L+M+G in Post-Conflict Afghanistan

By Alain Joyal, MBA, CPA

Introduction to the post-war health context in Afghanistan

 In 2002, at the fall of the Taliban regime after two decades of war, Afghanistan suffered some of the world’s worst health indicators, including a maternal mortality ratio of 1,600 per 100,000 live births and an infant mortality rate of 165 per 1,000 live births. Most of the health infrastructure was destroyed and many health workers had either been killed or forced to live in exile. The health situation there looked dire.

 To reverse this decline, the Ministry of Public Health (MoPH) has been working with the international community and the civil society first to provide emergency health services to a long-suffering population, then with its partners to reconstruct the health system, and develop the capacity of its health workers and organizations and institutions in a sustainable way.    

The results achieved by the health system in Afghanistan over the past decade are nothing short of remarkable. The health indicators from the 2010 Afghan National Mortality Survey and service indicators shown above help tell the story of a health system on the mend.

Maternal mortality had fallen by two-thirds, from an estimated 1,600 per 100,000 live births in 2002 to less than 400 in most parts of the country.

Infant mortality fell from an estimated 165 deaths per 1,000 live births in 2000, to 129 in 2004/2005, to 77 in the 2010 survey. Likewise, under-five mortality plummeted from 257 per 1000 live births in 2000, to 191 in 2004/5, to a remarkable 97 in 2010. This decrease is equivalent to saving 150,000 infant’s and children’s lives per year.

None of that could have happened without the inspired leadership, sound management, and transparent governance (L+M+G) demonstrated by Afghanistan’s partners and its health authorities throughout the stages of recovery from relief and rehabilitation to reconstruction and development of the health sector.

How Results Were Achieved

To achieve these results, important decisions were made across all of the six health system strengthening building blocks: service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership and governance (stewardship).

The leaders of the MoPH worked very closely with their key international donors and technical agencies to analyze the needs in-country and reach a consensus on what should be done. It is important to note as part of the lessons learned that four major decisions were made that profoundly affected Afghanistan’s health system development, and allowed for the achievement of early results:

  1. Interventions focused on basic and essential health services:

First, the MoPH and partners developed the Basic Package of Health Services (BPHS) and Essential Package of Hospital Services (EPHS) for use nationwide, based on the most effective clinical and public health interventions to reduce maternal, newborn, and child mortality as quickly as possible.

By focusing on defining from the outset, and keeping over time, the packages basic and essential rather than comprehensive, despite pressure to include a broader array of services, the MoPH made a controversial but important policy decision that set clear priorities and standards for the health system.

This sustained focus on selecting proven lifesaving interventions and communicating them through well disseminated packages has permitted Afghanistan to streamline health services arrangements and their scaling-up, facilitate coordination among all actors, allocate limited resources more rationally, and overall achieve a greater health impact.

According to Harr and Rubenstein in a United States Institute of Peace Special Report, “The success of this package and its capability to transition to more ministerial leadership is a key lesson in aligning priorities and strengthening government management of the health sector.

  1. MoPH concentrated on stewardship and oversight, and contracted out delivery of services:

Second, the MoPH decided that its primary functions would be stewardship, oversight, support and regulation and that the health needs of the population could best be met by contracting out nearly all of the delivery of the BPHS and EPHS to Afghan and international NGOs. Three major donors, USAID, the World Bank and the European Commission (EC) funded the BPHS delivery and the related MoPH support systems in all 34 of the country’s provinces.

In 2002, the major donors, USAID and EC, agreed on the principle of the contractual approach for the implementation of the health service packages championed by the World Bank based on its Cambodia experience. But both the Ministry and the NGOs had some doubt

As stated in Afghanistan’s Health System Since 2001 by Waldman, Strong and Wali, “Ministry officials viewed the delivery of the health services as a state function to fulfill  an important contributing element in making the new government legitimate in the eyes of the population.

The war period saw NGOs fill the gap and they were accustomed to a relative degree of independence. […]Still, both the Government and the NGOs acknowledged that they could not fulfill the responsibility of establishing a health system without each other.” Despite the initial concern of MoPH and some of the NGOs, the principle of having the MoPH contract out services was agreed upon, and now, after ten years of this institutional arrangement for heath service delivery, the concerns of the Government, NGOs, and some donors appear to have been unfounded.

  1. MoPH created a Grants and Contracts Management Unit to manage public funds:  

The establishment of the Grants and Contracts Management Unit tasked to manage public funds awarded for the implementation of the BPHS and EPHS greatly enhanced the ability of the MoPH to oversee the large international and national NGOs.

This unit has been carrying out its mandate effectively ever since, and today it manages procurement and monitoring of over $125 million of performance-based contracts annually.

After a formal review of the Afghan public sector financial management systems, the USAID mission in Afghanistan certified in 2008 the Ministry of Public Health (MoPH) to manage U.S. Government funds for implementing health services through NGOs under host-country contracting mechanisms.

In July 2008, USAID/Afghanistan signed an implementation letter with the Government of the Islamic Republic of Afghanistan to provide the mission’s first on-budget funding assistance to the MoPH in support of the Partnership Contracts for Health Services (PCH) Program.

Under this host-country contracting program, the mission was to provide MoPH with up to $236 million in on-budget assistance over 5 years to support the delivery of standardized health services in 13 target provinces.

  1. MoPH develops human resources for health with a strong focus on gender equity:

Another critical priority in post-2002 Afghanistan where severe shortage existed, was to mobilize, redeploy and develop its human resources for health. Educating nurses, mid-wives and physicians was and still remain a necessity that receives sustained attention but most critical to alleviate urgent and persistent needs in rural areas has been the expanded role played by voluntary community health workers (CHWs) and the increasing of their numbers.

