emergency services in the area.

Number of existing vehicles: 5 · Manufactured year 2000, South Korea, Hyundai Strarex, 2 vehicles, Mileage 46,000 km, minor failure Two of the existing vehicles are relatively new, well maintained, and able to respond to the · Manufactured year 2009, China, Haifei, 2 vehicles, mileage unknown, good 51 Zafarobod ★ 1 current emergency service demand. Therefore, it is not planned to deploy emergency ⑤⑦ ㋒-① 0 0 0 condition vehicles under the Project. A second hand vehicle was provided from the local government in January 2018. There are approximately 6 non-dispatch cases a month due to overlapping of requests.

Number of existing vehicles: 4 · Manufactured year 2003, Russia, UAZ, Mileage 350,000 km, bad condition, It is a planned facility located near the middle point of the main road going from Dushanbe malfunctioning city to Sughd. It is also a key point of transportation, and there are many emergency · Manufactured year 2007, Russia, UAZ, Mileage 250,000 km, bad condition, services dispatch by traffic accidents. Three quarters of the deployed vehicles are over 10 difficulty in use years old, and it is time to replace. On the other hand, regarding the number of ambulance 52 Shahriston ★ 1 ③④ ㋒-② 1 1 0 · Manufactured year 2007, China, Haifei, Mileage 110,000 km, bad condition but deployments in the area, it is necessary to deploy at least two emergency vehicles operable considering the number of population (40,000) and dispach requests (400). In addition to · Manufactured year 2017, Korea, Hyundai, Mileage 10,000 km, good condition the existing one, it is planned to replace one unit and improve the dispatching system by Vehicles except Korean one are frequently failure, and it is difficult to dispatch all two vehicles. the time. There are approximately 20 non-dispatch cases a month.

Number of existing vehicles: 5 · Manufactured year 1988, Russia, UAZ, Mileage 350,000 km or more, bad It is a facility located in the area of the foot of the mountain near by the northern border condition, malfunctioning with Kyrgyzstan, and the service coverage area is mostly the mountainous area. Since it · Manufactured year 1989, Russia, UAZ, Mileage 350,000 km or more, bad requires 3 to 4 hours to reach local cities with tertiary medical facilities on one way, condition, malfunctioning emergency vehicles are one of the lifeline for emergency patients. Despite these 53 M.Mastchoh ★ 1 · Manufactured year 2001, Korea, Hyundai, 2 vehicles, frequent failure, geographical environments, ambulances at the facility are aging rapidly and it is difficult ③④ ㋒-② 1 1 0 replacement required to respond quickly to emergency services. Calculating one existing vehicle not aged yet · Manufactured year 2015, Russia, UAZ, Mileage 10,000 km, operable and two Korean vehicles manufactured in 2001 which is in bad shape as one vehicles, it is Out of five vehicles, two vehicles manufactured in 1980s are aged remarkably, and planned to to replace one vehicle and strengthen the system for responding to emergency it is not able to response to dispatch requests. There are over 30 non-dispatch services by the equivalent of 3 vehicles. cases a month.

It is a facility located in the mountain town for 3 hours from the Khorog city to the Number of existing vehicles: 2 mountain direction. Emergency vehicles are used to accommodate emergency patients and · Manufactured year 2007, China, Haifei, Mileage 100,000 kilometers, bad condition transport patients to higher-level medical facilities. They carry 50 to 60 cases per year to but operable higher-level medical facilities in Khorog city and Dushanbe city. Since existing vehicles 54 Van j ★ 1 · Manufactured year 2007, China, Haifei, Mileage 90,000 km, bad condition but ③④ ㋒-② 1 1 0 are relatively old, and breakdowns are frequent, urgent deployment is necessary. It is operable assumed that the current two vehicles are low in operation rate due to repair, and the Two unavailable vehicles whose car age is over 30 years are parked outdoors for failure rate will be higher in the future. Therefore, it is planned to replace one emergency storage, and there are approximately 20 non-dispatch cases a month. vehicle under the Project, and improve and maintain the emergency medical service.

Number of existing vehicles: 5 · Manufactured year 1989, Russia, UAZ, Mileage 350,000 km or more, bad It is a city hospital in Khorog city, the center of emergency services. The number of condition, malfunctioning emergency dispatch requests is large and it is difficult to provide rapid emergency · Manufactured year 2006, Russia, Mileage 250,000 km, bad condition, difficulty in services with existing aged vehicles. Since distant transport such as the capital is not use many times a year, it is necessary to have an emergency medical service of at least three · Manufactured year 2008, Russia, Mileage 250,000 km, 2 units, bad condition but 55 Khorog city ★ 1 dispatchable vehicles. Two vehicles made in 2008 that are likely to fail at present and one ①② ㋒-③ 1 1 0 operable vehicle made in 2013 are considered to have a utilization rate of about 65%, which · Manufactured year 2013, China, Haifei, Mileage 110,000 km, bad condition but corresponding to two dispatchable vehicles.Estimating the current three vehicles as two operable in operation, it is planned to replace one vehicle and restore and strengthen the Although there are three dispatchable vehicles, failure and repair are frequent in emergency medical service. any vehicles. There are approximately 25 non-dispatch cases a month, and some cases respond by private vehicles of doctors.

It is a facility located in the region that borders Afghanistan across the river, the Number of existing vehicles: 2 southernmost tip of Tajikistan. There is no medical facility on the Afghan side, it accepts · Manufactured year 1989, Russia, UAZ, Mileage 400,000 km or more, bad patients such as cardiovascular diseases, patients with gastrointestinal disorders, trauma condition patients due to traffic accidents. Under these circumstances, renovation of buildings and · Manufactured year 2007, China, Haifei, Mileage 120,000 km, bad condition but meical equipment such as endoscopes were being carried out in Japan's Grant Aid Project 56 Ishkoshim ★ 1 ③④ ㋒-① 1 1 0 operable of 2014. Existing vehicles are aged and it is difficult to obtain repair parts. Also, the seat is The only one dispatchable vehicle is remarkably old. Also the seat is fixed in this fixed in the vehicle, it is impossible to carry emergency patients in a recumbent state. The van type, and the stretcher is not able to be loaded. There are approximately 7 non- occupancy rate of vehicles made in 2007 is about 65%. Therefore, it is required to replace dispatch cases a month. rapidly. Under the Project, it is planned to replace one aged vehicle and improve emergency medical service.

Number of existing vehicles: 4 · Manufactured year 1997, Russia, UAZ, Mileage 400,000 km, bad condition, malfunctioning It is a facility located in 50 km from the city of Khorog northwest of the main road, · Manufactured year 2002, Russia, UAZ, Mileage 250,000 km, frequent failure surrounded by steep mountains. Since only one dispatchable vehicle is deployed, even it · Manufactured year 2005, China, Mileage 90,000 km, bad condition but operable is waiting for repair, there are many cases which are not able to respond to the dispach 57 Rushon ★ 1 · Manufactured year 2008, China, Mileage 50,000 km, spring breakage, waiting for requests. It is necessary to deploy at least two emergency vehicles according to analysis ②③ ㋒-② 1 1 0 repair of numbers (15cases/day ) considering population and dispatch requests in service The Chinese vehicle manufactured in 2005 is used only for short distance coverage area. Under the Project, it is planned to replace one vehicle manufactured in 1997 transportation due to aging. In case that it is not able to respond to dispatch and build an emergency medical service by two dispatchable vehicles. requests due to lack of vehicles, private vehicles are arranged. There are approximately 40 non-dispatch cases a month.

It is a facility located in the center of Darvoz. Due to the small site of the facility, the Number of existing vehicles: 3 dispatch center of the emergency vehicles has installed a cargo container in front of the · Manufactured year 1991, Russia, UAZ, Mileage 300,000 km, breakdown, hospital. It is responded to emergency services for 24 hours, and the emergency system is malfunctioning well established. However, only two vehicles are dispatchable, and breakdown occurs 58 Darvoz ★ 1 · Manufactured year 2005, China, Mileage 250,000 km, 2 vehicles, bad condition ①③ ㋒-② 1 1 0 frequently due to aging. Therefore, it is difficult to respond to emergency dispatch but operable requests. Based on the calculation that the existing two vehicles are able to cover one new It is not able to respond for long distance transportation in any vehicles. There are vehicle, it is planned to replace one aged vehicle and establish the emergency medical approximately 35 non-dispatch cases a month due to frequent breakdown. service by two vehicles.

Number of existing vehicles: 4 Since it is the highest medical facility in Tajikistan, there are many cases that emergency · Manufactured year 2001, Russia, UAZ, engine malfunction, malfunctioning vehicles are dispatched to remote areas in order to accommodate serious patients. · Manufactured year 2006, South Korea, Damas, Mileage 300,000 km, bad condition Therefore, it is difficult to respond to the current number of emergency dispatch requests but operable National Medical by two existing vehicles. Basically, the service coverage area of the target facility extends 59 3 2 · Manufactured year 2012, Korea, Damas, Mileage 160,000 km, 2 units, operable ② ㋐-⑤ 2 2 0 Center nationwide. Each departure time is long, also there are cases that requires three days of There are only two dispatchable vehicles, and dispatch requests of patient round trip to accommodate patients. Under the Project, it is planned to replace two transportation are for long distance and long-term dispatch between hospitals. vehicles manufactured in the early 2000, and aim to restore emergency services by four Therefore, in case of overlapping of the requests, it is difficult to respond to dispatchable vehicles. dispatch. There are approximately 12 non-dispatch cases a month.

Number of existing vehicles: 14 An emergency call center is permanently installed at Dushanbe city Clinical Hospital of · Manufactured year 1991, Russia, Gazelle, second hand vehicle, bad condition, Emergency Medical Aid. Also three to four operators and emergency medical technicians malfunctioning are always on stand by at reception booths. Depending on the contents of the dispatch · Manufactured year 1997, Russia, Gazelle, second hand vehicle, 3 vehicles, bad request, a system in which doctors, nurses and others from special team such as cardiac condition, malfunctioning circulation, brain disease, mental disease, trauma ride together to the emergency site are · Manufactured year 2002, Korea, Damas, Mileage 200,000 km, frequent operated. Except for the four high standardized ambulances deployed recently, existing breakdown, replacement required vehicles are old and the aging is remarkable. The repair technician is assigned to the · Manufactured year 2003, Korea, Hyundai, Mileage 200,000 km, 3 vehicles, garage of the emergency vehicle. Also it corresponds to large-scale repair such as engine Dushanbe city frequent failures, replacement required exchange. However, the problem is that procurement of replacement parts becomes Clinical Hospital of 60 3 3 · Manufactured year 2006, South Korea, Hyundai, Mileage 180,000 km, 2 vehicles, difficult as car age is high. Vehicles manufactured before 2000 are difficult to obtain parts ①②③ ㋐-⑦ 3 3 0 Emergency Medical bad condition but operable even in second-hand markets. Also there are cases that vehicles are stored without being Aid · Manufactured year 2017, Germany, Mercedes, high standard specification, 4 repaired. Analyzing from the scope of activity, scale, and demand of the target facility, it is vehicles, running 10,000 km, good condition necessary to deploy at least 6 to 9 dispatchable vehicles. Currently, four vehicles with Three high standard vehicles were granted by the local government in January good operation and two vehicles which have problems in some parts are counted as 2018. Also other vehicles are frequently failure due to aging, and are used by effective vehicles for operation. Based on calculation that nonoperating period is 40% due repairing repetitively. Regarding vehicles with a high age, repair parts are difficult to repair correspondence, two vehicles are equivalent to 1.2 vehicles. Therefore, it is to procure, and the parts costs a lot. Therefore, it is desirable to replace urgently. estimated to be five vehicles in total. Under the Project, it is planned to replace three aged During a month, there are approximately 25 non-dispach days in total by 10 vehicles according to the calculation, and restore and strengthen the emergency medical operable vehicles due to repair. service by 8 vehicles in total deployed together with existing vehicles.

Number of existing vehicles: 1 Research Institute of · Manufactured year 2010, South Korea, Hyundai Strarex, Mileage 300,000 km, Since it is the top maternity hospital in Tajikistan, there are the emergency requests from Obstetrics, minor failure, good condition medical facilities all over the country. Also it may be dispatched to patients for two days. Gynecology and 61 2 1 Non-dispatch case is not many due to maintenance. However, in case of Therefore, it is difficult to provide rapid emergency services under the current situation by ② ㋐-② 1 0 1 Perinatology overlapping of dispatch requests, there are approximately 10 to 15 cases a month one vehicle. Under the Project, it is planned to replace one emergency vehicle, and (Maternity Hospital that requests to city emergency hospitals for transportation . strengthen emergency medical services deployed by the target facility. No.1) During a month, there are approximately 3 non-dispatch days due to repair.

Number of existing vehicles: 0 Since there is no plan to arrange staff such as emergency medical teams, vehicle Emergency services have been requested to Dushanbe city Clinical Hospital of management personnel, and drivers, the emergency medical service is not yet established Maternity Hospital 62 1 1 Emergency Medical Aid, and ambulances are used for patient transportation at the target facility. Also there is a Dushanbe city Clinical Hospital of Emergency Medical ⑥ ― 0 0 0 No.2 between hospitals. Aid which is able to provide emergency services in the neighborhood. Therefore, it is not (Number of dispatch requests in 2017 : 62 (newborns), 7 (pregnant women)) planned to replace for this facility.

Since there is no plan to arrange staff such as emergency medical teams, vehicle Maternity Hospital Number of existing vehicles: 0 management personnel, and drivers, the emergency medical service is not yet established No.1 Emergency services have been requested to Istiqlol city Hospital, 63 1 1 at the target facility. Also there is a Istiqlol city Hospital which is able to provide ⑥ ― 0 0 0 (Maternity Hospital and ambulances are used for patient transportation between hospitals. emergency services in the neighborhood. Therefore, it is not planned to replace for this No.3) (Number of dispatch requests in 2017 : 96 (newborns), 60 (pregnant women)) facility. Number of existing vehicles: 2 · Manufactured year 1989, Russia, UAZ, Mileage 400,000 km, failed in 1995, Since it is a general hospital in the oblast which has many dispatch requests from malfunctioning subordinate medical facilities, deployment of emergency vehicles is required urgently for · Manufactured year 2001, Russia, UAZ, Mileage 250,000 km, failed in 2013, accommodation of serious patients and dispatch of specialists. Until five years before the GBAO Region 1 malfunctioning emergency service was interrupted, there are 300 dispatch requests per month in the target ②③ ㋒-① 1 0 1 64-1 （General Hospital） Two vehicles are waiting for disposal. Therefore, transportation has been facility, and it has experienced deploying drivers and call center staff corresponding to the requested to Khorog city Hospital for emergency services since the vehicles service. Since there are no particular problems in resuming the emergency medical service, became unavailable. it is planned to replenish and provide one emergency vehicle under the Project. 2 It is an obstetric hospital located in the Khorog city of GBAO Region, and patients with severe perinatal disease within the oblast will be visited. Since transportation such as Number of existing vehicles: 0 ambulance are not well stablished, the number of request for dispatch is small. Also latent GBAO Region It was separated from autonomous oblast hospital and established in 2011. demand is estimated to be the same degree in other oblasts, approximately 250 dispatch 64-2 1 ② ㋒-① 1 0 1 (Matemity Hospital) Currently, emergency vehicles are not deployed. However, transportation is requests per month. Emergency services in private vehicles have problems when it comes carried out by individual or private vehicles of doctor. to safety for the patient, but also to a burden on the financial side. Therefore, improvement is desirable urgently. Under the Project, it is planned to supplement one emergency vehicle for the aim of improving the current emergency medical service.

It is a facility located 170 km south of Dushanbe city, along the main highway in the central part of the Khatlon oblast. The main road has a lot of traffic, and the dispatch requests for emergency vehicle by traffic accidents is increasing. Also existing vehicles Number of existing vehicles: 2 become old remarkably and it is time to replace. The service coverage area is widely · Manufactured year 2008, China, Mileage 130,000 km, bad condition but operable spread throughout the oblast, and emergency correspond is also changing / expanding Khatlon Region 65 2 1 · Manufactured year 2008, China, Mileage 120,000 km, bad condition but operable with pregnant women, Cardiac disease, trauma. Considering the number of dispatch ① ㋒-① 1 1 0 (Qurghonteppa) There are approximately 6 to 8 non-dispatch cases a month due to frequent requests, it is necessary to deploy approximately 2 dispatchable vehicles. Estimating the failures. The car body damage heavily, and it is time to replace. two vehicles which are not running well as 70%, it will be service activity which is equivalent to 1.4 vehicle. Based on these calculations, it is planned to replace one existing aged vehicle and deploy an emergency medical service by two dispatchable vehicles under the Project.

It is a facility located 200 km south of Dushanbe city, along the main highway in the west central part of the oblast of Khatlon. The main road has a lot of traffic, and the dispach Number of existing vehicles: 0 requests for emergency vehicle by traffic accidents is increasing. Although the target Since 2007 emergency vehicles have not been deployed, and emergency facilities had provided emergency services until 10 years ago, the provision of services Khatlon Region 66 2 1 transportation is corresponded by individual and private vehicles. The was suspended due to the disposal of existing ambulances for the reason of aging. ① ㋑-① 1 0 1 (Kulob) transportation costs are burdensome on the patient side, so financial burden for However, the demand for emergency services has increased along with recent changes of patients become problematic. the living environment, and establishment of an emergency medical service is required as a regional hospital. Under the Project, it is planned to supplement one emergency vehicle and restore emergency medical service.

Number of existing vehicles: 2 · Manufactured year 2002, Russia, UAZ, Mileage 250,000 km, 2 vehicles, frequent It is an oblast hospital in Sughd, and ambulances are frequently used to transport patients failures, bad condition but operable to higher medical facilities in Dushanbe city. Since existing emergency vehicles have old 67 Sughd Region 2 2 Regarding existing vehicles, the car age exceeds 16 years, the aging is remarkable. ①③ ㋐-② 2 2 0 age and reach durability limit, it is planned to replace two existing vehicles and support Also it is a matter how many more years they will be available. There are the continuous emergency medical service. approximately 15 non-dispatch cases a month due to repair. The finance of the facility is squeezed by repair costs such as engine replacement due to aging.

