1. Health Planning and Implementation in post-conflict Afghanistan by Laurence Laumonier-Ickx, MD November 8, 2006

2. Health in Afghanistan in 2002 Health Development IndicatorsAfghanistanCambodiaLow Income Maternal Mortality Rate (per 100000)1600450657 Births attended by skilled staff (%)12.431.838.5 Contraceptive Prevalence Rate (%)4.623.840.3 Infant Mortality Rate (‰)1659682 Under-5 mortality Rate (‰)257138126 Prevalence of Child Malnutrition (%)494544 Child Immunization Rate (% DPT3)475464 Health Expenditure per Capita (USD)8.030.023.2 Physicians per 10000.10.30.4 Hospital beds per 10000.22.1---

3. Building on what exists Afghanistan National Health Resources Assessment –MOPH, multiple donors and NGOs –National Inventory of: functioning health facilities Infrastructure Qualified staff and equipment Range of services offered Major findings: –Close to 1000 facilities still provide services –Huge inequities in distribution of facilities and services –Severe female understaffing –Only 25% of facilities able to deliver BPHS –Only 7% of population with ready access to BPHS –NGOs contribute to service delivery in 80% of the facilities –Lack of standardization and questionable quality in service delivery

4. Coordination and Transparency At central level –Coordination Group for Health and Nutrition ( MOPH, donors, NGOs, multinational and bilateral agencies ) –Taskforces and working groups –Technical Advisory Group ( technical review of proposed policies, strategies and interventions ) –National Technical Coordination Committee ( information forum for all MOPH partners ) –Executive board ( MOPH senior staff ) At provincial level –Provincial Public Health Coordination Committee ( Provincial MOPH and all partners in a province )

5. Policies and Strategies Interim Health strategy and Draft Health Policy –Developed early on –Defines values and working principles –Defines priority target groups Public Health Decision Framework: interventions should –Have proven impact on major health problems –Be affordable with available resources –Allow implementation at national scale –Attribute to more equitable distribution of health services Policy and strategy for each intervention Basic Package of Health Services (BPHS) Essential Package of Hospital Services (EPHS)

6. Basic Package of Health Services Elements –Maternal and Newborn Care (Antenatal, Delivery, Postnatal, Newborn and Family Planning) –Child Health and Immunization (IMCI & EPI) –Public Nutrition –Communicable Diseases Treatment and Control (TB, Malaria, HIV) –Mental Health –Disability –Essential Drugs Strong community-based component Targeted coverage : one BPHS facility per 30,000 Minimal staffing requirements (promotion of female health workers) Recommended equipment, supplies and drugs at each level

7. Essential Package of Hospital Services Hospital expenditures limited to 40% of the health budget Standardization of: –Services to be provided at each level –Staffing –Equipment, Supplies and Essential Drugs Emphasis on referral function and system Promotion of community ownership through hospital boards

8. Stewardship role of the MOPH Central Coordination of performance-based contracting out –ADB, EU, KFW, USAID, WB subscribe contracting out –Flexibility in actual implementation approach –Grants Management and Contracting Unit in the MOPH –Promote Provincial Public Health Coordination Committees Oversight of standardized implementation of BPHS and EPHS Monitoring and evaluation –Third party evaluation –National HMIS for BPHS and EPHS –Quality monitoring and improvement –Special studies and assessments

9. Main achievements by July 2006 Increase in number of service delivery points contracted out: > 800 BPHS facilities (80% with female health professional) > 6000 community health posts Standardized training of midwives and community midwives Routine service statistics available and used at local, provincial and national level Standard national monitoring tool developed and implemented Common quality standards applied nationally Lot quality assurance sampling in 13 provinces shows improvement in health outcome indicators measured in 2004 and 2006 –CPR from 16.2% to 25.9% –DPT3 coverage from 14.7% to 37.4% –Births attended by a skilled attendant from 12.2% to 23.2%

10. Population per BPHS facility in September 2002 Source: ANHRA 2002

11. Population per BPHS facility in July 2006 Source: MOPH/HMIS

12. Conclusion – key for success Clear coordination mechanisms at the central level, with transparent decision making processes; Assess what still exists and build on that; Early development of policies and strategies, using available information; Clear national priorities guiding the decision framework for interventions; MPOH in stewardship role, negotiating funding mechanisms; Use expertise of local implementers; Promote coordination at provincial level Insisting on standard-based management of facilities and services, allowing quality improvement parallel with expansion of services Measure progress (or lack thereof) and use data for decision making