Village nurses Gulshan Yusupova and Tahmina Niyozmamadova have been trained by the Aga Khan Health Services in a variety of health topics such as HIV/AIDS and safe motherhood.The Aga Khan Development Network’s (AKDN) overall objective in the health sector in Tajikistan is a sustainable improvement in the health status of the community, with a particular focus on the health status of children under five years of age, women of reproductive age, the disadvantaged and the geographically remote.
AKDN’s objective is closely linked with four of the eight Millennium Development Goals (MDGs): promote gender equality and empower women (MDG 3); reduce child mortality (MDG 4); improve maternal health (MDG 5); and combat HIV/AIDS, malaria and other diseases (MDG 6).
At independence in 1991, Tajikistan inherited a Soviet health system that had been chronically neglected in the decade immediately prior. The system exhibited deficiencies in the quality of care provided by physicians and nurses, acute shortages of medical supplies and pharmaceuticals, inadequate maintenance and operation of facilities, and the absence of programmes needed to inform the public about basic health practices.
Health Programme Phase I (1997-2004)
In Phase I of the AKDN Health Programme, interventions emphasised preventive and primary care with appropriate referral. This was a significant shift in focus from hospital-based curative care to community-based services.
During the phase, the programme sought to:
Evaluations by the Swiss Development Corporation and the United States Agency for International Development indicate that the implementation of two closely linked strategies has enabled the programme achieved dramatic and sustained effects in reaching and involving communities in health promotion and prevention initiatives. The first strategy addressed the absence of information needed to inform communities about basic health practices. AKDN collected and analysed information on the knowledge, attitudes and practices of community members and used the knowledge to develop, test and disseminate key messages that the community understood and acted upon. Communities have responded positively and enthusiastically to the messages and approaches used to address inappropriate practices and improve health.
Bahor Navruzova, a Chemistry teacher in Khorog, has been volunteering as a CHP since 2002 and covers 150 households.The second strategy identified was to train and support Community Health Promoters, who are volunteers based in each village. The Community Health Promoters interact with the community to improve health practices, and work closely with the Ministry of Health staff based at first-level village medpoints to provide appropriate and effective health information and basic care. The Community Health Promoters have become the crucial link between Ministry of Health staff based at medpoints and the community.
The success of this strategy is linked with working through village organisations, which are community self-help groups encouraged and formed by the Mountain Societies Development Support Programme (MSDSP), a non-governmental organisation established by AKDN.
Health Programme Phase II (2005-2010)
In Phase II, AKDN’s health programming will work to forge enduring partnerships between community-based health committees and public-sector health professionals and systems. The focus will be on consolidating community involvement in health care, expanding the geographic reach of the programme, documenting the impact of interventions on the health status of the target population and contributing to Health Sector Reform.
Phase II has six main objectives:
Implementing Lessons Learned From Phase I
Learning from its experiences in Phase I, and bearing in mind that Health Sector Reform takes a long time to achieve and that there is as yet no clear agreement on the direction reform efforts will take in Tajikistan, AKDN has adopted three operational policies in Phase II of the health programme:
Firstly, building or renovating facilities will be linked to reform plans promoting responsible operation and maintenance, cost-sharing and the use of revenues to improve services. Effective reform plans will foster improved services, more efficient use of resources and the redistribution of finances from hospitals to primary health care units.
Secondly, work within communities will only be undertaken within the framework of a Memorandum of Understanding that specifies the roles and responsibilities of the partners: the community, development partners, primary healthcare staff and the village organisation. A clear understanding of the part each group plays in improving health care encourages decentralisation of decision-making and active involvement of the community.
Finally, AKDN will actively collaborate with the government, development assistance agencies and non-governmental organisations as equal programme partners in the areas of operation rather than as financial supporters. This looks towards the sustainability of programme interventions, withdrawal of direct support and emphasis on Health Sector Reform.
AKDN has a long-term commitment to improving the health status and livelihoods of the citizens of the Republic of Tajikistan. The AKDN strategy for 2005-2010 reflects the Government’s reform policy and builds on lessons learned in Phase I. Experiences in Gorno-Badakhshan Autonomous Oblast, Khatlon Oblast and the Rasht Valley provide a strong foundation on which the expanded programme will build.
AKHS is working to improve the health status of the overall population in the country, with a focus on mothers and children under the age of five.Implementation of the AKDN Health Programme in Tajikistan is currently managed by the Aga Khan Health Services (AKHS). AKHS is working to improve the health status of the overall population in Tajikistan with a focus on mothers and children under the age of five. In driving towards this aim, AKHS places a specific focus on increasing the involvement of communities in addressing health issues.
AKHS has implemented a number of projects since the Aga Khan Development Network (AKDN) began its health activities in Tajikistan in 1997. Among its most recent are:
Community Health Project
AKHS disseminates to community members and health practitioners relevant information on common health issues affecting Tajikistan.AKHS’ Community Health Project works to empower community members and community-based organisations to address their own healthcare needs.
The project trains volunteer Community Health Promoters (CHPs) to serve as a communication and advocacy link between communities and local governments. Part of a CHP’s role is also to refer community members to appropriate health facilities when needed. Since inception, the Project has trained over 400 CHPs in GBAO and 100 in the Khatlon region of Tajikistan.
