LMG Support to Health Governing Bodies in Afghanistan

By: Mahesh Shukla, MD, MPA

The LMG Project in Afghanistan is assisting the Ministry of Public Health to improve Provincial Public Health Coordinating Councils governance at all subnational levels (i.e., provincial, district, and community levels). It assists the PPHCCs, DHCCs, facility health shuras (consultative assemblies), and community health shuras to discharge their roles and responsibilities in a more effective, efficient, transparent and accountable manner so that they are able to influence access to health care, quality of care, and overall health outcomes for the people living in the provinces. The project is well-prepared to provide similar assistance to governing bodies in many other low- and middle-income countries.

Provincial and district health governance

To help PPHCCs and DHCCs improve governance, the LMG/Afghanistan program, in working with the Ministry of Public Health and these committees, has supported drafting of governance guides through a consultative process. Four effective governing practices—cultivating accountability, engaging stakeholders, setting a shared strategic direction, and stewarding resources in a responsible way—are at the heart of these governance guides. PPHCC and DHCC members drafted these governance guides through a series of workshops. The draft guides are available in two national languages of Afghanistan—Dari and Pashto—and at this time, field-testing of the governance guides is taking place in three provinces (Herat, Khost and Wardak) and 11 districts (Narkh, Jalriz, Sayedabad, Ismailkhail-Mandozai, Alisher, Istalaf, Qarabagh, Eshkamish, Garam Sir, Spin Boldak, and Qaisar).

PPHCC and DHCC members enthusiastically participated in the workshops, during which they worked in groups to discuss how to put the four effective governing practices into operation in the context of their province or district. They identified concrete and specific actions to be taken over the next six months (April-October 2013) on various key dimensions of the four effective governing practices. They also carried out a self-assessment of their current governing/decision-making practices at three levels - committee level, subcommittee level and at individual member level. These self-assessments will be used to establish a baseline of their governing practices. The self-assessments will be repeated six months later to find out whether their governing practices have improved.

Three PPHCCs and 11 DHCCs have identified a total of 389 specific and practical steps to be taken during the field-testing period based on the four effective governing practices. The LMG Project will support the pilot provinces and districts with field testing through its provincial health system strengthening coordinators. The progress on specific actions will be an agenda item during monthly PPHCC and DHCC meetings. The respective committee (PPHCC or DHCC) will review the progress made in the province or the district on these specific steps.

As the field testing of the governance guides comes to an end, PPHCCs and DHCCs will discuss the overall experience as well as the applicability of the guides and four effective governing practices to their specific situation. The members will then make specific recommendations to the Ministry of Public Health. PPHCCs and DHCCs will, as described earlier, repeat a self-assessment at the end of the six months to see whether their governance practices and scores have improved.

Community health governance

During a consultative workshop, twelve health facility shura and health post shura members from eight provinces (Ghazni, Kabul, Kapisa, Kunar, Laghman, Logar, Nangarhar, and Paktia) expressed a need for guidance from the Ministry of Health on how to effectively carry out their roles and responsibilities, which also include community health leadership and community health governance. The LMG/Afghanistan program assisted the Community-based Health Directorate of the MOPH in drafting guidelines for health post shuras and health facility shuras.

The draft guidelines were then reviewed by a panel of 15 health post shura and health facility shura members from eight provinces (Kabul, Kapisa, Kunar, Logar, Nangarhar, Paktia, Panjshir and Parwan). The members expressed broad agreement with the draft guidelines, and made many suggestions to improve and contextualize the content. Their comments and concerns were addressed, and the draft guidelines were revised and will soon be shared with a panel of Afghan and international reviewers. Once finalized, health shura guidelines will be field-tested in about 20 health post and health facility shuras over a period of six months.

By Mahesh Shukla, MD, MPA, Public Sector Governance Senior Technical Advisor, Leadership, Management & Governance (LMG) Project.

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