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The numbers are grim, especially on maternal and child health. Women and children in Tajikistan face higher rates of malnutrition than women and children in other Central Asian countries and the South Caucasus. And babies are threatened, as well; acute infection is the leading cause of death for newborns and preventable illnesses play a part in a considerable proportion of all child deaths.

Basic preventative care is often hard to come by. For example, over 50 percent of the country's 5 year olds are iodine deficient. And about 21 percent have stunted growth.

The obstacles to health care are many. Distance is a particular problem. People who live in mountainous areas or poor regions without decent roads find simply getting to a health care clinic can be a struggle. As a result, many mothers-to-be don¡¯t go in for pre-natal check-ups or to learn about family planning.

Across Tajikistan, only 63 percent of kids under five who had symptoms of acute respiratory infection and 57 percent of children with fever were taken to a health care clinic.

But, with US$ 15 million  in support from the World Bank, the government of Tajikistan is working on better, more accessible health care via the Health Services Improvement Project.

¡°The main indicators for performance based financing are indicators of maternal and child health, such as child vaccination, providing services for reproductive age and pregnant women,¡± explains Karomat Niyozalieva, who is the deputy manager for child services at the Spitamen district health center.

Payment after Performance

Performance-based financing is a key part of the project. It is designed to reward primary health care workers and facilities, but only after they¡¯ve been inspected and found to have successfully met some targets. The system relies on a series of inspections and audits to assure compliance and to raise quality where necessary. Health care facilities¡¯ reported results are checked and confirmed for accuracy every quarter, before they get incentive payments.

So far, dozens of doctors, nurses and administrators have been trained in best practices. ¡°We were provided with modern equipment,¡± says Muhtaram Nurboeva, a family doctor working in a rural health center. ¡°We are using this equipment to provide timely aid to our patients, and our patients are satisfied. So, as a result, our income increased and we are also satisfied with our salary. We are doing our best to work better, to identify sick patients in a timely manner and to serve people.¡±

The crucial indicators of improved health - women and children - seem to be benefitting also. ¡°Doctors come home, consult us, advise what we need, and provide us with medicines. My child was born on the 15^th, and they came to my home in a week after we were discharged from the hospital, and examined us,¡± says Nargiza Nurmatova, who lives in the Spitamen district. ¡°So as you can see, my kid is happy and healthy.¡±

The targeted areas for the project are Tajikistan¡¯s more rural and isolated areas, says Gaffor Miraliev, with the Agency for Medical Services Control of the Ministry of Health and Social Protection. ¡°Within this project, we are conducting verification in eight pilot districts of Sughd and Khatlon oblasts. It is also planned to add Dangara and Faizobod districts to the pilot areas of the project.¡±

ľ¹ÏÓ°Ôº has a long history of engagement in health in Tajikistan. In the recent past, the World Bank helped the government improve primary health care in the Sughd and Khatlon oblasts. That project helped rebuild primary health care infrastructure and improve outreach, and included training for health workers and improved links between workers and communities.