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

Figures & data

Figure 1. The ExpandNet/WHO Framework [22]. Reproduced with permission from the World Health Organization

Table 1. The elements of scaling up Business Plans [12,21]

Name and definition	Assessment of the element of scaling up Business Plans
The innovation ‘a set of health service interventions that is being scaled up’ [21,p.7]	Business Plan tool set:
	Rural Health Centre (RHC) Business Plans: Four key areas focusing on status quo and planning, targets and actions, monitoring and analysis. Consolidated Business Plan: Summary of information regarding the PHC managers’ targets and actions, the targets of the health facilities (each RHC), and the results from on-site monitoring visits of the health facilities. Business Plan management trainings: Workshops consisting of training modules for regional working groups on Business Plans and trainings for PHC management teams and heads of health facilities.
	During scaling up, the Business Plan was diversified and more components were added to the initial Business Plan package:
	In 2014: Guideline on the involvement of Community Health Teams (CHTs) to increase the collaboration between health facilities and the communities they serve. In 2018: Introduction of a management training module in the Postgraduate Medical Institute (PGMI).
The user organization ‘the institutions or organizations that seek or are expected to adopt and implement the innovation on a large scale’ [21,p.8]	Health policy level: Business Planning department in the Republican Center for Family Medicine (RCCFM)
	Team of 4 specialists In charge of the implementation and control of Business Plans Tasked with the national roll-out/expansion of Business Plans
	Regional level: Regional working groups on Business Plans
	Teams of 6 to 8 specialists In charge of training the PHC management teams and the heads of RHCs Responsible for supervising and coordinating the process of Business Plan implementation
	District level: PHC management team
	Responsible for initiating, monitoring and analyzing the Business Plans
	Facility level: Head doctors of PHC facilities
	Tasked with elaborating the Business Plan for their RHC and its affiliated Health Houses
	Community level: Representatives of CHTs
	Tasked with representing the wider community in all matters regarding Business Plans
The resource team ‘individuals and organizations that seek to promote and facilitate wider use of the innovation’ [12,p.6]	From 2005–2015: “Enhancing Primary Health Care Services” (EPHC) Project by the Swiss Centre for International Health and its representative office in Tajikistan Tasks: Provision of technical, managerial and policy expertise, financial support, Business Plan trainings, and monitoring and evaluation of the Business Plan implementation Since 2015: Supervision, oversight and financial support for the implementation of Business Plans 2015-present: Business Planning department in the RCCFM Note: The RCCFM acts both as a resource team and user organization for scaling up Business Plans. Tasks: Responsible for trainings, monitoring and evaluation of the Business Plan, scale Business Plans nationwide by introducing them in all districts Establishment of inter-governmental partnerships: Department of Health Reform, PHC and International Relations (ideational support and advocacy, especially in the course of vertical scale-up efforts) Republican Healthy Lifestyle Centre: Coordination of the cooperation between the resource teams and the CHTs.
The environment ‘conditions and institutions which are external to the user organization but fundamentally affect the prospect for scaling up’ [12,p.6]	Policies and laws:
	The Conception of Health Sector Reform in Tajikistan (2002) Law on family medicine (Order No. 676, 29 December 2010) The National Programme on the Development of Family Medicine 2011–2015 in Tajikistan The Strategy Plan of the Primary Health Care based on the Family Medicine Principles in the Republic of Tajikistan for 2016–2020 The National Health Strategy 2010–2020 and 2021–2030

Table 2. The strategic choice areas of scaling up Business Plans [12,21]

Strategic choice areas	Actions and decisions taken during Business Plan scaling up
Type of scaling up	Horizontal scaling up (expansion) Vertical scaling up (institutionalization)
Organizational choices	Participatory approach: MoHSP as the main decision-maker Guidance and advice by a working group on Business Plans consisting of leaders and specialists from the Department of Health Reform, PHC and International Relations, the Economics and Planning of Health Budgets department, the RCCFM, the Health Policy Analysis unit, representatives from the EPHC Services Project and representatives from the WHO Standardized implementation: Implementation of a uniform set of guidelines for the Business Plan introduction by the PHC management team Pace of scaling up: To our knowledge, no development of a clear long-term or multi-year scale-up strategy for guiding the process of going to full national scale with Business Plans Elaboration of annual plans with key activities within the Business Planning department and the regional working groups
Cost and resource mobilization	Assessment of costs: An investment case for the Business Plans is available. Provision of budget: Coverage of expenses regarding the expansion (horizontal scaling up) of Business Plans to new districts partly by the MoHSP and partly by external agencies, such as the Swiss Agency for Development and Cooperation (SDC), the Aga Khan Health Services and the WHO Budgetary allocation: Little change to the budget of PHC facilities during scaling up
Monitoring and evaluation (M&E)	Integration of M&E within the Business Plan At the district level, M&E through an Information Specialist in the PHC management team Discussion of the results from M&E directly with the implementers (heads of the rural healthcare facilities) and feedback via the consolidated Business Plan to the policy-makers (MoHSP) M&E of the scaling up process Jointly by the Business Planning department and the EPHC Services Project Additionally, through a steering committee consisting of representative of the government, the EPHC Services Project staff and the SDC
Dissemination and Advocacy	Policy dialogues: Advocacy for scaling up through champions from the RCCFM, the Department of Health Reform, PHC, and International Relations and other specialists within the ministry Networking and advocacy through the EPHC Services Project, for example in annual round tables with development partners, international organizations and potential donors Training: Conduction of training in a joint setting between the EPHC Services Project and the Business Planning department specialists Gradual transition of the full responsibility for national roll-out of Business Plans from the EPHC Services Project to the Business Planning department Implementation of cascade trainings between regional and district health departments and introduction of a management training module in the PGMI Training of Community Health Coordinators tasked with communicating the needs of the community with the PHC managers and the EPHC Services Project

