Completion Report
Project Number: 33036 Loan Number: 2054-TAJ(SF) December 2010
Tajikistan: Health Sector Reform Project
CURRENCY EQUIVALENTS
Currency Unit – somoni (TJS)
At Appraisal At Project Completion (15 November 2003) (30 September 2009) TJS1.00 = $0.3274 $0.2282 $1.00 = TJS3.0544 TJS4.3822
ABBREVIATIONS
ADB – Asian Development Bank CDH – central district hospital DHD – district health department DHIS2 – Development Health Information System–2 DSG – district supervisory group ESRP – Education Sector Reform Project FGP – family group practice HMIS – health management information system HSRP – Health Sector Reform Project JFPR – Japan Fund for Poverty Reduction MOF – Ministry of Finance MOH – Ministry of Health NGO – nongovernment organization NMPC – National Medicine and Medical Commodities Procurement Centre NSC – national steering committee PAU – project administration unit PHC – primary health care PIU – project implementation unit PMU – project management unit PSFCI – Pharmaciens Sans Frontières Comité International RCDE – Research Center for Drug Expertise SDR – special drawing rights TA – technical assistance TSMU – Tajikistan State Medical University
NOTES
(i) The fiscal year (FY) of the government and its agencies ends on 31 December. (ii) In this report, "$" refers to US dollars.
Vice-President X. Zhao, Operations 1 Director General J. Miranda, Central and West Asia Department (CWRD) Country Director & J. Tokeshi, Tajikistan Resident Mission (TJRM), CWRD Team Leader Sector Director D. Kertzman, Financial Sector, Public Management and Trade Division, CWRD Team member N. Kvanchiany, Assistant Project Analyst, TJRM, CWRD
In preparing any country program or strategy, financing any project, or by making any designation of or reference to a particular territory or geographic area in this document, the Asian Development Bank does not intend to make any judgments as to the legal or other status of any territory or area.
CONTENTS Page
BASIC DATA i MAP v I. PROJECT DESCRIPTION 1 II. EVALUATION OF DESIGN AND IMPLEMENTATION 1 A. Relevance of Design and Formulation 1 B. Project Outputs 2 C. Project Costs 8 D. Disbursements 9 E. Project Schedule 9 F. Implementation Arrangements 9 G. Conditions and Covenants 10 H. Related Technical Assistance 10 I. Consultant Recruitment and Procurement 11 J. Performance of Consultants, Contractors, and Suppliers 12 K. Performance of the Borrower and the Executing Agency 12 L. Performance of the Asian Development Bank 12 III. EVALUATION OF PERFORMANCE 12 A. Relevance 12 B. Effectiveness in Achieving Outcome 13 C. Efficiency in Achieving Outcome and Outputs 13 D. Preliminary Assessment of Sustainability 13 E. Impact 14 IV. OVERALL ASSESSMENT AND RECOMMENDATIONS 14 A. Overall Assessment 14 B. Lessons 15 C. Recommendations 15
APPENDIXES 1. Project Framework 16 2. Basic Social, Economic, and Health Data on Tajikistan 25 3. Strengthening of Planning and Management Capacity in the Health Sector 30 4. Human Resource Development of Health Sector 34 5. Capacity Building for Family Group Practice 38 6. Strengthening Drug Quality Control and Drug Procurement 40 7. Delivery of Pro-Poor Health Services 42 8. Information on Civil Works Contracts 45 9. Project Cost and Financing Plan (Appraised and Actual) 47 10. Project Implementation Schedule 50 11. Project Organizational Diagram 52 12. Status of Compliance with Loan Covenants 53 13. Overall Assessment of the Health Sector Reform Project 62
BASIC DATA
A. Loan Identification
1. Country Republic of Tajikistan 2. Loan number 2054-TAJ(SF) 3. Project title Health Sector Reform Project 4. Borrower Republic of Tajikistan 5. Executing agency Office of the President 6. Amount of loan SDR5,238,000 7. Project Completion Report Number PCR: TAJ 1202
B. Loan Data 1. Appraisal – Date started 9 June 2003 – Date completed 20 June 2003
2. Loan negotiations – Date started 13 November 2003 – Date completed 15 November 2003
3. Date of Board approval 17 December 2003
4. Date of loan agreement 15 April 2004
5. Date of loan effectiveness – In loan agreement 14 July 2004 – Actual 15 July 2004 – Number of extensions 0
6. Closing date – In loan agreement 30 June 2009 – Actual 23 November 2009 – Number of extensions 0
7. Terms of loan – Interest rate 1% per annum during the grace period and 1.5% per annum thereafter – Maturity (number of years) 32 years – Grace period (number of years) 8 years
8. Disbursements a. Dates Initial Disbursement Final Disbursement Time Interval
26 August 2004 30 October 2009 63 months
Effective Date Original Closing Date Time Interval
15 July 2004 30 June 2009 59.5 months
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b. Amount (SDR million) Original Last Revised Amount Undisbursed Category Allocation Allocation Disbursed Balance Civil works 640,000 1,574,472 1,507,325 67,147 Equipment and furniture 1,240,000 1,613,460 1,681,657 (68,197) Overseas training 105,000 114,631 110,862 3,769 In-country training 283,000 418,038 384,705 33,333 International consultants 430,000 270,292 252,646 17,646 National consultants 37,000 124,493 116,814 7,679 Surveys and studies 71,000 24,340 11,493 12,847 Public information campaign 127,000 12,713 0 12,713 Materials and consumables 624,000 263,051 235,314 27,737 Project management 409,000 610,771 568,629 42,142 Procurement center/PSFCI 405,000 0 0 0 Family group practice seed capital 239,000 78,590 67,233 11,357 Recurrent cost 58,000 23,623 23,092 531 Interest charge 138,000 68,175 68,175 0 Unallocated 432,000 41,351 0 41,351 Total 5,238,000 5,238,000 5,027,945 210,055 PSFCI = Pharmaciens Sans Frontières Comité International. ( ) = negative. 9. Local costs (financed) - Amount ($ million) 2.869 - Percent of local costs 92.56 - Percent of total cost 37.17
C. Project Data
1. Project cost ($ million)
Cost Appraisal Estimate Actual
Foreign exchange cost 5.340 4.851 Local currency cost 4.035 4.611 Total 9.375 9.462
2. Financing plan ($ million)
Cost Appraisal Estimate Actual Implementation costs Borrower financed 1.875 1.742 ADB financed 7.302 7.616 Other external financing 0.000 0.000 Total 9.177 9.358 IDC costs Borrower financed 0.000 0.000 ADB financed 0.198 0.104 Other external financing 0.000 0.000 Total 0.198 0.104 ADB = Asian Development Bank, IDC = interest during construction.
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3. Cost breakdown by project component ($ million) Component Appraisal Estimate Actual
A. Base cost 1. Institutional development 2.022 2.058 2. Drug supply and quality control 1.254 0.910 3. Pro-poor health package 4.227 5.412 4. Project management 0.586 0.978 B. Contingencies 1.089 0.000 C. Interest charge 0.197 0.104 Total cost 9.375 9.462
4. Project schedule Item Appraisal Actual Estimate Date of contract with consultants International (National) Project management adviser Aug 2004 13 Nov 2004 Laboratory and drug quality control Jan 2005 20 Feb 2005 (22 Feb 2005) Human resource development Jan 2005 22 Feb 2005 (22 Feb 2005) Health personnel licensing and accreditation May 2005 17 Jun 2005 (22 Feb 2005) Family group practice May 2005 9 Aug 2005 (22 Feb 2005) Capitation payment specialist Jan 2006 10 Aug 2005 (22 Feb 2006) Clinical pharmaceutical specialist Feb 2006 3 Apr 2006 (14 Sep 2005) Drug marketing specialist Nov 2005 (1 Feb 2006) Health management information system Oct 2006 12 Nov 2007 (20 Dec 2006) Health planning and rationalization Mar 2007 29 Jun 2007 (22 Feb 2005) Monitoring and evaluation specialist Jun 2007 10 Jun 2008 (10 Oct 2007) Mapping of health facilities Apr 2006 Aug 2006 Civil works contract Date of award Jan 2007 4 Apr 2004 Completion of work Jun 2009 15 Sep 2009 Equipment and supplies First procurement Nov 2004 15 Oct 2004 Last procurement Nov 2008 23 Apr 2009 Essential drugs supply Sep 2005 Aug 2006 Trainings Overseas training Nov 2004 Dec 2004 In-country training Jun 2005 Sep 2005 Community awareness and participation (JFPR 9043a) May 2006 May 2007 JFPR = Japan Fund for Poverty Reduction. a ADB. 2004. Proposed Grant Assistance to the Republic of Tajikistan for Community Participation and Public Information Campaign for Health Improvement. Manila
5. Project Performance Report Ratings Ratings
Implementation Period Development Implementation Objectives Progress From 30 Dec 2003 to 29 Jun 2005 Satisfactory Satisfactory From 30 Jul 2005 to 30 May 2006 Satisfactory Highly satisfactory From 29 June 2006 to 30 Aug 2008 Satisfactory Satisfactory From 29 Sep 2008 to 30 June 2009 Satisfactory Highly satisfactory
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D. Data on Asian Development Bank Missions No. of No. of Specialization Name of Mission Date Persons Person-Days of Members Pre-loan inception mission 1 2–8 Feb 2004 2 10 a, c Pre-loan inception mission 2 5–9 Apr 2004 2 10 a, d Inception mission 13–17 Sep 2004 1 5 a Review mission 1 28 Jan–10 Feb 2005 2 28 a, c Review mission 2 22–30 Jul 2005 2 18 a, b Review mission 3 6–10 Feb 2006 2 10 a Review, reconnaissance, and 15–29 Jun 2006 4 60 a, d, e, f inception mission Midterm review mission 23 Oct–3 Nov 2006 5 60 a, c, e, g, h Review mission 4 11–23 Jun 2007 2 26 a, g Review mission 5 1–10 Dec 2007 3 30 a, e, g SOE review mission 17–20 Mar 2008 1 4 i Review mission 6 16–21 Oct 2008 2 12 g, j Review mission 7 18–25 May 2009 2 16 e, j Project completion review 1 Sep–5 Oct 2009 3 29 e, h, c a = senior health specialist/health specialist, b = senior project specialist/project specialist, c = project assistant/analyst, d = project implementation specialist, e = principal portfolio management specialist, f = transport specialist, g = social sector specialist, h = staff consultant, i = financial control specialist, SOE = statement of expenditures.
o 69 o 00'E 73 00'E
UZBEKISTAN TAJIKISTAN HEALTH SECTOR REFORM PROJECT (as completed)
Buston
Kayrokkum Reservoir Khujand Konibodom N Zafarobod Gafurov o Nov Isfara o 40 00'N Proletar 40 00'N 0 50 100
Istaravshan Vorukh Kilometers SUGD KYRGYZ REPUBLIC REGION Pandjakent Kuhistoni Ayni Mastchoh District Mehron
Ayni Rasht District District Jirgatol PEOPLE'S REPUBLIC Lake Karakul OF CHINA REGIONS Garm UNDER DIRECT Darband UZBEKISTAN REPUBLICAN JURISDICTION DUSHANBE
Kalaikhumb Tursun-zoda Vakhdat
Lake Sarez Yovon Nulvand KHATLON REGION Murgob Dangara Kulob District GORNO-BADAKHSHAN Kulob AUTONOMOUS REGION
Kurgonteppa Sarband
Jilikul Khorug o 37 00'N 37 o 00'N Shakhrituz Panj Roshtkala District Panji Poyon Roshtkala National Road Other Road Project District Railway National Capital River Ishkoshim Regional Center District Boundary Autonomous Regional Center Regional Boundary 10-2281a HR District Center/Town Autonomous Regional Boundary A F G H A N I S T A N Pilot District International Boundary
o Ministry of Health 69 o 00'E Boundaries are not necessarily authoritative. 73 00'E
I. PROJECT DESCRIPTION
1. Following independence in 1991, Tajikistan began to build a society based on free market principles. However, the country experienced a prolonged economic depression as a result of the transition process, the cessation of economic support from the former Soviet Union, and a civil war and subsequent political instability (1992–1997). These events have left more than 83% of the Tajik population below the poverty line.
2. In its diagnostic work, Asian Development Bank (ADB) identified the following major concerns in the health sector: (i) the high burden of disease and precarious health status of the population; (ii) greatly reduced public health expenditures and inefficient use of resources; (iii) a collapsed public health-care system; (iv) increased out-of-pocket payment by beneficiaries; (v) reduced access to and use of health services, particularly by the poor; (vi) a weakened and unreliable health information system; (vii) limited managerial, technical, administrative, and financial capacity at all levels of the health sector; and (viii) the urgent need to replace the drug supply system introduced and managed by humanitarian agencies with a well-managed, sustainable procurement and distribution system before their exit. The Health Sector Reform Project (HSRP) 1, approved by ADB on 17 December 2003 and made effective on 15 July 2004, was designed to respond to these issues, as well as support dialogue on policy and priorities.
3. The HSRP had three outcomes: (i) improve the management capacity and system efficiency of the health sector through institutional strengthening and reforms; (ii) increase equitable access to and use of high-quality basic health services by the poor, women, and children; and (iii) support informed policy dialogue to pursue reform. The HSRP comprised the following groups of outputs: (i) institutional development for the health sector, (ii) drug supply and quality control, and (iii) efficient and sustainable delivery of a pro-poor health service package. The project framework is in Appendix 1. The HSRP had three associated technical assistance (TA) projects and grants: (i) TA on Strengthening Planning and Policy Dialogue for Health Reforms, (ii) TA on Developing Drug Procurement Strategies,2 and (iii) Japan Fund for Poverty Reduction (JFPR) grant for the Community Participation and Public Information Campaign for Health Improvement.3
II. EVALUATION OF DESIGN AND IMPLEMENTATION
A. Relevance of Design and Formulation
4. The design of HSRP was highly relevant during the time of appraisal and approval, and it has remained so throughout its implementation. The HSRP was consistent with the government’s objectives to rehabilitate social infrastructure, and to reactivate delivery of vital social services disrupted during the civil war. Marked inequalities had emerged in the population's health conditions along with rising social and economic disparities. Child and maternal mortality rates were high, exceeding the levels in many neighboring countries. Under- 5 mortality rates were 100 per 1,000 live births for the poorest 60% of households compared with 74 per 1,000 live births for the richest 40%.4 Almost 46% of the poorest households found it impossible or very difficult to pay for health care, compared with 28% of the richest households.5 The main cause of difficulties in the health-care system appears to have been the large reduction in public expenditure on health since the beginning of transition. In 2007, public
1 ADB. 2003. Report and Recommendation of the President to the Board of Directors: Proposed Loan and Technical Assistance Grants to the Republic of Tajikistan for the Health Sector Reform Project. Manila. 2 ADB. 2003. Technical Assistance to the Republic of Tajikistan for Planning and Policy Dialogue for Health Reform. Manila (TA 4268-TAJ, for $300,000, approved on 17 December); ADB. 2003. Technical Assistance to the Republic of Tajikistan for Drug Procurement and Distribution Strategy. Manila (TA 4269-TAJ, for $150,000, approved on 17 December). 3 ADB. 2004. Proposed Grant Assistance to the Republic of Tajikistan for Community Participation and Public Information Campaign for Health Improvement. Manila 4 State Committee on Statistics of the Republic of Tajikistan. 2007. Tajikistan Multiple Indicator Cluster Survey 2005, Final Report. Dushanbe, Tajikistan: State Committee on Statistics of the Republic of Tajikistan. 5 World Bank. 2009. Republic of Tajikistan: Poverty Assessment (Report No. 51341-TJ) . Washington, DC.
2 spending on health was an estimated 1.2% of nominal gross domestic product, from levels upwards of 3-4% prior to the transition.
5. The HSRP's support for primary health care (PHC) and increased efficiency of health services delivery was consistent with Tajikistan's National Development Strategy, which aims to (i) reform the health-care system, including developing the private sector and attracting investment; (ii) improve maternal and child health; and (iii) improve availability, quality, and effectiveness of medical services. At the end of project implementation, the HSRP remained relevant to ADB’s strategy for Tajikistan.6 The HSRP increased the efficiency of and equality of access to essential medical services for vulnerable groups, in particular poor, women, and children.
6. The HSRP also supported (i) capacity building and reforms across the health sector, and (ii) strengthening of the national drug supply system in collaboration with other development agencies and nongovernment organizations (NGOs). On the reform front, the HSRP supported policy and institutional changes including (i) reorienting health service delivery from a hospital-based and cure-based approach to PHC, (ii) shifting provider payment mechanisms from fixed salary to capitation payment with pro-poor and efficiency incentives, (iii) refocusing budget preparation from norm-based to per-capita allocation, and (iv) accelerating system rationalization.
B. Project Outputs
7. Summary of Project Accomplishments: Overall, as summarized in Appendix 1, the HSRP outputs have been delivered in an effective and efficient manner. The changes introduced under HSRP are being sustained and quite likely to be so in the future. The most significant achievements are noted below:
• Sustained increase in the share of public budget allocated to PHCs from 6% in 2003 to 35% in 2008; Meaningful positive impact on women’s health seeking behavior over 2004-20087 • Design and adoption of a well-rounded legal, financial and operational framework for the Family Group Practice (FGP) system • Drug quality control mechanism considerably strengthened, as demonstrated– among other measures - by a sharp increase in the number of registered pharmacies (from 157 such units licensed out of 800 units in 2004 to 1,258 registered/licensed units in 2009); and by a significant increase in the quality analysis of drugs (from about 7,050 tests in 2004 to about 13,000 tests in 2007) • Reorganization of PHC facilities in five districts to improve service provision; a total of 49 health facilities were renovated or constructed; and • Training of over 130 family doctors and 580 district nurses on family medicine; 150 health specialists were also trained on health financing
8. There have, however, been some shortfalls which are being addressed by the government. For instance, the establishment of district health departments was postponed and had not been completed at the end of the project. This delay has not affected project implementation, since the government has established district supervisory groups with oversight responsibilities. The child vaccination program is being strengthened in the pilot districts as well as nationwide.
