AZERBAIJAN PRIMARY HEALTH CARE STRENGTHENING PROJECT Year 2 Annual Report September 1, 2008 – August 31, 2009 Submitted by Abt Associates Inc. TABLE OF CONTENTS Executive Summary ............................................................................................................................ 3 Component Summaries..................................................................................................................... 7 Monitoring and Evaluation Report................................................................................................25 Highlights and Success Stories.......................................................................................................28 Lessons Learned................................................................................................................................32 Looking Forward...............................................................................................................................34 List of Acronyms...............................................................................................................................36 Attachment 1: Progress Report on TB Activities......................................................................38 Attachment 2: Performance Monitoring Plan Indicators .........................................................43 PHCS Project: Year 2 Annual Report 2 EXECUTIVE SUMMARY In line with the Government of Azerbaijan’s vision for health care reform, USAID/Azerbaijan is providing technical assistance to the Ministry of Health (MoH) to expand the comprehensiveness of primary health care (PHC) and to improve the way that PHC is organized, delivered, and financed. The USAID Primary Heath Care Strengthening (PHCS) Project, implemented by Abt Associates, works closely with and provides technical assistance to the MoH to strengthen Azerbaijan’s health policies and its PHC system. The three-year PHCS Project started in September 2007 with an overall funding envelope of $2,800,000. In February 2009, USAID allocated an additional $992,000 to PHCS to provide technical assistance to the Government of Azerbaijan to improve tuberculosis (TB) care and treatment through health reform and health system strengthening activities. In Year 2, PHCS continued to provide technical assistance to the Government through five components: • Component 1: Increase public expenditures for health and improve resource allocation for PHC • Component 2: Create a policy and legal framework that defines PHC services and the delivery system • Component 3: Improve quality of PHC services • Component 4: Promote personal responsibility for health among individuals and families • Component 5: Improve TB care and treatment through health reform and health system strengthening PHCS Project: Year 2 Annual Report 3 Project components are implemented in an integrated and coordinated manner. Together, PHCS activities are assisting the Government of Azerbaijan to enact and make operational a legal framework and policies that are supportive of health care reforms; improve the mobilization, allocation and use of health care resources; improve the quality of health care services; and ensure that people are better informed about and can advocate for health care services, healthy lifestyles, and patient rights and responsibilities. Improving the quality, accessibility, and efficiency of health care will contribute to improving the health of the population and help Azerbaijan strive to meet the Millennium Development Goals. Project activities also contribute to USAID/Azerbaijan meeting its strategic objective of increasing use of quality health care services and practices in Azerbaijan in order to improve health and reduce the incidence of TB. In Year 2 of the Project, PHCS continued to cultivate effective working relationships with the MoH and other national-level stakeholders, build capacity among counterparts in both designing and implementing health reform activities, and actively coordinated Project assistance and support with other development partners including other USAID projects, the World Bank, the World Health Organization (WHO), and the Global Fund (GF). More specifically, PHCS accomplished the following in Year 2 of the Project: 1. Provided in-depth technical assistance to the Government, along with other development partners, to develop a new health care financing system resulting in: • Initial steps being taken to begin to implement the Action Plan of the Concept for National Health Financing Reform 2008-2012 and prepare to pilot new provider payment systems; • Development of “The Program of Implementation of the New Health Care Finance System and Mandatory Health Insurance in the Republic of Azerbaijan” that includes calculation of a simplified diagnostic related group (DRG) system for hospital payment as well as guidance on a phased introduction of new provider payment systems for PHC and hospitals; • Development of a “Concept of PHC Financing Reform” that includes a detailed methodology for the calculation of per capita rate and risk adjustment coefficients based on age and sex of the population; • Refinement of a computerized database to capture patient discharge information to better inform design of case-based hospital payment systems; and • Development of a concept for a unified health information system (HIS). 2. Helped to establish a supportive policy framework for health reform and PHC strengthening, by: • Conducting a number of assessments or studies to improve the evidence base for policies and strategies, including: o Stakeholder analysis on attitudes toward PHC and Family Medicine (FM); o Rational drug use survey; and o Internal assessment of TB indicators and services. • Facilitating the establishment of working groups to improve policy dialogue and coordination among stakeholders and development partners: o Working Group on Preparation of New Health Financing System led by MoH; PHCS Project: Year 2 Annual Report 4 o Regular interagency coordination meetings on Health Communication led by National Center for Public Health and Reform (NCPHR); o TB Interagency Working Group led by National TB Program (NTP); and o Working groups for development of specific clinical practice guidelines (CPGs). • Helping to draft or improve a number of policies, strategies, and documents, including: o The Program of Implementation of the New Health Care Finance System and Mandatory Health Insurance (includes Concept of PHC Financing Reform); o Concept for Unified HIS; o Essential Drug List; o National Drug Formulary; o National Health Communication Concept; o National TB Strategy; o MDR-TB Program Implementation Plan; o Health Care System in Transition (HiT) for Azerbaijan; o Health financing indicators for Health System Performance Assessment Framework; and o Health communication newsletters. 3. Supported continued introduction of evidence-based medicine (EBM), development of CPGs, and rational drug use (RDU) to improve the content of clinical practice at the PHC level resulting in: • Ongoing support to NCPHR to facilitate CPG development process (e.g., setting priorities for CPG development, identifying working group members, establishing working groups, etc.); • Significant contribution to the development/revision of 7 CPGs; • Establishment and training of District Monitoring Teams (DMTs) in 5 pilot districts; • More than 250 PHC providers in pilot districts trained in approved CPGs for acute respiratory infection (ARI), hypertension, peptic ulcer, and iron-deficient anemia; • Development and dissemination of patient education materials for anemia and ARI; • Introduction of quality improvement approaches and monitoring indicators in PHC facilities in pilot districts, and improvements in completeness of patient records; and • Documented improvements in quality of care in pilot PHC facilities in line with approved CPGs, as evidenced by increased routine screening for hypertension, reductions in unnecessary antibiotic prescribing for ARI, and improved drug prescribing for adults diagnosed with asthma. 4. Built capacity for health sector stakeholders through round tables, trainings, and workshops to empower them to design and implement health reform interventions, on topics including: o Health financing and health systems strengthening o PHC o EBM and CPG development o Health communication PHCS Project: Year 2 Annual Report 5 This annual report covers the period from September 1, 2008 – August 31, 2009, and includes a summary of key achievements by component, results against monitoring indicators, success stories, and lessons learned during Year 2 of project implementation. PHCS Project: Year 2 Annual Report 6 COMPONENT SUMMARIES This section provides a detailed description of progress on PHCS interventions achieved in Year 2 under the Project’s five components. In Year 2, PHCS continued to work closely with the MoH, its institutional structures, and other national stakeholders to develop capacity to identify key policy options for strengthening health financing and the organization and delivery of PHC and to develop strategies and programs for the successful testing and implementation of selected options. Because fundamental reform of the hospital and specialist-oriented health system inherited from the Soviet Union is still in its early stages in Azerbaijan, the Project concentrated on assisting the government in the development of national-level health policy and financing changes, while simultaneously testing critical interventions