Millions of dollars are invested annually under the umbrella of national health systems strengthening. Global health initiatives provide funding for low- and middle-income countries through disease-oriented programmes while maintaining that the interventions simultaneously strengthen systems. However, it is as yet unclear which, and to what extent, system-level interventions are being funded by these initiatives, nor is it clear how much funding they allocate to disease-specific activities – through conventional ‘vertical-programming’ approach. Such funding can be channelled to one or more of the health system building blocks while targeting disease(s) or explicitly to system-wide activities.
We operationalized the World Health Organization health system framework of the six building blocks to conduct a detailed assessment of Global Fund health system investments. Our application of this framework framework provides a comprehensive quantification of system-level interventions. We applied this systematically to a random subset of 52 of the 139 grants funded in Round 8 of the Global Fund to Fight AIDS, Tuberculosis and Malaria (totalling approximately US$1 billion).
According to the analysis, 37% (US$ 362 million) of the Global Fund Round 8 funding was allocated to health systems strengthening. Of that, 38% (US$ 139 million) was for generic system-level interventions, rather than disease-specific system support. Around 82% of health systems strengthening funding (US$ 296 million) was allocated to service delivery, human resources, and medicines & technology, and within each of these to two to three interventions. Governance, financing, and information building blocks received relatively low funding.
This study shows that a substantial portion of Global Fund’s Round 8 funds was devoted to health systems strengthening. Dramatic skewing among the health system building blocks suggests opportunities for more balanced investments with regard to governance, financing, and information system related interventions. There is also a need for agreement, by researchers, recipients, and donors, on keystone interventions that have the greatest system-level impacts for the cost-effective use of funds. Effective health system strengthening depends on inter-agency collaboration and country commitment along with concerted partnership among all the stakeholders working in the health system.
Aligned with the international call for universal coverage of affordable and quality health care, the government of Tajikistan is undertaking reforms of its health system aiming amongst others at reducing the out-of-pocket expenditures (OPE) of patients seeking care. Household surveys were conducted in 2005, 2007, 2008 and 2011 to explore the scale and determinants of OPE of users in four district of Tajikistan, where health care is legally free of charge at the primary level.
Using the data from four cross-sectional household surveys conducted between 2005 and 2011, time trends in OPE for consultation fees, drugs and transport costs of adult users of family medicine services were analysed. To investigate differences along the economic status, an asset index was constructed using principal component analysis.
Adjusted for inflation, OPE for primary care have substantially increased in the period 2005 to 2011. While the proportion of patients reporting the payment of informal consultation fees to providers and their amount were constant over time, the proportion of patients reporting expenditures for drugs has increased, and the median amounts have doubled from 5.3 US$ to 10.7 US$. Thus, the expenditures on medicine represent the biggest financial burden for patients accessing a primary care facility. Regression models showed that in 2011 patients from the most remote district with spread-out villages reported significant higher expenditures on medicine. Besides the steady increase in the median amount for OPE, the proportion of patients reporting making an informal payment to their care provider showed great variations across district of residence (between 20% and 73%) and economic status (between 33% among the ‘worst-off’ group and 68% among the ‘better-off’ group).
In a context of limited governmental funds allocated to health and financing reforms aiming to improve financial access to primary care, the present paper indicates that in Tajikistan OPE – especially in relation to expenditures for drugs – have increased over time, and vary substantially across geographical areas and economic status. The fact that better-off households report disbursing more and in higher proportions hints towards a discrimination along the capacity to pay from providers. Increased public investments in the health sector, incentives for family doctors to provide PHC services free of charge and a strengthened drug control and supply system are necessary strategies to improve access of patients to services.
Tajikistan; Informal payments; Out-of-pocket expenditure; Family medicine; Health reforms
In the first paper in a three-part series on health systems guidance, Xavier Bosch-Capblanch and colleagues examine how guidance is currently formulated in low- and middle-income countries, and the challenges to developing such guidance.
Recent years have seen an unprecedented increase in funds for procurement of health commodities in developing countries. A major challenge now is the efficient delivery of commodities and services to improve population health. With this in mind, we documented staffing levels and productivity in peripheral health facilities in southern Tanzania.
A health facility survey was conducted to collect data on staff employed, their main tasks, availability on the day of the survey, reasons for absenteeism, and experience of supervisory visits from District Health Teams. In-depth interview with health workers was done to explore their perception of work load. A time and motion study of nurses in the Reproductive and Child Health (RCH) clinics documented their time use by task.
