health policy in afghanistan two years of rapid change

Health Policy inAfghanistan:

two years of rapid change

A review of the process from 2001 to 2003

Lesley StrongAbdul Wali

Egbert Sondorp

Health Policy inAfghanistan:

two years of rapid change

A review of the process from 2001 to 2003

This study is supported by the European Commission’s Poverty Reduction Effectiveness Program (EC-PREP)

About the London School of Hygiene and Tropical Medicine…

The London School of Hygiene and Tropical Medicine (LSHTM) is a renowned research andteaching institute in public health, based in London, UK. Its aim is to contribute to the improve-ment of health worldwide through the pursuit of excellence in research, postgraduate teachingand advanced training in national and international public health and tropical medicine. TheDepartment of Public Health & Policy is one of three Departments within LSHTM. The mainthrust of the Department’s work is to link public health, policy and practice through research andanalysis. This is undertaken by the largest multidisciplinary group in Europe focused on publichealth, with epidemiologists, statisticians and mathematicians, economists and policy analystsworking together with anthropologists, sociologists, historians, psychologists and geographers.Within this Department sits the Conflict and Health Programme, which conducts a range of re-search and teaching activities related to conflict induced changes to population health and healthsystems as well as to the reconstruction of the health sector during the post-conflict phase. Oneof its projects is to look at the roll-out of the Basic Package of Health Services in Afghanistan. Moreinformation on other activities can be found on www.lshtm.ac.uk/hpu/conflict.

Copyright © 2005 London School of Hygiene and Tropical Medicine (LSHTM). All rights reserved.

Table of Contents

Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

Timeline of key events in the health sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

1.0 Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

3.0 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73.1 Afghanistan’s Turbulent Past . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83.2 A Historical Perspective on Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83.3 Present Day Afghanistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

3.3.1 Current health status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103.3.2 Current health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.3.3 Successes to date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

3.4 Challenges for the Health Sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

4.0 Health Policy Development in Afghanistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154.1 The Early Days (November 2001 – May 2002) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

4.1.1 Agenda setting and policy formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174.1.2 National development framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204.1.3 Formulation of the Basic Package of Health Services . . . . . . . . . . . . . . . . . . . . . . . 21

4.2 MOH in the Driver’s Seat (June 2002 – March 2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234.2.1 Pushing the agenda forward: the second Joint Donor Mission . . . . . . . . . . . . . . . 234.2.2 Development of an interim strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244.2.3 WB pre-appraisal mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254.2.4 Developments in health coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284.2.5 The influence of assessments and studies on the policy process . . . . . . . . . . . . . . 304.2.6 Infrastructure development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

4.3 Expanding the BPHS (April – December 2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324.3.1 Procurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334.3.2 Implementation mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

4.4 A Brief Overview of the Current State of Affairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374.4.1 Delivery of the BPHS: contracts and grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374.4.2 Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404.4.3 Policy developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

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Table of Contents

Inventory of Pictures

Frontpage, page 7, 15: Katja Schemionek; page 1, 2, 5, 13, 18, 27, 30, 37, 41, 43: World Vision

5.0 Concluding Remarks and Issues for Further Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

AnnexesAnnex 1 Similarities and differences in donor procurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

iv

Table of Contents

Acronyms

ADB Asian Development BankAHSEP Afghanistan Health Services

Expansion ProjectAIA Afghanistan Interim AuthorityANHRA Afghanistan National Health

Resource Assessment

BPHS Basic Package of Health Services

CDC Centre for Communicable Disease Control

CGHN Consultative Group for Health andNutrition

CHW Community Health WorkerCI Contracting InCO Contracting OutCSC Civil Service Commission

DFID Department for International Development

EC European CommissionEOI Expression of InterestEPI Expanded Programme on

Immunization

FC French Cooperation

GCMU Grants and Contract Management Unit

GTZ German Agency for International Development

HCTF Health Coordination Task Force

IARCSC Independent Administrative Reform And Civil Service Commission

ICRC International Committee of the Red Cross

IDB Islamic Development Bank

JDM Joint Donor MissionJHU Johns Hopkins UniversityJICA Japanese International Cooperation

Agency

KfW German Bank for ReconstructionKOICA Korea International Co-operation

Agency

LBG Louis Berger Group

MSF Medecins Sans FrontieresMSH Management Sciences for HealthMOF Ministry of FinanceMOH Ministry of HealthMOH-SM Ministry of Health Strengthening

Mechanism

NDF National Development Framework

NGO Non-government OrganisationNORAD Norwegian Agency for

Development CooperationNPM New Public ManagementNSP Non-State ProviderNTCC National Technical Coordination

Committee

OPM Oxford Policy Management

PACBWG Public Administration Capacity Building Working Group

PHCC Provincial Health Coordination Committee

PIU Project Information UnitPPA Performance-based Partnership

AgreementPRR Priority Reform and Restructuring

REACH Rural Expansion of Afghanistan’s Community-based Healthcare

v

Acronyms

RFA Request for ApplicationRFP Request for Proposal

SIDA Swedish International Development Agency

TA Technical Assistance

UN United NationsUNICEF United Nations Children’s Fund

UNFPA United Nations Population Fund USAID United States Agency for

International Development

WB World BankWCGHN Working Consultative Group for

Health and NutritionWDR World Development ReportWHO World Health Organisation

vi

Acronyms

Timeline of key events in the health sector

Nov. 27-29 2001: Islamabad Conference on Preparation for Reconstruction

Dec. 8 2001 – Jan. 10 2002: Preliminary Needs Assessment for Recovery and Reconstruction: WB, ADB, UNDP

Jan. – Mar. 2002: First draft of the National Health Policy released for circulation

Mar, 2002: National Health Planning Workshop

Mar. 19 – Apr. 2 2002: First Joint Donor Mission on Health, Nutrition and Populationsector: WB, ADB, EC, DFID, USAID, WHO (Afghanistan/EMRO), UNICEF (Afghanistan/New York), UNFPA

April 2002: First draft of the National Development Framework releasedfor circulation

May 2002: First draft of basic service package produced, WHOFinal draft of National Health Policy released

Jul. 17 2002: Costing of Basic Package of Health Services, MSH

Jul. 13 – 17 2002: Second Joint Donor Mission: WB, ADB, EC, USAID, GTZ, KfW,JICA, WHO (Afghanistan), UNICEF (Afghanistan/New York),UNFPA, MSH

July 22 – 25 2002: JDM seminar on government-NGO collaboration andPerformance-based Partnership Agreements

July 2002: Establishment of Consultative Group sectoral coordinationmechanism, called the Consultative Group for Health andNutrition in the health sector

Nov. 2002: Afghanistan National Health Resource Assessment PreliminaryResults, MSH

Dec. 2002: European Commission, Support to Health Services Delivery inAfghanistan, Guidelines for Application to Call for Proposals2002 for an Informal Consultation

