The politics of the basic benefit package health reforms in Tajikistan

Abstract

Background Health reform is a fundamentally political process. Yet, evidence on the interplay between domestic politics, international aid and the technical dimensions of health systems, particularly in the former Soviet Union and Central Asia, remains limited. Little regard has been given to the political dimensions of Tajikistan’s Basic Benefit Package (BBP) reforms that regulate entitlements to a guaranteed set of healthcare services while introducing co-payments. The objective of this paper is therefore to explore the governance constraints to the introduction and implementation of the BBP and associated health management changes. Methods This qualitative study draws on literature review and key informant interviews. Data analysis was guided by a political economy framework exploring the interplay between structural and institutional features on the one hand and agency dynamics on the other. Building on that the article presents the main themes that emerged on structure-agency dynamics, forming the key governance constraints to the BBP reform and implementation. Results Policy incoherence, parallel and competing central government mandates, and regulatory fragmentation, have emerged as dominant drivers of most other constraints to effective design and implementation of the BBP and associated health reforms in Tajikistan: overcharging and informal payments, a weak link between budgeting and policymaking, a practice of non-transparent budget bargaining instead of a rationalisation of health expenditure, little donor harmonisation, and weak accountability to citizens. Conclusion This study suggests that policy incoherence and regulatory fragmentation can be linked to the neo-patrimonial character of the regime and donor behaviour, with detrimental consequences for the health system.. These findings raise questions on the unintended effects of non-harmonised piloting of health reforms, and the interaction of health financing and management interventions with entrenched power relations. Ultimately these insights serve to underline the relevance of contextualising health programmes and addressing policy incoherence with long horizon planning as a priority.

Local health governance in Tajikistan: accountability and power relations at the district level

“…In the relationship between health providers and state actors the findings suggest accountability for the delivery of the BBP is limited by insufficient resources to carry out this mandate, a rigid resource allocation rationale that is de-coupled from population needs or provider performance and monitoring activities that appear more aimed at finding faults in record-keeping and opportunities for resource-extraction through fines and (informal) co-payment revenue than at support for service delivery. This rent-seeking behaviour, which was reported in both districts irrespective of the copayments associated with the BBP pilot, is in line with patterns in the wider bureaucracy as documented in a related study [14]. It is important to recognise that the negative, punitive character of this supervision style was found to be an important factor in health staff demotivation and attrition elsewhere and stands in contrast to the more supportive or coaching supervision approach by managers, which has been identified as a strong motivator for health workers in a broad variety of low and middle income settings [39][40][41][42][43].…”

“…The districts were purposefully chosen for their difference in proximity and interest to the political centre Dushanbe and the fact that the RRP district featured as one of the pilot districts for the implementation of the BBP reforms, while the GBAO district was excluded from the BBP pilot at the time of research. A key element of the reforms is the introduction of co-payments, with the exemption of vulnerable social and disease groups, which is intended to generate extra revenue [12,14]. In addition, health service delivery in the two districts was supported by two different external development partners, as will be elaborated in the results section, which was assumed to influence local accountability relations in distinct ways.…”

“…An overview of respondents is provided in Table 2. The study further draws on the contextual insights gained from 31 KIIs conducted among governmental, bilateral, multilateral and nongovernmental organizations, primarily at central level, which were used for another study [14]. Participants for KIIs were purposefully selected, focusing on those involved in the regulation, supervision, financing and provision of health services in the two districts.…”

“…Health governance in Tajikistan, or Central Asia in general, has received little attention, and has mainly been focused at central level reforms, such as the introduction of a Basic Benefit Package of health services (BBP) and the role of international aid in this [10][11][12][13][14][15]. Fragmentation in health financing regulations and stewardship functions coupled with insufficient donor coordination, leading to a proliferation of vertical and pilot programmes suggests the existence of a patchwork of different health governance arrangements across the country [14]. Closer insight into the way local stakeholders in the health system relate to each other, and how the local context shapes these patterns of power is therefore warranted.…”

Interpretation of China’s 2017 health expenditure: a latent profile analysis of panel data

“…43 However, very high health spending has not transformed into better access to quality care for all populations. 44 Broader policy development may promote optimal allocation of medical resources, 45 which implies that differences between the profiles in this study could ultimately be used for directing more resources to provinces belonging to the high county and township profile. Policy support will continue to be required, but it is noted that such support does not replace efforts within the regions.…”