Millennium Development Goals Needs Assessment

Tajikistan

Preliminary Report

 

 

 

September 2004

 

 


 

MDG Needs Assessment Team, Tajikistan


 

TABLE OF CONTENTS

 

 1. Introduction. PAGEREF _Toc84142750 \h 3

2. MDGs Needs Assessment in Tajikistan. PAGEREF _Toc84142751 \h 4

3. Education. PAGEREF _Toc84142752 \h 7

4. Health. PAGEREF _Toc84142753 \h 10

5. Water Supply and Sanitation. PAGEREF _Toc84142754 \h 14

6. Conclusion. PAGEREF _Toc84142756 \h 17

7. References. PAGEREF _Toc84142757 \h 18


 

 


 

1. Introduction

 

Today, Tajikistan is at a turning point of its development. Having survived a brutal civil war during 1992-97, its economic situation is now on the road to recovery and even progress.  The peacetime economy was bolstered by some initial economic reforms, allowing GDP to expand at an average rate of 9.3 percent over 2000-2004[1]. The sources of growth are becoming more diversified. Strengthening privatisation, particularly in the agricultural sector, as well as reform of public utilities and increased investment in public infrastructure are core elements of the national growth strategy. Actual progress on these fronts has been weak however, and the IMF accordingly anticipates that real economic growth will be slow. Real GDP is expected to expand at a rate of 5 percent over the medium term. Under an agreement with the IMF, external borrowing for public investment projects is capped at 3 percent of GDP, on account of Tajikistan’s large existing foreign debt burden. This condition underscores the difficult trade-off Tajikistan must make between maintaining macroeconomic stability and borrowing funds for badly needed public investment. With foreign financing limited, the Government hopes to increase public revenue as a percentage of GDP through a combination of reforms aimed at simplifying tax codes, and improving tax collection. Progress on these fronts, however, has been slow.

 

Poverty in Tajikistan has increased in both breadth and depth since the collapse of the Soviet Union. Recent evidence from the 2003 Tajik Living Standards Survey suggests that high rates of economic growth over the last several years have succeeded in reducing poverty. According to the World Bank’s recent Poverty Assessment Update,[2] all major poverty indices declined over 1999-2003. The proportion of the population living on less than $2.15 PPP per day fell by 16 percentage points to 67 percent. The proportion of the population living on less that $1.08 PPP per data also fell by around 13 percentage points to 18 percent. At least with respect to income poverty, rapid rates of economic growth have had a measurable impact on incomes.

 

While the country appears to be heading in the right direction, the overall poverty situation in the country remains severe and still numbers among the worst in the world. More than two thirds of the population continues to live on less than $2.15 per day. Higher income and consumption rates have not necessarily translated into improved living conditions for all: nutrition, for example, appears to have grown worse, with significantly more families reporting that they eat only one meal per day. Despite the apparent increase in income and consumption, a majority of households reported that they saw little improvement in their living conditions since 1999.

 

Though Tajikistan still is the poorest country in the region, it has a real chance to prove that through progressive economic, social and political reforms it can ‘move mountains’ and become an example of relative equality, modest prosperity and gradually evolving democracy in Central Asia. The government’s commitment to achieving the Millennium Development Goals (MDGs) provides the country with a unique opportunity to foster equitable and sustainable development.


2.  MDGs Needs Assessment in Tajikistan

 

Government

The Government of Tajikistan signed the Millennium Declaration in 2000 along with 191 countries.  Since then, the government has implemented a number of activities that demonstrated the seriousness of its commitment to achieving the MDGs:

  • In 2003, the Government of Tajikistan and the UN Country Team (UNCT) produced a joint report called “Progress towards the Millennium Development Goals” that reviews current challenges and opportunities that the country faces for achieving each of the MDG targets;

  • The government recognized that national development strategies and policies should be realigned with the MDG priorities, and that it should assess the financial resources needed to implement these priorities. Tajikistan is one of the 8 pilot countries where the MDG needs assessment exercise is being undertaken in partnership with the Millennium Project in New York.

  • In July 2004, President Emomali Rakhmonov conducted a videoconference with Prof. Jeffrey Sachs on the MDG needs assessment. In August 2004, five working groups were established by a Presidential decree, to be chaired by the relevant Deputy Prime Ministers to develop appropriate policies and financial costing for achieving the MDG targets in the following sectors:

    • Education

    • Health

    • Water and Sanitation

    • Gender

    • Food Security and Nutrition

 

The working groups are coordinated by the State advisor to the President on economic policy Mr. Kholboboyev and comprise relevant line ministries, government organizations, as well as experts from national and international NGOs.

·         The policy priorities resulting from the working group meetings will be incorporated into the MDG needs assessment final report, and will be built into the revised Poverty Reduction Strategy Paper (PRSP) in 2005.

 

UN Country Team

The UN support Tajikistan’s efforts to integrate the Millennium Development Goals into its national development strategies, budgetary frameworks, and ministries’ priorities, as well as donor assistance frameworks and development programmes. UNCT has a team of specialists working on preparing the MDG needs assessment document, and providing technical assistance to the government working groups on the MDGs.