Jan. 2003: MOH provincial planning workshops start

vii


Jan. – Feb. 2003: WB pre-appraisal mission

Jan. – May 2003: Ongoing debate and discussion between MOH, WB, USAID,EC and the French regarding implementation mechanisms forthe BPHS

Feb. 2003: World Bank presentation on Performance-based PartnershipAgreements for NGOs

Mar. 2003: Final draft of the Basic Package of Health Services released

Mar. 2003: Establishment of the Grants and Contract Management Unit(GCMU) in the MOH

Apr. 21 -23 2003: Third Joint Donor Mission

Apr. 2003: Transitional Islamic State of Afghanistan, Health SectorEmergency Reconstruction and Development Project,Provincial and Cluster level Performance-based PartnershipAgreements, Request for Expression of Interest

May 2003: European Commission, Support to Health Services Delivery inAfghanistan, Guidelines for Application to Call for Proposals2002 for an Informal Consultation (second round)

May 16 2003: USAID Rural Expansion of Afghanistan’s Community-basedhealth Care (REACH) program awarded to ManagementSciences for Health (MSH)

Jun. 2003: Request for Application , USAID Rural Expansion ofAfghanistan’s Community-based Health Care (REACH) GrantsProgram

Jul. – Dec. 2003: Second round of EC grants awarded (7 grants in total)

Aug. 2003: National Salary Policy finalized and released

Oct. – Nov. 2003: First round of REACH grants awarded (16 grants in total)

Nov. 2003: First round of WB/MOH contracts awarded (3 contracts in to-tal). In the second round of bidding another 5 contracts weresigned

viii


1 ExecutiveSummary

Health sector reform has flourishedsince 1980s in response to increasingrecognition of public sector inefficien-

cies in the delivery of health care.Consequently there has been an emphasis onideas surrounding New Public Management,which injects market-like principles intohealthcare provision through concepts such ascompetition and contracting. While there hasbeen an upsurge in interest in the use of con-tracting in the health sector, and performance-based contracting in particular, evidence of the-oretical benefits such as increased efficiencyand equity, are limited, inconsistent and large-ly outside of the public domain.

Despite a weak evidence-base these newideas are reflected in current health policy developments in post-conflict Afghanistan. In

order to address the alarming health trendsproduced by the last twenty years of war, threemajor donors (EC, USAID, and World Bank)are investing considerable sums of money torehabilitate Afghanistan’s devastated healthsystem. Together with the Ministry of Health,they are funding Non-State Providers (NSPs) todeliver a Basic Package of Health Services(BPHS) through various mechanisms includingPerformance-based Partnership Agreements(PPAs), within the framework of governmenthealth policy. This approach is premised on thenotion that delivery of a BPHS to a majority ofAfghans will address the major burden of dis-ease and mortality through a set of cost-effec-tive interventions at a cost that can be sus-tained. Furthermore, performance-based ap-proaches are based on the argument that

2

Executive Summary

delivery of this package by non-governmentalagencies, within a government-led (regulatedand monitored) framework, will not only leadto higher efficiency of the delivery of the pack-age, but also to better uptake by the poor (im-proved equity), in comparison to direct govern-ment provision.

Although the MOH has made the choice torestrict itself, mainly in relation to implementa-tion of the BPHS, to a stewardship role, subcon-tracting health service delivery to NGOs, theMOH will also directly implement the BPHSthrough a MOH Strengthening Mechanism(MOH-SM) in a selection of provinces. TheMOH-SM will receive funds from the WB and,similar to the PPA contracts with NGOs, pay-ment to the MOH will be linked to perform-ance. Moreover, the MOH-SM provinces willundergo the same third party evaluations asNGOs, which will allow for comparison be-tween public and private provision of theBPHS.

The promotion of the PPA approach by theWorld Bank is primarily based on experiences ofan Asian Development Bank pilot study inCambodia, where contracting out health servic-es to NGOs resulted in improved health care de-livery, increased transparency, reduced costs forthe poor and for health costs overall (Bhushan etal 2001; Bhushan et al 2002). However, availableevidence from this experience as well as fromother post-conflict and low-income countries(see Bhushan et al 2001; Soeters and Griffiths 2003;Nieves et al 2000; Loevinsohn 2002; Eichler et al2001) is still scarce and largely outside the pub-lic domain. Scaling up, sustainability, effects onhealth staff, definition of appropriate perform-ance indicators, and possible high transactioncosts are some of the expressed concerns (Palmer2001). Moreover, given that there is little evi-dence to support large scale contracting in low-income settings implementation of such a mech-anism in a post-conflict context, which faces a

myriad of additional challenges, could be calledinto question. Thus, there is an urgent need tostudy this contracting mechanism in much moredetail and in various settings.

This report is the first of a series that will beproduced at regular intervals throughout aqualitative research project conducted by theLondon School of Hygiene and TropicalMedicine that will follow health policy devel-opments and the implementation of the BPHSin Afghanistan between January 2004 andDecember 2005. The purpose of this initial pa-per is to outline policy developments in the re-construction of Afghanistan’s health system be-tween 2001 and 2003 which will establish thecontextual basis for the remainder of the re-search. In addition to this description of eventsbetween 2001 and 2003, a brief overview of thecurrent health system and successes to datewill be presented together with an update onmore recent developments. The paper is basedon a review of published and unpublished doc-umentation from Afghanistan’s health sectorand uses a policy analysis approach.

The paper describes health policy develop-ments in a fast moving, post-conflict environ-ment, characterised by a large number of inter-national stakeholders, all of which have differ-ent agendas, mandates and ideas of the bestway to reconstruct a health system. Despite thismultitude of actors and views, the process ofdeveloping health policy and implementationstrategies has been quick and by mid 2004, onlya year and a half after the articulation of theBPHS, the MOH together with its partnershave expanded coverage of BPHS proposals toreach approximately 59% of the population.Despite this progress signs of donor fatiguehint at problems of further expansion and sus-tainability, and insecurity is hampering NGOefforts to get down to the business of imple-mentation. Furthermore, although the MOH isnow clearly in the driver’s seat, side effects of

3

Executive Summary

donor driven policy in the early stages of thepost-conflict environment may become moreapparent with time.

The paper concludes by identifying a num-ber of issues for further research, some ofwhich will be the subject of further study underthis project. Such research is required to pro-vide the basis for more empirically-based policy making in the areas of contracting andthe use of a basic package of health services inpost-conflict and low-income settings.

This paper has been written from an exter-nal perspective and may under emphasize internal MOH dynamics as a result. It is impor-

tant to note that the opinions expressed in thispaper are those of interviewees and key in-formants, not the authors.

