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Review of Public Health Expenditures in the Republic of Tajikistan

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Review of Public Health Expenditures in the Republic of Tajikistan REVIEW OF PUBLIC HEALTH EXPENDITURE IN THE REPUBLIC OF TAJIKISTAN Public Disclosure Authorized DISCUSSION PAPER July 2021 Sven Neelsen Farrukh Egamov Husniya Dorgabekova Kate Madeville Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized REVIEW OF PUBLIC HEALTH EXPENDITURES IN THE REPUBLIC OF TAJIKISTAN Sven Neelsen, Farrukh Egamov, Husniya Dorgabekova, and Kate Mandeville July 2021 Health, Nutrition and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. For information regarding the HNP Discussion Paper Series, please contact the Editor, Jo Hindriks at [email protected] or Erika Yanick at [email protected]. RIGHTS AND PERMISSIONS The material in this work is subject to copyright. Because the World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: [email protected]. © 2020 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. i Health, Nutrition and Population (HNP) Discussion Paper Review of Public Health Expenditures in the Republic of Tajikistan Sven Neelsena, Farrukh Egamovb, Husniya Dorgabekovac and Kate Mandevilled a HNPGE, World Bank, Washington, DC, USA b Health Financing Consultant, World Bank, Dushanbe, Republic of Tajikistan c Consultant, World Bank, Dushanbe, Republic of Tajikistan d HEAHN, World Bank, Washington, DC, USA Abstract: This Public Expenditure Review updates previous assessments of the levels and efficiency of health financing in Tajikistan and its consequences for healthcare access and health of the Tajik population. Funding for the public healthcare system which provides almost all healthcare remains far short of levels required to provide a universal basic benefit package. As a result, household out-of-pocket payments account for most healthcare spending in the country, and Tajiks frequently forgo needed care for financial reasons. The underfunding of public healthcare in part results from an overall lack of public revenues. It is, however, exacerbated by the health sector enjoying limited priority, with a health share in total government spending far below internationally recognized targets. Inefficiencies in the spending of the limited public funds further undermine the system’s ability to provide the population with basic healthcare of appropriate quality. Despite efforts in the past two decades to introduce elements of strategic purchasing and direct a higher share of funding towards primary care, public health financing in Tajikistan still largely follows the centrally planned, hospital-focused, and mainly input-financed Semashko model. The result are substantial regional inequalities in per capita government health spending which reflect differences in health facility and health worker densities rather than healthcare need, a continued overemphasis on hospital and specialist care, and an inability of facility managers to take efficiency-oriented staffing decisions. Key recommendation to address these shortcoming are that a substantially higher share of public revenues be allocated to the health sector, that an independent, single payer organization, a fully-fledged capitation mechanism for primary care and elements of strategic purchasing for inpatient care be gradually introduced, and that current benefit packages are revised and extended to achieve more rational and equitable healthcare utilization. Broad consensus building among stakeholders will be essential for the success of such reforms. Keywords: public expenditure review, health expenditure, health system, Tajikistan Disclaimer: The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Sven Neelsen, World Bank, 1818 H St NW, Washington, DC, USA, telephone: +1-202-597-8006, Email: [email protected], website: www.worldbank.org ii TABLE OF CONTENTS RIGHTS AND PERMISSIONS ............................................................................................................................................. i ABBREVIATIONS ................................................................................................................................................................... iv FIGURES ..................................................................................................................................................................................... v TABLES....................................................................................................................................................................................... ix ACKNOWLEDGMENTS ........................................................................................................................................................ x EXECUTIVE SUMMARY ...................................................................................................................................................... xi PART I – INTRODUCTION .................................................................................................................................................. 1 PART 2 – ECONOMIC AND DEMOGRAPHIC CONTEXT .................................................................................... 2 GEOGRAPHY AND DEMOGRAPHY ...................................................................................................................................... 2 POLITICAL SYSTEM AND ECONOMY .................................................................................................................................. 4 PART 3 – HEALTH SYSTEM ORGANIZATION ......................................................................................................... 9 INSTITUTIONS AND HEALTH CARE PROVIDERS ............................................................................................................... 9 PUBLIC HEALTH CARE COVERAGE .................................................................................................................................. 11 PUBLIC HEALTH CARE BUDGETING AND PROVIDER PAYMENTS .............................................................................. 12 PART 4 – HEALTH OUTCOMES .................................................................................................................................... 16 PART 5 – HEALTH CARE ACCESS ............................................................................................................................. 21 PART 6 – HEALTH CARE EXPENDITURE ............................................................................................................... 29 TOTAL HEALTH CARE EXPENDITURE ............................................................................................................................... 29 PRIVATE HEALTH CARE EXPENDITURE ........................................................................................................................... 32 EXTERNAL HEALTH CARE EXPENDITURE ....................................................................................................................... 38 PUBLIC HEALTH CARE EXPENDITURE ............................................................................................................................. 40 Funding sources ......................................................................................................................................................... 40 Expenditure levels ...................................................................................................................................................... 44 Functional allocation ................................................................................................................................................ 48 Economic allocation.................................................................................................................................................. 53 Human resources ..................................................................................................................................................... 54 Medical goods and capital ...................................................................................................................................
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