 

United Nations Millennium Project

To support the MDG process, the UN Secretary-General launched the Millennium Project (MP) to find best practices and strategies to achieve the MDGs in the countries where there the challenges are greatest.  Over a period of three years, the Millennium Project is to draw up a plan that will allow all developing countries to the MDGs by 2015.  The MP is lead by Prof. Jeffrey Sachs, and its research focuses on identifying the operational priorities, organizational means of implementation and financing structures necessary to achieve the MDGs. While the country offices are in charge of carrying out country-specific MDG needs assessment the MP team of 300 experts is responsible for providing technical assistance and overall support.

 

 

 

The MDG Needs Assessment

The purpose of the MDG needs assessment work is the following:

  • Provide an analysis of the current development trends in Tajikistan and to discuss explicitly changes in national policies and sectoral strategies that may be required to achieve all 8 goals;

  • Build comprehensive, but flexible models through which the Government and its partners can discuss development scenarios, including detailed breakdowns of needs as well as estimates of both internal (government) and external (donor) resources needed to achieve the MDGs;

  • Provoke substantive discussion about the practicalities of development in Tajikistan.

 

The UN MDG needs assessment team aims to produce a document that:

·         provides a holistic analysis of the country’s development situation;

·         tailors the MDGs to Tajikistan’s national circumstances;

·         prioritizes policy reforms needed to achieve the MDGs;

·         identifies means of policy implementation;

·         calculates the total cost of achieving quantifiable MDG targets, and

·         evaluates financing options.

 

The Results

There will be three important outcomes of this joint process of the Government and the UNCT:

1.      Detailed needs assessment of achieving the MDGs in Tajikistan, including costing estimations for some of the quantifiable MDG targets

2.      Long-term national plan through to 2015 to outline the policies, institutions, and investments needed to achieve the MDGs

3.      Integration of the long-term plan into operative policy documents such as the revised Poverty Reduction Strategy Paper and the Medium-Term Expenditure Framework

 

Initial Report

An initial assessment of the financial, human and institutional resources needed for MDG attainment in Tajikistan has been drafted by the UN MDG team in conjunction with the Millennium Project. Initial estimates as of August 2004 focus on a set of five core “service delivery” targets: achieving universal primary education (MDG 2), lowering child (MDG 4) and maternal (MDG 5) mortality rates, combating the spread of disease (MDG 6), and improving access to drinking water (MDG 7). Costing issues for the remaining MDGs – poverty reduction, gender equality, food security and strengthening international cooperation – will be discussed in more detail in the draft document to be released for comments by January 2005. The final report incorporating feedback from government and relevant international and national organizations will be released by May 2005

·         Economic Development Trends

Real economic growth has been strong in recent years, and according to the IMF 2004 country report, the real GDP grew by 10 percent in 2003 and is expected to grow by 8˝ percent in 2004. With sustained economic growth, the overall goal of halving the poverty index between 2000 and 2015 will most likely be achieved[3]. However, unless the government channels considerable attention to social services and distributional concerns, it is unlikely that economic growth alone will be sufficient to produce significant improvements in living standards of the most vulnerable segments of the population. Progress towards the MDGs will require a sustained government commitment to strengthening the legal and institutional framework, implementing effective policy reforms in the social sector, improving the quality of public service delivery, and effectively managing financial resources. Fiscal policy aims to support economic growth and public service provision while striking a balance between increasing expenditures and limiting borrowing. The Government aims to reduce the burden of external debt, which, stood at 83 percent of GDP in 2002. Consequently, debt servicing absorbed 35 percent of revenues in 2003 and thus further limited financial resources available for public investment.[4] Despite progress on restructuring Tajikistan’s bi-lateral debts, the debt burden will remain heavy and it continues to pose a threat to macroeconomic stability.

  • Cost Estimates in Education, Health and Water sectors

The overall cost of achieving key MDG targets in education, health, and water services provision in Tajikistan by 2015 will be on the order of US$5 billion. This includes:

    • US$1.7 billion for education; 

    • US$2.4 billion for health;

    • US$0.9 billion for expansion of access to water and sanitation services[5]

 

               Table 1.  MDG Costs and Financing Gaps 2003-2015

 

 

 

 

 

 

 

Sector

MDG

Cost    

Notional

domestic

 financing

Notional

international

 financing

Financing

gap

Annual

average gap

 

 

$US mln

$US mln

$US mln

$US mln

$US mln

Education

2

1670

1010

260

400

36

Health*

4,5,6

2450

560

440

1,450

132

Water

7

920

290

85

545

50

Total

 

5040

1860

785

2395

218

Source: MDG team estimates.

* Domestic financing figure is for all health care; cost figure is not comprehensive and covers expenditures

required to provide for basic health care and interventions to fight HIV/AIDS, tuberculosis and malaria.