6 ADB. 2005. Country Strategy and Program Update: Tajikistan, 2006–2008. Manila. 7 Although the project is yet to show any significant increases in visits to PHCs or child vaccination (Appendix 7).
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1. Institutional Development for the Health Sector
a. Capacity Building for Planning and Management
9. Health policy reform. The HSRP drafted a number of policy and legal documents, most of which were approved as national policies or strategies by the government.8 With the support of the HSRP, the government approved an important strategic document: the 2005– 2015 Strategy of Health Care Financing.9 There are two innovative proposals in the strategy: (i) capitation-based allocation of the health budget to the regions and districts, which is a shift from the norm-based budget allocation; and (ii) provision of 40% of the district budget to PHC (with 60% to hospitals). PHC budgets increased annually from 2003 to 2008, and health worker salaries doubled in 2006. In 2008, the share of the public health budget allocated to PHC was 35%, up from 6% in 2003; and the government agreed to a number of budgetary and organizational reforms. The strategy also advocates the use of another capitation payment rate as a service provider payment mechanism. An experimental package of basic benefits was piloted in two districts in 2004 and then scaled up nationally in 2005. The HSRP contributed to the preparation of an implementation plan for the strategy, definition of the capitation rate, and design of guidelines for regional and district staff for planning and implementing allocations.
10. To facilitate capacity building, the HSRP conducted overseas training for key staff of the Ministry of Health (MOH) and Tajikistan State Medical University (TSMU). In 2005, the training committee developed the first training plan for MOH specialists and district health department and local health facility staff. MOH specialists and staff from province and district health centers and pilot districts received in-country training in health sector planning and management. In addition, the HSRP enhanced the ability of the MOH, the Ministry of Labor and Social Protection, and TSMU to analyze workforce situations. The project also supported the design and preparation of the first Tajikistan Health Sector Interim Workforce Plan for 2006–201010, and the Tajikistan Health Human Resource Management Guidelines, 11 approved on 6 December 2007 and widely distributed.
11. The capacity of TSMU was strengthened in response to the need for well-qualified health staff in the reformed health system. The MOH and TSMU piloted the coordination of student intake; distribution of graduates; staff numbers, profiles and distribution; job descriptions; and training needs. In accordance with the approved training plan, 4 conferences, 12 training seminars, and 16 training courses (overseas and in-country) were held. The in- country training started in May 2007 and was completed by the end of June 2009. The HSRP supported the establishment of the Faculty of Family Medicine at TSMU, procured the necessary equipment, and renovated part of the TSMU building to be used by the faculty. In 2008, the HSRP signed an agreement with TSMU to ensure further maintenance and repair of equipment. The project also provided support to family medicine training centers, with affiliated inter district family group practice (FGP) training centers in Sugd and Khatlon regions, and to the newly established center in Khorog (Gorno-Badakhshan Autonomous Region). The HSRP provided educational materials, training equipment and furniture to TSMU, Tajik Institute of Postgraduate Training for Medical Staff, and family medicine training centers. A new curriculum was adopted in TSMU in February 2007 to facilitate training. In September 2009, TSMU
8 The government issued the following national policies or strategies: Family Group Practice Model, National Health Management Information System, National Interim Workforce Plan and Health Human Resource Management Guidelines, National Medicines and Medical Commodities Procurement and Distribution Strategy, and National Policy for Rationalization of Hospital Facilities and Hospital Restructure Concept of Tajikistan 2006–2010. The national policy documents, which were planned under the HSRP served as a prerequisite for implementation of health sector reform. 9 Government of Tajikistan. 2005. Strategy of Health Care Financing in the Republic of Tajikistan for the period 2005 – 2015 (Government Decree No. 171 dated 10 May 2005). Dushanbe 10 Salimov N.F. and Radjabova L.C. 2006. Tajikistan Health Sector Interim Workforce Plan for 2006–2010. Dushanbe: Anjumani Devashtich. (Approved by MOH order no. 208 dated 15 May 2008.) 11 Ministry of Health of the Republic of Tajikistan. 2008. Tajikistan Health Human Resource Management Guidelines. Dushanbe: Devashtich
4 established graduate courses in FGP and 255 interns started their training. A working group comprising the MOH and NGOs was set up to review medical education programs.
12. Health system rationalization. The HSRP assessed location, function, staffing, and use of health facilities in pilot districts in 2005 and 2007. The project also assisted the MOH in designing a framework and guidelines for FGP mapping and population registration, creating questionnaires, training health staff, and conducting mapping in pilot districts. The baseline data were used for concept development, planning, design of computerized geographic information system (GIS), and digitized maps. Software for development of the health information system was designed, and distributed to the pilot districts and central health institutions. The consolidated data served as a baseline against which the impacts of the project could be measured.
13. The revised national policy for rationalization of PHC facilities was designed and approved by the government in January 2006. In the same year, the HSRP designed and tested a rationalization plan for Kulyab district. Reorganization of PHC facilities and hospitals was completed in five pilot districts in 2007.
14. The HSRP built on and integrated past achievements and produced significant outputs in the health management information system (HMIS), health surveys, and poverty assessments.12 The HMIS team conducted a comprehensive situation analysis, designed a national HMIS, and created an action plan for piloting and national expansion of the system. The open-source software, Development Health Information System–2 (DHIS2), was adopted and piloted in five districts. The HMIS report covering 2008 was finalized in early 2009— incorporating development partners' recommendations—and disseminated to the MOH, provincial health centers, central health institutions of pilot districts, and development organizations. The collection of health statistical indexes for 2003–2006 was completed in all pilot districts.
15. Computer equipment was procured and delivered to the centers for medical statistics in all regions, and pilot districts. A series of seminars on the collection, analysis and presentation of data about the health of the population was conducted in health facilities. In total, 125 staff from central and district PHC facilities and health centers attended the seminars. The HSRP financed some members of the HMIS team to participate in an international seminar, “Health System Development: integration challenges”, in New Delhi; followed by a study tour in Gujarat province in India, where DHIS2 has been implemented. Capacity building seminars to enable specialists to provide technical and program support to DHIS2 were conducted in the pilot districts. Training materials and user manuals were developed in the Russian and Tajik languages. The technical working group conducted more than 50 meetings with representatives of health facilities (immune prophylactics, sanitary epidemiological services, tuberculosis center, etc.) and developed a catalogue of 258 electronic recording forms, 37 reporting forms, and 834 health indicators.
16. HMIS development has raised awareness among government officials of the importance of (i) information collection and monitoring, (ii) policy dialogue between the government and external development partners, and (iii) public–private partnership. The HSRP succeeded in raising awareness of the need for strategic planning in the public sector and the use of information to increase the capacity of staff in peripheral health facilities. Eight district, regional, and national workshops were organized for 150 participants. In addition, more than 60 meetings and interviews took place with stakeholders.
17. Licensing and accreditation. The HSRP anticipated the design and introduction of a system with various fee levels corresponding to specific categories of health personnel. A set of policy and legal documents for licensing and accreditation of health personnel and health
12 For a complete evaluation of the TA see: ADB. 2006. Technical Assistance Completion Report: Planning and Policy Dialogue for Health Reform (Tajikistan). Manila.
5 facilities was prepared and submitted for approval in August 2005. The MOH assigned the function of licensing and accreditation to the Center on Pharmaceutical and Medical Activity (formerly the State Center for Drug and Health Expertise). The HSRP supported the development of (i) standards for accreditation of PHC facilities, and (ii) expert guidelines for self-appraisal and evaluation of PHC facilities.
18. Increasing financial sustainability. A key project area was support for capacity development of the MOH in health economics (costing), financing, and planning. The HSRP supported implementation of the following strategies: (i) introduction of a copayment system at district health departments, to generate revenue that could be used as an incentive for health personnel at PHC facilities, and (ii) allocation of revenue to district health centers and health houses. This allocation was to be performance-based, assessed through monitoring of quality assurance.
19. Despite operational difficulties in introducing a copayment scheme, the HSRP has developed a comprehensive model of per-capita payment, and the government is now finalizing it. This community copayment or cofinancing mechanism would need a strong monitoring and evaluation system for replication of the model.
20. Capitation payment. The HSRP developed a per-capita formula for health facility budget allocation, with an adjustment for risk groups and health facility performance, excluding staff salaries. Based on feedback from international development partners, the formula was reviewed by the HSRP Working Group (Aga Khan Foundation, Project Sino, United Nations Children’s Fund, World Bank, World Health Organization, and ZdravPlus) and international consultants. The stakeholders agreed to introduce a simpler formula (a common capitation rate for all the population) with an adjustment for risk groups—children less than 5 years old, women of child bearing age, and the elderly (over 65 years). The HSRP designed an improved capitation payment methodology and assisted in data collection and budget review. Guidelines on capitation payment methodology were designed, modules were tested at PHC facilities in pilot districts, and district financial and public health officers were trained in capitation payment.
b. Developing a Family Group Practice Framework
21. The HSRP assisted the MOH in establishing legislative, financial, and operational frameworks for the FGP system. This included setting up an accreditation scheme for FGPs, developing a framework and guidelines for FGP mapping and population registration, and designing performance-based contracts and capitation payment mechanisms as incentives. Working groups were established for the FGP system and for retraining, human resource development, hospital rationalization, licensing and accreditation, health financing, and drug quality control. The FGP framework was discussed at the National Conference on the Family Medicine Model in December 2005 and the proposed FGP unit was recommended to be introduced nationwide in the PHC system. The FGP framework was tested in five pilot districts and the results were reviewed at two national conferences on family medicine (in 2007 and 2008). A monitoring system was designed to measure the impacts at PHC facilities, which were consolidated in district data reports. Standards and guidelines for FGP training, including the FGP model, were endorsed by the MOH on 12 January 2006. A set of family medicine legal and recording–reporting documents was also developed to facilitate nationwide expansion of the FGP system.
2. Drug Supply and Quality Control
22. Establishment of an efficient drug procurement center. This output was intended to strengthen the capacity of the national procurement and distribution system. The HSRP assisted MOH in (i) the reorganization and establishment of the National Medicine and Medical Commodities Procurement Centre (NMPC) on 28 August 2006, and (ii) the design of the Medicines and Medical Commodities Procurement and Distribution Strategy (approved by MOH order no. 638 on 2 December 2006). The expertise of Pharmacists Without Borders (PSFCI),
6 an international NGO, was helpful in building public sector capacity in drug supply management and transferring responsibility for running the relief procurement and supply system to the national center. Specifically, public sector capacity in drug supply management was strengthened in (i) the procurement process: drug selection and tender management; (ii) distribution and management: needs assessment, stock management, and distribution; (iii) storage: warehouse management and working protocols; (iv) software for implementing stock management; (v) training and retraining health workers in pilot districts in stock management; and (vi) rational planning for warehousing, equipment distribution, and staffing.
23. Two regional pharmaceutical warehouses were constructed in Khudjand and Kurgan- Tube in April 2007; procurement of equipment, furniture, and a stand-by generator for both warehouses was completed in December 2007 (Appendix 6, Table A6.1). By this date, the NMPC had already put on sale drugs and medical commodities amounting to TJS752,296 ($217,426), i.e., 33.8% of the estimated annual supply needs.
24. Developing a drug quality control mechanism. In order to meet international quality requirements, the HSRP strengthened the drug quality control center by (i) assessing the capacity of the center and establishing a time-bound improvement plan; (ii) providing a regulatory framework and guidelines for drug quality control; (iii) providing a laboratory for drug quality monitoring with equipment, reagents, and reference literature; and (iv) guaranteeing sustainability through a cost recovery mechanism for quality control services and capacity building.
25. The Research Center for Drug Expertise (RCDE) was established in 2000 to provide control over drugs, cosmetics and food products; and a laboratory was created in 2001. However, due to budgeting constraints, the system and equipment were insufficient for proper drug analysis. The HSRP and TA on Developing Drug Procurement Strategies 13 provided resources to the RCDE to improve existing equipment and reagents for drug analysis. In 2006, the HSRP and the RCDE signed an agreement on cost recovery measures for reagents. The HSRP also supported renovation of RCDE premises and provision of laboratory equipment. The RCDE was equipped with up-to-date laboratory equipment, reagents and literature, bringing it in line with international standards and allowing it to analyze the quality of imported medicines. Twenty-two trainees from the RCDE, NMPC, and MOH were trained in physical and chemical analysis for drug quality control in August–September 2007.
26. HSRP consultants in cooperation with MOH specialists supported the formulation of a regulatory framework and guidelines for drug quality control. HSRP consultants conducted training on up-to-date methods of drug quality analysis (40 laboratory staff were trained in 2008). Guidelines on quality control of medicines14 were developed, approved and published in early 2009. This resulted in a significant increase in the quality analysis of drugs (from 7,053 tests in 2004 to 12,975 tests in 2007), cosmetics, and food additives (Appendix 6, Tables A6.2– A6.3).
3. Efficient and Sustainable Delivery of a Pro-Poor Health Service Package
a. Providing a Pro-Poor Health Service Package
27. Providing equipment and drugs. The HSRP designed and provided a standard pro- poor health package, including basic drugs and contraceptives, to FGPs and rural health centers in the pilot districts. The package covered basic neonatal care, breast-feeding, growth monitoring, nutrition, integrated management of child illness, acute respiratory diseases, diarrhea, typhoid, school health, worms, contraceptives, safe motherhood (antenatal, delivery, and postnatal care), sexually transmitted infections, brucellosis, and hypertension. The first and second batches of medicine were delivered to PHC facilities in 2007–2008. The population in
13 ADB. 2003. Technical Assistance to the Republic of Tajikistan for Drug Procurement and Distribution Strategy. Manila (TA 4269-TAJ, for $150,000, approved on 17 December). 14 Saydaliev S. 2008. Physicochemical properties of medicinal agents. Dushanbe: Devashtich
7 pilot districts was given access to free drugs at PHC facilities (71 titles). Immunization and tuberculosis control were important components of the package; as a result, immunization of all children under 1 year old for diphtheria, whooping cough, tetanus, measles, hepatitis B, and tuberculosis was achieved.
28. Reproductive health centers in five pilot districts and national centers were also provided with adequate medical equipment, resulting in improved antenatal care coverage among pregnant women. The HSRP provided two ambulances to each central district hospital (CDH), where previously there were none, to support effective referral from PHC facilities. Agreements were signed with hospitals and hukumats (local administration) to ensure that sufficient funds would be allocated to cover recurrent costs, such as fuel, maintenance and repair, drivers, and insurance.
29. Introducing the FGP system in HSRP districts. Staff of FGPs, rural health centers, and district hospitals was trained to deliver the services included in the standard pro-poor package. The roles of health staff were defined in line with pro-poor interventions and delivery strategies. The role of community nurses in providing communication and information was emphasized to increase the demand for health services and improve family health practices. In six cycles of family medicine training, 134 family doctors and 588 district nurses were retrained. Short-term training courses introduced the FGP clinic standards to 62 FGP doctors and 328 FGP nurses (Appendix 4, Tables A4.2–A4.4). The HSRP created a critical mass of FGPs in the pilot districts by retraining specialists and mid-level personnel in family medicine through 6- month courses (Appendix 4, Table A4.6).
30. Short-term training sessions for family medicine specialists on the use of clinical practice guidelines were conducted in 2009 by the National Training and Clinic Centre on Family Medicine. The HSRP trained pharmacists and health specialists in five HSRP districts on Tajikistan’s essential drug list, treatment guidelines, clinical pharmacy and evidence-based medicine, stock management, and procurement. A series of seminars on health and population data collection, analysis, and presentation was conducted in pilot districts. In total, 125 participants from the PHC facilities and the central and district health centers were trained to collect, analyze, and use data on health management, health-care financing, health sector reform, and use of the HMIS.
31. Civil works for renovation or construction of health facilities. At appraisal, the project was expected to renovate and rebuild about 40 PHC facilities. Mapping of health facilities and FGPs was conducted in the first year and served as the basis for the rationalization plan in each district. As a result of this assessment, the number of facilities identified for renovation or construction increased to 67. At the end of the project, the facilities renovated or constructed were as follows: 30 health houses, 12 rural health centers, 4 rural divisional hospitals, 3 regional health centers, 7 CDH departments, 6 project management units (PMU) and project implementation unit offices, 1 microbiology department of State Drug Expertise Center, 2 warehouses for the regional affiliate of the Republican medicines procurement centre, 1 power supply line in the warehouse of the regional RMPC affiliate in Kurgan-Tube, and 1 family medicine department in Dushanbe.
32. A local consulting firm was recruited to assist with the design of six types of health facilities. These were designed in accordance with the services provided at the facilities, caseloads, energy efficiency, technical requirements such as telephones, heating, water, and sanitation, and environmental requirements. A medical waste management plan and wastewater management measures were developed and implemented at the new facilities.
b. Reforming Service Delivery and Financing
33. The HSRP financed and tested the capitation payment mechanism for FGPs. It was anticipated that copayment would be in place at the PHC facilities within the HSRP implementation. However, in January 2009, the piloting of per-capita financing was expanded to
8
15 districts out of 58 districts in Tajikistan. Of the pilot district population, 90% was registered with FGPs.
34. Rationalization of the system and staffing in HSRP districts and strengthening the capacity of the region and district administrations. The HSRP helped rationalize the health system and staffing distribution in pilot districts to reflect the national plans and reallocate savings to finance the FGP system, PHC, and the pro-poor health package. The assessment and mapping of health facilities in pilot districts informed the design of the rationalization plan for Kulyab in 2006. Subsequently, the plan was modified for the remaining four project districts in 2007.
35. Health personnel were trained in human resource development, capitation payment, financial management, preparation of business plans, implementation of the pro-poor package, and other management issues. Representatives of the district supervisory groups (DSGs) were trained in health planning and management in 2006–2007 in Almaty and Bishkek. In total, 50 specialists were trained.
36. The establishment of district health departments (DHDs) was postponed until the end of the project. 15 The MOH is developing a mechanism for establishing DHDs and for the segregation of management responsibilities in the regions. Although DHDs were not created as scheduled, DSGs were established to monitor workforce distribution, FGP system implementation, capitation payments, facility functions, and use of pharmaceuticals; oversee repair and distribution of equipment; and coordinate and manage public information campaigns.
