MCS prepares to set new path toward better learning, better stewardship
Afghanistan Now: On the Path to Better Health
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Transcript of Afghanistan Now: On the Path to Better Health
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
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160
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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
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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
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10000
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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