 

Tajikistan is unlikely to meet all its MDG targets on its own. The initial estimates project that the financing gap for MDGs related to education, health and water sectors will be approximately US$2.4 billion. Tajikistan is highly dependent on external financing for its current poverty reduction framework and is likely to remain so in the future. Although significant external financing will be needed to help Tajikistan achieve the MDGs, calls for additional funding must be balanced with the imperative to manage a heavy burden of the existing foreign debt. The Government aims to reduce the burden of external debt, which stood at 83 percent of GDP in 2002. Serving this debt has absorbed 35 percent of revenues in 2003 and constituted a significant drain on financial resources that might otherwise be used for public investment.[6]
 


3.  Education

 

Current Situation

Due to the combined effects of the civil war and the challenges of transition, Tajikistan faces considerable obstacles in achieving the MDG target of providing basic education to all girls and boys[7]. Dropping attendance levels, a widening gender gap, growing barriers to full participation in the basic education for children of vulnerable groups, inappropriate curricula, low teacher salaries and the resulting difficulties in retaining good teachers, an inadequate and deteriorating physical infrastructure of schools, and weak capacity for conducting policy assessments are some of the difficulties that the education system is facing today. The attendance level has declined to 88% in 2003 compared to 90% in 2000.[8] The gender gap in school attendance has been widening in recent years, and in 2003, the dropout rate was twice as high among girls than boys in rural areas, and three times as high in urban areas. Dushanbe city has the worst indicators – it has the lowest attendance level and the highest gender gap. The education system has to adopt to the changing social structure and market economy, and meet the demands for a high-quality, up-to-date curriculum as well as to bridge the widening gender gap and increase attendance levels across the country, especially in Dushanbe and in remote rural areas.

 

Tajikistan has placed increasing emphasis on improving educational outcomes and views strengthening the education system as a key component of the overall program to reduce poverty. This commitment to education is indicated by the fact that over 16 percent of general expenditures (US$31 million in 2002) is allocated to education, a higher percentage than in most OECD countries.[9]  In 2003 the Government was able to allocate 2.8 percent of GDP to the sector, one of the highest expenditure items in the state budget but a low share by international standards, even in comparison to other low-income countries.[10] Nonetheless, the government emphasises the need for increased funding; donors emphasise that financial pressure can also be relieved by improving the allocation of resources in the education system. Reforms to the curriculum, staffing policy and the norms governing education sector budget disbursements could help to alleviate financial pressure by creating an environment in which additional funds can have a stronger impact on improving schooling outcomes.

 

National education strategy

The Government accords a high priority to education and initiated an ambitious program of reforms for the general education sector in July 2004. Reform of the national curriculum, the centrepiece of the reform effort, has several implications for the system. The authorities have reduced the number of courses in the curriculum to focus more resources on core subjects; student curriculum hours have been reduced; teachers will be required to teach more hours to collect their ‘stavkas’ (salaries per teaching load); salaries are set to rise by 25 percent in the 2004/2005 school year. These changes have broad implications for many other areas of the education system: textbooks must be brought into line with the new curriculum standards, teachers must be trained to teach multiple subjects. In addition to these reforms, the education authorities will focus on creating new norms of distributing financial resources on a basis of actual needs and demands, taking account of higher per-student costs in sparsely settled areas. Rehabilitation of and investments in the capital infrastructure are also priorities for the government, but the government’s resources are inadequate to support even the basic operating costs of the school system.

 

An important means of relieving financial pressure is to improve the allocative efficiency of expenditures. Accordingly, the Ministry of Finance and the Ministry of Education have undertaken to develop new per capita financing norms and have produced some preliminary proposals for reform in this area. The distribution of resources in the sector could be improved by ensuring that small schools in sparsely populated areas – schools that do not benefit from the returns to scale enjoyed in larger urban schools – are not short-changed of funds simply because they have fewer students.

 

Costing

Assuming baseline GDP growth, the cost of achieving the MDG is estimated at approximately US$1.7 billion, or around US$150 million annually. Recurrent expenditures on general education (excluding the cost of the school feeding programme, which is largely met by foreign aid, and not including spending on pre- and post-general education programmes, which currently absorb around 25 percent of the education budget) would need to rise from 2.0 percent of GDP in 2002 to 3.6 percent of GDP by 2015. In all, the expenditures needed to meet the MDG for education are estimated to average 5.2 percent of GDP annually for the general education system alone.

 

Table 2. Summary costs of education

Components

2005

2010

2015

% of

2015 Total

Total

2005-2015

Avg.

2005-2015

Capital costs

38

52

71

33%

560

51

Recurrent costs

60

99

146

67%

1108

101

Total

98

151

217

 

1,668

152

% GDP

5.0%

5.3%

5.3%

 

 

 

Per student

57

79

95

 

 

 

Per student spending % of per capita GDP

22%

26%

27%

 

 

 

 

Annual notional funding is estimated at US$116 million, including public spending of US$65 million (assuming achievement of a 4% spending target for education as a share of GDP by 2010), private spending of US$27 million, and international spending of US$24 million. The annual incremental cost of meeting the MDG in education – the amount of additional spending required to raise enrolment rates to 100 percent – is over US$30 million per year. This suggests that the international community will need to double disbursements to the general education sector if the MDG target for education is to be met.