The authors would like to acknowledge themany people who took time out of their busyschedules to give comments on earlier drafts.While the authors have tried to present an accurate picture of events, any errors in inter-pretation are the responsibility of the authorsand do not reflect on the interviewees whohave participated in the study to date.

Any comments on the report are welcomeand can be sent to [email protected] or [email protected].

4

Executive Summary

2 Introduction

In an attempt to curb some of the worsthealth statistics in the world three majordonors (EC, USAID, and World Bank) are

investing considerable sums of money inAfghanistan’s health system. Together with theMinistry of Health, they are funding Non-StateProviders (NSPs) to deliver a Basic Package ofHealth Services (BPHS) through various mech-anisms including Performance-based Part-nership Agreements (PPAs), within the frame-work of government health policy. Althoughdonors have adopted different implementationmechanisms, the MOH, through the WB, hasestablished PPAs with NSPs, which ties pay-ment to performance measured against prede-termined indicators. A pilot project in Cam-bodia showed that this model may achieve theobjective of increasing efficiency as it loweredtotal cost, while at the same time increasing eq-uitable access as well as lowering out of pocketpayments by the poor.

Evidence from other post-conflict and low-income settings however, is limited, inconsis-tent and largely outside of the public domain.To contribute to research efforts towards docu-menting the experiences of this novel healthdelivery mechanism in Afghanistan, theLondon School of Hygiene and TropicalMedicine has been awarded a grant to conducta research project entitled “Contracting healthservices in Afghanistan: Can the twin objec-

tives of efficiency and equity really beachieved?”, funded by the European Commis-sion’s Poverty Reduction Effectiveness Pro-gram (EC-PREP). The study consists of 3 parts:(i) description of the context, policy and actorsin Afghanistan (ii) field-based study of the im-plementation phase through the establishmentof 6 prospective case studies, and (iii) evalua-tion of the initial 2 years of implementation.The study will document experiences and con-tribute an objective perspective to the evidence-base on the utility of contracting out a basicpackage of services in a post-conflict and low-income settings.

This paper has been produced as phase oneof the study with the objective to provide acommentary of the development of Afgha-nistan’s new health policy between 2001 and2003 and an update on the current state of af-fairs with regard to the roll out of the BPHS.The report will establish the contextual basisfor the remainder of the research and serve as apoint of referral in the ongoing development ofAfghanistan’s health system. The paper isbased on a review of published and unpub-lished documentation from Afghanistan’shealth sector, supplemented by preliminary in-terviews held with key stakeholders to triangu-late findings and gain further insight into earlypolicy developments.

6

Introduction

3 Background

3.1. Afghanistan’s Turbulent Past

Since the dawn of history, the landlockedterritory of Afghanistan has been thecrossroads for Asia and a buffer zone for

warring civilisations. Countless armies andconquerors have made their way through theregion dating as far back as 329 BC, bringingwith them different religions, languages, andcultures. Afghanistan today is a product ofthese influences with the population compris-ing an interesting mix of ethnicities and lan-guages.

The arrival of the soviet army in 1979 wasjust the beginning of what was to be over 20 years of devastating war and instability.Afghanistan however, had been at the center ofinternational rivalry before. In the 19th century,Afghanistan’s kings had to hold off two newexpanding empires: Britain’s Indian empire tothe east and Russia’s ever growing control overmuch of Central Asia to the north. Whatemerged in the years that followed has beencalled ‘the Great Game’, with Britain andRussia using Afghanistan as a buffer state tokeep each other at a safe distance as theyfought for domination over Central Asia(Rashid 2001).

Following the overthrow of PresidentSardar Mohammad Daud in 1978 by Marxistsympathisers, the Soviet army rolled intoAfghanistan in 1979. Despite large amounts offinancial support ($5 billion USD/year) to sub-due the anti-Soviet Mujahedin troops whowere strongly backed by Western and Islamiccountries (a total of over $10 billion USD be-tween 1980 – 1992), the Soviet army withdrewin 1989 unvictorious. During the course of theiroccupation (1979–1988), some 1.5 millionAfghans lost their lives. The Mujahedin en-dured and overthrew the communist govern-ment in 1992, making them heroes in the eyesof their fellow Afghans. Instead of peace, how-

ever, the struggle for power betweenMujahedin factions resulted in “…theMujahedin forfeit[ing] the title of heroes andassume[ing] the mantle of criminals when theytook Kabul in 1992 and turned their guns oneach other and the surrounding civilians”(Gannon 2004).

The Taliban emerged in late 1994 withAfghanistan on the brink of collapse. The coun-try was divided up by warlords, all of whom“…had fought, switched sides and foughtagain in a bewildering array of alliances, be-trayal and bloodshed” (Rashid 2001 p.21). TheTaliban regime quickly gained control ofAfghanistan, with forces in control of over 90%of the country by 1998. In the four-year fight forKabul another 50,000 Afghans were killed,most of whom were civilians, with countlessmore maimed (Gannon 2004). Despite theregime’s control over most of the country, theirrepressive policies, particularly regardingwomen, prevented their recognition as a legitimate government by the internationalcommunity.

The Taliban fell in November 2001 after theUS-led coalition forces launched an attack onthe country in response to the September 11th

attacks. Since then Afghanistan has been labelled as post-conflict and aid has poured into assist in rebuilding various sectors of thecountry that have been eroded over years ofwar and political turmoil.

3.2 A Historical Perspective on Health

Although Afghanistan remained free ofwar throughout the 1960s and 1970s,health statistics occupied no higher a

ranking amongst other countries in the regionor even amongst developing countries as awhole, as they do today. Child mortality was30% higher than the average of the least devel-

8

Background

oped countries in 1960 (360 per 1,000 livebirths) and 61% higher than the average for de-veloping countries (MOH 2004). Health care,largely provided by the government, was large-ly absent in rural areas with the exception of acollection of vertical disease control programssuch as tuberculosis, malaria and leishmania-sis. In urban areas, the health system was dominated by hospitals and large numbers ofdoctors, a trend which still resonates today.Despite this curative-focused, inequitable pic-ture of health care, the government did attemptto introduce a district health system, incorpo-rating the principles of primary health care.However, with only 1-4% of the national bud-get devoted to health between 1952–1972(Pavignani and Colombo 2002), facilities remainedill equipped and understaffed and thus, underutilised.

Starting from this already weak foundationthe public health system continuously deterio-rated in the years of war that followed. Thehealth administration, already highly cen-tralised, became even more detached from theprovincial and district levels, which were in-creasingly under the control of local Mujahedincommanders (MOH 2004). NGOs emerged inthe mid-1980s, congregating in Pakistan to pro-vide health care for the millions of Afghanrefugees, and later on establishing small cross-border operations. With the signing of theGeneva Accords in 1988 and the injection ofdonor funds, NGO activities flourished result-ing in an increase in the number of health facil-ities, especially in rural areas. However, lack ofa strong centralised government, coherent na-tional framework, and the outbreak of civilwar, resulted in fragmented service provisionreflecting the mandates of donors and their im-plementing partners.