We found that only 14% (122/854) of the recommended number of nurses and 20% (90/441) of the clinical staff had been employed at the facilities. Furthermore, 44% of clinical staff was not available on the day of the survey. Various reasons were given for this. Amongst the clinical staff, 38% were absent because of attendance to seminar sessions, 8% because of long-training, 25% were on official travel and 20% were on leave. RCH clinic nurses were present for 7 hours a day, but only worked productively for 57% of time present at facility. Almost two-third of facilities had received less than 3 visits from district health teams during the 6 months preceding the survey.
This study documented inadequate staffing of health facilities, a high degree of absenteeism, low productivity of the staff who were present and inadequate supervision in peripheral Tanzanian health facilities. The implications of these findings are discussed in the context of decentralized health care in Tanzania.
As countries strive to strengthen their health systems in resource constrained contexts, policy makers need to know how best to improve the performance of their health systems. To aid these decisions, health system stewards should have a good understanding of how health systems operate in order to govern them appropriately. While a number of frameworks for assessing governance in the health sector have been proposed, their application is often hindered by unrealistic indicators or they are overly complex resulting in limited empirical work on governance in health systems. This paper reviews contemporary health sector frameworks which have focused on defining and developing indicators to assess governance in the health sector. Based on these, we propose a simplified approach to look at governance within a common health system framework which encourages stewards to take a systematic perspective when assessing governance. Although systems thinking is not unique to health, examples of its application within health systems has been limited. We also provide an example of how this approach could be applied to illuminate areas of governance weaknesses which are potentially addressable by targeted interventions and policies. This approach is built largely on prior literature, but is original in that it is problem-driven and promotes an outward application taking into consideration the major health system building blocks at various levels in order to ensure a more complete assessment of a governance issue rather than a simple input-output approach. Based on an assessment of contemporary literature we propose a practical approach which we believe will facilitate a more comprehensive assessment of governance in health systems leading to the development of governance interventions to strengthen system performance and improve health as a basic human right.
Intestinal parasitic infections represent a public health problem in Tajikistan, but epidemiological evidence is scarce. The present study aimed at assessing the extent of helminths and intestinal protozoa infections among children of 10 schools in four districts of Tajikistan, and to make recommendations for control.
A cross-sectional survey was carried out in early 2009. All children attending grades 2 and 3 (age: 7-11 years) from 10 randomly selected schools were invited to provide a stool sample and interviewed about sanitary situation and hygiene behaviour. A questionnaire pertaining to demographic and socioeconomic characteristics was addressed to the heads of households. On the spot, stool samples were subjected to duplicate Kato-Katz thick smear examination for helminth diagnosis. Additionally, 1-2 g of stool was fixed in sodium acetate-acetic acid-formalin, transferred to a specialised laboratory in Europe and examined for helminths and intestinal protozoa. The composite results from both methods served as diagnostic 'gold' standard.
Out of 623 registered children, 602 participated in our survey. The overall prevalence of infection with helminths and pathogenic intestinal protozoa was 32.0% and 47.1%, respectively. There was pronounced spatial heterogeneity. The most common helminth species was Hymenolepis nana (25.8%), whereas the prevalences of Ascaris lumbricoides, hookworm and Enterobius vermicularis were below 5%. The prevalence of pathogenic intestinal protozoa, namely Giardia intestinalis and Entamoeba histolytica/E. dispar was 26.4% and 25.9%, respectively. Almost half of the households draw drinking water from unimproved sources, such as irrigation canals, rivers and unprotected wells. Sanitary facilities were pit latrines, mostly private, and a few shared with neighbours. The use of public tap/standpipe as a source of drinking water emerged as a protective factor for G. intestinalis infection. Protected spring water reduced the risk of infection with E. histolytica/E. dispar and H. nana.
Our data obtained from the ecological 'lowland' areas in Tajikistan call for school-based deworming (recommended drugs: albendazole and metronidazole), combined with hygiene promotion and improved sanitation. Further investigations are needed to determine whether H. nana represents a public health problem.
Tuberculosis (TB) control is based on early detection and complete treatment of infectious cases. Consequently, it is important that TB suspects and patients can readily access medical care. This qualitative study investigated determinants of access to DOTS services as identified by patients, health providers and community members in four districts in Tajikistan.
