Lessons from the development process of the Afghanistan integrated package of essential health services.

In 2017, in the middle of the armed conflict with the Taliban, the Ministry of Public Health decided that the Afghan health system needed a well-defined priority package of health services taking into account the increasing burden of non-communicable diseases and injuries and benefiting from the latest evidence published by DCP3. This leads to a 2-year process involving data analysis, modelling and national consultations, which produce this Integrated Package of Essential health Services (IPEHS). The IPEHS was finalised just before the takeover by the Taliban and could not be implemented. The Afghanistan experience has highlighted the need to address not only the content of a more comprehensive benefit package, but also its implementation and financing. The IPEHS could be used as a basis to help professionals and the new authorities to define their priorities.

Long and short Integrated Management of Childhood Illness (IMCI) training courses in Afghanistan: a cross-sectional cohort comparison of post-course knowledge and performance.

BACKGROUND: In 2003 the Afghan Ministry of Public Health (MoPH) adopted the Integrated Management of Childhood Illness (IMCI) for delivering child health services in primary care facilities. Key problems were subsequently identified: high cost of training, frequent health worker turnover and poor quality of IMCI implementation by those trained - specifically in the use of job aids and protocols for assessment, classification, treatment and counselling. The high financial, human resources and opportunity costs of implementing IMCI spurred the MoPH to prioritize developing a shortened IMCI course of comparable quality to the 11-Day training. METHODS: This cross-sectional evaluation compared knowledge before and after training, and health worker performance in assessment, classification and treatment of sick children in two similar cohorts, eight months post-training. RESULTS: The mean increase in knowledge scores of the thirty 7-Day course trainees was 29 [95% Confidence Interval (CI): 24, 34] compared to 23 (95% CI: 18, 28) in the 31 trained in the 11-Day course. During assessment visits, mean scores in the 7-Day course trainees and the 11-Day course trainees were 93% (95% CI: 91, 95) versus 94% (95% CI: 91, 96) in assessment; 95% (95% CI: 89, 100) versus 96% (95% CI: 91, 100) in classification; 95% (95% CI: 92, 100) versus 97% (95% CI: 95, 100) in treatment; and 81% (95% CI: 76, 86) versus 80% (95% CI: 75, 85) in counselling. The 7-Day course was 36% less expensive than the 11-Day course. For each course opportunity costs, measured as numbers of children who potentially received poorer care than usual during trainee absence, were 3,160 for the 11-Day course and 2,016 for the 7-Day course. This measure was chosen because trainee absence commonly resulted in higher patient volumes per remaining provider or complete closure of a health facility with one single health worker. CONCLUSION: Given similar performance and knowledge of health workers trained in both courses, potential cost savings, the possibility of training more health workers and the relative ease with which health workers in remote settings might participate in a shorter course, it seems prudent to standardize the 7-Day course in Afghanistan where child mortality rates remain unacceptably high.

Aid effectiveness in rebuilding the Afghan health system: a reflection.

The Paris Declaration defined five components of aid effectiveness: ownership, alignment, harmonisation, managing for results and mutual accountability. Afghanistan, which has received a high level of donor aid for health since 2002, has seen significant improvements in health indicators, expanded access to health services and an increased range of services. Do the impressive health outcomes in this fragile state mean that aid has been effectively utilised? The factors that contributed to the success of the Ministry of Public Health (MOPH)-donor partnership include as follows: Ownership: a realistic role for the MOPH as the steward of the health sector that was clearly articulated to all stakeholders; Donor alignment: donor coordination and collaboration initiated by the MOPH; Joint decisions: participatory decision-making by the MOPH and donors, such as the major decision to use contracts with nongovernmental organisations for health service delivery; Managing for results: basing programmes on available evidence, supplementing that evidence where possible and performance monitoring of health-sector activities using multiple data sources; Reliable aid flows: the availability of sufficient donor funding for more than 10 years for MOPH priorities, such as the Basic Package of Health Services, and other programmes that boosted system development and capacity building; Human factors: these include a critical mass of individuals with the right experience and expertise being deployed at the right time and able to look beyond agency mandates and priorities to support sector reform and results. These factors, which made aid to Afghanistan effective, can be applied in other countries.

Afghanistan's basic package of health services: its development and effects on rebuilding the health system.

