The population coverage dimension of the BP is defined by citizenship (8). Tajikistan has approximately one million people residing outside the country for work (9). By ensuring coverage for all people, as compared to a residency- or contributory-based entitlements system, from which they would have been excluded, this definition is an inclusive, transparent, and administratively efficient approach.

At its independence in 1991, Tajikistan inherited a health system in which prioritization of resources was absent, as all available health care was free. In several steps over the course of 20 years, the Ministry of Health and Social Protection (MoHSP) has developed the benefits description in several steps (2). Aligned with primary health care (PHC) reforms, Tajikistan formally established free point-of-care services for the most essential health care, including a broad and general description of doctor and nurse appointments, with priority for maternal and child care. The explicitly described universal benefits in the current BP include a range of preventative services (such as vaccinations for children, consultations on healthy lifestyle, and disease prevention activities) as well as consultations with family doctors and home visits by nurses (Supplementary File 1). The BP further describes a long range of additional services, both outpatient and inpatient, but these are all associated with heavy user-fees and a complicated exemptions system (8). Medicines, with vaguely regulated and very large differences in prices and availability among retailers (10), are absent in the BP. By tradition, PHC facilities do distribute some medicines, such as insulin, although with varying availability. Laboratory services are formally included for defined vulnerable groups but data on utilization are not available.

All interventions that are not provided by the family doctor or nurse come with a user-fee based on a nationally estimated cost. The national hospital price list is regulated centrally and is based on an 80% cost-sharing principle, conditional on the hospitalization occurring at the facility where the patient is registered (determined by place of residence) and subject to a doctor’s referral. All other utilization, including outpatient services, is priced at 100% of the cost. An important aspect is that the estimated costs are probably below actual provider costs, which makes these formal percentages lower in reality. Laboratory services and medicines for the general population are fully funded by patients themselves (8).

The BP defines vulnerable population groups who are formally exempted from user-fees (“beneficiaries”) using two dimensions: social status and a set of medical conditions. The largest beneficiary group is individuals defined by their poverty status. But the social register used to identify these households classify only 1.6% of the total population as poor, despite 23% of the population in 2021 falling under the national poverty line (11). There is no health information system to monitor who is granted beneficiary status, to what extent they overlap, nor what their care utilization is.

Chronic non-communicable diseases (NCDs) like hypertension and diabetes constitute a large and growing part of the disease burden in Tajikistan (12). These conditions are manageable at low cost in PHC, especially if managed early. Official statistics underestimate them as indicated by the much lower prevalence in the official records than in survey-based data. The latter data also show low patient awareness and severe under-treatment, e.g., that 44% of men have never had their blood pressure measured (13, 14). It has been shown that many hospital cases in Tajikistan could be prevented if these risk-factors and conditions were managed better (15). Unnecessary hospitalizations resulting from ineffective PHC are a major factor in the estimate that half of all hospital spending in Tajikistan could be saved without adverse effects for patients (16).

Chronic NCDs are most effectively managed by a continuous, iterative process of well-defined interventions, including availability of essential medicines and diagnostics (17, 18). The network of primary care clinics in Tajikistan is extensive and services like weight and blood pressure measuring at consultation are provided to all. The MoHSP and international organizations have also made large efforts to implement and increase adherence to clinical guidelines. But the absence of laboratory diagnostics and outpatient medicines in the current BP interrupts the chain of effective disease management for patients who cannot pay, or opt not to pay, for these relatively simple elements of the care pathway (Figure 1).

The BP does include some point-of-care diagnostics, such as sugar level tests and urethral and vaginal smear tests for pregnant women. But these few items are not sufficient to diagnose and manage the most common NCDs and, in reality, access is limited and utilization is subject to out-of-pocket payments (11). Similarly, specific medicines are formally provided for free-of-charge distribution to beneficiary groups through vertically organized programs, such as insulin for diabetic type 1 patients by endocrinology centers and basic medicines for diarrhea and respiratory infections for children, but data on utilization is not available and both clinicians and patients testify to difficulties in affordable access.

In addition to forgone care causing illness and unnecessary later care needs, financial hardship caused by gaps in essential benefits is common. In 2022, 18% of Tajikistan households experienced catastrophic health spending, heavily concentrated among the poorest households. About 70% of all cases were caused by people's expenditure on outpatient medicines (19), although it's unknown how much of these are from the WHO Essential Medicines List (EML) and prescribed by protocol.