4. Examination of improvement contents of ambulance vehicles and on-board equipment As mentioned above, ambulance procured under the Project is 2 types, Type A and Type B. Type A is a 4WD vehicle suitable for patient transportation on bad mountain roads. On the other hand, Type B is suitable for medium-range distance transportation, so that it is wide-interior, and possible for attending medical personnel to conduct life-saving measures. Type B is divided into two according to the contents of the activities of the designated facilities, Type B-1 will be equipped with on-board equipment suitable for emergency medical facility and Type B-2 will be equipped with the equipment suitable for Maternity Hospital. The ambulance type and the procurement plan of on-board equipment are shown in the following table.

Table 2-4 Plan of Ambulance Type and On-board Equipment

Quantity Quantity Quantity Total No. Equipment Type A Type B-1 Type B-2 Quantity

1 Type A Ambulance (two box car) 86 - - 86 2 Type B Ambulance (one box car) - 7 1 8 No. －On-board equipment－

*1 Roll in Stretcher 86 7 1 94

*1 Stretcher 86 7 1 94 3 Resuscitation set, manual 86 7 1 94 4 Defibrillator 86 7 1 94 5 Suction unit - 7 1 8 6 Pulse Oximeter - 7 1 8 7 Scoop Stretcher - 7 1 8 8 ECG - 7 1 8 9 Patient Monitor - - 1 1 10 Transport Incubator - - 1 1 Source: Survey Team *1 Roll-in stretcher, stretcher, oxygen inhalation set, O2 cylinder, and flowmeter set etc. are incorporated in composition of both type of ambulances.

(2) Equipment plan The services provided by the ambulances in Tajikistan can be put into 2 categories: [1] support for highly specialized medical services / transportation of emergency patients, and [2] patient transportation to higher medical facilities. Emergency patients, such as pregnant women, childbirth related, injuries due to traffic accidents, cardiac diseases, and brain diseases account for about 80% 13 . Round-trip transportation of emergency patients and transportation to higher medical facilities takes about 2 hours, and to and from the remote place takes about 2 to 4 days. Ambulances at target facilities are repaired frequently due to deterioration stemmed from aging, frequent breakdown, accidents, etc., and repair costs may exceed the administrative budget of emergency medical service depending on the repair site. Furthermore, while repairing, there is no choice but to ask private vehicles or ambulances from

13 It is based on a result of totaling interview and questionnaire survey at the field work.

neighboring facilities to respond to ambulance dispatch request, which impedes the provision of rapid emergency medical service. According to the guidelines of the MoHSPP, medical personnel such as doctors and nurses will be on-board an ambulance during patient transport to provide emergency care such as drip infusion, cardiopulmonary resuscitation, hemostasis etc. Since the medical treatment during emergency patient transportation is required, large patient compartment, and side passenger seat (sitting facing the patient) are required, so that medical treatment can be provided.

1) Specification and grade of Ambulance Ambulance grades and specifications are based on current emergency medical service. In view of emergency medical service status in Tajikistan, the specifications of ambulances and on-board equipment under the Project are as follows.

(i) Durable and fuel-efficient diesel-powered vehicles. The Project will provide diesel-powered vehicles because, compared to gasoline-powered vehicles, diesel-powered vehicles have simple engine electric system, durable, low incidence of defects, good fuel economy, and suitable for running long-haul and on mountainous roads. Diesel fuel, which is available in remote areas in Tajikistan, has been set to be used in temperature conditions of up to 15 below zero. It is confirmed that it can be used in a temperature environment lower than the setting condition by adding commercially available additives. ℃

(ii) Type A, planned for deployment in rural areas, the vehicles will be 4WD vehicles suitable for bad road driving. Since the area of ambulance activity is the mountainous areas around central hospitals and district hospitals, most of the roads to be travelled in the mountains are unpaved roads. Due to the occurrence of flowing water etc. during the rainy season, road surface environment will become bad, muddy road, etc. Even with stuck wheels, it is possible to escape with 4WD vehicles. The body specification of the 4WD vehicle is common two-box car on the same model.

(iii) Type B, planned for deployment in urban areas, the vehicles will be 2WD vehicles suitable for traveling on a relatively well-maintained highway. Ambulance activity starting point is medical facilities in urban areas. Since most patient transportation destinations are medical facilities connected to the main road, in order to reduce burden on transported patients due to vibration and shaking of the vehicle, it shall be a 2WD vehicle with high axle cushioning properties. The body specification of the 2WD vehicle is a common one- box car on the same model.

(iv) The car models with the care-giver seat facing the patient side Medical personnel constantly monitor patients during long periods of patient transportation, and to perform medical treatment if necessary, the seat shall be a lateral seat that enables the medical

personnel to work easily.

(v) The car models with sufficient ceiling height in the patient compartment In order to secure a treatment space as a standard ambulance activity such as primary emergency care of sternal pressure or secondary care of using defibrillator, it is necessary to maintain a certain amount of ceiling height. Many patients with cardiovascular system, respiratory diseases and poisoning, high fever, altitude sickness etc. require intravenous drip during emergency transport. The ceiling height of the patient compartment shall be such that the space necessary for drip can be maintained.

2) Deployment plan for ambulances and on-board equipment Ambulance After examining the improvement plan of the ambulances requested by the Tajikistan side, the ambulances will be deployed as shown in Table 2-5. As mentioned above, since 4 facilities out of the 67 target facilities were excluded from improvement, 63 facilities will be improved. The number of vehicles for the planned improvement is 94, of which 83 will be replaced, and 11 will be supplemented. In addition, the on-board equipment is installed in each type A or B vehicle, refer to Table 2-4 for details.

Table 2-5 Ambulance Deployment Evaluation and Distribution List

Site Name of Site Name of No. County/Region/City No. County/Region/City Project Project Additional Additional Replacement Replacement Original Requested Q'ty Original Requested Q'ty Planned Q'ty (after Survey) Planned Q'ty (after Survey) Planned Type of Vehicle in this Planned Type of Vehicle in this Quantity at Minutes of Discussion Quantity at Minutes of Discussion Original Type of Requested Vehicle ofOriginal Type Requested Vehicle ofOriginal Type Requested 1 Rudak i 2 B A 1 1 0 1 35 Khovaling 1 B A 1 1 1 0 2 Vahdat 2 B A 2 2 2 0 36 Levakant city (Sarband city) 1 B A 1 1 1 0 3 Hissor city 2 B A 1 1 1 0 37 N. Khusrav 1 B A 2 2 1 1 4 Tursunzoda city 2 B A 2 2 2 0 38 Baljuvon 1 B A 1 1 1 0 5 Rasht 2 B A 1 1 1 0 39 Bobojon Ghafurov 1 B A 2 2 2 0 6 Shahrinav 2 B A 2 2 1 1 40 Isfara city 1 B NA 0 0 0 0 7 Faizobod 1 B A 1 2 2 0 41 Panjakent city 1 B A 2 2 2 0 8 Nurobod 1 B A 1 1 1 0 42 Istaravshan city 1 B A 2 2 2 0 9 Varzob 2 B A 1 2 2 0 43 Konibodom 1 B A 2 2 2 0 10 Lakhsh (Jirgatol) 1 B A 2 1 1 0 44 Khujand city 1 B A 4 4 4 0 11 Tojikobod 1 B A 2 2 2 0 45 Devashtich (Ghonchi) 1 B A 1 1 1 0 12 Rughun city 1 B A 1 1 1 0 46 Asht 1 B A 1 0 0 0 13 Sangvor (Tavildara) 1 B A 1 2 2 0 47 S pitamen 1 B A 1 1 1 0 14 Bokhtar 1 B A 2 2 2 0 48 J. Rasulov 1 B A 1 1 1 0 15 Kulob city 1 B A 1 1 1 0 49 Mastchoh 1 B A 2 2 2 0 16 Vose 1 B A 1 1 1 0 50 Ayni ★ A 2 2 2 0 17 Yovon 1 B A 2 2 2 0 51 Zafarobod ★ A 1 0 0 0 18 J.Balkhi (J. Rumi) 1 B A 1 1 1 0 52 Shahriston ★ A 1 1 1 0 19 Vakhsf 1 B A 2 2 2 0 53 M. Mas tchoh ★ A 1 1 1 0 20 Qabodiyon 1 B A 1 1 1 0 54 Vanj ★ A 1 1 1 0 21 A. Jomi 1 B A 1 1 1 0 55 Khorog city ★ A 1 1 1 0 22 Farkhor 1 B A 1 2 2 0 56 Ishkoshim ★ A 1 1 1 0 23 Mir Said Ali Hamadoni 1 B A 1 1 1 0 57 Rushon ★ A 1 1 1 0 24 Danghara 1 B A 1 1 1 0 58 Darvoz ★ A 1 1 1 0 25 Jayhun (Qamsangir) 1 B A 1 1 1 0 59 National Medical Center 3 C B-1 2 2 2 0 Dushanbe city Clinical Hospital of 26 Shahrituz 1 B A 2 1 0 1 60 3 C B-1 3 3 3 0 Emergency Medical Aid Research Institute of Obstetrics, Gynecology and 27 Panj 1 B 61 2 C A 1 1 1 0 Perinatology (Maternity Hospital No. 1) B-2 1 1 0 1 28 Dusti (Jilikul) 1 B A 2 1 0 1 62 Maternity Hospital No. 2 1 C B-2 1 0 0 0 Maternity Hospital No. 1 29 Khuroson 1 B A 2 2 1 1 63 1 C B-2 1 0 0 0 (Maternity Hospital No. 3)

30 Muminobod 1 B A 1 1 1 0 64-1 GBAO Region General Hospital A 1 1 0 1 2 C Bokhtar city 31 1 B A 3 3 3 0 64-2 GBAO Region Maternity Hospital A 1 1 0 1 (Qurghonteppa city) 32 Temurmalik 1 B A 2 2 2 0 65 Khatlon Region Qurghonteppa Hospital 2 C A 1 1 1 0 33 S. Shohin 1 B A 3 2 1 1 66 Khatlon Region Kulob Hospital 2 C A 1 1 0 1 34 Norak city 1 B A 2 2 2 0 67 Sughd Region Hospital 2 C B-1 2 2 2 0 Source: Result of analysis by Survey Team

On-board equipment In Tajikistan, patients are transferred to higher medical facilities for advanced treatment for only patients with stable symptoms, not for patients in a shock state. Therefore, it is not necessary to install advanced medical equipment. Although MoHSPP, Order No. 33 advocates the standard for the recommended equipment for ambulances, most vehicles are not equipped with emergency lifesaving equipment, except for some high standard ambulance vehicles. The following table shows the main recommended equipment and the equipment considered necessary for providing the emergency medical service. It is possible to procure some equipment in Tajikistan, from the standpoint of the need for urgent improvement, and effective input benefits etc.

Table 2-6 Recommended Ambulance On-board Equipment Vehicle type No. Equipment Study results Plan Remark A B ● ● Procured as equipped equipment with A and B type ◎ 1 Defibrillator ambulance ● Procured as equipped equipment with B type ◎ 2 ECG ambulance 3 Ventilator for emergency medical care ● Procurement by Tajikistan side. ― *1 ● Procured as equipped equipment with B type ◎ 4 Patient monitor ambulance 5 Inhalation anesthesia apparatus ● Procurement by Tajikistan side. ― *1 ● Procured as equipped equipment with B type ◎ 6 Suction unit ambulance 7 Portable blood glucose meter ● Procured by Tajikistan side. ― *3 ● Procured as equipped equipment with B type ◎ 8 Pulse oximeter ambulance ● ● Procured as equipped equipment with A and B type ◎ 9 Roll-in Stretcher ambulance ● Procured as equipped equipment with B type ◎ 10 Scoop Stretcher ambulance ● ● Procured as equipped equipment with A and B type ◎ 11 Stretcher ambulance 12 Immobilization vacuum mattress ● Procured by Tajikistan side. ― *1 13 Emergency medical care doctor’s kit ● Procured by Tajikistan side. ― *2 ● ● Procured as equipped equipment with A and B type ◎ 14 Infusion stand or hook ambulance 15 Obstetric set ● Procured by Tajikistan side. ― *2 ● ● Procured as equipped equipment with A and B type ◎ 16 Resuscitation set, manual ambulance 17 Pediatric Set ● Procured by Tajikistan side. ― *2 Traumatology kit for emergency 18 ● Procured by Tajikistan side. ― *2 medical care 19 Treatment kit against drugs and toxins ● Procured by Tajikistan side. ― *4 Thermal insulating container with 20 ● Procured by Tajikistan side. ― *2 automatic heating 21 Portable compressor nebulizer ● Procured by Tajikistan side. ― *2 22 Bactericidal irradiator ● ● Procured by Tajikistan side. ― *2 23 Syringe pump ● Procured by Tajikistan side. ― *2 24 Folding chair stretcher ● Procured by Tajikistan side. ― *1 25 Transportation splint ● ● Procured by Tajikistan side. ― *4 ● ● Procured as equipped equipment with B type ◎ 26 Oxygen inhalation set ambulance ● ● Procured as equipped equipment with B type ◎ 27 Oxygen reducer-inhaler, with cylinder ambulance ● Procured as equipped equipment with B type ◎ 28 Infant incubator ambulance ● ● Procured as equipped equipment with A and B type ◎ 29 Sphygmomanometer ambulance 30 Emergency medical Care set ● ● Procured as equipped equipment with A and B type ◎ (Stethoscope, Thermometer etc.) ambulance Source: Result of analysis by Survey Team ◎ Equipment to be procured under the Project *1 Since frequency of use is not high, it is possible to deal with alternative products. It is proposed that, in future, the preparations of the Tajikistan side should be according to the degree of necessity for each target facility. *2 It is proposed to substitute the existing equipment used in hospitals. *3 Consumables such as inspection paper are specified for each manufacturer, and continuous procurement is difficult, so they are not covered by the Project. *4 These are categorized as consumables so that those should be procured by the Tajikistan side.

Currently, most emergency rescue teams take out equipment such as medical diagnostic equipment sets, ECG, defibrillators, suction unit, and blood pressure monitors from the hospital at the time of dispatching. Analyzing from the current emergency medical service activities in Tajikistan, ambulances should be equipped with medical diagnostic equipment sets (heart rate, respiration, blood pressure, body temperature), airway securing, cardiopulmonary resuscitation equipment, oxygen inhalation, and oxygen cylinders etc. Under the Project, the above-mentioned equipment is divided into [1] equipment to be deployed as ambulance equipment, [2] simple sets of medical equipment/materials (emergency medical sets, resuscitation sets for adults/children), and [3] classified as equipment (treatment kit against drugs and toxins, obstetrics set, blood glucose meter, etc.) that can be procured by the Tajikistan side. Procurement is examined whether is possible or not. Table 2-7 summarizes the procurement plan for on-board equipment.

Table 2-7 Main On-board Equipment Equipment Quantity Equipment Quantity Roll-in Stretcher 94 Pulse Oximeter 8 Stretcher 94 Scoop Stretcher 8 Resuscitation set, manual 94 ECG 8 Defibrillator 94 Patient Monitor 1 Suction unit 8 Transport Incubator 1 Source: Survey Team

(3) Major equipment Table 2-8 shows the major equipment and main ambulance specifications and its purpose of use.

Table 2-8 Main Specification of Ambulance and its Purpose of Use Equipment Main Specification Purpose of use Quantity Diesel Engine, Transportation of emergency Ambulance Left Handle, 4WD patients at city / Oblast and Rayon 86 Type A Exhaust amount：2,500cc or more level hospitals, patient transport Patient compartment with air conditioning between medical facilities Diesel Engine, Accommodation of emergency Ambulance Left Handle, 4WD / 2WD patients, transportation of patients 8 Type B Exhaust amount：2,500cc or more between medical facilities and Patient compartment with air conditioning Sanitary aviation Source: Survey Team

Table 2-9 Main Specifications of the Equipment to be Procured and Purpose of Use (Equipment with ambulance) Ambulance Classification Equipment Main specification Purpose of use Quant. Ambulance Resuscitation set Ambu bag, Used to assist respiration to 94 Type A, Type B (manual) Oxygen tube, shallow spontaneous patients, Airway etc. providing breathing assistance with oxygen inhalation etc. Defibrillator Waveform: Used to deliver an electric shock to 94 Biphasic synchronize: rescue the patient from the lethal I to III Induction (Manual) cardiac arrhythmia such as Ventricular fibrillation, and Cardiac failure. Ambulance Suction unit Max. suction capacity: 20 Used for suction of body fluids 8 Type B L/min or more such as sputum. Max. suction pressure: -600 mmHg or more Pulse Oximeter Display: Used for measurement of oxygen 8 LCD 4 inches or more concentration in the patient’s Measurement range: blood during transportation 35-100% or more Scoop Stretcher Length: 1,650 to 2,020 mm Used like a shovel to rescue the 8 ± 10% victim from an accident scene such Width: 430 mm ± 10% as a slope, and transport it as a tanker ECG Electrocardiogram Used to observe the activity of a 8 induction: standard 12 lead patient’s heart during / manual / auto transportation. Ambulance Patient Monitor Size: 10.2 inches or more Used for the observation of vital 1 Type B Measurement: ECG, heart signs such as heartbeat, ECG, body (Obstetrics and rate, respiration rate, body temperature, respiration of the gynecology temperature etc. patient during transportation. institute) Transport Temperature setting range: Used for transportation of newborn 1 Incubator 25°C - 35°C baby between medical facilities. Oxygen concentration display range: 25% - wider than 55%

2-2-3 Outline Design Drawing The target site location map of the Project is as shown in Figure 2-1 below.

* The sites indicated by No. 40, No.46, No.51, No.62, No.63 were excluded from the Project by the examination result of the request content

Figure 2-1 Site Map

2-2-4 Implementation Plan 2-2-4-1 Implementation Policy As for the execution of work in the Project, the work plan is formulated paying attention to the following items bearing in mind that the Project is implemented in accordance with the framework of the Japanese grant aid scheme of the Government of Japan.

(1) To avoid interference with one another, the executing agency of Tajikistan, a Japanese consultant (the Consultant) and a Japanese equipment supplier (the Supplier) shall consider the implementation schedule, define the scope of works to be carried out by the Japanese and Tajiki sides, set out the starting time of each stage and adjust the completion time.