This trend continued with the emergence ofthe Taliban in 1994. With no health profession-als amongst them, religious leaders were

placed in charge of health sector. NGOs becamethe primary providers of health services, man-aging over 80% of facilities by the fall of theTaliban. Despite the Taliban’s restrictions oneducation for girls and strict gender segrega-tion rules NGOs played a key role in facilitat-ing the return to work for female medical staffwho were completely forbidden to do so for aperiod of time. Also a key factor was that fe-males could only use the services of femalehealth providers. As a result doctors, nurses,vaccinators and even health educators werepermitted to work in the clinics. Although ac-cess to health care continued to be frustrated bya lack of roads and transportation infrastruc-ture, insufficient numbers of facilities, person-nel and socio-cultural factors some opportuni-ties were created to improve the situation facedby Afghanistan’s women. The Taliban’s restric-tions on education for females however, pre-vented the development of female healthproviders from higher education systemswhich has created one of the main constraintsthat the new government faces in increasing ac-cess to health care for women.

3.3 Present Day Afghanistan

Following the fall of the Taliban inNovember 2001, Afghanistan woke up tofind an interim authority in place, newly

appointed through the Bonn Agreement inDecember 2001, later to become the Transitio-nal Islamic Government elected by the LoyaJirga in June 2002. The MOH, whose staff hadbeen whittled away through several years ofconflict, emerged with a relatively new team ofleaders, many of whom came from UN agen-cies and NGOs with valuable exposure to therealities of the field. This group of health pro-fessionals collectively inherited a health systemthat had been producing some of the worst

9

Present Day Afghanistan

health statistics in the world for nearly half acentury. Indeed, the newly appointed MOHfaced a formidable task in establishing a frame-work for an efficient and equitable health system.

3.3.1 Current health status (June 2004)Afghanistan emerged from over 2 decades ofwar with some of the worst health statistics inthe world. Various agency produced reportsand studies such as the 1997 and 2000 MultipleIndicator Cluster Survey (MICS) conducted by

UNICEF revealed staggering rates of infantand child mortality, ranking fourth highest inthe world. While the overall rate of acute mal-nutrition is considered relatively low, factorssuch as micronutrient deficiencies, sustainedfood insecurity and poor caring practices havecombined to produce a 50% chronic malnutri-tion rate (moderate and severe stunting) (MOH2004). Infectious disease contributes heavily tothe burden of disease with diarrhoea, acute res-piratory infections and vaccine preventable ill-nesses accounting for an estimated 60% ofdeaths among children. Tuberculosis, whichleads to an estimated 15,000 deaths a yearamong adults, disproportionately affects fe-males with women accounting for approxi-mately 70% of detected cases (MOH 2004).

The health of Afghanistan’s women andgirls has suffered tremendously due to a com-bination of factors including lack of femalehealth staff, gender segregation and restrictionsplaced on the female population by local tradi-tions. In Afghanistan’s first ever national ma-ternal mortality survey, a UNICEF/CDC/MOH study estimated maternal mortality at1,600/100,000 (UNICEF CDC MOH 2002). This

10

Background

Location Chil d Mortality Infant Mortality Life Expectancy Fertility RateRate Rate

1960 2002 1960 2002 1970 2002 1960 2002Afghanistan 360 257 215 165 38 43 7.7 6.8

The Region

Bangladesh 248 77 149 51 44 61 6.8 3.5

Bhutan 300 94 175 74 42 63 5.9 5.1

India 242 93 146 67 49 64 5.9 3.1

Maldives 300 77 180 58 50 67 7.0 5.4

Nepal 315 91 212 66 42 60 5.9 4.3

Pakistan 227 107 139 83 48 61 6.3 5.1

Sri Lanka 133 19 83 17 64 73 5.7 2.0

UNICEF 2004

Table 1: Health trends in the region

Under 5 mortality 257/1000 live births

Infant mortality 165/1000 live births

Maternal mortality 1600/100,000 live births

Acute malnutrition 6-12%

Chronic malnutrition 50%

Iron Deficiency Anaemia 71% in pregnant women

TB 70,000 new cases/year

Annual incidence for TB 225/100,000

Life expectancy 42.6

(CDC/UNICEF/MOH 2002, MOH 2004, UNICEF MICS 2003)

Box 1: Health Status (as of June 2004)

1 Although the results of the ANHRA are widely quoted in documentation, the reliability of the results has been called into questionby some stakeholders. While the ANHRA results constituted the only comprehensive data on health facilities and human resources atthe time it was conducted, it has been suggested that the results can not be used for planning purposes. Consequently, the statisticsquoted above should be viewed with caution. A more detailed description of the ANHRA can be found in section 4.2.5.

2 BPHS health facilities include district hospitals and all health facilities below (comprehensive health center, basic health center andhealth post)

figure varies dramatically throughout thecountry (400 to 6,500/100,000), and with some50 women a day dying in childbirth, Afgha-nistan has the second highest maternal mortal-ity in the world.

3.3.2 Current health system (June 2004)The health status of the Afghan populationpoints to the failings of a health system that hasbeen battered and bruised over several years ofwar. As can be seen in table 1 Afghanistan’shealth indicators still lag significantly behindother countries in the region.

In response to a lack of information regard-ing the current status of the health system, theAfghanistan National Health ResourcesAssessment (ANHRA) was carried out in June –September 20021. The ANHRA confirmed sub-stantial inequities in the distribution of healthfacilities and services both between and withinprovinces throughout the country. Althoughthe national ratio of BPHS health facilities2 topopulation is 25,823 to 1, well above the MOHsshort term goal of 30,000 to 1, variation be-tween districts in Ghazni, for example, rangesfrom 1:5,725 to 1:145,300. The sheer lack ofhealth facilities in many areas of the countryprecludes access to essential services, even ifpeople could afford to, if females were permit-ted to, or if families recognised the need to. Awoman quoted in an article on reproductivehealth in Afghanistan explains “Well, the ques-tion is not if I would go or if I would be allowedto go [to a health facility] by my husband, butrather where I could go. (…) We would certain-ly use those services if they were accessible andproven to be reliable” (del Valle 2004).