37. Quality assurance of health care. The working group for health services and family medicine defined criteria and indicators for monitoring the quality of services provided by family doctors and family nurses. These criteria and indicators were discussed and approved by a working group. They cover quality of health facilities, quality of services, patient satisfaction, and rational drug use. The monitoring system was designed with the help of international and national monitoring and evaluation specialists and incorporates indicators on processes, outputs, and outcomes.
38. Incentive for FGPs. As noted in the report and recommendation of the President,16 the HSRP allocated seed money to be used as an incentive for FGPs. However, concerns were raised about the sustainability of funding for incentives after the completion of the project. After consultation, it was agreed that, instead of financial incentives, the funds allocated would be used for additional training and provision of medical literature to FGPs.
39. Public information campaigns. The HSRP assisted district administrations in conducting public information campaigns and mobilizing community participation to raise awareness and understanding of the health reforms, the FGP-based PHC system, and major health problems. Campaigns were conducted with the full participation of local governments, communities, and local NGOs under a JFPR grant. The campaigns were designed to reach the poor and women in particular as their lack of information on health services is one of the barriers that keep them from accessing services. Local government staff was trained to organize campaigns and mobilize communities. The capacities of the three regional and five rural health promotion centers were strengthened and 90 community health boards were established to ensure community participation in health planning and budgeting.
C. Project Costs
40. The project cost at completion was $9.462 million; $0.087 million (1%) higher than the $9.375 million estimated at appraisal due to SDR’s appreciation against the dollar. This total
15 In January 2009 the President of Tajikistan approved the creation of DHDs in all districts. DHDs were expected to have been created by the end of June 2009 but this was postponed due to budget constraints. 16 ADB. 2003. Report and Recommendation of the President to the Board of Directors: Proposed Loan and Technical Assistance Grants to the Republic of Tajikistan for the Health Sector Reform Project. Manila.
9 cost comprised $4.851 million in foreign currency costs (compared with $5.34 million estimated at appraisal), and $4.611 million equivalent in local currency costs (versus $4.035 million at appraisal). The actual cost of civil works was $3.38 million, against $1.31 million (excluding physical and price contingencies) at appraisal. The higher cost of civil works was mainly the result of an underestimation at appraisal and changes in project scope involving renovation of additional health facilities, but was also due to a significant increase in prices of construction materials. The cost of training, national consultant services, and project management was also underestimated in the report and recommendation of the President12, which led to higher costs under these categories. The loan funds were not spent on the activities of the Drug Procurement Center (which were transferred to PSFCI and the European Commission) nor on the public campaigns (which were conducted under the JFPR grant). Appendix 9, Table A9.1 compares in detail the project costs at appraisal and at completion.
41. Under the financing plan envisaged at appraisal, ADB was to provide a loan of $7.5 million (80% of the total project cost) to finance 100% of the foreign currency costs and 54% of the local currency costs. The rest of the local costs were to be financed by the government ($1.875 million) to cover civil works, taxes and duties, training, workshops, surveys, studies, and other recurrent costs. At completion, the ADB loan financed $7.72 million, all of the foreign currency costs ($4.851 million) and 62% of the local currency costs ($2.869 million). The government financed $1.742 million (18.4%) of the project cost. The government made counterpart funds available satisfactorily during project implementation. The appraisal and actual financing plans are compared in detail in Appendix 9, Table A9.2.
D. Disbursements
42. Disbursement under the ADB loan started in 2004 and peaked in 2008. At completion, disbursements under the project loan amounted to $7.72 million (95.9% of the net loan amount). The amount of SDR0.210 million was cancelled upon loan closing. The breakdown of annual disbursements is in Appendix 9, Table A9.3. Disbursements were made in accordance with ADB’s Loan Disbursement Handbook (2007, as amended from time to time). An imprest account was established and an initial advance of $0.150 million was provided. The imprest account was particularly effective, with a turnover ratio of 3.49. An amount equivalent to $5.235 million of ADB-financed expenditure was paid through the imprest account, of which $5.103 million was under the statement of expenditure procedure (under $50,000 per payment).
E. Project Schedule
43. The project was approved on 17 December 2003, declared effective on 15 July 2004, and completed on 30 June 2009 as scheduled, with a 5-year implementation period. There was no delay in loan effectiveness and no loan extension. Overall, project implementation was carried out according to the agreed implementation schedule. Implementation of some project activities was delayed, but all activities ended within the stipulated time. The MOH training committee and the HSRP PMU organized and managed training programs in accordance with the Indicative Training Program and Human Resource Development Interim Plan, and completed all training activities as scheduled. The completed project facilities, particularly health centers, took more than 1.5 years to become fully operational. The delay was due to additional needs, underestimated at appraisal, and seasonal specificity: in some areas civil works cannot take place during winter because of heavy snow. The appraisal and actual project implementation schedules are in Appendix 10.
F. Implementation Arrangements
44. The President’s Office was the executing agency for the project, with the deputy prime minister as project coordinator. A national steering committee was established to give overall guidance and coordinate both the HSRP and the Education Sector Reform Project (ESRP).17
17 ADB. 2003. Report and Recommendation of the President to the Board of Directors: Proposed Loan and Technical Assistance Grant to the Republic of Tajikistan for the Education Sector Reform Project. Manila.
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The committee was chaired by the project coordinator and comprised of senior officials from the MOH, Ministry of Education, the Ministry of Finance, departments of the President's Office and Aid Coordination Unit, district representatives, and selected sector specialists.
45. The HSRP originally planned to share a PMU and district project implementation units with the ESRP. However, at implementation this arrangement was reviewed and found to be unrealistic and ineffective, and separate PMUs were established for each project. The HSRP also established district project implementation units in each of five pilot districts. The DSG (comprising representatives of local governments, CDHs, chief doctors, the HSRP, and ESRP pilot district education department heads) was established to guide the preparation of district plans, review progress quarterly, and coordinate and implement all district activities.
46. To ensure efficient development of policy, strategy, and legal documents on health sector reform, six working groups were established with participation of specialists in each sector: (i) human resource development, (ii) medicines quality control, (iii) licensing and accreditation, (iv) health services and family medicine, (v) health planning and rationalization, and (vi) capitation payment.
G. Conditions and Covenants
47. The government complied with nearly all the loan covenants set out at appraisal (Appendix 12). Separate accounts were maintained and audited for the loan and government counterpart funds. The covenant requiring insurance of project facilities was met. The covenants related to implementation arrangements were complied with.
48. The loan agreement required that after project completion the MOH provide, through its public health budget, the capitation payment budget and pro-poor health package cost to ensure their sustainability. The government also agreed to submit to ADB a budget plan addressing capitation payment and the pro-poor package at the midterm review of the project. This was partially complied with as the modalities for calculation of per-capita financing were not formalized by the MOH and were still under review by the HSRP completion date.
H. Related Technical Assistance
49. TA on Strengthening Planning and Policy Dialogue for Health Reforms. An advisory TA18 was provided to (i) develop the HMIS framework and action plans at the MOH, regions, and districts; (ii) establish the basis for planning, monitoring, and performance measurement systems and reforms; and (iii) create a mechanism for monitoring and policy dialogue between the government and international aid agencies.
50. The TA built on and integrated past achievements and produced significant outputs in the areas of HMIS, health survey, and poverty assessment. This approach was efficient and effective in avoiding duplication and consolidating products. The TA contributed to building public sector institutional capacity and provided a technical basis for project activities under the HSRP.
51. The TA developed a countrywide HMIS strategy and framework. The framework (i) is user-friendly, meeting the information needs of various decision makers in the health system; (ii) enables health professionals to develop epidemiological profiles by using a standard data and mapping template that can accommodate data generated by the newly developed HMIS; and (iii) enables the MOH to compare inter-regional and inter-district performance and consider strategies to improve equity and performance.
52. The TA was rated successful (footnote 6). It was implemented in close consultation and coordination with the HSRP PMU. This allowed the TA to play a significant advisory and supporting role to the HSRP. The TA raised awareness among government officials on (i)
18 Para.3, footnote 2
11 information collection and monitoring, (ii) policy dialogue between the government and external development partners, and (iii) public–private partnerships. It succeeded in raising awareness of the need for strategic planning in the public sector and use of information to increase the capacity of peripheral health facility staff. Eight district, regional, and national workshops were organized for a total of 150 participants. In addition, more than 60 meetings and interviews took place with stakeholders.
53. TA on Developing Drug Procurement Strategies. From April 2004, this TA19 was implemented by PSFCI. TA activities included (i) creation of a drug procurement and distribution strategy, (ii) finalizing the NMPC's charter, and (iii) conducting the final national conference on establishment of the national drug center in October 2006 to secure the government's commitment to the follow-up action plan.
54. The drug procurement and distribution strategy established the RMPC as a nonprofit state agency under the MOH. ADB, the HSRP, the MOH, and PSFCI supported the NMPC in capacity development in marketing and management, renovation of the NMPC in Dushanbe, and the construction of two regional warehouses in Khujand and Kurgan-Tube. The HSRP organized a national conference on 17 October 2006 at which support for the NMPC was requested from the government, development partners, and the private sector.
55. The HSRP supported capacity development in, and system development of, the RCDE, which is responsible for national drug quality control and licensing, and accreditation of pharmacy premises and pharmacists. Medical literature, reagents and laboratory equipment were procured for the RCDE, with technical input from an international and a local consultant.
56. JFPR grant for Community Participation and Public Information Campaign for Health Improvement. The JFPR grant 20 was designed to complement the HSRP through information strategies and community participation. The goal of the project was to improve access to and use of innovative health-care procedures promoted under the HSRP by the poor—particularly poor women of reproductive age, mothers, and children. To achieve this goal, the JFPR project aimed to strengthen public information dissemination and community and family participation in determining, implementing, and monitoring health needs, practices, and services in five HSRP pilot districts. The areas were selected for their level of poverty and of infant and maternal mortality. One of the main strengths of the project was the design and piloting of sustainable mechanisms for community participation in health promotion, health delivery and monitoring.
57. The project contributed to (i) the establishment of mechanisms of community participation in health planning and monitoring, (ii) the upgrading of healthy lifestyle facilities and services in pilot areas and related provincial centers, and (iii) the provision of information and TA to community groups and health volunteers. The MOH reported that the Kulyab model of community health boards had spread to nonintervention districts. Similarly, integrated multisectoral approaches were used by the MOH in planning and implementing the national immunization campaign of 2009.
58. As one of the mechanisms for extending services to the most vulnerable, 90 community health boards, which were new to Tajikistan, were established to plan and evaluate health services. To assist the health reform process, NGOs, community organizations, including women's groups and pilot district and community representatives were involved in designing strategies for the JFPR project together with the MOH. The JFPR project was rated successful.
I. Consultant Recruitment and Procurement
59. The HSRP provided (i) international consultants with expertise to support FGP implementation and management, health-care financing, management and quality assurance,
19 Para.3, footnote 2 20 Para.3, footnote 3
12 licensing and accreditation, human resource development, hospital sector rationalization, services privatization, and monitoring and evaluation; (ii) a project implementation specialist; and (iii) 106 person-months of national consulting services. The actual consulting services are listed in Appendix 3, Table A3.3. All consultants were recruited directly on an individual basis and were selected based on their qualifications for the assignment. Consultants were selected and engaged in accordance with ADB's Guidelines on the Use of Consultants (2007, as amended from time to time). Goods, services, and civil work contracts were procured in accordance with ADB's Procurement Guidelines (2007, as amended from time to time). The procurement mode was largely as envisaged at appraisal and bulk procurement was promoted as much as possible. All civil works were procured using local competitive bidding among prequalified contractors.
J. Performance of Consultants, Contractors, and Suppliers
60. Technical consultants were recruited as scheduled. Their inputs in the formulation of relevant programs, including FGP system development, human resource development, and drug quality control were considered generally satisfactory.
61. Civil works were delayed by 1–5 months as compared with the construction period estimated at appraisal. The construction of health centers during the first 2 years of implementation was delayed by slow finalization of the mapping of health facilities and related bidding and award of contracts; lack of experience with the construction of health centers, particularly in remote areas; and restrictive winter weather. The quality of work was deemed satisfactory. There were no serious deviations from the agreed specifications, with regard to drugs, reagents, basic medical equipment, and other supplies. The performance of the civil works contractors, suppliers of basic medical equipment, and national and international consultants was satisfactory.
K. Performance of the Borrower and the Executing Agency
62. The government and the MOH showed strong commitment to strengthen the delivery of PHC services and pursued reforms as planned. The MOH technical committee and working groups guided the PMU and carried out their tasks satisfactorily. The government provided the required counterpart funds within an acceptable period, in kind and in cash for construction of the new facilities. The performance of the PMU was satisfactory. The unit guided and coordinated well with various government agencies, monitored major activities, and resolved project implementation issues. Overall, the performance of the government and the executing agency was satisfactory.
L. Performance of the Asian Development Bank
63. ADB provided leadership, facilitated the mobilization of resources, made serious efforts to address implementation problems and was responsive to needs that arose. However, ADB’s efforts to ensure proper implementation of the monitoring and evaluation program were less successful, partly due to MOH's weakness in PHC information systems. During project implementation, ADB fielded several loan review missions to review project progress. Overall, ADB’s performance was satisfactory.
III. EVALUATION OF PERFORMANCE
A. Relevance
64. The design and objectives of the HSRP were highly relevant to the needs of the health sector and were in line with ADB’s operational strategy for Tajikistan. The design was tailored to the needs of a country with limited capacity, facing severe economic and social challenges and health reform opportunities. The HSRP took a comprehensive and integrated approach to achieving broad health policy reforms and to meeting immediate institutional and PHC delivery needs. The HSRP successfully provided a solid foundation for future sector development.
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65. A number of minor changes in scope and related reallocations of loan proceeds were approved in response to the findings of health facility mapping and during the midterm review; additional civil works were implemented and additional medical and office equipment were procured. The changes were necessary to improve service quality in affected areas and to improve effective management of the PHC system in areas affected by urban migration. The changes enhanced HSRP's relevance.
B. Effectiveness in Achieving Outcome
66. Overall, HSRP is rated effective, while the degree of effectiveness varied across the different components. The HSRP is rated highly effective in promoting PHC and improving health-care delivery to communities, the poor and the vulnerable. The FGP system was established nationwide and family doctors and nurses were trained and equipped. The HSRP successfully developed and implemented a legal framework for FGP, and the accreditation and licensing system. Budget allocations to PHC increased, but have not yet reached optimal level. To increase PHC allocation, savings must be made by rationalizing hospitals and staff, which is pursued under the reform agenda.
67. The HSRP is rated partly effective in rationalizing hospitals and personnel, as these issues are complex and face serious constraints. Concerning hospital rationalization, the HSRP initially achieved the target of reducing the number of beds. However, the trend has subsequently reversed because of the limited reduction of public hospitals and beds. The government was inactive in rationalizing hospitals, and this was exacerbated by traditional usage patterns.
68. A human resource management policy was developed for the health sector, and vacant health staff positions in pilot areas were mostly filled, as intended. All the required policies, strategies, action plans, and technical guidelines were produced under the HSRP for hospital and staff rationalization, but the government's commitment in this area needs to be improved to support effective implementation.
69. The HSRP was less effective in establishing a health service financing model and a payment mechanism for pro-poor health package providers, as these areas were targeted by the MOH and other development partners in other districts. The promotion of community involvement is rated efficacious.
C. Efficiency in Achieving Outcome and Outputs
70. Overall, the HSRP is rated efficient in investment and process. Investments were made in (i) civil works; (ii) equipment; (iii) technical support for policy setting, system framework design, and guidelines development; (iv) training; and (v) public information campaigns. Both civil works and equipment targeted PHC and the first referral level, and are cost-effective compared with investments at the tertiary level. Technical work covering health sector reform and training was carried out by highly competent consultants, through intensive discussions with stakeholders, and under timely and appropriate supervision of the executing agency and PMU. Policy dialogue was also efficient, with a high level of government commitment to and ownership of reform policy and strategies, in particular on PHC. ADB participated in technical discussions and made decisions without delay. During the initial phase, ADB sent frequent review missions. Public information campaigns were also efficiently carried out.
71. Equity and performance were improved through adequate nationwide implementation of the HMIS strategy. The quality of pharmaceuticals was improved by establishing a legal framework for licensing and accreditation of pharmacists and pharmacy premises.
D. Preliminary Assessment of Sustainability
72. The sustainability of the HSRP is rated likely. The government established the FGP system nationwide following the modalities established under the HSRP. The HSRP renovated
14
PHC facilities and provided equipment. Local government budgets and health insurance allocations replaced the ADB loan proceeds, and capitation payments are set to start funding nationwide in 2010. These are considered positive signs of sustainability.
73. The human resource development strategy initiated by the HSRP has been established nationwide. The strategy is recognized as the most important guidepost for health sector management. The licensing and accreditation principles that were designed and piloted by the HSRP are a powerful tool in assuring the quality of medical practice. The new and strengthened management capacity in the MOH and in the provinces and districts will help ensure the sustainability of HSRP achievements.
74. The HSRP and the JFPR developed the necessary technical foundations for FGP quality assurance; improvement of hospital management; capacity building for national and local authorities (in planning, budgeting, managing, monitoring, and reforming the health sector); and for information campaigns to change perceptions and attitudes toward health services. They also created community health councils.
75. An area to monitor, however, is the delivery of services to mothers and children, specifically with respect to vaccination. From 2004 to 2007, there was a clear increase in the percentage of children vaccination against various common diseases. However, there is a reported decline in 2008 (Table A7.3, Appendix 7), which indicates that the sustainability of the investments made by the project cannot be taken for granted on all fronts. There is also one possible exogenous factor: the impact of the financial crisis on Tajikistan, which in turn might have reduced resource allocations for certain heads of health expenditures in 2008-2009. Nonetheless, the significant improvements made in the FGP and PHC are likely to revert back this trend and ensure full immunization in the future.
