2019 Assessment of business planning in primary care facilities in Tajikistan Assessment of business planning in primary care facilities in Tajikistan Abstract This report presents the main findings and recommendations of the assessment of the business planning implementation in primary health care facilities in Tajikistan. Since it was introduced in 2005, business planning in Tajikistan has grown into a nationally adopted mechanism for strengthening district and primary health care facility management. In 2019, an assessment took place to evaluate the results of the business planning implementation. The findings revealed that business planning was regarded as an efective managerial tool that improved the health of and relationships with the populations served. The most important outcome of business planning is the reported improved responsiveness to the health needs of the population, especially more vulnerable groups. Implementation of business planning has increased the transparency of the health facilities’ activities and resources and has strengthened the primary care management capacity. Nevertheless, the health system has challenges afecting the success of business planning that need to be addressed for its further success and sustainability in the country.
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Abbreviations 4
Tables and figures 4
Executive summary 6
Introduction 11
Background 11
Aim of the assessment 18
Methods 19
Qualitative component 19
Quantitative component 22
Findings 25
Community health team perspectives 25
Rural health facility managers and health 30 professionals’ perspectives
Perspectives of the district primary health care 38 management teams
Policy-makers’ perspectives 42
International partners’ perspectives 43
Analysis of the findings 45
Achievements resulting from business planning 45
Contributing factor one: 46 community engagement
Contributing factor two: 46 strengthening health services
Contributing factor three: 47 management responsiveness
Challenges afecting the success 49 and sustainability of business planning
Recommendations 51
Annex 1 Interview protocol for policy-makers 54
Annex 2 Interview protocol for international partners 55
Annex 3 Interview protocol for district primary 56 health care management teams
Annex 4 Interview protocol for rural health centre 57 managers
Annex 5 Interview protocol for community members 58
Annex 6 Indicators relevant to business planning 59 in primary health care 3 Annex 7 Characteristics of rural health centres 65 Abbreviations PHC primary health care TB tuberculosis
Tables and figures Tables Table 1 Introducing business planning in PHC facilities in Tajikistan 13
Table 2 Interviews by district and management position 21
Table 3 Business planning districts involved in other pilot programmes 23
Table 4 List of all health priorities by frequency of reporting during 31 the interviews with managers of rural health facilities
Table 5 Percentage change in antenatal services 33
Figures
Fig. 1 Districts implementing business planning across Tajikistan, 2018 16
Fig. 2 Total number of visits by business planning districts, 2014–2018 26
Fig. 3 Causes of visits — business planning districts, 2014–2018 28
Fig. 4 Causes of visits — non-business planning districts, 2014–2018 28
Fig. 5 Maternal and child health — business planning districts, 2014–2018 32
Fig. 6 Maternal and child health — non-business planning district, 2014–2018 32
Fig. 7 Maternal mortality rate per 100 000 live births, 2014–2018 39
Fig. 8 Diabetes morbidity in business planning districts and non-business planning 40 district, 2014–2018
Fig. 9 How top-down vertical programmes conflict with bottom-up business planning 48
Fig. 10 Integrated vertical programmes in primary health care 52
4 Acknowledgements
This report has been prepared by the WHO European Centre for Primary Health Care of the Division of Health Systems and Public Health under the guidance of WHO Regional Director for Europe Hans Kluge.
The assessment is the result of the shared commitment and technical contributions of the Ministry of Health and Social Protection of the Population of the Republic of Tajikistan, the WHO Regional Ofce for Europe through the WHO European Centre for Primary Health Care in Almaty and the WHO Country Ofce in Tajikistan, and the Representative Ofce of the Swiss Tropical and Public Health Institute in Tajikistan/Enhancing Primary Health Care Services Project in Tajikistan (Sino Project).
The assessment has been completed under the oversight of Dilorom Sadykova (Ministry of Health and Social Protection of the Population of Tajikistan) and Gulara Afandiyeva (Representative Ofce of the Swiss Tropical and Public Health Institute in Tajikistan/ Enhancing Primary Health Care Services Project in Tajikistan).
Authors Brett J. Craig, Consultant, WHO Regional Ofce for Europe Zulfiya Pirova, Technical Ofcer, WHO European Centre for Primary Health Care Farrukh Egamov, Consultant, WHO Regional Ofce for Europe Arnoldas Jurgutis, Consultant, WHO Regional Ofce for Europe Rhys Lewis, Consultant, WHO Regional Ofce for Europe
Technical review Ayesha De Lorenzo, WHO European Centre for Primary Health Care Anne Johansen, WHO European Centre for Primary Health Care Sabine Kiefer, Swiss Tropical and Public Health Institute Juan Tello, WHO Regional Ofce for Europe
Other contributors Nasrullo Abdujabborov, Representative Ofce of the Swiss Tropical and Public Health Institute in Tajikistan/Sino Project; Ilkhom Bandaev, Republican Family Medicine Clinical and Training Centre; Mouazamma Djamalova, Swiss Cooperation Ofce in Tajikistan; Bunafsha Dzhonova, Republican Family Medicine Clinical and Training Centre; Zarofat Hamidova, Representative Ofce of the Swiss Tropical and Public Health Institute in Tajikistan/Sino Project; Gulzira Karimova, Representative Ofce of the Swiss Tropical and Public Health Institute in Tajikistan/Sino Project; Helen Prytherch, Enhancing Primary Health Care Services Project; Guldarbog Sadonshoeva, Aga Khan Health Services; Erica Barbazza, WHO Regional Ofce for Europe; Marthe Everard, WHO Country Ofce in Tajikistan; Nargis Maqsudova, WHO Country Ofce in Tajikistan provided comments and shared their valuable insights during the report elaboration.
This report was produced with the financial assistance of the Government of Kazakhstan through the WHO European Centre for Primary Health Care in Almaty, Kazakhstan.
5 Executive summary
Business planning in primary health care facilities in Tajikistan is an initiative that was started as a project (Enhancing Primary Health Care Services Project (Sino Project)) funded by the Swiss Agency for Development and Cooperation in 2005 in two districts. Over time, the project has evolved, expanded to 24 districts, with new funding and implementation partners joining the initiative. The project uses a business planning tool at the facility level (district facilities and rural health facilities) to strengthen the managerial capacity of primary health care (PHC), focusing on budgeting and human resources. Based on recommendations from the project, a Department of Business Planning and Analysis of Family Medicine Development in the Republican Clinical and Family Medicine Training Centre was established and is now responsible for implementation in the remaining districts and for overseeing the realization of business planning at the national level. The donor-funded phase of the business planning project is ending, and the Ministry of Health and Social Protection of the Population will take over implementation. The objective of this study is to conduct a rigorous assessment of the implementation of business planning across primary health care facilities in Tajikistan and its efect on managerial performance. To accomplish this, the WHO technical team conducted bilateral meetings with ofcials from the Ministry of Health and Social Protection of the Population, senior staf of the Republican Clinical and Family Medicine Training Centre and development partners; interviews with managers, health professionals and community health team volunteers from selected districts; and data on health and performance indicators from these districts collected between 22 July and 2 August 2019 in Dushanbe, Tajikistan. The assessment explored how business planning afects management at the district and rural health centre levels.
Training session for family doctors, Republican Family Medicine Training and Clinical Centre WHO ©
6 Main findings
Overall, business planning was widely regarded at the district, rural health facility and community levels as an efective managerial tool that improved the health of and relationships with the populations served. Community health teams interviewed predominantly noted that business planning had the visible efect of increasing the use of health services among the community members, thereby reducing resistance or hesitancy; enhancing the health education of communities regarding disease prevention; and encouraging additional community support such as assisting patients with financial contributions from community charities. Managers and health professionals of rural facilities shared community health teams’ perspectives that business planning afected their work by: increasing their focus on the health needs of the communities they serve; improving their responsibility for and awareness of the managerial opportunities in their facilities; mobilizing communities to take action and participate in their own health; improving the quality of clinical practices; and raising their awareness of the allocation of budget funds while identifying further needs. According to the interviewed management teams of district facilities (district health centres), business planning improved their districts by making rural health facility managers more responsive to community needs and by developing a learning culture between rural health facility managers. They still felt limited by insufcient funds, however, and were concerned that the dependence on donor involvement would make continuing business planning difcult. Policy-makers interviewed stated that business planning was successful because of greater budget transparency, improved clinical governance of managers, more patient-centeredness among the health professionals and greater trust in the health-care system and health professionals from the communities. The international partner perspectives focused on how business planning improved the problem identification and action planning of managers, increased the communities’ involvement in selecting health priorities and that, likewise, much training and resources are required to make it successful. Many challenges in collecting and reporting the performance indicators in business planning became apparent during this assessment since not all data were available from the clinics for analysis. This was partly attributed to the reporting burden faced at the clinics because of the many diferent reports and vertical programmes involved outside business planning. The analysis did reveal that business planning appears to have improved the responsiveness of managers to community needs and relations with community members, especially among vulnerable populations. It also revealed the need for responsive management, since district and rural facilities’ needs difer significantly from one another and vary from year to year. However, combining these data with interviews reveals that many managers need to further strengthen their use of data for monitoring and selecting health priorities for their facilities and communities. An analysis of all collected data provides an overview of these three main achievements of business planning and the rationale for its adoption and support nationwide.
7 Achievements resulting from business planning
• Improved health outcomes. The most important outcome of business planning is the reported improved health of the population, particularly among more vulnerable groups. Rural health centre managers observed success in targeting important health indicators such as early registration of pregnant women, the number of assisted childbirth deliveries, vaccinations, infectious diseases and noncommunicable diseases. • Increased transparency of the health facilities’ activities and resources, fostering greater trust and satisfaction from community members. The increased trust and satisfaction from community members in the health services is evidenced by the increased visits, participation in screening and interest in improving the health facilities, sometimes by contributing their own funds. • Increased managerial capacity to manage financial and human resources. Both district and rural health facility managers reported an increase in their managerial capacity to monitor progress, manage the financial resources allocated to them, respond to the needs of their population and manage their stafng needs accordingly. The following contributing factors were identified as the most important in ensuring the success of business planning moving forward, along with challenges that need to be addressed.
CONTRIBUTING • Relations between rural health facility managers and community FACTOR ONE: COMMUNITY leaders. Community engagement contributed to many of the ENGAGEMENT improved health outcomes by involving community health teams in determining health priorities and subsequent community education. These teams improved health literacy and encouraged the population to access health services, which contributed to the improved health outcomes.
CONTRIBUTING • Capacity and knowledge of health-care personnel. The targeting FACTOR TWO: of health priorities led to health personnel increasing their STRENGTHENING knowledge on these issues to educate the community leaders, SERVICES thereby improving the quality of the services. Improving relations with the community further led to more frequent and timely access to services. Physical improvements to health centres by repairing the buildings and procuring equipment also contributed to strengthening services. • Donor contributions to facilities and equipment. Some communities raised funds to repair rural health centres, but many improvements to facilities and equipment came from the involvement of donor agencies working with business planning and other programmes. Increasing the knowledge of the health personnel, however, largely resulted from initiatives of the rural health facility managers based on the business plan.
CONTRIBUTING • Using data to respond to local health needs. Business planning FACTOR THREE: provides experience to managers in setting the priorities and goals MANAGEMENT relevant to the population they serve, implementing activities RESPONSIVENESS together with community health teams and analysing the outcomes of those activities. The transparency in goals and activities, as well as in the budget, benefits managers and communities alike in using information to make decisions. 8 • Improving management of the network of PHC facilities at the district level. The consolidation of the business plans of rural health centres in one unified district business plan would give district PHC managers the opportunity to conduct a comparative analysis of rural health centres’ activities, identify existing problems in service delivery and respond to them. This would improve the capacity of PHC managers in managing the network of PHC facilities at the district level. The potential benefit of the consolidated business report is not always realized, since turnover and delays in training have afected many PHC facilities at the district level. • Opportunities to increase responsiveness and efciency. The responsiveness of managers to the health needs of their communities was primarily directed towards community engagement because this is the aspect of management they could most directly influence. Additional burdens in reporting detracted from greater involvement with communities and patients. Opportunities to increase the responsiveness of managers to communities and improve efciency would include greater flexibility in budget spending and integrating reporting within the framework of business planning.
Challenges afecting the success and sustainability of business planning
HEALTH SYSTEM CONSTRAINTS Discretionary budget spending. Although transparency in the budget at the rural health facilities level has increased with the implementation of business planning, one challenge is the significantly limited amount the budget managers can allocate at their own discretion. With often less than 5% of a budget available for discretionary funding, managers can do little to adjust to their management needs and the needs of their populations. Human resource barriers. In addition to budgetary constraints, human resource barriers were also reported in the forms of training needs, increased personnel and improvements to the business planning monitoring framework. Turnover in stafng, especially among district health facility managers as well as the rural health facility personnel, causes a strain on resources for providing the necessary training courses on business planning. Additional human resource barriers have to do with the difculty of improving business planning and related services when current workloads already appear to exceed capacity. Limited improvements in clinical practice. The capacity of business planning as a quality improvement tool has not been fully used. These interviews provided very few examples of changes in clinical practice, and these examples primarily had to do with achievements in detecting disease resulting from improved trust from the community. The comprehensive actions reported to address health priorities were not always grounded in evidence provided by the monitoring of business planning indicators. These key informants expressed their opinion that clinical changes could not happen at the level of business planning but instead changes would need to originate at a higher level. Reporting burden. An additional and important factor that constrains managers and health personnel from doing more to engage communities and care for patients is the excessive reporting currently required to serve all the various programme needs. However, the reporting and activities required by these programmes is not in alignment with the activities planned at the rural health facility level, for example, because the involvement of communities through business planning at the rural health facility level determines how the health priorities are being addressed. This burden is evident not only in the inefciency of paper reporting at the rural health facility level but in the number of diferent reports that must be submitted to diferent entities, with diferent timelines, which can also lead to some overlap in the information reported. Although business planning is a helpful managerial tool, reporting burdens may be a barrier to growth in responsibility and creativity on how to monitor performance on selected priorities. 9 Challenges with graduating from donor support. With an overall strong commitment to business planning because of the increased efectiveness of addressing community needs and the clarity of management responsibility, several types of support provided as a part of the Enhancing Primary Health Care Services Project (Sino) were noted as potential challenges moving forward. Because of the difculty most managers face when learning business planning, the amount of training necessary requires adequate funding. Other financial constraints mainly focused on insufcient funds in the allocated budget and included specific issues such as transport for district health facility management teams and rural health facility managers for meetings and conducting on-site visits as well as operating costs such as stationery needed to carry out business planning. Given how much time and funds international partners spent implementing business planning, there are concerns that the Department of Business Planning and Analysis of Family Medicine Development in the Republican Clinical and Family Medicine Training Centre is not adequately equipped with stafng or funding for the necessary training, monitoring and supporting of business planning. In addition, the importance of involving the community health teams in making business planning efective and improving health outcomes in the communities being served cannot be overstated. Districts without donor involvement did not demonstrate fully functioning community engagement activities, which are essential for the success of business planning. Even in the districts where donors had worked but were phasing out or no longer active, community leaders reported a decline in community involvement because of the lack of support. Since community engagement is currently under the stewardship of the Republican Centre for Healthy Lifestyles, it can be strengthened through the Centre to fulfil this need.