Perhaps one of the biggest challenges facing the health sector is human resources.Doctors make up a quarter of the healthproviders in the country with an average ratioof 0.4 docs per 1,000 population, well below the average of 1.1 for all developing countries(WB 2001). The majority of these physicians are

11

Present Day Afghanistan

Infrastructure

Avg. pop. per BPHS facility

(clinic to district hospital) 1: 25,823

Range 1:11,800 (Wardak) to 1:52,278 (Ghor)

Existing BPHS facilities 926 (42% of

actual requirement)

Damaged health facilities 292

NGO ownership/support 80%

Services

Bed patient ratio 0.4/1000

BPHS facilities offering delivery services with

approp. equipment and female staff 18%

Hospitals with complete equipment to perform

c-sections 10%

Immunisation (DPT3) coverage 30%

Antenatal care (at least one visit) 16.1%

Human Resources

Avg. doctor per pop. 0.4/1000

Range 3.1 (Balkh) to 0.01 (Uruzgan and Pakitka)

Male/female ratio 3:1

Range 2:1 (Hirat) to 43:1 (Nuristan)

BPHS facilities with no female health

provider 40%

(UNICEF MICS 2003, MOH 2004, MSH/MOH 2004)

Box 2: Health System (as of June 2004)

located in Kabul and other city centers result-ing in enormous distortion in the distributionof health professionals. Moreover, only 24% ofthe overall number of doctors in the countryand 21% of nurses are female (MOH/MSH2002).

Only 21% of BPHS facilities have a midwifeand some 40% of facilities have no femalehealth provider at all, which, given the restric-tions placed on women, creates a serious bar-rier for them to access health services (Ibid).Given the lack of female health providers cou-pled with a lack of facilities having the appro-priate equipment to offer delivery services, it isnot surprising that just 10% of deliveries are at-tended by skilled personnel. It has been sug-gested that this figure is overestimated andskilled attendance is thought to be even lower.

Routine immunisation (DPT3) is offered inonly 58% of BPHS facilities, perhaps contribut-ing to an alarming routine coverage rate of just30% (MOH 2004). Moreover the ANHRA showsthat some 70% of existing primary care clinicsare unable to provide even basic mother andchild services.

3.3.3 Successes to date (June 2004)Despite these abysmal health conditions andthe state of the health system there have beenrapid strides forward in the health sector sinceNovember 2001 that can give hope to theAfghan people that the MOH and its partnersare taking the improvement of health seriously.The most important achievements include:

● The choice of the MOH to refrain from im-plementation, mainly in relation to theBPHS, instead taking on a stewardship roleand subcontracting health service deliveryto NGOs

● The early development of numerous policiesand strategies to guide health system de-velopment and investment including a

national health policy (02/2002), the BPHS(finalised 03/2003 but used for guidancesince mid 2002), the Interim Health Strategy(02/2003), National Salary Policy (08/2003),Recommended Human Resource Devel-opment Policy (08/2003), and ReproductiveHealth Strategy (06/2003) (MOH 2004).These have been developed with the contri-bution and participation of all stakeholderswhich has increased ownership and thuscommitment to uphold national policy

● Successful coordination amongst donors facilitated by the adoption of a common approach for health service delivery and thegeographical division of the country bydonor to prevent duplication of service pro-vision. Coordination is enhanced throughactive participation in the ConsultativeGroup process, a coordination mechanismintroduced to all ministries by the Ministryof Finance

● Successful coordination between NGOs andthe MOH as illustrated by the replacementof the national health NGO coordinationplatform with coordination mechanismssuch as the National Technical CoordinationCommittee (NTCC)

● Several studies have been conducted to inform planning and direct resource alloca-tion, such as the costing of the BPHS, theAfghanistan National Health ResourceAssessment (ANHRA), the National Hos-pital Assessment, the Maternal Mortalitysurvey, a nutrition survey, and a large base-line drug indicator study

● As of July 2004 44 contracts awarded to 32 NGOs and the MOH in 30 provinces and243 districts, covering 70% of districts and59% of the population, using a third partyevaluator who will conduct annual nation-wide health facility assessments (semi-annu-al in 13 provinces in which services will bedelivered province wide through one service

12

Background

provider), and analysis of the performanceindicators using the MICS database (baselineand after two years)

● Graduation of the first group of certifiedcommunity midwives in April 2004 and thedevelopment of a new midwifery trainingcurriculum

● Mass polio vaccination campaigns have re-duced the number of cases in the country to4 in 2004 and measles campaigns havereached more than 90% of children between6 months and 12 years

● Establishment of the Grants and ContractManagement Unit (GCMU) within the MOHwhose main task is to coordinate and man-age the PPA contracts and coordinate donorinputs in the health sector3

● Start of the Priority Reform and Restruc-turing (PRR) of the MOH civil service; pro-posals for the Provincial Health Department(including Provincial Health Offices) and thePolicy and Planning General Directoratehave been approved with the remainingDirectorates expected to follow suit in 2005

3.4 Challenges for the Health Sector

In order to achieve an efficient and equitablehealth system that is sustainable in the longterm, there are a number of challenges fac-

ing the MOH. Several factors preclude access tohealth services for which there are no quick fixes. A shortage of skilled staff, particularly females, may be one of the biggest constraintsto scaling up health service delivery. Althoughcontracts have been awarded to NGOs fortraining of midwives and women have alsobeen enrolled in community midwife trainingschemes, a training period of at least 18 months

means that service providers will find it diffi-cult to adequately staff health facilities with female health professionals for the present.Existing capacity to train the numbers requiredis scarce and furthermore, even after traininghas been completed, attracting females to ruralareas will remain a challenge, particularly ifcurrent insecurity persists. Presently, even withthe offer of exceptionally high salaries, NGOsare experiencing extreme difficulties in recruit-ing female staff to rural areas. Given that a re-duction in the millennium development goalfor maternal mortality of three quarters is a pri-ority for the MOH, these human resource con-straints will pose a formidable challenge inachieving this goal.

Recruitment of skilled male staff, while notas drastic as for females, will also present dif-ficulties. While the ratio of physicians to popu-lation in Kabul is 1:1,765, the number in the restof Afghanistan is 1:14,432 (MOH 2004). Lack ofschools, housing and other social infrastructure

13

Challenges for the health sector

3 Although the GCMU was established primarily to manage the WB contracts, their role has expanded to include development and im-plementation of various other policies. See section 4.4.1 for more details.

4 The ongoing development of the Essential Package of Hospital Services (EPHS) has gone some way to address the issues of hospitalsbeyond first level referral facilities. However, with continuing gaps in funding for the BPHS, the MOH may find it difficult to identi-fy further sources of funding for the EPHS.

such as potable water, mean that male healthprofessionals are just as likely to remain in ur-ban centers. Furthermore, even if staff can bedrawn to rural areas the adverse effects of theTaliban regime on medical education mean thatthe quality of medical skills may also be ques-tionable (Ibid).

Other significant challenges in the healthsector include lack of infrastructure, weak man-agerial capacity particularly at the provinciallevel, slow roll out of systems to the provincesand lack of security throughout the country(Ibid). The difficult socio-political circumstancesthat NGOs will face in delivering the BPHS inrural, underserved areas are further con-strained by low population density in many areas, problematic geographical access andmarked seasonal variations in access.