 

Table 3.  Notional financing for general education 2005-2015 (US$ mln 2003)

 

 

 

 

 

 

 

 

Government Financing

 

 

 

Private Financing

International financing

(grants and loans)

Government expenditure target

 (% GDP by 2010)*

3%

4%

5%

 

 

 

 GDP growth scenario

(2005-2015)

High (7%)

626

810

841

 

344

 

240

Baseline (5%)

549

707

741

 

302

 

240

Low (3%)

483

617

653

 

266

 

240

* Assumes increase from 3% in 2004 to target in 2010 and no change thereafter

 

 

 

 

If Tajikistan is to meet the MDG target for universal basic education enrolment by 2015, both the Government and its international partners must redouble their efforts to set the education system on a favourable course. For the Government, the low share of GDP allocated to education in general and to the basic education sector in particular must be raised. Deeper reforms will be needed to ensure that increased spending is used effectively. The attention currently being directed to per capita financing norms is very important in this regard. A strong commitment to implementing the recently decreed curriculum and staffing reforms will also help to improve the allocation of funds and improve the quality of schooling.

 

Tajikistan’s international partners also have an important role to play if MDG targets are to be reached. International aid agencies, NGOs and financial institutions should continue to improve coordination with one another and with the Government. International organisations must also strive to improve the efficiency and effectiveness of their own projects in the education sector. Most importantly, as Tajikistan demonstrates its willingness to undertake difficult reforms and direct more domestic financial resources towards the education system, international partners should be prepared to respond by increasing their own support and assistance.

 


4. Health

 

Health MDGs

To estimate the costs of meeting MDG goals 4 (reduce child mortality), 5 (improve maternal health) and 6 (combating HIV/AIDS, malaria and other diseases), this study examines the finances needed to stabilise the core pillars of the primary care system: rural health houses, rural health centres, urban polyclinics, and general hospitals (city hospitals and central district hospitals), as well as laboratory facilities of the national public health authority, the Sanitary and Epidemiological Service (SES). These institutions represent the mainstays of the basic health system and provide the platform from which interventions to address maternal and child health as well as disease control will be implemented. The study also provides some estimates of long-term resource needs for combating HIV/AIDS, tuberculosis and malaria.

 

Current Situation

Over the past decade both the quality and accessibility of health care has deteriorated sharply in Tajikistan, and achieving the Millennium Development Goal targets for health will be extremely difficult. As a result of the economic transition and the civil war, spending on the health sector fell from 4.5 percent of GDP in 1991[11] to less than 1 percent of a much lower level of GDP in 2002. Public expenditure on health was just US$ 2 per capita in 2003. Such low levels of public spending are inadequate to operate the current system much less to meet critical investment needs or direct resources to the country’s most vulnerable groups. As the Government’s role in health care declines, the health system is becoming increasingly dependent on informal private payments to pay for basic services and on foreign aid to relieve the acute shortage of essential drugs and medical equipment. In 2003 total private spending on health services was US$12 per capita, one of the lowest levels of health spending in the world. Private payments comprised 70 percent of expenditures, compared with 16 percent from government and 13 percent from international sources.[12] Tajikistan’s health care system is largely based on hospital-based tertiary care, preventative and primary health services being underutilized, or of poor quality. Procurement of drugs is largely through unofficial channels, which causes serious problems for controlling the quality of drugs and prescribing the right treatments. Households perceive health care to be one of their greatest concerns[13], which absorbs as much as 30 percent of household expenditures.[14]

·         Infant and Maternal Mortality. The 2002 Demographic and Health Survey (DMS) estimated the infant mortality rate at 87 deaths per 1000 live births – the highest in the former Soviet Union. Also, Tajikistan has the worst chronic malnutrition (stunting) among the countries in Central Asia.[15] DMS estimated an under-five mortality rate of 110 deaths per 1000 live births over the period 1992-1996. A high percentage of unattended births, lack of access to reproductive and pre-natal health services, and lack of awareness about basic maternal health issues present serious obstacles to efforts at lowering mortality rates. As the Government’s 2003 Millennium Development Goal Report indicates, targeted reductions in maternal and child mortality rates are unlikely to be met on schedule. Improving the standard of health services will require not only increased financial resources but also significant structural reforms to ensure that physical, financial and human assets are allocated more efficiently within the sector. Tajikistan’s progress towards the MDGs will be determined in large part by the success of these reforms, especially the reorientation of the health system away from hospital-based tertiary care and towards preventative and primary health services.

  • Infectious Diseases. The incidence of infectious diseases remains very high, and in the cases of tuberculosis and malaria, the situation has worsened in recent years. The number of registered cases of tuberculosis doubled from 32 per 100,000 in 1996 to 64 per 100,000 in 2002.[16] The HIV infection is estimated at 4000, expected to rise to 5000 by the end of 2004.  The malaria infection is at 6,150 per 100, 000 population.  Recently, international funding for fighting against malaria has significantly decreased, due to discontinuation of funding from agencies such as USAID, which has negative impact on achieving the MDG target of reversing malaria.  Thus, barring a substantial increase in investment for disease control, it is also unlikely that Tajikistan will be able to halt the spread of malaria, tuberculosis and other diseases, including HIV/AIDS, by 2015. With so many pressing needs in the health sector, disease control and epidemiological services may receive less attention from authorities. Indeed, the capacity of the Sanitary and Epidemiological Service has been severely curtailed over the last decade, even more than other elements of the health system. In general, the private payments and international aid that support so much of the health sector cannot substitute for a strong public health service, which, like other public goods, requires Government leadership to develop and maintain. Urgent attention to improving epidemiological services, raising public awareness and strengthening preventative measures is needed to arrest the advance of diseases in Tajikistan. In the long run these investments could save the country considerable expense.