(2) To minimize the term of work, the Supplier investigates target facility (the parking lot designated by MoHSPP in Dushanbe) 2 months before the delivery of the equipment. In addition, the Supplier checks the route of bringing in the equipment, parking spaces, and the security condition of facilities, but also prepares the schedules for bringing in and setting up the equipment.

(3) To ensure basic operation appropriate maintenance of the planned equipment, Japanese engineers or engineers of local agents authorized by manufacturers shall be sent to provide technicians of the target facilities with initial operation training of the Supplier.

(4) Since the ambulance’s on-board equipment and the defibrillator are not mounted on the vehicles deployed in the rural areas, medical personnel are not familiar with the method of maintaining and managing equipment in a moving vehicle with large temperature differences and vibrations. When procuring equipment under the Project, it is deemed necessary to introduce technical guidance (soft component) based on the manual in Russian to encourage long-term good use of the equipment.

(5) The doctors in the field basically have the general defibrillator operation skills acquired in emergency care education, but local doctors are less likely to receive training continuously and there are concerns about the decline in knowledge, etc. The Project promotes the effective utilization of the procured equipment through the introduction of soft component related to medical technical support by Japanese emergency physicians, and guidance on appropriate and safe use.

2-2-4-2 Implementation Conditions Ambulances require repairs with replacement of parts due to aging or accidents. Some manufacturers do not sell repair parts on the Tajikistan market, so they will be procured from local vehicle agents in Tajikistan. Also, if the local vehicle agent does not stock the parts, they will be ordered from overseas. Since the selection of models requires stable procurement of repair parts and consumables, it is essential that there is an authorized agent of the vehicle manufacturer in Tajikistan or neighboring countries as a condition of procurement.

2-2-4-3 Scope of Works The following table shows the result of the confirmation on the burden scope of works taken by both Japan and Tajikistan sides.

Table 2-10 Major Undertakings to be Taken by Japan and Tajikistan Sides Burden of Burden of Item Japan Tajikistan Commission of the Japanese Bank

1 ① Advising Commission of Authorization to Pay (A/P) ●

② Payment Commission ● Procurement of materials and equipment, Marine transportation, unloading, customs clearance, domestic transportation ① Procurement of planning equipment ● ② Transport costs to Tajikistan by airplane or ship from third country or Japan ● ③ The measures of custom clearance of the materials and equipment at the port of 2 ● disembarkation ④ Domestic transport to the equipment delivery site from the port of disembarkation ● ⑤ Adjustment of vehicles, a test drive/ technical guidance of maintenance and ● inspection ⑥ Domestic transport from the equipment delivery site to the Project site ● Procedures relating to the domestic tax exemptions. Securing necessary budget. Tax 3 ● exemption such as tariffs, Value Added Tax (VAT) and other internal taxes.

4 Procedures for registrations of the ambulances procured under the Project ●

5 Convenience for stay and the immigration of Japanese Project relevant parties ● Ensure the proper use of equipment procured by Japanese grant aid, garages with roof, 6 ● securing necessary personnel for operation 7 Burden of necessary expenses according to the other ●

In addition, the ambulances will be delivered to the capital, Dushanbe, in Tajikistan. Delivery of the ambulances to the 63 target facilities shall be in the responsibility of the MoHSPP.

2-2-4-4 Consultant Supervision (1) Implementation system The Project is implemented by the following 4 parties

1) The Tajikistan executing agency The responsible agency for the Project shall be the MoHSPP of Tajikistan, and the executing agency is a Department of Reforms PHC, and International Relations.

2) The Consultant Since the Project is implemented through Japanese grant aid, the Consultant makes guidance, advice, and coordination throughout the stages of bidding/procuring on a fair basis, in accordance

with the contracts with the implementation institutions in Tajikistan and performs necessary works to promote a smooth implementation of the Project. Specific works are as follows.

・Confirmation of Bidding documents Checking bidding documents for equipment procurement (bidding conditions, equipment specifications, form of bid price)

・Promotion of bidding/ Supplier's Contract Decision of procuring contract system, preparation of procuring contract draft, investigation of equipment supply and handover document, selection of the Supplier (bid announcement, bidding and bid evaluation, contract negotiation and contract witnessing)

・Examination and approval of manufacturing and delivery plans, etc. Examination and approval of equipment specification and procurement plan submitted from the Supplier

・Report of procurement progress situation Supervising and reporting of procurement progress to the MoHSPP and related institutions

・Cooperation for payment approval procedure Cooperation for content investigation and procedure of bills, etc. related to payment to be made after shipping

・Consultant works for procurement Witnessing of various operations of the works from commencement to completion

3) The Supplier The equipment is procured by the Supplier selected through bidding. The Supplier is in charge of equipment manufacturing, supplying and delivering in accordance with the contract concluded with the Tajikistan side. Also, handover will be implemented after giving guidance on initial operation and maintenance/management of the equipment to the Tajikistan side.

4) Japan International Cooperation Agency (JICA) JICA, an independent administrative institution, gives advises the Consultant to be properly conducted the Project in accordance with the scheme of Japanese grant aid. In addition, to consult with the MoHSPP, if necessary, and to promote the implementation of the Project.

(2) Personnel Plan Those who are engaged in the consulting work as to the implementation design and the procurement supervision are as follows:

1. Project Manager (Japanese consultant): 1 person 2. Equipment Planner (Japanese consultant): 1 person 3. Resident procurement supervision engineer (Japanese consultant): 1 person 4. Inspection engineer (Japanese consultant): 1 person

2-2-4-5 Quality Control Plan The model of an ambulance will be selected taking into account the cold climate in Tajikistan. The equipment shall be the products that comply with the international standards such as JIS, BS, DIN, FDA, etc. The ambulance on-board equipment shall be manufactured at the factory with products meeting the criteria in the ISO13485 of the medical equipment quality control standards or the Pharmaceutical Affairs Act of Japan, Good Manufacturing Practice (GMP), in case of Japanese made.

2-2-4-6 Procurement Plan (1) Country of Origin of the Equipment The Equipment shall be procured principally in Japan or Tajikistan. However, some of the equipment shall be procured from third countries, if they fall under any of the following 4 conditions:

(i) Equipment which is not manufactured in Japan. (ii) Equipment is manufactured in Japan, but competition in the bidding will not be effective if the country of origin is confined to Japan, and thus it is highly unlikely to be able to ensure fair bidding process. (iii) Equipment which is considerably expensive because of the transport or other costs if the country of origin is confined to Japan, and thus has no economic rationality. (iv) Equipment which has to be procured urgently, or there are any other unavoidable reasons.

(2) Countries to procure Spare Parts Spare parts made in Japan and third countries shall be procured, for which sales agents are available in Tajikistan, and which can be regularly and easily procured on the local market in Tajikistan. If there is no local agent in Tajikistan, spare parts of manufacturers which have agencies in neighboring countries (Kazakhstan, Turkey, and Russia) shall be procured.

(3) Equipment delivery procedure Among the procured equipment from overseas, Japanese products have been landed at the Lianyungang port in China from the sea route, transported on land via. Kazakhstan, Kyrgyzstan, etc., then cleared at Dushanbe customs in Tajikistan. For third country’s products, after transportation by air route or railroad, they are cleared at Dushanbe customs in Tajikistan and then transported to the target facilities.

2-2-4-7 Operational Guidance Plan In the Tajikistan’s emergency medical service, since the drivers are in charge of maintenance of the vehicle, MoHSPP requested the initial operation guidance and the implementation of the operation guidance at the time of delivery of the ambulances. Under the Project, the Japanese local procurement management personnel at the time of delivery of all the vehicles in Dushanbe City conduct inspection, confirmation of quantities, vehicle drive unit adjustment/commissioning, and initial operation guidance. After the delivery of the ambulances, the vehicle managers of each target facility, and ambulance drivers (all 63 facilities) are summoned to 5 places such as the capital city and provincial capitals (Khatlon Oblast capital Kurgan-Tyube and the former capital Kulob), and local procurement management personnel (vehicle maintenance technicians) will provide operation guidance pertaining to equipment maintenance and management. The commissioning and operational guidance of the ambulances is shown in the following table.

Table 2-11 Commissioning and Operation Training for Ambulances

A. Initial operation and commissioning guidance Implementation B. Operation guidance implementation （94 vehicle, 7 days） (1.0 days) x 5 times To give guidance for 94 drivers in Implementation of 5 seminars for about 350 drivers in 5 provincial capitals Dushanbe City

・Maintenance and handling guidance ： How to keep vehicles in cold winter climate, importance of warming up driving, countermeasures against engine unit freezing, temperature control, freeze ・ Initial operation guidance： protection of door key, guidance on engine oil change method and its oil quality Activation of engine, headlight, (hardness), washer fluid replenishment, oil filter, air filter method of exchange operation of front wheel / rear wheel

transmission (4WD case), car width ・Operation management guidance ： light, direction indicator, stop light, Detection of abnormal sound from the transmission and axle, how to utilize low hazard light operation confirmation, and high-speed operation, bad road driving, protection of car body, suspension loudspeaker, siren function check exhaustion, warming driving method, vehicle interior cleaning, fixation of on-

board equipment ・ Start-up inspection：

Tire tightening bolt confirmation, air ・Checkpoint of cyclic replacement part： pressure check, spare tire Inspection of brake shoe and wiper rubber blade confirmation, steering wheel rattling, Radiator cooling water level control, antifreeze water concentration abnormal engine sound detection, air Lifetime of fan belt, rubber packing, etc. conditioning equipment adjustment, Battery life, battery replacement timing, battery reset method, cold battery cleaning management etc. management at cold temperature, How to replace a spare tire at puncture. Timing of snow tire installation, timing of tire rotation, etc.

In accordance the operation shift, 3 to 4 drivers will be responsible for each ambulance to be procured under the Project, a total of 330 - 370 drivers will be responsible for vehicle maintaining and managing for the 94 vehicles. Bringing all the drivers for a certain period of time will be a huge burden on the Tajikistan side, as it will disrupt the operation of emergency medical service, and is a travel financial

burden, hence the guidance is divided into two, A and B below.

A. At the time of delivery of a vehicle, one driver for each vehicle will gather at the delivery point in Dushanbe City to pick up the vehicle. At the time of delivery of the vehicle, the 94 drivers are divided in groups of about 20 people to conduct commissioning and initial operation guidance.

B. After the vehicle has been transported by the Tajikistan side to the target facility, approximately 40 to 50 people in charge of the vehicle maintenance in the area are invited to the nearest capital city of the facility, and the vehicle local agent technicians will provide training in repair, maintenance and operation management.

2-2-4-8 Soft Component Plan Doctors who are engaged in emergency medical care took a lecture on defibrillators for about 20 hours, plus a doctors and nurses attended an emergency medical training course called emergency medical service for about a month. Although they have basic knowledge to practice the clinical activities utilizing the Defibrillator planned under the Project, doctors and nurses in rural hospitals, which make up most of the facilities covered by the Project, are working in remote areas, and they have few opportunities to receive review training continuously, and there are concerns about the decline in the acquired knowledge, etc. The Project will dispatch Japanese emergency physicians, and introduce medical technical support for the smooth launch of procured equipment, and the acquisition of appropriate, effective and safe usage methods. A detail content of soft component is as follows;

(i) Guidance on flow from primary lifesaving method (basic life support) to secondary life-saving method through lectures. (ii) Guidance on the determination of electric shock voltage according to patient's physique, electrocardiogram waveform etc. (Practice using emergency resuscitation simulator manikin), and practical guidance on electric shock method synchronized with QRS wave for atrial fibrillation patients who need synchronous cardioversion. (iii) Guidance on basic maintenance method of equipment using "Maintenance management manual for on-board equipment" elaborated by the Consultant

2-2-4-9 Implementation Schedule (1) Implementation Schedule The Project, if it is to be carried out as a grant aid project of the Government of Japan, shall follow the procedures given below after the signing and conclusion of an E/N and G/A.

1. Signing of the E/N between both governments, and conclusion of the G/A between JICA and the Government of Tajikistan. 2. Arrangements on payment of the Japanese grant aid for the Project between the executing agency and a bank in Japan [Banking Arrangement (B/A)]. 3. Conclusion of consultancy agreement between the executing agency and the Consultant. 4. Issuance of the written A/P to the consultancy agreement by the executing agency. 5. Verification of the above contract in "4. " by JICA. 6. Preparation of bidding documents by the Consultant. 7. Approval of the bidding documents by the executing agency and preparation for bidding by the Consultant. 8. Implementation of bidder, and evaluation of bidding proposal. 9. Conclusion of Supplier's Contract between the executing agency and the Supplier. 10. Verification of Supplier's Contract by JICA. 11. Guidance in issuing A/P by the Consultant for contract between the executing agency and the Supplier 12. Equipment inspection by the executing agency (If necessary, the Consultant that witnesses an inspection of the equipment before shipment from factory, approves as the executing agency.). 13. Confirmation and adjustment of the schedule for equipment installation by the Consultant. 14. Procurement management (In accordance with the agreement, the Consultant conducts the procurement work on behalf of executing agency such as an inspection and approval of the equipment specification, an inspection and approval of the equipment, supervision and instruction of the inland-transport, and a supervision of implementation status borne by the recipient country). 15. Process management (the Consultant manages the process to complete Supplier's Contract within the period stated in the E/N, and gives necessary instructions to the Supplier.).

16. Commissioning and delivery inspection (the Consultant conducts inspections of a commissioning and an equipment procurement to verify the quality described in the specifications is ensured, and submits a certificate of completion of inspection to the executing agency.) 17. Complete and delivery of equipment

(2) Implementation period Implementation works schedule of the Project after the conclusion of E/N is indicated in the Figure 2-2 Implementation schedule.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ★ E/N・G/A （Bidding Stage：4 months）

(Confirmation of Schedule）（） Stage Bidding Document/Technical Specification

（Confirmation of Bidding Document）（Bidding Notice） Bidding （Bids / Evaluation of Bid / Supplier’s Contract）（Confirmation of Drawings） (Implementation Stage：10 months）（Manufacturing / Procurement）

（Pre-shipment Inspection）

（Transportation / Procedures）

（Inspection, Initial operation guidance）

▲（Inspection and Handover） Implementation （Initial operation guidance for ambulance）

（ Initial operation guidance for medical equipment）

（Soft Component：0.5 months）

Soft

Component

Overseas work Domestic work

Figure 2-2 Implementation Schedule

2-3 Obligation of Recipient country The Tajikistan side shall cover the following obligations involved in implementation of the Project;

(i) To provide a site in the MoHSPP facility as a temporal office, during the implementation period of the Project. (ii) To provide any assistance that facilitates prompt landing, customs clearance, inland transport of materials and equipment to be imported for the Project. (iii) To provide space to provisionally store ambulances to be procured under the Project. (iv) To deliver the ambulances to be procured under the Project, from the delivery site to the Project site. (v) To conduct promptly the procedure of vehicle registration for the ambulances to be procured under the Project. (vi) To exempt custom duties and other taxes for the Japanese staying in Tajikistan for the purposes of the Project. (vii) To provide any assistance necessary for Japanese to stay in Tajikistan for the Project implementation, and secure the security of these people. (viii) To pay fees for B/A and A/P. (ix) To secure necessary budgets and personnel so that the equipment etc. procured under the Japanese grant aid will be appropriately and effectively utilized and maintained. (x) To provide the garage with roof for the ambulances to be procured in order to ensure the protection of the vehicle in a severe cold environment under the Project, even though the ambulance is designed suitable for cold regions. (xi) To maintain and manage the equipment procured by the Japanese grant aid adequately and effectively. Also, to regularly report to the Government of Japan on the state of use and maintenance of the equipment etc. procured under the Japanese grant aid. (xii) To bear all of expenses generated by implementation such as customs duties and value added taxes other than those covered by the Japanese grant aid.

2-4 Project Operation and Maintenance Plan (1) Personnel deployment plan MoHSPP shall allocate the necessary personnel to the Project. Regarding ambulances scheduled for replacement, in order to utilize the existing personnel, in principle, there is no need to increase personnel. However, for facilities supplemented with new ambulances, it is necessary to increase number of drivers. Also, medical personnel are to be assigned to medical facilities scheduled to be supplemented with ambulance, and it is considered not a problem providing emergency medical service because these medical staffs are on board. Regarding the driver, it is confirmed that the procedure for arranging personnel deployment has been confirmed between MoHSPP and the Oblast Health Department, which has jurisdiction over the target facilities, and it is considered not a problem.

(2) Equipment maintenance plan Regarding repair and maintenance, routine inspection, and repairs due to breakdown and accident of ambulances under the jurisdiction of MoHSPP, small repairs are handled by drivers or technicians assigned to each facility. For major repair and maintenance, the services are provided from private repair workshops. Dushanbe Health Department is in charge of “Shifobakhsh” National Medical Center in the metropolitan area, Dushanbe Emergency Hospital, Maternity Hospital etc., and the Oblast Health Departments are responsible for the Oblast, Rayon, and Central District Hospital in rural areas. The same system will be used in the maintenance and management of ambulances planned to be procured under the Project.

(3) Securing the Project budget The Dushanbe Health Department and the Oblast Health Department are required to secure an operational budget for ambulances to be provided under the Project. Initial expenses such as vehicle registration will be borne by the Tajikistan side. In particular, Tajikistan will record expenses for the new supplement of 11 ambulances as new expenses. Maintenance and management expenses including ambulance-related personnel and fuel costs are covered by the government budget. The flow of the budget depends on the institution to which the facility belongs. National facilities such as the “Shifobakhsh” National Medical Center expend from the MoHSPP city facilities such as Dushanbe Emergency Hospital expend from the Dushanbe City Health Department, the Oblast facilities such as the Oblast hospitals, Rayon Central District Hospital etc. expend from the Oblast Health Department. The budget of each medical facility differs according to the contents of activity, but increase or decrease of payment amount depends on the financial situation of the Local administration at Oblast level. Regarding the budget shortfall, hospital medical paid fees or an additional budget application, it is secured from their financial resources. Although the Oblast Health Department and the Rayon Health Department are responsible for the operation and maintenance of these ambulances, MoHSPP is responsible for the Project that manages these budget procedures.

2-5 Project Cost Estimation 2-5-1 Initial Cost Estimation According to the integration condition shown in "2-5-1 2) Cost Estimation Condition" below, the breakdown based on the Tajikistan scope of work is estimated as follows.