Another important long term challenge willbe finding additional funds for the health sec-tor. As of July 2004 only 59% of the populationhave been ‘covered’ by the minimum health fa-cility to population ratio through contracts andgrants in the initial phase of Afghanistan’s tran-sition to post-conflict. In addition to this lack offunds for even basic services, lack of an earlypolicy regarding secondary and tertiary hospi-tals has had a significant impact on monies allocated for the hospital sector. While it iscommendable that the majority of scarce re-sources have been allocated to the BPHS ratherthan sunk in expensive hospital costs, this lackof attention to the hospital sector has createddisappointed expectations and dissatisfactionamongst the urban and semi-urban popula-tions of Afghanistan. This carries some political

risk in addition to being a potential health issuefor these populations4.

A review of the literature on the constraintsto scaling up health interventions has shownthat developing countries experience con-straints on five different levels: (i) communityand household level, (ii) health service deliverylevel, (iii) health sector and strategic manage-ment level, (iv) public policies cutting acrosssectors, and (v) environmental characteristics(Hansen et al 2001). For countries emerging fromconflict, these constraints may be heightened.Lack of skilled human resources, weak govern-ment capacity and lack of infrastructure havebeen frequently cited as major constraints inother post-conflict settings such as Cambodiaand East Timor. Indeed, ‘year zero’ inCambodia was characterised by a depletedwork force and a lack of sound structural build-ings for static health facilities, with continuinginsecurity precluding access to rural popula-tions (Bhushan et al 2001). Describing the reha-bilitation of the health sector in Cambodia eightyears after the cessation of conflict, authors ofan evaluation report comment: “The magni-tude of this task is hard to convey to anyonewho has not firsthand seen what a “year zero”society is like, and the progress which has beenmade in less than a decade is enormous.Nonetheless, it is still very much a society andcountry in the making, lagging far behind therest of the region in its socio-economic indica-tors and human resource capital” (Ibid). Thisdescription illustrates that the challenges facingAfghanistan in re-building the health systemare many in the years to come.

14

Background

4 Health PolicyDevelopment in Afghanistan

Increasing attention has been devoted to therole of health systems and the significanceof policy-making in achieving effective

health systems (Hanney et al 2003). Indeed it iswidely recognised that unwise policies con-tribute extensively to the underperformance ofhealth systems in many countries (Ibid). Inpost-conflict contexts policy choices made canhave profound and long-lasting consequences.In this regard, attempting to understand theprocesses involved in the formulation of policycan help to shed light on the forces that shapethe health sector and can highlight constraintsto decision-making and future implementation(Pavignani 2003). It has been shown elsewherethat early formulation of a national policyframework is crucial in post-conflict settingswith improved health outcomes suggested asone product of better health policy formulation(Bornemisza and Sondorp 2001). A major chal-lenge, however, is how to initiate and maintainpolicy momentum while maintaining a consid-ered and rationale approach to decision mak-ing that is contextually appropriate and ad-dresses the demands of the health sector. Giventhe impact that policy can have on the ability ofhealth systems to perform effectively, and theunique opportunity in post-conflict settings todevelop and overhaul ineffective policy fromthe past and revitalise health systems, it is use-ful to describe and document the ways inwhich health policy is developed.

This section describes the development ofAfghanistan’s health strategy from 2001 to 2003and details the processes through which poli-cies were developed, the contribution of vari-ous stakeholders, and where the MOH is at to-day with the roll out of the BPHS. The sectionis divided into 3 parts coinciding with threeJoint Donor Missions that took place, as it wasduring these times that policy options wereplaced on the agenda, debated, and concretesteps were taken to ensure that discussion was

transformed into action. During each of themissions there was an element of ‘taking stock’of events and processes. Moreover, these timeperiods coincided with the phenomenon ofplanning and resource allocation.

4.1 The Early Days (November 2001 – May 2002)

The first key event following the fall ofthe Taliban was the Islamabad Confer-ence on Preparation for Reconstruction

that was held in Islamabad on November 27th –29th, 2001 by the ADB, WB, and UNDP. Planswere made at the conference to carry out a series of needs assessments to determine theexternal assistance required for the reconstruc-tion of Afghanistan in the short to mediumterm, and to identify priorities for a ministeri-al meeting to be held in Tokyo in January 2002.The priorities identified during the conferenceincluded institutional support, repairing struc-tures and delivery of an essential package ofprimary health care services. This was the firstpoint that delivering a basic package was artic-ulated as a strategy to improve health.

The assessments were carried out by theADB, WB and UNDP between December 2001and January 2002, primarily from Islamabadand Peshawar, and results were presented atthe ministerial meeting. It was estimated that$12.2 billion would be required to address im-mediate reconstruction needs over the first fiveyears (WB/ADB/UNDP 2002). An importantoutput of the meeting was the designation ofagencies to lead assessment missions in each ofthe major sectors in order to collect more de-tailed information. It was agreed that under theleadership of the Afghan Interim Admini-stration (AIA), the WB and WHO would headthe mission for the health and nutrition sectorwith members from ADB, DFID, EU, UNICEF,

16

Health Policy Development in Afghanistan

UNFPA and USAID. Although the mission re-port states that meetings were held with NGOs,they were not included as members on the mission despite supporting over 80% of heathfacilities in the country.

4.1.1 Agenda setting and policy formulationAfter the signing of the Bonn Agreement onDecember 5th, 2001, the newly revamped MOHgot right down to business. With the support ofWHO an initial National Health Policy wasagreed in February 2002, in order to outlinestrategies for priorities in the health sector. Thepolicy was explicit in stating that ‘the nationalhealth sector will be organised and streamlinedto deliver an essential package of health servic-es to the entire population’ (MOH 2002). Whilethis represented a step in the right direction,the policy was confined to technical details andthe ideals of a health system to aspire to butprovided no direction on the nuts and bolts ofcritical policy issues such as the role of theMOH, health care financing, and the approachto service delivery (Pavignani and Colombo 2002).A qualitative policy study conducted in 2002(Bower) reveals that although there was an at-tempt to involve different stakeholders in theprocess, the document lacked critical analysisdue to the failure to present different approach-es, weak capacity in the MOH and lack of pol-icy vs. programmatic knowledge amongstNGOs, and poor coordination within the inter-national community. Nonetheless, a policystatement has rarely been produced faster in apost-conflict environment and while some ar-gue it was too fast, it got policy momentumrolling.

