Tajikistan - Health Results Based Financing Impact Evaluation 2018

The 2018 endline survey of the impact evaluation (IE) for Health Performance-Based Financing (PBF) in Tajikistan sought to ascertain: (i) the impact and cost-effectiveness of the PBF model implemented in Tajikistan; and (ii) whether PBF is more effective or cost-effective if implemented in conjunction with additional low-cost interventions (Collaborative Quality Improvement, Citizen Report Cards). The results from the IE will help inform the Ministry of Health on whether PBF should be scaled-up to additional PHC level institutions in other regions. The Collaborative Quality Improvement intervention responds to policy concerns that performance incentives may not produce the desired improvements if providers lack the necessary competencies to inform decisions and knowledge. The Citizen Report Card attempts to improve the effectiveness of PBF by strengthening the 'short route' of accountability (e.g., by increasing accountability of health facilities to their local constituents). Since PBF, collaborative quality improvement (CQI), and citizen report cards (CRC) have never been implemented on a large scale in Tajikistan, it is to be expected that the results from the IE will be useful for designing national PHC policy in Tajikistan, and that they will also contribute to the larger body of knowledge on these interventions.The IE employs both difference-in-difference and experimental approaches to identify the impact of the different combinations of interventions. Assignment to PBF was not random. Three districts in the Sughd region and four districts in the Khatlon region were selected to implement the program. All Rural Health Centers (RHCs) in these seven districts are covered by the program. Nine additional districts (two in Sughd and seven in Khatlon) were selected as control districts. The selection of the control districts was guided by geographical proximity to treatment districts and similarity in terms of number of health facilities and doctors per capita. The districts were also selected such that the number of RHCs in treatment and control groups in each region would be similar. Within the chosen 16 districts (treatment and control districts), clusters consisting of an RHC and its subsidiary Health Houses were randomly assigned to implement Collaborative Quality Improvement, Citizen Score Cards, or neither of these two interventions. The randomization was blocked by district. In sum, RHCs were assigned into six study arms.The goal of the facility-based survey is to measure multiple dimensions of quality of care and collect detailed information on key aspects of facility functioning. Household surveys are primarily used to measure health service coverage at the population level as well as select health outcome indicators measured through anthropometry or tests. The surveys also collect broader data on the health of the households, health seeking behaviors and barriers to use of health services. In addition, PBF and other administrative data would be used to track outcomes over time in the treatment groups 1-3 (the ones receiving performance-based payments). The endline (follow-up) survey took place three years after project implementation. The survey is largely based on the HRITF instruments that were modified to the Tajik and project context.

塔吉克斯坦卫生绩效付费（Health Performance-Based Financing, PBF）影响评估（Impact Evaluation, IE）2018年终线调查旨在明确两大核心目标：其一，评估塔吉克斯坦已实施的PBF模式的影响与成本效益；其二，探究PBF配合额外低成本干预措施——协同质量改进（Collaborative Quality Improvement, CQI）与公民报告卡（Citizen Report Cards, CRC）——时，是否能实现更优的有效性与成本效益。本影响评估的研究结果将为卫生部提供决策依据，助力判断是否应将PBF推广至其他地区的更多基层卫生保健（Primary Health Care, PHC）机构。协同质量改进干预措施旨在回应一项政策关切：若医疗服务提供者缺乏支撑决策所需的能力与知识，绩效激励可能无法达成预期的改善效果。公民报告卡则通过强化问责的“短路径”（例如提升卫生机构对本地服务对象的问责程度），试图提升PBF的实施有效性。鉴于PBF、协同质量改进（CQI）与公民报告卡（CRC）此前从未在塔吉克斯坦大规模实施，本影响评估的结果不仅可用于塔吉克斯坦国家基层卫生保健政策的制定，也将为这类干预措施的全球知识体系积累宝贵经验。本影响评估同时采用双重差分法（difference-in-difference）与实验研究方法，以识别不同干预组合的影响。PBF的分配并非随机。研究选取了索格德州（Sughd region）的3个县区与哈特隆州（Khatlon region）的4个县区作为项目实施县区，上述7个县区内的所有农村卫生中心（Rural Health Centers, RHCs）均纳入项目覆盖范围。另有9个县区作为对照县区（索格德州2个、哈特隆州7个），对照县区的选取以与干预县区的地理邻近性、每千人拥有的卫生机构与医生数量相似度为依据，同时确保两个区域内干预组与对照组的农村卫生中心数量相近。在上述选定的16个县区（含干预与对照县区）中，以农村卫生中心及其下属卫生所为单位的集群被随机分配至协同质量改进、公民评分卡（Citizen Score Cards）干预组，或不接受任何上述两类干预的对照组。随机分组按县区进行区组化。综上，农村卫生中心共被划分为6个研究组。本机构层面调查的目标是衡量医疗服务质量的多个维度，并收集关于机构运营关键方面的详细信息。家庭调查则主要用于测算人群层面的卫生服务覆盖情况，以及通过人体测量或检测获取的关键健康结局指标。此外，调查还收集了关于家庭健康状况、就医行为及就医障碍的更广泛数据。除上述调查外，研究还将利用PBF及其他行政数据，追踪1-3组（接受绩效付费的组别）干预组的结局变化情况。本次终线（追踪）调查于项目实施三年后开展，其问卷主要基于适配塔吉克斯坦国情与项目场景的HRITF工具包修订而成。