1) Estimated Cost to be borne by Tajikistan side Approximately 177 thousand TJS (approx. 2.1 million yen)

Table 2-12 Estimated Cost to be Borne by Tajikistan Side Unit: TJS

Japanese Yen Unit Items Classification Quantity Amount Converted amount price (thousand yen) For short 124 10 1,240 15 distance areas*1 (1) Automobile insurance For long distance 206 84 17,304 209 areas*2 (2) Vehicle registration fee 415 94 39,010 472 For short 496 10 4,960 60 (3) Domestic transport distance areas*1 insurance For long distance 976 84 81,984 991 areas*2 (4) Bank Commission 32,175 389 Total 176,673 2,136 ※Some total and breakdown do not match due to rounding off. *1 For short distance areas, target facilities in the vicinity of Dushanbe, within 15 km *2 For long distance areas, target facilities located outside 15km or more from Dushanbe

2) Cost Estimation Condition 1. Time of estimation: May, 2018 2. Exchange Rate: US Currency 1 USD = 109.22 JPY Tajikistan Currency 1 TJS = 12.09 JPY14 3. Procurement period: Periods of the detailed design and equipment procurement are shown in Figure 2-2. 4. Others: The Project shall be implemented in accordance with the grant aid scheme by the Government of Japan.

2-5-2 Operation and Maintenance Cost The estimated annual maintenance cost for each target location, such as fuel costs necessary to operate procured ambulances, is shown in Table 2-13.

14 1 TJS = 12.09 JPY (June 2018). https://www.oanda.com/lang/ja/currency/converter/

Table 2-13 Estimated Costs of Operation and Maintenance (Fuel Costs) Unit: TJS Fuel cost Fuel cost for Government Special budget for Budget ratio Region Budget Total Supplement budget（2017）（2017） replaced (%)*1 vehicle vehicle Dushanbe 176,360,898 28,110,738 204,471,636 44,631.38 9,358.19 0.004% RRS 147,139,574 67,445,938 214,585,512 212,358.98 17,996.52 0.008% Sughd 334,180,363 1,541,253 335,721,616 244,032.84 0 - Khatlon 356,230,297 23,855,167 380,085,464 347,692.77 69,106.62 0.018%

GBAO 63,446,140 13,318,670 76,764,810 63,347.76 23,035.54 0.030%

Source: Trial calculation with field survey data. Total fuel cost 912,063.73 119,496.87

Japanese yen 11,026,850 1,444,717 *1 Ratio of fuel cost of newly replenished vehicles to total sum of budgets of each sector

Estimated conditions base on the outline survey analysis: ・Non assumption of increase of the number of ambulance dispatch. ・Non assumption of price increasing. ・Price of fuel /oil :7.1 TJS/L.

Ambulances scheduled for procurement under the Project will be focusing on the replacement of ambulances currently in operation at the target facilities. Therefore, no major problems are expected to arise in operation and maintenance cost. However, since some ambulances are supplement, if the scope of the emergency medical service activities expands, the operating costs are expected to increase. For that part, additional budget measures for the operation and maintenance costs including fuel of ambulances by the Tajikistan side will be required. The following table shows the operation and maintenance costs of personnel expenses, consumables etc. for newly supplement vehicles.

Table 2-14 Estimate of O&M Costs (Labor and Consumables)

Description Quantity TJS Japanese Yen

Drivers’ salary for new ambulance per year 11 160,984 approx. 1,950,000 Expenditure of annual charges for 11 6,414 approx. 80,000 Consumables for new ambulances Expenditure of annual costs for 8 5,300 approx. 64,000 Consumables for ambulance equipment

As shown in Table 2-13 and 2-14 above, the annual operation and maintenance costs for the equipment scheduled for procurement under the Project is approximately 11.02 million yen (about 910 thousand TJS) for the ambulances to be replaced, and about 1.44 million yen (about 120 thousand TJS) for new ambulances, and the estimated total is about 12.46 million yen (about 1.03 million TJS). The average labor costs for the drivers of new ambulances is about 1.95 million yen (about 160 thousand TJS), and the average annual costs for replacement parts, the oil filter, fan belt, etc. are about 80 thousand yen (about 6 thousand TJS). The operation and maintenance costs including fuel for these new ambulances

are about 3.47 million yen (about 290 thousand TJS), which about 0.28% of the total health sector budget (2017) of about 12.11 billion yen (about 100 million TJS) 15 , and it is within the current budget expenditure range. Regarding consumables for ambulance equipment, such as ECG, patient monitor, which is mounted on a B-type vehicle, it is necessary to have disposable electrodes. These consumables are estimated to cost around 8 thousand yen per vehicle annually, in addition to electrocardiographs and monitors. The estimate is based on current emergency transport demand, although the amounts of consumables varies depending on number of emergency patients. The estimated cost of the consumables needed for emergency services for ambulance vehicles scheduled to be provided in the Project plan is 64 thousand yen per year (about 5,300 TJS). Since the operation and maintenance costs of the ambulances to be replaced are the costs that have already been spent, and the operation and maintenance expenses of the new supplement ambulances are within the range that can be handled by the current budget of MoHSPP, it is concluded that there is no problem in the operation and maintenance management in the implementation of the Project.

15 Source：National Budget Financial Year 2017, Ministry of Finance

CHAPTER 3 PROJECT OF EVALUATION

Chapter 3 Project Evaluation

3-1 Preconditions The main preconditions for the implementation of the Project as follows.

1. Tajikistan shall promptly arrange for tax exemption concerning the importation of equipment and assist in customs clearance procedure and other various procedures at Tajikistan border. 2. The Japanese side bears the cost for the transportation of ambulances and on-board equipment to be procured under the Project to the place of handover in Dushanbe. The Tajikistan side bears the cost for the transportation of the vehicles from Dushanbe to the Project’s target facilities, as well as vehicle registration, provision of insurance, and arrangement of drivers needed for transportation. 3. Employ drivers and medical personnel needed for the operation of the ambulances to be replaced including for the new ambulances to be procured.

3-2 Necessary Inputs by Recipient Country The purpose of the Project is to develop a nation-wide emergency medical service network and provide “effective emergency medical service accessible to all people” for local people through the procurement of ambulances. Although the provision of ambulances will improve the emergency patient transport system, medical facilities in remote areas do not have sufficient medical service systems for diagnosing and treating transported patients. Since Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and other equipment that are effective in accurate diagnosis of emergency patients are available only in major cities, patients who may or may not need the treatment are transported to the capital under the present circumstances. To establish a more effective system for emergency medical services, it is desirable to consider how to develop the system to cover both examination and treatment in main cities and local areas. In order to strengthen and expand the emergency medical service system in Tajikistan, in the face of a shortage of physicians and other medical personnel, it is also necessary to train and secure medical personnel who can perform life-saving procedures, and to maintain the function of sanitary aviation service.

3-3 Important Assumptions Important assumptions for effective and sustainable project impacts are as follows.

1. Tajikistan will continue to implement the present policy for emergency medical services. 2. The fuel for ambulances will be supplied stably at appropriate prices. 3. Efforts will be made to maintain the total number of ambulances currently deployed and it will be possible to provide the cost of replacement of vehicles that will become unusable due to aging, accidents, etc. 4. There will be no extensive disruption of the road network due to a natural disaster or other causes.

3-4 Project Evaluation 3-4-1 Relevance The Project relevance for implementation under the Japanese Gant Aid Project is as follows.

1. MoHSPP aims to "secure effective emergency medical services accessible to all people" which enables them to receive medical service promptly and effectively in each area. However, many of the ambulances needed for patient transportation have become unusable due to breakdown from aging, accidents, etc. Meanwhile the demand for emergency medical services is rising because of increase in NCDs and the change of traffic environment. Therefore, there is urgent need for provision of ambulances in this situation. Through provision of ambulances, the Project plans to help with the establishment of the emergency medical service system.

2. The project does not include advanced equipment. As the types of equipment to be procured are already in use in the country and the maintenance systems already established, it can be operated and managed by a minimal addition of personnel and can be used effectively for a long time.

3. The Project beneficiary areas are the whole of Tajikistan, and the beneficiary population is the general people of the country, which is approximately 8.9 million people. This means that the Project will be beneficial to Tajikistan.

4. The goal of the Project is “securing effective emergency medical service accessible to all people” for the public. It is in line with the aim of ensuring Basic Human Needs (BHN) through “improvement of health services” stipulated under the priority area “social development” in the assistance policy of Japan. In addition, the development of a nationwide emergency medical service network through the Project is expected to ensure the rapid provision of ambulance services to inhabitants in remote areas and improve accessibility.

3-4-2 Effectiveness The implementation of the Project will enhance the emergency medical service system pertaining to the transportation of emergency patients, and the following quantitative and qualitative impacts can be expected.

(1) Quantitative impacts (Indicators showing the achievement of the Project)

Table 3-1 Quantitative Impacts Target value (2022) Baseline Indicators (3 years after the Project (Actual value as of 2016) completion) 1. Number of emergency dispatch in Rayon, City, and Oblast (case)

Target facilities under the Project*1 499,926 570,000

2. Number of emergency dispatch of the facilities where vehicles are supplemented

Khatlon Region (Kulob) 0 1,800

GBAO Region（General Hospital） 0 1,500

GBAO Region (Maternity Hospital) 0 1,500 *1 The emergency transportation cases (6,767 cases) in Sughd Oblast, Istiglio, Buston and the emergency transportation cases (3,177 cases) in GBAO, Murghob, Roshtqal'a, Shughnon were excluded from the reference values, since they are not targeted facilities of the Project.

Basis for calculating indicators 1. Number of emergency transportation in City, District and Oblast.  The reference values are based on the 2017 annual statistics of the MoHSPP.  From the interviews at the target facilities, it is estimated that the ambulance dispatch rate at the target facilities is approximately 68-70% hence the non-response rate, no dispatch despite the call, is 30-32%. Unnecessary calls such as consultation, inquiries, complaints etc. make up 20% of the calls. Therefore, the rate at which it is impossible to dispatch even though the response is necessary is calculated as 10-12%. The non-response is due to insufficient number of vehicles because of maintenance and repair.  The improvement rate of emergency service as a result of vehicle maintenance under the Project is calculated as approximately 16% increase (80/69) from the comparison between the median value of the present dispatch rate 69% and 80% out of total number of calls (excluding 20% of unnecessary for emergency dispatch correspondence). Therefore, the target value after the completion of the project is set to increase by 16% of the reference value.

2. Number of emergency dispatch at the facilities where vehicles are supplemented  The ambulance emergency calls are 350 cases a month (4,200 cases a year) in Khatlon Region (Kulob). For 20% of those calls it is not necessary to dispatch because it is just consultation and inquiries. 70% of them are to be dispatched since some cases are not able to dispatch due to

overlapping or shortage of vehicles. The average emergency dispatch request is 6.4 cases per day (4,200×0.8×0.7÷365). However, since long distance transportation is expected in 20% of those cases, the number of actual transportations is expected to be five cases per day.  There are 250 to 300 calls per a month (3,300 calls per year) for ambulance emergency services in GBAO (General Hospital) and GBAO (Maternity Hospital), however they also include consultation, inquiries calls, and cases unnecessary to dispatch so the daily needs are calculated based on 5.1 cases per day (3,300×0.8×0.7÷365） from estimating example of Khatlon Region (Kulob). In addition, since the long-distance transportation is assumed in about 20% of those cases, the number of actual emergency dispatch is set at 4.1 cases per day.

(2) Qualitative Effects 1. The scope16 and type17 of emergency medical services will be expanded and upgraded through replacement of vehicles and on-board equipment. 2. The replacement of vehicles and on-board equipment will enable medical personnel to provide safe emergency medical services. 3. Emergency medical services can be provided timely and appropriately during emergency transportation.

16 With the introduction of 4WD suitable for bad roads, it is possible to accommodate patients at mountains emergency sites even during snowfall. 17 In some facilities, it is possible to transport premature babies and observe vital signs of patients during transporting them.

APPENDICES

1. Member List of the Study Team

2. Study Schedule

3. List of Parties Concerned in the Recipient Country

4. Minutes of Discussions (M/D)

5. Soft component plan

6. References

7. Other materials / information

Appendix 1. Member List of the Survey Team (1) Field Survey I (12th of March – 14th of April, 2018: 34 days) Name Position Organization Health Team 4, Health Group 2 Tatsuya ASHIDA Team Leader Human Development Dept. Senior Advisor JICA Mitsuo ISONO Technical Adviser

Health Team 4, Health Group 2 Masato MAT SUN O Cooperation Planning Human Development Dept. Chief Consultant / Yasuko ASANUMA Binko International Ltd. Equipment Planning 1 Deputy Chief / Shinichi KIMURA Binko International Ltd. Equipment Planning 2 Procurement Planning / Koei Research and Consulting co., Yusuke ICHIMASA Consul- Cost Survey 1 Ltd. tant Toshitsugu MATSUMURA Facility Planning Binko International Ltd. Koei Research and Consulting co., Keiko KOBAYASHI Health Planning Ltd. Kenji SAWAI Coordinator Binko International Ltd.

(2) Explanation of Draft Final Report (23rd of August – 1st of September, 2018: 10 days) Name Position Organization Senior Advisor Mitsuo ISONO Team Leader

JICA Health Team 4, Health Group 2 Yukari MAEDA Cooperation Planning Human Development Dept. Chief Consultant / Yasuko ASANUMA Binko International Ltd. Equipment Planning 1 Consul- Deputy Chief / Shinichi KIMURA Binko International Ltd. tant Equipment Planning 2 Kenji SAWAI Coordinator Binko International Ltd.

Appendix 2. Survey Schedule (1) Field Survey I (12th of March – 14th of April, 2018: 34 days)

Project M anager Equipment procurement JICA Equipment planning-2 Facilities planning Health planing /Cost estimation Mitsuo ISONO Equipment planning-1 No Date Tatsuya ASHIDA Masato MATSUNO Yasuko Asanuma Shinichi Kimura Yusuke Ichimasa Toshitsugu Matsumura Keiko Kobayashi

1 2018/3/12 Mon Dep. Narita⇒Seoul⇒Almaty

Almaty⇒ AM Arr. Dushanbe Courtesy visit JICA Tajikistan office 2 2018/3/13 Tue Health and Social Protection Ministry visit / discussion Meeting with Local Consultant

National Compound of Tajikistan "Shifobakhsh" (Explanation of Inception Report / Check itinerary） 3 2018/3/14 Wed National medical equipment maintenance center, M edtechnika Hearing survey on medical equipment

National Compound of Tajikistan "Shifobakhsh" 4 2018/3/15 Thu Dep. Narita⇒Seoul⇒Almaty Hearing survey on medical equipment / ambulances

No.51 Dushanbe Municipal Emergency Clinic Hospital, Almaty⇒AM Arr. Dushanbe 5 2018/3/16 Fri No.52 Maternity Hospital No.1 No.52 Maternity Hospital No.1 Hearing survey on Ambulances Hearing survey on Ambulances（Same as PM / Equipment plannig)

National Compound of Tajikistan National Compound of Tajikistan National Compound of Tajikistan "Shifobakhsh" 6 2018/3/17 Sat "Shifobakhsh" "Shifobakhsh" Hearing survey on Pediatric Dep, Ob/Gy Dep Hearing survey on M edical facilites Hearing survey on budget, etc

DRS, No.4 Tursunzoda city ,No5 Shahrinav 7 2018/3/18 Sun Internal Meeting / Documentation Hearing survey on Ambulances, Survey methods meeting (Project team and Local consultant team)

Dep. Dushanbe⇒Darvoz Dep. Dushanbe⇒Khujand DRS, No.8 Nurobod DRS, No.9 Varzob National Compound of Tajikistan National Compound of Tajikistan No.13 Sangvor (Tavildara) Soghd Oblast, No.64 Ayni, No.66 Hearing survey on medical equipment "Shifobakhsh" "Shifobakhsh" 8 2018/3/19 Mon GBAO, No.63 Darvoz Shahriston manufacturer's local agencies Hearing survey on M edical facilites Baseline survey (Survey on Emergency Hearing survey on Ambulances Hearing survey on Ambulances planinig Health care sevices) (Halt at Darvoz) (Halt at Khujand）

Soghd Oblast Dep.Darvoz⇒Khorugh No.47 Spitamen GBAO Oblast, National Compound of Tajikistan National Compound of Tajikistan No.58 Soghd Region Hospital No.55 GBAO Region Hospital Hearing survey on local forwarder "Shifobakhsh" 9 2018/3/20 Tue "Shifobakhsh" No.44 Khujand city GBAO, No.60 Khorog city insurance company Hearing survey on M edical facilites, Hearing survey on Health care services Hearing survey on Ambulances Hearing survey on Ambulances Water Supply and Drainage System (Halt at Khujand） (Halt at Khorugh)

Soghd Oblast National Compound of Tajikistan No.49 Mastchoh GBAO, No.61 Ishkoshim National Medical Compound National Compound of Tajikistan "Shifobakhsh" 10 2018/3/21 Wed No.65 Zafarobod Hearing survey on Ambulances “Shifobakhsh” "Shifobakhsh" Hearing survey on M edical facilites, Hearing survey on Ambulances (Halt at Khorugh) Hearing survey on Medical equipment Hearing survey on Health care services Water Supply and Drainage System (Halt at Khujand）

Soghd Oblast Dep.Khorugh⇒Darvoz National Compound of Tajikistan No.43 Konibodom GBAO, No. 62 Rushon National Compound of Tajikistan "Shifobakhsh" "Shifobakhsh" 11 2018/3/22 Thu No.39 Bobojon Ghafurov No.59 Vanji Meeting/ discussion(Estimation of renovation cost etc.） Baseline survey (Survey on Emergency Hearing survey on Ambulances Hearing survey on Ambulances Health care sevices) (Halt at Khujand） (Halt at Darvoz)

Dep. Khujand⇒Dushanbe National Compound of Tajikistan National Compound of Tajikistan Soghd Oblast Dep.Darvoz⇒Dushanbe Hearing survey on medical equipment "Shifobakhsh" "Shifobakhsh" 12 2018/3/23 Fri No.48 J.Rasulov DRS, No.2 Vahdat manufacturer's local agencies Hearing survey on M edical facilites, Additional baseline survey (Survey on Hearing survey on Ambulances Hearing survey on Ambulances Water Supply and Drainage System Health care sevices)

