Integrated Maternal and

Child Health Project

Republic of Tajikistan
Stakeholder Consultation Workshop
June 13, 2018
Why Integrated Maternal
and Child Health?

Integrated concept for

MCH in Tajikistan

Project Structure

Group Consultations
Why Integrated Maternal
and Child Health?
High Child High Maternal
Mortality Mortality

High Home
Deliveries
 Health System Challenges
EMERGING DEMAND SYSTEM CONSTRAINTS
Unhealthy behaviors &
lifestyle choices Lack of community empowerment
and engagement

Double burden of
disease and morbidity Insufficient financing &
HEALTH Inefficient spending
SYSTEM

Increased need to
self managed care Sub-optimal Health Workforce

Service fragmentation and

Need for cost efficiency inappropriate service delivery
Limited inter sectoral
and accountability
collaboration
WHO Global Strategy on People Centered and
Integrated Health Systems (PCIHS)
Empowering and Strengthening
engaging people and Governance and
communities accountability

1 2
“…the management and
delivery of health services such
Creating
enabling that people receive a
environment continuum of health
promotion, health protection
and disease prevention
services, through the different

4
levels and sites of care within
3 the health system and
according to their needs.”

Reorienting model
Coordinated services
of care
Integrated concept for
MCH in Tajikistan
 How the project intends to move towards
Integrated care?
Empowering and engaging Strengthening Governance
people and communities and accountability

1 2 • Strengthening of Human Resource

Behavior change Planning and Continuous Medical
Communication Education functions
Creating • Enhancement of the Continuous Quality
enabling
environment Improvement and Institutionalization of
Supportive Supervision Systems
• Introduction of case-based financing
3 4
Coordinated services Reorienting model of care

Coordination of primary care and Rationalization/reorganization of district

hospital MCH services at district Human Resource health system (PHC & Hospital) according
level through strengthening of capacity building to the master plan and infrastructure
referral pathways improvement & supply of equipment
 2
Creating
enabling
environment Strengthening
Governance and
accountability
 2 Strengthening Governance and accountability

Strengthening
Human Resource
Enhance
Planning and
Continuous
Professional
Medical Education
Development
System
Function

Institutionalize
Continuous Quality Introduce output /
Improvement & outcome based
Supportive financing modality
Supervision systems
 Creating
enabling
environment

4
Reorienting model of
care
District Health
Master Plan
 Principles of District Health Master
Plan
Current System Future System

Rural Health Houses Rural Health Houses

Rural Health Comprehensive

Centers Rural Health
Rural Primary
Center
Health Center
Numeric Hospitals

District Policlinic District Hospital District Policlinic District Hospital

 Principles of District Health Master Plan
Current System Future System

Integration of
functions
District Policlinic
EPI Center Reproductive
Health Center

Healthy Lifestyle
Center

District Policlinic

Tropical Medicine
Center
TB Center HIV Center
 Principles of District Health Master Plan

Current Future
Structure Structure
District Hospital
Ward A Ward A

10 15
Ward B
Ward B

20 15
Ward C Ward C

25
40
Ward S

10
Principles of District Health Master Plan

Current Future
Structure Structure

District Hospital
Health System
8.1%
Doctors and
Specialists

Nurses
26.6%
Masterplan – Addressing key issues

• Optimal level of care (appropriateness) – inpatient setting only when

needed (for medical and or social reasons)
• Integrated models of care (responsiveness) – inter-sector (primary /
secondary) as well as multi- and interdisciplinary arrangements provide for
more capacity / better competency and consequently improved scope and
quality of care
• Increased efficiency in resource utilization
• Human resources
• Materials / consumables
• Financial resources
• Targeted investments in improved health care infrastructure (buildings,
equipment, capacity development)
 Creating
enabling
environment

Coordinated
services
 Coordinated services
DISTRICT HEALTH SYSTEM
Referral to District PHC Center
Rural Health District Health Enforcement of
Center
House &
Rural Health Referral for home treatment and follow-up
referral pathways
Center
Facility visit