In 2001, Afghanistan's Ministry of Public Health inherited a devastated health system and some of the worst health statistics in the world. The health system was rebuilt based on the Basic Package of Health Services (BPHS). This paper examines why the BPHS was needed, how it was developed, its content and the changes resulting from the rebuilding. The methods used for assessing change were to review health outcome and health system indicator changes from 2004 to 2011 structured along World Health Organisation's six building blocks of health system strengthening. BPHS implementation contributed to success in improving health status by translating policy and strategy into practical interventions, focusing health services on priority health problems, clearly defining the services to be delivered at different service levels and helped the Ministry to exert its stewardship role. BPHS was expanded nationwide by contracting out its provision of services to non-governmental organisations. As a result, access to and utilisation of primary health care services in rural areas increased dramatically because the number of BPHS facilities more than doubled; access for women to basic health care improved; more deliveries were attended by skilled personnel; supply of essential medicines increased; and the health information system became more functional.

Improving nutrition in Afghanistan through a community-based growth monitoring and promotion programme: a pre-post evaluation in five districts.

In Afghanistan, malnutrition in children less than 60 months of age remains high despite nutritional services being offered in health facilities since 2003. Afghanistan's Ministry of Public Health solicited extensive community consultation to develop pictorial community-based growth monitoring and promotion (cGMP) tools to help illiterate community health workers (CHWs) provide nutritional assessment and counselling. The planned evaluation in the five districts where cGMP was implemented demonstrated that a mean weight-for-age (WFA) Z-score of 414 participant children was 0.3 Z-scores higher than that of matched non-participants who lived outside of cGMP programme catchment areas. The mean change in WFA Z-scores at evaluation was 0.3 (95% CI 0.3, 0.4) Z-scores higher than at entry into the programme. The most influential factor on WFA Z-score changes in participants was initial WFA Z-score. Those with an initial WFA Z-score of less than -2 experienced a mean increase of 0.33 (95% CI 0.29, 0.38) WFA Z-scores per session attended, while those with a baseline WFA Z-score of greater than zero showed a decrease of 0.19 (95% CI 0.22, 0.15) WFA Z-scores per session attended. These results are encouraging since they demonstrate that the cGMP programme in Afghanistan for illiterate women has some potential to contribute to improving nutrition, specifically in underweight children of either sex who enter the programme at less than nine months of age and attend 50% or more sessions.

Barriers to appropriate care for mothers and infants during the perinatal period in rural Afghanistan: a qualitative assessment.

This study, conducted in five rural districts in Afghanistan, used qualitative methods to explore traditional practices of women, families and communities related to maternal and newborn care, and sociocultural and health system issues that create access barriers. The traditional practices discussed include delayed bathing of mothers and delayed breastfeeding of infants, seclusion of women after childbirth, restricted maternal diet, and use of traditional home remedies and self-medication instead of care in health facilities to treat maternal and newborn conditions. This study also looked at community support structures, transportation and care-seeking behaviour for maternal and newborn problems which create access barriers. Sociocultural barriers to better maternal-newborn health include shame about utilisation of maternal and neonatal services, women's inability to seek care without being accompanied by a male relative, and care-seeking from mullahs for serious health concerns. This study also found a high level of post-partum depression. Targeted and more effective behaviour-change communication programmes are needed. This study presents a set of behaviour-change messages to reduce maternal and newborn mortality associated with births occurring at home in rural communities. This study recommends using religious leaders, trained health workers, family health action groups and radio to disseminate these messages.

Compliance with referral of sick children: a survey in five districts of Afghanistan.

BACKGROUND: Recognition and referral of sick children to a facility where they can obtain appropriate treatment is critical for helping reduce child mortality. A well-functioning referral system and compliance by caretakers with referrals are essential. This paper examines referral patterns for sick children, and factors that influence caretakers' compliance with referral of sick children to higher-level health facilities in Afghanistan. METHODS: The study was conducted in 5 rural districts of 5 Afghan provinces using interviews with parents or caretakers in 492 randomly selected households with a child from 0 to 2 years old who had been sick within the previous 2 weeks with diarrhea, acute respiratory infection (ARI), or fever. Data collectors from local nongovernmental organizations used a questionnaire to assess compliance with a referral recommendation and identify barriers to compliance. RESULTS: The number of referrals, 99 out of 492 cases, was reasonable. We found a high number of referrals by community health workers (CHWs), especially for ARI. Caretakers were more likely to comply with referral recommendations from community members (relative, friend, CHW, traditional healer) than with recommendations from health workers (at public clinics and hospitals or private clinics and pharmacies). Distance and transportation costs did not create barriers for most families of referred sick children. Although the average cost of transportation in a subsample of 75 cases was relatively high (US$11.28), most families (63%) who went to the referral site walked and hence paid nothing. Most caretakers (75%) complied with referral advice. Use of referral slips by health care providers was higher for urgent referrals, and receiving a referral slip significantly increased caretakers' compliance with referral. CONCLUSIONS: Use of referral slips is important to increase compliance with referral recommendations in rural Afghanistan.