E. Impact
76. The overall impact of the HSRP is rated substantial, in particular on the poor, mothers, and children. FGP services are used by a significant number of infants aged 0–1 and females aged 16–49, according to a survey of the utilization of health services by community health councils. 21 This is also supported by the findings of monitoring and evaluation of the HSRP by international and national consultants. FGP services target vulnerable groups effectively. For some Millennium Development Goal targets, such as infant mortality, maternal mortality, and prevalence of HIV, direct attribution is difficult to establish while the HSRP has contributed to their reduction. The construction of new health facilities was carried out on empty land owned by the government, and did not involve land acquisition and resettlement.
IV. OVERALL ASSESSMENT AND RECOMMENDATIONS
A. Overall Assessment
77. Based on the assessment of the project as highly relevant, effective, efficient, and likely sustainable, the project overall is rated successful (Appendix 13). At the outcome or purpose level, progress is evident. Indicators of the progress toward targets are shown in Appendixes 1 and 12. Targets related to PHC were achieved in most fields. The infrastructure of health centers in the pilot areas improved. Most PHC staff were retrained, and new graduates from TSMU joined the newly established postgraduate training on FGP. The level of community participation in PHC activities was rated fully satisfactory. Health indicators have generally improved (Appendix 2), with a decline in infant mortality in two of the five project districts and under-5 mortality in four of the five districts and an increase in the use of contraceptives and professionally-assisted child birth in all five districts.
21 N.F.Salimov et al. 2007, Final Report of the Community Participation and Public Information Campaign Program. Dushanbe: GraphicArt
15
78. The HSRP logical framework was well prepared and covered all the critical aspects of the project. Some outcome targets were too ambitious, but most of the outputs were realistic and achievable. Due to the radical changes under the proposed health reforms, the Government took some time to understand them and formulate the required legislation. Once the Government realized the long-term impact of the proposed reforms, significant progress was made in implementing them. The PHC strategy supported by the project was recognized by the government as the most cost-effective way to improve the health of the population, but it presents a political burden by raising costs in the short term for benefits to appear in the long term. Thus, finding support within the government for this strategy was in itself a success. The recent health reform achievements and the fact that the government is considering the next stage of the health reform (2010–2015) illustrate the significant progress made.
B. Lessons
79. The project experience:
(i) confirms that rationalization of PHC institutions and provision of adequate health financing should go "hand in hand". Thus, the restructuring of health institutions should be accompanied by trained PHC staff, sufficient coverage of PHC facilities, adequate supplies of essential drugs and medical commodities, and health reform; (ii) illustrates the value of conducting a comprehensive needs assessment before drawing up civil works and equipment lists, to ensure that the right inputs are made in the right places; (iii) demonstrates the need for advance recruitment of consultants to assist with planning and review, pre-implementation preparations, and legal support to ensure that project implementation is not delayed; (iv) indicates the need for intensive information campaigns to ensure a high degree of community participation in PHC management, sourcing of financing, co-sharing, contributions in kind, and other expressions of support that help to sustain health reform projects.
C. Recommendations
1. Project Related
80. The following recommendations are made:
(i) To facilitate monitoring of the overall impact and social benefits of the project, monitoring and evaluation activities should be strengthened and indicators developed at the start of project implementation. Communities and other stakeholders should continue to participate actively in identifying and solving problems in the village. They should also assist in the development and evaluation of health policies and initiatives. (ii) Adequate budget should be allocated, in addition to the community cost-sharing scheme for the project facilities. Options for financial schemes, such as user fees for health facilities, or capitation payments should be considered to ameliorate difficult working conditions, low salaries, and other health budget constraints. (iii) The MOH should continue to coordinate staff training within its own departments and related government agencies. The Human Resource Development Plan should be regularly assessed and continue to be used as a framework document for training health workers, including curriculum design and in-service training for PHC staff.
2. General
81. The relative success of the PHC component indicates that it is better to reinforce existing institutions. As such institutions normally become an integral part of the public financial management landscape, supporting them also helps increase the efficacy of public sector resource allocations. ADB’s Health Sector Operational Plan, adopted to support implementation of Strategy 2020.
16 Appendix 1
PROJECT FRAMEWORK
Design Summary Performance Targets Results/Achievements
Goal By 2008, For some MDG targets, such as infant Improve health MMR reduced from 43.1 to mortality, maternal mortality, and prevalence of status of children, 39.1 per 100,000 live births HIV, progress is difficult to evaluate. especially women, by MOH data Administrative and survey data tend to disagree children and the about the extent that infant and maternal poor IMR reduced from 36.7 to mortality have been reduced since the 1990s. 30.9 per 1,000 live births by However, the available data suggest that it is MOH data unlikely that either the under-5 mortality target or the maternal mortality target will be met.
Increased access to Access to reproductive health services did not reproductive health reach the target. Nationwide, access increased services from 21.8% to from 14.6% in 2004 to 19.0% in 2007; however 25.9% among females of significant progress was made in pilot areas: reproductive age from 24.8% to 32.1%, on average (Appendix 7, nationwide Table A7.2).
Purpose By 2008, PHC budgets increased annually from 2003 to Improve system Increased share of PHC 2008, and health worker salaries doubled in efficiency and budget in public health 2006. In 2008, the share of the public health management expenditure from 6% in budget allocated to PHC reached 35%, up from capacity 2001 to 20% 6% in 2003. The government also agreed to a number of budgetary and organizational reforms.
Improved capacity for The HSRP drafted the policy and legal annual planning and documents required for implementation of budgeting at all levels health sector reform. Most of the legal documents were developed and approved by the government as national policies or strategies.
The HSRP provided funding for overseas training for key staff from the MOH and TSMU. Staff from the MOH, regions, and pilot districts received in-country training in health sector planning and management.
HMIS set up and The HMIS development plan was approved in implemented at the national 2006. In November 2007, situation analysis, and pilot district levels conceptualization, and design of the national HMIS took place. The HMIS action plan was implemented in pilot districts. National implementation will be continued with the support of the European Union.
The HSRP designed and implemented the following HMIS components: (i) definition of health indicators, data collection and consolidation (on the basis of ICD-10); (ii) district, provincial and national system development; and (iii) the introduction of HMIS elements in all 5 districts.
Rationalization plans The rationalization of PHC facilities and
Appendix 1 17
Design Summary Performance Targets Results/Achievements
implemented to reduce hospitals was completed in 5 pilot districts in excess accommodation and November 2006 and the guidelines were poor staff distribution in endorsed by the government as the Hospital pilot districts Restructuring Concept of Tajikistan. Rationalization was expanded to the national level.
At this first stage the rationalization did not result in a tangible reduction of the number of beds but reorganized the network of health facilities.
Increase equitable By 2008 in five HSRP pilot The vaccination program was efficiently access to and use districts, implemented in pilot districts and has reached of basic health At least 90% of children and exceeded the targets (Appendix 7, Table services by women, under 1 year are A7.3). children, and the immunized against DTP, poor polio, and tuberculosis (56% in 2000)
100% of antenatal care Antenatal care coverage has not reached the coverage among pregnant target, though registration of pregnant women women in the first 12 weeks of pregnancy reached 58.5% in Kuhistoni Mastchoh district (the lowest was 31.9% in Rasht district).
At least 75% of deliveries While in general, the number of deliveries at attended by qualified health maternal hospitals increased, only in Ayni attendants (50% in 2000) district was the target reached (77.1% in 2007). However, under the JFPR grant for the Community Participation and Public Information Campaign for Health Improvement, the health community boards of pilot districts developed a mechanism for transportation of pregnant women to an obstetric facility for childbirth, which resulted in a reduction of home births without participation of trained birth attendants. In 2008, all newborns in Chorbog village of Kulyab district were delivered in the obstetric facilities with the assistance of trained medical personnel.
Consultation by the poor The HSRP did not manage to reach the target. increased to the level of While initial consultations were done at an that by the non-poor appropriate level, with an adequate number of participants, the sustainability of continued consultations is in question.
Support informed By 2008, A working group was organized to monitor policy dialogue for An intersectoral committee HMIS implementation in HSRP pilot districts. health sector organized to monitor The HMIS report covering 2008 was finalized in reform system rationalization and early 2009— incorporating development reforms based on HMIS partners' recommendations— and data disseminated to the MOH, provincial health centers, central health institutions of pilot districts and development organizations. The open-source software, DHIS2 was adopted and adapted for local use by a local partner,
18 Appendix 1
Design Summary Performance Targets Results/Achievements
CIPI and was piloted in all five districts. The system will be expanded to other regions by the European Union, the World Bank, and the Swiss Agency for Development and Cooperation through the Swiss Health Reform and Family Medicine Project (Project Sino).
National workshops The HSRP assisted in three national organized to evaluate the conferences on the FGP system: (i) design and FGP system in HSRP pilot introduction in December 2005, (ii) review of districts and decide its implementation and legal framework nationwide expansion (November 2007), and (iii) consideration of achievements and review of further nationwide expansions (November 2008).
Relevant policies and laws The HSRP drafted the policy and legal promulgated for nationwide documents required for implementation of expansion of the FGP health sector reform. Most of the legal system documents were developed and approved by the government as national policies or strategies.
The HSRP finalized the Standards and Guidelines for FGP Traininga on 12 January 2006, including the FGP model, which has become a legal document providing the basis for rationalization of PHC facilities.
The HSRP supported the establishment of the Faculty of Family Medicine No. 2 at TSMU to strengthen the teaching of family medicine and increase the number of qualified family medicine specialists.
Family medicine clinical training centers, with branches in Rasht, Kulyab districts and Khorog (Gorno-Badakhshan Autonomous Region), were established as interdistrict FGP training centers in March 2008, to which the HSRP provided educational materials, training equipment, and furniture.
Outputs 1. Institutional Development of the Health Sector 1.1 Strengthened 6 senior staff trained In total, 17 senior health staff and 62 health capacity of MOH, overseas – master’s course specialists and managers from the MOH, regional, and on health sector planning national health institutions, and pilot districts district in planning and management attended overseas training in France, Italy, and managing Kazakhstan, the Kyrgyz Republic, Mongolia, services delivery, Turkey, and the United States. financing, and staffing 30 MOH and PGMI staff 50 health specialists were trained in Dushanbe with short courses on in 2008 in health system management, health health service delivery, service delivery, and financing. Also, 150 financing, human resource district health managers were trained in pilot development, and health areas in 2008. system in Dushanbe.
Appendix 1 19
Design Summary Performance Targets Results/Achievements
100 staff at all levels trained Short-term training courses for district health in health services and managers were organized. The National hospital planning and Conference on Rationalization and management in Dushanbe Restructuring of Hospitals was held in Dushanbe in 2009 and involved 135 participants.
1.2 Built MOH and A workforce plan with goals The Tajikistan Health Sector Interim Workforce the medical developed by early 2005 Plan for 2006–2010b was adopted in 2006. university's and to be finalized by end capacity for staffing February 2006
Detailed action plans for Detailed action plans for the MOH and TSMU MOH and the medical were developed in mid-2005. The Tajikistan university developed by Health Human Resource Management mid–2005 Guidelinesc were approved and adopted on 6 December 2007 by the MOH as the National Human Resource Development Guidelines. The guidelines were published and distributed to institutes and specialists in Tajikistan.
A working group set up and A working group comprising the MOH and aid functioning comprising agencies was set up and reviewed medical MOH and aid agencies to education programs provided by NGOs. The review continuing medical concept of continuous medical education for education family medicine specialists was developed jointly with Project Sino and was submitted to the MOH.
1.3 Strengthened HMIS concept developed HMIS development started in January 2005 HMIS as a planning and operational by mid under the TA on Planning and Policy Dialogue and monitoring tool 2004 for Health Reform.d The HMIS strategy for 2006–2010 was developed and approved by MOH order no. 144 in April 2006.
200 Staff at all levels A series of seminars devoted to collection, trained on data collection, analysis and presentation of data about the analysis and use health of the population was conducted. 125 health specialists were trained in pilot areas in 2007–2008 in health data collection, and 258 specialists were trained in health system management, health service delivery, and financing. All pilot districts were provided with computers for HMIS use.
Annual HMIS reports Health statistical indexes for 2003–2006 were published and disseminated collected in all pilot districts. The HMIS report to donors covering 2008 was finalized in early 2009— incorporating development partners' recommendations— and disseminated to the MOH, provincial health centers, central health institutions of pilot districts and development organizations.
1.4 Developed 50 MOH, region, and pilot The training plan was approved by the HSRP legislative, districts trained in the FGP training committee in December 2006. financial, and system and financing
20 Appendix 1
Design Summary Performance Targets Results/Achievements
operational mechanisms (study tour 3 senior MOH staff and 13 senior health frameworks of the and in-country training) specialists from the MOH and the regions were FGP system trained in Mongolia on the FGP system and in the Kyrgyz Republic on health financing.
150 health specialists from 5 pilot districts were also trained in health financing (see Table A4.5, Appendix 4).
The FGP accreditation In August 2005, the HSRP prepared and scheme set up and submitted a set of policy documents necessary operational by end of 2004 for licensing and accreditation of health through office capacity personnel and health facilities. The policies on increase, developing accreditation of family doctor institutions were criteria and procedures, approved by the MOH in April 2008, and were legislation, and operational further revised in 2009 and 2010. documents The commission on licensing and accreditation of health specialists and institutions was established within the MOH and is guided by standards developed by the HSRP.
Guidelines for introducing The Tajikistan family medicine model was FGPs prepared by end of introduced in December 2005 and approved by 2005 (to be implemented in the MOH in January 2006. Family medicine pilot districts from 2006) legal and recording–reporting documents were also developed.
FGP monitoring system The FGP monitoring system was designed at proposed by end of 2005 the end of 2005 but the introduction was limited to the attestation criteria and certain indicators, which were used during HSRP monitoring and evaluation in 2008.
2. Drug Supply and Quality Control 2.1 An efficient By 2008, The HSRP assisted the MOH in reorganization drug procurement 80% of the essential drugs and establishment of the National Medicine and center established timely distributed to health Medical Commodities Procurement Centre (30 facilities nationwide Dec 2005) and design of the Medicines and Medical Commodities Procurement and Distribution Strategy of the Republic of Tajikistan (approved in Dec 2006).
The National Conference on Establishment of the National Drug Center was held in October 2006, to introduce the center and encourage support from development partners. Initial grants of €330,000 were allocated by ЕСНО for drug procurement.
Two regional pharmaceutical warehouses were constructed, in Khojand and Kurgan-Tube. ADB also provided one international and two national consultants to advise the government on a business planning and marketing strategy for the Pharmaceutical Procurement Center.
The import of drugs doubled in 2005–2008 and
Appendix 1 21
Design Summary Performance Targets Results/Achievements
in 2008 equaled $97,186.
100% of health personnel 60 pharmacists (100%) from the NMPC, the responsible for medicine RCDE, and 5 pilot districts were trained. management in the 5 pilot districts are trained in 4 specialists from the RCDE were trained medicine stock overseas (Armenia study tour); 20 specialists management. from the MOH, NMPC, and RCDE were trained in laboratory control; and 14 specialists were trained in drug procurement and distribution. 40 pharmacists from pilot areas were trained in rational use of drugs in 2008 (Roshtkala district).
2.2 Drug quality 800 pharmacies officially In 2009, there were 1,258 officially registered control mechanism registered in Tajikistan from pharmacies in Tajikistan, including 568 licensed set up and 450 pharmacies currently pharmacies and 690 drugstores. This is functioning registered among 2,000 significant progress compared to 2004, when pharmacies nationwide only 157 pharmacies were licensed out of more than 800 drugstores.
100% of 40 laboratory 100% of RCDE laboratory staff were trained personnel trained with the assistance of international and national consultants.
A cost recovery measure The RCDE received resources to improve the for drug quality analysis set existing equipment and reagents for drug up and operational by analysis under the HSRP and the TA on midterm of the HSRP Developing Drug Procurement Strategies.e In 2006, the HSRP and the RCDE signed an agreement regarding cost recovery measures for reagents. The HSRP also supported renovation of RCDE premises and provision of laboratory equipment. Renovation works were completed in 2007.
The RCDE was equipped with up-to-date laboratory equipment, reagents and literature, bringing it in line with international standards and allowing it to analyze the quality of all imported medicines. This resulted in a significant increase in quality analysis of drugs (from 7,053 tests in 2004 to 12,975 tests in 2007), cosmetics and food additives.
100% of the drugs of the The list of basic medicines was reviewed under pro-poor health package of the TA on Developing Drug Procurement international quality Strategies.e The list was used by the MOH in standard in pilot districts further policy documents on the pro-poor health package in rural and remote areas.
The guidelines on Quality Control of Medicinesf were developed, approved, and published in early 2009.
3. Effective and Sustainable Delivery of Health Service Package 3.1 A pro-poor In 5 pilot districts, 25 PHC Renovation and construction started in 2007. At
22 Appendix 1
Design Summary Performance Targets Results/Achievements
health service facilities renovated or the end of the project, the facilities renovated or package provided constructed, constructed were as follows: 30 health houses, effectively 5 existing referral hospitals 12 rural health centers, 4 rural divisional renovated hospitals, 3 regional health centers, 7 CDH departments, 6 project implementation unit offices, 1 microbiology department of State Drug Expertise Center, 2 warehouses for the regional affiliate of the Republican medicines procurement centre, 1 power supply line in the warehouse of the regional RMPC affiliate in Kurgan-Tube, and 1 family medicine department in Dushanbe.
100% of drug kits and The first and second batches of drugs were equipment timely delivered delivered to PHC facilities in 2007–2008. 71 and installed at FGPs and titles were provided to the PHC facilities in the rural health centers pilot districts, where the population had access to free drugs.
All FGPs, staff of rural The HSRP has created a critical mass of FGPs health centers, and in pilot districts by retraining specialists and pharmacists to be trained to midlevel personnel in family medicine through deliver the service package 6-month courses. FGPs, staff of all rural health effectively centers, and pharmacists were trained to deliver the service package effectively.