Focus group discussions were conducted in order to investigate access to TB services. A conceptual framework for access to care guided the analysis. Thirteen focus group discussions involving a total of 97 informants were conducted. Content analysis of discussions and a rating to quantify the relative importance of discussed factors were carried out. The conceptual framework identifies five main components of access to which factors can be assigned: availability, adequacy, acceptability, accessibility and affordability.
Financial factors were considered the most important determinants of access to diagnosis and treatment of tuberculosis. Expenditure for drugs and consultations, for transport, and for special foods as well as lost income were identified as major barriers to treatment. Stigma, doubts about curability and low perceived quality of care were not seen to be significant determinants of access to care for tuberculosis. Community members were well aware of symptoms of tuberculosis and of medical services. These findings were consistent between different respondent groups (community members, patients and providers). They were also highly consistent between the open discussion and the confidential rating.
Illness-costs to households were identified as the main barrier to tuberculosis diagnosis and treatment. To improve access and ultimately adherence to tuberculosis treatment, effective mitigation strategies, e.g. changes in case management, food contributions or financial stimuli, need to be explored and implemented.
Illness-related costs incurred by patients constitute a severe economic burden for households especially in low-income countries. High household costs of illness lead to impoverishment; they impair affordability and equitable access to health care and consequently hamper tuberculosis (TB) control. So far, no study has investigated patient costs of TB in the former Soviet Union.
All adult new pulmonary TB cases enrolled into the DOTS program in 12 study districts during the study period were enrolled. Medical and non-medical expenditure as well as loss of income were quantified in two interviews covering separate time periods. Costs of different items were summed up to calculate total costs. For missing values, multiple imputation was applied.
A cohort of 204 patients under DOTS, 114 men and 90 women, participated in the questionnaire survey. Total illness costs of a TB episode averaged $1053 (c. $4900 purchasing power parity, PPP), of which $292, $338 and $422 were encountered before the start of treatment, during intensive phase and in continuation phase, respectively. Costs per month were highest before the start of treatment ($145) and during intensive phase ($153) and lower during continuation phase ($95). These differences were highly significant (paired t-test, p < 0.0005 for both comparisons).
The illness-related costs of an episode of TB exceed the per capita GDP of $1600 PPP about two-and-a-half times. Hence, these costs are catastrophic for concerned households and suggest a high risk for impoverishment. Costs are not equally spread over time, but peak in early stages of treatment, exacerbating the problem of affordability. Mitigation strategies are needed in order to control TB in Tajikistan and may include social support to the patients as well as changes in the management of TB cases. These mitigation strategies should be timed early in treatment when the cost burden is highest.
Tajikistan has the highest incidence rate of tuberculosis (TB) in Central Asia. Its health system still bears many features from Soviet times and is under-funded. Affordability is a major barrier to health care. Little is known about health care seeking of TB patients in post-Soviet countries and their delay until the start of TB therapy. The low estimated case detection rate in Tajikistan suggests major problems with access to care and consequently long delays are likely.
The study investigated extent and determinants of patient and health system delays for TB. A questionnaire was administered to a cohort of TB patients in twelve study districts representing a wide range of conditions found in Tajikistan. Common patterns of health care seeking were analysed. Cox proportional hazards models using eight predictor variables, including characteristics of health services delivery, were built to identify determinants of patient and health system delays.
Two-hundred-and-four TB patients were interviewed. A common pattern in treatment-seeking was visiting a specialised TB facility at some stage. Typical delays until start of TB therapy were moderate and did not confirm the expectation of long delays. Median patient, health system and total delays to TB treatment were 21.5, 16 and 52 days, respectively. None of the investigated predictors was significantly associated with patient delay. The type of facility, where patients made their first contact with the health system, was the main determinant of health system delay (p < 0.00005). We show for the first time that patients who had fallen ill and first presented to health care in Russia had the longest delays. Those who first presented to peripheral primary care facilities also had relatively long delays.
While overall delays were moderate, further improvement is needed for different subgroups. An international referral system between Russia and Tajikistan to reduce delays of Tajik migrants who develop active TB in Russia is urgently needed and would benefit both countries. Within Tajikistan, diagnostic pathways for patients in the periphery should be shortened. To achieve this, strengthening of sputum smear examination possibly including collection of sputa at peripheral primary care facilities may be needed.
