Afghanistan Now:On the Path to Better

HealthDr. Abdul Wali Ghayur

Health System Strengthening Coordinator and Focal Point

Ministry of Public Health

Islamic Republic of AfghanistanRwanda June 2008

Outline

Background Progress BPHS implementation mechanisms RBF in Afghanistan History New initiatives Constraints

.

Background The Islamic Republic of Afghanistan is an

impoverished, landlocked country of 25 million people

Afghanistan has been affected by twenty-three years of war.

Health Situation-Post Tabliban 2002 Health system infrastructure:

Inequitable distribution of health services Insufficient numbers of health workers

Health indicators: Children Under-five mortality rate was 257 and IMR of 165

deaths per 1,000 live births per year Maternal mortality ratio was estimated at 1600 pregnancy-

related deaths per 100,000 live births year

Developed Basic Package of Health Services (BPHS).

Contracted with NGOs to deliver services through standardized health centers and outreach teams.

Rigorous evaluation twice a year.

Rebirth of the Health System: Actions launched in March 2003

The Results of the Investments: Improvements in Health

There is a 25% Reduction in Child Mortality since the Taliban

165

129

257

191

100

120

140

160

180

200

220

240

260

Infant Mortality Rate Under 5 Mortality Rate

2001

2004-05

80,000 more children are surviving each year compared to during the Taliban

BPHS Implementation Schemes

Contracting NSPs MOPH –SM

WB USAID EC

How is contracting being used in Afghanistan? WB Performance-based Partnership Agreements

(PPAs) Lump sum service delivery contract; financial bonuses MOPH management through GCMU 11 Province-wide provinces, 6 clusters (3 MoPH-SM)

USAID performance-based grants No financial bonuses but payment can be withheld for poor performance Management subcontracted through MSH then WHO&MOPH Intensive technical assistance 13 cluster-wide provinces

EC grant contracts No performance-based elements Management through local EC delegation 4 province-wide and 6 cluster-wide provinces Talks to decentralize

RBF in Afghanistan: History: NGOs under contracts paid 1% for 10% increase in reaching the

targets Almost all NGOs at least received one time bonus except one

contract termination case The bonuses were issued using several sources of information

especially findings of the third party evaluation (Balance Score Card)

These bonuses paid against substantial progresses made in several important areas, including: average new outpatient visits, provision of antenatal care delivery care shura-e-sehie activities, equipment functionality and the availability of essential drugs and family

planning supplies, laboratory functionality, staffing levels, provider knowledge, staff

training, use and availability of clinical guidelines, and so on

RBF in Afg con…………: Insecure province of Hilmand (

Trend of services before and after introduction of incentive schemes

Hilmand Province

0

500

1000

1500

2000

2500

3000

3500

Jan Feb Mar Jan Feb Mar

2007 2008

Deliveries New ANC Family Planning DPT3 TT2+

RBF in Afg con…………:Change of OPD visits in Hilmand Province

0

10000

20000

30000

40000

50000

60000

70000

2007 Last Q 2008 Last Q

GAVI-HSS initiative:

Will start in mid 2008 through contracting out mechanism Study will have four arms to see the results of:

1: Paying performance based incentive to volunteer community health workers

2: Paying incentives to families utilizing delivery and EPI services

3: Results of both interventions in the same sites 4: Control districts

Efforts will be paid to compare the findings across GAVI/Norwegian approved initiatives

New Afghanistan’s RBF proposal:

RBF support through Norwegian funds , Early 2008

Assigning a committee of local public health experts assisted by international TA to develop the proposal particularly the World Bank

Approval of Afghan MoPH RBF proposal on April 2008

Implementation period 2010-2013 Estimated amount of RBF component is

$16.7Million

Rational: Why? Reach MDGs and ANDS targets High levels of MMR and <5MR and IMR Data indicate there is access but limited utilization (Of women living

within an hour walk of a health facility, fewer than 30% delivered with a skilled attendant in 2006).

Build on already going experience ( very small) Improve efficiency : Only 25% of Basic and Comprehensive Health

Centers achieve the volume levels set by the MoPH. International experiences shows positive results (exp. Haitian NGOs

with 10% potential annual bonuses for increasing primary health care coverage showed substantially higher utilization of immunization and antenatal care compared to historic trends)

Will add to the international experience and will answer some unanswered questions

Further strengthen community based health care services

Areas to be targeted by the RBF

Pilot 1:

Improving NGO coverage of life-saving maternal and child health services:

Pilot 2:

Increasing volume of hospital-based maternal and child services

Both includes intervention and control arms

Implementation mechanism:

Contract out with an experienced research entity

Contract between the research entity and the health services delivery implementing organizations

MOPH will actively facilitate and monitor the process

Implementation/progress reports will be provided to the MOPH

Expected outcomes from the RBF pilots

1. 10% increase in the accomplishment of the

following indicators: Deliveries attended by skilled birth attendants Antenatal visit to a skilled health worker Children 12-23 months receiving vaccines ( BCG,

DPT3, OPV3, measles) Children <5 with symptoms of pneumonia

visited a health facility

Continued……

Institutional deliveries Facility visits for children under 5 Equity of institutional delivery 2. Five percent increase in the accomplishment of

the following indicators: Equity of facility visits for children <5 Mean quality score on Hospital Balanced

Scorecard

Challenges

Even with these impressive gains, it is only a start—much remains to be done: Infant, child and maternal mortality remain

high Health is an essential element for improving

the country’s security Many communities continue to have

inadequate access to health services Quality of health services must be improved Further health gains require sustained

support from our partners for the long-term