Abstract
BackgroundHealth 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.MethodsThis 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.ResultsPolicy 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.ConclusionThis 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.
Highlights
Health reform is a fundamentally political process
Governance and the health sector in Tajikistan: the institutional and health system context Governance background Tajikistan Partly as a consequence of the national state’s lack of resources to organize local systems, and partly as a legacy from the political settlement that ended the violent conflict in the 1990s informal power relations in Tajikistan have shaped the implementation of governmental policy [33,34,35,36,37,38,39]
Political power is highly centralized in the position of President Emomalii Rahmon, while his domination of the political landscape depends on his ability to pacify a fragmented set of groups through the distribution of spoils and ‘virtual politics of peace’ [43]
Summary
Health reform is a fundamentally political process. Yet, evidence on the interplay between domestic politics, international aid and the technical dimensions of health systems, 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. Over the past fifteen years, reform processes in the health sector have been launched in Tajikistan to overhaul the inherited Semashko health system and address the high level of out-of-pocket payments on health. Among these reforms is the introduction of the Basic Benefit Package (BBP). When aimed at enhancing universal health coverage, is a fundamentally political process with major collective action challenges, as it entails the redistribution of power and resources with inevitably winners and losers [8]
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