Recommendations
Based on this assessment and analysis, the following recommendations are made to facilitate the scaling up of business planning. 1. Integrate vertical programmes into primary health care to increase the capacity of managers of district and rural facilities in responding to local health needs with increased resources and personnel while reducing inefciency and reporting burdens. 2. Increase support for the Department of Business Planning and Analysis of Family Medicine Development of the Republican Clinical and Family Medicine Training Centre in business planning implementation and expand its scope of work to include providing the necessary training and support. 3. Expand the existing guideline on partnership with communities on health issues within the Republican Centre for Healthy Lifestyles, the organization currently responsible for community engagement, in collaboration with the implementation of business planning at the national level to ensure the essential involvement of communities in organized and communicative ways.
10 Introduction
Background
Over the past decade, Tajikistan has given priority to a national policy of using a family medicine model as the basis of service. The National Health Strategy 2010–2020 articulated a vision for family medicine–based primary health care. This Strategy guided the National Programmes on the Development of Family Medicine for both the 2011–2015 and 2016–2020 periods. The implementation of these programmes engages a wide range of national and international actors and includes pilot, regional and nationwide initiatives. The progress of the health strategy and family medicine programme has been monitored and assessed at regular intervals, including at joint annual reviews. The implementation of business planning in primary health care facilities has spanned across national programmes. It has scaled from a donor-initiated pilot project to a mechanism for strengthening the performance of primary health care facilities that now spans across regions. It has also been formalized through a national protocol (prikas) calling for the use of this mechanism in primary health care facilities. A Department of Business Planning and Analysis of Family Medicine Development in the Republican Clinical and Family Medicine Training Centre — a national actor mandated to oversee the development of family medicine in Tajikistan — has been established and operating since 2015. The donor-funded phase of the business planning project is ending, and the Ministry of Health and Social Protection of the Population will take over implementation. WHO / Didor Sadulloev ©
Rudaki Monument in Dushanbe 11 WHAT IS BUSINESS PLANNING? Business planning in primary health care facilities in Tajikistan is an initiative that was started as the Sino Project funded by the Swiss Agency for Development and Cooperation in 2005 in two districts. Over time, the project has evolved, expanded to 24 districts, with new funding and implementation partners joining the initiative. The activities included initial training and distribution of the package of documents on business planning, workshops, refresher training and follow-up monitoring visits. To further facilitate the implementation, primary care management teams were provided small financial incentives and ofce equipment. By design, business planning aims to increase transparency, to support the management of health-care facilities and ensure that primary health care services are of a high quality, efcient and community oriented. The business plan comprises a set of tools that facilitate this process throughout the year at diferent levels. The “main” business plan is elaborated and implemented at the level of facilities. At the district level, the primary health care management team elaborates biannually a consolidated business plan that provides the team with an overview on their health facilities and how they are progressing on their business plans. Specifically, it also provides an overview on the budget execution and the indicators. Lastly, a monitoring tool was developed to help the primary health care management team to monitor business planning activities at the health facility level. One member of the district team is expected to visit each health facility annually to monitor the business plan activities. This is expected not only to facilitate the communication and interaction between the levels but also ensure that the facilities receive support in implementing their plan. Each year, facility managers are expected to facilitate a process of identifying health priorities and planning actions for their facility and its network of primary health care centres. These action plans are recorded in a business plan. Managers of rural facilities report the agreed targets and indicators (Annex 6) to the manager of the district primary health care facility at the start of each calendar year. At the end of the year, the management and their team are expected to review their progress and take stock of their achievements. They are then to set new priorities for the coming year. Ultimately, the initiative aimed to install a culture of managerial autonomy, making facility managers more aware of their budget, stafng and performance. Previously, as a donor-driven initiative, participating facilities would receive support throughout the year-long planning process in the form of training. The Swiss Agency for Development and Cooperation and Swiss Tropical and Public Health Institute/ Sino Project developed the initial materials used for training managers. The materials provided to facilities included a binder of templates to set targets and forms for reporting monitoring on a regular basis. External expertise as a resource for identifying improvement opportunities and some financial resources for investing in improvements (that also work as an incentive for meeting facility-specific targets) were also provided. Since 2014, the Sino Project has awarded a small grant to a few facilities that work well on the business plan. The grant can be used to address wider health issues together with the community (such as on water and sanitation) and to improve the infrastructure of the rural health facilities. Since 2016, the Sino Project has also supported a one-year primary health care management training programme for primary health care managers and, in 2018, a module on business planning was added.
12 Table 1. Introducing business planning in PHC facilities in Tajikistan
TIME ACTIVITIES ROLL-OUT FUNDED PLANS FRAME (TRAINING, FINANCIAL SUPPORT, BY FOR FURTHER FINANCIAL INCENTIVES SUPPORT FOR PERFORMANCE ETC.)
2005– Training Districts of Swiss Exit of the 2010 Support for printing a package of Republican Agency for project from documents on business planning Subordination — Develop- these pilot 2 districts, ment and districts in 2010 Workshops 18 rural health Coopera- Monitoring visits centres tion Refresher training Varzob — Little financial support for the PHC 9 rural health management team (manager, accountant centres and information specialist) Dangara — Support for the PHC management team 19 rural health with ofce equipment centres 2007– Training Districts of Swiss From 2018, 2017 Support for printing a package of Republican Agency for continue documents on business planning Subordination – Develop- support by the 2 districts, ment and Department of Workshops 37 rural health Coopera- Business Planning Quarterly meetings centres tion and Analysis of Monitoring visits Shahrinav — Family Medicine Refresher training 19 rural health Development Exchange visit centres of the Republican Clinical and Little financial support for the PHC Tursunzoda — Family Medicine management team (manager, accountant 28 rural health Training Centre and information specialist) centres Support for the PHC management team with ofce equipment Small grant 2013– Training Khatlon oblast — Swiss Support is 2020 Support for printing a package of 2 districts, Agency for gradually being documents on business planning 59 rural health Develop- transferred to the centres ment and Department of Workshops Coopera- Business Planning Quarterly meetings Vose — 39 rural health tion and Analysis of Monitoring visits centres Family Medicine Refresher training Development Hamadoni — Exchange visit of the Republican 20 rural health Clinical and Little financial support for the PHC centres Family Medicine management team (manager, accountant Training Centre and information specialist) Support for the PHC management team with ofce equipment Small grant 2014– Training Districts of Swiss Support is 2020 Support for printing a package of Republican Agency for gradually being documents on business planning Subordination — Develop- transferred to the 2 districts, ment and Department of Workshops 46 rural health Coopera- Business Planning Quarterly meetings centres tion and Analysis of Monitoring visits Rudaki — Family Medicine Refresher training 30 rural health Development Exchange visit centres of the Republican Clinical and Little financial support for the PHC Faizobod — Family Medicine management team (Manager, Accountant 16 rural health Training Centre and Information specialist) centres Support for the PHC management team with ofce equipment Small grant 13 TIME ACTIVITIES ROLL-OUT FUNDED PLANS FRAME (TRAINING, FINANCIAL SUPPORT, BY FOR FURTHER FINANCIAL INCENTIVES SUPPORT FOR PERFORMANCE ETC.)
2015– Training (supported by Sino Project Gorno- Were 2018 specialist) Badakhshan supported Support for printing a package Autonomous by Aga of documents on business planning oblast — Khan 7 districts, Health Monitoring visits 52 rural health Services centres Rushan — 9 rural health centres Roshtkala — 4 rural health centres Shugnon — 8 rural health centres Vanj — 10 rural health centres Ishkashim — 9 rural health centres Murgab — 5 rural health centres Darvaz — 7 rural health centres 2016– Training (supported by Sino Project Khatlon oblast — Were 2019 specialist) 3 districts, 54 supported Support for printing a package of rural health by Aga documents on business planning centres Khan Health Monitoring visits Muminobod — 20 rural health Services centres Hovaling — 19 rural health centres Sh.Shohin – 15 rural health centres
2016– Training (supported by Sino Project Districts of Continue 2020 specialist) Republican supported Support for printing a package Subordination — by Aga of documents on business planning 6 districts, Khan 46 rural health Health Monitoring visits centres Services Roghun — 5 rural health centres Tojikobod — 4 rural health centres Rasht — 19 rural health centres Nurobod — 5 rural health centres Sangvor — 4 rural health centres Lakhsh — 9 rural health centres 14 TIME ACTIVITIES ROLL-OUT FUNDED PLANS FRAME (TRAINING, FINANCIAL SUPPORT, BY FOR FURTHER FINANCIAL INCENTIVES SUPPORT FOR PERFORMANCE ETC.)
2018– Training Sughd oblast — Swiss Support is 2020 Support for printing a package of 1 district Agency for gradually being documents on business planning Kanibadam — Develop- transferred the ment and Department of Workshops 16 rural health centres Coopera- Business Planning Quarterly meetings tion and Analysis of Monitoring visits Family Medicine Refresher training Development of the Republican Little financial support for the PHC Clinical and management team (manager, accountant Family Medicine and information specialist) Training Centre Support for the PHC management team and Oblast with ofce equipment business planning Small grant trainers (working group on business planning) 2018 Training (supported by Sino Project Sughd oblast — Supported Oblast business specialist) 1 district by the planning trainers Support for printing a package of Isfara — 15 rural Enhancing to continue documents on business planning health centres Primary the process of Health Care business planning Services in the other Project and districts of Sughd by Sughd oblast according oblast to their approved business plan planning trainers Training Sughd oblast — Supported Oblast business Support for printing a package 1 district by WHO planning trainers of documents on business planning Istarafshan — to continue 18 rural health the process of centres business planning in the other districts of Sughd oblast according to their approved plan 2019 Training Sughd oblast — Supported Oblast business Support for printing a package 4 districts by the Sug- planning trainers of documents on business planning Devashtich — hd oblast to continue business the process of Refresher training 16 rural health centres planning business planning Support for oblast business planning trainers in the other trainers with ofce equipment (Enhancing B. Gafurov — districts of Sughd Primary Health Care Services Project) 31 rural health oblast according centres to their approved Asht — 18 rural plan health centres Aini — 10 rural health centres
Training Khatlon oblast — Supported Oblast business Refresher training 3 districts by the planning trainers Levakant — Khatlon to continue Support for oblast business planning oblast the process trainers with ofce equipment (Enhancing 7 rural health centres business of business Primary Health Care Services Project) planning planning in the Norak — 4 rural trainers other districts of health centres Khatlon oblast Bokhtar — 3 rural according to their health centres approved plan 15 Status of roll-out of business planning Business planning first began as an initiative of the Swiss Agency for Development and Cooperation, overseen by Sino Project, and implemented in two districts (Varzob and Dangara) from 2005 to 2010. This piloting process worked to streamline the implementation process and simplify the training and monitoring tools. Consecutive phases of the Sino Project (later Enhancing Primary Health Care Services Project) involved six districts and more than 150 family health centres and health houses, primarily from 2006 to 2017. At present, some districts are still receiving support from the Enhancing Primary Health Care Services Project (Sino Project) jointly with the Republican Clinical and Family Medicine Training Centre with plans to shift more responsibility to the Centre. Others now continue without the Sino Project under the oversight of the districts and the Republican Clinical and Family Medicine Training Centre. In addition, the Aga Khan Foundation has engaged in business planning in 16 districts. In 2018, the region of Sughd also initiated business planning in two districts: the Kanibadam district, which was supported by the Enhancing Primary Health Care Services Project (Sino Project); and the Istaravshan district, which was supported by WHO and the Republican Clinical and Family Medicine Training Centre. The Centre has the mandate to continue to implement the operation and roll-out of business planning to all districts in Tajikistan. In the past 10 years, business planning has been rolled out to 24 districts (40%) across three regions: Khatlon (five districts); the Districts of Republican Subordination (10 districts); and the Gorno- Badakhshan Autonomous Oblast (7 districts) (Fig. 1).
Fig. 1. Districts implementing business planning across Tajikistan, 2018
districts actively implementing business Maschoh planning Sughd Kanibadam districts no longer Oblast Districts of Republican implementing business planning Istaravshan Subordination
Jirgatol
Rasht (Garm) Tojikobod Gorno-Badakshan Shahritus Autonomous Oblast Varzob Fayzabod Tursunzoda Roghun Darvoz Vanj Hovaling
Muminobod Rudaki Danghara Rushon Murgob
Shugnon Shuroobod
Hamadoni Roshtqala
Khatlon Oblast Ishkoshim
Cities or districts Total cities or districts Region Coverage by region with business planning in the region
Sughd Oblast 2 18 11%
Districts of Republican 10 13 69% Subordination
Khatlon Oblast 5 25 24%
Gorno-Badakshan 7 8 87% Autonomous Oblast
16 Total countrywide 24 64 37% RATIONALE In 2020, as a new national health strategy is being developed and the current family medicine strategic plan has drawn to a close, there is a need to take stock of the progress made and set priorities for future activities. The Ministry of Health and Social Protection of the Population has also requested the extended implementation of business planning. There is no known comprehensive study on business planning or reporting on its status of implementation. Given current priorities and to ensure its optimal expanded use, this study was planned. This mission has been conducted as a joint efort with the WHO European Centre for Primary Health Care, WHO Country Ofce in Tajikistan, Republican Clinical and Family Medicine Training Centre and Representative Ofce of the Swiss Tropical and Public Health Institute in Tajikistan/Sino Project and with the contribution of Aga Khan Health Services.
