Tajikistan is reforming Primary Health Care to reach Universal Health Coverage

Tajikistan is transforming its health system to accelerate progress toward Universal Health Coverage (UHC). For the last two decades, the country has been undertaking significant reforms to shift towards a Primary Health Care (PHC) approach with a strong family medicine focus conducive to strengthening the health system to attain its objectives of 'health for all'. 

Putting PHC at the centre

Tajikistan's transition from a highly centralized healthcare system to PHC began with legal reforms to establish new financing mechanisms to increase health spending and improve financial protection for the population. The Tajikistan government has, as a result, progressively increased funding for primary care services, resulting in higher government health spending and an overall increase in public health spending as a percentage of GDP.1Health financing reforms are underway to provide a more comprehensive and unified approach to healthcare financing, fostering a move from input-based resource allocations to strategic purchasing of primary healthcare services. Progressively increasing public resources available for PHC is pivotal to improving communities’ access to essential healthcare services.

Improving the demand for and access to primary care services is another crucial aspect of Tajikistan's transition. The country is shifting from a system heavily reliant on hospital-based secondary and tertiary care towards primary care and public health, increasing the portion of their public health budget allocated to PHC, rising from 34.6% in 2010 to 40.7% in 2022.1 As a result, the number of PHC visits per person has been rising steadily from 4.8 in 2010 to 7.6 in 2022.2 To further improve access to essential health services, especially to the poorest and most vulnerable households, Tajikistan is also revising the Basic Benefit Package (BBP), using a phased implementation starting with priority groups alongside additional co-payment arrangements. As of 2021, the BBP covers 33.1% of the Tajikistan population,2 with ongoing efforts to expand coverage and harmonise different co-payment and fee-for-service arrangements to reduce financial barriers to healthcare.

Tajikistan has also made strategic investments to improve the organisation and strengthen the quality of primary care services. These investments are aimed at reducing the fragmentation of services by incorporating established vertical health services under a unified PHC structure within the framework set by the National PHC Development Master Plan.  Medical and nursing education changes have been implemented to bridge human resource gaps in family medicine doctors (FMDs) and nurses (FMNs) to provide essential primary care services. The proportion of primary healthcare institutions practising family medicine principles has increased from 56% in 2010 to 88% in 2022. Between 2010 and 2022, the number of doctors who have had family medicine training increased from 271 (4.4%)  to 4597 (82.3%), with the number of nurses also increasing from 327 (3%)  to 9669 (73.4%).1

Accelerating progress through collaboration

Collaboration has been crucial in supporting Tajikistan’s PHC reforms. In 2019, Tajikistan joined the SDG3 Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP) as a pilot country, focusing on PHC and sustainable health financing to accelerate progress to achieve the health-related SDGs. The collaboration involves 13 humanitarian, development, and health agencies. These agencies and other partners, among them USAID, have increasingly supported Tajikistan through collaborative approaches that leverage their respective strengths and expertise. 

The main partner coordination platform is the Development Coordination Council (DCC) health. It fosters dialogue, coordination and joint implementation between partners and Tajikistan's government agencies. It also facilitates information exchange, agreements on collective outcomes and coordination, in alignment with Tajikistan's National Health Strategy 2021-2030. Under its auspices, opportunities for joint advocacy and the development of a common vision, exemplified by a joint position statement on strengthening PHC in 2022, are made possible. The statement was endorsed by all key development partners and signed personally by the Minister of Health of Tajikistan. In September 2023, the Head of the Department of Health Reforms and International Relations at the Ministry of Health presented the key priorities for improving PHC to SDG3 GAP focal points through the PHC Accelerator (PHC-A) working group. The dialogue identified areas to strengthen PHC, such as revising regulatory documents, enhancing management skills, implementing a Districts of Excellence PHC model, and modernizing emergency medical services.

To date, partners from various sectors have joined forces to implement Tajikistan's National Health Strategy 2021-2030. This collaborative effort involves shared funding and initiatives towards PHC reforms. Notably, the Ministry of Finance and the Ministry of Health and Social Protection, in conjunction with the Global Financing Facility for Women, Children, and Adolescents (GFF), have taken a lead role in developing a Prioritized Investment Plan (PIP). This plan, created in close cooperation with all partners, serves as a roadmap for implementing the 2030 National Health Strategy. Within the PIP, clear details regarding the costs of priority activities and investments have been outlined for the next three years, allowing development partners to align their programs and investments in the healthcare sector. Simultaneously, the World Bank and the GFF are actively supporting a government investment plan, spearheaded by Tajikistan's Ministries of Finance and Health. This investment plan places a significant emphasis on strengthening PHC and aims to contribute to the objectives set forth in Tajikistan's National Health Strategy 2021-2030.

Collaboration extends to the joint implementation of PHC reforms as well. For instance, the European Union (EU)-funded Health Development Program, implemented by WHO, UNICEF, and GIZ, is strengthening health-sector governance, financing, and access to quality integrated primary care services. WHO, the GFF and the World Bank work closely together to support the Government in implementing critical health financing and service delivery reforms to improve the efficiency of PHC. WHO is supporting the piloting of strategic purchasing of PHC services, while the World Bank’s new Project, the Tajikistan Millati Solim Project, will scale up these reforms. Further instances of collaborative efforts include UNICEF’s partnership with the Asian Development Bank for the Maternal and Child Health Integration Project, and the collaboration between the Swiss Government and the EU to enhance public finance management.

Monitoring for sustained PHC improvement

Tajikistan’s journey towards its PHC goals is yet confronted with key challenges, notably the need for increased per capita spending for more effective primary care, addressing the growing burden of out-of-pocket expenditure, and fully integrating vertical programs into primary care. To sustain current momentum in addressing these key challenges, SDG3 GAP partners have piloted a monitoring framework on their joint efforts in countries including Tajikistan. This framework aims to  encourage ongoing government feedback, enabling continuous improvements in their coordinated support to government to align better with national priorities, plans and coordination mechanisms and systems. In 2022, the government of Tajikistan reported successful collaboration practices within the national COVID-19 response and partners aligning their support with national plans, with increased donor funding alignment to  budget priorities. The government also highlighted partners’ increased use of local monitoring systems and improved joint technical assistance. 

The government recommended further improvements in their feedback, including enhancing coordination within the Ministry of Health and Social Protection, strengthening the DCC health platform, and developing a unified resource mapping tool to prevent duplication. In response, partners have introduced new coordination mechanisms, including the new technical subgroups, to enhance coordination within the DCC health platform. To further improve quality, Tajikistan is using a data-driven approach to accelerate progress in primary healthcare and other priority health areas, through the WHO Delivery for Impact 100-day challenge. As a pilot country on this challenge, the government of Tajikistan is using data to identify priority areas and develop joint delivery plans, building on the collaborative structures established.

Tajikistan government’s strong political will and stakeholder collaboration continues to drive progress toward UHC via PHC.

What is the SDG3 GAP?

The Global Action Plan for Healthy Lives and Wellbeing for All (SDG3 GAP) is a set of commitments by 13 agencies that play significant roles in health, development, and humanitarian responses to help countries accelerate progress on the health-related SDG targets. The added value of the SDG3 GAP lies in strengthening collaboration across the agencies to take joint action and provide more coordinated support aligned to country owned and led national plans and strategies.