Figure 2. Milestones of the horizontal and vertical scaling up of Business Plans

Table

Scaling up process and management
History and implementation of Business Plans
Please describe how the agreements and orders for the roll-out^1 of Business Plans to the PHC facilities of the cities and rayons (districts) were reached. What steps were taken to establish the Business Planning department? How did the introduction of Business Plans affect the PHC facilities?
Questions specific to the interviewee sub-groups
Members of the MoHSP and the donor agencies	Now that there are formal orders and a fairly new department to manage the Business Plan roll-out^1, how and by whom is the Business Plan roll-out^1 to the PHC facilities organized?
Members of the EPHC Services Project	Who were your most important partners for making the national roll-out^1 of Business Plans possible? Who were the most important people [politicians, policy-makers, institutions and organizations] to promote the roll-out^1 of Business Plans to the PHC facilities of cities and rayons (districts)? Now that there are formal orders and a fairly new department to manage the Business Plan roll-out^1, how and by whom is the Business Plan roll-out^1 to the PHC facilities organized? Is it different to the past? Which responsibilities and activities related to the introduction of Business Plans in the PHC facilities could be transferred to the RCCFM so far?
Members of the regional Business Plan working groups	Now that there are formal orders and a fairly new department to manage the Business Plan roll-out^1, please describe what your tasks are for the Business Plan roll-out to the PHC facilities. How did the introduction of Business Plans affect PHC facilities? Which responsibilities and activities related to the introduction of Business Plans in the PHC facilities have been transferred to you by the EPHC Services Project?
Members of the district level PHC management teams	Now that there are formal orders and a fairly new department to manage the Business Plan roll-out^1, have you observed any differences in the way that Business Plans are introduced in the RHCs? Now that there are formal orders and a fairly new department to manage the Business Plan roll-out^1, have you observed any differences in the way that Business Plans are used in the RHCs?
Scaling up barriers and facilitators
From your experience, what has made extending/scaling-up/rolling-out Business Plans successful? What have been the major problems and challenges to extending/rolling-out Business Plans? How did you solve these problems? Looking back, what would you have done differently when rolling-out Business Plans?
Future scaling up
What challenges do you see in scaling up/rolling out Business Plans to the remaining districts? How could they be solved? What would your proposal be to make the Business Plan roll-out^1 successful? What changes have to occur to ensure the use of the Business Plans in the future?
Wrap-Up
Would you like to add any remarks to help us understand your experience with the process of implementation and scale up better? Thank you very much for this interview and for your support of this study.

¹We used the term ‘roll-out’ to refer to scaling up in the interview questions because the stakeholders were more used to this terminology from prior studies and surveys conducted by the EPHC Services Project. Additionally, this term proved to be easier translated into Tajik and Russian.

ExpandNet/WHO. Beginning with the end in mind: planning pilot projects and other programmatic research for successful scaling up [Internet]. 2011 [cited 2020 Mar 3]. Available from: https://expandnet.net/PDFs/ExpandNet-WHO%20-%20Beginning%20with%20the%20end%20in%20mind%20-%202011.pdf.

 Google Scholar

ExpandNet/WHO. Nine steps for developing a scaling-up strategy [Internet]. 2010 [cited 2021 Jun 3]. Available from: https://www.who.int/immunization/hpv/deliver/nine_steps_for_developing_a_scalingup_strategy_who_2010.pdf

 Google Scholar

ExpandNet/WHO. Practical guidance for scaling up health service innovations [Internet]. 2009 [cited 2021 Jun 3]. Available from: https://apps.who.int/iris/bitstream/handle/10665/44180/9789241598521_eng.pdf?sequence=1&isAllowed=y.

 Google Scholar