Some Practical Lessons on Implementing RBF from Afghanistan Benjamin Loevinsohn World Bank October 2008

Outline 1. Background on Afghanistan 2. What the Government tried to do 3. Some of the results accomplished 4. Practical lessons about implementation

Very conservative society where social obstacles impede women’s access to services

Country Context  Pop’n = 25 Million  km2  34 provinces  One of the poorest countries in the world (GDP ~ 300 dollars/ capita/year  Civil War since 1978  1-2 million people died, >5 million refugees  80% rural

Afghanistan in Reasons to Worry Little physical infrastructure MOPH had limited capacity Health workers afflicted by the “3 wrongs” wrong gender wrong skills wrong location Little coordination of NGO activities

Distribution of NGO Health Centers was Chaotic and Unequal – 1 HF per 50,000 un-served Road

Inequalities were very serious, MMR much worse in rural and remote areas

What the Government did: Established the “Basic Package of Health Services” – priority health interventions Signed Results-Based Contracts with NGOs on a very large scale – 90% of rural Afghans live in areas served by contracted NGOs Competitively recruited Afghans to work in MOPH at market wages Invested heavily in monitoring & 3 rd party evaluation including HFSs, HHSs, HMIS

Results-Based Contracting EC, USAID, MOPH (with WB funding) signed contracts/grants with NGOs Similarities: focused on BPHS; same indicators & M&E process; clear geographic responsibility (provinces); competitive recruitment; move towards MOPH management of all grants and contracts

Results-Based Contracting - PPAs MOPH signed “performance-based partnership agreements” (PPAs) using WB funds 46% local NGOs, 27% INGOs, 29% with consortia credible threat of sanctions – one INGO was terminated for poor performance, one local NGO’s contract not extended considerable autonomy – lump sum instead of line item budgets

Results-based Aspects of PPAs Credible threat of termination Bonuses for NGOs: annual 1% of contract value for 10 point increase in BSC, 5% for increase in coverage at the end of the contract Could have been better designed (+23% in year 1, less bonus than 10% and 10%) bonuses also paid to provincial health officials to align incentives

Setting up a Grants and Contract Management Unit Competitive recruitment of local consultants Transparent recruitment thru involvement of external stakeholders Paid market wages but on contract Caused considerable resentment in MOPH However, attracted very capable people, many from NGO sector Much appreciated by senior management Much cheaper than international consultants

Health Facility Surveys JHU worked with stakeholders to develop a health facility assessment Carried out annually since facilities per year Formulated a “balanced score-card” (BSC) that rated facilities on a scale of 0-100

Health Facility Surveys – An Important M&E Tool BSC looked at 29 areas of care including: (i) equity; (ii) patient satisfaction; (iii) availability of drugs, equipment, & staff; (iv) knowledge of providers; (v) quality of patient-provider interaction; (vi) patient load, etc. Costs about $300,000 per year

32% Improvement in Quality of Care from facility survey (BSC)

Improvements in Reproductive Health – Household Surveys 2003 to 2006

Changes in Routine Immunization Coverage

U5MR in Afghanistan: Actual and MDG4 Target

Implementation Lessons Learned 1.Have clear objectives: The MOPH focused on the BPHS in rural areas and ensured all DPs did too!! 2.Have explicit contracts: The MOPH spent time and effort to ensure contracts were clear on what was expected but left how to NGOs. Used a checklist in designing them 3.Have an explicit plan: PIP dealt with NGO selection, contract management, M&E

Implementation Lessons Learned 4.Clear Arrangements for Contract Mgt: MOPH set up GCMU: 10 people with proper budget – look after all DP contracts/grants a.Field visits to assess progress, ID issues, and diagnose causes b.Ensure prompt payment of NGOs c.Hold NGOs accountable for obligations d.Track performance using available data e.Keep MOPH leadership informed

Implementation Lessons Learned 5.Monitor Carefully: Used different sources of information to assess performance on explicit indicators: a.Health facility surveys – very useful to do yearly by 3 rd party b.HMIS – insisted on high reporting rate c.Household surveys to verify HMIS data – found big differences for vaccination & ANC coverage d.Field visits using checklists e.Involve community

Implementation Lessons Learned 6.Give Implementers Autonomy: MOPH gave NGOs substantial autonomy by: a.Use of lump-sum (not line item budgets) b.Allowing NGOs to procure their own drugs, supplies, and equipment c.Focusing on what not how; e.g. insisted on female health workers d.Encouraging NGOs to innovate

Per capita outpatient visits per year in Secure and Insecure Provinces with PPAs by same NGO

Introduction of Conditional Cash Payment by NGO

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