OTHER INITIATIVES WHO PEN/HEARTS initiative The HEARTS initiative has been implemented in a single geographical district (Shahrinav) and was nominated by the Ministry of Health and Social Protection of the Population. All 19 primary health care facilities in the district that met inclusion criteria were included; half were randomly assigned to the intervention arm and half to the control arm. The overall process is organized into seven steps: 1. refreshing the clinical decision support tools including open-source WHO PEN (Package of Essential Noncommunicable disease interventions for primary health care in low-resource settings) and HEARTS (technical package for cardiovascular disease management in primary health care) resources, 2. update the training package for primary health care workers, 3. collect baseline data, 4. train personnel in intervention clinics, 5. apply protocols and implementation coaching, 6. collect follow-up data after 12 months and 7. evaluate results and share experience. The project is currently in stage five. Simple clinical protocols and clinical decision support tools have been developed, and about 100 family doctors, nurses and managers from intervention clinics have been trained in their use. The 12-month implementation period began on 1 April 2019, and first-quarter supervisory and monitoring visits already indicated positive developments, with increased screening for cardiovascular risk factors, detection of hypertension, preventive counselling and task sharing. Quarterly monitoring visits will continue, and there will be a mixed-methods evaluation at 12 months to identify any improvements in process and outcome indicators compared with the baseline and the controls.
The World Bank–financed Health Services Improvement Project Performance-based financing is one component of the Health Services Improvement Project financed by the World Bank. It is aimed at improving the coverage and quality of basic PHC services in rural health facilities and selected districts by introducing financial incentives for PHC providers based on performance indicators. About 14 indicators have been used to score performance, and these are linked to financial incentives to be paid quarterly. Indicators include, for example, maternal and child health targets and a few on noncommunicable diseases, such as taking blood pressure measurements. To date, performance-based financing has been introduced in eight pilot districts.
17 Peer groups With the support of the Sino Project, in 2007, a new model for continuous quality improvement was developed and implemented to introduce peer groups. Peer groups work to provide a practical, problem-based approach for family doctors and nurses following six-month retraining programmes and two-year clinical residency (ordinatura) for family doctors. The groups are led by trained facilitators tasked with organizing and overseeing discussions on topics, such as challenges associated with using clinical practice guidelines and the diagnosis and treatment of various diseases encountered in family medicine practice. Facilitators are also responsible for evaluating meetings of groups with a quick tool developed by the Enhancing Primary Health Care Services Project (Sino Project) to reflect on each meeting. By 2019, there were 62 peer groups involving approximately 650 family medicine specialists in the project districts of Tursunzoda, Rudaki, Shakhrinav, Vose, Hamadoni, Faizobod and Kanibadam.
Aim of the assessment
This study aimed to assess the implementation of business planning across primary health care facilities in Tajikistan and how it afects managerial performance. The investigation explored the programme’s performance over the past five years on (1) the district primary health care management teams, (2) rural facility managers and their awareness of and responsiveness to the needs of the population they serve and (3) the budget they are assigned. A non-business planning site was used for comparative purposes.
Observed variables that were expected to influence the efect of business planning include: • stage of implementation (starting out, actively running or well established); • intensity of other initiatives (districts in which parallel eforts have been running); • presence of partner organization; and • use of financial incentives.
Study questions • What efect does business planning in primary care have on the management and performance of the district and health facilities? • What variables appear to influence the implementation and efect of business planning? • What lessons can be learned from high-performing health facilities? • What lessons can be learned from health facilities in which business planning appears to have a lesser efect?
18 Methods
This mixed-methods assessment included both quantitative and qualitative components. The approach was designed to quantify changes over time for priority indicators while also engaging key informants through facility visits to study how business planning is implemented in practice. The process of data collection was organized into these two components.
Qualitative component
Building on existing work, the qualitative component collected the input of key informants at the Ministry of Health and Social Protection of the Population, Republican Family Medicine Clinical and Training Centre and the international organizations involved in implementing business planning. In addition, interviews were conducted at the district and rural health facility levels.
KEY INFORMANTS Interviews were used to complement the available information. Key informants interviewed included those from the Department of Health Reforms, Primary Care and International Relations, the Ministry of Health and Social Protection of the Population, the Department of Business Planning and Analysis of Family Medicine Development of the Republican Clinical and Family Medicine Training Centre, representatives of the Enhancing Primary Health Care Services Project (Sino Project) and a representative from an Aga Khan– supported district and the Swiss Agency for Development and Cooperation.
Categories of key informants interviewed Policy-makers International Partners Ministry of Health and Social Protection Swiss Tropical and Public Health Institute/ of the Population, Department of Health Enhancing Primary Health Care Services Project Reforms, Primary Care and International (Sino Project) Relations Republican Clinical and Family Medicine Aga Khan Health Services Training Centre
A detailed mapping of business planning was developed. Annexes 1 and 2 outline the interview protocols for the categories of key informants involved in business planning.
DISTRICT VISITS AND INTERVIEWS District visits were made to a subset of districts implementing business planning. The facilities selected were chosen to represent the diferent stages of business planning, keeping in mind their accessibility given the schedule of the study. The districts using business planning in the North of the country and the Gorno-Badakhshan Autonomous Oblast, to which time did not permit a visit, were accessed via teleconference. Ultimately, the aim of this stage of data collection was to generate insights into the workings of business planning in practice from those implementing it: what is working well versus what needs improvement. The reality of business planning on the ground should also be gauged through the key informant interviews, which sought to assess the processes that are put in place to jointly establish health priorities, reflect and improve performance, provide feedback to practitioners, invest in incentives (if these are received), etc. 19 Categories of key informants in the districts interviewed District PHC management team (manager, deputy manager and information specialist or accountant) Rural health centre managers Community health team members
Annexes 3–5 outline the interview protocols for district visits and teleconference calls.
The purpose of these interviews was to obtain a detailed overview of the districts using business planning and the perspectives of key informants and district health centre managers. They aimed to determine key lessons on the benefits and challenges of implementing business planning, analyse findings that can add depth to quantitative findings and identify any discrepancies between perceptions of individuals and the actual performance of districts. The WHO team conducted interviews at the district level in 11 interview sessions for 12 districts (Table 2). Of these 11 sessions, seven were conducted during a site visit, and the remaining four were conducted via videoconferencing. Interview participants included community health team members, rural health centre managers and health professionals and district health facility management teams. WHO ©
Rural health centre in Uzun, Shahrinav District
To validate preliminary findings when the assessment activities ended, a stakeholder meeting to discuss and reach preliminary agreement was held on Wednesday, 31 July and included representatives from the Republican Clinical and Family Medicine Training Centre, Swiss Tropical and Public Health Institute/Enhancing Primary Health Care Services Project (Sino Project) and other development partners supporting PHC work in the country. In addition, the ofcial meeting was held with the Adviser to the Minister of Health and Social Protection of the Population on Friday, 2 August 2019. Finally, the results were been validated with the Ministry of Health and Social Protection of the Population and development partners at a round-table held on 11 October 2019.
20 Table 2. Interviews by district and management position
Rural health Enhancing centre Business Primary Health District PHC Community managers planning Care Services District management teams health team and health project Project (Sino interviewed volunteers providers started Project) support interviewed ended
Two rural 3 (women) Tursunzoda Manager, accountant health centre 2007 2017 managers 2 (men) Current manager Two rural Shahrinav (3 days only), health centre 5 (women) 2007 2017 Former manager managers Ongoing; with Department of Deputy manager, Three rural Business Planning business planning Vose health centre 4 (women) 2013 and Analysis of communication (former managers Family Medicine deputy manager) Development support Ongoing; with Department of Two rural Business Planning Hamadoni Deputy manager health centre 4 (women) 2013 and Analysis of managers Family Medicine Development support Non- Three rural business Hissor Manager, accountant health centre 0 No support planning managers district Ongoing; with the Department of Two rural Business Planning Manager, deputy Kanibadam health centre 2 (women) 2018 and Analysis of manager managers Family Medicine Development support Non-Sino, with the Department of Two rural Business Planning Manager, deputy Istaravshan health centre 2 (male) 2019 and Analysis of manager managers Family Medicine Development support Ongoing; with the Department of Four rural Business Planning Acting manager, deputy Faizobod health centre 6 (female) 2013 and Analysis of manager managers Family Medicine Development support Ongoing; with the Department of Four rural Business Planning health centre Rudaki Manager 7 (female) 2013 and Analysis of managers; Family Medicine three nurses Development support One rural Shugnon Accountant, regional health centre and health department team 1 (female) 2015 Aga Khan manager; one Roshtkala member accountant Two rural Rasht Deputy manager health centre 2 (male) 2017 Aga Khan managers 21 Quantitative component
The purpose of the quantitative component was to identify needs in the population that can be used as a reference in examining the responsiveness of managers (how business planning correlates with chosen indicators). A data extraction tool was used for collecting quantitative data. These data do not indicate an improvement in management performance per se but rather a change in the needs of the population that can be compared with managerial responsiveness. Indicators for comparison over time include (Annex 6): • priority indicators used for business planning; • any facility-specific measures (if they set their own measures) — to be determined by the facilities; and • PHC indicators based on the National Health Sector Strategy and the Strategic Plan for the Development of Family Medicine. The primary source for these data is the Republican Clinical and Family Medicine Training Centre and relevant departments of the Ministry of Health and Social Protection of the Population for measures related to the national health sector strategy. Aggregated data on business planning are available only at the district level. Depending on the size, one district health facility collects data from an average of 10–25 rural health facilities. The data were collected for the previous five years, beginning with 2014. Since no facility reported using its own measures or indicators, the data collection focused on business planning indicators and those belonging to national health priorities.
LIMITATIONS There were many challenges in collecting these data from the districts interviewed. Not all the data for the business planning indicators were available from all districts for the years within the scope of this analysis, even in the districts that had been using business planning since the beginning. Although the business planning indicators were designed to track the progress and evaluate the success of activities in achieving their goals, a strong and harmonized monitoring and evaluation component was not observed in any of the centres. Statistics units at the districts visited were characterized by an excessive quantity of data, largely collected on paper forms, unlikely to be used optimally for monitoring and evaluation and formulating future aims. Some data that were unavailable at the district sites were available from the Republican Centre for Medical Statistics and Information, but only through 2017. Aggregated data for several indicators that were available from both the districts and the Republican Centre for Medical Statistics and Information were nevertheless reported with difering numbers. Explanations for discrepancies in the data may include diferent reporting dates, calculations for indicators, monitoring mechanisms as well as errors. This emphasizes the need for a standard procedure to check the quality of statistical data. In these instances, the Republican Centre for Medical Statistics and Information data were used, as it was assumed that these had been verified and were more accurate. The reason for these, sometimes vast, discrepancies was unclear. In addition, data from the districts were almost always consolidated. This is because reporting from rural health facilities is typically conducted using paper copies, which are then submitted electronically in aggregate format at the district level. This creates difculty in verifying the data. Only by using data from the Enhancing Primary Health Care Services Project (Sino Project ) were disaggregated data from a few rural health facilities available. This eliminated the possibility of an analysis at the rural health facility level for most districts. Therefore, this analysis uses the limited data available. In addition, some business planning districts are also serving as pilot districts for other health-care programmes such as peer groups, PEN/HEARTS and results-based financing (Table 3). The involvement of these other pilot programmes may afect the performance 22 and experience of these facilities and personnel. Table 3. Business planning districts involved in other pilot programmes
Peer groups PEN/HEARTS Results-based financing
Tursunzoda Shahrinav Faizobod Rudaki Rasht Hamadoni Vose Faizobod
DESCRIPTIONS OF STATISTICAL ANALYSIS For comparative analysis, several indicators referring to counts were converted to percentages. • The percentages of both the total state and special means budgets spent on each component of spending were calculated using the total budget as the denominator. These total 100%. • The proportion of all visits by cause was calculated using the total number of visits as the denominator. This is not an exhaustive list of causes and the results therefore do not add up to 100%. In some instances, the percentages were directly reported by statistics managers and add up to more than 100%. Since the number of visits is used as a productivity measure, it may often be inflated. • The percentage of home deliveries assisted was calculated using the number of home deliveries as the denominator. • The percentage of deliveries in hospital was calculated using the total number of deliveries as the denominator. • The percentage of women registered in the first 12 weeks was calculated using the number of pregnant women as the denominator. • The percentage of children younger than 12 months who received three doses of pentavalent vaccine and the percentage who received an anti-measles vaccine were calculated using the total number of children younger than 12 months. • The percentage of newborns who were vaccinated against tuberculosis (TB) was calculated using the total number of newborns as the denominator. This was sometimes greater than 100% (although in these instances a value of 100% was used). Time-series graphs were used to observe how the indicators changed during the implementation of business planning and the efects of the goals set each year. Indicators were grouped and presented together using relevant categories from the business planning indicators and National Health Strategy indicators frameworks: that is, maternal and child health indicators, communicable disease indicators etc. Graphs were produced to show how indicators changed over the period 2014–2018 in each district. Similarly, time-series graphs were used to show how indictors changed over the same time period in the rural health facilities where non-aggregated data were available. To better enable comparison between districts, time series were also produced for all districts for each of the indicators separately. The percentage change between 2014 and 2018 (or 2017 where data for 2018 were not available) was also calculated and presented for all indicators at the district and the rural
23 health facility level. o P = (B–F)/B o baseline (B) and the follow-up (F) The recording burden and other limited resources contributed to the limited and incomplete data on business planning and national indicators, making analysis challenging. Further, the staggered start dates of the business planning districts make comparisons between them and with the non-business planning district difcult. It is also important to remember that business planning is a management tool and that, although it can and should afect health outcomes, other environmental factors and systemic constraints also afect outcomes. It was therefore important not to generalize or make specific conclusions based on the available data. Despite these limitations, however, the data do reveal some diferences, primarily in terms of increased visits among vulnerable groups for preventive care and decreased incidence of diseases targeted by business planning districts, which is what one would expect from a management tool that emphasizes community engagement and responsiveness to population health needs.
24 Findings
Community health team perspectives
Key messages
EFFECTS OF BUSINESS PLANNING
LESSONS LEARNED IN THE COMMUNITY CHALLENGES Increased use of health services Dependence of the community engagement in community, reduced resistance on donor support More educated communities regarding disease prevention Patients assisted with financial contributions from community charities
The community health team leaders interviewed had a positive view of business planning and stated that business planning was significantly afecting community engagement. Business planning was seen to improve managers’ responsiveness to the needs of the communities they serve by increasing the recording and analysis of data for decision- making, increasing the transparency of the budget and strengthening the relationship with communities through community health teams. These interviews provided information from the community perspective regarding the activities of these teams as well as the successes of business planning and challenges they still face. Predominantly, these volunteers focused on their roles in improving relations between their communities and the rural health facility personnel, increasing the community’s use of health services, educating the public and changing health behaviours and even helping with the financial needs of patients.