The first Joint Donor Mission (JDM) wasconducted in March – April 2002, co-chaired byWHO and the WB5. The JDM took charge of

raising some of the policy issues not addressedin the national health policy and proposedstrong recommendations for the MOH to con-sider. The JDM, as mentioned above, was partof a request from the newly established AIAthat came out of the January Tokyo meetings to,among other things, delineate a framework forassistance for the following 2.5 years, and moreimportantly, to define a government-led mech-anism for coordination (WB 2002a). Using thepolicy goals outlined in the National HealthPolicy as a springboard, the aide memoire putforth 3 concrete policy options to operationalisethe health system:

1) Expansion of the MOH to become a providerof services

2) Continuation of the current system of fund-ing NGOs with limited guidance from theMOH

3) Establishment of Performance-based Part-nership Agreements between the MOH andNGOs which would allow the MOH toutilise existing NGO capacity to deliverservices while still maintaining control overthe strategic direction of the health sector

Given the post-conflict context and the estima-tion that some 80% of health facilities were being operated by NGOs (WHO database in WB2002a), the aide memoire made strong recom-mendations that the government refrain fromservice provision in favour of a stewardshiprole focusing on policy development and regu-lation. In line with this concept, option threewas suggested as the best way forward.Through PPAs, the government would estab-lish contractual agreements with NGOs to deliver health services within geographicallydefined areas. NGOs would go through a com-

17

The Early Days (November 2001 – May 2002)

5 Other participants included the ADB, DFID, EU, UNICEF, UNFPA and USAID

petitive bidding process and payment for serv-ices, on a per-capita basis, would be based onachievement towards pre-determined nationalindicators with performance measuredthrough regular monitoring by the MOH andindependent evaluations (WB 2003b).

The proposed PPA strategy was premisedon positive findings from a pilot project inCambodia which tested the performance of 2 different contracting models against govern-ment provision (Bhushan et al 2001; Bhushan et al2002). Afghanistan’s transition to post-conflictcoincided with the completion of the pilot eval-uation in November 2001 that concluded“Government contracting of the provision ofhealth services to non-government entities is:feasible, cost-effective, high performing, [and]equitable” (Bhushan et al 2001). Conclusionsreached and recommendations made in theevaluation were used as one of the primary jus-tifications for the promotion of the PPAs. Aspart of the JDM the MOH were given a presen-tation of the findings of the evaluation.

The aide memoire tackled hard issuesevaded in the national health policy and be-

came an important document in the policy are-na due to the practical nature of its content.Essentially, it became the backbone of the na-tional health policy, and some argue, served tosteer policy development in such a way thatwould facilitate health service delivery throughPPAs (Bower 2002; Daly 2003).

It was in these early stages of the post-con-flict environment, through the JDM mecha-nism, that the WB began to assume a primaryrole in shaping health policy. Although theJDM was co-chaired by WHO and the WB, theproactive presence of the WB made it an influ-ential player in the policy arena. While WHOwas selected as the focal point for policy for-mulation and planning, the WB arrived incountry with concrete ideas about how to move forward with the reconstruction ofAfghanistan’s health sector. According to viewsfrom key informants, the charisma of veryproactive staff enhanced the WB’s influence.The JDMs were successful in initiating policydebate and served as a mechanism for effectivecoordination and communication betweendonors and the MOH. Bower (2001) points out

18


that, “…JDM experts … followed up their ad-vice closely, regularly and in managerial detail,albeit often at a distance”. Although WHO cre-ated some early opportunities for policy de-bate, recommendations and advice providedby various policy experts brought in on shortterm consultancies was not acted upon or fol-lowed up when these experts left. As suchWHO’s role contracted to focus more on tech-nical assistance in programmatic areas such asEPI (Ibid).

The WB’s influence gained momentumeven after the JDM as they continued to remainengaged with the MOH via audio-conferencecalls from Washington regarding developmentsand next steps forward. The conference callsfilled a gap in coordination and were an effec-tive mechanism with efficiently chaired meet-ings and people phoning in regularly to receiveupdated information that wasn’t availablethrough other channels. Although WHO could(and should) have stepped into this coordina-tion role, internal politics and underutilisationof policy expertise brought in from outsidehampered their performance with regard to co-ordination and policy functions.

Also playing an active role in the policyarena were USAID/MSH, French Cooperation,UNICEF, UNFPA, JICA and the EC to a morelimited extent. While USAID was fiercely op-posed to some of the ideas that would evolvefrom the PPA concept they brought in a num-ber of technical experts on topics such as healthreform and health financing at an early stagewho participated in various meetings, work-shops, task forces, and working groups. Thistechnical capacity was brought in through anearly contract established with MSH inFebruary 2002 to operate the AfghanistanHealth Services Expansion Project (AHSEP)program. This injection of technical expertiseprovided much needed process support andassisted the MOH in moving policy forward in

an informed way. While the EC was also a keyplayer in policy discussions, their participationwas more reactive than proactive; they did notbring alternative options to the policy agendaand were slow to bring in technical assistance.On the other hand, the EC did continue to pro-vide considerable financial support to NGOs,who were some of the very few that were in-volved in the policy process, albeit to a limitedextent.

Although not interested in directly fundingthe BPHS due to the abundance of funds fromother larger sources, the French Cooperation(FC) was also playing an active role in the pol-icy debate. While the FC did not oppose theconcept of the PPAs entirely, they urged thegovernment to carefully consider the promo-tion of PPAs on a large scale (as was proposedby the WB) due to lack of evidence to supportthe expansion of the PPA mechanism from a pi-lot level.

UNICEF also played an important role interms of support to the policy process. Presenceof an action-oriented individual contributedtechnical expertise in more programmatic areassuch as maternal and child health, nutritionand EPI. In addition they actively participatedin policy discussions and an international advi-sor was seconded to the GCMU in early 2003 toprovide support. UNICEF is also contributingsubstantial funding support in areas such asEPI, safe motherhood, salt iodization, waterand sanitation and education.

Although most health NGOs were inter-viewed by members of the JDM, and it was in-formation obtained through these interviewsthat fed into the policy debate, they remainedlargely unaware of the PPA proposal that wasmade at this point in the process (Bower 2001,Waldman and Hanif 2002). During research forthe AREU report ‘The Public Health System inAfghanistan: Current Issues’ (Waldman andHanif 2002), NGOs requested a meeting in order

19


for the research team to present the key features of the PPAs. The report notes that keyconcerns at this stage revolved around their ca-pacity to provide the entire range of servicesfrom health post to district hospital on aprovincial level. There was also apprehensionregarding reactions of provincial health author-ities and their involvement in the designprocess of this kind of delivery strategy.Although there were a few NGOs included asfocal points of programmatic areas such as TB(Medair), malaria and leishmaniasis (HNI) andnational level emergencies (ICRC), and somewere included in smaller advisory groups, adistinct lack of NGO involvement in the policydebate in these early stages has been noted(Ibid). It has been suggested that NGO involve-ment in the health sector pre 2001 was largelyprogrammatic and they came into the post-con-flict period with the same focus, which leftthem ill-prepared for discussions on policy is-sues. Nonetheless there were a few active par-ticipants from a limited number of NGOs whodid raise their voice in the meetings they wereinvited to and took the initiative to get in-volved in the process beyond programmatic is-sues. However, observers have commentedthat contributions were individual rather thanorganisational, and it was these individuals

that were chosen (by the MOH and not theNGO community) to represent NGOs in formalmeetings.

