Scaling up Business Plans in Tajikistan: a qualitative study of the history, barriers, facilitators and lessons learnt

Abstract

Background To improve health planning at primary health care (PHC) level, Business Plans were introduced in Tajikistan by the Enhancing Primary Health Care (EPHC) Services Project. Objective To describe the history and process of implementation of Business Plans and to identify barriers, facilitators and lessons learnt from scaling up Business Plans. Methods Set in a qualitative research design, we conducted a desk review of project and official documents and seventeen semi-structured interviews with key stakeholders at national and sub-national levels between May and July 2020. We used an interview guide informed by the ExpandNet/WHO framework and analyzed the data following a content analysis approach facilitated by MAXQDA. Results With the participation of various user organizations and resource teams and through a variety of strategic scale-up choices, Business Plans have been scaled up from a vertical pilot project to institutionalized health management tools covering 45% of Tajikistan’s PHC facilities. The most prominent facilitators for scaling up Business Plans were the institutionalization and integration of the tool into the Tajik health system, the close collaboration with Community Health Teams (CHTs), the high acceptance of the tool among the users, the advocacy through champions and policy-makers and the large dissemination network. The most outstanding barriers to scaling up Business Plans were insufficient financial or human resources, general weaknesses in health governance, the lack of a strategic scale-up plan and strategic decisions, the lack of motivation or overall vision to implement Business Plans at a large scale and difficulties in donor coordination. Conclusion To ensure the continuity of scaling up Business Plans, developing a scale-up strategy, strengthening cross-sectoral collaboration and participation during scaling up, and capacitating the user organizations of Business Plans are important next steps to ensure the sustainability and effectiveness of Business Plans in the future.

Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review

“…At the same time, QI is scalable when QI interventions are perceived to be easily transferable to a new area of work within a PHC setting, to other health workers, or even to other health facilities by adopting small incremental changes rather than rapid disruptions [ 44 , 52 , 57 , 72 , 73 ]. Additionally, QI interventions are supported by health workers and health facilities when perceived to be sustainable, i.e., when participants feel confident of continued implementation beyond the planned intervention period [ 45 , 48 , 50 , 56 , 62 , 69 , 72 , 75 , 80 ].…”

“…But the presence of concurrent and similar QI programmes in the same organization might introduce fragmentation and bring about confusion regarding organizations’ priorities, a potential barrier [ 70 ]. Lack of institutional knowledge, where implementers do not fully understand organizational bureaucracies, can also hamper QI [ 80 ] where planned changes are complex and system wide. QI teams with short tenure due to high staff turnover appeared to reduce organizational maturity for QI implementation, e.g., in Benin where QI team members took up new jobs, and lack of community support and irregular monetary incentives affected teams’ longevity [ 58 ].…”

“…Availability of resources to support QI was the focus of studies in Kenya [ 46 ], Uganda [ 52 , 57 ], Democratic Republic of the Congo [ 51 ], Zimbabwe [ 53 ], Ethiopia [ 54 , 72 , 82 ], Malawi [ 55 , 73 ], Haiti [ 56 ], India [ 59 ], Benin [ 58 , 89 ], South Africa [ 60 , 65 , 69 , 75 ], Tanzania [ 42 , 61 , 90 ], Zimbabwe [ 62 ], Rwanda [ 64 ], Namibia [ 66 ], Indonesia [ 70 ], Mozambique and Burkina Faso [ 79 ], Tajikistan [ 80 ], Mali [ 81 ], and Nigeria [ 44 , 45 , 86 ], underscoring its importance to impede QI and shared concerns across many LMIC contexts.…”

“…Inadequate patient referral systems, they reported, affected QI where the initiative aimed to enhance linkage and networking within a care network. Other enablers uncovered took the form of continuing (medical/health/nursing) education [ 47 ] and knowledge exchange platforms [ 48 , 50 , 54 , 80 ]. Knowledge exchange platforms, it was reported, could enhance chances of successful QI by breaking down silos and fostering the integration of care packages.…”

“…Also, policies that limit access to PHC budgets as part of larger health systems configuration can also bar QI in LMICs. Conversely, Manisha Yapa and colleagues [ 69 ] report that availability of key guidelines and tools, and according to Werner et al [ 80 ], national policies e.g., those that give a high visibility to PHC can indeed foster a supporting environment for PHC-focused QI.…”