Hearing survey on local forwarder No.53 Maternity Hospital No.2 National Compound of Tajikistan insurance company, survey on customs 13 2018/3/24 Sat No.54 Maternity Hospital No.3 "Shifobakhsh" Same as PM / Equipment plannig-1 related circumstances at local forwarder Hearing survey on Ambulances Meeintg on renovation plan draft company

14 2018/3/25 Sun Internal Meeting / Documentation

Dep. Dushanbe ⇒Qurghonteppa Dep. Dushanbe ⇒Kulob city Ministry of Finance, Hearing survey on Khatlon Oblast Khatlon Oblast tax exemption No,56 Khatlon Region (Qurghonteppa) National Compound of Tajikistan No,57 Khatlon Region (Kulob) Hospital Hearing survey on local forwarder Hospital "Shifobakhsh" 15 2018/3/26 Mon No.15 Kulob city insurance company, survey on Same as PM / Equipment plannig-1 No.14 Bokhtar Hearing survey on construction site and No.16 Vose equipment procurement and maintenance No.31 Qurghonteppa city MRI/CT installation location Hearing survey on Ambulances ability of medical equipment Hearing survey on Ambulances （Halt at Kulob city） manufacturer's local agencies （Halt at Qurghonteppa）

Dep. Qurghonteppa ⇒ Dushanbe Khatlon Oblast Khatlon Oblast No.36 Sarband city Dep. Dushanbe ⇒ National Compound of Tajikistan No.30 Muminobod No.24 Danghara ⇒ Almaty "Shifobakhsh" 16 2018/3/27 Tue No.35 Khovaling Same as PM / Equipment plannig-1 Hearing survey on Ambulances, Hearing survey on medical equipment Hearing survey on M edical facilites, M eeting with JICA Technical Hearing survey on Ambulances （） manufacturer's local agencies Water Supply and Drainage System Cooperation Project Team Halt at Kulob city

Dep. Kulob city ⇒Dushanbe National Compound of Tajikistan Health and Social Protection Ministry Khatlon Oblast Hearing survey on medical equipment "Shifobakhsh" Hearing survey on Emergency Health 17 2018/3/28 Wed Internal Meeting / Documentation No.38 Baljuvon manufacturer's local agencies Hearing survey on M edical facilites, care sevices, Implementation structure No,34 Norak city Water Supply and Drainage System relevant policies Hearing survey on Ambulances

Hearing survey on local forwarder National Compound of Tajikistan National Compound of Tajikistan "Shifobakhsh" insurance company, survey on customs "Shifobakhsh" Health and Social Protection Ministry 18 2018/3/29 Thu Dep. Narita⇒Seoul⇒Almaty Hearing survey on National Medical Center(Radiology dep, Laboratory dep), related circumstances at local forwarder Additional Survey on Medical facilites, Survey of healthcare system etc Republican Specialized Center(Cardiology/Oncology) company Water Supply and Drainage System

Almaty⇒Arr.Dushanbe Survey of other donner (WB, WHO, KfW) Survey on construction related laws and Survey of Dushanbe fire work station Dep. Almaty ⇒Seo ul regulations(Radiation protection 19 2017/3/30 Fri Same as PM / Equipment plannig-2 provision, Electromagnetic wave regulation etc.） PM: Internal Metting

Health and Social Protection Ministry visit / discussion 20 2017/3/31 Sat ⇒Arr. Nrita Survey for private hospital Survey of Similar facilities in Dushanbe city (Municipal Isitis hospital)

21 2017/4/1 Sun Internal Meeting / Documentation Dep. Dushanbe ⇒ Almaty

⇒ ⇒ 22 2017/4/2 Mon Survey for National Compound of Tajikistan "Shifobakhsh" Almaty Seoul Arr.Narita

Dushanbe City Clinical Hospital of Emergency Medical Aid Survey of Similar Facilities (International 23 2017/4/3 Tue Maternity Hospital No.1(No.52) Clinic Ibn Sina, Survey on medical Hearing survey on medical equipment and ambulances services and its situations)

24 2017/4/4 Wed Minutes of Discussions

National Compound of Tajikistan "Shifobakhsh" M eeting with JICA Technical 25 2017/4/5 Thu Hearing survey on National Medical Center(Radiology dep, Laboratory dep), Cooperation Project Team Republican Specialized Center(Cardiology/Oncology)

Minitu of signing 26 2017/4/6 Fri Interime report for JICA Tajikistan office

Survey of other donner (USAID etc） 27 2017/4/7 Sat Internal Meeting / Documentation Additional survey on Dushanbe Municipal Emergency Clinic Hospital

28 2017/4/8 Sun Dep. Dushanbe ⇒ Almaty Internal Meeting / Documentation

29 2017/4/9 Mon Almaty⇒Seoul⇒Arr.Narita Additional survey on National Compound of Tajikistan "Shifobakhsh"

National Compound of Tajikistan "Shifobakhsh" 30 2017/4/10 Tue Hearing survey on hospital maintenance, Meeting on soft component

Additional survey on Health and Social Protection Ministry, 31 2017/4/11 Wed Confirmation of Implementation Structure

32 2017/4/12 Thu Confirmation of hospital finance etc, Finalization of technical note

33 2017/4/13 Fri Dep. Dushanbe ⇒ Almaty 34 2017/4/14 Sat Almaty⇒Seoul⇒Arr.Narita PM: Project Manager KfW: Kreditanstalt für Wiederaufbau WB: World Bank WHO: World Health Organization

(2) Explanation of Draft Final Report (23rd of August – 1st of September, 2018: 10 days)

Mission Members from JICA Consultant Team

Mitsuo ISONO Yukari MAEDA Yasuko ASANUMA Shinich KIMURA

Chief Consultant / Team Leader Cooperation Planning Equipment Planner 2 Equipment Planner 1 Departure from Narita - Incheon - Almaty 23-Aug Thr Stay at almaty

AM Arrival at Dushanbe 24-Aug Fri Sama as JICA member PM Data collection from MoHSPP or target facilities

Courtesy call for MoHSPP AM WHO for emergency medical services 25-Aug Sat National M edical Center PM Cardiovascular surgery center PM:Arrival at Dushanbe AM: Preparation of MM Russian version or other documents 26-Aug Sun Internal meeting with consultant PM: Internal meeting with JICA members

AM : National M edical Center for detail explanation of technical spec 27-Aug Mon Explanation of Minutes of Discussion PM: Explanation / Discussion of Minutes

Explanation of Minutes of Discussion Sama as JICA member 28-Aug Tue Signing of Minutes of Discussion Data collection from MoHSPP or target facilities

AM: Reporting to EOJ / JICA Tajikistan office AM: Reporting to EOJ / JICA Tajikistan office 29-Aug Wed PM : back to Japan PM: Cardiovascular surgery Center for detail explanation of technical spec

National M edical Center for detail explanation of technical spec 30-Aug Thu Arrival in Japan Local agent survey

31-Aug Fri Dushanbe - Almaty - Incheon

1-Sep Sat Inchon - Narita

EOJ: Embassy of Japan MoHSPP: Ministry of Health and Social Protection of Population MM: Minutes of Meeting WHO: World Health Organization

Appendix 3. List of Parties Concerned in the Recipient Country

1. Ministry of Health and Social Protection of Population Name Position Dr. Nasim OLIMZODA Minister Senior expert, Sanitary and Epidemiological Department for Mrs. Zulfiya Azizova Emergency Situations and Emergency Care Deputy director, Department of pharmacy and procurement of Mr. Marufov Ashurmat medical goods under the MOH Dr. Mahmudzoda Isfandiyor Head, Department of Reforms, PHC, and International Relations Head of International Relation Unit, Department of Reforms, PHC, Ms. Rano Rahimova and International Relations Mr. Abdurakhimov Jumakhon Head of Department, Department of Transport under the MOH Mr. Rakhmatuloyev Sherali Head of Department, Maternity and pediatric healthcare and planning Head of Department, Department for organizational medical services Mr. Sharipov Shaidullo delivery Mr. Dilorom Sodiqova First Counselor of the Minister

2. Ambulance request site Name Position Rudaki Dr. Sharipov Mirzoaziz Latipovich, Director Vahdat Dr. Burakova Dilbar Gafarovna, Chief Doctor Hissor city Dr. Kurbonov Khurshed Hakimovich, Deputy Chief Doctor Tursunzoda city Dr. Ibodu Iioyv Zoiljon, Head Ambulances center Rasht Dr. Solihov Ali Mahmadovich, Chief Doctor Shahrinav Dr. Akhmedor Ddiljon, Head Ambulances center Faizobod Dr. Bobishoev Faizali, Deputy Chief Doctor (therapeatic) Nurobod Dr. Halimov Alishers, Head of hosptial Varzob Dr. Solehov Amrijin, Head of dispatch center Lakhsh (Jirgatol) Dr. Suurov Jumabek Ziyotovich, Deputy Chief Doctor for therapy Dr. Taghdirov Dilshod Zarobiddinovich, Medical Tojikobod And Sanitary Aid Manager Roghun city Dr. Mardonaev Kh., Head of Hospital Sangvor (Tavildara) Dr. Saidov Rajabali, Head of hosptial Bokhtar Dr. Tomanov Mohamad, Head of hosptial Kulob city Dr. Shomadov Nigoznad, Head of hosptial Vo se Dr. Tagoev Boynazar, Head of hosptial Yovon Dr. Khalilov Burhoniddin Gulomovich, Chief Doctor J. Balkhi (J. Rumi) Dr. Buzmakov Sherali Malaevich, Chief Doctor Vakhsh Dr. Obidjonov Muhammad, Chief Doctor Qabodiyon Dr. Toshev Temur Avvalovich, Chief Doctor A. Jomi Dr. Soliev Amriddin Menakulovich, Chief Doctor Farkhor Dr. Isiev Farhod Chilakhonovich, Chief Doctor Mir Said Ali Hamadoni Dr. Malikoev Jurakhon Musokhonovich, Chief Doctor Danghara Dr. Barotov Rajab, Head of dispatch center Jayhun (Qamsangir) Dr. Shamsova Firuza Musofirovna, Chief Doctor Shahrituz Dr. Jahongirzoda Zarif Orif, Chief Doctor Panj Dr. Umarov Nurmuhammad Rozikovich, Chief Doctor Dusti (Jilikul) Dr. Kurbonov Niyozmahmad Safaralievich, Chief Doctor Khuroson Dr. Gulov Rajabali Kodirovich, Chief Doctor Muminobod Dr. Sharipov Rustam, Head of hosptial

Bokhtar city (Qurghonteppa city) Dr. Burhonova Rurigad, Head of dispatch center Temurmalik Dr. Orzubek Azizov Izzatulloevich Chief Doctor S.Shohin Dr. Saidzoda Madismon Ikrom, Chief Doctor Norak city Dr. Kahorzoda Tagoybek, Head of hosptial Khovaling Dr. Saidahmad, Head of hosptial Levakant city (Sarband city) Dr. Izatuloyev Ahror, Head of CDH N.Khusrav Dr. Kholmurodov Nazar Tagoykulovich, Chief Doctor Baljuvon Dr. Gulmahmsdzoda Zamir Gulmahmad, Head of hosptial Bobojon Ghafurov Dr. Kasimoria Malika, Head Isfara city Dr. Muhammedov Saibiddin, Chief Doctor Panjakent city Dr. Safarov Mahmadmurod Mirzoevich, Chief Doctor Istaravshan city Dr. Ma'rufov Ghafur Raufovich, Deputy Chief Doctor Konibodom Dr. Gaforov Abolujabor, Head Khujand city Dr. Umarozea Galina, Head Devashtich (Ghonchi) Dr. Mahmadaliev Nasim Rahimovich, Chief Doctor Asht Dr. Mirzovaliev Dilshod, Head of Emergency Dept. Spitamen Dr. Biobutarv Obimjon, Head J.Rasulov Dr. Rakhmatov Shukhrat, Chief Doctor Mastchoh Dr. Baholurov M.T, Head of hosptial Ayni Dr. Yorov Acagullo, Head Zafarobod Dr. Sanginov Zufar, Head of hosptial Shahriston Dr. Umarozea Galina, Head M.Mastchoh Dr. Fatulloev Shukur, Chief Doctor Vanj Dr. Caopapal Ayxabbos, Chief Doctor Khorog city Dr. Alinazarov Davlatbek, Chief Doctor Ishkoshim Dr. Augopl Bozy, Deputy Doctor Rushon Dr. Mapqoueb X, Chief Doctor Darvoz Dr. Dabrosuel Heabuoueebe, Chief Doctor National Medical Center Dr. Khayotzoda Nurkhon, General Director Dushanbe City Clinical Hospital of Emergency Medical Dr. Abdurahimov Bobohon Ishatovich, Main doctor Aid Research Institute of Obstetrics, Gynecology and Perinatology Dr. Mardonova Salomat Mahmudmurodovna, Deputy Director (Maternity Hospital No.1) Maternity Hospital No.2 Dr. Davlatov Kholmizro, Head of MCH Maternity Hospital No.1 Dr. Mansurova Nigora, Deputy head of MH (Maternity Hospital No.3) GBAO Region Dr. Nekruz Jamshedov, Chief Doctor General Hospital GBAO Region Dr. Aogyeooekeb, Chief Doctor Matemity Hpital Khatlon Region Qurghonteppa Dr. Sharipova Maidague, Deputy of maternal health and sanaviation Hospital center Khatlon Region Kulob Hospital Dr. Safarov Faidun, Deputy doctor of hosptial Soghd Region Hospital Dr. Sobizov Sobizjon, Head

Appendix 4. Minutes of Discussions (M/D) (1) Field Survey (2) Explanation of Draft Final Report

(1) Field Survey

(2) Explanation of Draft Final Report

This part is closed due to the confidentiality

Appendix 5. Soft component plan

Tajikistan ambulance development plan Soft component plan

1. Background for Planning Soft Component 1-1 Outline of the project plan, and the current status and issues of the medical sector In the Republic of Tajikistan (hereinafter referred to as Tajikistan), about 270 ambulances were deployed nationwide as of 2016. The goal is to deploy one ambulance per 10 thousand residents, but the current situation is only about one-third of that and the absolute number is still insufficient. In addition, most of the existing vehicles have been in service for 10 to 20 years or more since procurement, both vehicles and equipment have deteriorated due to aging, and experience frequent failures, hence the improvement of the quality of the ambulances has become an urgent task. In rural areas, only two-wheel drive vehicles are deployed in mountainous areas that can only be accessed by four-wheel drive. It is also seen that the vehicles cannot access the patients’ homes or accident sites, especially during the winter season when closed by snow. In addition, frequent vehicle failures due to aging requires a lot of time and are expensive to the repair, vehicles cannot be dispatched in winter, if dispatched transportation using a vehicle is not possible all the way, and takes time to reach the patient, delaying the start of treatment. In addition, about 65% of the target facility of the Project plan are secondary medical facilities which are said to be Central District Hospitals. Many facilities are in remote areas away from the urban areas1, and ambulances are the only means of transporting serious patients to higher-level medical facilities. However, most of the existing ambulances at Central District Hospitals are obsolete, so the occupancy rate per month is about 70% due to malfunction, repair, etc. The only ambulance on-board medical equipment provided in the existing ambulance vehicles are the stretchers, with exception of high-standard ambulances at the Dushanbe Emergency Hospital in the metropolitan area and Isutiqlol Municipal Hospital. For this reason, defibrillators and electrocardiographs are borrowed from nearby hospitals. However, this not only takes time to prepare for dispatch but shortage of medical equipment in the hospital during the emergency dispatch period hinders hospitals medical service activities. It is important that ambulance dispatch requests are accepted at any time of day and night. It is also important that the ambulances are equipped with the minimum necessary emergency equipment at all times and have a system which ensure immediate dispatch. In response to the current situation, the Project plan targets 63 regional medical facilities and emergency medical centers nationwide with serious shortage and aging ambulances. It intends to strengthen emergency medical services through the improvement of 94 ambulances and onboard equipment such as defibrillators, oxygen saturation meters, aspirators, etc. In the Project plan, priority is given to the improvement of ambulances in rural areas where the service infrastructure is extremely vulnerable compared to urban areas. In recent years, in the prehospital services (pre-arrival hospital medical service), there are cases such as traffic injuries and heart disease patients where the emergency life-saving measures using defibrillators are

1 The remote place mentioned here refers to the GBAO state or the southern part of the Khatlon state, and ambulance requests in about 15 of the 67 sites are applicable.

effective2. In the Project plan, defibrillators will be standard onboard equipment on all the 94 ambulances to be procured. The Tajikistan government has set the goal of "reducing the hospital mortality rate due to myocardial infarction to 2% or less" in the Strategy for Prevention and Control of NCDs and Injuries for the period of 2013-2023. Penetration of emergency life support activities using defibrillators is one of the emergency medical services that contributes to achieving the same goal.

1-2 Current situation and issues concerning the utilization of equipment (1) The current utilization status of procured equipment (level of medical personnel and operating environment) Doctors and nurses engaged in emergency medical care have taken a one-month emergency medical training called EMS (Emergency Medical Service)3 , and are said to have basic skills to practice clinical activities making use of the equipment planned in the Project. A 20-hour lecture related to the defibrillators have been conducted for symptoms of cardiac dysfunction. The lecture consists of 5 hours of theory, 10 hours of practical skills and 5 hours of practice and it is 12.8% of the total lectures. However, the lecture did not incorporate sufficient guidance on the method for giving an electric shock synchronized with an electrocardiogram QRS waveform to an atrial fibrillation patient, and there are insufficient skills on this point. Therefore, for emergency cases for heart disease patients, respiratory disease patients, traffic accident trauma patients etc., in addition to the electric shock during ventricular fibrillation, it is necessary to receive additional training so that it can handle both cardioversion, which is a atrial fibrillation medical procedure based on the of the electrocardiogram waveform for patients with arrhythmia. The defibrillator planned under the project is not an Automatic External Defibrillation (AED) type which prompts the timing of electric shock with a recorded voice. To effectively utilize the defibrillator to be procured, understanding of the flow of activities from the primary lifesaving to the secondary lifesaving is important. There is a need to learn how to give appropriate electric shocks with a defibrillator at the right time for ventricular fibrillation or atrial fibrillation patients depending on the patient condition. Also, since it is necessary to mount the defibrillator in the ambulance in a state that it can be used at any time, it is necessary to provide guidance on the necessary minimum daily preventive maintenance activities.

