1. 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

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

3. 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 .

4. 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.

6. The Results of the Investments: Improvements in Health

7. There is a 25% Reduction in Child Mortality since the Taliban
80,000 more children are surviving each year compared to during the Taliban

8. BPHS Implementation Schemes
Contracting NSPs MOPH –SM
WB USAID EC

9. 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

10. 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

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

12. RBF in Afg con…………:

13. 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

14. 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
Estimated amount of RBF component is $16.7Million

15. 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

16. 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

17. 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

18. 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 months receiving vaccines ( BCG,
DPT3, OPV3, measles)
Children <5 with symptoms of pneumonia
visited a health facility

19. 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

20. 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