Referral of severe and complicated cases

Home visiting

Discharge and referral for follow-up

Human Resource
capacity building
District Hospital
1
Creating
enabling
Behavior Change
environment
Communication
 Behavior Change Communication
1

Targeted at:
Topics
Pilot Districts
Process and Criteria for Selecting Districts for
Inclusion in the Project
• Step 1: selection of rayons
(1)percent of home delivery; (2) infant mortality rate; (3) early
neonatal mortality rate; (4) neonatal mortality rate; (5) stillbirths per
1,000; (6) child mortality rate; (7) maternal mortality rate; and (8)
poverty rate.

• Step 2: Non-duplication with development partners

Districts with World Bank, KfW, Aga Khan Foundation projects were
excluded

• Step 3: Readiness of management

Focus group discussions and survey questionnaires were fielded to
identify readiness for reforms
 Criteria based site selection
Maternal
Average Birth Infant Early Stilbirth Child Availability
Home Neonatal mortality
number of Pregnant (per mortality neonatal (per mortality Poverty of other
Districts Region delivery mortality rate
population women 1000 rate (per mortality 1000 rate (per rate donors or
(%) rate (100 000
(Thousands) pop) 1000 l/b) rate l/b) 1000 l/b) partners
per l/b)
SUM OF
INDICATORS AVERAGE

Sh. Shohin Khatlon 50.70 1,598.00 30.90 16.30 27.10 11.90 13.70 13.90 33.10 ––
1 116.00 19.3
Khovaling Khatlon 53.60 2,003.00 25.50 47.40 21.70 1.30 4.50 15.30 24.30 65.50 JICA, AKF
0 180.00 25.7
Baljuvon Khatlon 27.60 1,090.00 34.40 20.50 32.80 14.30 17.40 2.10 34.80 –– JICA
0 121.90 20.3
Norak Khatlon 55.90 2,530.00 33.90 3.60 21.50 8.80 9.70 9.30 26.00 –– JICA
1 78.90 13.2
Sangvor RRS 21.40 636.00 26.50 48.70 23.80 6.80 11.90 8.50 27.20 ––
0 126.90 21.2 AKF
Rasht RRS 115.20 3,891.00 26.90 35.70 12.50 3.40 4.30 11.20 16.90 29.20
1 113.20 16.2 AKF, RFG

RBF project
Faizobod RRS 93.40 3,923.00 29.50 6.60 21.30 10.90 13.20 2.10 24.80 29.60
district, Sino
1 108.50 15.5 (SDC)
Aini Sogd 77.60 2,265.00 29.40 1.70 13.70 4.70 6.00 3.80 17.90 42.70
0 90.50 12.9
Criteria based site selection

The final shortlist will be based on the following criteria:

• Focused investment to obtain maximum impact;

• Efficiency of investment;
• Implementation capacity;
• Estimated investment cost;
• Commitment to adopt master plan
Project Structure
 Integrated Health Services

Component 2:
Component 1:
MCH Service delivery rationalization,
Integration of MCH service delivery
Infrastructure improvement and
and quality improvement
equipment provision
• Strengthening Governance and Reorienting model of care
accountability & Care Coordination
• Coordinated services

Component 3:
Improving Maternal and Child Component 4:
Health care and practices at Project Implementation
community level

Community Empowerment & Engagement

Main Project Principle: Coordinated
Effort
Ministry of Health
and Social Protection

Development
Partners

Integrated MCH
Project

Health System of
Republic of Tajikistan
GROUP Consultations
TOPIC 1:
Strengthening Governance and
accountability & Care Coordination

TOPIC 2:
Reorienting model of care – District Master
Plans

TOPIC 3:
Case –Based Financing
GROUP Consultations

TOPIC 1:
• Strengthening
Governance &
accountability
• Care Coordination
 Integrated Health Services

