Scaling up Business Plans in Tajikistan: a qualitative study of the history, barriers, facilitators and lessons learnt.

BACKGROUND: To improve health planning at primary health care (PHC) level, Business Plans were introduced in Tajikistan by the Enhancing Primary Health Care (EPHC) Services Project. OBJECTIVE: To describe the history and process of implementation of Business Plans and to identify barriers, facilitators and lessons learnt from scaling up Business Plans. METHODS: Set in a qualitative research design, we conducted a desk review of project and official documents and seventeen semi-structured interviews with key stakeholders at national and sub-national levels between May and July 2020. We used an interview guide informed by the ExpandNet/WHO framework and analyzed the data following a content analysis approach facilitated by MAXQDA. RESULTS: With the participation of various user organizations and resource teams and through a variety of strategic scale-up choices, Business Plans have been scaled up from a vertical pilot project to institutionalized health management tools covering 45% of Tajikistan's PHC facilities. The most prominent facilitators for scaling up Business Plans were the institutionalization and integration of the tool into the Tajik health system, the close collaboration with Community Health Teams (CHTs), the high acceptance of the tool among the users, the advocacy through champions and policy-makers and the large dissemination network. The most outstanding barriers to scaling up Business Plans were insufficient financial or human resources, general weaknesses in health governance, the lack of a strategic scale-up plan and strategic decisions, the lack of motivation or overall vision to implement Business Plans at a large scale and difficulties in donor coordination. CONCLUSION: To ensure the continuity of scaling up Business Plans, developing a scale-up strategy, strengthening cross-sectoral collaboration and participation during scaling up, and capacitating the user organizations of Business Plans are important next steps to ensure the sustainability and effectiveness of Business Plans in the future.

Out of pocket expenditures of patients with a chronic condition consulting a primary care provider in Tajikistan: a cross-sectional household survey.

BACKGROUND: Within its reform efforts, the Government of Tajikistan is embracing the essential role of primary health care (PHC) in decreasing out of pocket (OOP) expenditures and increasing equity in access to health services. In the light of the increasing burden of disease relating to chronic conditions, we investigated OOP expenditures of patients with chronic conditions within a PHC setting; and if and how those expenditures are impacted by several interventions currently being implemented within Tajikistan. METHODS: A cross-sectional survey among 1600 adult patients who had visited a PHC facility was conducted. The data obtained through interviews were descriptively analysed, and logistic regressions and gamma generalized linear models were performed. RESULTS: The total OOP expenditures related to a patient's last visit to the PHC facility were 17.2 USD for those with chronic conditions and 13.9 USD for those visiting due to an acute condition. Adjustment for potential confounders reduced the discrepancy from 3.3 USD to 0.5 USD. This convergence of costs was only observed in districts covered by the Basic Benefit Package (BBP), a governmental pilot project, aiming to standardise exemptions for payment and formal co-payments for health care services. Hence, we found the BBP to have a protective impact for patients with chronic conditions. However, considering the demographics of these patients (older in age, with greater dependency on pensions and social aid, and lower socio-economic status) in combination with the 40% higher utilisation rate of PHC and the high rate of onward referrals to specialists; it is clear that patients with chronic conditions continue to face substantial long-term costs and disadvantages. CONCLUSIONS: After accounting for confounders, patients with chronic and acute conditions faced similar costs related to a single visit to a PHC facility in districts covered by the BBP. However, greater efforts are required to ensure that citizens are well informed about their rights to health care, the BBP and the services that should be provided at no cost at the point of delivery. Moreover, the needs of patients with chronic conditions warrant a more integrative approach that takes long-term expenditures and services beyond the level of PHC into account.

Drug prescribing patterns at primary health care level and related out-of-pocket expenditures in Tajikistan.