IMPROVING RELATIONS BETWEEN COMMUNITIES AND RURAL HEALTH FACILITY PERSONNEL The role of the community health teams is to bring the rural health facility personnel and community members closer together. The community health team volunteers interviewed confirmed that the input of the community is an important and valued part of business planning. All community health team leaders interviewed stated that they were very involved in choosing the health priorities for their rural health facilities each year. Their contributions and opinions were valued, and some even reported examples of how they were successful at changing one of the health priorities because the community was concerned about it. One such example in a rural health facility of a health priority coming from the community and replacing an existing priority that rural health facility personnel wanted to keep was that of helminthiasis. Because community health teams reportedly meet regularly, both with rural health facility personnel and among themselves, they can keep an open connection between the health personnel and members of the communities. This open connection also facilitates greater responsiveness on the part of the rural health facility personnel throughout the year and not only at the end of the year when business planning occurs.
25 INCREASING THE COMMUNITY’S USE OF HEALTH SERVICES An important claim these volunteers made was that their involvement in improving community health was demonstrated in the increase in the population’s use of health services because of both increased awareness and increased trust. Community health teams would engage their communities through organized events such as educational events in facilities or in their homes and in informal conversations in public and private spaces. Even beyond raising awareness of specific health issues, these volunteers worked to help community members to understand health and health care in general, explaining how health is largely determined by their environment, behaviour and lifestyles and not only treatments doctors provide. They help communities to understand the importance of disease prevention, which encourages participation in screening and visits to the rural health facilities for earlier detection.
Fig. 2. Total number of visits by business planning districts, 2014–2018
8 000 000
7 000 000
6 000 000
5 000 000
4 000 000
3 000 000
2 000 000
1 000 000
0 2014 2015 2016 2017 2018
Faizobod Rudaki Kanibadam Istaravshan Rasht
Shahrinav Tursunzoda Vose Hamadoni
Sino Project support No Sino Project support
Source: PHC facilities from each district.
The data reviewed also support this claim. The average total number of visits in the business planning districts increased by 94% from 2014 to 2017 versus only 22% in the non-business planning districts during the same period. Nevertheless, not all business planning districts are increasing equally in the number of visits (Fig. 2). Through the work of these volunteers, community members come to not only use the services more but trust more in their providers. Whereas before many community members were travelling to the city to seek treatment because of a low opinion of their local rural health facility, more are reportedly coming to the rural health facility for treatment and are experiencing the positive benefits of it. These community health team members understand the perspectives of their peers and know how, for example, repairs to facilities are not only functional but provide an increased level of trust from the community because the appearance of the facility largely determines the perception of quality.
26 EDUCATING THE PUBLIC AND CHANGING HEALTH BEHAVIOUR The community health teams have been successful according to these volunteers because of their ability to learn from the rural health facility health personnel and change the attitudes and behaviour of their communities. They report that they have learned throughout their experience as community health teams how to persuade those in the community who may resist or avoid care. They have learned how to talk about health behaviour in ways that matter to the community members such as how disease prevention will save them money or which members in the family are more receptive to messages and will encourage others in the household. Some reported that their communities initially resisted these awareness-raising eforts because they did not believe the community health teams were qualified or knowledgeable enough. However, as they started to see that it was for their own benefit, communities began to trust and listen more. The close cooperation with the rural health facility personnel is critical in this regard because the community health teams need to learn about the health issues and contributing factors. As they said in the interviews, they are not health specialists. Most of them are farmers, but they are knowledgeable on many health topics and can give relevant advice. Many successes revolved around improvements in indicators related to maternal and child health. Beyond holding events to raise awareness and educate the public on health issues such as exclusive breastfeeding or avoiding complications during pregnancy, the members of these community health teams work with the communities in informal settings as well. From having conversations with others in public spaces such as the drinking-water source for the village to larger gatherings at weddings or circumcisions, they listen to the concerns of the community and disseminate important health information. Many of these volunteers pointed out that, because of their work with pregnant women in their communities, these women were now getting registered at the rural health facility within the first 12 weeks. The rural health facility personnel count on these volunteers to reach those in the community who have not yet been included on the registry of the rural health facility. With this came more antenatal visits and no end to deliveries. Moreover, vaccination coverage reportedly improved and there were fewer cases of diarrhoea among children, which decreased mortality rates. These community health teams worked not only to encourage the use of services but also to address public health issues stemming from the village environment. An example is how one community health team conducted an awareness campaign on the health hazards of littering, especially near drinking-water sources. After their campaign, they reported that people stopped littering in the water and were more cautious. They even held clean- up events in their communities, which encouraged further improvements in sanitation and was considered to positively afect many health problems, including the incidence of hepatitis A. Despite limitations, the data from business planning and non-business planning districts does reveal some diferences, primarily increased visits among vulnerable groups for preventive care and decreased incidence of diseases (Fig. 3, 4). Combining this evidence with the accounts of the community members explains how diferences such as increased visits among people 15–49 years old for screening and prenatal care and decreased visits for children younger than 12 months because of fewer preventable diseases can both be positive. Most notable are the higher numbers of visits of children with disease in the non- business planning district compared with the business planning districts.
27 Fig. 3. Cause of visits — business planning districts, 2014–2018
50
40
30
20
10 percentage of all visits percentage 0
2014 2015 2016 2017 2018
% of visits for % of visits for children % of visits for women children < 1 year old < 5 years old 15–49 years old
% of visits for % of visits for children % of visits for children TB-related illness < 5 years old related <5 years old related to acute to diarrhoea respiratory infection
Source: PHC facilities from each district.
Fig. 4. Cause of visits — non-business planning districts
50 45 40 35 30 25 20 15
percentage of all visits percentage 10 5 0 2014 2015 2016 2017 2018
% of visits for % of visits for children % of visits for women children < 1 year old < 5 years old 15–49 years old
% of visits for % of visits for children % of visits for children TB-related illness < 5 years old related <5 years old related to diarrhoea to acute respiratory infection Source: PHC facilities from each district.
28 WHO ©
Rural health centre in Uzun, Shahrinav District
HELPING WITH THE FINANCIAL NEEDS OF PATIENTS These volunteers also reported their successful eforts in organizing financial support for patients who need treatments they cannot aford. After learning that one reason members of their communities are not keeping appointments or not adhering to treatment regimens is because of the financial strain, many community health teams reported organizing fundraising in the form of a charity or sometimes loan to assist in these cases. These organized collections are often very minimal, soliciting 5 somoni or less from community members, but go to people with diabetes or for transport for treatment, for example. A few reports of fundraising were also allocated to repairing the rural health facility. Despite their successes, these community health team leaders did report facing challenges. Many were trained under donor community engagement programmes, and they believe that this training is essential for efectively working with both rural health facility personnel and communities. More training was requested, especially on health and medical topics and how to persuade community members and motivate other volunteers. Although resistance from the community was reportedly rare, there were many reports that motivation among the community health team volunteers did decline over time. Many community health teams have continued through the dedication of only a few members, whereas the rest have become less active over time. In the Shahrinav and Tursunzade districts, where Save the Children, another donor organization, initiated community involvement programmes during Phase V of the Sino Project, this was especially visible. Some teams that started with as many as 12 members have only one or two active members now. Although these dedicated members expressed their motivation to be even higher now that they have seen success and understand more, they admit that most team members will require some external motivation. The stronger motivation present at the beginning of these teams coincides with donor involvement, where gifts were given to members and funds were available for transport and supporting events or printing materials for raising awareness. From training to financial support, these community health teams reportedly still depended on the support of the donor programmes that organized them, since many of them do not have sufcient means to provide for their own transport. For many they have no other source of income. In addition to support for themselves, those interviewed also detailed some ways in which more financial support for the communities would facilitate their work. Instead of the strain of raising funds for charities to assist patients in need being placed on community members, the existence of some charity bank or fund to support communities was deemed to be very beneficial. Another improvement suggested that would help to reach communities better included mobile clinics for those in the more remote areas.
29 Rural health facility managers and health professionals’ perspectives
Key messages EFFECTS OF BUSINESS PLANNING
LESSONS LEARNED IN THE COMMUNITY CHALLENGES More focused on local health needs Limited improvements to clinical practices Increased responsibility and awareness Still constrained by lack of resources, of managerial opportunities allocation of funds Communities mobilized and participating in their own health
Interviews at the district level also included selected rural health facility managers and nurses (see Annex 7 for key characteristics of the selected rural health facilities interviewed). These interviews revealed the health priorities chosen at each of these rural health facilities (Table 4), the actions planned to address these priorities and the successes of these actions. The first group of most commonly chosen priorities included antenatal care, diabetes, immunization, acute respiratory diseases and diarrhoea. The second group included family planning and birth spacing, complications of pregnancies, breastfeeding, hypertension, TB, hepatitis B and C and HIV. The results of the interviews with rural health facility managers and health professionals revealed the positive efects of business planning as being an increased focus on local health priorities, a shift in responsibility for management and learning from the district health facility to the rural health facility, communities became empowered through business planning, increased interactions between rural health facility managers within each district and some sustainable improvements in clinical practice.
INCREASED FOCUS ON LOCAL HEALTH PRIORITIES Rural health facility managers were enthusiastic in sharing the health priorities chosen, providing a rationale for why each priority was selected. The two groups providing input towards selecting the priorities are the rural health facility professionals and the community health team volunteers. Despite this increased focus on local health priorities, the priorities identified and selected did not vary much among the rural health facilities and districts. As Table 4 shows, a significant majority of the priorities chosen among the 27 rural health facilities interviewed are among only 5 to 6 priorities. Further questioning revealed that, in identifying these priorities, many of the targeted problems were broad and not well grounded in an understanding of root causes. For example, when asked about the target underlying the selected priority of diseases of the nervous system, one manager described that it is stroke for adults, encephalopathy for children also osteochondrosis for adults and other diseases of the nervous system. This rural health facility manager was not able to provide a rationale for why diseases of the nervous system specifically were targeted. Although the rural health facility managers interviewed at the non-business planning site claimed to work closely with their communities, there was no evidence similar to what community health teams organized in the business planning districts, which also suggests that little to no feedback or input from the communities is reaching the rural or district health facilities. Interviews with rural health facility managers revealed a similar approach to management in that they reported an emphasis on responsiveness to their communities but in practice revealed more of a focus on carrying out national priorities. In contrast to the business planning sites, these managers did not have any health priorities selected for their own communities because, as they stated, these priorities come from the district health facility management. Two of the three rural health facility managers interviewed in this district reported that all rural health facilities experience the same health problems, 30 so there is no need to select health priorities for each rural health facility. The district health facility manager requires them to submit their own plans to him yearly, but they are rigid and do not change from one year to the next. Any work with communities appeared to be monodirectional, implementing and informing of national health priorities without responding to the needs of the communities themselves. The only example of cooperative work with communities was the report that some had assisted with constructing much needed village rural health facilities. More focus on local health needs has shown an improvement in some of the health conditions and problems given highest priority. For example, maternal and child health demonstrates a general trend towards improvement over time. Fig. 5 shows maternal and child mortality trending down on average in business planning districts, which could be in part caused by the increased attention given as a result of the selecting of health priorities.
Table 4. List of all health priorities by frequency of reporting during the interviews with managers of rural health facilities
Frequency of repeated Ranking of Selected health priority priorities from 27 rural frequency health facilities 1 Antenatal care 24 2 Diabetes 17 3 (tie) Immunization of children 14 3 (tie) Acute respiratory diseases 14 3 (tie) Diarrhoea 14 6 Family planning (between pregnancies) 8 7 (tie) Threats to or complications of pregnancy 7 7 (tie) Breastfeeding 7 7 (tie) Hypertension 7 7 (tie) Tuberculosis 7 11 Hepatitis B and C and HIV 5 12 (tie) Goitre 4 12 (tie) Noncommunicable disease risk factors 4 12 (tie) Anaemia 4 15 (tie) Helminthiasis 3 15 (tie) Hepatitis A 3 15 (tie) Disorders of the nervous system 3 18 (tie) Ischaemic heart disease 2 18 (tie) Botulism 2 20 (tie) Chronic respiratory diseases 1 20 (tie) Postnatal carea 1 20 (tie) Breast cancer preventiona 1 20 (tie) Sanitationa 1 20 (tie) Blood donationa 1 a From the same rural health facility. Each facility chooses four health priorities at the start of the year.
31 Fig. 5. Maternal and child health – business planning districts, 2014–2018 percentage mortality rate
Infant mortality rate Under 5 child mortality Maternal mortality rate per 1000 live births rate (per 1000 live births) per 100 000 live births
% of newborns with % of children under low body weight 5 years old who are late in their development
Source: PHC facilities from each district.
These same indicators, when examined at the non-business planning district of Hissor in Fig. 6, either appear stagnant year after year or fluctuate significantly.
Fig. 6. Maternal and child health — non-business planning district, 2014–2018 percentage mortality rate
Infant mortality rate Under 5 child mortality Maternal mortality rate per 1000 live births rate (per 1000 live births) per 100 000 live births
% of newborns with % of children under low body weight 5 years old who are late in their development
Source: PHC facilities from each district.
A comparison of antenatal services demonstrates similar trends between business planning districts and the non-business planning districts and can be seen even more visibly in the percentage change in these two groups (Table 5).
32 Table 5. Percentage change in antenatal services
Business planning Non-business districts planning district Indicator % change % change (2014–2018) (2014–2017) % of women who had antenatal care according 8.2% 4.2% to the national standards % of deliveries in hospital 9.3% 3.2% % of pregnant women registered in first 12 weeks 28.2% 6.7% % of home deliveries assisted 27.2% –43.4%
SHIFT IN RESPONSIBILITY AND LEARNING FROM THE DISTRICT HEALTH FACILITY TO RURAL HEALTH FACILITY Rural health facility managers reported that, before the business planning initiative, planning occurred only at the district level, whereas now it exists at every rural health facility. Before business planning was implemented, their role was just to implement the orders of district health facility managers. Interviewed nurses also expressed an appreciation of business planning and the opportunities it has granted them to learn, better understand their own targets and plan their own activities. As health professionals in the rural health facilities, they now have a better understanding of how their own work contributes to the success of business planning. These nurses were able to provide sound arguments as to why a specific problem is relevant for their district and explain what should be done and what their role is in addressing the priorities. Despite this expressed confidence, however, these nurses were not able to provide examples of what concrete targets they personally need to achieve. In addition, rural health facility managers were only able to refer to the 29 business planning monitoring indicators and were not able to provide examples of any additional indicators or monitoring tools for measuring the contribution of their staf members in addressing priority problems. The possible reasons for this include a lack of training on understanding the purpose of indicators and the expressed high reporting burden coming from many ad hoc requests to provide information on various health problems. Although business planning is a helpful managerial tool, reporting burdens may be a barrier to growth in responsibility and creativity on how to monitor performance on selected priorities. Nevertheless, business planning has shifted managerial responsibilities from districts to the rural health facilities and introduced more team-based PHC models. There was still a lack of evidence of more systematic planning, with clear roles, responsibilities and targets for each health professional.
