Afghanistan Now: On the Path to Better Health Dr. Abdul Wali Ghayur Health System Strengthening Coordinator and Focal Point Ministry of Public Health Islamic Republic of Afghanistan Rwanda 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 .

Rebirth of the Health System: Actions launched in March 2003 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.

The Results of the Investments: Improvements in Health

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

RBF in Afg con…………:

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