246 family doctors and 20 134 family doctors and 588 district nurses were family nurses trained and retrained in 6-month courses on family qualified medicine. 3 interdistrict family medicine education centers (in Rasht, Kulyab, and Horog) were created and equipped with new educational and medical equipment.
3.2 Increased Capitation payment with A capitation payment model was developed efficiency and pro- performance based and introduced in 6 pilot districts, including 2 poor focus in contract tested for FGPs HSRP districts (Rasht and Kulyab). Following services delivery from year 3 discussions on the complexity of the formula, the model was simplified, with adjustments for risk group. In January 2009, per-capita financing was expanded to 15 pilot districts. At present, salary components for health personnel at RHCs and health houses are not included in the per-capita payment system. However, in the future it is expected that a salary component be included in the per-capita payment scheme.
100% of the pilot district Forms for patient registration with FGPs were population registered with prepared and 90% of the pilot district FGPs population registered with FGPs.
100% of the FGPs in the The HSRP and the MOH agreed on the pilot district contracted following strategies: (i) A copayment system will be introduced at CDHs to generate revenue. (ii) Revenue will be allocated at RHCs and health houses though performance-based payment, assessed by monitoring the quality of services provided.
Appendix 1 23
Design Summary Performance Targets Results/Achievements
HMIS system set up with The HMIS report was finalized in 2009 and baseline data collected to distributed to the government and development measure the impact of the organizations. FGP system The DHIS2 software, which was adopted to meet the needs of district health service management, improved data collection and aggregation. The HSRP initiated the local health management network to provide timely and reliable collection of basic health service indicators (on a quarterly basis), but frequent power cuts and the lack of an Internet connection prevented evaluation of the results by the project completion date.
At least the same level of No data available contacts with FGPs reached among the poor and non-poor
100% coverage of quality HSRP consultants assisted in the design of a control (on-the-job training monitoring system that incorporated indicators and consultation) of FGP on process, output and outcome. The indicators services and the guidelines on their use were submitted to the MOH.
3.3 Increased District health department The establishment of district health management created in each pilot district departments was postponed and had not been capacity in district by mid– 2004 completed at the end of the project. The MOH administration is developing a mechanism for establishing DHDs and segregating management responsibilities in the regions. The delay in creating DHDs was caused by the conducting of a situation analysis and feasibility study on introducing new structures in the districts.
Two staff members from Although, the DHDs were not created as each district health scheduled, district supervisory groups were department and one staff established, consisting of representatives from member from regional hukumats (local administration), djamoats (sub- office trained 3–6 months in district level of local administration), the health planning and education department, and the chief medical management courses in officer. Representatives of the district Dushanbe supervisory groups were trained in health planning and management in 2006–2007, in Almaty and Bishkek. In total, 50 health specialists from regional and district hukumats in 5 pilot districts were trained.
Intensive consultation and The district supervisory groups organized monitoring meetings regular consultation and monitoring meetings to organized at districts for implement and monitor the FGP system. The staff of regions and HSRP criteria and indicators were discussed and districts to install and approved by a working group. These cover monitor the FGP system quality of health facilities, quality of services, patient satisfaction and rational drug use. Currently available data is being used as a baseline. The FMTCC and the MOH monitor
24 Appendix 1
Design Summary Performance Targets Results/Achievements
and evaluate the introduction of FGP system.
3.4 Increased Rationalization plan The rationalization plan for Kulyab was sustainability of developed and approved in 2006. The plan was applied to the service package implemented in 5 HSRP remaining four project districts in 2007. and PHC districts from end of 2004
100% of savings retained at In 2006, the Ministry of Finance issued the the level of district health order on retaining savings in district health departments (legislation as budgets. conditions for loan negotiations).
Increased share in public The Strategy of Health Care Financing in the health budget allocation for Republic of Tajikistan for 2005–2015g proposed PHC from 6% in 2003 to that 40% of the district budget be allocated to 20% by 2008 PHC. In 2008, PHC had a 35% share of the public health budget (against 6% in 2003).
3.5 Increased Increased health Information brochures, leaflets and posters community knowledge and practice in were distributed widely in pilot areas and awareness of and family planning and reached 38.1% of the pilot district population, participation in nutrition including 77.8% of women of fertile age. health practice and services Informal payment reduced No information available to 35 % from 60%
5 feldsher in each pilot 90 PHC workers from pilot areas assisted district trained in community community health boards, which were participation and public established under a JFPR grant for the campaign Community Participation and Public Information Campaign for Health Improvement.
ADB = Asian Development Bank, CDH = central district hospital, CIPI = Civil Initiative on Policy of Internet, DHD = district health department, DHIS2 = Development Health Information System–2, DTP = diphtheria–tetanus– pertussis, FGP = family group practice, FMTCC = Family Medicine Training Clinical Center, HIV = human immunodeficiency virus, HMIS = health management information system, HSRP = Health Sector Reform Project, ICD-10 = international classification of disease, tenth revision, IMR = infant mortality rate, JFPR = Japan Fund for Poverty Reduction, MDG = Millennium Development Goal, MMR = maternal mortality rate, MOH = Ministry of Health, NGO = nongovernment organization, NMPC = National Medicine and Medical Commodities Procurement Centre, PGMI = postgraduate medical institute, PHC = primary health care, RCDE = Research Center for Drug Expertise, RHC = rural health center, TA = technical assistance, TSMU = Tajikistan State Medical University. a MOH order No. 13 dated 12 January 2006 b MOH order No. 208 dated 15 May 2008 c Ministry of Health of the Republic of Tajikistan. 2008. Tajikistan Health Human Resource Management Guidelines. Dushanbe: Devashtich d ADB. 2003. Technical Assistance to the Republic of Tajikistan for Planning and Policy Dialogue for Health Reform. Manila (TA 4268-TAJ, for $300,000, approved on 17 December) e ADB. 2003. Technical Assistance to the Republic of Tajikistan for Drug Procurement and Distribution Strategy. Manila (TA 4269-TAJ, for $150,000, approved on 17 December). f Saydaliev S. 2008. Physicochemical properties of medicinal agents. Dushanbe: Devashtich g Government of Tajikistan. 2005. Strategy of Health Care Financing in the Republic of Tajikistan for the period 2005 – 2015 (Government Decree No. 171 dated 10 May 2005). Dushanbe Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
Appendix 2 25
BASIC SOCIAL, ECONOMIC, AND HEALTH DATA ON TAJIKISTAN
Table A2.1: Socioeconomic Development Profile of Tajikistan Item Unit 1990 1995 2000 2003 2004 2005 2006 2007 2008 Permanent population (as of 1 July) million 5.30 5.67 6.19 6.57 6.71 6.85 6.99 7.14 7.30 Urban population, as % of total % 32.10 28.10 26.50 26.50 26.40 26.40 26.40 26.30 26.30 population
Employed ’000 1,939.0 1,853.0 1,745.0 1,885.0 2,088.0 1,997.0 2,000.0 2,150.0 2,036.0
GDP at current market prices TJS million 7.3 66.6 1,637.0 4,253.1 5,487.5 6,375.4 8,241.5 12,804.3 17,609.3 Agriculture % 30.1 35.9 27.3 27.0 21.5 23.8 23.9 21.9 24.8 Industry % 38.4 36.5 38.4 37.0 34.6 30.7 30.5 29.8 27.0 Services % 31.5 27.6 34.3 36.0 44.0 45.6 45.6 48.3 48.3 GDP growth rate % … … 8.3 9.1 10.2 10.6 6.7 GDP per capita TJS … 12.3 288.7 724.4 919.1 1,052.0 1,335.1 1,793.3 2,412.2
Poverty rate % … … 82.0 64.0 … … … … …
Consumer price index (previous year = % … … 132.9 116.4 107.1 107.1 110.0 113.1 120.5 100) Food % … … 130.7 107.9 107.6 101.5 100.8 106.4 107.7 Nonfood % … … 122.8 115.4 116.5 110.4 142.7 121.2 120.3
GNI at current market prices TJS million … … 2,198.1 5,797.6 7,971.8 9,213.6 12,613.4 16,858.3 … Per-capita GNI TJS … … 355.2 882.0 1,188.0 1,345.0 1,804.0 2,361.1 …
Government total revenue and grants TJS million … 7.0 251.7 824.4 1,104.3 1,414.5 1,823.4 2,457.4 3,436.4 Total revenue TJS million … 7.0 251.7 809.7 1,063.6 1,383.4 1,800.5 2,420.9 3,436.4
Government total expenditure TJS million … 12.1 261.8 772.3 1,090.6 1,402.7 1,778.8 3,494.9 5,058.1 Education TJS million … 1.5 41.6 112.1 164.3 253.1 317.7 437.0 722.3 Health TJS million … 0.9 16.9 43.3 58.2 82.4 105.4 145.2 259.5 Social security and welfare TJS million … 0.1 32.1 109.0 158.3 232.4 317.0 355.6 485.8 2 Appendix Total exports $ million … 778.6 784.3 797.2 914.9 908.7 1,399.0 1,468.1 1,409.0 Total imports $ million … 838.1 675.0 880.8 1,191.3 1,330.1 1,725.4 2,547.2 3,273.0
Exchange rate (average of period) TJS:$ … 0.12 2.08 3.06 2.97 3.12 3.30 3.44 3.43
Total debt outstanding and disbursed $ million … 633.6 1,033.7 1,151.7 1,041.4 1,065.5 1,016.4 1,227.9 … 25 GDP = gross domestic product, GNI = gross national income, TJS = Tajikistan somoni. … = not available. Source: ADB. 2009. Key Indicators of Developing Asian and Pacific Countries, 2009. Manila.
26 Appendix 2
Table A2.2: Dynamics of Selected Millennium Development Goal Indicators for Tajikistan
Indicator 2000 2001 2002 2003 2004 2005 2006 2007 2008 Percent of population living in 44.5 … … 41.5 21.5 … … 17.1 … extreme povertya Percent of children under 6 … … … … … 17.0 … 15.0 … who are underweighta Percent of population … … … … … 34.0 … … … consuming less than 2,100 Kcal per day
Under-5 child mortality rate, 93.0 … … 79.0 … 71.0 68.0 67.0 … per 1,000 live birthsb, c Infant mortality rate, per 1,000 75.0 … 86.0 65.0 … 59.0 56.0 56.6 … live birthsb, c
Maternal mortality rate, per … … … … … 170.0 … … … 100,000 live births Percent of births attended by … … … … … 83.0 … … … qualified personnel Percent of pregnant women … … … … … … … … … with anemia Percent of children vaccinated 80.0 … … 91.0 … … … 69.0 … against measlesb, c Percent of children vaccinated … … … … 89.0 … 96.0 86.0 … against diphtheria, pertussis, tetanus-3d Percent of children vaccinated … … … … 84.0 … 95.0 85.0 … against poliomielithisd Contraceptive prevalence rate 34.0 … … … … 38.0 … 37.1 … (percent of married women 15–49 years)c
Percent of population with 57.0 … … … … 70.0 … … … sustainable access to safe drinking waterc Percent of population with 90.0 … … … … 94.0 … … … sustainable access to seweragec Kcal = kilocalorie … = not available. a World Bank estimates based on the 2003 and 2007 Tajikistan living standards surveys. b Multiple Indicators Cluster Surveys 2000 and 2003. United Nations Children’s Fund. c State Committee on Statistics of the Republic of Tajikistan, UNICEF. 2009. Tajikistan Living Standards Measurement Survey 2007. Dushanbe. d World Health Organization, 2007. Source: ADB. 2009. Key Indicators of Developing Asian and Pacific Countries, 2009. Manila.
Appendix 2 27
Table A2.3: Selected Project Performance Indicators
Item 2004 2005 2006 2007
A. Infant Mortality Rate (per 1,000 live births) Ayni 40.5 22.0 27.8 20.7 Kulyab 17.1 9.7 14.4 13.1 Kuhistoni Mastchoh 19.4 35.3 38.8 19.9 Rasht 3.3 6.9 10.0 15.9 Roshtkala 4.0 22.3 11.7 24.9
B. Child Mortality Rate (per 1,000 live births) Ayni … … 26.5 30.9 Kulyab … … 27.0 22.4 Kuhistoni Mastchoh … … 46.8 38.7 Rasht … … 14.3 13.7 Roshtkala … … 38.9 22.3
C. Maternal Mortality Rate (per 100,000 live births) Ayni … 174.0 73.2 … Kulyab … … … 38.4 Kuhistoni Mastchoh … 35.3 36.8 … Rasht 125.5 43.0 125.0 77.5 Roshtkala … … … 498.8
D. Use of Family Planning Practice by Women of Fertile Age (percent of women aged 15-49 who are using contraceptives) Ayni 15.4 17.5 13.6 15.2 Kulyab 23.1 25.7 22.3 26.3 Kuhistoni Mastchoh 7.4 7.7 3.5 6.4 Rasht 23.7 26.0 22.8 24.8 Roshtkala 29.3 18.5 21.2 12.0 … = not available. Source: National Centre on Medical Statistics and Data.
28 Appendix 2
Table A2.4: Health-Care Expenditures in Tajikistan in 2005–2009
2005 2006 2007 2008 2009 Item (Jan– Aug) A. Health Economy GNP ($ million) 7.20 8.40 9.60 14.80 20.00 Health budget (TJS million) 71.00 112.70 178.30 255.50 395.70
B. Health-Care Expenditures Ayni Health-care expenditures (TJS thousand) 362.43 467.94 588.74 1,104.05 1,565.81 PHC expenditures (TJS thousand) 141.29 127.57 282.24 594.83 783.45 Share of PHC expenditures (%) 38.98 27.26 47.94 53.88 50.03 Annual growth of health expenditures (%) … 29.11 25.82 87.53 41.82 Annual growth of PHC expenditures (%) … (9.71) 121.25 110.75 31.71
Kulyab Health-care expenditures (TJS thousand) 593.54 693.20 791.59 1,451.09 2,440.11 PHC expenditures (TJS thousand) 225.38 293.56 342.30 752.91 1,373.28 Share of PHC expenditures (%) 37.97 42.35 43.24 51.89 56.28 Annual growth of health expenditures (%) … 16.79 14.19 83.31 68.16 Annual growth of PHC expenditures (%) … 30.25 16.60 119.96 82.40
Kuhistoni Mastchoh Health-care expenditures (TJS thousand) 55.59 170.23 172.31 338.45 377.10 PHC expenditures (TJS thousand) 24.88 39.35 82.80 208.12 240.16 Share of PHC expenditures (%) 44.75 23.12 48.05 61.49 63.69 Annual growth of health expenditures (%) … 206.23 1.22 96.42 11.42 Annual growth of PHC expenditures (%) … 58.17 110.42 151.35 15.40
Rasht Health-care expenditures (TJS thousand) 636.38 851.95 1,147.46 1,688.03 2,459.79 PHC expenditures (TJS thousand) … … 206.89 829.64 1,373.72 Share of PHC expenditures (%) … … 18.03 49.15 55.85 Annual growth of health expenditures (%) … 33.87 34.69 47.11 45.72 Annual growth of PHC expenditures (%) … … … 301.00 65.58
Roshtkala Health-care expenditures (TJS thousand) 162.40 234.20 204.00 344.62 594.00 PHC expenditures (TJS thousand) 56.20 84.20 102.00 144.00 184.00 Share of PHC expenditures (%) 34.61 35.95 50.00 41.79 30.98 Annual growth of health expenditures (%) … 18.64 13.05 44.07 65.18 Annual growth of PHC expenditures (%) … 49.82 21.14 41.18 27.78 GNP = gross national product, PHC = primary health care, TJS = Tajikistan somoni. ( ) = negative … = not available. Source: Ministry of Health of Tajikistan, departments of health of pilot districts.
Appendix 2 29
Figure A2: Dynamics of Health-Care Expenditures in Tajikistan
2,515,000 Total health expenditures
PHC expenditures 2,015,000
1,515,000
1,015,000
515,000
15,000 Aini Aini Aini Rasht Rasht Rasht Kulyab Kulyab Kulyab Roshtkala Roshtkala Roshtkala Kuhistoni Mastchoh Kuhistoni Mastchoh Kuhistoni Mastchoh Kuhistoni
2005 2007 2009
Source: Ministry of Health of Tajikistan, departments of health of pilot districts.
30 Appendix 2
30 STRENGTHENING OF PLANNING AND MANAGEMENT CAPACITY IN THE HEALTH SECTOR
Table A3.1: Capacity Building for Health Planning and Management 3 Appendix National Health Ministry of Health Institutions District Health Institutions Human Medical Other District Other HSRP Item Unit MOH Resource HSRP Data National Health HSRP District Funds ($) Depart- Depart- Manage- National Health Depart- Manage- Health ments ment ment Center Centers ments ment Centers A. Civil Works Renovation contracts 6 1 3 4 152,088 Subtotal 152,088 B. Equipment and Furniture Basic medical equipment set 1 16 5 261,241 Basic furniture set 1 1 1 5 5 165,239 Subtotal 426,480 C. Audio-visual Equipment Multimedia projector/screen set 1 2,540 Digital camera piece 3 5 3,154 TV set/ DVD player set 1 5 2,331 Subtotal 8,025 D. Computers, Printers and Networks Desktop computer set 12 1 18 1 15 15 6 81,463 Laptop computer piece 1 2 2 1 10,818 Printer piece 12 1 12 1 5 5 6 23,989 Scanners piece 2 400 Local network/communication set 5 3,178 Copying machine piece 1 3 5 14,020 Subtotal 133,868 E. Miscellaneous Technical equipment 5 24,242 Vehicles piece 2 10 5 5 334,910 Subtotal 359,152
Total: 1,079,613 Sources: Ministry of Health of Tajikistan, departments of health of pilot districts, and Health Sector Reform Project reports.
Appendix 3 31
Table A3.2: Capacity Building for Health Management Information System
Medical Medical District Data Data Health HSRP National Provincial Depart- Manage- HSRP Item Unit Center Centers ments ment Funds ($) Desktop computer set 11 2 13 30,550 Laptop computer piece 1 2,290 Printer piece 3 2 13 1 6,270 Local network/ set 5 1,020 communication Copying machine piece 1 3 10 6,790 Subtotal 46,920 Technical equipment set 1 3 5 24,100 Total 71,020 Sources: Ministry of Health of Tajikistan, departments of health of pilot districts, and Health Sector Reform Project reports.