33 COMMUNITIES BECAME EMPOWERED THROUGH BUSINESS PLANNING All rural health facility managers agreed that when community health teams were established and started to produce results, there was a great move towards a more bottom-up approach, and business planning became more efective at addressing selected priority problems. The key idea of business planning is that the performance of the rural health facility can be better informed and can better address the priority needs of the community. Communities were able to advance their ideas for health priorities which, in addition to the health statistics, brought concerns and lesser known health needs of the community to the attention of the rural health facilities. It was reported that community health teams contribute to the entire cycle of business planning by informing the selection of health priorities, assisting in developing an action plan and implementing and monitoring activities. Nurses interviewed confirmed that the community voice is strong, and they have to take into account the community proposals. The empowered community influenced the setting of priorities, which led to greater ownership and consequently higher commitment to addressing selected priorities. This was largely because the training component of business planning, along with other partner programmes, included training for both managers and community leaders. An emphasis on improving the professionals’ understanding of their role and for the communities on their rights was instrumental in strengthening community participation. However, training activities will not be continued after the Sino Project ended. As many as three to four diferent community health teams coordinate with a rural health facility. Community health teams seemed to be very active under Enhancing Primary Health Care Services Project (Sino Project) support. However, interest reportedly declined among the communities where the Sino Project was no longer active. The most extreme example is in one rural health facility where a transition from the resource-intensive Save the Children community programmes to the Republican Centre for Healthy Lifestyles’ Partnership with Community for Health guidelines has resulted in a decline in participation. Where three community health teams previously operated, now there is only one. Instead of around 10 community members attending the priority setting meeting in December, now only one to two members are attending. The strength of community health teams is in their ability to spread health knowledge to other community members. Diferent channels of communication within the communities were used, from religious leaders to mothers-in-law. As an example, a mosque was used to inform a population about the importance of early detection in the treatment of TB. It resulted in reducing stigma for TB and an increase in preventive check-ups. Beyond raising awareness, these community health teams have organized fundraising activities for either repairing the rural health facilities or for assisting families in need to be able to pay for health care. An example is how one community initiated the establishment of a special fund that provided co-payments needed for referrals to narrow specialists and testing as well as assisting with other forms of financial access to services for people in need. This empowerment and increased community participation took time, often requiring at least a one-year period to establish trust of the rural health facility and efective communication with the community. Rural health facility managers emphasized the need to support communities to remain strong partners in advocating for the health and strengthening of health literacy of the population.
34 INCREASED INTERACTIONS BETWEEN RURAL HEALTH FACILITY MANAGERS WITHIN EACH DISTRICT Interviewed rural health facility managers informed that before business planning, they had rather limited knowledge of how other rural health facility managers in their district are performing. Previously, the formality of meetings and reporting did not facilitate a discussion of existing priorities, challenges faced, and methods or actions to address priorities. With increased interactions and opportunities to learn from one another, as well as transparency in resource allocation, rural health facility managers’ own initiatives improved as they learned to give priority to the gaps in quality and search for solutions on how to improve performance by themselves. For example, rural health facility managers and nurses from one district reported how they worked through peer groups to improve the management of hypertension. They had regular meetings with peer groups interested in the same topic. These peer discussions mainly focused on treatment for hypertension, what medicines to prescribe for a better response and adherence to the treatment. These peer discussions did not elaborate on solutions of how to enhance the detection of hypertension in the community or how to improve the follow-up of those with hypertension. The Enhancing Primary Health Care Services Project (Sino Project) facilitated increased interaction and learning from each other through peer groups. Rural health facility managers from the non-business planning district reported having monthly meetings with the district health facility management team as the business planning sites do. The diference, however, is that the meetings are for disseminating information and mandates whereas the business planning sites focus these meetings on learning, problem-solving and sharing experiences for mutual benefit.
SUSTAINABLE CHANGES IN CLINICAL PRACTICE Interviewees gave very few examples of changes in clinical practice, and these examples primarily focused on achievements in disease detection because of improved trust from the community. For example, TB was highly stigmatized, and people would avoid visiting the doctor because of the fear of being diagnosed with TB. One interviewee explained that, before business planning, only a few cases were detected in 2013–2015, and all those detected were in hospitals. When TB was selected as a priority in 2016–2017, the rural health facility detected 25 new cases during the two-year period. Since 2018, TB have not been chosen as a priority, and they had only one new case in 2018. Another example of such achievements comes from a rural health facility that, in 2016, set brucellosis as a priority health problem because of 3–4 annual cases. For two years, business planning in this rural health facility targeted brucellosis in the priorities and action plans, and since 2018 no new cases have been registered. Work with the community through trained volunteers and contributions from workers in the sanitation and epidemiological station were key contributing factors for this achievement. Nevertheless, the comprehensive actions reported to address health priorities were not always grounded in evidence provided by the monitoring of business planning indicators. For example, in one rural health facility, hypertension was selected as a priority in 2018. The rural health facility managers described their activities as including training of community members on the threat of hypertension, on the importance of regular check-ups and on treatment in the event of an established diagnosis. As a result, health professionals paid more attention to detecting new cases of hypertension, but during that year, only four patients with hypertension were added to their list of chronic patients. Given the population size (5700 inhabitants) and an increase of only 51 to 55 patients, it is doubtful whether this should be promoted as an achievement.
35 Further interviews indicate that lack of financial access may be responsible for this low increase in hypertensive patients. A possible confounding factor in this example was found in another interview. Patients are added to the list of chronic patients only if all necessary tests have been performed. However, some cannot aford the co-payment for the diagnostic tests. For example, the co-payment for cholesterol testing costs 50 somonis, which is a considerable amount for those with low income. For this reason, the managers felt that business planning monitoring indicators did not sufciently reveal the achievements in selected priorities. Further, many felt restricted in the selection of priorities because of the limited number of indicators in business planning. Some rural health facility managers had the impression that they were not permitted to add indicators to their business planning, even when health priorities such as goitres, breastfeeding or HIV were chosen with no corresponding business planning indicators. Only one manager of a rural health facility proposed to add an indicator relevant to his facility’s health priority: how many received oral rehydration treatment. Another example came from a rural health facility that had chosen vaccinations of children as one of its health priorities. There are three indicators in business planning for monitoring vaccinations, and although there was an increase from 74 children vaccinated in 2018 to 86 in 2019, the difculty for some managers is that they were calculating these indicators as the number of children vaccinated and not as a percentage of the children registered with the rural health facility. Although this figure can be easily calculated from other indicators, as has already been shown, these managers for the most part did not demonstrate increased comprehension beyond the basic framework of business planning as delivered to them. In addition to the detection of diseases and delivering vaccinations, there were rather limited examples on what changes in human resources the managers made through business planning. One example came from a rural health facility, where the manager had requested and received, due to understanding the budget and stafng needs per capita, three additional nurses (from seven nurses per 5800 to 10 nurses in 2018). With this increase in stafng, he was able to change the scope of practice of nurses by moving all preventive work with healthy patients to the nurses so that he now can better concentrate on the ill population. Some rural health facility managers shared achievements such as repairs done on their buildings, but these were most often funded by Swiss Agency for Development and Cooperation grants. For example, in one facility the roof was replaced through a Swiss Agency for Development and Cooperation grant, whereas in others, playgrounds for children were built. Grants were not permitted to be used for salaries, but they helped to improve practices, by improving facilities such as building toilets or installing a water supply system for health facilities. Between 2014 and 2019, the following facilities received rehabilitation work, including medical equipment and furniture, as a result of small grants in the pilot districts:
Rudaki 26 rural health facilities, 9 laboratories; Faizobod 16 rural health facilities, 6 laboratories; Kanibadam 9 rural health facilities, 9 laboratories, Rayon Health Centre (polyclinic) the four rooms of the PHC management team, a training hall and the two working rooms of the rayon healthy lifestyles centre.
Despite the aforementioned examples and availability of small grants, the managers of rural health facilities reported that the government is still investing too little in rehabilitating facilities. Managers and/or communities often reported investing their own money in minor renovations or even supplies such as stationery.
36 BARRIERS AFFECTING THE RESPONSIVENESS AND EFFECTIVENESS OF BUSINESS PLANNING Despite its reported successes, several financial and human resource barriers limit the responsiveness and efectiveness of managers using business planning in addressing the health needs of their communities. All interviewed managers reported on the positive outcomes of the increased transparency of their budget, whereas this knowledge of the budget and resource allocation was absent in the non-business planning district. However, since they were not able to afect budget planning, this benefit is still limited. With often less than 5% of a budget available for discretionary funding, managers can do little to adjust to the needs of their populations. Although some managers reported some success in requesting changes to the budget based on their business planning, many others did not and even appeared to be unaware of this possibility. This both demonstrates the importance and success of business planning in budget transparency and reveals the need for further changes in this area. Financial constraints for patients also interfere with the efectiveness of the delivery of services and being able to use reliable data to understand the population. For many in the rural health facilities, co-payments are a barrier to being monitored on their noncommunicable diseases, and avoiding testing can keep patients from being included in the lists of chronic patients. Co-payments for consultations with a narrow specialist difer for districts in which the basic package of services has been implemented (50% with referral, 70% without) and for districts under Order 600 (80% with referral and 100% without). Consultations can cost between 7 and 10 somoni, which is a barrier for many people served by rural health facilities. The afordability of medicines was also reported to be a barrier to adhering to long-term treatment. Some examples were reported of how district governments provided support for rehabilitating and renovating rural health facilities when there was donor involvement. As an example, when one rural health facility received a grant for their achievements in business planning from the Sino Project, their use of the grant in renovations was supplemented with new furniture purchased by the district government. In another district, the district government provided a water supply to the rural health facility premises where the Swiss Agency for Development and Cooperation grants paid for all arrangements for providing water inside the building. In addition to financial barriers, human resource barriers were also reported in the form of training needs, increased personnel and improvements to the business planning monitoring framework. The health management training course provided by the Tajik Postgraduate Medical Institute and funded by the Enhancing Primary Health Care Services Project (Sino Project) was intensive, totalling 10 modules on various managerial topics. This training was provided for PHC managers, and the rural health facility managers received training directly through Enhancing Primary Health Care Services Project (Sino Project). Despite the training, the managers of the rural health facilities reported that the business planning process was difcult to understand at first, and some needed three years before feeling comfortable in understanding the purpose and use of the business planning model. Because of the rotation of health professionals, and especially nurses, new rural health facility personnel need training, which increasingly is no longer available. Other human resource barriers have to do with the difculty of improving business planning and related services when current workloads already seem to exceed capacity. Many reported that the monitoring system for business planning provides opportunities for identifying improvements to be made, but translating ideas into actionable revisions is challenging because of the lack of capacity in governance. There is limited capacity for governance of business planning at both the national and regional levels. The burden of work was not only at these levels but also reportedly felt by most of interviewed managers of their own workloads. As an example, one rural health facility manager reported that, in 1991, when he started to work, the population was only 5600, but now the number of inhabitants had increased to 11 800 with the same number of providers.
37 Perspectives of the district primary health care management teams
Key messages
EFFECTS OF BUSINESS PLANNING
LESSONS LEARNED FROM DISTRICT HEALTH CHALLENGES FACILITY MANAGEMENT TEAM PERSPECTIVE Rural health facilities managers more Limited by insufcient funds, dependent responsive to community needs on donor involvement Learning culture between rural health facilities managers
The district health facility management team interviewed also expressed a positive view of business planning at the district, rural health facility and community levels. Interviews were also conducted with district level management and rural facility managers at the district health facility in the Hissor district, which is a non-business planning site, to compare their perspectives and current actions with those practising business planning. The people using business planning described it as a guide for management on how to identify problems within the district while still comparing those problems with national health priorities. With problems more easily identified, management could then plan actions to address these problems and then monitor improvements from the business planning indicators. Before business planning, problems were not identified at the district or even rural health facility level, and any action plans to address problems were not usually implemented. They also reported the importance of not only a transparent budget but, because of per capita funding, a fair budget that more appropriately distributed funds and that improved management as well. Business planning was seen not as added work but a tool that helped make the necessary work easier.
RESPONSIVENESS OF RURAL HEALTH CENTRE MANAGERS District health facility managers reported on their observations of how business planning has afected the rural health facility managers as well. Many acknowledged that what is most important about business planning is the strengthening of the responsiveness of rural health facility managers to community needs. These managers under business planning can begin to solve problems independently, as soon as they identify them, especially when these needs are unique to their area, such as health issues of migrant workers or animal-borne diseases. With the community needs coming to the rural health facility managers, several district health facility management teams credited business planning for equipping rural health facility managers with the necessary tools to engage their communities and address these needs, but more help is needed. The importance of responsiveness is evident when the indicators are disaggregated by district. For example, charting the maternal and child health indicators in the same time- series fashion, but by district rather than averaged together, shows clearly how much variance there is among the districts and likely by rural facilities as well. For example, the maternal mortality rate demonstrates this variance (Fig. 7).
38 Fig. 7. Maternal mortality rate per 100 000 live births Mortality rate
2014 2015 2016 2017 2018
Faizobod Rudaki Kanibadam Istaravshan
Rasht Shahrinav Tursunzoda Vose
Source: PHC facilities from each district.