Component 2:
Component 1:
MCH Service delivery rationalization,
Integration of MCH service delivery
Infrastructure improvement and
and quality improvement
equipment provision
• Strengthening Governance and
accountability & Care Coordination
• Coordinated services

Component 3:
Improving Maternal and Child Component 4:
Health care and practices at Project Implementation
community level
 Component 1:
Integration of MCH service delivery
and quality improvement

Sub-Component 1.1: Health Sub-Component 1.3:

workforce planning and capacity Institutionalization of Continuous
building Quality Improvement System

Sub-Component 1.2:
Sub-Component 1.4: Piloting of
Operationalization of effective
Case Based Financing
referral systems

TOPIC 3
 Sub-Component 1.1:
Health workforce planning and capacity building

• What do we need to DO?

• How we can enhance health workforce planning function at central level?
• What kind of technical support is required?
• What should be tools to enable effective health workforce planning?
• Is there a need to improve capacity building in health workforce planning?
Central Level/Oblast/District level?
• Is there a need to train health workforce at PHC and Hospital Level?
• Who should be trained?
• What should potential training courses?
• Where trainings have to take place? Central? Oblast? District Level?
 Sub-Component 1.1:
Health workforce planning and capacity building

Human Resource Capacity Building Target Groups?

• Management Teams • Obstetrician & Gynecologists

• Family Doctors
• Family nurses
• Midwives
• Pediatricians
• Neonatologists
• Infectionist
• Emergency & ICU physicians
• Lab Specialists
• Clinical Engineers
• Other?
 Sub-Component 1.1:
Health workforce planning and capacity building

Human Resource Capacity Building: Training modules?

• Nutrition
• Newborn Resuscitation
• Child Growth and Development
• Management of complicated deliveries
• Infant, Young Child Feeding
• Referral Algorithms
• Integrated management of Childhood
• Continuous Quality Improvement
Illnesses
• Supportive Supervision
• Safe immunization
• Equipment maintenance
• Effective Perinatal Care
• Other?
• Emergency Obstetric Care
• Antenatal and postnatal Care
 Sub-Component 1.2:
Operationalization of effective referral systems

• What do we need to DO?

• What needs to be done to enhance referral system?
• Development/update OF MCH clinical guidelines/protocols?
• Development of referral protocols/pathways?
• Staff training?
• Transport?
• Monitoring of compliance with referral protocols?
• Financing mechanism?
• Etc.?
 Sub-Component 1.3:
Institutionalization of Continuous Quality Improvement
System

• How can we improve the quality of MCH services?

• Is there a strategy/policy for Quality Assurance and Quality Improvement?
Do you think there is a need to develop the strategy/policy
• Which State agency should be responsible for coordination of Quality
Assurance and Quality Improvement system?
• How we can ensure that quality improvement is implemented routinely by
the health facilities?
• What type of support will the health facilities require to ensure continuous
quality improvement?
• Training in quality management and monitoring and evaluation? Management?
Staff? Both?
• Supportive Supervision? Local? From Center?
• Mentoring and coaching? By whom?
GROUP
Consultations

TOPIC 2:
Reorienting model of care –
District Master Plans
 Integrated Health Services

Component 2:
Component 1:
MCH Service delivery rationalization,
Integration of MCH service delivery
Infrastructure improvement and
and quality improvement
equipment provision
Reorienting model of care

Component 3:
Improving Maternal and Child Component 4:
Health care and practices at Project Implementation
community level
 Component 2:
MCH Service delivery rationalization,
Infrastructure improvement and equipment
provision

Sub-Component 2.1:
Sub-Component 2.2: Procurement of
Construction/Renovation of District
equipment and furniture
Hospitals and District Policlinics

Sub-Component 2.3: Equipment

Sub-Component 2.4: Stakeholder
Maintenance System Development
Communication
 Sub-Component 2.1:
Construction/Renovation of District Hospitals and
District Policlinics

