2013年-世界发展银行全球_Tajikistan___Review_of_Public_Expenditures_on_Health_44页_1mb

Summary of Tajikistan Policy Notes on Public Expenditures: Review of Public Expenditures on Health

Core Content

This policy note provides an analysis of public expenditures on health in Tajikistan, focusing on institutional structures, health outcomes, financing trends, and reform initiatives. It outlines key challenges and recommendations for improving the efficiency and equity of the health system.

Main Messages

• Mixed Progress in Health Outcomes: Tajikistan has seen improvements in life expectancy and reduced infant and maternal mortality rates over the past two decades, but under-five and adult male mortality rates remain higher than in comparator countries. The incidence of tuberculosis has more than doubled since the 1990s.
• Low and Inefficient Public Health Spending: Public health spending in Tajikistan is among the lowest in the region, at 2% of GDP in 2012. The allocation is inefficient, with a heavy reliance on hospitals and underutilization of primary health care (PHC).
• High Out-of-Pocket (OOP) Expenditures: OOP spending accounts for three-quarters of total health expenditures, increasing the risk of catastrophic and impoverishing health costs for households.
• Need for Increased Public Spending: To reduce OOP expenditures, public health spending needs to increase. This should be achieved through rationalizing other parts of the government budget and improving efficiency within the health sector.
• Current Financing System is Inefficient: The existing system combines line-item budgets and fee-for-service payments, leading to inefficiencies and unequal access. Reforms are necessary to improve financial sustainability and equity.
• Opportunities for Reform: Pilots of new financing mechanisms, such as result-based financing (RBF) and full capitation for PHC, offer potential for improving efficiency and equity. These mechanisms should be expanded nationwide.

Institutional and Administrative Structure

• The Ministry of Health (MoH) formulates health policy and oversees quality and safety of services, pharmaceuticals, and equipment. It manages specialized facilities and procurement for priority programs.
• Local governments (oblasts and rayons) are responsible for financing and managing most health facilities, with limited institutional capacity.
• Central rayon and city hospitals act as administrators for local health services, with deputies overseeing rural clinics, polyclinics, and maternal-child health services.
• The Ministry of Finance is the main authority for allocating health sector budgets, while the MoH plays a subordinate role in budgetary decisions.
• Parallel health services are managed by other ministries (e.g., Ministry of Defense, Ministry of Internal Affairs) and are directly funded by these entities.

Health Outcomes and Service Utilization

A. Mixed Progress in Health Outcomes

• Life expectancy increased from about 63 years in 1990 to 67.5 years in 2011.
• Infant mortality dropped from 90.6 per 1,000 live births in 1990 to 34 per 1,000 in 2012.
• Under-five mortality decreased from 114.3 per 1,000 to 43 per 1,000.
• Maternal mortality was estimated at 95 per 100,000 in 1990 and 65 per 100,000 in 2010.
• Despite these improvements, Tajikistan still lags behind in meeting the Millennium Development Goal (MDG) for maternal health by 2015.
• Tuberculosis incidence has more than doubled over the past two decades.
• Health workforce is higher per capita compared to other countries in the ECA region, yet health outcomes remain poor.

B. Persistent Inequalities in Service Utilization

• Utilization of adult curative services is highly unequal, with the richest quintile using twice as much outpatient care and three times as much inpatient care as the poorest quintile in 2011.
• Maternal and child health services are more equitably accessed, with 87.5% of women attending prenatal consultations and 72% delivering in hospitals.
• Prenatal care is more utilized by the wealthiest quintile, with 91.2% of women in the highest quintile attending prenatal consultations compared to 84.6% in the lowest.
• Regional disparities are significant, with Khatlon showing greater improvements in maternal health indicators than Sogd.

Health Financing: Composition and Trends

• Public health spending is low, at 2% of GDP in 2012, and remains among the lowest in the region.
• Resource allocation is based on existing infrastructure and line-item budgets, leading to significant disparities between rayons and oblasts.
• Out-of-pocket (OOP) spending dominates health financing, accounting for 75% of total health expenditures, which increases the risk of catastrophic health spending for households.
• Efficiency gains are possible through rationalizing the health delivery system and expanding planned health financing reforms.
• External resource mobilization is limited, and new mechanisms like dedicated taxes or payroll contributions are not feasible.

Health Financing and Organizational Reforms

• Recent health reforms aim to improve financial sustainability by restructuring the oversized hospital network inherited from the Soviet era.
• Key reforms include:
  • Introduction of an explicit Basic Benefits Package (BBP).
  • Implementation of formal co-payments for diagnostic services.
  • Provider payment reforms, such as partial capitation in PHC, case-based hospital payments, and RBF in PHC.
• The Government plans to introduce full capitation and RBF in PHC, and to pool all public health funds at the oblast level.
• RBF pilots with independent verification of results are expected to enhance accountability and transparency in the health sector.
• New financing mechanisms in Sogd oblast offer opportunities to promote equity and rationalize health facilities networks.

Policy Recommendations

• Increase public health expenditures to reduce OOP spending, by rationalizing other parts of the government budget and improving efficiency within the health sector.
• Rationalize the hospital sector, reducing the number of hospitals and beds, and using savings for modernizing remaining facilities.
• Reform hospital payment systems to adopt case-based financing.
• Introduce full per-capita financing for PHC, complemented by RBF to incentivize the delivery of priority services.
• Improve institutional capacity of PHC through the establishment of an effective accounting and expenditure tracking system.
• Promote open enrollment to increase competition and quality among PHC facilities.
• Expand and evaluate new financing mechanisms across the country following successful pilot projects.

Key Information

• Health system structure: Centralized under the MoH, with local governments managing most facilities.
• Health financing trends: OOP spending dominates, with public spending at 2% of GDP in 2012.
• Regional disparities: Sogd and Khatlon show significant differences in health outcomes and service utilization.
• Reforms: RBF, capitation, and case-based financing are being piloted to improve efficiency and equity.
• Challenges: Inefficient resource allocation, high OOP spending, and weak institutional capacity.
• Opportunities: Expanding RBF and capitation models, and improving governance and accountability in the health sector.

Conclusion

The health system in Tajikistan faces significant challenges in terms of financial sustainability, efficiency, and equity. While there have been improvements in some health outcomes, the system remains underfunded and inequitable. Reforms such as result-based financing and capitation models are being piloted and offer potential for better resource allocation and service delivery. Increasing public health spending through rationalization of the budget and strengthening governance are critical steps to achieving more equitable and efficient health care.