Investment case for two-year post university speciality training in family medicine in Tajikistan: how much is needed for continuing and scaling up the improved education of family doctors?

Background: A new two-year Post University Specialty Training (PUST) programme in family medicine was introduced to improve the quality of postgraduate speciality medical education in Tajikistan. Postgraduate education of family doctors (FDs) needs to be urgently scaled up, as 38% of FD positions in Tajikistan remained unfilled in 2018. Moreover, the international financial support for the PUST programme is ending. This investment case assesses the minimum funding needed for the continuation and scale-up of PUST and establishes the rationale for the investment in the light of a recent evaluation. Methods: The costs of the programme were calculated for 2018 and a scale-up forecast made for the period 2019-2023. The impact of the scale-up on the shortage of FDs was assessed. An evaluation using a Multiple Choice Questionnaire and Objective Structured Clinical Examination (OSCE) assessed and compared theoretical knowledge, clinical skills and competencies of PUST trained and conventionally trained FDs. Results: The annual costs of the programme were US$228,000 in 2018. The total investment needed for scaling up PUST from 31 new FDs in 2018 to 100 FD graduates each year by 2023 was US$ 802,000.However, when the retirement of FDs and population growth are considered, the scale-up will result only in maintaining the current level of FDs working and not solve the country's FD shortage. The PUST FDs demonstrated significantly better clinical skills than the conventionally trained interns, scoring 60 and 45% of OSCE points, respectively. Theoretical knowledge showed a similar trend; PUST FDs answered 44% and interns 38% of the questions correctly. Conclusions: The two-year PUST programme has clearly demonstrated it produces better skilled family doctors than the conventional one-year internship, albeit some enduring quality concerns do still prevail. The discontinuation of international support for PUST would be a major setback and risks potentially losing the benefits of the programme for family medicine and also other specialities. To guarantee the supply of adequately trained FDs and address the FD shortage, the PUST should be continued and scaled up. Therefore, it is essential that international support is extended and a gradual transition to sustainable national financing gets underway

Medical education reform in Tajikistan: comparison of the conventional one-year family medicine residency program and the new two-year residency program for postgraduate medical education

INTRODUCTION: The last two decades have seen a shift in former Soviet countries from highly specialized to more family medicine-focused systems. Medical education has slowly adjusted to these reforms, although the region is still at risk to have a chronic shortage of family doctors. This paper presents the evaluation of a new post-graduate family medicine program in Tajikistan, focused on competency-based training. The findings are relevant for policy makers, international organizations and practitioners participating in similar medical education reform programs. METHODS: We employed a quasi-experimental control group design and compared intervention residents, control group residents with traditional training, and 1st year residents with no training in two outcomes, clinical knowledge and competencies. We employed two objective measures, a written multiple-choice question test (MCQT) and an Objective Structured Clinical Examination (OSCE), respectively. We report reliability and validity of the measures along with ANOVA, planned contrasts and effect size estimates to examine differences across groups. RESULTS: We found statistically significant differences in both clinical knowledge and competencies between intervention and control groups. We also detected a large intervention effect size. Participants in the intervention outperformed control group participants in the two measures. Our analysis suggests that intervention and control group participants are comparable in terms of initial knowledge and competencies, strengthening the argument that the intervention caused the improvement in the program outcomes. DISCUSSION: Receiving tailored training and structured opportunities to practice knowledge and competencies in clinical settings have a positive effect on the education of family medicine doctors in Tajikistan. Our results support curriculum reform and investment in medical education in the form of longer and supervised on-the-job preparation designed to be more in line with international standards. We discuss suggestions for future studies and potential requirements to inform replicability in other countries. CONCLUSION: Family medicine is well recognized as central to health systems throughout the world, but high quality residency training lags behind in some countries. Our study showed that investing in family medicine residency programs and structured training is effective in increasing critical clinical competencies. We encourage promoting comprehensive post graduate family medicine doctor training so that the goals of a family medicine centered health system are attainable

Bringing greater transparency to health workforce planning in Tajikistan: using the WISN approach

Background For many countries, overcoming problems related to human resources is critical for progress towards Universal Health Coverage. Planning the workforce means to make decisions on required number, qualification and distribution of health workers. In Tajikistan, despite significant reforms, the health workforce is unequally distributed with physicians being mainly specialized and concentrated in urban areas. Description Using the Tajik case, we present a first comprehensive assessment of the Primary Health Care (PHC) staffing situation in a Central Asian setting applying and critically discussing the Workload Indicators of Staffing Need (WISN) method developed by the World Health Organization. Staffing requirements were derived using annual service statistics, obtained from a re-count of monthly routine data from registration books at facility level in the year 2016. Available health cadres in PHC at district and facility level were compared to the according staffing needs. Sensitivity analysis was performed to test the robustness of the predictions, and to identify the main contributors to uncertainty in the predicted staff requirements. Results For doctors performing general tasks in the PHC, there is currently an excess of full time equivalents. Moreover, health centres are overstaffed in terms of nurse positions. If the various speciality doctors currently working at rural health centres are not included, there is a shortage of family doctors in place. Sensitivity analysis revealed that staffing requirements in the PHC sector in Tajikistan are most importantly influenced by antenatal care visits. Lessons The present study concludes that there is an oversupply of doctors and nurses at PHC and a shortage of family doctors working at the level of health centres. Consequently, a more rational health workforce planning based on well-grounded methodology such as WISN has potential to contribute to more efficient and effective health service delivery in Tajikistan. Key messages Countries shifting towards a family medicine model face challenges like an oversupply of specialists performing general medical tasks and a lack of general/family doctors in the transition phase. To identify staffing requirements a transparent and reproducible approach, such as the WISN methodology, is required to steer future staffing needs and possible re-training of current staff