Recent years have seen growing awareness of the importance of human resources for health in health systems and with it an intensifying of the international and national policies in place to steer a response. This paper looks at how governments and donors in five countries – Cameroon, Indonesia, Malawi, Rwanda and Tanzania – have translated such policies into action. More detailed information with regard to initiatives of German development cooperation brings additional depth to the range and entry doors of human resources for health initiatives from the perspective of donor cooperation.
This qualitative study systematically presents different approaches and stages to human resources for health development in a cross-country comparison. An important reference to capture implementation at country level was grey literature such as policy documents and programme reports. In-depth interviews along a predefined grid with national and international stakeholders in the five countries provided information on issues related to human resources for health policy processes and implementation.
All five countries have institutional entities in place and have drawn up national policies to address human resources for health. Only some of the countries have translated policies into strategies with defined targets and national programmes with budgets and operational plans. Traditional approaches of supporting training for individual health professionals continue to dominate. In some cases partners have played an advocacy and technical role to promote human resources for health development at the highest political levels, but usually they still focus on the provision of ad hoc training within their programmes, which may not be in line with national human resources for health development efforts or may even be counterproductive to them. Countries that face an emergency, such as Malawi, have intensified their efforts within a relatively short time and by using donor funding support also through new initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.
The country case studies illustrate the range of initiatives that have surged in recent years and some main trends in terms of donor initiatives. Though attention and priority attributed to human resources for health is increasing, there is still a focus on single initiatives and programmes. This can be explained in part by the complexity of the issue, and in part by its need to be addressed through a long-term approach including public sector and salary reforms that go beyond the health sector.
Bioterrorism and preparedness; disease outbreaks; communicable disease control; quarantine; patient isolation; information dissemination; travel; transportation; public health practice; letter
Reported malaria cases in rice growing areas in western Tajikistan were at the root of a rapid appraisal of the local malaria situation in a selected agro-ecological setting where only scarce information was available. The rapid appraisal was complemented by a review of the epidemiology and control of malaria in Tajikistan and Central Asia from 1920 until today. Following a resurgence in the 1990s, malaria transmission has been reduced considerably in Tajikistan as a result of concerted efforts by the government and international agencies. The goal for 2015 is transmission interruption, with control interventions and surveillance currently concentrated in the South, where foci of Plasmodium vivax and Plasmodium falciparum persist.
The rapid malaria appraisal was carried out in six communities of irrigated rice cultivation during the peak of malaria transmission (August/September 2007) in western Tajikistan. In a cross-sectional survey, blood samples were taken from 363 schoolchildren and examined for Plasmodium under a light microscope. A total of 56 farmers were interviewed about agricultural activities and malaria. Potential Anopheles breeding sites were characterized using standardized procedures. A literature review on the epidemiology and control of malaria in Tajikistan was conducted.
One case of P. vivax was detected among the 363 schoolchildren examined (0.28%). The interviewees reported to protect themselves against mosquito bites and used their own concepts on fever conditions, which do not distinguish between malaria and other diseases. Three potential malaria vectors were identified, i.e. Anopheles superpictus, Anopheles pulcherrimus and Anopheles hyrcanus in 58 of the 73 breeding sites examined (79.5%). Rice paddies, natural creeks and man-made ponds were the most important Anopheles habitats.
The presence of malaria vectors and parasite reservoirs, low awareness of, and protection against malaria in the face of population movements and inadequate surveillance may render local communities vulnerable to potential epidemics. To attain malaria transmission interruption in Tajikistan by 2015, there is a need for rigorous surveillance along with strengthening of primary health care facilities for effective case management, and possibly a more differentiated vector control strategy based on additional local evidence.
In Tajikistan it is estimated that out of pocket payments constitute two-thirds of all health spending with high proportions of these contributions through informal payments. As a consequence, access to basic care is a major concern particularly among the most needy and vulnerable groups.
This article evaluates accessibility of prescription medicines and patient expenditures for primary care services in two rural districts of Tajikistan.
901 patients aged 18 years or above who had accessed primary care facilities were interviewed, using a questionnaire based on questions regarding patient's experience of visiting the health facility. To group respondents by socio-economic status, an asset index was created using principal component analysis of the information included in the questionnaires.
76.7% of patients were prescribed a medicine during the visits and more than 83% of them managed to obtain it. Patients spent on average US$ 9.3 on medicines, with wide variation among socio-economic groups. Around 45% of patients paid the Family Doctor. Additionally, over 41% of patients in the highest socioeconomic quintile were referred to a specialist, while only 29% of the poorest 40%.