1-3 The need to introduce soft components Based on the preceding paragraph, the tasks of facilities covered by the ambulance development plan are summarized as follows, smooth establishment of the project covered by this cooperation and ensuring the sustainability of the procured equipment. ① In the EMS training course, although a 20-hour training session was provided which include the care for heart disease patients, sufficient skills have not been acquired on the electric shock method for the atrial fibrillation patients who need synchronous cardioversion4. ② To achieve the goal of "reducing the hospital mortality rate due to myocardial infarction to 2% or less",

2 March to April 2018, from the results of the questionnaire survey for hospitals targeted for ambulance deployment 3 Dushanbe Emergency Hospital has conducted a 156-hour training course. 4 When electric shock is given to an arrhythmia to restore the normal waveform, energization synchronous with the patient's QRS waveform is called cardioversion and is defined separately from asynchronous energization.

which is a priority task among NCD / trauma prevention strategies 2013 - 2023, pre-hospital services (medical service before arrival at the hospital) using defibrillation devices need to be performed reliably for emergency patients with heart disease.

To improve and solve these problems, this soft component plan targets emergency medical service providers such as emergency doctors and nurses at facilities under the ambulance improvement project. There is need to introduce soft components related to the flow of activities from the primary lifesaving to the secondary lifesaving, and acquisition of skills on how to use the defibrillator on a case by case basis. The outline of the soft components is as follows. ① Flow from primary lifesaving method (basic life support) to secondary lifesaving method ② Lecture on selection method of electric shock power according to patient's physique, electrocardiogram waveform etc. (practical exercises using emergency resuscitation simulator dolls). Practical guidance on electric shock method synchronized with QRS wave for atrial fibrillation patients who need synchronous cardioversion. ③ Lecture on basic maintenance method of equipment using "Vehicle-mounted equipment maintenance manual"5.

2. Soft component goal Proper use of the 94 defibrillation devices to be procured under this plan and mounted on ambulances when necessary, it will possible to carry out necessary emergency medical services.

3. Results of soft components The results of implementing the soft component are as follows.

Table 1: Contents of soft component guidance and expected results Lecture details Achievement ① Flow from primary lifesaving method to  Able to determine the need to start resuscitation and move secondary lifesaving method using it into action defibrillator  Understand when to change life-saving method from primary life to secondary life-saving according to patient's situation. ② Lecture on selection method of electric  Electric shocks can be carried out safely and reliably shock joules according to physique of  Synchronous cardioversion can be performed on patients patient, electrocardiogram waveform with atrial fibrillation. etc. (Practical exercise with emergency resuscitation simulator doll) ③ Maintenance method specific to vehicle-  Method for fixing band, moving indoors to prevent the mounted equipment battery deterioration in winter, etc. will be used and the donated equipment is used in good condition.

In addition, as a way of confirming the achievement of this software component, the "Japan Emergency

5 The defibrillator is equipped with a battery, and a manual that summarizes points to keep in mind when maintaining and managing vehicle-mounted equipment, such as moving it inside e.g., driver's waiting room and storing it in the winter

Medical Society" is set to be aware of the goals of the course. Since the course aims to acquire "the first 10-minute response and appropriate team resuscitation, especially of sudden cardiac arrest among cardiovascular emergency conditions", this is also in line with the priority issue of Tajikistan's NCD / trauma prevention strategy.

4. The method to check the achievement level Items and methods for confirming achievement results are shown in the table below.

Table 2 Method of checking achievement level Lecture details Achievement confirmation item Confirmation method ① Flow from primary lifesaving The instructor will introduce some patient The instructor will ask the method to secondary cases and evaluate the answers to when the participants to understand the lifesaving method using secondary lifesaving should begin. timing of the transition from the defibrillator primary life-saving method to the secondary life-saving method. ② Lecture on selection method Implementation of practical tests (how to Perform practical exercises using of electric shock joules select the heat of the electric shock the simulator, and the teacher's according to physique of according to the patient's physique and emergency care physician patient, electrocardiogram electrocardiogram waveforms, synchronous confirms the degree of retention waveform etc. (Practical cardioversion implementation method: by the participants. exercise with emergency synchronization with QRS wave) resuscitation simulator doll) ③ Maintenance method specific Participants can browse the manuals and After the manual content is to vehicle-mounted enumerate the items that need to be noted for explained, the participants are equipment maintenance and management, especially as randomly nominated, and oral vehicle-mounted equipment. questions are taken to keep management in mind and confirm the degree of retention.

5. Activities of Soft Components (Input Plan) 5-1. Input time and period The timing of inputting this software component shall be immediately after delivery of the equipment. In line with the guidance of the ambulance, the soft component will have seminars for emergency physicians, nurses and vehicle administrators in the: ① Dushanbe, ② City of Khujand, the capital of the Sughd Region, ③ Bokhtar District formerly Kurgan-Tyube) in the Khatlon Region, ④ Kulob city in the Khatlon Region, ⑤ Khorog, the Capital city of GBAO. One seminar by an emergency life-saving doctor is planned to be carried out for about a half day, for a total of 6 days including the travel time. It will make a final report including the recommendations for future curriculum at the Dushanbe Emergency Hospital in the capital and the Ministry of Health and Social Protection and Population. In this case, ambulances will be deployed to medical institutions centered on 63 District Central hospitals. Therefore, it is essential to have logistic services for dispatching emergency physicians/nurses from the target hospital facilities to the seminar venue through the provincial health departments. In addition, the lecturer, an emergency medical doctor will demonstrate in a video the practical exercise using emergency resuscitation simulator doll and create review materials and teaching materials for the newly-organized emergency medical service team.

5-2 Activity details Activity content in the soft component is as described below. Prior to the start of each session, the company will confirm the acceptance status of the Tajikistan side, and prepare training materials considering the specifications, composition and characteristics of the ambulance onboard medical equipment procured under the Project. Also, after the end of each session, compile the implementation report etc.

 Activities of soft components and participants

Table 3 Soft component activity timetable and participants Lecture details Lecture duration  Primary life support ⇒ Lecture on a series of emergency and life support activities 0.5 hour up to secondary lifesaving  Practical exercises on electric shock using emergency resuscitation simulator 2.5 hours  Synchronous cardioversion practical guidance 1.5 hours  Maintenance management guidance using 'vehicle mounted equipment maintenance 0.5 hour manual'  Q & A session, lecturer review 0.5 hour Total time 5.5 hours

The target audience is expected to be about 100 to 126 participants, emergency physicians and nurses from 63 locations where ambulances will be deployed under the Project.

6. Procurement of software component implementation resources This software component will have two lecturers (training instructors) with clinical experience, one emergency life-saving doctor (0.37 MM) with actual life-saving experience with heart disease patients and one training coordinator (0.47 MM) for technical guidance and training supervision. For training, there shall be one local Russian-English interpreter on-site (0.4 MM). In this case, for the training of maintenance and management of medical equipment, coordination work is essential during the gathering of targeted training participants on the Tajikistan side to be available on the scheduled date of training, since they are from 63 sites in 4 regions.

Emergency life-saving doctor A person with clinical experience. (1 person): Technical guidance / training A person who can coordinate participants from the partner coordinator (1 person): countries, creating soft component materials, creating a roster for participants, improving the teaching materials in the soft component, and creating new materials (especially video and image editing)

Table 4 Soft component schedule Day Contents Emergency medical Training Interpreter doctor coordinator Day 1 Narita – Seoul – Almaty ● Day 2 Almaty – Dushanbe ● Afternoon: Meeting with interpreter Day 3 ・ Explanation of training to the Ministry of Health and Social Affairs ・ Confirmation of the arrangement status of ● ● training participants in Sughd state and GBAO state, re-request Day 4 ・ Arrangement of training participants in the Khatlon Province and Sughd Province ・ Preparation of Russian language training ● ● ● materials (Narita - Seoul – Almaty) Day 5 (Almaty – Dushanbe) ・ Hold seminar in Dushanbe ● ● ● ・ Travel to Khujand, Sughd Province Day 6 ・ Hold seminar in Khujand, Sughd Province ● ● ● ・ Travel to Kulob, Khatlon Province Day 7 ・ Hold seminar in Kuloh, Khatlon Province ● ● ● ・ Travel from Kulob to Kurgan-Tyube Day 8 ・ Hold seminar in Kurgan-Tyube in Khatlon Province ● ● ● ・ Travel from Kurgan-Tyube to Dushanbe Day 9 ・ Travel from Dushanbe to GBAO ・ Re-confirmation of training participants ● ● ● with the GBAO State Health Department, preparations for training Day 10 ・ Hold seminar at GBAO ● ● ● (Overnight stay in GBAO) Day 11 ・ Travel from GBAO to Dushanbe ● ● ● Day 12 ・ Report on the training skill levels to Dushanbe Emergency Hospital and advise on the need for additional educational content for emergency ● ● ● physicians in addition to the current curriculum ・ Report to the Ministry of Health and Social Protection Day 13 ・ Dushanbe – Almaty ● ● ● Day 14 ・ Almaty – Inc – Narita ● ● ● Total dispatch (engaged) days 11 days 14 days 12 days

7. Implementation schedule of soft component It starts immediately after the delivery of the equipment (ambulance), visit the scheduled sites conducting 5 seminars on a caravan (patrol), including emergency lifesaving doctor's consultation and reporting work to the Ministry of Health and Social Protection and Population. The emergency lifesaving doctor will be engaged for 11 days (0.37 MM), training coordinator engaged in Japan for 3 days (0.15 MM) and in the field for 14 days (0.47 MM), and the Russian interpreter for 12 days (0.4 MM). This software component requires 17 days (0.62MM) from the start to finish, including domestic preparation and days to summarize after returning home.

Table 5 Soft component planning implementation process Year 2019 2020 MM Calendar month 1 2 3 4 5 6 7 8 Project implementation In In the 10 11 12 13 14 15 16 17 month Japan field Emergency medical 0 0.37 doctor

Technical guidance / 0.15 0.47 training coordination

Soft component ▲

Submit implementation Field work

status report Submission Soft component ▲ Completion report

Local operation Domestic operations

8. Deliverables of soft components 8-1 Soft component implementation report It will be submitted at the end of May 2020. ① Training materials ② Training participants list ③ Implementation report on training of emergency medical personnel ④ Photographic teaching materials for practical emergency medical activities using simulation dolls ⑤ Maintenance management manual for on-board equipment

8-2 Soft component completion report It will be submitted as the final in the mid-June 2020. ① Software component completion report (including picture of implementation situation, participant list)

9. Summary of software components The total estimated cost of this software component is 5.795 million yen. (It is planned to rent an emergency life-saving simulator as portable equipment for the implementation of the curriculum)

10. Responsibilities of the recipient country 10-1 The responsibilities of the recipient country in the implementation of this soft component When implementing this soft component, the Tajikistan needs to coordinate the work so that emergency physicians and nurses, who will be trainees, can attend the training without fail. Also, the recipient shall prepare the payment of trainees’ daily allowance and/or transport expenses when necessary for the provision of the planned facilities (including the State Health Department etc.). In addition, for Japanese experts to be dispatched, if the method for applying for entry visa to the country changes from the present situation, it will be the responsibility of Tajikistan to ensure issuance of visas.

10-2 Responsibility of the recipient country in maintaining and managing medical equipment This soft component makes effective use of the provided equipment to enable the implementation of necessary lifesaving medical activities through practical guidance on the emergency medical activities using the defibrillator procured under the Project. In addition, when a new emergency medical service team is constituted, it is necessary to provide educational training using soft component materials. End

Appendix 6. References Original / Issue Donation / No. Title Size Page Issuance Copy year Purchase Agency for Statistics under the Demographic Statistics Book 1 A4 337 Original President of the 2017 Purchase (Russian version) Republic of Tajikistan

Ministry of Health Health Bulletin 2016 (Russian and Social 2. A5 367 Original 2017 Donation Version) Protection of Population

Formation and Development of Dr. Abdurahimov unkn 3 Emergency Medical Service in Copy Donation Bobohon Ishatovich Dushanbe (Russian version) own

Appendix 7. Other materials / information ANNEX 1 Current Status of Target Facilities in Emergency Medical Service 1/3

Maintenance / fuel costs Site Administrative City, Rayon, Site Service coverage area Number of emergency Number of (Unit price: local currency Number of staff / beds No. division (former name) Population / Area medical teams ambulance drivers Somoni) 1 Somoni＝12.5 yen

Population : 387,000 people Doctors:7 Maintenance / fuel costs:10,000 1 RRS Rudaki Area : Rudaki district, around 40 to 60 km 2 Teams 5 Nurses: 65 (2017) from the facility

Population:311,000 people Maintenance cost:32,000 (2017) 2 RRS Vahdat Area : 35-70 km from Vahdat Central Beds:620 3 Teams 30 Fuel cost:60,000 (2017) Hospital

Population : 275,000 people Maintenance cost:3,000 (2017) 3 RRS Hissor city Beds: 578 1 Team 4 Area : Within 20 to 40 km from the facility Fuel cost:2,985 (2016)

Doctors:65 Population : 250,000 people Maintenance cost:30,000 (2017) 4 RRS Tursunzoda city Nurses: 85 4 Teams 8 Area : Tursunzoda city within 40 to 50 km Fuel cost:40,000 (2017) Beds:

Doctors:71 Population : 109,000 people Maintenance cost:10,000 (2017) 5 RRS Rasht Co-medicals: 340 2 Teams 4 Area : Within 20 to 30 km of Rasht outskirts Fuel cost:60,000 (2017) Beds: 432

Doctors:136 Population : 108,000 people Maintenance cost:15,000 (2017) 6 RRS Shahrinav Nurses: 407 1 Team 16 Area : 90 to 100 km around Shahrinav Fuel cost: 9,000 (2017) Beds: 203

Doctors:38 Population : 94,000 people Maintenance cost: 8,000(2017) 7 RRS Faizobod Nurses: 162 5 Teams 9 Area : Within 40 to 50 km from Faizobod Fuel cost:40,782(2017) Beds: 175

Population : 78,000 people Doctors:25 Maintenance cost:10,000 (2017) 8 RRS Nurobod Area : 100 km from Nurobod Central 2 Teams 5 Beds: 214 Fuel cost:15,000 (2017) Hospital

Population : 73,000 people Doctors:4 5 Maintenance cost: 2,800 9 RRS Varzo b Area : 72 km from the hospital within the Nurses: 2 5 Teams Fuel cost:15,000 (2017) prefecture, transportation to Dushanbe Beds: 105

Doctors:34 Population : 67,000 people Maintenance cost:10,000 (2017) 10 RRS Lakhsh (Jirgatol) Nurses: 116 1 Team 5 Area : 70 to 90 km Range near Lakhsh Fuel cost:10,000 (2017) Beds: 220

Population : 46,000 people Doctors:28 1 Team Maintenance cost:12,910 (2017) 11 RRS Tojikobod 4 Area : 90 to 110 km Range near Tojikobod Nurses: 84 Fuel cost:25,990 (2017)

Population : 40,000 people Doctors:35 Maintenance cost:16,000 (2017) 12 RRS Roghun city Area : Within 90 to 110 km Distance to 2 Teams 5 Nurses: 86 Fuel cost:40,000 (2017) Logon city

Population : 30,000 people Doctors:12 Maintenance cost:10,000 (2017) 13 RRS Sangvor (Tavildara) Area : 150 km from Tavildara Central Nurses: 76 1 Team 3 Fuel cost:17,745 (2017) Hospital Beds: 70

Doctors:15 Kushoniyon Population : 244,000 people Maintenance cost:10,000 (2017) 14 Khatlon Nurses: 60 1 Team 3 (Bokhtar) Area : 30 km from Kushoniyon Hospital Fuel cost:13,000 (2017) Beds: -

Population : 203,000 people Doctors:28 Maintenance cost:12,000 (2017) 15 Khatlon Kulob city Area : Kulob city and its surrounding 10 3 Teams 21 Nurses: 85 Fuel cost: 1,400 (2017) district

Doctors:3 Population : 199,000 people Maintenance cost:10,000 (2017) 16 Khatlon Vo s e Nurses: 6 3 Teams 6 Area : 30 km around Vosse Fuel cost:12,000 (2017) Beds: 194

Doctors:186 Population : 198,000 people Maintenance cost:10,000 (2017) 17 Khatlon Yovon Nurses: 442 2 Teams 4 Area : Yovon District Fuel cost:15,000 (2017) Beds: 734

Doctors:65 Population : 178,000 people Maintenance cost:22,215 (2017) 18 Khatlon J. Balkhi (J. Rumi) Nurses: 163 1 Team 4 Area : Jaloloddini Balkhi Fuel cost: 4,347 (2017) Beds: 545

Doctors:105 Population : 171,000 people Maintenance cost:3,100 (2017) 19 Khatlon Vakh s h Nurses: 725 1 Team 5 Area : Vakhsh Fuel cost:6,000 (2017) Beds: 465

Doctors:78 Population : 161,000 people Maintenance cost: unknown 20 Khatlon Qabodiyon Nurses: 268 1 Team 6 Area : Kubodiyon Fuel cost:1,000 (2017) Beds: 330

Doctors:34 Population : 154,000 people Maintenance cost: unknown 21 Khatlon A . Jomi Nurses: 168 1 Team 4 Area : 40 to 70 km around A. Jomi Fuel cost:6,000 (2017) Beds: 316

Maintenance cost: Population : 153,000 people Doctors:91 22 Khatlon Farkhor 5 Teams 15 Appropriate budget allocation Area : Farkhor area around 60 to 90 km Nurses: 482 Fuel cost:7,000 (2017)

Population : 142,000 people Doctors:51 Mir Said Ali Maintenance cost:3,500 (2017) 23 Khatlon Area : Around Mir Said Ali Hamadoni 60 to Nurses: 429 2 Teams 7 Hamadoni Fuel cost:750 (2017) 90 km Beds: 465