Table A3.3: International and National Consulting Services
Role Contract Dates A. International Consultants Human resource development 28/02/2005 30/06/2005 Health personnel licensing and accreditation 20/06/2005 20/09/2005 Family group practice 12/08/2005 12/01/2006 Capitation payment specialist 13/08/2005 02/11/2005 Clinical pharmaceutical specialista 07/04/2006 21/05/2006 Health management information systemb 17/11/2007 17/01/2008 Laboratory and drug quality controla 21/02/2005 21/05/2005 Health planning and rationalization 02/07/2007 02/09/2007 Monitoring and evaluation specialist 13/07/2008 13/10/2008 Project management adviserc 15/11/2004 15/02/2006
B. National Consultants Human resource development 22/02/2005 31/12/2008 Health personnel licensing and accreditation 22/02/2005 30/06/2008 Family group practice 22/02/2005 31/12/2008 Capitation payment specialist 20/02/2006 30/06/2008 Health planning and rationalization 22/02/2005 28/02/2008 Health management information systemb 20/12/2006 31/03/2009 Laboratory and drug quality controla 22/02/2005 31/12/2008 Clinical pharmaceutical specialista 14/09/2005 31/12/2008 Drugs marketing specialista 01/02/2006 31/12/2008 Monitoring and evaluation specialist 22/10/2007 21/10/2008 a ADB. 2003. Technical Assistance to the Republic of Tajikistan for Drug Procurement and Distribution Strategy. Manila (TA 4269-TAJ, for $150,000, approved on 17 December). b ADB. 2003. Technical Assistance to the Republic of Tajikistan for Planning and Policy Dialogue for Health Reform. Manila (TA 4268-TAJ, for $300,000, approved on 17 December). c Under Project Management category of the loan. Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
32 Appendix 3
Table A3.4: Overseas Training Courses and Study Tours
Govern- Ministry National Project Pilot Activity ment of Health Centers Staff Districts Total $ Study tour on health sector reform, 5 2 7 14,080 Mongolia, 8–13 November 2004 Training course on health system 1 2 2 5 17,120 development, Kyrgyz Republic, 23 May–3 June 2005 ADB Project Implementation and 1 1 17,120 Administration Seminar, Manila, Philippines, 9–20 May 2005 Study tour on health sector reform, 1 4 1 4 10 35,100 Turkey, 15–23 June 2005 Training course on quarantine 1 1 2 3,840 infections, Kazakhstan, 1 September–31 October 2005 ADB Project Implementation and 2 2 4,772 Administration Seminar, Uzbekistan, 12–23 September 2005 Conference on capitation payment, 2 2 8,400 France, 23–28 January 2006 ITC-ILO training courses on 4 4 32,300 international drugs procurement, Italy, 13–24 March 2006 Training courses on financial 1 1 6,360 management and disbursement in World Bank-financed projects, Italy, 27 March–7 April 2006 Training courses on healthy living, 1 8 9 10,490 Kazakhstan, 3–14 April 2006 Study tour on drug quality control, 3 1 4 9,280 Armenia, 10–16 April 2006 Conference on licensing and 2 1 3 12,750 accreditation in health, United States, 20–22 April 2006 Training course on health system 4 6 10 20,800 development, Kyrgyz Republic, 22 May–2 June 2006 WBI/WHO training courses on 3 1 5 9 19,800 accelerating MDG achievement, Kyrgyz Republic, 17–28 September 2006 Training courses on policy, 2 3 5 10 13,240 economics, and regional health management, Kazakhstan, 16–21 April 2007 HMIS training course, India, 18–28 2 2 9,405 August 2008 Total 2 26 5 35 13 81 234,857 ADB = Asian Development Bank, HMIS = Health Management Information System, ITC-ILO = International Training Centre of the International Labour Organization, MDG = Millennium Development Goal, WBI = World Bank Institute, WHO = World Health Organization. Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
Appendix 3 33
Table A3.5: In-Country Conferences (number of participants)
Government Authorities Health Sector Pilot Areas Kuhis- Interna- Ministry toni tional of National PMU/ Mast- Rosht- Agen- Activity Central Local Health Centers HSRP Ayni Kulyab choh Rasht kala cies Total $ National Conference on 4 5 9 169 10 3 4 2 3 3 18 230 8,559 Family Medicine Model, 15–16 December 2005, Dushanbe National Conference on 2 10 30 8 10 60 3,488 Establishment of the National Drug Center, 17 October 2006, Dushanbe Conference on Family 1 5 9 169 10 5 5 4 5 5 12 230 5,773 Medicine Introduction, 16 November 2006, Dushanbe National Workshop on 4 5 7 5 4 3 4 4 14 50 2,297 HMIS Development, 7– 10 January 2008, Dushanbe National Conference on 4 5 11 162 10 3 4 5 5 5 16 230 11,716 Family Medicine Issues, 14 November 2008, Dushanbe National Conference on 2 10 11 72 10 4 4 4 4 4 10 135 5,825 Rationalization and Restructuring of Hospitals, 5–6 June Appendix 3 2009, Dushanbe Total 11 27 54 607 55 20 21 18 21 21 80 935 37,659 HMIS = Health Management Information System, HSRP = Health Sector Reform Project, PMU = project management unit. Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports. 33 33
34 Appendix 4
HUMAN RESOURCE DEVELOPMENT OF HEALTH SECTOR
Table A4.1: Strengthening Capacity of Postgraduate Medical Education and Training Facilities
Family Medicine
Training Centers Tajik Institute National
Tajikistan of Training
State Postgraduate and Provincial
Medical Training for Clinic Training HSRP Item Unit University Medical Staff Center Centers Funds ($)
A. Civil Works Renovation contracts 2 47,442 Subtotal 47,442
B. Equipment and Furniture Basic medical set 1 3 33,413 equipment Basic furniture set 2 4 38,152 Basic training 1 3 3,920 equipment Subtotal 75,485
C. Audiovisual Equipment Multimedia set 2 4 9,360 projector/screen Digital camera piece 2 5 4,220 TV set/DVD player set 1 4 1,740 Subtotal 13,950
D. Computers, Printers, and Networks Desktop computer set 15 1 1 4 30,525 Laptop computer piece 2 1 1 2 9,080 Printer piece 8 1 1 4 4,964 Scanner piece 2 375 Copying machine piece 3 3 7,875 Subtotal 52,819
E. Miscellaneous Medical reference piece 2,593 52 55 227 71,189 literature Vehicles piece 1 2 55,050 Subtotal 126,239
Total 317,305 Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
Appendix 4 35
Table A4.2: Postgraduate Training to Support Family Group Practice
Pilot Kuhistoni Item Ayni Kulyab Rasht Roshtkala areas Mastchoh in total
A. Six-Month Training Courses on Family Group Practice 1st Cycle (Sep 05–Feb 06) FGP doctors 10 10 3 8 2 33 FGP nurses/midwives 11 13 5 11 2 42
2nd Cycle (Mar–Aug 06) FGP doctors 6 6 1 12 3 28 FGP nurses/midwives 16 29 4 16 7 72
3rd Cycle (Sep 06–Feb 07) FGP doctors 9 5 2 5 1 22 FGP nurses/midwives 23 31 5 30 16 105
4th Cycle (Mar–Aug 07) FGP doctors 6 4 1 6 2 19 FGP nurses/midwives 25 37 3 25 17 107
5th Cycle (Oct 07–Apr 08) FGP doctors 6 4 1 9 0 20 FGP nurses/midwives 34 44 5 38 16 137
6th Cycle (Apr–Oct 08) FGP doctors 3 3 3 2 1 12 FGP nurses/midwives 26 58 1 23 17 125
Total: 175 244 34 185 84 722
B. Short-Term Training Courses on FGP Clinic Standards FGP doctors 15 16 8 17 6 62 FGP nurses/midwives 55 104 32 103 34 328
Total: 70 120 40 120 40 390 FGP = family group practice. Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
36 Appendix 4
Table A4.3: Six-Month Postgraduate Training Courses on Family Group Practice
Pilot Kuhistoni Item Ayni Kulyab Rasht Roshtkala Areas Mastchoh in Total A. Medical Doctors Medical practitioners 17 14 4 15 4 56 Pediatricians 16 7 5 23 3 56 Gynecologists/ 4 5 1 3 1 14 obstetricians Surgeons 3 60 1 1 11 Subtotal (A) 40 32 11 42 9 134
B. Nurses/Midwives Midwives 18 34 6 32 8 98 Doctor's assistants 24 54 9 33 15 135 Public health nurses 93 124 8 78 52 355 Subtotal (B) 135 212 23 143 75 588
Total 175 244 34 185 84 722 Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
Table A4.4: Short-Term Training Courses on Family Group Practice Clinic Standards
Pilot Kuhistoni Item Ayni Kulyab Rasht Roshtkala Areas Mastchoh in Total A. Medical Doctors Medical practitioners 8 6 3 5 2 24 Pediatricians 6 7 5 9 3 30 Gynecologists/ 1 2 0 1 1 5 obstetricians Surgeons 0 1 0 2 0 3 Subtotal (A) 15 16 8 17 6 62
B. Nurses/Midwives Midwives 5 22 2 14 6 98 Doctor's assistants 17 12 1 23 2 135 Public health nurses 33 68 29 66 26 355 Subtotal (B) 55 104 32 103 34 328
Total 70 120 40 120 40 390 Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
Appendix 4 37
Table A4.5: In-Country Training Courses and Study Tours
PMU/ Kuhistoni Rosht- Activity Ayni Kulyab Rasht Total $ HSRP Mastchoh kala Training course on project 20 4 4 2 4 4 38 2,306 implementation and administration, 22 February–7 March 2006, Dushanbe Training courses on DOTS 33 6 32 71 4,697 introduction, 28 May–13 October 2007 Training courses on public 60 30 60 30 30 210 6,537 health management (health institutions), 9 July 2007–21 September 2008 Training courses on common 30 30 30 90 2,879 diseases, 2 July 2007–21 September 2008 Training courses on HMIS 30 30 30 30 30 150 309 implementation, 23–31 January 2008 Training courses on rational 18 18 3,488 use of drugs, 16–22 March 2008 Training courses on public 30 30 30 30 30 150 4,869 health program management and financing, 10 April–11 May 2008 Training courses on health data 25 25 25 25 25 125 3,024 collection and processing in health institutions, 15 May–6 July 2008 Total 20 179 167 180 155 151 852 28,108 HMIS = Health Management Information System, HSRP = Health Sector Reform Project, PMU = project management unit. Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
Table A4.6: Proportion of FGP Staff Trained in Pilot Areas
Kuhistoni Item Ayni Kulyab Rasht Roshtkala Mastchoh A. Proportion of Trained Health Staff to Total Staff Medical doctors 48.2 66.7 100.0 45.7 81.8 Nurses/midwives 51.0 75.4 41.1 59.8 70.5
B. Proportion of Trained Health Staff to PHC Staff Medical doctors 64.0 100.0 100.0 60.3 100.0 Nurses/midwives 94.2 97.2 58.1 69.9 100.0 PHC = primary health care. Sources: Ministry of Health and Health Sector Reform Project reports.
38 Appendix 5
CAPACITY BUILDING FOR FAMILY GROUP PRACTICE
Table A5: Capacity Building for Primary Health Care Facilities
Number of units Item Unit Sum ($) 2006 2007 2008 2009 A. Basic Medical Equipment Health houses/health centers set 66 424,835 District health centers set 5 … 107,411 Other district health facilities … 52,530 Subtotal 584,776
B. Basic Drugs First drug batch set … 132,554 Second drug batch set … 96,014 Subtotal 228,568
C. Ultrasound Diagnostic Equipment District health centers set 6 94,800 Other district health facilities set 1 6,500 Subtotal 101,300
D. Basic Medical Furniture Village health houses set 66 342,214 District health centers set 5 5 … 109,260 Subtotal 451,474
E. Computers, Printers and Networks Desktop computer set 15 21 42,710 Printer piece 5 11 9,370 Local network set 5 685 Copying machine piece 5 4,478 Subtotal 57,243
F. Miscellaneous Electric power generators piece 97 51,770 Vehicles piece 5 10 5 275,430 Subtotal 327,200
Total 1,750,561 … = not available. Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
Appendix 5 39
Figure A5: Rationalization of Hospital Beds in Pilot District
13.0 2003 18.9 general 11.3 diseases 2007 11.0
Tajikistan
7.7 2003 Rasht District surgical 6.9 7.0 diseases 2007 5.8
5.5
2003 5.7 obstetrical 5.0 2007 5.3
3.5 2003 infectious 2.3 diseases 3.0 2007 2.1
2.9 2003 tuberculosis 1.7 3.1 2007 1.6
7.3 2003 pediatric 16.6 5.7 general 2007 14.4
2.1 2003 pediatric 1.7 1.9 surgical 2007 1.6
3.0 2003 pediatric 1.1 infection 2.5 2007 0.5
Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports
40 Appendix 6
STRENGTHENING DRUG QUALITY CONTROL AND DRUG PROCUREMENT
Table A6.1: Strengthening Capacity of Drug Supply and Quality Control Centers
National Medicine and Medical National Commodities Procurement Center Research NMPC Item Unit Center for NMPC NMPC Total ($) Branch Drug Central Branch Kurgan- Expertise Office Khudjand Tube A. Civil Works Civil construction contracts 1 2 389,567 Renovation contracts 1 17,939 Subtotal 407,506
B. Equipment, Reagents, and Special Furniture Drug control set 1 325,497 laboratory equipment Steel shelves set 1 1 43,509 Drug control set 1 38,942 laboratory reagents Subtotal 407,948
C. Audiovisual Equipment Multimedia set 1 1 3,910 projector/screen Subtotal 3,910
D. Computers, Printers, and Networks Desktop computer set 3 2 2 7,605 Laptop computer piece 1 1 2,970 Printer piece 2 1 1 1,900 Local network set 1 1 510 Copying machine piece 1 545 Subtotal 13,530
E. Miscellaneous Medical reference piece 224 5,193 literature Vehicles piece 1 7,200 Subtotal 12,393
Total 845,287 NMPC = National Medicine and Medical Commodities Procurement Center. Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
Appendix 6 41
Table A6.2: Quality Control on Imports of Drugs, Cosmetics and Food Additives in Tajikistan in 2003–2008 (quantities of registered items/applications)
Region of Origin 2003 2004 2005 2006 2007 2008
CIS countries 116 346 223 180 551 305
Other countries 30 106 57 276 479 378
Total 146 452 280 456 1030 683 CIS = Commonwealth of Independent States. Source: Ministry of Health of Tajikistan.
Table A6.3: Quality Control on Imports of Drugs, Cosmetics, and Food Additives in Tajikistan and Destruction of Counterfeit Drugs and Food Additives in 2002–2008
Item 2002 2003 2004 2005 2006 2007 2008 A. Number of Tests on Drug Quality Control Drugs … … 2,694 7,053 10,175 12,975 Food additives and … … 1,692 1,929 6,226 9,642 cosmetics Total 4,386 8,982 16,401 22,617
B. Amount of Counterfeit Drugs and Food Additives Discovered and Destroyed (metric tons) In total 1.81 60.00 4.90 10.20 11.60 32.60 21.40 Not meeting standards … … 4.31 9.01 10.31 31.55 21.38 For humanitarian 1.81 60.00 0.60 1.19 0.54 1.05 1.32 relief … = not available. Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
42 Appendix 7
DELIVERY OF PRO-POOR HEALTH SERVICES
Table A7.1: Attendance at Primary Health Care Facilities in Pilot Areas
Kuhistoni Year Ayni Kulyab Rasht Roshtkala Mastchoh A. Number of Visits to District PHC Facilities (per capita per year)a
2004 3.6 2.2 2.1 1.7 0.4 2005 3.8 1.5 1.7 1.4 0.5 2006 3.7 1.6 1.5 1.3 0.3 2007 3.5 1.8 1.6 2.1 0.3 2008 3.2 1.7 1.0 1.7 0.8
B. Number of Visits to District Health Center (per capita per year)b 2004 2.4 0.9 1.4 1.1 0.3 2005 2.8 0.8 0.8 1.1 0.3 2006 2.8 7.0 1.2 1.0 0.2 2007 2.5 0.9 1.0 1.6 0.1
C. Number of Visits to Village Health House (per capita per year)b 2004 1.0 1.0 1.8 0.4 0.5 2005 0.6 0.9 1.2 0.4 0.5 2006 0.5 0.8 1.5 0.4 0.5 2007 0.4 0.8 0.5 0.4 0.5 PHC = primary health care Sources: a National Center on Medical Statistics and Data. b Data collected from pilot districts.
Appendix 7 43
Table A7.2: Selected Indicators on Women's Health in Pilot Areas in 2004–2007
Item 2004 2005 2006 2007 A. Use of Contraceptives by Women of Fertile Age (percentage) Ayni 15.4 17.5 19.8 23.7 Kulyab 34.8 39.5 33.0 36.1 Kuhistoni Mastchoh 7.4 10.9 8.2 8.4 Rasht 29.7 30.2 30.1 34.6 Roshtkala 36.6 27.8 39.5 57.9
B. Attendance of Pregnant Women at Primary Health Care Facilities in Early Pregnancy (percentage) Ayni 32.1 32.7 33.0 16.5 Kulyab 17.8 34.9 37.9 31.2 Kuhistoni Mastchoh 40.2 39.5 41.2 45.9 Rasht 49.5 31.8 50.1 64.3 Roshtkala 19.2 10.1 8.6 16.0
C. Attendance of Pregnant Women at Primary Health Care Facilities in Late Pregnancy (percentage) Ayni 49.5 52.2 54.5 56.3 Kulyab 76.6 45.6 72.5 89.7 Kuhistoni Mastchoh 64.3 66.2 70.2 73.8 Rasht 25.1 10.7 35.8 29.0 Roshtkala 12.8 16.9 14.7 23.4
D. Percentage of Home Deliveries Ayni 16.3 17.7 14.9 13.6 Kulyab 65.6 37.5 29.7 31.0 Kuhistoni Mastchoh 71.0 68.1 68.0 66.3 Rasht 61.3 60.9 64.2 56.8 Roshtkala 40.4 34.8 28.4 40.5 Source: Data collected from pilot districts.