A tool for assessing management capacity at the decentralized level in a fragile state.

Fragile states need assessment of decentralized management capabilities, not just of the central level, to design capacity-building efforts focused on improving management. Improving the management capacity of health departments at the provincial or district level is just as critical as strengthening the central ministry in fragile states if a health system that effectively addresses the real health needs of the population is to be formed. This paper describes a management capacity assessment tool developed for use in fragile states. It uses a framework that describes six critical management areas: oversight and coordination; human resources; resource management; health financing; community involvement; and health information management. These core areas of health system management are assessed with regard to capacity in three core management functions: the capacity to plan, to implement, and to monitor and evaluate. The tool was applied to assess the management capacity of six counties in Liberia. The results helped differentiate the level of capacity of the different counties and clarify the actions required to strengthen the health system in the periphery. The assessment also allowed the prioritizing of county health offices with regard to the level of capacity building required to improve management. The tool also identified successes that can inform the design of future health programs in other county health offices. The tool can be applied to other challenging country situations to assess management capacity, which will help focus technical assistance to the health sector in fragile states.

Rebuilding and strengthening health systems and providing basic health services in fragile states.

The international community has compelling humanitarian, political, security and economic reasons to engage in rebuilding and strengthening health systems in fragile states. Improvements in health services and systems help to strengthen civil society and to restore legitimacy to governments. Effective engagement with fragile states to inform the design of health programmes and selection of interventions depends on donor coordination and an understanding of health system challenges. Planning requires consideration of allocation (services to be delivered), production (organisation of services), distribution (beneficiaries of services) and financing. The criteria for selecting interventions are: their impact on major health problems; effectiveness; the possibility of scale-up; equity; and sustainability. There are various options for financing and models of engagement, but support should always combine short-term relief with longer-term development. Stakeholders should aim not only to save lives and protect health but also to bolster nations' ability to deliver good-quality services in the long run.

Contracting for health services: effects of utilization and quality on the costs of the Basic Package of Health Services in Afghanistan.

OBJECTIVE: To research the effects of changes in health service utilization and quality on the costs of the Basic Package of Health Services (BPHS) in 13 provinces of Afghanistan. METHODS: The study grouped data from 355 health facilities and more than 4000 health posts into 21 data points that represented 21 different nongovernmental organization contracts for service delivery between April 2006 and March 2007. Data were pooled from five data sets on expenditure, service utilization, quality (i.e. client satisfaction and the availability of essential medicines and female health-care providers), pharmaceuticals, and security and remoteness scores. Pearson's partial correlation and multiple linear regression models were used to examine correlations between expenditure and other study variables. FINDINGS: Fixed costs were found to comprise most of the cost of BPHS contracts. There was no correlation between cost and utilization rate or security. The distance to the health facility was negatively correlated with costs (R(2) = 0.855, F-significance < 0.001). The presence of female health workers, indicative of good quality in this cultural context, was negatively correlated with security (r = -0.70; P < 0.001). There was a significant correlation between the use of curative services and client satisfaction but not between the use of preventive services and client satisfaction (R(2) = 0.389 and 0.272 for two types of health facilities studied). CONCLUSION: Access to health services can be extended through contracting mechanisms in a post-conflict state even in the presence of security problems. Service characteristics, geographical distance and the security situation failed to consistently explain, alone or in combination, the observed variations in per capita costs or visits. Therefore, using these parameters as the basis for planning does not necessarily lead to better resource allocation.

Rebuilding health systems in post-conflict countries: estimating the costs of basic services.

After the fall of the Taliban in 2001, the Afghan transitional government and international donors found the health system near collapse. Afghanistan had some of the worst health indicators ever recorded. To begin activities that would quickly improve the health situation, the Ministry of Health (MOH) needed both a national package of health services and reliable data on the costs of providing those services. This study details the process of determining national health priorities, creating a basic package of services, and estimating per capita and unit costs for providing those services, with an emphasis on the costing exercise. Strategies for obtaining a rapid yet reasonably accurate estimate of health service costs nationwide are discussed. In 2002 this costing exercise indicated that the basic package of services could be provided for US dollars 4.55 per person. In 2006, the findings were validated: the four major donors who contracted with non-governmental organizations (NGOs) to provide basic health services for nearly 80% of the population found per capita costs ranging from dollars 4.30 to dollars 5.12. This study is relevant for other post-conflict countries that are re-establishing health services and seeking to develop cost-effective and equitable health systems.