Guiding principles
• Renovating or building new hospitals (as appropriate) in up to three target
districts with focus on quality rather than quantity (rationalization of bed
capacity -> optimization of hospital and outpatient care)
• Renovation of existing infrastructure where possible
• Integration of District PHC center
• Strengthening of referral system specifically for maternal and pediatric care
 Sub-Component 2.1:
Construction/Renovation of District Hospitals and
District Policlinics

District Facility Action

Sangvor Hospital New
Clinic REHABILITATION
Shoroobod
Hospital NEW
Polyclinic NEW
Fayzobod
Hospital RENOVATION + EXTENSION
Polyclinic NONE
Ayni
Hospital NEW
Polyclinic NEW

Rasht Hospital RENOVATION + EXTENSION

Polyclinic RENOVATION
 Sub-Component 2.2:
Procurement of equipment and furniture

• What Type of Equipment is Needed?

• For various MCH service related wards
• Furniture?
• Other?
 Sub-Component 2.3:
Equipment Maintenance System Development

• What are mandatory elements of a maintenance system that would

guarantee sustainable functioning of the equipment ?
• Staffing of the clinical engineers?
• Training of clinical engineers?
• Tools for clinical engineers?
• Spare parts?
• Maintenance Standard Operation Procedures?
• Maintenance budget ? How can necessary financial resources be made
available
• Other?
 Sub-Component 2.4:
Stakeholder Communication
 Component 1:
Integration of MCH service delivery
and quality improvement

Sub-Component 1.3:
Sub-Component 1.1: Health workforce
Institutionalization of Continuous
planning and capacity building
Quality Improvement System

Sub-Component 1.2:
Sub-Component 1.4: Piloting of Case
Operationalization of effective
Based Financing
referral systems

TOPIC 3
MCH budgeting and financing
Existing system
• The budget of medical facilities is
compiled on the basis of the
number of hospital beds and staff
standards, the target expenses for
the MCH are not provided for;
• The budget is compiled in two
formats - by functional and
economic classification
• Financing is made monthly -
according to the approved cost
estimate, within the approved
budget for economic classification
Proposed system
• The budget of the institutions is compiled on
the basis of the per capita normative
targeting the MCH, with the possibility of
applying adjustments to cover additional
costs related to geographical location, budget
growth, provision of specialized services,
• Functional classification of the budget
consists of category 05101 General hospitals,
which are calculated on the basis of per
capita standards for the MCH and other
inpatient services, and economic
classification is compiled according to the
existing system
• Financing is based on the functional
classification of the budget - within the
amount of category 05101 General Hospitals
according to the provided reports and
monthly acceptance for the treated cases
 Budget calculation scheme for pilot regions
Functional classification, line 05101

Per capita normative for MCH

Per capita normative for other

hospital services

Number of children attached to the region,

number of pediatricians cases, number of
deliveris, number of women attached to the
region, number of gynecological cases
Local/Republican budget General
Hospital Services
Number of adult population attached to the
region, number of provided cases with
breakdown by departments and/or services
 Case based financing (Scheme 1, for not
subsidized pilot regions)
Local Government Budget Paid services
By Functional classification
line 05101

Financing (SGP 100%, 50%, 30%)

Reporting (SGP 100%, 50%, 30%) Patient

State Guaranteed
Package (SGP) (50%,
30% co-payment by the
case)
Case based financing (Scheme 2, for subsidized pilot regions)
Republican Budget subsidy
+
Local Government Budget
Paid services
By Functional classification
line 05101

Financing (SGP 100%, 50%, 30%)

