2008年-世界发展银行全球_Republic_of_Tajikistan___Health_Sector_Fiduciary_Capacity_Assessment_Report_81页_1mb

报告摘要

To assess the fiduciary capacity in the health sector of Tajikistan.
To identify weaknesses in financial management and procurement.
To recommend short-term and medium-term action plans for capacity building.
To support the Government of Tajikistan (GOT) in improving the management of public and donor resources in the health sector.

Central Level: Ministry of Health (MOH), Center for State Sanitary-Epidemiological Surveillance (SES), and a central hospital.
Oblast Level: Khatlon and Sogd oblasts, including their administrations, SESs, and hospitals in Kurgan-Tyube and Khudjand.
Rayon Level: Three rayons in each oblast, including Spitamen, Gonchi, and Zafarabad in Sogd; Dangara, Kabodiyon, and Kurgan-Tyube in Khatlon; and two Rayons of Republican Subordination (Vahdat and Rudaki).
Local Level: Rural health centers, polyclinics, and health houses (HH) providing primary care.

Fiduciary capacity building in the health sector is weak.
Reforms in financial management (FM) and public procurement are ongoing, mainly supported by donors.
The Ministry of Finance (MOF) is the main driver of PFM reforms, but the health sector is not a specific focus.
The MTEF (Medium-Term Expenditure Framework) is being introduced, but implementation is limited.
The health sector lacks transparency, accountability, and effective internal controls.

Informal payments constitute a significant portion of health expenditures.
The current Public Procurement Law (PPL) is not fully implemented.
Procurement practices vary across levels and institutions.
The health sector suffers from poor infrastructure, weak institutions, and inadequate staffing, especially in rural areas.

FM reforms are ongoing at the central level, driven by donor-supported initiatives.
The MOH has limited capacity in financial management, including internal control and monitoring.
Budgets and strategies are not well linked.
Discretionary powers of public health officials are extensive, but accountability is weak.
Donor-funded projects are managed outside the health sector, leading to limited reform in FM systems.

Public procurement reform was initiated in 1995 and the first PPL enacted in 1997, but it had significant deficiencies.
A new PPL was introduced in 2006, aligning with international standards.
However, the decentralization provisions of the PPL have not been implemented, and procurement remains centralized in the Agency on Procurement (PA).
Procurement practices in the health sector are inconsistent and lack transparency.
The absence of non-commercial procurement entities forces state health facilities to purchase from commercial organizations at higher prices.

Procurement of pharmaceuticals is distinct due to shelf-life limitations, storage needs, and quality control.
Some facilities procure through the Republican Medicines and Medical Commodities Procurement Center (RMMCPC), while others purchase directly from private pharmacies.
The lack of non-commercial entities leads to the procurement of low-quality drugs at high prices.

The health sector is vulnerable to corruption due to:
- Complexity of the system and information asymmetry between providers and users.
- Poor record-keeping and inefficient markets.
- Informal payments constitute 70% of health expenditures.
The GOT has initiated a pilot scheme to transition informal payments to a formal co-payment system.
Addressing corruption requires a holistic approach, including:
- Reforming budgetary allocations.
- Restructuring payment systems.
- Introducing anti-corruption measures.
- Encouraging private alternatives and improving accountability.

Action 1: Create a special task force for MTEF implementation.
Action 2: Provide regular accounting training to MOH FM staff.
Action 3: Prepare a manual on financial management for donor-funded activities.
Action 4: Create a procurement division in the MOH and strengthen the Capital Construction Department (CCD).
Action 5: Appoint two consultants to support procurement functions.
Action 6: Provide training in national and international procurement and CCD.
Action 7: Provide training to the Department of Pharmacy and the RMMCPC on pharmaceutical procurement.
Action 8: Provide short procurement training to all MOH staff.
Action 9: Provide office and training equipment for procurement division and CCD.
Action 10: Prepare an anti-corruption action plan for the health sector.
Action 11: Develop a website at the MOH for dissemination of laws, regulations, and tender notices.
Estimated Cost: US$306,000.

Action 1: Create a task force for MTEF introduction at oblast level.
Action 2: Issue sectoral budget guidelines following MOF guidelines.
Action 3: Issue a decree on regulation of reallocation of salary funds.
Action 4: Issue a decree on competitive and fair staff selection.
Action 5: Translate MOF essential laws and regulations into Tajik.
Action 6: Introduce unified financial reporting formats.
Action 7: Provide computers for central rayon hospitals.
Action 8: Install accounting software across the health sector.
Action 9: Prepare health-sector specific procurement manuals and standard bidding documents.
Action 10: Build procurement capacity at oblast and rayon levels.
Action 11: Disseminate procurement laws, regulations, and documents to all health sector staff.
Action 12: Organize two seminars on pharmaceutical procurement.
Estimated Cost: US$717,600.

A team of senior officials, led by a Deputy Minister, is recommended to oversee the implementation.
The Department of Reform and International Relations, designated by the Minister, will handle day-to-day implementation and coordination.
Capacity building of this department is necessary, possibly through the hiring of a local consultant.
Support will be provided by other MOH divisions, such as the procurement and accounting divisions.
International and local consultants will be contracted to implement various fiduciary capacity building activities.
The goal is to eventually integrate local consultants into MOH departments for sustainability.

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