This variation not only between districts but within the same district from year to year demonstrates the constant need for monitoring and planned actions by the health facilities. Although on average the business planning districts have shown improvement in their approach to maternal and child health, if nothing else, this analysis strengthens the justification for a management model that focuses on responsiveness to unique community needs. Each district from year to year visibly has diferent needs and, therefore, must increase their capacity to identify and respond to these current needs. In contrast, no community health team members were present to be interviewed at the non- business planning district site. This indicated the low level of community engagement. This is not to say that the district health facility manager was unaware of the possibly unique needs of the villages and the benefit of greater responsiveness on the part of the rural health facility. In the interview, he was quick to point out examples of how the diferent areas within the district have diferent needs, such as the remoteness of some villages making service delivery more challenging, the higher than average birth rate of others or the density of the city of Hissor being more vulnerable to the spread of disease. From a managerial perspective, he knew the population statistics and corresponding issues well but without community input of concerns or resistance to treatments. His focus was more on the constraints he faced in stafng and budgeting, since these matters were all in the hands of the Department of Finance and not based on a per capita funding model yet. When examining diabetes morbidity, the importance of selecting health priorities based on indicators and subsequently planning actions as part of business planning becomes apparent. Diabetes was one of the more commonly selected health priorities in the business planning districts, and the business planning districts difered from the non-business planning district in addressing the issue (Fig. 8). The important diference is not in the performance of the business planning districts compared with the non-business planning districts but in how business planning strengthens the responsiveness of the health facilities to the needs of the population. If business planning is implemented well, the business planning districts will be monitoring the morbidity of diabetes and will be planning actions to address it, expectedly keeping diabetes from dramatically increasing in their districts. Without this monitoring and subsequent actions, a health issue could quickly become more prevalent, which is what is likely happening in this non-business planning district. 39 Fig. 8. Diabetes morbidity rate in business planning districts and non-business planning district, 2014–2018 Morbidity rate
Business planning Non-business planning
Source: PHC facilities from each district.
LEARNING FROM OTHER MANAGERS District health facilities management teams reported that rural health facility managers can receive continued guidance through regular meetings with district health facility managers and other rural health facility managers where they can share problems and learn from each other’s experiences. Likewise, through the transparency of the budget, rural health facility managers can learn to track expenses and make requests for changes as needed, another way they were reportedly improving in their medical knowledge. Moreover, it is not only rural health facility managers, the doctors and nurses working at the facilities were reportedly increasing their knowledge of the chosen health priorities to educate the community health team members. These community health teams were more efective at educating communities on health issues and persuading people to change health behaviour and to access services. The efect was reportedly evident in the increases in numbers of visits, vaccinations and even in the decreased number of hospitalizations, which was a result of improved trust between health-care professionals and their patients, along with improved referrals to specialists.
CHALLENGES WITHOUT DONOR SUPPORT With an overall strong commitment to business planning because of the increased efectiveness of addressing community needs and clarity of management responsibility, most district health facility management teams were confident of the continued use of business planning even without support from the Enhancing Primary Health Care Services Project (Sino Project). Despite this confidence, several types of support provided as a part of the Enhancing Primary Health Care Services Project (Sino Project) were noted as potential challenges moving forward. Due to the difculty most managers face when learning business planning, the amount of training necessary requires adequate funding. In addition, the Enhancing Primary Health Care Services Project (Sino Project) incentivized community health leaders for their participation by covering travel costs and providing funds for organizing community health events. In districts where the Enhancing Primary Health Care Services Project (Sino Project) is being phased out, some have observed that the participation of community volunteers is not as strong. Some district health facility management teams were also paid a stipend as an incentive to implement business planning and cover the additional travel to facilities. Beyond the support provided by the Enhancing Primary Health Care Services Project (Sino Project), other financial constraints were reportedly observed at the district level. These constraints mainly focused on insufcient funds in the allocated budget and included specific issues such as transport for district health facility management teams and rural health facility managers to travel to meetings and conduct on-site visits as well as operational costs such as stationery to carry out business planning. Other perspectives 40 expressed as tangentially related issues to business planning included insufcient numbers of family doctors (especially those with some management training), reports of inefciency because of overlapping in forms and the lack of electronic reporting equipment. The WHO team made several observations in these interviews regarding the status of business planning and the potential challenges moving forward. Although the commitment to business planning was evident, district health facility management teams and their reports of rural health facility managers demonstrated a limitation in their potential efectiveness. Action plans were limited to community engagement only and lacked clinical innovations to address needs. No additional indicators were created or added to business planning, even when none of the existing business planning indicators tracked the health priorities chosen. Management was abiding strictly to the original business planning guidelines and had not adapted any further. One constraint inhibiting further adaptation and responsiveness is the significantly limited amount of the budget managers can allocate at their own discretion. Most frequently this amount was reportedly only 4–5% of the entire budget. It was also very evident in these interviews that the high level of turnover of district health facility managers was afecting the implementation and monitoring of business planning. Many of the district health facility managers using business planning that were present for the interviews had been in their position for less than a year. Most managers had delegated business planning to a deputy manager, which for consistency is a logical decision; however, it does detract from the efectiveness of business planning as a managerial tool. This observation, combined with the absence of many of the district health facility managers from the interviews, signified a lower commitment to business planning of the district health facility managers than the other members of the management team and rural health facility managers. The most significant diference between the business planning districts and the non- business planning district interviewed was in the flow of information and decision-making. From the community engagement to the selecting of health priorities, the non-business planning district managers demonstrated conformity to a strictly top-down managerial approach, whereas managers in the business planning districts demonstrated the importance of merging both national health priorities and the priorities of the populations they serve by opening communication channels and increasing the responsiveness to communities. These managers nevertheless were ready to implement business planning as it is a national mandate; however, they are waiting for training and further support.
41 Policy-makers’ perspectives Key messages
EFFECTS OF BUSINESS PLANNING
LESSONS LEARNED FROM POLICY MAKERS' CHALLENGES PERSPECTIVES Greater budget transparency Turnover of stafng, financial constraints Improved clinical governance of managers More patient-centeredness of providers Trust from communities in health care
Although policy-makers reported that business planning is very positive for PHC by strengthening the management of facilities, improving the quality of services and developing better relationships with the communities, they also admitted to challenges in sustainability. Business planning has provided greater transparency of the budget for rural health facility managers. This new transparency has informed rural health facility managers of budget amounts and allocations, which the key informants claim improves their managerial decision-making. The ways business planning strengthened management were also reportedly due to how business planning as a tool helped managers to improve the monitoring of their facilities’ performance on the business planning indicators. Previously, they were not aware of these figures and their relevance to health services delivery. Because of this increased awareness of performance, rural health facility managers and providers are improving their clinical governance by improving the use of clinical protocols and guidelines. Managers have reportedly improved in their documentation and clinical management of patients. However, it was acknowledged that these improvements are also due to parallel projects addressing family medicine and establishing peer groups for improving performance. Business planning is also seen as improving the quality of services because it reportedly has changed the attitude of providers towards their patients, helping them to become more patient-centred. This change in attitude has come from business planning encouraging providers to see patients as partners in achieving improved performance on indicators, thus improving the quality of services. Examples given in this case included improvements in access to services for the population, including preventive services such as vaccination coverage. With this improved attitude also have come greater relationships of trust with the communities being served by facilities using business planning. Because of the emphasis on engaging the community in business planning, rural health facility managers and community leaders have developed better partnerships to identify health needs among their community members and take action to address these needs. This was reportedly done by having regular meetings with community leaders as well as increasing home visits and other community engagement activities. Although no weaknesses or criticisms were presented and they were generally positive about business planning during these interviews, some systemic constraints were acknowledged that may afect the success or sustainability of business planning. Turnover in stafng, especially among district health facility managers but also among the rural health facility personnel, causes a strain on resources for providing the necessary training courses on business planning. Although transparency in the budget at the rural health facility level has increased with the implementation of business planning, the budget still comprises almost completely (95%) protected lines, limiting the flexibility of managers at the rural health facility level.
42 International partners’ perspectives Key messages
EFFECTS OF BUSINESS PLANNING
LESSONS LEARNED FROM INTERNATIONAL CHALLENGES PARTNERS' PERSPECTIVES Improved problem identification Much training and resources required and action planning of managers A lack of coordination at the district Communities more involved in selecting level between the departments of health health priorities and finance The low level of unprotected budget lines
The interviews with international partners likewise reported business planning to be very positive for primary health care by strengthening management and community engagement. Some challenges to implementing business planning and moving forward without their involvement were also shared. Those interviewed from the international partners who initiated and implemented business planning in pilot districts described the benefits of business planning similarly to the policy-makers interviewed: the improvement in management and relations with communities. In particular, they mentioned the observed diference in management was in the managers’ ability to identify and trace problems in their facilities and communities and then to make action plans to address these problems. Examples were given of this improvement, which included planning events to raise awareness on issues such as hypertension and holding education campaigns to reduce stigma surrounding TB. In addition, the transparency in the budget was reportedly a significant change since it provided managers greater knowledge and control of their facilities and operations. Similar to the policy-makers interviewed, these international partners stressed the importance of the community health teams in the success of business planning. With the introduction of business planning, they reported that community needs were being taken into account, with actions planned to address these needs, all while still working on the national health priorities. The community health teams have been instrumental in encouraging members of the communities to use the health services when they were previously hesitant to do so. By working with community members, changes in attitude (including stigma) have reportedly led to better health outcomes as well. Although many examples were given of successful community engagement leading to behaviour change, no examples of clinical changes resulting from business planning and responsiveness to community needs could be provided. These key informants expressed their opinion that clinical changes could not happen at the level of business planning but that changes would instead need to originate at a higher level. Although the Ministry of Health and Social Protection of the Population has supported the adoption of business planning, it has not been structurally integrated as a feedback loop or source of information travelling up from the community level. Not all districts and rural health facilities perform equally well in terms of business planning according to these key informants. From their experience, these diferences are due to the commitment of the managers at the district and rural health facility levels as well as context-specific issues such as adequate stafng of health professionals and turnover. Turnover was reported to be mostly an issue at the district health facility level; however, some difculties occur at the rural health facility and even village facility levels since young professionals often do not want to stay in rural areas. These interviews yielded other challenges for business planning as well. Although managers praised business planning for helping them make significant improvements in managing health facilities, they also reportedly had a difcult time learning business planning. Progress had been made in identifying problems, but managers did not understand how to improve performance on relevant indicators despite years of training 43 and support. Financial challenges, a lack of coordination at the district level between the departments of health and finance and the low level of unprotected budget lines for more managerial responsiveness were also reported. Lastly, the international partners noted how much time and funds had been spent in implementing business planning and were concerned that the Department of Business Planning and Analysis of Family Medicine Development of the Republican Clinical and Family Medicine Training Centre was not adequately equipped with stafng or funding for the necessary training, monitoring and supporting of business planning. In addition to supporting the training of business planning, these international partners used financial incentives in the form of rewards for structural repairs and equipment for high-performing facilities. Other programmes that facilitated the formation of community health teams and improved clinical practices such as medical education programmes also contributed indirectly to the observed successes of business planning. WHO ©
Staf of Republican Family Medicine Training and Clinical Centre
44 Analysis of the findings
Overall, interviewees widely regarded business planning as an efective managerial tool that improved the health of and relationships with the populations served at the district, rural and community levels. Analysis of the performance of these districts and rural health facilities according to the business planning indicators reveals that, although some areas still need to be strengthened, business planning is an efective managerial path to follow and is indeed having the efect those using it believe it is. This section describes the most significant achievements and challenges for the sustainability of the initiative.
Achievements resulting from business planning
IMPROVED HEALTH OUTCOMES The most important achievement of business planning is the reported improved health of the population, especially of the more vulnerable groups of women of childbearing age and children younger than five years. According to the managers of the rural health facilities, the health of these populations, and patients individually, improved because they targeted related indicators and involved community health teams to work with their communities, focusing mainly on registering pregnant women before 12 weeks, increasing the number of assisted childbirth deliveries, resolving concerns regarding vaccinations, educating on early signs of infectious diseases and preventing noncommunicable diseases.
INCREASED TRUST AND SATISFACTION OF COMMUNITIES IN THE RURAL HEALTH FACILITIES The increased trust and satisfaction of community members in the health services is reportedly evidenced by the increased visits, participation in screening and interest in improving the health facilities, sometimes by contributing their own funds. The perceptions of the population were seen to change as a result of the budget and planning becoming more transparent under business planning, which allowed communities to understand the structure, flow and purpose of health services delivery and their own role in it. As health services improved and community health teams demonstrated the benefits of seeking care, the quality and credibility of rural health facilities and the health personnel was perceived to increase.
INCREASED CAPACITY TO MANAGE FINANCIAL AND HUMAN RESOURCES Both district and rural health facility managers reported increased transparency and ownership, a managerial capacity to respond to the needs of their population, to manage their stafng accordingly, to monitor progress and to administer the financial resources allocated to them. With increased participation in identifying needs, monitoring progress and other forms of needed decision-making, these managers felt empowered to respond to the needs of their populations and direct resources and eforts more efectively. A list of identified contributing factors and considerations for business planning to roll out as the core of management practice in primary health care nationally is provided below.
45 Contributing factor one: community engagement
RELATIONS BETWEEN RURAL HEALTH FACILITY MANAGERS AND COMMUNITY LEADERS Structured eforts to engage communities, especially in forming community health teams and involving them in business planning, contributed to many of the improved health outcomes by raising awareness and educating the population. These community health teams improved health literacy and encouraged the population to access health services in their communities, thereby contributing significantly to the improved health outcomes, especially among the most vulnerable populations, with maternal and child health issues consistently selected as health priorities.
Contributing factor two: strengthening health services
CAPACITY AND KNOWLEDGE OF HEALTH PERSONNEL Within business planning, the identification of health priorities and creating action plans to engage the population also led to health personnel increasing their knowledge related to the health priorities in order to adapt the knowledge to their populations and educate the community leaders, thereby improving how the quality of related services they provide. This increase in the knowledge of the health personnel, however, largely resulted from the initiatives of the rural health facility managers. According to interviews and indicator data, improving the knowledge of health personnel and consequently the relationship with the community further led to more frequent and timely access to services in districts such as Tursunzoda, Shahrinav, Rudaki, Istaravshan, Kanibadam, Shugnon and Roshtkala.
DONOR CONTRIBUTIONS TO FACILITIES AND EQUIPMENT Although some communities reportedly raised funds to repair rural health facilities, many improvements to facilities and new equipment came from the involvement of donor agencies working with business planning and other pilot programmes. Improvements to health centres through building repair and equipment procurement also contributed to strengthening services in districts such as Faizobod, Kanibadam, Tursunzoda and Shahrinav. If these donor contributions cannot be replaced by national contributions, however, then there may be a loss in commitment and motivation in business planning as well as a negative efect on the population’s perception of the quality of the health services. Further, these donor contributions and awards seems to have afected the managers in these districts, since their perceived solutions to any problems revolved around awards made by either a donor organization or the Republican Family Medicine Clinical and Training Centre. Managers in other districts in which donor contributions were not as prominent seemed to demonstrate more creativity with lower resources. With increased flexibility in budget spending, however, some motivation may be recovered to address these needs.