  • Primary health care. Although primary health services still exist owing to the Soviet legacy, due to severe deterioration in both quality and infrastructure, most patients choose to bypass these facilities, and seek care at urban hospitals and polyclinics. Mistrust of the primary health system is so deep that even fully rehabilitated and equipped local facilities may have trouble attracting patients.[17] Rehabilitating the primary health infrastructure will therefore require not only direct financial investment for upgrading the standard of services but also time and effort to strengthen the links between the health system and local communities.

 

National health strategy

There is broad consensus in the Government about the need to expand access to the health system and improve the standard of services in the sector. The National Poverty Reduction Strategy Paper and the 2002 Concept of Health Care Reform in the Republic of Tajikistan outline a vision for national health policy which highlight the following priorities:

·         Revising the state’s role in the health sector. In June 2003 an amendment to the constitution abolished the state guarantee of free health care and implicitly recognized the de facto system of private payments that currently supports most health services in the country. The change in the legal framework opens the door for the introduction of new policy measures that would formally recognize and regulate private fee for service arrangements.

·         Strengthening primary care services. Strengthening the accessibility and quality of the primary health care system is as a key goal for the sector. Provision of improved community health services could have a significant impact on health outcomes in the country by making quality basic health services more accessible to households.

·         Rationalising the hospital sector. Streamlining secondary and tertiary hospital care is an important complement to the development of the primary health care system. The match between resources and needs in the hospital system needs to be improved.

·         Developing human resources. The policy emphasis on strengthening general care services underscores the need for new staffing and training norms. The distribution of staff, particularly deployment to rural areas, should be improved. Redressing extremely low health sector wages[18] is one of the most pressing needs in the health system.

·         Strengthening health care financing. This will mean giving more weight to primary care services and abandoning norms that allocate funds to the hospital system according to an inefficient “per-bed” formula.

·         Improving monitoring and information systems. Raising awareness about diseases, nutrition, hygiene and available medical services is an important element in the strategy to improve health outcomes. Policy formulation and resource allocation is inhibited by weak data collection. Health reforms also aim to improve the dissemination of information about basic public health and hygiene.

·         Managing drug supply. Spending on medicines is the single largest expense in the health system,[19] and most activity takes place in the largely unregulated private market. High levels of spending indicate that resources are available for purchasing medicines, but the lack of regulation has at best encouraged ineffective use of medicines and at worst served to develop drug resistance in the population and allow improper, sometimes harmful use of pharmaceuticals to grow. Availability of vaccines is also a concern, as the population is increasingly exposed to a range of epidemics.

 

Costing

In all, it would require some US$2.5 billion[20] to provide for the essential health care of the population over the 11 years from 2005-2015. This figure represents the cost of investments in disease control, the costs of capital investments in core medical facilities and equipment for the basic health care system as well as the recurrent expenditures needed to operate and maintain those facilities. Also, the net estimate reflects the cost of providing higher wages and in-service training for all health personnel and consumable supplies to cover essential national pharmaceutical needs. 

 

                                 Table 5. Summary costs for Health Sector

 

 Units

 2005

 2010

 2015

 2005-2015

 

 

 

 

 

 

US$ mln (2003)

 

 

 

 

(Total)

Total costs

US$ mln

113.4

231.5

328.1

2454.2

Primary health care system

US$ mln

107.3

217.6

306.5

2302.3

HIV/AIDS

US$ mln

1.9

9.6

17.3

103.8

Malaria

US$ mln

1.5

0.5

0.5

8.0

Tuberculosis

US$ mln

2.7

3.8

3.8

40.1

 

Percentage of GDP

 

 

 

 

(Average)

Total costs

% GDP

6.23%

9.91%

11.00%

9.20%

Primary health care system

% GDP

5.91%

9.31%

10.28%

8.64%

HIV/AIDS

% GDP

0.11%

0.41%

0.58%

0.38%

Malaria

% GDP

0.06%

0.02%

0.02%

0.03%

Tuberculosis

% GDP

0.15%

0.16%

0.13%

0.16%

 

Per capita

 

 

 

 

(Average)

Total per capita costs

US$

16.5

30.4

39.0

28.8

Primary health care system

US$

15.5

28.5

36.4

27.0

HIV/AIDS

US$

0.3

1.3

2.1

1.2

Malaria

US$

0.3

0.1

0.1

0.2

Tuberculosis

US$

0.4

0.5

0.4

0.5

 

 

 

 

 

 

 

Even if all potential sources of domestic and international financing for health care were directed exclusively to the primary health care system and programmes on HIV/AIDS, TB and Malaria, the financing gap for meeting these MDG targets would still be considerable, from US$333 to US$852 million.  Expenditures on other elements of the health system – chronic diseases, tertiary medical care, etc. – would require even more funding to support. Closing the financing gap would require not only an increase in international assistance, but also a considerable improvement in the efficiency of that assistance

.

