1. FHS2 Afghanistan Activities (June, 2011- May, 2012) CBHC/ MoPH

2. 2 FHS II/CSC Objectives The main objective of the community scorecard in Afghanistan is that through active engagement of communities it will lead to improved health service delivery in terms of utilization and quality of care, and also result in other non-health dividends like enhanced trust in public institutions and services. It is also hypothesized that the development of community indicators for health facility and provider performance through the CSC will result in improved provider performance and involvement of communities in the management oversight of health facility operations improving accountability and transparency.

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4. 4 PHASES OF FHS2 AFGHANISTAN Phase I: Inception phase Phase II: CSC Implementation Phase III: Dissemination

5. 5 PHASE I June, 2011 to December, 2012 Selected provinces: Bamyan and Takhar Data Collection - KII - FGD (CBHC WG and TG, Shura, Community members) [Baseline FGDs] - Structured Interviews (NGO managers, CHS) - HFA (CHWs, Health Facility workers, Patients and Caretakers, Facility-in-Charges) + [Baseline HF BSC performance] Data analyzed Report almost completed Community Sampling Strategy 2 PDQ, 2 PDQ+FHAG, 4 CSC = 8 Communities

6. 6 EVALUATION End line FGDs in all 8 communities - Trust, transparency, accountability, transparency BSC Data - Overall Client Satisfaction and Perceived Quality of Care Index - Community Involvement and Decision Making Index - Health Worker Satisfaction Index - Staffing Index - Equipment Functionality Index - Pharmaceuticals and Vaccines Availability Index - Laboratory Functionality Index (CHCs only) - Functional Infrastructure Index - Client Background and Physical Assessment Index - Client Counseling Index - Time Spent with Client - Total Number of New Outpatients - Total Number of Institutional Deliveries

7. 7 StakeholderAssessment StrategySampling StrategyTotal Sample Qualitative MoPH Policy MakersKIIPurposive selection of 5 key personnel at the MoPH involved in policy making and community health. 5 CBHC WGFGDAll1(6) CBHC TGFGDAll1(6) HF councils (Facility Shura)FGD1M and 1F per HF13(83) HP councils (Community Shura)FGD1M and 1F per HP6(39) Community membersFGD1M and 1F per Community16(105) Quantitative NGO Managers –NationalStructured InterviewsAll NGO’s implementing BPHS? 29 NGO Managers - ProvincialStructured InterviewsBamyan and Takhar2 Community Health SupervisorsStructured InterviewsAll CHS from 8 HF8 Health provider interviewsStructured InterviewsRandom selection of up to 5 providers in each HF of 25 HF selected by stratified systematic sampling in 33 provinces (METASHARP) 1821 Community Health WorkersStructured InterviewsRandom selection of 1 CHW in the catchment area of each HF of 25 HF selected by stratified systematic sampling in 33 provinces (METASHARP) 436 Patients and CaretakersStructured InterviewsRandom selection of 5 adult patients and 5 caretakers of patients under 5 years in each HF of 25 HF selected by stratified systematic sampling in 33 provinces (METASHARP) 5152 Community health postsStructured instruments for observation Random selection of 1 community health post in the catchment area of each HF of 25 HF selected by stratified systematic sampling in 33 provinces (METASHARP) 342 Health facility-in-charge interviewsStructured InterviewsHealth facility-in-charges in each HF of 25 HF selected by stratified systematic sampling in 33 provinces (METASHARP) 640

8. 8 PHASE II January, 2012 to present (ongoing) Two communities were selected in each province for CSC pilot Three rounds at three month intervals punctuated by two monthly monitoring visits First rounds of both provinces done Second monthly monitoring visit to be completed mid June Second round in July

9. 9 PHASE II: Field Work Takhar Province March 15 th to March 24 th Districts: Kalafgan and Namak Ab Kalafgan district: Kalafgan CHC and Zeer Shakh village Namak Ab district: Namak Ab CHC and Deh Bala village. *Namak Ab was dropped after the first round for security reasons

10. 10 PHASE II: Field Work Zeer Shakh Community member input scorecard - Men and women were in separate FGDs: scores were subsequently integrated. There 9 men in the male FGD and 6 women in the Female FGD Input indicatorsScores by Men Scores by women Integrated Scores 1Number of Staff9109.5 2Facility Infrastructure 634.5 3Drug Availability534

11. 11 PHASE II: Field Work Zeer Shakh Community member performance scorecard

12. 12 FGD with Zeer Shakh Community members in Takhar Province

13. 13 PHASE II: Field Work Kalafgan CHC provider input scorecard - One FGD was conducted for this group. There were 5 men and 3 women: Input indicatorsScores 1Clinic staff (number)9 2Drug availability10 3Clinic Infrastructure5 4Equipment8.5

14. 14 Self-assessment meeting of Kalafgan CHC staff in Takhar province

15. 15 PHASE II: Field Work Kalafgan CHC provider self assessment performance scorecard Performance indicatorsScores 1Staff attitude9 2Waiting time8 3Health education and counseling9 4Staff punctuality9 5Patient examination9

16. 16 PHASE II: Field Work Action plan for input and performance indicators developed by Kalafgan CHC staff and Zeer Shakh community members

17. 17 FGD with Deh Bala Community members in Takhar Province

18. 18 Self-assessment meeting of Namak Ab CHC staff in Takhar province

19. 19 PHASE II: Field Work Action plan for input and performance indicators developed by Namakab CHC staff and Deh Bala community members:

20. 20 PHASE II: Field Work Bamyan Province April 25 th to May 4 th Sar Qul BHC and Manar Sufla Ulya village Syadara BHC and Sorkh Qala/ Noorka village

21. 21 FGD with Manar Sufla Ulya Community members in Bamyan Province

22. 22 Self assessment FGD of Sar Qul BHC staff in Bamyan province

23. 23 Self-assessment meeting of Siadara BHC staff in Bamyan province

24. 24 FGD with Sorkh Qala/ Noorka Community members in Bamyan Province

25. 25 Communication & Coordination Close coordination with the CBHC department of MoPH, PHD of Takhar and Bamyan provinces and BPHS implementers in Takhar and Bamyan (CAF and AADA respectively) Obtain important information about security, food and accommodation for field teams and transportation costs Support from these partners was invaluable during field work

26. 26 Monitoring of progress May 15 th to 17 th, 2012 in Takhar in Kalafgan by FHS2 project manager Action plan reviewed There was noticeable progress on the action plan: a female nurse was at post within 15 days of the development of the action plan. Progress had not been made on some items however. Attention was drawn to these and the associated timeline extended. All involved declared their commitment to work on the action plan more seriously.

27. 27 Takhar monitoring visit: PPHD, Providers and NGO

28. 28 Group photo of the FHS2 team members and Namakab CHC staff in Takhar Province

29. 29 CHALLENGES Security - Kabul- Bamyan Road - AOG Checkpoints and attacks on vehicles on the road - Kabul- Takhar Road - AOG attacks on the road targeted at NATO and ISAF supply convoy and Afghan police and Army vehicles - AOG abductions of NGO staff and government officials have been reported on this road - Namak Ab - Strong Taliban links (Provincial governor during Taliban time was from Deh Bala) - Namak Ab CHC works based on the dictates of the Taliban - Taliban have destroyed communication networks in the area