The Project distributes educational brochures containing culturally appropriate health messages concerning common health issues, including immunisations, treatment of infectious diseases, HIV and sexually transmitted infections (STIs) and maternal and child health.
At over 195 existing primary healthcare centres (PHCs), the Project has trained staff members on a range of basic health topics including safe motherhood, immunisation, nutrition, prevention of HIV and STIs and integrated management of childhood illnesses.
The Growth Monitoring and Promotion (GMP) component of the Project trains PHC staff and mothers in the community on how to monitor the health and nutritional status of children under five years of age. Since the introduction of GMP, over 8,000 children have been reached.
Nursing Development Project
The Nursing Development Project (NDP) of AKHS aims to improve the education of nurses in Tajikistan. In partnership with the World Health Organization, the NDP has developed and implemented a new four-year nursing curriculum in all medical colleges of Tajikistan. Teachers from nursing institutions throughout the country are now trained in an expanded range of disciplines including sociology, psychology, research methods, nursing management, family health, communication, health promotion and safe motherhood.
At Khorog General Hospital (KGH), NDP has developed and implemented a programme on nursing competencies in Pediatrics. It also organises trainings and meetings for nurses from various medical facilities in GBAO to come together at KGH to share knowledge and discuss best practices. These nurses also have access to the Internet through a library established by AKHS at the hospital.
NDP has partnered with institutions such as the Aga Khan University’s School of Nursing in Karachi, Pakistan and the Tajik Postgraduate Medical Institute to send nurses and nurse teachers in Tajikistan for further skill enhancement. It also helps nurses prepare to take up leadership roles and management responsibilities within their medical workplaces. It supports Tajikistan’s National Nursing Council, an organisation which advocates for the professional development of nurses at a national level.
Rationalising Pharmaceuticals Policy and Management Project
The Rationalising Pharmaceuticals Policy and Management project has been making essential pharmaceuticals available throughout GBAO since the late 1990’s, including in the aftermath of the country’s civil war, when few other sources of medicine were present in the region. Training provided by the Project enables doctors to make better diagnoses and to prescribe pharmaceuticals more rationally.
The Project introduced the Revolving Drug Fund (RDF) in 1997 in GBAO, which requires patients to pay a small percentage towards the cost of the drugs which they would otherwise receive for free. This requirement generates funds that can be used for procurement, delivery and distribution of good quality and affordable essential drugs to the community. To date, the fund has collected enough revenue to become almost completely self-sustaining and expects to operate with minimal external funding in the near future.
Health Sector Reform Project
The Health Sector Reform Project (HSRP) aims to build the capacity of the GBAO Department of Health (DoH) so that it is able to successfully implement the health reform strategies put forth by the Government of Tajikistan.
HSRP is currently promoting the introduction of Family Medicine in GBAO to improve access to quality and efficient health care. In the Rushan district of GBAO, a Family Medicine pilot project is being conducted in which two doctors and six nurses are undergoing training at the Tajik Postgraduate Medical Institute.
Upon returning to Rushan, these individuals will work as family doctors and family nurses in their respective health facilities. The main expected outcomes from the initiative are increased access to healthcare services in local communities, greater participation in health-promotion and disease-prevention activities, reduced hospitalisations and reduced utilisation of specialists.
Other HSRP initiatives include study visits, trainings and discussions to build capacity amongst GBAO DoH staff. In 2007, HRSP gave members of the DoH the opportunity to attend a two-week management course in Bishkek, Kyrgyz Republic. During the trip, health professionals from the DoH also visited AKDN health facilities in the Osh oblast in order to exchange experiences.
Finally, HSRP has conducted a number of Public Health expenditure reviews in GBAO. These studies enable comparisons between the funding provided by the government, non-governmental organisations and local communities to the health sector. The technique is now being used as a model by the Tajikistan Ministry of Health in conducting studies elsewhere in the country.
From 2001 through 2004, with the support of the Swiss Agency for International Development and Cooperation (SDC), AKHS completed renovations at three hospitals in Ishkashim, Vanj, and Murghab and provided equipment for their intensive care units and laboratories. Since 2004, AKHS has worked with the support of the Japanese Government to provide equipment and renovations to address diagnostic, treatment, kitchen and laundry needs in the KGH, Rushan and Darwaz hospitals.
Health Promotion Development Units
AKHS has established Health Promotion Development Units which provide resources and training to enable medical staff to continually update their knowledge.Health Promotion Development Units (HPDUs) have been established in Khorog and five other districts in GBAO and the Garm region to provide health professionals with opportunities to update their knowledge and attend courses on novel topics in medicine.
HPDUs provide resources such as computers, books and periodicals to allow health professionals to continuously enhance their knowledge. The units also conduct courses on English and information technology, enabling doctors to study evidence-based practices written in English and perform Internet searches.
By the end of 2007, all six GBAO district HPDUs had been handed over to district health authorities as resource centres. In the future, these centres will be used to promote clinical excellence amongst health professionals.
AKHS is working with local governments and civil society organisations to continue to support CHPs and their sustainability, facilitate the implementation of national health reforms and explore the development of public private partnerships to address healthcare needs. It also continues to expand the topics covered in its informative trainings and brochures, including on the issue of HIV/AIDS.
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