This survey showed that there are financial barriers potentially inactivating utilization of basic services. These barriers can only be reduced by mobilizing more public resources to fund the health sector, providing incentives for family doctors to stop requiring payments from patients, and increasing the availability of prescription drugs in PHC facilities.
Vaccinating nomadic pastoralists and their livestock at the same time reduces delivery costs.
Vaccination services for people and livestock often fail to achieve sufficient coverages in Africa’s remote rural settings because of financial, logistic, and service delivery constraints. In Chad from 2000 through 2005, we demonstrated the feasibility of combining vaccination programs for nomadic pastoralists and their livestock. Sharing of transport logistics and equipment between physicians and veterinarians reduced total costs. Joint delivery of human and animal health services is adapted to and highly valued by hard-to-reach pastoralists. In intervention zones, for the first time ≈10% of nomadic children (>1–11 months of age) were fully immunized annually and more children and women were vaccinated per day during joint vaccination rounds than during vaccination of persons only and not their livestock (130 vs. 100, p<0.001). By optimizing use of limited logistical and human resources, public health and veterinary services both become more effective, especially at the district level.
Vaccination delivery; children; women; livestock; remote rural zones; measles; polio; anthrax; synopsis
During the Soviet era, malaria was close to eradication in Tajikistan. Since the early 1990s, the disease has been on the rise and has become endemic in large areas of southern and western Tajikistan. The standard national treatment for Plasmodium vivax is based on primaquine. This entails the risk of severe haemolysis for patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Seasonal and geographical distribution patterns as well as G6PD deficiency frequency were analysed with a view to improve understanding of the current malaria situation in Tajikistan.
Spatial and seasonal distribution was analysed, applying a risk model that included key environmental factors such as temperature and the availability of mosquito breeding sites. The frequency of G6PD deficiency was studied at the health service level, including a cross-sectional sample of 382 adult men.
Analysis revealed high rates of malaria transmission in most districts of the southern province of Khatlon, as well as in some zones in the northern province of Sughd. Three categories of risk areas were identified: (i) zones at relatively high malaria risk with high current incidence rates, where malaria control and prevention measures should be taken at all stages of the transmission cycle; (ii) zones at relatively high malaria risk with low current incidence rates, where malaria prevention measures are recommended; and (iii) zones at intermediate or low malaria risk with low current incidence rates where no particular measures appear necessary. The average prevalence of G6PD deficiency was 2.1% with apparent differences between ethnic groups and geographical regions.
The study clearly indicates that malaria is a serious health issue in specific regions of Tajikistan. Transmission is mainly determined by temperature. Consequently, locations at lower altitude are more malaria-prone. G6PD deficiency frequency is too moderate to require fundamental changes in standard national treatment of cases of P. vivax.
Rural African communities, especially those that are nomadic, often have poor access to health care. Collaboration with other services could help improve coverage
For any wide-ranging effort to scale up health-related priority interventions, human resources for health (HRH) are likely to be a key to success. This study explores constraints related to human resources in the health sector for achieving the Millennium Development Goals (MDGs) in low-income countries.
Methods and framework
The analysis drew on information from a variety of publicly-available sources and principally on data presented in published papers in peer-reviewed journals. For classifying HRH constraints an analytical framework was used that considers constraints at five levels: individual characteristics, the health service delivery level, the health sector level, training capacities and the sociopolitical and economic context of a country.
Results and discussion
At individual level, the decision to enter, remain and serve in the health sector workforce is influenced by a series of social, economic, cultural and gender-related determinants. For example, to cover the health needs of the poorest it is necessary to employ personnel with specific social, ethnic and cultural characteristics. At health-service level, the commitment of health staff is determined by a number of organizational and management factors. The workplace environment has a great impact not only on health worker performance, but also on the comprehensiveness and efficiency of health service delivery. At health-sector level, the use of monetary and nonmonetary incentives is of crucial importance for having the accurate skill mix at the appropriate place. Scaling up of priority interventions is likely to require significant investments in initial and continuous training. Given the lead time required to produce new health workers, such investments must occur in the early phases of scaling up. At the same time coherent national HRH policies are required for giving direction on HRH development and linking HRH into health-sector reform issues, the scaling-up of priority interventions, poverty reduction strategies, and training approaches. Multisectoral collaboration and the sociopolitical and economic context of a country determine health sector workforce development and potential emigration.
Key determinants of success for achieving international development goals are closely related to human-resource development.