In Tajikistan, we are focusing on addressing the cornerstones of thriving communities in a Global Development Alliance with the U.S. Agency for International Development (USAID) called Economic and Social Connections: A Multi-Input Area Development Financing Facility for Tajikistan (ESCoMIAD). Our first series on that partnership traced the impact of dynamic communities and local governance structures on the foundation of flourishing economies (links to that series here). This series looks at another set of those building blocks: innovative institutions. This means building capacity at local health facilities in isolated communities. Enhancing the skills of teachers who ensure schools are dynamic places that stimulate children’s minds and strengthening systems for delivering energy to homes, businesses and public facilities. Together these tell the story of how the Alliance is improving the quality of life for communities in Tajikistan.
Weaving a Safety Net for Services at the Border
Alongside economic growth, ESCoMIAD seeks to sustainably support improved social programs, filling needs in areas where services are scarce. The Aga Khan Foundation (AKF), through its health program, has reinforced structures to improve healthcare with shared information and collaboration among medical professionals on both sides of the Tajik-Afghan border that increase the quality of care for Afghans.
The effort goes back to a 2002 national-level agreement between the two countries on cross-border collaboration. That agreement created a framework for activities at the province-oblast level, between Badakhshan Province in Afghanistan, Gorno-Badakhshan Autonomous Oblast (GBAO) in Tajikistan, and the AKDN. That framework helped to start annual meetings between the two sides on needs ranging from healthcare and markets to education and cross-border irrigation.
Improving Health Care
To improve health care, Aga Khan Health Services (AKHS) worked with authorities to design a Cross-Border Health Program in 2009. They started with the recognition that facilities on the Tajik side of the border were better equipped than those on the Afghan side, and their staff were trained to handle complex medical procedures and operations. With the program, Tajik medical professionals would cross to Afghanistan on short-term arrangements to provide emergency and routine care; and Afghan medical professionals would shadow visiting colleagues, and cross to Tajikistan for training in particular procedures at better facilities.
Getting buy-in from border agencies was crucial. In emergency situations, the authorities recognized that the medical work sometimes had life-and-death stakes, and in those cases they even permitted medical staff to cross the border without delaying for a visa. This partnership has made it possible for Afghan patients to receive emergency care by orthopedic surgeons, anesthesiologists and other medical professionals for critical injuries.
Noziyai Alidod, a six-year-old girl, fell and impaled her head on a sharp rock. She arrived at a clinic in Ishkashim unconscious with a skull fracture. The clinic assessed her critical situation and arranged her transfer to Khorog Oblast General Hospital where a neurosurgeon used an emergency CT scan as a guide for a three-hour operation to remove bone fragments from her brain.
The surgery was a life-changing success. She was discharged in two weeks and escorted by an orthopedic specialist back to Ishkashim, where she continued her recovery in the care of Afghan health professionals.
In Shugnan, for example, the district has three facilities (one Sub Health Center in Darmorakht, one Basic Health Center in Roshan and one Comprehensive Health Centre in Bashor) to treat a population of almost 30,000 Afghans. The sub health center has a staff of three health professionals. The basic health center has six health professionals. Only the third is a comprehensive healthcare clinic (CHC) with 18 health professionals (for example, ob-gyn, lab techs, nurses) plus 10 support staff. Besides the CHC in Shugnan, the program has supported two other principal clinics in Afghanistan (CHCs in Ishkashim and Nusai).
What motivates a doctor in Tajikistan to take time from their practice and journey to a poorly equipped, overcrowded clinic? Most cite a desire to be part of an effort to improve life for people across the border. The program also provides per diems, which help make it practically feasible. (A doctor in Tajikistan typically makes around $200 per month.)
In two and a half years, ESCoMIAD has provided funding support for medical professionals from Tajikistan to treat over 5,600 Afghan patients in routine and emergency situations.
Telemedicine Pushes the Envelope
The institutional system for improving health in the border area involves the AKDN’s model of hub-and-spoke facility relationships. In this case, Khorog Oblast General Hospital serves not only as a hub for eHealth, but also provides diagnostics through an AKHS and GBAO government public-private partnership that created a Regional Diagnostic Unit to serve Tajik and Afghan populations. The diagnostic unit offers CT scans, a blood bank, x-ray and mammography, and ultrasound tests. Its staff can perform pathology tests, including biochemistry, hematology and cytology. Many of these tests can be done using samples brought to the lab, without need for the patient to travel. The results are sent back to the participating CHC for use in treating the patient.
Since mid-2016, Tajik government concerns over border security have made teleconsultation an easier option at times for treatment of Afghan patients. An Afghan patient who goes to their closest clinic may get considered for treatment in Tajikistan. If the results of the teleconsultation confirm the need for a visit to the Khorog hospital, the consultation provides the added benefit of familiarizing Tajik staff with the patient and their needs before their arrival.
Growing Capacity of Border Clinics
For skills development, AKHS reviews the staffing needs of the Afghan facilities, often gathering 3-4 professionals at a time and coordinating the group’s travel with Tajik counterparts. AKHS will then arrange for visas, transport and per diem support so that the Afghan practitioners can visit the Tajik hospital and learn by doing. That way, they get to treat patients while under supervision and coaching by cardiologists, ophthalmologists, dermatologists, endoscopists, orthopedic surgeons and others.
In two and a half years, ESCoMIAD has provided funding support for over 220 health professional cross-border visits and 50 health professional trainings. It has also provided needed equipment in Shamsiddin Shohin district of Khatlon oblast and an ambulance service in GBAO.
This combination of in-person and e-health connectivity is a groundbreaking partnership. “The combination inspires more creative ways to meet the needs of patients in these isolated situations,” says Umed Nazrishoev, Manager, Cross-Border Health Program, AKHS.
Building a Healthier Future
All these programs work together to lay the groundwork for a strong and quality healthcare system in eastern Tajikistan and northern Afghanistan. In this remote and mountainous region, it can often take hours or days of difficult travel to reach the nearest hospital. Innovative programs like ehealth, hands-on training, and traveling doctors helps to bring care to those who need it. The institutional relationships this program is building, help to raise standards of care and services for communities that live at the margins but whose vitality is at the heart of Central Asia’s future.