46 Contributing factor three: management responsiveness
USING DATA TO RESPOND TO LOCAL HEALTH NEEDS Business planning as a management tool establishes a cycle of information that uses feedback to inform decision-making and emphasizes problem-solving at the local level. If this cycle is fully implemented as intended, then business planning provides experience to managers in setting priorities and goals relevant to the population they serve, implementing activities together with community health teams and analysing the results of these activities. The transparency in goals and activities, as well as in the budget, benefits managers and communities alike in using information to make decisions.
Monitor Analyse Track and monitor Analyse the efect of performance planned actions by indicators
Plan Identify Plan actions to Identify health address health priorities in priorities population
IMPROVING MANAGEMENT OF THE NETWORK OF PHC FACILITIES AT THE DISTRICT LEVEL The consolidation of the business plans of rural health centres into one unified district business plan would give district PHC managers the opportunity to conduct a comparative analysis of rural health centres’ activities, identify existing problems in service delivery and respond to them. This would improve the capacity of PHC managers in managing the network of PHC facilities at the district level. The potential benefit of the consolidated business report is not always realized, since turnover and delays in training have afected many PHC facilities at the district level. OPPORTUNITIES TO INCREASE RESPONSIVENESS AND EFFICIENCY The responsiveness of managers to the health needs of their communities was primarily directed towards community engagement because this is the aspect of management they could most directly influence.
47 Fig. 9. How top-down vertical programmes conflict with bottom-up business planning
DISTRICT PRIMARY HEALTH CARE CENTRE
Analysis of Business planning reporting performance Maternal and child health indicators Goals and activities
Health information for community on maternal and child health Reporting indicators
Requirements for activities, MATERNAL RURAL HEALTH CENTRE COMMUNITY reporting forms, AND CHILD indicators HEALTH VERTICAL PROGRAMME Community concerns regarding maternal and child health, vaccine hesitancy, pregnancy registration, etc. WHO ©
48 Rural health centre in Uzun, Shahrinav District Challenges afecting the success and sustainability of business planning
HEALTH SYSTEM CONSTRAINTS Discretionary budget spending. Although transparency in the budget at the rural health facilities level has increased with the implementation of business planning, one constraint is the significantly limited amount of the budget managers can allocate at their own discretion. With often less than 5% of a budget available for discretionary funding, managers can do little to adjust to the needs of their populations. Human resource barriers. In addition to financial barriers, human resource barriers were also reported in the form of training needs, increased personnel and improvements to the business planning monitoring framework. Turnover in stafng, especially among district health facility managers but also among the rural health facility personnel, causes a strain on resources for providing necessary training courses on business planning. Other human resource barriers have to do with the difculty of improving business planning and related services when current workloads already seem to exceed capacity. Limited improvements in clinical practice. The capacity of business planning as a quality improvement tool has not being fully used. Very few examples of changes in clinical practice were given in these interviews, and these examples were primarily related to achievements in disease detection because of improved trust from the community. The comprehensive actions reported to address health priorities were not always based on evidence provided by monitoring business planning indicators. These key informants expressed their opinion that clinical changes could not happen at the level of business planning but that changes would instead need to originate at a higher level. Although the Ministry of Health and Social Protection of the Population has supported the adoption of business planning, it has not been structurally integrated as a feedback loop or source of information travelling up from the community level. Reporting burden. An additional and important factor that constrains managers and health personnel from doing more to engage communities and care for patients is the excessive reporting currently required to serve all the diferent programme needs. However, the reporting and activities required by these programmes are not aligned with the activities planned at the rural health facility level, for example, because the involvement of communities through business planning at the rural health facility level determines the way the health priorities are being addressed. This burden is evident not only in the inefciency of paper reporting at the rural health facility level but in the number of diferent reports that must be submitted to diferent entities, with diferent timelines, which can also lead to some overlap in the information reported. While business planning is a helpful managerial tool, reporting burdens may be a barrier to growth in responsibility and creativity on how to monitor performance on selected priorities. The responsiveness of rural health facility managers to the health needs of their communities was limited to an increase in community engagement and for the most part did not include clinical, budgetary or stafng changes. Community engagement is essential and is discussed in the first contributing factor. However, the fact that managers were only directing planned actions towards community engagement even when additional actions could and should have been taken is a result of the systemic constraints that do not currently grant managers with the authority to make other changes. Opportunities to increase responsiveness of managers to communities and improve efciency would therefore include greater flexibility in budget spending and integrating reporting within the framework of business planning. As it is currently organized, vertical programmes such as those addressing maternal and child health are not integrated within primary health care, even though maternal and child health priorities (among others) are being selected at the local levels and addressed by communities and rural health faculties. This causes not only a reporting burden but a conflict in bottom-up and top-down approaches as well as inefciency in the allocation of resources and eforts (Fig. 8). 49 CHALLENGES WITH DONOR SUPPORT ENDING With an overall strong commitment to business planning because of the increased efectiveness of addressing community needs and clarity of management responsibility, several types of support provided as a part of the Enhancing Primary Health Care Services Project (Sino Project) were noted as potential challenges moving forward. Because most managers have difculty in learning business planning, the training necessary requires adequate funding. Other financial constraints mainly focused on insufcient funds in the allocated budget and included specific issues such as transport for district health facility management teams and rural health facility managers for meetings and conducting on- site visits as well as operational costs such as stationery to carry out business planning. Given how much time and funds international partners spent in implementing business planning, there were concerns that the Department of Business Planning of the Republican Family Medicine Clinical and Training Centre was not adequately equipped with stafng or funding for the necessary training, monitoring and support for business planning. In addition, the Enhancing Primary Health Care Services Project (Sino Project) incentivized community health leaders for their participation by covering travel costs and providing funds for organizing community health events. In districts where the Enhancing Primary Health Care Services Project (Sino Project) is being phased out, some have observed that the participation of community volunteers is not as strong. Some district health facility management teams were also paid a stipend as an incentive to implement business planning and cover the additional travel to facilities. Districts without donor involvement (Hissor and Istaravshan), however, did not demonstrate fully functioning community health teams and engagement activities, which are essential for business planning to succeed in afecting health outcomes. Even in the districts in which donors had worked previously but were phasing out or no longer active (Tursunzoda and Shahrinav), community leaders reported a decline in community involvement because of the lack of support. This shows the need not only for well-supported organization of the community health teams at the beginning but also for some form of continued support for these teams to continue making their essential contributions. Within the existing delegation of responsibilities and stewardships, community engagement falls under the scope of the Republican Centre for Healthy Lifestyles, and this is an essential collaboration for strengthening community engagement not only for business planning but for all health initiatives.
50 Recommendations
Based on the findings and analysis of the collected data and interviews, the following three focus areas should be considered for subsequent actions to strengthen business planning and ensure successful scaling up and continued maintenance in all districts.
Integrate vertical programmes into primary health care to increase the capacity of districts and rural health facility managers to respond to local health needs
Business planning strengthens the competencies of managers in working with communities to direct activities that will ultimately improve the health of these individuals and communities. This efect, however, is limited by what these managers can do at their level of management, whether at the district, rural or even village health facility level. These limitations are found in discretionary budget spending, stafng decisions and the reporting burden. Integrating the existing vertical programmes into primary health care is a necessary step in increasing managers’ capacity. This integration will align resources and coordinate eforts to address each of the health issues the vertical programmes currently deal with that are also being addressed at the community level through business planning. One of the burdens on managerial personnel and providers is the excessive reporting currently required to serve all the diferent programme needs. However, the reporting and activities required by these programmes is not aligned with the activities planned at the rural health facility level, for example, because the involvement of communities through business planning at the rural health facility level determines how the health priorities are being addressed. As previously demonstrated, an example of this discrepancy between the rural health facility and community level and the level of the vertical programmes is in maternal and child health (Fig. 9). Instead of vertical programmes operating separately from primary health care, even though these issues are being brought by the communities and addressed jointly with the rural health facilities according to their needs and resources, these resources and eforts should be integrated and brought into alignment to eliminate duplication in reporting, inefciency in service delivery and wasteful spending. An integrated vertical programme would work within business planning and the eforts to address these health issues at each community, bringing the resources and personnel from the vertical programmes to the level of district and rural health facilities (Fig. 10). Integration would not only address the burden of reporting, but with additional resources and increased budgetary discretion, health facility managers would be able to increase their responsiveness by being able to make clinical and stafng changes in addition to the community engagement decisions that have been demonstrated to be efective in addressing health priorities.
51 Fig. 10. Integrated vertical programmes in primary health care
DISTRICT PRIMARY HEALTH CARE CENTRE
MATERNAL AND CHILD HEALTH VERTICAL PROGRAMME
Analysis of Business planning reporting performance Maternal and child health indicators Goals and activities
Health information for community on maternal and child health
COMMUNITY RURAL HEALTH CENTRE
Community concerns regarding maternal and child health, vaccine hesitancy, pregnancy registration, etc.
Increase support for the Department of Business Planning and Analysis of Family Medicine Development of the Republican Clinical and Family Medicine Training Centre, in implementing and expanding business planning
The interviews and the comparisons of interview reports with indicator data very clearly show that business planning, although highly valued by managers, is not learned or implemented easily. It takes time and continued follow-up for both district and rural health faculty managers to improve how they use business planning with positive efects. Adequate stafng at the national and regional levels as well as funds for travel for training sessions are therefore necessary. Business planning also needs to be revised and developed. As a pilot programme, 29 indicators were chosen as a manageable number for managers learning to use this tool. However, business planning is the tool managers should be using to monitor and plan all activities for their facility and the populations that they serve. Business planning should grow beyond a pilot-level programme into the full-scale managerial tool under which all monitoring, analysis, reporting and planning occurs. Since it has proven difcult at first for managers to learn the pilot version of business planning, this growth should be gradual. Nevertheless, it should be the eventual goal and purpose of implementing business planning nationwide.
52 Develop community engagement programmes within the Republican Centre for Healthy Lifestyles
The importance of involving community health teams in making business planning efective and improving health outcomes in the communities being served cannot be overstated. However, this analysis clearly showed that community health teams do not function without first receiving training and being organized. In addition, these teams do not necessarily last without some form of support for the dedicated members working as volunteers. Since the Republican Centre for Healthy Lifestyles is charged with community engagement through a programme on partnership with communities on health issues, strengthening this component through collaboration should be the next step in ensuring the successful implementation of business planning across the country. Rather than additional programmes or eforts, strengthening community engagement through existing institutions is sustainable and efective, especially if this Centre is integrated into primary health care along with the others.
53 Annex 1. Profiling business planning by district Interview protocol for policy-makers • The main goals and objectives of business planning • Confirm the start dates of business planning in each district
• Confirm the dates of collaboration with development partners, if applicable
• Turnover of managers (how many times has the manager changed since the start date)
• Availability of incentives (did this district receive financial incentives?). If yes, what is the source of incentives?
• Profile of network (number of facilities in district catchment area and total population)
• Did you monitor the business planning implementation?
• Is there autonomy for managers and heads of primary health care for planning and distributing the budget?
Relevant parallel performance and outcome-oriented initiatives in primary care
• For districts in which implementation has included another parallel pilot project (PEN/HEART implementation or pay for performance), what was the start date? What is the current status?
• To what extent are the priority measures of business planning aligned with the indicators assessed by the health care inspectorate? (State Surveillance Service over Medical Activity and Social Protection)
Experiential and perspective questions
• From your experience, what have been the successes of business planning in the districts that have implemented it?
• What have been the challenges?
• What has been the diference in implementing business planning with and without the collaboration of the development partner?
• Are there diferences in the performance of the districts or regions that are using business planning? If so, what do you think has most contributed to these diferences?
• What are the lessons you have learned from implementing and observing business planning?
• What challenges do you see in scaling business planning to the remaining districts?
• What would your proposal be to make business planning more successful?
• What are examples (if any) of policy measures and/or changes in legal regulations or financing that occurred because of a business planning initiative?
a) Any national policy measures, especially related to the legal framework and/or design of services?
b) Financing?
c) Professional development and other workforce strategies?
54 Annex 2. • The main goals and objectives of business planning Interview protocol for • Confirm districts and dates (start and finish) of collaboration with international partner international partners • Ask for description of training for business planning, process, successes and challenges • From your experience, what have been the successful outcomes of business planning in the districts you have worked with? • What have been the challenges? • What are the lessons you have learned from implementing and observing business planning in these districts? o What was the learning process like? o What can be done to facilitate the learning process in other districts? • What challenges do you see in scaling business planning to the remaining districts? What would make it more successful? • To what extent were local communities engaged in the process of implementing training for business planning? • How did those being trained respond to the shift towards giving priority to the needs of the population? What work still needs to be done in this area? • At what levels did you engage those involved in the health system? Local level? PHC level? • What was your engagement with patients?
55 Annex 3. Performance questions Interview protocol for • The main goals and objectives of business planning district primary health • Do you have business planning manuals? (for PHC facilities, monitoring the care management business planning and consolidated business plan at the rural health facility) teams • Are business plans up to date for the current year? What are the specific targets or areas set for improvement? How do these difer from year to year? • What additional indicators have you added that are monitored through your business planning? • What process is used in developing the business plan? • What stakeholders are engaged in setting priorities for performance and planning? • What data are used in decision-making regarding planning? • What data are used in monitoring the business plan indicators? For additional indicators? • What are the processes in place for improving performance? For example, are measures reported to practitioners? Are external experts engaged? Courses ofered? • Is the performance of other nearby facilities known? How is this information used? • What form of training have the manager and personnel in the district undergone related to business planning? (For example, some managers have completed a one-year certificate in primary health care management, including one module on business planning. led by the Enhancing Primary Health Care Services Project (Sino Project)) • Do rural health facility head doctors control their budgets? • Is there a delay in the budget implementation? How does the business planning help to monitor the budget distribution? • Do you have another tool that is similar to the consolidated business plan (business planning)? • How do you use the consolidated business plan? • Did you implement monitoring visits from the district health facility team to the rural health facility? • Has the reporting quality improved? • How are resources (if any) generated from business planning being used? • How do you plan the primary health care budget? Based on the business planning manual or social protection of the population per capita financing guidelines? • Do you have the authority to use the saved items of expenditure for another item?
Experiential and perspective questions • What successes and challenges have you as the manager experienced in implementing business planning? o Does it vary from year to year? o If yes, what causes the variation? • In the opinion of the manager, what efect has business planning had in their district or specific facility? How can it be further improved? • What could make business planning easier to implement? • What could make business planning more efective? • What could be done to overcome challenges at the district or facility level? • What lessons have you learned that can be shared with districts that have not yet implemented business planning?
