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Table 1 Study Settings

From: Local health governance in Tajikistan: accountability and power relations at the district level

The Gorno-Badakhshan Autonmous Region (GBAO) is the largest region of Tajikistan in landmass but the smallest in population. It is dominated by the Pamir mountains, known as ‘the roof of the world’, which have contributed to the region’s historical isolation and the development of a distinct regional identity [19] in linguistic, cultural and religious terms. The majority of the population adheres to the Ismaili faith and speaks one of the Eastern Iranian (Pamiri) languages as opposed to the Western Iranian Tajik, with a Kyrgyz minority in the East of the region. Partly as a result of this isolation, low population density and mountainous geography, the region is less developed socioeconomically compared to the central regions of Tajikistan. Most households rely on subsistence agriculture and remittances from migrated family members for their livelihood. During Soviet times tens of thousands of Badakhshanis, also denoted as Pamiris, were forcibly resettled to the cotton growing plains in the southwestern Qurqontheppa south-region, while positions of authority were mostly filled by non-Badakhsanis, which fostered local resentment towards central authorities [20]. This marginalisation was part of the reason for Pamiris to ally with Gharmi and other regional and ideological groups against the government in Dushanbe and form the United Tajik Opposition during the civil war (1992–1997). Given this historical background, the geographical isolation and cultural distinction from the rest of the country, the region remains more distant from the political centre up to this day. However, key positions continue to be filled through appointment from the centre, ensuring a degree of political control.

The districts of republican subordination (usually denoted by its Russian acronym RRP) are a collection of districts that are governed directly by the central government. The area stretches horizontally across the middle of the Republic of Tajikistan from the Hisor valley at the border with Uzbekistan around 70 km west of the capital Dushanbe, to the Rasht or Karotegin valley in the east, bordering Kyrgyzstan, hemmed in by mountain ranges in the north and southeast. The region has historically never been a unified territory. Rather, it encompasses mountainous areas in the east that were strongholds of the United Tajik Opposition (Karotegin / Gharm region), and more populous plains in the west that have remained under firm control of the central administration in nearby Dushanbe. The district that forms one of the two study sites in this paper is located in the Hisor valley in the western part of the RRP. Due to its proximity to Dushanbe, intensive cotton production on the irrigated plains, and the presence of the largest aluminium manufacturing plant in Central Asia, Tajikistan’s main industrial asset, the area has been of vital interest to the political and economic elite, receiving most of its capital investments. As an expression of that the Hisor elite was closely allied with those from the Khujand/Leninobod north and the Southern Kulobis that dominated the government by the end of the Soviet period and throughout the civil war in the 1990s [20].