Public resources are spread thin across all types of specialized services, inpatient and outpatient, with heavy user-fees in practice being the main source of funding. here is an apparent risk that public resources are being spent on relatively wealthy and healthy individuals who can afford these user fees. In combination with the highly prevalent informal payments for health care, the user-fees risk that utilization of publicly provided services is based on who can pay, as opposed to who is in most need, leads to inequities and financial hardship.

The defined beneficiary groups are questionable from a BP perspective. For example, groups who typically have high health needs, such as children above one year, people aged under 80 years, and people with chronic diseases, do not fall within any of the beneficiary groups. Pediatric care tends to be beneficial when health gains and costs are compared (20). Both for social protection and cost-effectiveness reasons, neither 1 nor 80 are purposeful age thresholds. The age cut is also not aligned with other legislation, e.g., the 2008 Social Health Insurance law, which defines “child” at age 16 and is probably a more rational threshold.

An absence of clear priority setting rules and an overpromising as to what the state can provide risk leading to implicit prioritizations in all health systems, for example lower-than-necessary quality services, informal payments, or long waiting times. Criteria-based prioritization (6, 21) between specific conditions/diagnoses (horizontal prioritization) and between interventions within a specific condition/diagnosis (vertical prioritization) is common in countries with formalized health technology assessment processes (22) and are increasingly applied in middle-income contexts (23–25). Tajikistan's BP regulation and its implementation lacks explicit criteria for prioritization. In Supplementary File 2, we therefore suggest a set of criteria based on WHO guidelines (6) and objectives expressed in the national health strategy. An intervention is considered for inclusion in the BP if it addresses a condition prominent in the country’s burden of disease, is cost-effective, mitigates social vulnerability, and, finally, can be covered by the government’s health budget. The criteria are applied in a stepwise manner, with each criterion serving as a prerequisite for the next and only interventions that satisfy all criteria in a sequence being eligible for inclusion. For example, including interventions that the government budget can afford but which have less medical need (burden of disease) or are less effective relative to their cost (cost-effectiveness) than alternative interventions would mean priority setting is governed by budget space rather than medical needs.

Effective detection and management of primary care–sensitive conditions require simple yet essential diagnostic tools. The WHO Essential Diagnostics List (EDL) recommends a basket of diagnostic tests that should be available at point-of-care and in laboratories and includes a designated section on primary-care-relevant tests (26). Next, effective control and treatment can come at a low cost. The annual pharmaceutical cost for controlling blood pressure of patients with uncomplicated hypertension in India has been estimated to be $2–4 per patient (27). Among adults aged 30-79 in Tajikistan, only 33% of those diagnosed with hypertension take their medicine (28). The individual's cost creates a barrier for some and signals that the public system does not find it important. A defined set of generic medicines for management of the largest chronic NCDs should be in the BP based on the WHO EML (29).

The challenge with both the EML and EDL from a BP perspective is that they do not prioritize among their specific items and hence do not rank what is most crucial to fund publicly within the lists. This has to be defined in each country separately, primarily depending on the budget situation (30, 31). Hence, these lists provided by the WHO can be seen as gross lists where all BP candidates for prescribed pharmaceuticals and diagnostic interventions are listed but with further prioritization needed. For example, the list of medicines can be short to start with, covering first-line options in the medical protocols for hypertension, diabetes, and asthma, and can be extended in updates of the BP. Both Uzbekistan and Ukraine are good examples of countries with earlier reforms where drug lists have been introduced on different levels of ambition, with later extensions based on market conditions and budget availability. Ukraine introduced a nation-wide list in 2018 and later extended the number of medicines (32). In Uzbekistan, a list was introduced in one region in 2022 and later extended geographically (33).

The currently applied user-fees for maternal and child care do not align well with either the priority setting criteria or the national health strategy. The next BP needs to expand free-of-charge services in this direction. Instead of 80% cost-sharing across all hospital services, they can be divided into two simple tiers, one with 0% cost-sharing (free-of-charge for the patient) and one with 100% (full cost paid by the patient), by type of services. Free-of-charge maternal and child services can be made budget neutral by charging other services with lower priority at their full cost. Supplementary File 3 illustrates this with hospital utilization and facility-level revenue data from the Tajikistan district of Tojikobod.

These suggested changes are illustrated in the three-dimensional UHC framework by population, interventions, and cost sharing (Figure 2). While the current population coverage definition is kept, the system would not “promise” the same extensive package of interventions but instead abolish user-fees on those with the highest priority.