Table 6. MDG Financing Gap for Health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total cost

of MDG interventions

 

Notional Available Financing

 

 

Financing Gap

 

 

Annual Average Financing Gap

Gov't expenditure target 1/

 

 

 

1%

2%

3%

 

1%

2%

3%

 

1%

2%

3%

 

 

 

 

mln

Mln

mln

 

mln

mln

mln

 

 Mln

 mln

 mln

GDP growth scenario, 2005-2015 

High (7%)

2609

 

1773

2024

2276

 

836

585

333

 

76

53

30

Baseline (5%)

2454

 

1608

1826

2045

 

846

628

410

 

77

57

37

Low (3%)

2319

 

1466

1655

1845

 

852

663

474

 

77

60

43

1/ Reached by 2010 and maintained thereafter .

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

As the Government’s 2003 Millennium Development Goal Report indicates, targeted reductions in maternal and child mortality rates are unlikely to be met on schedule. Improving the standard of health services will require not only increased financial resources but also significant structural reforms to ensure that physical, financial and human assets are allocated more efficiently within the sector. Tajikistan’s progress towards the MDGs will be determined in large part by the success of these reforms, especially the reorientation of the health system away from hospital-based tertiary care and towards preventative and primary health services.

 


5.  Water Supply and Sanitation

 

MDGs related to safe water supply

Target 10 of the MDG 7is to “halve, by 2015, the proportion of people without sustainable access to safe drinking water.” Improving water and sanitation systems is also an important element in the effort to achieve the MDG 2 of providing universal basic education, and health related MDGs 4, 5 and 6. Provision of safe water is one of the most important human development goals, without which MDG targets are not realistic.

 

Current Situation

At present, water supply and sanitation facilities in Tajikistan are neither safe nor adequate. With an annual production of over 13,000 cubic metres of water per capita, Tajikistan is one of the most water wealthy states in the world,[21] yet the country is able to provide just 59 percent of its population with access to safe drinking water. Overall, the country has the worst access to drinking water in the CIS, and outbreaks of waterborne illnesses pose a serious risk to public health. In urban areas, untreated river water flows directly into cities’ water pipes, and water systems are badly decayed and are subject to frequent service outages. In rural regions, where less than half of residents have access to improved water sources, large tracts of the population take their water from ponds, canals, rivers and other unsafe sources. With regard to sanitation, nearly all households have access to pit latrines, but most of these are of poor construction and pose a risk to public health.[22] A majority of schools and rural medical institutions lack proper sanitation and water facilities.

 

There are several reasons for the poor state of Tajikistan’s water and sanitation services. As in other sectors, the hardships of post-Soviet economic transition and the civil war have taken a toll on the water supply infrastructure. Low levels of official budget allocations and difficulties collecting user fees have severely limited domestic financing, which has been insufficient to meet the substantial requirements for capital investment. Even if increased funding were made available, it is doubtful that the water authorities could apportion resources effectively among the sector’s many and pressing needs. As a complement to investment, structural reforms are needed to improve the efficiency of service provision and strengthen incentives to rationalise consumption.

 

Given the potential benefits for social development, investment in and development of water services should be a high priority for Tajikistan. The resource needs for expanding access to safe water and adequate sanitation[23] in Tajikistan are much lower than in the health and education sectors. The greatest needs are in rural areas – where water systems development is relatively cheap to build and operate. The cost of rehabilitating urban water systems, however, is high and adds considerably to the challenges and financing requirements facing the sector.

 

 

 

Table 7. Access to improved water sources

 

Tajikistan

Urban

Rural

 

 

percent

 

Safe*

59.0

92.9

46.9

Unsafe

40.9

7.1

53.0

Total

100

100

100

Source: UNICEF MICS 2000.

*Safe water in Tajikistan often fails to meet formal standards for potability

 

National drinking water strategy

The national poverty reduction strategy notes that water supply and sanitation, along with other key infrastructure services, are “essential to economic growth and contribute much to the improvement of living conditions.” In 2002, the Government approved the National Concept on the Rational Use and Protection of Water Resources, which emphasises the need to reduce wastage and strengthen conservation of national water supplies. Ultimately, progress will depend on the Government’s ability to translate its strategic vision into specific, well-implemented actions, and on the ability of Tajikistan and its international partners to meet resource requirements for development in this area. The Government distinguishes between priorities for rural and urban areas: “in urban areas the focus will be on improving the reliability of the infrastructure, in rural areas the priority will be to provide access” to essential goods and services.[24] Authorities also acknowledge the need to reform water sector financing to bolster incentives for rational consumption and ensure that service provision is financially “self-supporting” while taking steps to cushion the impact of tariff reforms on low-income households through targeted subsidy programmes.

 

Costing

Tajikistan is unlikely to meet the MDGs for water and sanitation without a concerted effort on the part of national authorities, local communities and international partners. Altogether, the cost of meeting the MDG 7 target for water and sanitation provision is estimated at US$800 million. The single largest expense for meeting MDG 7 is the rehabilitation of badly degraded urban water systems. Without significant investment in this area Tajikistan’s growing urban population is likely to become increasingly exposed to hazards of waterborne disease. Outbreaks of typhoid in the capital during the fall of 2003 and summer of 2004 underscore the potential consequences of failing to invest in water services.

