2008年-世界发展银行全球_Immunization_Resource_Tracking_Exercise___Case_Study_on_the_Republic_of_Tajikistan_46页_360kb

Summary of the Immunization Resource Tracking Exercise in the Republic of Tajikistan

Core Content

This document presents a case study on an immunization resource tracking exercise conducted in the Republic of Tajikistan from 2001 to 2005, with a focus on the year 2005. The study was part of the Health PETS (Public Expenditure Tracking Survey) and aimed to examine how donor and government resources are allocated and used for immunization services. It also explores the effectiveness of these resources in improving immunization coverage rates and service delivery.

Main Findings

1. Financing Trends

• The National Immunization Program (NIP) in Tajikistan saw an annual increase in financing from approximately $1.5 million, or $0.22 per capita.
• The NIP was heavily dependent on external financing, accounting for 97% of total funding.
• Donor contributions, including $8 million from the GAVI Alliance, did not result in significant improvements in immunization coverage rates, with some areas reporting declines in DTP3 coverage.

2. Resource Allocation and Use

• Government and donor resources were allocated inequitably from the central to sub-national levels, unrelated to needs or program performance.
• GAVI ISS (Immunization Services Support) funds were mostly retained at the national level and used for capital expenditures, rather than recurrent costs, leading to potential future funding gaps.
• At the facility level, GAVI resources had a positive but insignificant relationship with the number of immunization doses administered.

3. Facility-Level Underfunding

• The mean total requirement for immunization activities in 2005 was S2,079 ($650) per facility, which was over four times the level of government resources allocated to primary health facilities.
• Voluntary payments by staff accounted for 20% of total facility financing for immunization activities, highlighting the need for further research on these contributions.

4. Vaccine Stockouts

• The PETS survey revealed widespread vaccine stockouts across all childhood vaccines in 2005, with 98% of facilities reporting at least one stockout.
• On average, facilities were without vaccines for six weeks, likely due to poor forecasting and high transaction costs.

5. Determinants of Immunization Doses

• Controlling for population income and regional characteristics, the availability of facility resources and hours worked by staff positively influenced the number of immunization doses administered.

Key Information

• GAVI Support: Tajikistan received the largest GAVI Alliance support in the ECA region since 2002, totaling $8 million, including $1 million in ISS (Immunization Services Support) funding.
• Health System Context: The health sector in Tajikistan is underfunded, with only $1 per capita spent on health, and 71% of health expenditures coming from private, out-of-pocket sources.
• Coverage Discrepancies: Official coverage rates for immunization were overestimated, with the MICS survey showing significantly lower coverage (e.g., DTP3 at 76% vs. official 96%).
• Budgeting Process: The NIP budget is a top-down process led by the RepCI, with final allocations typically around 30% of the initial estimate. The RepCI prepares a detailed line item budget reflecting needs at the regional and rayon levels.
• Challenges in the Health System: Tajikistan's health system faces bottlenecks such as lack of personnel, weak logistics, and poor governance, which hinder immunization program performance.

Recommendations

• Advocacy and Allocation: Greater advocacy is needed to ensure adequate allocation of resources for facility operating costs at the rayon and jamoat levels.
• Annual Reporting: The NIP should provide annual reports on the allocation and use of donor funding, including GAVI commodity and cash resources.
• Policy Alignment: A short policy note should be developed to outline criteria for allocating donor resources and aligning them with immunization outcomes.
• Tracking Tools: A simple tracking tool should be developed to monitor the allocation of donor and government resources to sub-national levels over time.
• Monitoring System: The NIP monitoring system should be revamped with updated denominator information, streamlined reporting forms, and improved record-keeping and reporting capacity.
• Logistics and Forecasting: Strengthening vaccine stock management and logistics, including better forecasting and a tracking system for critical supplies, is urgently needed.
• Capital Equipment Register: A register for capital equipment, especially vehicles, should be developed to track usage and improve efficiency.
• Guidelines for GAVI Assistance: Guidelines on best practices for planning, budgeting, resource allocation, and reporting of GAVI cash assistance should be developed and disseminated.

Methods and Data Collection

• The study was conducted in three phases: a fact-finding mission, program-specific budget and expenditure analysis, and a facility survey using a pre-tested questionnaire.
• Data were collected from a nationally representative sample of 328 health facilities in 2006, covering 2005 activities.
• The facility data were entered into a statistical database for analysis using STATA.

Limitations and Future Directions

• The PETS methodology had limitations in capturing immunization-specific resource flows due to the lack of budget preparation by primary health facilities.
• The cost and time of field work may make such an extensive resource tracking exercise challenging for other countries.
• Future studies should consider using a National Health Accounts (NHA) framework, particularly the recently developed Child Health Sub-Accounts, to organize information on donor and government contributions and their use in vertical programs.
• Further research is needed to understand the sources and implications of staff contributions to PHC and immunization services.

Conclusion

The case study highlights the challenges in resource allocation and utilization for immunization services in Tajikistan. Despite increased funding from both government and donor sources, the program has not seen proportionate improvements in coverage rates. The study underscores the importance of improving financial sustainability, strengthening logistics, and ensuring that resources reach frontline providers effectively. These findings can inform policy and program reforms in Tajikistan and other countries facing similar challenges.