BACKGROUND: The Government of Tajikistan is reforming its health system to make access more equitable. Nonetheless, out-of-pocket expenditures (OPE) remain a key modality for purchasing health care. Drugs remain a major driver of household expenditures for health. We conducted a household survey to investigate drug prescribing patterns at primary health care (PHC) level as well as the related OPE. METHODS: Adult patients in eight districts who had visited a PHC facility in the period March to May 2014 were interviewed at home, using a structured questionnaire. A descriptive analysis was conducted and regression models were constructed to identify factors influencing the number of drugs provided and the types of drugs prescribed. RESULTS: There were 1281 (80.1 %) patients who received a drug prescription after visiting a doctor at PHC level. 16.2 % of them had five or more drugs prescribed concomitantly. The number of drugs prescribed to patients ranged from 0 to 8 and was statistically different across regions (RRS region =3.3; Khatlon region = 3.1; p = 0.05), after adjusting for age and sex. In 31.1 % of cases, prescriptions included an intra-venous (IV) injection; in 45.6 % of cases, a non-IV injection; in 52.9 % of cases, an antibiotic; and in 61.0 % of cases, vitamins. Patients suffering from a respiratory disease had higher odds of being prescribed an IV injection and antibiotics. Vitamins were widely prescribed across all diseases. In 94.5 % of cases, the patients interviewed procured at least one of the prescribed drugs. Among those who received a prescription, 2.0 % were not able to procure at least one drug due to a lack of money. In 94.9 % of cases, respondents reported purchasing drugs in private pharmacies. Median expenditures for drugs procured following consultation were 45 TS (US$ 6.9) corresponding to 77.6 % of total expenditures related to the visit (58 TS, US$ 8.8). CONCLUSIONS: In a context where OPE are important, drugs represent an important income source for health service providers. Such a situation does not favour rational prescribing nor efficient service delivery, and is potentially harmful for patients. In particular, the economic ramifications cause high levels of expenditure for patients and households with detrimental, knock-on effects in the more vulnerable segments of the population.

Prevalence of impaired glucose metabolism and potential predictors: a rapid appraisal among ≥ 45 years old residents of southern Tajikistan.

BACKGROUND: An estimated 2% of all deaths in Tajikistan can be attributed to diabetes but reliable data are scarce for the country and across Central Asia. We assessed the prevalence of impaired glucose tolerance and diabetes and associated predictors among residents aged ≥ 45 years in two districts in southern Tajikistan. METHODS: A population-representative survey following the WHO STEPwise approach to surveillance and including a two-stage cluster sampling was conducted. Enrolled participants were asked about risk factors for diabetes, and blood pressure, height and weight were measured. The blood glucose level was determined after overnight fasting, and the 2 h oral glucose tolerance test was performed if indicated. RESULTS: Complete datasets were available for 584 out of 672 study participants. One third of the cohort was male and half were 45-54 years old. Overall, 21.2% of the participants were found to be diabetic, 5.1% had impaired glucose tolerance and 4.3% impaired fasting glucose. An elevated body mass index ≥ 25 was observed in 61.5% of the cohort and an elevated blood pressure in 45.6% (systolic, cut-off 140 mm Hg) and 52.3% (diastolic, cut-off 90 mm Hg) respectively. Half of the participants classified as diabetic were aware of their status. CONCLUSIONS: Impaired glucose tolerance and overweight are common among elderly residents of southern Tajikistan. Primary health care services should be strengthened to improve early detection and ensure adequate treatment of diabetes and quality of care. Community-based awareness rising about available peripheral services is crucial.

Iodine nutritional status and risk factors for goitre among schoolchildren in South Tajikistan.

BACKGROUND: Iodine deficiency affects nearly 1.9 billion people worldwide, but it can be prevented by salt iodization. This cross-sectional survey assessed current iodine status, iodized salt coverage and risk factors for goitre among schoolchildren in South Tajikistan. METHODS: Ten primary schools in four districts in South Tajikistan were randomly selected. In schoolchildren aged 7 to 11 years, a spot urine sample was collected for measurement of urinary iodine, dried blood spots were collected for measurement of thyroglobulin, and goitre was assessed by palpation. Iodine content of salt samples and local selling points was determined by coloration using rapid test kits and titration method. RESULTS: Of 623 schoolchildren enrolled, complete data was obtained from 589. The overall median urinary iodine concentration (UIC) was 51.2 µg/L indicating mild-to-moderate iodine deficiency. Among all children, 46.6% (95% Confidence Interval (CI) = 42.4%-50.6%) of children were found to be goitrous (grade 1 goitre: 30.6%, 95% CI = 26.9%-34.5%; grade 2 goitre: 16.0%, 95% CI = 13.1%-19.2%). The risk factor for goitre remaining significant in the multivariable logistic regression model was 'buying salt once a month' (OR = 2.89, 95% CI = 1.01-8.22) and 'buying salt once every six months' (OR = 2.26, 95% CI = 1.01-5.04) compared to 'buying salt every one or two weeks'. The overall median thyroglobulin concentration was elevated at 13.9 µg/L. Of the salt samples from households and selling points, one third were adequately iodised, one third insufficiently and one third were not iodised. CONCLUSION: Iodine deficiency remains a serious health issue among children in southern Tajikistan. There is a persisting high prevalence of goitre, elevated thyroglobulin and low UIC despite interventions implemented by Tajikistan and international partners. Quality control of salt iodine content needs to be improved. Continued efforts to raise awareness of the health effects of iodine deficiency are needed to increase consumer demand for iodised salt.

Prevalence and risk factors of helminths and intestinal protozoa infections among children from primary schools in western Tajikistan.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.