44 Appendix 7
Table A7.3: Selected Indicators on Child Vaccination in Pilot Areas in 2004–2007
Item 2004 2005 2006 2007 2008 A. Percentage of Children Vaccinated against Tuberculosis Ayni 94.2 95.1 97.0 100.0 87.2 Kulyab 98.3 96.0 98.8 98.0 98.2 Kuhistoni Mastchoh 100.0 100.0 100.0 100.0 98.0 Rasht 95.0 94.0 98.0 100.0 99.0
B. Percentage of Children Vaccinated against Diphtheria, Pertussis, and Tetanus Ayni 89.9 94.0 94.4 100.0 86.0 Kulyab 96.1 93.0 96.7 96.7 96.1 Kuhistoni Mastchoh 100.0 100.0 100.0 100.0 100.0 Rasht 94.0 97.0 97.0 98.0 97.0
C. Percentage of Children Vaccinated against Poliomielithis Ayni 89.9 94.0 94.5 100.0 86.0 Kulyab 95.8 93.1 97.8 97.8 95.7 Kuhistoni Mastchoh 100.0 100.0 100.0 100.0 95.6 Rasht 94.0 96.0 97.0 97.0 97.0
D. Percentage of Children Vaccinated against Measles Ayni 83.6 67.3 100.0 100.0 84.1 Kulyab 93.2 92.3 98.6 98.6 97.5 Kuhistoni Mastchoh 88.7 97.4 100.0 100.0 100.0 Rasht 93.0 97.0 97.0 97.0 96.0
E. Percentage of Children Vaccinated against Hepatitis B Ayni 91.6 95.4 97.2 100.0 88.3 Kulyab 96.9 93.0 97.3 96.3 92.2 Kuhistoni Mastchoh 100.0 100.0 100.0 100.0 98.0 Rasht 95.0 96.0 99.0 99.0 97.0 Source: Data collected from pilot districts.
Appendix 8 45
INFORMATION ON CIVIL WORKS CONTRACTS (Tajikistan: Health Sector Reform Project, Loan 2054)
Subproject № Total Contract Contract Name Code PCSS Cost ($) Rehabilitation of PMU office, Dushanbe CW 001 0001 17,505.00 Rehabilitation of additional PMU office, Dushanbe CW 002 0017 34,233.17 Rehabilitation of microbiological department of State CW 007 0043 17,938.58 Drug Expertise Center Rehabilitation of the second family medicine CW 026 0108 19,891.27 department of Dushanbe Additional rehabilitation of the second family CW 030 0131 27,550.24 medicine department of Dushanbe Total Dushanbe 117,118.26 Construction of warehouse in regional RMPC CW 003 Lot 1 0023 158,514.15 affiliate, Sugd Region, Khujand Total Khujand 158,514.15 Construction of warehouse in regional RMPC CW 003 Lot 2 0022 166,307.53 affiliate, Khatlon Region, Kurgan-Tube Installation of power supply line in the warehouse of CW 013 0059 64,745.40 regional RMPC affiliate in Kurgan-Tube Total Kurgan-Tube 231,052.93 Rehabilitation of PIU office and RHC policlinic CW 004 Lot 1 0027 31,179.27 Rehabilitation of CDH therapeutic department CW 009 Lot 1 0053 59,313.43 Construction of RHC, Shakhri Nav CW 027 0123 70,726.49 Construction of RHC, Voring CW 023 Lot 2 0115 66,681.60 Construction of RHC, Navdi CW 023 Lot 1 0116 71,229.29 Construction of HH, Kamarob CW 015 Lot 1 0088 41,079.43 Construction of HH, Kul CW 015 Lot 2 0089 42,037.34 Construction of HH, Niyozbegim CW 015 Lot 3 0090 41,180.16 Construction of HH, Khost CW 015 Lot 4 0091 46,400.19 Construction of HH, Bedak CW 015 Lot 5 0092 35,763.08 Construction of HH, Kizrok CW 015 Lot 6 0093 39,746.03 Construction of HH, Belgi CW 015 Lot 7 0094 38,098.78 Construction of HH, Duoba CW 015 Lot 8 0095 37,282.74 Construction of HH, Khisorak CW 015 Lot 9 0096 38,519.94 Rehabilitation of HH, Dashti Rasht CW 009 Lot 2 0054 18,091.21 Rehabilitation of HH, Shoindara CW 009 Lot 3 0055 17,466.36 Rehabilitation of RHC, Khichborak CW 009 Lot 4 0056 20,941.54 Rehabilitation of CDH water supply and sewerage, CW 031 Lot 3 0141 30,221.52 Rasht district Total, Rasht District 745,958.40 Rehabilitation of PIU office CW 004 Lot 2 0028 19,298.16 Rehabilitation of CDH surgical department CW 008 0044 79,624.94 Construction of RHC, Chorbog CW 028 0124 81,008.07 Construction of RHC, Aftoluk CW 022 0113 74,341.20 Construction of HH, Sari Jar CW 014 Lot 1 0078 45,027.48 Construction of HH, Kukhnashar I CW 014 Lot 2 0079 43,386.08 Construction of HH, Sarezi Dasht CW 014 Lot 3 0080 39,539.92 Construction of HH, Zarbdor CW 014 Lot 4 0081 39,453.83
46 Appendix 8
Subproject № Total Contract Contract Name Code PCSS Cost ($) Construction of HH, Mirapok CW 014 Lot 5 0082 41,987.40 Construction of HH, Madinom Ibron CW 014 Lot 6 0083 42,941.23 Construction of HH, Korezi Poyon CW 014 Lot 7 0084 43,664.81 Construction of HH, Tokakappa CW 014 Lot 8 0085 45,837.49 Construction of HH, Faizaliev CW 014 Lot 9 0086 37,885.79 Construction of HH, Davlatobod CW 018 0101 27,636.17 Rehabilitation of HH, Navobod CW 012 Lot 5 0070 23,033.91 Rehabilitation of CDH infectious disease department CW 031 Lot 1 0139 43,382.52 roof, Kulyab district Rehabilitation of CDH water supply and sewerage, CW 031 Lot 2 0040 98,273.92 Kulyab district Total, Kulyab District 826,322.91 Rehabilitation of PIU office CW 005 0031 17,831.19 Rehabilitation of CDH surgical department CW 010 Lot 1 0058 76,290.85 Construction of RHC policlinic CW 025 0112 131,572.72 Rehabilitation of RHC, Tavdem CW 010 Lot 2 0057 38,567.16 Construction of HH, Shujev CW 016 Lot 1 0126 34,377.18 Construction of HH, Lakhshik CW 016 Lot 2 0127 35,589.89 Construction of HH, Leskhoz CW 016 Lot 3 0128 36,032.68 Construction of HH, Dasht CW 016 Lot 4 0129 35,430.27 Total, Roshtkala 405,691.93 Rehabilitation of PIU office CW 006 Lot 1 0032 15,426.68 Rehabilitation of CDH children’s department CW 012 Lot 1 0066 54,362.08 Rehabilitation of RHC policlinic CW 020 0109 95,767.68 Construction of RHC, Shurmashk CW 021 0110 77,726.27 Construction of RHC, Pokhut CW 029 0125 82,041.67 Rehabilitation of RDH, Zarafshon CW 012 Lot 2 0067 55,986.56 Rehabilitation of RHC, Takfon CW 011 Lot 1 0060 34,626.57 Rehabilitation of RHC, Madm CW 012 Lot 3 0068 31,061.94 Construction of HH, Marzich CW 017 0130 38,795.95 Total, Ayni District 485,795.40 Rehabilitation of PIU office CW 006 Lot 2 0033 16,615.13 Rehabilitation of RDH, Langar CW 012 Lot 4 0069 65,666.87 Construction of RDH, Rog CW 024 Lot 2 0111 93,932.76 Construction of RDH, Pastigav CW 024 Lot 1 0114 76,897.92 Rehabilitation of RHC, Revomutk CW 011 Lot 2 0061 17,901.79 Construction of HH, Guzn CW 019 Lot 1 0103 38,198.12 Construction of HH, Khudgifi Soya CW 019 Lot 2 0104 35,023.44 Construction of HH, Langar CW 019 Lot 3 0102 35,797.38 Total, Kuhistoni Mastchoh 380,033.42 Total 3,350,487.00 CDH = central district hospital, HH = health house, PIU = project implementation unit, PCSS = procurement contract summary sheet, PMU = project management unit, RDH = rural divisional hospital, RMPC = Republican Medicines Procurement Centre. Source: Project management unit of Health Sector Reform Project.
PROJECT COST AND FINANCING PLAN (APPRAISED AND ACTUAL) Table A9.1: Project Costs ($ million)
Appraisal Estimate Actual Item Foreign Local Foreign Local Total Cost Total Cost Exchange Currency Exchange Currency
A. Investment Cost 1. Civil works 0.476 0.834 1.310 1.194 2.186 3.380 2. Equipment and furniture 1.776 0.000 1.776 2.607 0.000 2.607 3. Training and workshops a. Overseas training 0.150 0.000 0.150 0.165 0.000 0.165 b. In-country training 0.000 0.811 0.811 0.000 1.135 1.135 4. Consulting services a. International consultants 0.616 0.000 0.616 0.376 0.000 0.376 b. National consultants 0.000 0.053 0.053 0.000 0.178 0.178 5. Surveys and studies 0.020 0.180 0.200 0.000 0.031 0.031 6. Public information campaign 0.073 0.292 0.365 0.000 0.000 0.000 7. Materials and consumables 0.824 0.070 0.894 0.224 0.148 0.372 8. Project management 0.260 0.326 0.586 0.144 0.833 0.978 9. Procurement center/PSFCI work 0.580 0.000 0.580 0.000 0.000 0.000 10. FGP seed capital 0.000 0.342 0.342 0.000 0.100 0.100 Subtotal (A) 4.774 2.908 7.683 4.7104.611 9.322
B. Recurrent Cost 0.083 0.323 0.405 0.036 0.000 0.036
C. Total Base Cost 4.857 3.231 8.088 4.746 4.611 9.358
D. Contingencies 1. Physical contingencies 0.132 0.045 0.177 0.000 0.000 0.000 2. Price contingencies 0.153 0.759 0.912 0.000 0.000 0.000
Appendix 9 E. Interest Charges 0.198 0.000 0.198 0.104 0.000 0.104 Total 5.340 4.035 9.375 4.851 4.611 9.462 FGP = family group practice, PSFCI = Pharmaciens Sans Frontières Comité International. Sources: ADB. 2003. Report and Recommendation of the President to the Board of Directors: Proposed Loan and Technical Assistance Grants to the Republic of Tajikistan for the Health Sector Reform Project. Manila; ADB loan financial information system; and information from project management unit of Health Sector Reform Program 47 47
48 Table A9.2: Financing Plan ($ million)
9 Appendix
Appraisal Estimate Actual
Foreign Local Total Foreign Local Total Source Share (%) Share (%) Exchange Currency Cost Exchange Currency Cost
Asian Development Bank 5.340 2.160 7.500 80.0 4.851 2.869 7.720 81.6 Government 0.000 1.875 1.875 20.0 0.000 1.742 1.742 18.4 Total 5.340 4.035 9.375 100.0 4.851 4.611 9.462 100.0 Sources: ADB. 2003. Report and Recommendation of the President to the Board of Directors: Proposed Loan and Technical Assistance Grants to the Republic of Tajikistan for the Health Sector Reform Project. Manila; ADB loan financial information system; and information from project management unit of Health Sector Reform Project.
Appendix 9 49
Table A9.3: Annual Disbursement of ADB Loan Proceeds
Annual Disbursement Cumulative Disbursement Year Amount Amount % of total % of total ($ million) ($ million) 2004 0.237 3.07 0.237 3.07 2005 0.538 6.97 0.775 10.04 2006 1.109 14.37 1.884 24.40 2007 1.319 17.09 3.203 41.49 2008 3.200 41.45 6.403 82.94 2009 1.317 17.06 7.720 100.00 Source: Asian Development Bank.
Figure A9: Cumulative ADB Disbursement $ Million 8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0 2004 2005 2006 2007 2008 2009
Source: Asian Development Bank.
Table A9.4: Annual Disbursement of Counterpart Funds (Government of Tajikistan)
Annual Disbursement Cumulative Disbursement Year Amount Amount % of total % of total ($ million) ($ million) 2004 0.005 0.27 0.005 0.27 2005 0.044 2.53 0.049 2.80 2006 0.239 13.72 0.288 16.52 2007 0.388 22.27 0.676 38.79 2008 0.769 44.16 1.445 82.95 2009 0.297 17.05 1.742 100.00 Source: Ministry of Health of Tajikistan.
50 Appendix 10
PROJECT IMPLEMENTATION SCHEDULE (comparison of appraisal and actual)
2004 2005 2006 2007 2008 2009 Component/Subcomponent/Activity III IV I II III IV I II III IV I II III IV I II III IV I II III 1. Institutional Development 1.1 Capacity Building of MOH, PGMI, and the Med.Univ. Overseas training of staff Creating the national training team Training in planning/ management Improving the licensing system FGP accreditation development Facility rationalization plan refined Training in public information campaign
1.2 Workforce Planning Review of status and legislation Workforce model and legislations produced Workforce workshops Action plans developed and implemented Standardization and meetings on cont.education
1.3 HMIS Development Review HMIS performance and capacity Development of HMIS framework Training and computerized system proposed Regular intersector/donor committee Training for data collection and analysis Computerized HMIS set up
1.4 FGP System Framework Development Training on FGP system and payment Development of framework National workshop
2. Drug Supply and Quality Control On-the-job training of Dorui Tajik Review of drug supply system Procurement of equipment laboratory Training of laboratory analysis Review of quality control system
Appendix 10 51
2004 2005 2006 2007 2008 2009 Component/Subcomponent/Activity III IV I II III IV I II III IV I II III IV I II III IV I II III 3. Effective and Sustainable Delivery of a Pro-Poor Health Service Package 3.1 Provision of a Pro-Poor Health Services Package Distribution of drug kits Installation of equipment Training of staff Rehabilitation/construction of facilities Training of family doctors and nurses
3.2 Increase in Efficiency and Pro-Poor Focus of Services Discussion for FGP system installation Test system and payment mechanism FGP mapping/population registration Capitation payment and arrangements HMIS set-up and functioning Framework and data surveys Monitoring and quality control of FGP Conference to evaluate FGP system
3.3 Management Capacity Building of District Administration Creation of district health department Training of staff for the health department
3.4 Facility Rationalization Plan development and implementation Workshops on business plan preparation
3.5 Community Awareness and Participation Training of feldshers and health workers Community mobilization and participation Public information campaign conducted
- planned - actual implementation FGP = family groups practice, HMIS = health management information system, MOH = Ministry of Health, PGMI = post-graduate medical institute, PHC = primary health care. Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
52 PROJECT ORGANIZATIONAL DIAGRAM
Appendix 11 11 Appendix
HSRP = Health Sector Reform Project, JFPR = Japan Fund for Poverty Reduction, PHC = primary health care, PMU = Project Management Unit, TA = technical assistance. Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
Appendix 12 53
STATUS OF COMPLIANCE WITH LOAN COVENANTS
Reference in Covenants Loan Status of Compliance Agreement
Standard Covenants
The Borrower shall cause the Project to be carried out Section Complied with with due diligence and efficiency and inconformity with 4.01 (a) sound administrative, financial, engineering, environmental, and health practices. In carrying out of the Project and operation of the Project Section Complied with Facilities, the Borrower shall perform, or cause to be 4.01 (b) performed, all obligations set forth in Schedule 6 of this Loan Agreement. The Borrower shall make available, promptly as needed, Section Complied with the funds, facilities, services, land and other resources 4.02 which are required, in addition to the proceeds of the loan, for carrying out of the Project and for the operation and maintenance of the Project facilities. In carrying out of the Project, the Borrower shall cause Section Complied with competent and qualified consultants and contractors, 4.03 (a) acceptable to the Borrower and the Bank, to be employed to an extent and upon terms and conditions satisfactory to the Borrower and the Bank. The Borrower shall cause the Project to be carried out in Section Complied with accordance with plans, design standards, specifications, 4.03 (b) work schedules and construction methods acceptable to the Borrower and the Bank. The Borrower shall furnish, or cause to be furnished, to the Bank, promptly after their preparation, such plans, design standards, specifications, and work schedules, and any material modifications subsequently made therein, in such detail as the Bank shall reasonably request. The Borrower shall make arrangements satisfactory to Section Complied with. the Bank for insurance of the Project facilities to such 4.05 (a) The insurance extent and against such risk and in such amounts as arrangements for project shall be consistent with sound practice. facilities and equipment were made through the government. Without limiting the generality of the foregoing, the Section Complied with Borrower undertakes to insure or caused to be insured, 4.05 (b) the goods to be imported for the Project and to be financed out of the proceeds of the Loan against hazards incident to the acquisition, transportation, and delivery thereof to the place of use or installation, and for such insurance any indemnity shall be payable in a currency freely usable to replace or repair such goods. The Borrower shall maintain, or caused to be Section Complied with maintained, records, and accounts adequate to identify 4.06 (a) the goods and services and other items of expenditure financed out of the proceeds of the Loan, to disclose the use thereof in accordance with consistently maintained sound accounting principles, the operations and financial condition of the agencies of the Borrower responsible for
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Reference in Covenants Loan Status of Compliance Agreement carrying out of the Project and operation of the Project facilities, or any part thereof. The Borrower shall (i) maintain, or cause to be Section Complied with. maintained, separate accounts for the Project; (ii) have 4.06 (b) Audit reports for FY2004– such accounts and related financial statements audited FY2009 were submitted to annually in accordance with appropriate auditing ADB on time. The reports standards consistently applied, by independent auditors were found to be whose qualifications, experience and terms of reference acceptable. are acceptable to the Bank; (iii) furnish to the Bank as soon as available but in any event not later than six (6) months after the end of each related fiscal year, certified copies of such audited accounts and financial statements and report of the auditors (including the auditor’s opinion on the use of the Loan Proceeds and compliance with loan covenants as well as the use of imprest account/statement of expenditures), all in English language; and (iv) furnish to the Bank such other information concerning such accounts and financial statements and the audit thereof as the Bank shall from time to time reasonably request. The Borrower shall enable the Bank, upon the Bank’s Section Complied with request to discuss the Borrower’s financial statements 4.06 (c) for the Project and its financial affairs related to the Project from time to time with the Borrower’s auditors. The Borrower shall furnish or cause to be furnished, to Section Complied with the Bank all such reports and information as the Bank 4.07 (a) shall reasonably request concerning (i) the Loan, and the expenditure of the proceeds and maintenance of the service thereof; (ii) the goods and services and other items of expenditure financed out of the proceeds of the Loan; (iii) the Project; (iv) the administration, operations, and the financial conditions of the agencies of the Borrower responsible for the carrying out of the Project and operation of the Project facilities, or any part thereof; (v) financial and economic conditions in the territory of the Borrower and the international balance-of-payments position of the Borrower; and (vi) any other matters relating to the purposes of the loan. Without limiting the generality of the foregoing, the Section Complied with. Borrower shall furnish or cause to be furnished, to the 4.07 (b) Quarterly progress reports Bank quarterly reports on carrying out of the Project and were submitted regularly on the operation and management of Project facilities. and on time. Promptly after physical completion of the Project, but not Section Complied late. later than 3 months thereafter or such later date as 4.07 (c) The local consultant was maybe agreed upon between the Borrower and the recruited by the PMU to Bank, the Borrower shall prepare and furnish a report in assist with preparation of such form as the Bank shall reasonably request. the borrower's PCR (the cost of the consultant's services will be covered by the government counterpart funds). The Russian version of the report was received on 6 January 2010; the English
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Reference in Covenants Loan Status of Compliance Agreement version of the report is awaited. The Borrower shall enable the Bank’s representatives to Section Complied with inspect the Project, the goods financed out of the 4.08 proceeds of the Loan, and any relevant records and documents. The Borrower shall ensure that the Project facilities are Section Complied with operated, maintained and repaired in accordance with 4.09 sound administrative, financial, engineering, environmental, and maintenance and operational practices. (a) It is the mutual intention of the Borrower and the Section Compliance waived a Bank that no other external debt owed a creditor other 4.10 than the Bank shall have any priority over the Loan by way of a lien on the assets of the Borrower. To that end, the Borrower undertakes (i) that, except as the bank may otherwise agree, if any lien shall be created on any assets of the Borrower as security for any external debt, such lien will ipso facto equally and ratably secure the payment of the principal of, and interest charge and any other charge on, the Loan; and (ii) that the Borrower, in creating or permitting the creation of any such lien, will make express provision to that effect. (b) The provisions of paragraph (a) of this section shall not apply to (i) any lien created on property, at the time of purchase thereof, solely as security for payment of the purchase price of such property; or (ii) any lien arising in the ordinary course of banking transactions and securing a debt maturing not more than one year after its date. (c) The term “assets of the Borrower” as used in paragraph (a) of this Section includes assets of any political subdivision or any agency of the Borrower and assets of any agency of any such political subdivision, including the National Bank of Tajikistan and any other institution performing the functions of a central bank for the Borrower.