           

Table 7. Summary costs for Water and Sanitation

 

2005

2010

2015

Total 05-15

 

2005

2010

2015

Avg. 05-15

 

US$ million (2003)

 

% of per capita GDP per person

Capital costs

48.7

52.2

54.6

573.1

 

6.6

6.4

6.1

6.4

Recurrent costs

16.1

20.4

26.0

226.6

 

2.2

2.5

2.9

2.5

Water supply

46.4

50.5

53.7

554.9

 

6.3

6.2

6.0

6.2

Sanitation and wastewater treatment

17.4

21.1

25.9

234.2

 

2.4

2.6

2.9

2.6

Public awareness

0.9

1.0

1.0

10.5

 

0.1

0.1

0.1

0.1

Total costs

64.8

72.5

80.6

799.6

 

8.8

8.9

9.0

8.9

 

Improving water and sanitation services in rural areas is the most important objective for the country in this area. Developing these services is also relatively inexpensive:  the needs assessment suggests that the MDG target for water supply in rural areas could be met by investing less than US$100 million.

 

 

           Table 8. Notional financing for water supply and sanitation

 Source

2005-2015

 

 

Urban households 1/

154

Rural households 2/

22

Government 3/

33

International 4/

85

Total

294

 

 

Financing gap

505

 

 

1/ Assuming 95% collection and tariff rate of $0.145 by 2015.

2/ Assuming all water supply O&M can be met by private payments.

3/ Based on 2002 expenditures of US$1.7 million for DVK, TSK and TMA and average annual budget spending under the 2004-2006 PIP of $1.3 million.

4/ Based on average annual expenditures of US$7.7 million under the 2004-2006 PIP.

 

 

 

 

 

 

 

 

 

 

 

 

 

As is noted in Tajikistan’s 2003 National Human Development Report, the implications of unsafe water and poor sanitation for human development are considerable. It is highly unlikely that the MDG targets for infant and child mortality (MDGs 4 and 5) or for disease control (MDG 6) could be met without significant improvements in water and sanitation services. The high incidence of water-borne disease in areas with inadequate water and sanitation services is a prime cause of infant mortality and malnutrition in the country. Diarrhoea is the most widespread problem, affecting more than 1 in 100 residents in 2002.[25] Other water-borne diseases, such as typhoid and bacterial dysentery also pose serious threats to public health.

 

Improving water and sanitation systems is also an important element in the effort to raise school enrolment and attendance (MDG 2) as well as in efforts at promoting gender equality and the empowerment of women (MDG 3). For example, enrolment and attendance rates for girls have been shown to rise with the provision of clean latrines in schools. And supplying households with a convenient household or community water point can spare women and girls significant time and effort fetching water from more distant sources. Higher levels of female education can help reduce the incidence of disease among children.

 

Improvements in basic water and sanitations services can have especially strong benefits for poor households, which either lack the resources to cope with poor water and sanitation or pay disproportionately more for these services. Indeed, international studies have suggested that despite being less able to bear the costs, poor households often pay more per cubic meter for drinking water than do wealthier households with better access to water systems.[26]  


 6.  Conclusion

 

The focus of this and similar studies on certain prominent inputs for development (e.g. health and education infrastructure) should not obscure the significance of other factors that, although not explicitly considered in the analysis, may be equally important for development. Sound macroeconomic policy, an effective legal system that can enforce laws and regulations, financial accountability, good governance and strong institutions, among many other factors, have an important bearing on the cost of improving development outcomes, which will be discussed in detail in the final MDG needs assessment report. It is important to note that achieving advances in these areas will require additional financial investments and, to the extent that improvements are achieved in these areas, that such investments could lower the ultimate cost of meeting the MDGs. Without additional investments of money and political will in these areas the commitment of additional financial resources to social development is less likely to bring about welfare improvements. It should also be noted that MDG targets are all interlinked and that achieving one goal has a potential to positively effect realization of other MDG targets, ultimately leading to a decrease in the overall costing.

 

Tajikistan’s partners in the international community are committed to supporting the country in its efforts to accelerate human development. The volume of assistance already provided to Tajikistan stands as an indication of the continued interest of the international community in partnering with the Government to improve prospects for development. The Millennium Declaration stands not only as an affirmation of this commitment but also as a pledge to devote more attention and more resources to meeting the challenges of human development in countries like Tajikistan. As partners in this difficult but worthy endeavour, both Tajikistan and its international partners need to stand up to their respective commitments and responsibilities.