56 Annex 4. Performance questions Interview protocol • The main goals and objectives of business planning for rural health • Are you aware of the business plans for the current year at your facility? centre managers o What are the specific targets or areas set for improvement? o How do these difer from year to year in your experience? o What was your role in developing the business plan? o Do you have a specific role implementing the business plan? Please provide concrete examples. o If yes for above, do you have specific indicators to achieve? Do they align with incentives (if provided)? Examples. • Are you made aware of the performance of your facility? o For example, are measures reported to you as practitioners? o What steps are then taken to improve on that performance? o What training have you received to improve performance? o From your personal experience, how does business planning afect your performance as a health practitioner? What competencies have you upgraded based on business planning initiatives? Please describe how this relates to business planning. o What new measures have been introduced to support your performance (clinical practice guidelines, new laboratory and diagnostic tools, preventive measures etc.)? o What changes have taken place in your or your colleagues’ scope of practice and how does it relate to business planning? • From your personal experience, how has business planning afected your patients and community members? o Examples of initiatives to better engage patients in self-management? What are results of such initiatives for the patients? Are they measured? o Examples of initiatives to enhance the health literacy of community members?
Experiential and perspective questions • What successes or improvements have you seen because of business planning at your facility? o How can it be further improved? • What could make the business plans at your facility easier to implement? • What could make business planning more efective? • What lessons have you learned or challenges you have experienced that would help managers and policy-makers before implementing business planning in other districts?
57 Annex 5. • To what extent were community representatives engaged in the business Interview protocol for planning initiative? Examples.
community members • To what extent did community members provide support in implementing business planning?
Experiential and perspective questions
• From your experience, what have been the successes of business planning in the district?
• What have been the challenges?
• In your opinion, what changes has business planning made in the community (focus on health literacy, patient engagement and reaching vulnerable groups)?
• What are the lessons you have learned from implementing and observing business planning?
• What would make it more successful?
58 Annex 6. Indicators relevant to business planning in primary health care
INDICATORS CURRENTLY BEING MONITORED BY BUSINESS PLANNING
Cluster Indicator Visits No. of visits at the facility No. of home visits No. of visits for doctors No. of visits for middle-level personnel Total number of visits Proportion of all visits Children <1 year old Children <5 years old Women 15–49 years old People older than 60 years TB-related Diarrhoea related (<5 years old) Acute respiratory infection related (<5 years old) Total number of antenatal care visits Pregnancy and child delivery No. of deliveries No. of assisted deliveries No. of newborns No. of pregnant women registered No. of pregnant women registered in first 12 weeks thereof Vaccines No. of children younger than 12 months No. of children <1 year old who received three doses of pentavalent vaccine No. of children <1 year old who received an anti-measles vaccine No. of newborns who were vaccinated against TB Diagnosis No. of people with a new diabetes diagnosis No. of people with a new diagnosis of hypertension No. of diarrhoea cases (children <5 years old) No. of acute respiratory infection cases (children <5 years old) Referrals No. of referrals for hospitalization No. of specialist referrals Financing Per capita normative (standard) Total state budget % for wages % for drugs % for other expenditure Special means % for wages % for drugs % for other expenditure
59 INDICATORS CONSIDERED TO BE ADDED FROM THE NATIONAL HEALTH STRATEGY 2020 IF THEY ARE DISAGGREGATED BY DISTRICTS
Target Indicator Baseline 2010 Source 2015 2020 Ministry of Health and Social Protection of the А-1.1. Infant mortality rate Population, 16.8 25 20 per 1000 live births Republican Centre for Medical Statistics and Information Ministry of Health and Social Protection of the А-1. Impact on the А-1.2. Under-5 child Population, maternal, newborn mortality rate (per 1000 live 20.9 38 20 Republican and child health births) Centre for Medical Statistics and Information Ministry of Health and Social Protection of the А-1.3. Maternal mortality Population, 45.0 30,0 25,0 rate per 100 000 live births Republican Centre for Medical Statistics and Information
Ministry of Health and Social Protection of the А-2.1. TB morbidity rate per Population, 78.5 60,4 42,0 100 000 population Republican Centre for Medical Statistics and Information
А-2. Impact of Ministry of communicable Health and Social diseases Protection of the А-2.2. TB mortality rate per Population, 133.4 81.3 30.0 100 000 population Republican Centre for Medical Statistics and Information
Republican А.2.3. Hepatitis morbidity Centre for Medical 13.2 80 100 rate per 100 000 population Statistics and Information Statistics Agency А-3.1. Cardiovascular disease under Tajikistan mortality rate per 100 000 Government, population 208 190.3 140.0 Republican Centre for Medical Coronary heart disease Statistics and Information Republican А-3.2. Diabetes morbidity Centre for Medical А-3. Impact of rate per 100 000 population 57.4 118.2 88.9 Statistics and noncommunicable (primary) and chronic diseases Information, Republican А-3.3. Malignant tumours Centre for Medical morbidity rate per 100 000 37.8 35.9 35.0 Statistics and population Information Republican А-3.4. Injuries mortality rate Centre for Medical 21.9 15.8 15.0 per 100 000 population Statistics and Information
60 Target Indicator Baseline 2010 Source 2015 2020
В-1.2. % of population who do not seek needed В-1. Improvement in health care for financial access to health-care n/a n/a n/a Household survey and regional reasons by services and equity socioeconomic status (quintiles)
C-1.1. Strengthening С-1.1.1. % of health facilities Ministry of the governance of and other organization Health and Social the health system 13 30 50 managers trained in health Protection of the and improving the management issues Population legislative base
State Surveillance С-2.2.2. % of health-care Service over facilities introducing clinical n/a n/a n/a Medical Activity protocols at the primary and and Social secondary levels separately Protection
Ministry of Health and Social С-2.2. Improving the Protection of the system for standards С-2.2.3. % of health-care Population, of treatment and facilities where therapeutic 0 10 90 State Surveillance prevention activities committees function Service over Medical Activity and Social Protection
Ministry of С-2.2.4. % of accredited Health and Social 0 30 60 health-care facilities Protection of the Population Household survey (multiple indicator cluster survey and others), С-2.3.1.1. % of women Republican who had before-delivery Centre for Medical 64.9 68 71.7 examination according to Statistics and the national standards Information, National Centre for Reproductive Health and Family Planning С-2.3.1. Scaling up Ministry of the accessibility Health and Social of health-care Protection of the services: С-2.3.1.2. % of women Population, of fertile age using 25.1 36.7 40.0 Republican maternal contraception Centre for Medical and child health Statistics and Information, surveys Ministry of Health and Social Protection of the С-2.3.1.3. % of home Population, deliveries with attendance of 95.0% 98.0% 100.0% Republican health personnel Centre for Medical Statistics and Information, surveys
61 Target Indicator Baseline 2010 Source 2015 2020 Ministry of Health and Social Protection of the С-2.3.1.8. % of newborns with Population, 32% 26% 20% low body weight Republican Centre for Medical Statistics and Information Ministry of Health and Social С-2.3.1.9. % of children under Protection of 5 years with diarrhoea 34% 25% 50% the Population, treated according to clinical Republican Centre protocols for Paediatrics and Child Surgery С-2.3.1.10. % of children under 5 years with acute respiratory infection 60% (2012) 65% 70% receiving treatment according to the clinical protocols Ministry of Health and Social С-2.3.1.11. % of children under С-2.3.1. Protection of the 5 years old who are late in Growth 26%, Growth 23%, Growth20%, Scaling up Population, their development (–2z to cachexia 10%, cachexia 8%, cachexia6%, the accessibility Republican –3z score weight–growth weight 12% weight10% weight 8% of health-care Centre for Medical indicators) services: Statistics and Information maternal and child health Ministry of С-2.3.1.12. % of families Health and Social with children under 5 Protection of the years trained in issues on Population, 65% (2012) 68% 75% dangerous signs of acute Republican respiratory infection and Centre for Medical diarrhoea Statistics and Information Ministry of Health and Social С-2.3.1.13. % of adults and Protection of the children who need and 55.7% 90% 90% Population, receive antiretroviral therapy Republican Centre for AIDS Control Ministry of Health and Social Protection of the С-2.3.1.14. % of children living Population, with HIV born to mothers Republican Centre living with HIV covered 0% 25% 25% for AIDS Control, by the maternal and child Republican health HIV programme Centre for Medical Statistics and Information
62 Target Indicator Baseline 2010 Source 2015 2020 People who People who People who inject drugs С-2.3.2.1. % of young people inject drugs inject drugs >60% (from the most vulnerable 41% >70% Ministry of population groups: people Health and Social Sex worker who inject drugs, sex Sex workers Sex Protection of >80% workers and men who have 76% workers>80% the Population, sex with men) covered by Men who Republican Centre Men who Men who HIV prevention and control have sex for AIDS Control have sex with have sex with programmes with men men 41% men >50% >30%
С-2.3.2. Scaling up Ministry of the accessibility of С-2.3.2.2. % of detected TB Health and Social cases in PHC facilities of the Protection of health-care services: 35% 44% 100% communicable total number of detected TB the Population, diseases cases Republican TB Control Centre Ministry of Health and Social С-2.3.2.3. % of the examined Protection of population of high-risk TB 40.0% 50.0% 100.0% the Population, groups in PHC facilities Republican TB Control Centre С-2.3.2.4. % of population aware about the risks of Not Not available Not available Household survey HIV and other sexually available transmitted infections С-2.3.3.1. % of population Republican undergoing preventive Centre for Medical 4% 15–20% 40% medical check-up for Statistics and detecting cancer Information Ministry of Health and Social 56 000 Protection of С-2.3.3.2. % of the the Population, population screened for 1.23% of the 2% 5% Republican detecting hypertension employable population Centre for Medical Statistics and Information С-2.3.3. Scaling up С-2.3.3.3. % of the the accessibility of population who are aware 20% 25% 40% Household survey health-care services: about noncommunicable noncommunicable disease risk factors diseases С-2.3.3.4. % of the population who are aware about providing first aid CPR 0.5% CPR 2% 4% Household survey if injuries occur and of correct cardiopulmonary resuscitation Ministry of Health and Social С-2.3.3.5. % of population Protection of the covered with medical check- 10.4 7.9 7.7 Population, ups to detect endemic goitre Republican Endocrinology Centre
63 INDICATORS PROPOSED FROM THE STRATEGIC PLAN FOR THE DEVELOPMENT OF FAMILY MEDICINE-BASED PRIMARY HEALTH CARE IN THE REPUBLIC OF TAJIKISTAN, 2016–2020
Number of PHC facilities Ministry of Health, providing support Republican Family To support patient to enable patient self- Continually Medicine Clinical self-management management until 2020 and Training Centre, for chronic conditions development Number of approved partners packages for patient education Number of patient support groups established at PHC facilities (hypertension, diabetes, TB, breast cancer) Ministry of Health, 1.3 Engaging To strengthen patient Continually Republican Family Percentage of patients patients peer-to-peer support until 2020 Medicine Clinical with chronic conditions and Training Centre, covered by schools development (school of diabetes, partners hypertension, breast cancer) and developing no complications in the reporting period (based on survey findings)
To initiate a dialogue on Number of events to raise establishing a platform on Ministry of Health, patients' awareness about Continually discussion of patients’ rights, development their rights until 2020 engaging NGOs and other partners New legislation approved sectors on patients’ rights
Ministry of Health, Number of joint activities To increase the involvement 1.4 Engaging local Continually Republican Family carried out with the of local authorities in health authorities until 2020 Medicine Clinical support from local promotion and Training Centre authorities
Increase in the average number of visits per inhabitant per year (2009 – 4.2; 2015 – 6.0; 2020 — 8.0) (B—1.1) To design patient transitions, Reducing the number including referrals and of ambulance calls during counterreferrals, to organize Ministry of Health, working hours of PHC 2017–2018 the optimal routes for working groups facilities (2009 — 30%; patients across the whole 2015 — 20%; 2020 40%) 2.2 Organizing family care pathway medicine practice Reduced demand with other providers for inpatient care and settings of care (number of bed-days per 1000 population): 2009 — 1142.6; 2015 — 15.0%; 2020 — 30.0%) Reduced hospitalization rate of patients with To coordinate providers to chronic extensive diseases facilitate regular exchanges Ministry of Health, 2017–2018 (asthma, diabetes, across specialties for more working groups hypertension, congestive coordinated services heart failure) (2009 — 64%; 2015 — 50%; 2020 — 40%)
64 Annex 7. Characteristics of rural health centres
POPULATION SERVED, TOTAL NUMBERS OF HEALTH PROFESSIONALS AND SELECTED HEALTH PRIORITIES FOR 2019 OF 12 SELECTED RURAL HEALTH CENTRE MANAGERS AND PROFESSIONALS INTERVIEWED
Rural health Population PHC doctors Nurses Health priorities Health priorities centre, district (number of (family (by rural health centre) (by community) family doctors) medicine + other nurses) Toichi, 12 266 6 (4 family 15 (9) Noncommuni- Immunization Antenatal Family Tursunzoda doctors) cable disease care planning district prevention + 0.25 (gynaecologist) Chkalov, 9150 2 (2) 15 (8) Noncommuni- Immunization Goitre Hypertension Tursunzoda cable disease district prevention Mulloshodi, 3600 2 (2) 7 (5) Anaemia Immunization Antenatal Acute Shahrinav care respiratory district +1 dentist infection and diarrhoea Hosilot, 2803 1 (1) 7 (3) Diabetes Hypertension Antenatal Acute Shahrinav care respiratory district + 1 dentist infection and diarrhoea Toskala, Vose 6500 2 (2) 18 (1) Diabetes Hypertension Antenatal Acute district care respiratory infection and diarrhoea Zarkamar, Vose 6806 2 (1) 18 (2) Neurological Helminthiasis Antenatal Anaemia district care Okjar, Vose 9800 1 (1) 16 (1) Diabetes Diarrhoea Antenatal Threats of districta care pregnancy Safedob, 5766 2 (1) 11 (4) Immunization Diarrhoea Family Breastfeeding Hadamoni planning districta Pushkin, 5669 2 (2) 10 (2) HIV and AIDS Goitre Breast- Acute Hadamoni feeding respiratory district infection and diarrhoea Gornyi 4284 1 (1) 4 (0) Not available Not available Not Not available Khonako, available Hissor districtb Oybosh Hissor 3742 1 (1) 4 (4)+1 Not available Not available Not Not available districtb midwife available Noji Bolo 6524 2 (2) 6 (6) Not available Not available Not Not available Hissor districta available a Interviewed nurse. b Non-business planning district.
65 The WHO Regional Ofce for Europe Member States
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