Project Specific Covenants Project Implementation Joint Implementation
The Project shall be executed in conjunction with the Schedule Complied with. Education Sector Reform Project and in the same five 6, para. 1 Separate project directors pilot districts. The Project and the Health Sector Reform were appointed on 4 June Project shall have separate project managers but share 2004 under Presidential the same project coordinator. The two projects shall also Decree No.67-p. The share the same NSC, PAU, and DSGs. President’s Office was the executing agency for both projects, with the deputy prime minister as project coordinator. With the agreement of ADB, separate PMUs were established for each
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Reference in Covenants Loan Status of Compliance Agreement project. Separate NSCs for the HSRP and the ESRP were established in October 2004. DSGs, which were established under the ESRP project, were used to coordinate and implement the HSRP activities in pilot districts.
Project Executing Agency/Project Coordinator
As Project Executing Agency for both the Project and the Schedule Complied with Education Sector Reform Project, the President's Office 6, para. 2 shall be responsible for the overall implementation of both projects. Within the President's Office, the deputy prime minister responsible for the social sectors shall act as Project coordinator. The Project coordinator shall be responsible for the timely and efficient execution of the work of the Project as approved by the NSC.
National Steering Committee
The National Steering Committee (NSC), chaired by the Schedule Complied with. Project coordinator, shall consist of representatives of 6, para. 3 The NSC was formed for key stakeholders including the President's Office, MOE, the HSRP on 19 October the Ministry of Health and the Ministry of Finance, 2004 and the list of together with district representatives from the five pilot members was changed on districts, and selected sector specialists. The NSC will 26 May 2006. meet at least quarterly and be responsible for The NSC met annually (26 (i) approving the annual sector plan; and (ii) reviewing November 2005, 18 May implementation progress of the Project, and resolving 2006). any implementation bottlenecks that may require high- level interventions or intra-governmental consultation. The Project Executing Agency shall act as secretariat and coordinator for the NSC.
Project Implementing Agency
The implementing agency for the Project shall be MOH, Schedule Complied with. acting through the PIU. With support from the PAU and 6, para. 4 The PAU and PIU were with the assistance of the district departments of combined to form a single education in each of the pilot districts, MOH through the PMU in accordance with PIU shall be responsible for the day-to-day planning, Government Order No. management and implementation of Project activities in 238 dated 4 June 2004. the pilot districts. The HSRP Implementation Committee (MOH Order No. 98 dated 1 March 2005), which coordinated 6 working groups for various project activities, took some of the PAU responsibilities.
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Reference in Covenants Loan Status of Compliance Agreement
Project Implementation Unit-Project Manager
Throughout Project Implementation, the Project Schedule Complied with. Executing Agency shall maintain at MOH a national 6, para. 5 The HSRP PMU worked Project Implementation Unit (the national PIU) (a) in accordance with the comprising the Project Director, an education sector implementation schedule reform coordinator, an administrator and two civil and annual project work engineers. The national PIU shall manage Project plans, as amended from implementation with support from a Project time to time. Administration Unit (PAU) to be shared with the Health The PMU submitted Sector Reform Project. The key responsibilities of the financial and technical national PIU shall be to: (i) prepare the Project work reports to the NSC and plans, budgets and progress reports; (ii) propose Project ADB on time. expenditures and procurement needs; and (iii) implement Project activities in accordance with the annual work plan. The national PIU shall also provide administrative support to the district PIUs. It shall also ensure timely submission of financial and technical reports to the NSC and the Bank. The Project manager as head of the PIU, acting under Schedule Complied with under the the guidance of the Project coordinator, shall: (i) 6, para. 5 revised implementation coordinate the implementation of the annual work plan (b) arrangements. as approved by the NSC; (ii) review Project expenditures and procurement, and ensure that they are made or carried out in line with approved plans and pertinent administrative procedures; and (iii) be the main focal point for the Borrower on policy coordination and Project implementation review discussions with the Bank.
Joint Project Administration Unit
Throughout Project implementation, the Project Schedule Complied with. Executing Agency shall maintain a Project Administration 6, para.6 Separate PMUs have Unit (PAU) to be shared with the Education Sector (a) been established to Reform Project. The PAU shall provide secretarial and conduct all PIU–PAU administrative support to the national PIU, the five district duties. The district PIUs PIUs. were established for the HSRP in February 2006. The PAU shall have responsibility for administrative Schedule Complied with by the matters (procurement/civil works, disbursement and 6, para. 6 HSRP PMU. The PMU consultant recruitment), logistic arrangements and (b) comprised 47 staff, reporting. The PAU shall comprise about nine including 25 PIU staff in administrative, procurement/ engineering, and logistic pilot districts. staff, including drivers, and shall be headed by a senior accountant. The PAU shall assist the national PIU to submit timely financial and technical reports to the NSC and the Bank The PAU shall also have two international consultants as Schedule Complied with. advisors (a project management advisor and a civil 6, para. 6 An international works/ procurement/ environment advisor). (c) consultant/project management advisor was recruited by the HSRP and the ESRP. Civil works and procurement management were implemented by
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Reference in Covenants Loan Status of Compliance Agreement PMU local staff with initial support from the international advisor and under ADB guidance. The costs associated with the establishment and Schedule Separate PMUs were operation of the PAU shall be shared equally between 6, para. 6 established with separate the Project and the Education Sector Reform Project. (d) budgets under the respective loans.
District Supervisory Groups
Within three months of the Effective Date, the Executing Schedule Complied with. Agency shall cause a District Supervisory Group (DSG) 6, para. 7 DSGs consist of to be established in each of the pilot districts. The DSGs representatives of local will be for the joint benefit of the Project and the government, CDH chief Education Sector Reform Project. Each DSG shall doctors, and heads of comprise the district governor (chair), the chief medical district education doctor at the district hospital, the director of the departments. Activities department of education, and selected village leaders. were implemented for The DSGs shall guide the preparation of district plans, active involvement of pilot review progress on a quarterly basis, and coordinate and district populations implement all district-level activities. (headed by DSGs) in practical implementation of the rationalization plan for hospitals and PHC facilities.
District Level Project Implementation Units/District Health Departments
Within three-months of the Effective date, the Project Schedule Complied with. Executing Agency shall establish, or cause to be 6, para. 8 The pilot district PIUs for established, within each of the pilot districts, a district- the HSRP were level Project Implementation Unit (a district PIU), established in February comprising a Project coordinator, procurement/civil 2006. The PIU district engineer, a health service specialist and district coordinators and technical support staff, all from the district office. The administrators were district PIUs will be responsible for district level selected on a competitive implementation and day-to-day management and shall basis and trained. PIU in addition perform as district health departments in their offices (as part of district respective pilot districts. health centers) were supplied with office equipment, furniture, computers, vehicles, and mobile phones.
Other Matters Reform Planning, Monitoring and Policy Dialogue Based on Health Management Information System
Within six-months of the Effective Date, an intersectoral Schedule Complied with. committee/forum (MOH / MOF/, the Medical University 6, para. 9 The MOH approved the and donors) shall be created to review and use the data national HMIS to plan and monitor the reform process and to maintain Development Program for policy dialogue with the donors on reform. 2006–2010 on 14 April 2006. The MOH and the PMU developed a mechanism for program
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Reference in Covenants Loan Status of Compliance Agreement implementation. The HMIS working group was established under the MOH. In addition, the MOH established the Donor Aid Coordination Board and convened regular meetings.
Human Resources Development
Within 15 months of the Effective Date, MOH and the Schedule Compiled with. Medical University shall assess the workforce 6, para. 10 The MOH approved the conditions, including student intakes and outputs and Tajikistan Health Sector distribution (geographical and professional) of Interim Workforce Plan for graduates, and develop a workforce plan and targets, 2006–2010 on 15 May acceptable to the Bank. Accordingly, MOH shall develop 2006. a time-bound action plan, acceptable to the Bank, to From 2007, the Human meet workforce targets on the staff reduction and Resources and Science equitable distribution of staff, as set out in the above Department (MOH) and workforce plan, within 21 months of the Effective Date. the medical university The Medical University shall develop a time-bound followed the plan’s action plan, acceptable to MOH and the Bank, to meet principles for a rational workforce targets on student intake and outputs and approach to staff training geographical and health system level’s distribution, and employment of within 21 months of the Effective Date. doctors and nurses, including family medicine specialists. The HSRP PMU designed and widely circulated the Guidelines on Health Human Resources Management b (1,000 copies), which served as a reference book for health system managers.
Introduction of the FGP System in the Pilot Districts
Within 15 months of the Effective Date, MOH shall Schedule Complied with. develop the legal and financial framework of the FGP 6, para.11 Family medicine system to be pilot tested in the pilot districts legislation documents were approved and introduced by the Ministry of Health (MOH Order No.584 dated 31 October 2005). These included qualification requirements for family medicine specialists, regulations for family doctors and family nurses, a list of PHC facility equipment, and staffing norms for PHC facility specialists. Within 18 months of the Effective Date, the Borrower Schedule The FGP framework was shall legalize, as a pilot test, the introduction of the FGP 6, para.12 tested in 5 pilot districts
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Reference in Covenants Loan Status of Compliance Agreement system with a financial and monitoring package in the and the results were pilot districts. The package shall include FGP reviewed at 2 national geographical mapping, population registration, capitation conferences on family payment, performance-based contract, monitoring of medicine. The design of access to and utilization of FGP geographical services in the FGP system was general population and in particularly by the poor, discussed at the national women of reproductive age, infants, and other conference in December vulnerable groups, user satisfaction, and FGP's 2005 and the proposed performance. FGP unit was recommended for introduction as the national PHC system. The standards and guidelines for FGP training, including the FGP model, were endorsed by the MOH on 12 January 2006. A set of family medicine legal and recording–reporting documents was also developed to promulgate a nationwide expansion of the FGP system.
Environmental and Other Safeguards
The Borrower shall ensure that (i) implementation is Schedule carried out in accordance with all existing environmental 6, para.19 Complied with laws, regulations and requirements of the Borrower, and in accordance with the Bank's environmental policies and procedures, in particular those set out in the Bank's Environmental Assessment Guidelines (2003); (ii) all environmental mitigation and monitoring measures identified in the Initial Environmental Examination (IEE) for the Project, and also in any environmental management plan or plans (EMP/s) associated with subprojects under the Project, are to the extent necessary fully implemented, and such mitigation and monitoring measures are incorporated into subproject design, and into any related bidding documents and contracts; (iii) the national PIU assumes overall responsibility for (a) ensuring that environmental classification, assessment, mitigation and monitoring are carried out by qualified and appropriate parties, and (b) ensuring that EMP monitoring information is reported semiannually to the Bank.
Midterm Review
The Borrower and the Bank shall together carry out a Schedule Complied with. midterm review of the Project approximately 18 months 6, para. 18 The ADB review mission into implementation. This review shall: (i) assess the was fielded on 23 Project's progress and achievements against the October–3 November objectives; (ii) identify any problems and constraints; and 2006. (iii) recommend any remedial action that may be required.
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Reference in Covenants Loan Status of Compliance Agreement Financial Matters Use of Savings
The borrower shall cause any savings generated from Schedule Complied with. efficiency measures under the project, including as a 6, para. 14 The MOH adopted the result of system rationalization, to be provided to the instruction on reallocation local governments in the pilot districts to support quality of funds released from the improvement, equity measures, and staff motivation in rationalization and the education sector. restructuring process for PHC facilities. However the minor savings limited the improvement activities. MOH shall provide, after the project is completed and Schedule Partly compiled with. through its public health budget, the capitation payment 6, para. 15 In March 2007, the MOH budget and pro-poor health package cost introduced by and MOF introduced the Project to ensure their sustainability. The piloting of capitation Government shall submit to the Bank the budget plan payment in 4 districts that addresses capitation payment and a pro-poor including Rasht district. package at the time of the mid-term review of the Project The project team designed a comprehensive model of per-capita payment, but the government postponed its introduction due to a lack of resources. Throughout the implementation period of the project, Schedule Complied with. MOF and MOH shall engage in policy dialogue with the 6, para. 16 The government approved Bank with a view to increasing the share of public health the reallocation of funds expenditure devoted to PHC to 20% by the end of 2008. (60% for PHC and 40% Within six-months of the Effective Date, MOH and MOF for hospitals) in pilot shall provide the Bank with baseline data of the budget areas. allocation among different levels of the health system. ADB = Asian Development Bank, CDH = central district hospital, DSG = district supervisory group, EMP = environmental management plan, ESRP = Education Sector Reform Project, FY = financial year, HMIS = health management information system, HSRP = Health Sector Reform Project, MOE = Ministry of Education, MOF = Ministry of Finance, MOH = Ministry of Health, NSC = National Steering Committee, PAU = project administration unit, PCR = project completion report, PIU = project implementation unit, PMU = project management unit a ADB. 2009. Tajikistan: Request for Waiver of Negative Pledge Clause. Manila. b N.F. Salimov, S.R. Miraliev et al. 2008. Guidelines on Health Human Resources Management in Tajikistan. Dushanbe: Devashtich Sources: Ministry of Health of Tajikistan and Health Sector Reform Project reports.
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OVERALL ASSESSMENT OF THE HEALTH SECTOR REFORM PROJECT
Criterion Weight Definition under ADB Rating Rating EAPCR Score (%) Guidelines Description Value Rating Relevance 20 Relevance is the Highly relevant 3 3 0.6 consistency of a project’s Relevant 2 impact and outcome with Partly relevant 1 the government’s Irrelevant 0 development strategy for the country, and Asian Development Bank’s strategic objectives at the time of approval, and evaluation and the adequacy of the design. Effectiveness 30 Effectiveness describes the Highly effective 3 2 0.6 extent to which the Effective 2 outcome, as specified in the Less effective 1 design and monitoring Ineffective 0 framework, either as agreed at approval or as subsequently modified, has been achieved. Efficiency 30 Efficiency describes, ex- Highly efficient 3 2 0.6 post, how economically Efficient 2 resources have been Less efficient 1 converted to results, using Inefficient 0 the economic internal rate of return, or cost effectiveness, of the investment or other indicators as a measure, and the resilience to risk of the net benefit flows over time. Sustainability 20 Sustainability considers the Most likely 3 2 0.4 likelihood that human, Likely 2 institutional, financial, and Less likely 1 other resources are Unlikely 0 sufficient to maintain the outcome over its economic life. Overall Highly successful: Overall weighted average is greater than or equal Total 2.2 assessment to 2.7 Successful: Overall weighted average is greater than or equal to 1.6 and less than 2.7 Partly successful: Overall weighted average is greater than or equal to 0.8 and less than 1.6 Unsuccessful: Overall weighted average is less than 0.8