Reporting (SGP 100%, 50%, 30%) Patient

State Guaranteed
Package (SGP) (50%,
30% co-payment by the
case)
 MCH budgeting and financing risk assessment
Existing system
• There is no analysis of profitable and unprofitable
divisions, the costs for medical services and / or
departments are not taken into account
• Promotes capacity expansion
• There is no incentive to provide services in
accordance with the requirements of quality and
quantity, there is no incentive to apply advanced
technologies,
• Limited opportunity to encourage medical
personnel,
• Financing is based on approved cost estimates, not
taking into account the volume and quality of the
services provided,
• No binding with final results,
• Lack of incentives to support the referral system,
• Lack of incentives for integration of duplicated
functions, for reorganization and optimization of
the facilities and services on all level of provision;
Proposed system
• Updating the system of reporting and data
collection,
• Revision of existing budget formulation and
financing mechanisms for medical facilities
• Integration of duplicated functions, us a result
the restructuring and optimization of medical
facilities and services,
• The increase in the number of admissions and
hospital cases,
• The increase in the number of complicated
cases,
• Admissions of non-hospital cases,
• Increase hospital admissions from other
regions,
• Calculation of prices for hospital cases,
• The amount of payment, the list of privileged
groups and diseases
Case based financing mechanism introduction stages at the
hospital level
• Stage 1 - data collection and analysis, assessment of the feasibility of
implementing a case- based financing system, evaluation of existing information
systems for data collection and analysis, as well as the possibility become a
reporting system for payments,
• Stage 2 - development of a methodology for the budget calculation and
financing, agreeing and confirming of the methodology, virtual budget calculation
and financing, development of monitoring and evaluation indicators,
development of reporting and information systems proposal,
• Stage 3 - analysis and assessment of the impact of virtual budget and financing
calculations according to monitoring and analysis indicators, improvement of
methodology and confirmation (if necessary), development of an automated
module for data collection and analysis, calculations,
• Stage 4 – buget calculation and financing on the basis of new methods and using
an automated module, budget execution monitoring and evaluation
• Stage 5 - consideration of issues and assessment of the possibility of introducing
a new budget calculation and financing method at the national level
Actions and requirements
• Evaluation of existing regulatory and legal documents;
• Evaluation of existing pilot projects for case based financing;
• Assessment of paid services and SGP;
• Evaluation of the current systems of motivation of medical personnel;
• Evaluation of the current referral system;
• Assessment of macroeconomic indicators and opportunities to increase health
budgets at the republic and district level;
• Improve the capacity of institutions, districts and ministries to case based finance
management, data collection and analysis, monitoring and evaluation
• Budgeting and financing principles changes in the pilot regions,
• The distribution of responsibility for implementation, in particular the collection
and provision of data by reporting forms in fix date, the reorganization and
optimization of institutions and services via integration of duplicate functions at
all levels of medical services provision, preserving budget allocations at a
historical level, changing the financing system.
 Issues for discussion
• Changes in budget calculations;
• The possibility of case based financing, taking into account the average amount of co-payment for groups
of services included in the SGP and the approved price calculations for paid services;
• The possibility of applying the case based financing method for all types of inpatient services;
• The possibility of applying the current forms of the report for case based financing;
• The development of a new method based on the regulations and prices for paid services, the regulations
and amount of the co-payments in SGP, the possibility of applying the costing / justification of the costs for
MCH in accordance with the investigations carried out by UNICEF;
• The issue of providing services to patients from other regions, the possibility of mutual settlements
between districts or reimbursement of such cases from the special account of the MOHSP of Tajikistan;
• The possibility of applying extra wage allowances taking into account the volume of work performed by
medical staff;
• The possibility of calculating the per capita normative for the MCH, taking into account the
costing/justification of the costs of MCH in accordance with the investigations carried out by UNICEF;
• Applying to PHC medical staff performance based financing on maternal and child health. As part of this,
consider the integration of health centers with the aim of using financial resources for medical personnel
performance based financing.
Project Preparation Plan
Negotiations
4

An international firm is currently

October 2018 Due diligence
being recruited to assist MOHSP
assessments and
in conducting due diligence and
refinement of project
elaborate on project design.
concept

2
3 Fact-finding 1
mission

April 20, 2018

June 4-15, 2018

August 6-17, 2018