Since most Afghans lived in isolated villages, the Ministry decided to establish a major community-based health program with large numbers of volunteer community health workers.

Under the stewardship of the MoPH Community-Based Health Care Department more than 22,000 CHWs (half of them women) are deployed in all 34 provinces of Afghanistan and see two-thirds of all family planning clients and nearly half of all sick children. The MoPH made it its policy to have a least 50% of the CHWs being selected among female members of their rural communities.

In addition, in order to substantially increase services for women and children, the MoPH leadership decided to greatly expand the number of female health workers in rural areas, with a focus on community midwives.

Young women were recruited from remote rural areas, trained as community midwives for 18-24 months, and deployed to health facilities near their homes to provide skilled birth attendance and other reproductive health services. More than 2,000 community midwives trained and deployed in rural health facilities since 2004 are making a major contribution to maternal health in Afghanistan.

LMG's Role in Afghanistan

Despite persistent security challenges confronting the Afghan rural population and health workers, the health sector in Afghanistan has entered a phase of consolidation of the important achievements it realized since 2002 with the assistance of the international community.

During this period, Management Sciences for Health (MSH), through USAID-funded activities, has actively supported the development of thousands of Afghan health managers and leaders at all levels of the health system and has strengthened numerous organizations’ capacity in management, leadership and governance.

Since August 2012, the Leadership, Management and Governance (LMG) project has pursued important initiatives that support the health sector in Afghanistan in evolving toward greater institutional, programmatic, and financial sustainability.

One of the main goals of the LMG project in Afghanistan is to strengthen the MoPH financial management systems and capacity so that a growing proportion of the U.S. Government assistance (beyond what is described in item 3 above) can be channeled through a well-established and well-performing on-budget mechanism.

This is in line with the objectives set at the 2010 Kabul International Conference where the goal was adopted that 50% of international public development assistance allocated to the country should be handled through the nation’s public sector financial management system.

LMG is also assisting the MOPH on its goal of institutionalizing L+M+G capacity building of the health work force, in particular through the development of the capacity of the Ministry’s Management and Leadership Development Directorate to design, plan, budget for, implement, and adjust leadership, management, and governance focused-training.

LMG supported the development of the MoPH Strategic Plan 2011-15, in which seven out of 10 Strategic Directions are linked to governance:  equitable access to quality health services; the stewardship role of MoPH and governance in the health sector; evidence-based decision-making and a culture that uses data for improvement; regulation and standardization of the private sector to provide quality health services; community empowerment for disease prevention and health promotion; financial governance; and the human resource governance.  

A Health for All Afghans document includes a goal that 30% of staff of health facilities be female (including at decision-making levels), and that women and men have equal access to health services that are free of discrimination and address gender-based violence and mental health.

To support this goal and contribute at reducing barrier to health services access and improve gender equity, the LMG Afghanistan project contains a focus on gender in all of its components, which include: hospital management; health information systems; community-based healthcare; nursing and midwives education; and L+M+G capacity building.

Finally, LMG will provide assistance to promote transparency, participation, respect for human rights, and accountability from all parties. These are all values that are important to the MoPH and are vital in contributing to improving the health status of the Afghan population, and in moving Afghanistan progressively away from the situation of fragility that the country has been mired in for so long.

Where We Stand Now

The challenges facing the health sector in Afghanistan are complex and varied. Only through the combined efforts of stakeholders at all levels lead by the Ministry of Public Health in its stewardship capacity will continued positive change be possible.

Health indicators have improved tremendously but they remain among the worst in the world, and much remains to be done. Still, health and development specialists agree that the positive changes that have been made are significant.

With continued progress in inspired leadership, sound management, and transparent governance, the country in general and its health sector in particular could shift from a situation of fragility toward a situation of increased stability.

Related reading:

Sources: 2002: Reproductive Age Mortality Survey (RAMOS); 2003: Population Reference Bureau (PRB); 2008: National Risk and Vulnerability Assessment (NRVA); 2010: Afghanistan Mortality Survey (AMS); 2011: Partnership Contract for Health (PCH) Household Survey; 2012: Ministry of Health and Population Health Management Information System.

MSH Global Health Impact Blog, “Rebuilding Health Systems in Fragile States through High-Impact Interventions: Lessons Learned” (April 2012) by Jonathan D. Quick, Management Sciences for Health (MSH).

Solter, Steve & Saleh, Hedayatullah, “Health System Strengthening in Afghanistan 2002-11: Putting the Pieces Together to Maximize Health Impact” (2012), unpublished.

Haar, Rohini Jonnalagadda and Rubenstein, Leonard S., “Health in Post Conflict and Fragile States” (2012), United States Institute of Peace (USIP): http://www.usip.org/files/resources/SR_301.pdf.

Saint-Firmin, Patrick P., “Health Systems Planning and Governance in Afghanistan 2002-2010: Achievements of Public Health Leaders in a Difficult Context” (2010). Gadue-Niebling-Urdaneta Fellowship Report, Management Sciences for Health (MSH).

Dr. Ronald Waldman, Lesley Strong and Dr. Abdul Wali, “Afghanistan’s Health System Since 2001: Conditions improved, Prognostic Cautiously Optimistic” (2006), Afghanistan Research and Evaluation Unit (AREU) Briefing Paper Series.

Development assistance is channeled through the host country’s core budget.

The Afghanistan Health System Enhancement Project (AHSEP), 2002-03; the Rural Expansion of Afghanistan’s Community-Based Healthcare Project (REACH), 2003-06; the Technical Support to the Central and Provincial Ministry of Public Health Project (Tech-Serve), 2006-12; Leadership, Management and Governance (LMG)/Afghanistan project, 2012-14.

By Alain Joyal, MBA, CPA is the Country Programs Team Leader, Management Sciences for Health.