ANNEX 1 Current Status of Target Facilities in Emergency Medical Service 2/3

Doctors:35 Population : 134,000 people Maintenance cost: (2017) 24 Khatlon Danghara Nurses: 71 3 Teams 16 Area : 90 Fuel cost: (2017) ㎞ Beds: -

Doctors:71 Population : 119,000 people Maintenance / fuel costs: 25 Khatlon Jayhun (Qamsangir) Nurses: 164 1 Team 5 Area : 45 to 60 km around Jayhun 4,500 (budget in 2018) Beds: 380

Doctors:29 Population : 115,000 people Maintenance cost: unknown 26 Khatlon Shahrituz Nurses: 160 1-2 Teams 6 Area : 45 to 60 km around Shahrituz Fuel cost:3,000 (budget in 2018) Beds: 320

Doctors:68 Maintenance cost: 4,500 (budget in Population : 111,000 people 27 Khatlon Panj Nurses: 433 1 Team 5 2018) Area : 40 to 50 km around Panj Beds: 546 Fuel cost:19,000 (budget in 2018)

Doctors:34 Maintenance cost:500 (budget in Population : 99,000 people 28 Khatlon Dusti (Jilikul) Nurses: 133 1-2 Teams 6 2018) Area : 40 to 50 km around Dusti Beds: 220 Fuel cost:3,000 (budget in 2018)

Doctors:88 Population : 100,000 people Maintenance cost:9,996 (2017) 29 Khatlon Khuroson Nurses: 243 2 Teams 5 Area : 35 to 45 km around Khuroson Fuel cost:3,200 (budget in 2018) Beds: 111

Population : 86,000 people Maintenance cost: unknown (2017) Doctors:18 30 Khatlon Muminobod Area : 40 to 50 km within the Rayon from 1-2 Teams 8 Fuel cost:10,000 (2017) Beds: 189 Muminobod Central Hospital Population : 79,000 people Doctors:55 Bokhtar city Area : 20 km from the city of Bokhtar city Maintenance cost:15,000 (2017) 31 Khatlon Nurses: 83 4-5 Teams 25 (Qurghonteppa city) and the capital Dushanbe Fuel cost:50,000 (2017) Beds: -

Doctors:47 Maintenance cost:18,000 (2017) Population : 66,000 people 32 Khatlon Temurmalik Nurses: 387 1 Team 3 Fuel cost: 6,000 (2017) Area : Within 50 km from Temurmalik Beds: 155

Doctors:28 Maintenance cost: 9,000 (budget in Population : 58,000 people 33 Khatlon S.Shohin Nurses: 124 ２ Teams 4 2018) Area : Shohin district Beds: 193 Fuel cost:18,500 (budget in 2018)

Population : Doctors:38 Maintenance cost: (2017) 34 Khatlon Norak city Vahdat, Danghara, 100,000 people Nurses: 171 3 Teams 6 Fuel cost:35,000 (2017) Area : 100 km around Norak city Beds: 221

Population : 54,000 people Doctors:16 Maintenance cost: (2017) 35 Khatlon Khovaling Area : 80 km from Khovaling Central Nurses: 52 2 Teams 6 Fuel cost:31,750 (2016) Hospital Beds: 125

Doctors:16 Maintenance cost: (2017) Levakant city Population : 43,000 people 36 Khatlon Nurses: 38 2 Teams 6 Fuel cost:12,000 (2017) （Sarband city） Area : Around 38 km Beds: 140

Doctors:11 Maintenance cost: (2017) Population : 32,000 people 37 Khatlon N.Khusrav Nurses: 50 2 Teams 3 Fuel cost:4,000 (2017) Area :50 to 70 km around N.Khusrav Beds: 155

The budget is allocated from the Population : 30,000 people Doctors:20 Rayon government.。 38 Khatlon Baljuvon Area : 100 km from Baljuvon Central Nurses: 159 1 Team 3 Maintenance cost: (2017) Hospital Beds: 120 Fuel cost: (2017) Fuel cost:3,600 (2017)

Maintenance cost:48,000 (budget in Population : 340,000 people Doctors:5 Headquarters: 4 39 Sughd Bobojon Ghafurov 5 Teams 2018) Area : 120 km around Bobojon Ghafurov Nurses: 99 Branch office:5 Fuel cost:50,000 (budget in 2018)

Doctors:195 Population : 256,000 people Maintenance cost:16,700 (2017) 40 Sughd Isfara city Nurses: 994 5 Teams 19 Area : 100 km around Isfara city Fuel cost:72,395 (2017) Beds: 1042

Doctors:77 Population : 256,000 people Maintenance cost:unknown 41 Sughd Panjakent city Nurses: 700 1 Team 9 Area : 50 to 70 km around Panjakent city Fuel cost:30,000 (2018) Beds: 370

Doctors:124 Maintenance cost:24,000 (15k local Population : 250,000 people 42 Sughd Istaravshan city Nurses: 745 5 Teams 24 budget, 9k ggp) Area : 100 km around Istaravshan city Beds: 1020 Fuel cost:30,000 (2018) 2 Teams Population : 197,000 people (There are nurses and Maintenance cost: 23,000 (2017) 43 Sughd Konibodom Beds: 483 9 Area : 80 to 100 km around Konibodom drivers Teams in two Fuel cost: 84,000 (2017) branch offices) Population : 171,000 people Doctors:22 Maintenance cost:unknown 44 Sughd Khujand city Area : 50 to 70 km of the entire city of 11 Teams 86 Nurses: 22 Fuel cost:unknown Khujand

Doctors:36 Devashtich Population : 155,000 people Maintenance cost:2,000 (2017) 45 Sughd Nurses: 410 3 Teams 4 (Ghonchi) Area : 100 km around Devashtich Fuel cost:2,000 (2017) Beds: 325

Population : 149,000 people Doctors:12 Maintenance cost:16,527 (local 46 Sughd Asht 1 Team 5 Area : 100 km around Asht Nurses: 10 budget) (2018)

ANNEX 1 Current Status of Target Facilities in Emergency Medical Service 3/3

Doctors:6 Population : 129,000 people Maintenance cost:13,700 47 Sughd Spitamen Nurses: 28 2 Teams 3 Area : 45 km around Spitamen Fuel cost:20,000 Beds: 270

Doctors:8 Population : 127,000 people Maintenance cost: 3,500 (2017) 48 Sughd J.Rasulov Nurses: 36 2 Teams 7 Area : 30-60 km around J.Rasulov Fuel cost:28,000 (2017) Beds: 240

Doctors:42 Population : 113,000 people Headquarters:1 Team Maintenance cost:5,000 (2017) 49 Sughd Mastchoh Nurses: 58 4 Area : 60-90 km around Mastchoh Branch office: 6 Teams Fuel cost:5,000 (2017) Beds: -

Doctors:31 7 nurses Population : 78,000 people Maintenance cost:7,000 (2017) 50 Sughd Ayni Nurses: 45 (Emergency training 3 Area : 100 km around Ayni Fuel cost:6,500 (by 3 vehicles) Beds: 25 participant)

Population : 66,000 people Maintenance cost:5,000 (2017) 51 Sughd Zafarobod Beds: 12 2 Teams 4 Area : 80 km around Zafarobod Fuel cost:2,265 (2017)

Doctors:9 Maintenance cost:3,000 (2017) Population : 38,000 people 52 Sughd Shahriston Nurses: 32 1 Team Fuel cost:5,750 (2017) Area : 35-40 km around Shahriston 4 Beds: -

Doctors:7 Population : 30,000 people Maintenance cost:3,740 (2017) 53 Sughd M.Mastchoh Nurses: 42 2 Teams 3 Area :80 km around M.Mastchoh Fuel cost:4,700 (2017) Beds: 100

Doctors:18 Population : 32,000 people The emergency team is not Maintenance cost:7,500 (2017) 54 GBA O Van j Nurses: 52 4 Area : 42 km fromVanj Central Hospital particularly established. Fuel cost:4,000 (2017) Beds: 133

Population : 31,000 people Doctors:16 5 Teams Maintenance cost: 32,000 55 GBA O Khorog city Area : 80 km around Khorog city and the Nurses: 20 6 Fuel cost:150,000 (2017) neighboring 3 Rayon Beds: 120

Population : 30,000 people Doctors:11 The emergency team is not 56 GBA O Ishkoshim Area : 88-170 km from Ishkoshim Central Nurses: 42 4 Maintenance cost:6,000 (2015) particularly established. Hospital Beds: 80 Fuel cost:8,000 (2015)

Doctors:18 Population : 27,000 people Organize team according to Maintenance cost:8,000 (2017) 57 GBA O Rushon Nurses: 62 8 Area : 75 km from Rushon Central Hospital patient case Fuel cost:6,500 (2017) Beds: 140

Doctors:15 Population : 26,000 people 1 Team Maintenance cost:9,000 (2017) 58 GBA O Darvoz Nurses: 51 6 Area : 72 km from Darvoz Central Hospital Fuel cost:8,500 (2017) Beds: -

Doctors:562 National Medical Population : 8.7 million people Maintenance cost:10,000 (2017) 59 Dushanbe Nurses: 958 4 Teams 8 Center Area : Nationwide Fuel cost:35,000 (2017) Beds: 2,000 Dushanbe city Population : 800,000 people Doctors:259 Clinical Hospital of Maintenance cost: (2017) 60 Dushanbe Area : Dushanbe City and two neighboring Nurses: 274 7 Teams 50-60 Emergency Medical Fuel cost: (2017) areas, around 30 km Beds: 348 Aid

Research Institute of Obstetrics, Doctors:154 Gynecology and Population : Women all over the country 1 Team Maintenance cost:unknown 61 Dushanbe Nurses: 254 2 Perinatology Area : Nationwide Fuel cost:unknown Beds: 234 (Maternity Hospital No.1) Population : 84,000 people Doctors:34 Maternity Hospital Area : Dushanbe city and two neighboring Maintenance cost:- (2017) 62 Dushanbe Nurses: 95 ― ― No.2 areas (Shohmansur, Somoni) Fuel cost:- (2017) Beds: -

Maternity Hospital Population : 84,000 people Doctors:60 No.1 Maintenance cost:- (2017) 63 Dushanbe Area : Dushanbe city and two neighboring Nurses: 121 ― ― (Maternity Hospital Fuel cost:- (2017) areas (half of Shohmansur and Somoni) Beds: - No.3) Doctors:19 Population : 80,000 people Emergency services are GBAO Region Midwife: 20 64-1 Area : 40 - 60 km of the 3 districts of requested to Khorog city ― - （General Hospital） Nurses: 120 Khorog city and its surrounding areas Hospital. Beds: 125

GBA O If urgently needed, doctors and nurses will be Population : 30,000 people Doctors:28 GBAO Region dispatched according to Vehicle-related costs are borne by Area : 40 - 60 km of the 3 districts of Nurses: 69 1 (Matemity Hospital) cases the patient Khorog city and its surrounding areas Beds: 60 64-2 (Individual vehicles used)

Khatlon Region Population : 100,000 people Maintenance cost:25,000 (2017) 65 Khatlon Beds: 610 2 Teams 4 (Qurghonteppa) Area : Over the Oblast, around 100 km Fuel cost:40,000 (2017)

3 people (A physician, a Population : 200,000 people nurse, a driver) are Khatlon Region Doctors:63 Maintenance cost:- (2017) 66 Khatlon Area : 100 km of Kulob city and its dispatched according to 0 (Kulob) Nurses: 263 Fuel cost:- (2017) surrounding 10 area cases (individual vehicles are used)

In addition to 6 Population : 250,000 people Doctors:58 Maintenance cost:Repair support at appointment specialists, 8 67 Sughd Sughd Region Area : 40 km of Khujand and its Nurses: 75 state vehicle base contract is signed to be able surroundings Beds: - Fuel cost:- (2017) to dispatch 100 specialists

ANNEX 2 Activity Status of Target Facilities in Emergency Medical Service 1/4

Number of Requested Number of existing ambulances / City, Rayon, Site Number of emergency Site requested vehicle jurisdiction branch offices Main reasons for dispatch

No. dispatch requests t type (former name) vehicle type Deploymen

1) Delivery Number of existing vehicles:2 1 Rudaki 2 B 700-950 cases / month 2) Accident A Branch office:- 3) Heart attack

Number of existing vehicles:8 1) Delivery 2 Vahdat 2 B Branch office:6 1,000 cases / month 2) Accident A 3) Heart attack

1) Delivery Number of existing vehicles:2 3 Hissor city 2 B 150-200 cases / month 2) Myocardial infarction A Branch office:- 3) Stroke

1) High blood pressure Number of existing vehicles:4 4 Tursunzoda city 2 B 1,200 cases / month 2) Myocardial infarction A Branch office:1 3) Delivery, Trauma

1) Delivery bleeding Number of existing vehicles:2 5 Rasht 2 B 450-500 cases / month 2) Delivery A Branch office:- 3) Trauma

1) Myocardial infarction Number of existing vehicles:3 6 Shahrinav 2 B 700-900 cases / month 2) Trauma A Branch office:3 3) High blood pressure

1) High blood pressure Number of existing vehicles:5 7 Faizobod 1 B 300-450 cases / month 2) Myocardial infarction A Branch office:5 3) Delivery 1) Myocardial infarction Number of existing vehicles:3 2) Trauma 8 Nurobod 1 B 300-350 cases / month A Branch office:5 3) High blood pressure

Number of existing vehicles:3 1) Accident 9 Varzo b 2 B Branch office:5 400-500 cases / month 2) Delivery A 3) Respiratory disease

1) Delivery Number of existing vehicles:2 10 Lakhsh (Jirgatol) 1 B 280 cases / month 2) Brain surgical case A Branch office:- 3) Trauma

1) Arteriosclerosis Number of existing vehicles:2 11 Tojikobod 1 B 500-650 cases / month 2) Heart attack A Branch office:- 3) Various trauma

Number of existing vehicles:4 1) Delivery 12 Roghun city 1 B Branch office:4 360 cases / month 2) Cardiovascular disease A 3) Trauma 1) High blood pressure/ Fever Number of existing vehicles:3 2) Kidney failure 13 Sangvor (Tavildara) 1 B 200 cases / month A Branch office:2 3) Cardiovascular disease

1) High blood pressure Kushoniyon Number of existing vehicles:2 14 1 B 410 cases / month 2) Cardiovascular disease A (Bokhtar) Branch office:2 3) Delivery/ Trauma

1) Cardiac disease Number of existing vehicles:7 15 Kulob city 1 B 650-700 cases / month 2) Brain disease A Branch office:2 3) Trauma 1) High blood pressure Number of existing vehicles:5 2) Respiratory disease 16 Vo s e 1 B 500-650 cases / month A Branch office:2 3) Brain infarction, Brain hemorrhage 4) Accident trauma 1) High blood pressure Number of existing vehicles:2 17 Yovon 1 B 300-420 cases / month 2) Cardiac disease A Branch office:- 3) Heavy bleeding

1) High blood pressure/ Heart attack Number of existing vehicles:2 18 J. Balkhi (J. Rumi) 1 B 150-280 cases / month 2) Brain disease A Branch office:4 3) Delivery / Trauma

1) High blood pressure/( Cardiac disease) Number of existing vehicles:2 19 Vakh s h 1 B 900 cases / month 2) Delivery A Branch office:4 3) Trauma

1) High blood pressure Number of existing vehicles:2 20 Qabodiyon 1 B 120-200 cases / month 2) Brain disease A Branch office:3 3) Trauma

ANNEX 2 Activity Status of Target Facilities in Emergency Medical Service 2/4

Number of Requested Number of existing ambulances / City, Rayon, Site Number of emergency Site requested vehicle jurisdiction branch offices Main reasons for dispatch

No. dispatch requests t type (former name) vehicle type Deploymen

1) Cardiac disease Number of existing vehicles:2 21 A . Jomi 1 B 400-450 cases / month 2) Trauma A Branch office:- 3) Delivery

1) High blood pressure Number of existing vehicles:5 22 Farkhor 1 B 750-950 cases / month 2) Influenza A Branch office:4 3) Delivery

1) High blood pressure/ Fever (Influenza) Mir Said Ali Number of existing vehicles:3 23 1 B 550-650 cases / month 2) Delivery A Hamadoni Branch office:4 3) Trauma

1) Cardiac disease Number of existing vehicles:5 24 Danghara 1 B 930-950 cases / month 2) Brain disease A Branch office:3 3) Trauma

1) High blood pressure/ Fever Number of existing vehicles:2 25 Jayhun (Qamsangir) 1 B 250 cases / month 2) Kidney failure A Branch office:4 3) Trauma

1) High blood pressure / Influenza Number of existing vehicles:2 26 Shahrituz 1 B 450 cases / month 2) Trauma A Branch office:3 3) Delivery

1) High blood pressure/ Fever Number of existing vehicles:2 27 Panj 1 B 300 cases / month 2) Kidney failure A Branch office:- 3) Trauma

1) High blood pressure / Fever Number of existing vehicles:1 28 Dusti (Jilikul) 1 B 370 cases / month 2) Brain infarction, Brain hemorrhage A Branch office:3 3) Trauma, Delivery

1) Traffic accident injury Number of existing vehicles:2 29 Khuroson 1 B 420 cases / month 2) Delivery A Branch office:3 3) High blood pressure / ( Cardiac disease)

1) High blood pressure Number of existing vehicles:3 30 Muminobod 1 B 350 cases / month 2) Myocardial infarction A Branch office:2 3) Delivery, Trauma

1) Trauma Bokhtar city Number of existing vehicles:7 31 1 B 1,150 cases / month 2) Cardiac disease A (Qurghonteppa city) Branch office:- 3) Delivery

1) High blood pressure Number of existing vehicles:2 2) Cardiac disease 32 Temurmalik 1 B 380 cases / month A Branch office:2 3) Heavy bleeding ( Kidney failure/ at birth)

1) High blood pressure/ Cardiac disease Number of existing vehicles:1 33 S.Shohin 1 B 380 cases / month 2) Infectious disease A Branch office:4 3) Trauma 1) High blood pressure Number of existing vehicles:3 2) Myocardial infarction 34 Norak city 1 B 550 cases / month A Branch office:- 3) Delivery 4) Traffic accident 1) Cardiac disease Number of existing vehicles:2 35 Khovaling 1 B 250 cases / month 2) Respiratory disease A Branch office:2 3) High blood pressure