 

 


7.  References

 

1.       Achieving Universal Primary Education by 2015, A New Policy and Financing Framework, Barbara Bruns, 2003

2.       Central Asia and Caucasus. How significant is the book famine in the countries of Central Asia and Caucasus? Centre for publishing Development, EFA, 2000

3.       Education at a Glance 2001, OECD, 2001

4.       Education Financing in the Central Asian Republics: Issues and Options, Cheryl Cashin, 2003

5.       Financing Education – Investments and Returns. Analysis of the World Education Indicators, OECD /UNESCO, 2002

6.       Implementation Plan: Education Sector Reforms 2004-2009, Government of Tajikistan, 2004

7.       Is EFA Affordable? Estimating the Global Minimum Cost of ‘Education for All’, Working Paper # 87, 2001

8.       National Health Development Review, Ministry of Health, 2003

9.       National Concept of Education in the Republic Tajikistan, Ministry of Education, 2002

10.    National Education Sector Development Plan for 2003-2010, Government of Tajikistan, 2002

11.    National Plan of Actions on Education for All, UNICEF, 2002

12.    Pedagogy Renewal Project:  Tajikistan Education Reform, Asian Development Bank, 2002

13.    A population Projection Model Designed to Support and Inform Education Planning, Policy & Decision-Making, Popex 2001 User’s Guide

14.    Poverty Reduction Strategy Paper, Government of Tajikistan, 2002

15.    Progress Towards the Millennium Development Goals, Government of Tajikistan and United Nations Tajikistan, 2003

16.    Public Investment Programme 2004-2006, Government of Tajikistan, 2004

17.    Report and Recommendation of the President to the Board of Directors on a Proposed Loan to the Republic Tajikistan for the Education Sector Reform Project, Asian Development Bank, 2003

18.    Social Sector Expenditure Review, World Bank, 2003

19.    Strategia respubliki Tajikistan po okhranye zdorov’ya naseleniya v period do 2010, Ministry of Health, 2003

20.    Tajikistan Country Report, International Monetary Fund, 2004

21.    Tajikistan Health Sector Note: Health Financing Report, World Bank, 2004

22.    Tajikistan Living Standards Survey, World Bank and State Statistical Committee, 2003

23.    Tajikistan Poverty Assessment Update, World Bank, 2004

24.    Teacher Education and Professional Development in the Republic of Tajikistan: A Needs Assessment of skills and associated Relationships, CARE Tajikistan, 2003

25.    Water Supply and Sanitation and the Millennium Development Goals, World Bank and IMF, 2003

26.    Water, Sanitation and Health, UNICEF, Tajikistan, 2003

 


 

[1] According to the IMF 2004 Country Report, real GDP grew by 10 percent in 2003, and is expected to grow by 8˝ percent in 2004

[2] Tajikistan Poverty Assessment Update. World Bank, June 2004.

[3] Assuming that the GDP growth will be sustained at minimum 5% per annum

[4] PIP 2004-2006.

[5] Based on the projection that the population growth will reach 8.42 million people, compared to the current 6.25 million and that the real GDP will increase to US$2,982million, compared to the 2003 levels of US$1,555million

[6] PIP 2004-2006.

[7] While MDG 2 specifically refers to primary education (in Tajikistan “primary education” refers to grades 1-4), this study considers the costs of achieving universal enrolment in the compulsory nine-year program of basic education

[8] World Bank Poverty Assessment Update, 2003

[9] OECD counties dedicated an average of 13 percent of spending to education in 1998. See OECD “Education at a Glance 2001.” Figures for Tajikistan do not include expenditures under the Public Investment Programme.

[10] UNESCO data from 90 low and lower-middle income countries indicate that on average public expenditure on education is approximately 3.5 percent of GDP among low-income countries, compared with 5 percent of GDP among high-income countries.

[11] “Strategia respubliki Tajikistan po okhranye zdorov’ya naseleniya v period do 2010” p.77.

[12] World Bank Health Sector Note, June 2004

[13] TLSS 2003

[14] World Bank SSER.

[15] World Bank Poverty Update Assessment, 2004

[16] Ibid

[17] Notes from Interagency Health Coordination Meeting. Dushanbe, August 2003.

[18] Burnett and Temourov, p.34. Health sector wages in early 2002 were only TJS 11 or US$4 per month, lower than in any other sector but agriculture. Anecdotal evidence suggests that doctors may earn between US$50 and US$150 from informal private payments each month.

[19] Cashin, C. “Draft Tajikistan Health Sector Note: Health Financing Report.” 2004. Estimates suggest that approximately 63 percent of all health spending in 2003 was for drugs and pharmaceuticals. Private payments account for roughly 80 percent of spending on medicines.

[20] Assuming baseline GDP growth of 5% annually

[21] NHDR 2003.

[22] UNICEF Tajikistan. “Water, Sanitation and Health” 2003.

[23] “Adequate” sanitation (disposal of excreta) refers to modern septic facilities, flush- or pour-toilets, ventilated and simple covered pit latrines, all of which provide some additional measure of protection, beyond that offered by open pit latrines, from unhygienic contact between excreta and insects or humans.  See World Bank and IMF background paper  “Water Supply and Sanitation and the Millennium Development Goals”, March 2003. “Safe” water (also referred to as water from an “improved” source) refers to household connections, public taps, water drawn from boreholes, protected wells, spring- and rain-water catchments. It should be noted that even so-called safe water sometimes fails to meet formal standards for potability.

[24] PRSP 2002.

[25] MDGR.

[26] World Bank and IMF, March 2003.