1) Delivery Levakant city Number of existing vehicles:2 36 1 B 200 cases / month 2) Trauma A （Sarband city） Branch office:1 3) Cardiac disease

1) High blood pressure Number of existing vehicles:1 37 N.Khusrav 1 B 250-350 cases / month 2) Respiratory problem due to asthma A Branch office:1 3) Trauma / Delivery

1) High blood pressure Number of existing vehicles:2 200 cases / month 38 Baljuvon 1 B 2) Myocardial infarction A Branch office:2 3) Delivery, Trauma Headquarters: Number of existing vehicles 1) Cardiac disease 520 cases / month 39 Bobojon Ghafurov 1 B Headquarters:4 2) Respiratory disease A Branch office: Branch office:13 3) High blood pressure 390 cases / month 1) Delivery Number of existing vehicles:5 40 Isfara city 1 B 750-890 cases / month 2) Pediatric accidental ingestion NA Branch office:- 3) Brain surgery

ANNEX 2 Activity Status of Target Facilities in Emergency Medical Service 3/4

Number of Requested Number of existing ambulances / City, Rayon, Site Number of emergency Site requested vehicle jurisdiction branch offices Main reasons for dispatch

No. dispatch requests t type (former name) vehicle type Deploymen

1) Delivery Number of existing vehicles:5 41 Panjakent city 1 B 700 cases / month 2) Vascular problems A Branch office:6 3) Trauma, Brain injury

1) Delivery Number of existing vehicles:6 42 Istaravshan city 1 B 700-950 cases / month 2) Tumor A Branch office:3 3) Cardiac disease

1) Stroke Number of existing vehicles:7 43 Konibodom 1 B 1,300-1,700 cases / month 2) Cardiac disease A Branch office:3 3) Abdominal pain

1) Cardiac disease Number of existing vehicles:11 44 Khujand city 1 B 1,800 cases / month or more 2) Trauma A Branch office:1 3) Chronic disease

1) High blood pressure Devashtich Number of existing vehicles:3 45 1 B 250 cases / month 2) Myocardial infarction A (Ghonchi) Branch office:2 3) Delivery

1) Tuberculosis Number of existing vehicles:3 46 Asht 1 B 1,000 cases / month 2) Cardiac disease A Branch office:7 3) Trauma

1) High blood pressure Number of existing vehicles:5 900-1,200 cases / month 47 Spitamen 1 B 2) Cardiac disease A Branch office:- 3) Cardiac disease

1) High blood pressure Number of existing vehicles:4 400-600 cases / month 48 J.Rasulov 1 B 2) Cardiac disease A Branch office:- 3) High fever, Consciousness opacity

1) High blood pressure Number of existing vehicles:8 650-920 cases / month 49 Mastchoh 1 B 2) Cardiac disease A Branch office:6 3) Respiratory disease

1) High blood pressure Number of existing vehicles:4 550-650 cases / month 50 Ayni ★ 2) Endogenous disease A Branch office:5 3) Infectious disease

1) High blood pressure Number of existing vehicles:4 51 Zafarobod ★ 250-500 cases / month 2) Delivery A Branch office:1 3) Trauma

1) High blood pressure Number of existing vehicles:4 300-520 cases / month 52 Shahriston ★ 2) Respiratory disease A Branch office:- 3) Appendicitis, Abdominal pains

1) surgical case Number of existing vehicles:5 53 M.Mastchoh ★ 430-500 cases / month 2) Delivery A Branch office:3 3) Trauma

1) High blood pressure Number of existing vehicles:2 54 Van j ★ 560-650 cases / month 2) Cardiac disease A Branch office:1 3) Heavy bleeding

1) Cardiac disease Number of existing vehicles:5 55 Khorog city ★ 700-1,000 cases / month 2) Brain disease A Branch office:1 3) Trauma

1) Cardiac disease Number of existing vehicles:2 56 Ishkoshim ★ 50-200/ cases / month 2) Respiratory disease A Branch office:2 3) High blood pressure

1) Cardiac disease Number of existing vehicles:4 57 Rushon ★ 450 cases / month 2) Brain disease A Branch office:3 3) Trauma

1) High blood pressure Number of existing vehicles:3 58 Darvoz ★ 560 cases / month 2) Cardiac disease A Branch office:3 3) Respiratory disease 1) Cardiac disease National Medical Number of existing vehicles:4 1,500-1,600 cases / month 2) Respiratory disease 59 3 C B-1 Center Branch office:- 3) High blood pressure

1) High blood pressure Dushanbe city 2) Respiratory disease Clinical Hospital of Number of existing vehicles:14 3) Brain infarction, Brain hemorrhage 60 3 C 1,800-2,500 cases / month B-1 Emergency Medical Branch office:- 4) Appendicitis, Abdominal pains Aid 5) Accident, Trauma

Research Institute of 1) High blood pressure Obstetrics, Number of existing vehicles:1 420 cases / month 61 2 C 2) Respiratory disease B-2 Gynecology and Branch office:- 3) Appendicitis・ Abdominal pains Perinatology

ANNEX 2 Activity Status of Target Facilities in Emergency Medical Service 4/4

Number of Requested Number of existing ambulances / City, Rayon, Site Number of emergency Site requested vehicle jurisdiction branch offices Main reasons for dispatch

No. dispatch requests t type (former name) vehicle type Deploymen

Maternity Hospital Number of existing vehicles:0 62 1 C No accept 1) Perinatal disease B-2 No.2 Branch office:-

Maternity Hospital No.1 Number of existing vehicles:0 63 1 C No accept 1) Perinatal disease B-2 (Maternity Hospital Branch office:- No.3)

Existing vehicles were broken and became unrepairable in 64-1 2013. Since then, there is no 1) Cardiac disease GBAO Region Number of existing vehicles:2 replacement and emergency 2) Respiratory disease A （General Hospital） Branch office:- services activities are 3) Accident, Trauma suspended. 2 C Before 2013 200-300 cases / month

64-2 10 cases / month GBAO Region Number of existing vehicles:0 ※ Call center has not been 1) Perinatal disease A (Matemity Hospital) Branch office:- established yet

1) Cardiac disease Khatlon Region Number of existing vehicles:2 200-300 cases / month 65 2 C 2) Pregnancy related problems A (Qurghonteppa) Branch office:- 3) Trauma, Accident

1) High blood pressure Khatlon Region Number of existing vehicles:0 before 2007 66 2 C 2) Respiratory disease A (Kulob) Branch office:- 300 cases / month 3) Appendicitis, Abdominal pains

1) Brain infarction, Brain hemorrhage Number of existing vehicles:2 400-450 cases / month 67 Sughd Region 2 C 2) Respiratory disease B-1 Branch office:- 3) Appendicitis, Abdominal pains

ANNEX 3 Maintenance Cost Estimate Table (Fuel Cost) 1/2

1 Rudaki Maintenance / fuel costs:10,000 (2017) 1 0 70 0 0.00 1 1,419 10,078.05 121,843

Maintenance cost:32,000 (2017) 2 Vahdat 2 2 90 3,650 25,915.00 313,312 0 Fuel cost:60,000 (2017) Maintenance cost:3,000 (2017) 3 Hissor city 1 1 80 1,622 11,517.77 139,249 0 Fuel cost:2,985 (2016) Maintenance cost:30,000 (2017) 4 Tursunzoda city 2 2 80 3,244 23,035.55 278,499 0 Fuel cost:40,000 (2017) Maintenance cost:10,000 (2017) 5 Rasht 1 1 80 1,622 11,517.77 139,249 0 Fuel cost:60,000 (2017) Maintenance cost:15,000 (2017) 6 Shahrinav 2 1 55 1,115 7,918.47 95,734 1 1,115 7,918.47 95,734 Fuel cost: 9,000 (2017) Maintenance cost: 8,000(2017) 7 Faizobod 2 2 90 3,650 25,915.00 313,312 0 Fuel cost:40,782(2017) Maintenance cost:10,000 (2017) 8 Nurobod 1 1 90 1,825 12,957.50 156,656 0 Fuel cost:15,000 (2017) Maintenance cost: 2,800 9 Varzo b 2 2 70 2,839 20,156.11 243,687 0 Fuel cost:15,000 (2017) Maintenance cost:10,000 (2017) 10 Lakhsh (Jirgatol) 1 1 95 1,926 13,677.36 165,359 0 Fuel cost:10,000 (2017) Maintenance cost:12,910 (2017) 11 Tojikobod 2 2 85 3,447 24,475.27 295,906 0 Fuel cost:25,990 (2017) Maintenance cost:16,000 (2017) 12 Roghun city 1 1 85 1,724 12,237.63 147,952 0 Fuel cost:40,000 (2017) Maintenance cost:10,000 (2017) 13 Sangvor (Tavildara) 2 2 80 3,244 23,035.55 278,499 0 Fuel cost:17,745 (2017) Maintenance cost:10,000 (2017) 14 Kushoniyon (Bokhtar) 2 2 65 2,636 18,716.38 226,281 0 Fuel cost:13,000 (2017) Maintenance cost:12,000 (2017) 15 Kulob city 1 1 65 1,318 9,358.19 113,140 0 Fuel cost: 1,400 (2017) Maintenance cost:10,000 (2017) 16 Vo s e 1 1 70 1,419 10,078.05 121,843 0 Fuel cost:12,000 (2017) Maintenance cost:10,000 (2017) 17 Yovon 2 2 65 2,636 18,716.38 226,281 0 Fuel cost:15,000 (2017) Maintenance cost:22,215 (2017) 18 J. Balkhi (J. Rumi) 1 1 65 1,318 9,358.19 113,140 0 Fuel cost: 4,347 (2017) Maintenance cost:3,100 (2017) 19 Vakh s h 2 2 70 2,839 20,156.11 243,687 0 Fuel cost:6,000 (2017) Maintenance cost: unknown 20 Qabodiyon 1 1 90 1,825 12,957.50 156,656 0 Fuel cost:1,000 (2017) Maintenance cost: unknown 21 A . Jomi 1 1 75 1,521 10,797.91 130,546 0 Fuel cost:6,000 (2017) Maintenance cost: 22 Farkhor Appropriate budget allocation 2 2 80 3,244 23,035.55 278,499 0 Fuel cost:7,000 (2017) Maintenance cost:3,500 (2017) 23 Mir Said Ali Hamadoni 1 1 80 1,622 11,517.77 139,249 0 Fuel cost:750 (2017) Maintenance cost: (2017) 24 Danghara 1 1 80 1,622 11,517.77 139,249 0 Fuel cost: (2017) Maintenance / fuel costs: 25 Jayhun (Qamsangir) 1 1 75 1,521 10,797.91 130,546 0 4,500 (budget in 2018) Maintenance cost: unknown 26 Shahrituz 1 0 80 0 0.00 1 1,622 11,517.77 139,249 Fuel cost:3,000 (budget in 2018) Maintenance cost: 4,500 (budget in 2018) 27 Panj 1 1 80 1,622 11,517.77 139,249 0 Fuel cost:19,000 (budget in 2018) Maintenance cost:500 (budget in 2018) 28 Dusti (Jilikul) 1 0 80 0 0.00 1 1,622 11,517.77 139,249 Fuel cost:3,000 (budget in 2018) Maintenance cost:9,996 (2017) 29 Khuroson 2 1 80 1,622 11,517.77 139,249 1 1,622 11,517.77 139,249 Fuel cost:3,200 (budget in 2018) Maintenance cost: unknown (2017) 30 Muminobod 1 1 75 1,521 10,797.91 130,546 0 Fuel cost:10,000 (2017) Maintenance cost:15,000 (2017) 31 Bokhtar city (Qurghonteppa city) 3 3 80 4,867 34,553.33 417,749 0 Fuel cost:50,000 (2017) Maintenance cost:18,000 (2017) 32 Temurmalik 2 2 80 3,244 23,035.55 278,499 0 Fuel cost: 6,000 (2017) Maintenance cost: 9,000 (budget in 2018) 33 S.Shohin 2 1 80 1,622 11,517.77 139,249 1 1,622 11,517.77 139,249 Fuel cost:18,500 (budget in 2018) Maintenance cost: (2017) 34 Norak city 2 2 65 2,636 18,716.38 226,281 0 Fuel cost:35,000 (2017) Maintenance cost: (2017) 35 Khovaling 1 1 80 1,622 11,517.77 139,249 0 Fuel cost:31,750 (2016) Maintenance cost: (2017) 36 Levakant city （Sarband city） 1 1 80 1,622 11,517.77 139,249 0 Fuel cost:12,000 (2017) Maintenance cost: (2017) 37 N.Khusrav 2 1 80 1,622 11,517.77 139,249 1 1,622 11,517.77 139,249 Fuel cost:4,000 (2017) The budget is allocated from the Rayon government.。 Maintenance cost: (2017) 38 Baljuvon 1 1 80 1,622 11,517.77 139,249 0 Fuel cost: (2017) Fuel cost:3,600 (2017) Maintenance cost:48,000 (budget in 2018) 39 Bobojon Ghafurov 2 2 65 2,636 18,716.38 226,281 0 Fuel cost:50,000 (budget in 2018) Maintenance cost:16,700 (2017) 40 Isfara city 0 0 0 0 0.00 0 Fuel cost:72,395 (2017)

ANNEX 3 Maintenance Cost Estimate Table (Fuel Cost) 2/2

Adjusted Maintenance / fuel costs Annual Annual quantity Mileage Annual fuel cost Annual fuel cost Site City, Rayon, Site (Unit price: local currency consumpti Japanese yen Supplem consumpti Japanese yen after / day ＠ 7.1 ＠ 7.1 No. on fuel ＠ 12.09 entation on fuel ＠ 12.09 (former name) Somoni) domestic （ Km) Somoni /1L Somoni /1L ＝ (18Km/L) (18Km/L) 1 Somoni 12.5 yen analysis Replacement Maintenance cost:unknown 41 Panjakent city 2 2 65 2,636 18,716.38 226,281 0 Fuel cost:30,000 (2018) Maintenance cost:24,000 (15k local budget, 9k ggp) 42 Istaravshan city 2 2 65 2,636 18,716.38 226,281 0 Fuel cost:30,000 (2018) Maintenance cost: 23,000 (2017) 43 Konibodom 2 2 75 3,042 21,595.83 261,093 0 Fuel cost: 84,000 (2017) Maintenance cost:unknown 44 Khujand city 4 4 70 5,678 40,312.22 487,374 0 Fuel cost:unknown Maintenance cost:2,000 (2017) 45 Devashtich (Ghonchi) 1 1 80 1,622 11,517.77 139,249 0 Fuel cost:2,000 (2017)

46 Asht Maintenance cost:16,527 (local budget) (2018) 0 0 0 0 0.00 0

Maintenance cost:13,700 47 Spitamen 1 1 70 1,419 10,078.05 121,843 0 Fuel cost:20,000 Maintenance cost: 3,500 (2017) 48 J.Rasulov 1 1 70 1,419 10,078.05 121,843 0 Fuel cost:28,000 (2017) Maintenance cost:5,000 (2017) 49 Mastchoh 2 2 75 3,042 21,595.83 261,093 0 Fuel cost:5,000 (2017) Maintenance cost:7,000 (2017) 50 Ayni 2 2 85 3,447 24,475.27 295,906 0 Fuel cost:6,500 (by 3 vehicles) Maintenance cost:5,000 (2017) 51 Zafarobod 0 0 0 0 0.00 0 Fuel cost:2,265 (2017) Maintenance cost:3,000 (2017) 52 Shahriston 1 1 80 1,622 11,517.77 139,249 0 Fuel cost:5,750 (2017) Maintenance cost:3,740 (2017) 53 M.Mastchoh 1 1 95 1,926 13,677.36 165,359 0 Fuel cost:4,700 (2017) Maintenance cost:7,500 (2017) 54 Van j 1 1 90 1,825 12,957.50 156,656 0 Fuel cost:4,000 (2017) Maintenance cost: 32,000 55 Khorog city 1 1 90 1,825 12,957.50 156,656 0 Fuel cost:150,000 (2017) Maintenance cost:6,000 (2015) 56 Ishkoshim 1 1 95 1,926 13,677.36 165,359 0 Fuel cost:8,000 (2015) Maintenance cost:8,000 (2017) 57 Rushon 1 1 80 1,622 11,517.77 139,249 0 Fuel cost:6,500 (2017) Maintenance cost:9,000 (2017) 58 Darvoz 1 1 85 1,724 12,237.63 147,952 0 Fuel cost:8,500 (2017) Maintenance cost:10,000 (2017) 59 National Medical Center 2 2 65 2,636 18,716.38 226,281 0 Fuel cost:35,000 (2017)

Dushanbe city Clinical Hospital Maintenance cost: (2017) 60 3 3 60 3,650 25,915.00 313,312 0 of Emergency Medical Aid Fuel cost: (2017)

Research Institute of Obstetrics, Maintenance cost:unknown 61 Gynecology and Perinatology 1 0 65 0 0.00 1 1,318 9,358.19 113,140 Fuel cost:unknown (Maternity Hospital No.1)

Maintenance cost:- (2017) 62 Maternity Hospital No.2 0 0 0 0 0.00 0 Fuel cost:- (2017) Maternity Hospital No.1 Maintenance cost:- (2017) 63 0 0 0 0 0.00 0 (Maternity Hospital No.3) Fuel cost:- (2017) 64-1 GBAO Region（General - 1 0 80 0 0.00 1 1,622 11,517.77 139,249 Hospital） GBAO Region Vehicle-related costs are borne by the patient 1 0 80 0 0.00 1 1,622 11,517.77 139,249 (Matemity Hospital) Maintenance cost:25,000 (2017) 65 Khatlon Region (Qurghonteppa) 1 1 90 1,825 12,957.50 156,656 0 Fuel cost:40,000 (2017) Maintenance cost:- (2017) 66 Khatlon Region (Kulob) 1 0 80 0 0.00 1 1,622 11,517.77 139,249 Fuel cost:- (2017)

Maintenance cost:Repair support at state vehicle base 67 Sughd Region 2 2 80 3,244 23,035.55 278,499 0 Fuel cost:- (2017)

Total (Japanese Yen) 912,063.73 11,026,850 119,496.87 1,444,717 **The mileage per day was calculated by proportional allocating the number of operation record of short-range dispatch and long-range dispatch