4.1.2 National development frameworkA first draft of the National DevelopmentFramework (NDF) was produced in April 2002,which reflected results of the preliminary needsassessments carried out for the Tokyo ministe-rial meeting in January. The goal of the NDFwas to identify national strategies, prioritiesand policy directions in order to guide assis-tance from development partners to a series ofprograms and projects (MOH 2002a). The NDFsstrategy identified three pillars (see table 2).Health and nutrition, one of 12 Public Invest-ment Programs (PIP) to be funded by recurrentand development budgets, was slotted underpillar I with malnutrition and essential obstet-ric care identified as priorities requiring urgentattention.

Within health and nutrition, six priorityneeds were identified: (i) decrease infant andchild morbidity and mortality (ii) decrease ma-ternal mortality; (iii) combat malnutrition; (iv)decrease incidence of communicable disease;(v) improved equitable distribution of qualityhealth services, and (vi) enhanced capacity ofMOH to implement effective and efficient

20


Humanitarian, human & Physical reconstruction & Private sector development, social capital natural resources governance & security

Refugee return Transport and communications Trade & investmentEducation and vocational Water and sanitation Governance & training public administration

Health and nutrition Energy & natural Security and rule of lawresource management

Livelihoods & social protection Urban developmentCultural heritage, media & sport

Table 2: Three pillars of the National Development Framework

health services. For 2002-3 (Afghan year 1381)the PIP was $173M. By 2003-4 (Afghan year1382) it was estimated a total of $320.52M wasrequired to fund all 46 programs under healthand nutrition. Delivery of the BPHS was to ac-count for $90M of this total (28% of the PIP),with projects aimed at improving the quality ofhospital services accounting for 14% and en-hanced capacity of the MOH at 17%. Despitethis shift in focus away from curative, hospitalbased care towards basic preventative healthcare, there was a 61% gap in funds to imple-ment priority programs (MOH 2003).

Funding support for the NDF was identi-fied to come from domestic resources, the inter-national community and the AfghanistanReconstruction Trust Fund (ARTF). The ARTFwas established in April 2002 in order to createa coordinated funding mechanism to financepriority expenditures for Afghanistan’s recon-struction. Three categories of expenditure wereidentified as eligible through the fund: (i) re-current costs including salaries and non-projecttechnical assistance; (ii) investment activitiesand programs, and (iii) salaries for returningAfghans who were living abroad. The fund isadministered by the WB with a managementcommittee consisting of ADB, UNDP, IDB andthe WB. While the ARTF represents an attemptto give the government more control over theallocation of funds to development priorities,Bower (2001) points out that funds were slowto come in with donors reluctant to fund recur-rent costs and provide un-earmarked fundspreventing channelling of money to their ownpriorities. Indeed, by May 2002, only 90M outof 400M requested by the government hadbeen committed (BIC 2004). With domesticsources of revenue estimated to contribute$80M to the government budget a gap of$230M for the recurrent budget still existed.

4.1.3 Formulation of the Basic Package of Health Services

In the weeks that followed the JDM, discussionsurrounding contracting and the PPAs cap-tured center stage in the policy debate.Dialogue concerning a basic package only start-ed with the realisation that in order to contracthealth services the services had first to be iden-tified. In this respect the concept of a basicpackage appeared closely related to the con-tracting strategy. Indeed, even in the seconddraft of the BPHS, it is stated “One of the firststeps to achieve [contracts with NGOs underthe recommended PPAs] … is to define a basicservice package, which can later be used todraft the contracts and establish the progressindicators” (WHO/MOH 2002).

Having sparked interest amongst MOH officials with the PPA approach, the WB contin-ued to push forward with a strict timeline forfulfilling the ‘next steps’ recommendations inthe process. It wasn’t until pressure was ap-plied from the WB in Washington that an advi-sory committee was appointed by the Health

21


Maternal and newborn health

Antenatal care, delivery care, postpartum care,

family planning, care of the newborn

Child health and immunisation

Immunisation (EPI), Integrated Management of

Childhood Illnesses (IMCI)

Public nutrition

Micronutrient supplementation, treatment of

clinical malnutrition

Communicable diseases

Control of tuberculosis, control of malaria

Mental Health

Disability

Supply of essential drugs

MOH 2003

Box 3: Basic Package of Health Services

Coordination Task Force6 (HCTF) to work onproducing the package. The committee consist-ed of the MOH, WHO, UNICEF, UNFPA, andMSH. As the focal point for policy formulationand planning and the secretariat for the coordi-nation task force, WHO took the lead in pro-ducing the package. With limited input fromthe MOH or the task force, little assistance fromthe advisory committee, and no examples towork from, a draft of the Basic Package ofHealth Services (BPHS) was essentially formu-lated by one WHO consultant who was armedwith very limited information about the coun-try (X. Modol, personal communication, May 26,2004). Expertise was sought from various UNagencies and NGOs on all aspects of the pack-age, to add to available existing information.As there was no literature regarding the cost-effectiveness of the components specific toAfghanistan (mental health and disability) local expertise was relied on exclusively.

Just two weeks after being commissioned,the first draft of the BPHS was presented to theHCTF for comments, again with little input re-ceived. Due to mounting pressure from the WBand other key actors, discussion on the con-tents of the BPHS and important aspects suchas the role of community health workers7 waslargely limited, with the MOH anxious to haveit endorsed. Rather than certain stakeholdersbeing excluded from the process, limited inputwas more a consequence of hectic schedulesand the time constraints of producing a docu-ment (Ibid). Another contributing factor was the

lack of understanding of the implications of abasic package approach. While some tried toinject words of caution into discussion regard-ing the limitations of adopting such an ap-proach, these were mostly drowned out by theperceived necessity to keep on track. Some ofthe main constraints highlighted included: (i)the weaknesses inherent in producing such apolicy with limited consultation and local evi-dence8, (ii) the BPHS is demanding in terms ofits requirements for human resource develop-ment, which will be problematic in Afghani-stan, (iii) the demographic pattern of the coun-try translates into heavy reliance on communi-ty health workers and outreach which are lessdependable and more costly than routine serv-ices from health facilities, and (iv) limited capacity of all stakeholders to commission, co-ordinate and monitor service provision(WHO/MOH 2002). The authors specificallyemphasised that “…although each one of thecomponents listed in the basic package pro-posed can be regarded as modest, providingthe whole range of services has proven too biga challenge for most developing countries”(Ibid).

The final document was issued in March2003 and outlined the contents of the BPHS (seeBox 3) including four service levels through fa-cilities (health post, basic health center, com-prehensive health center, and district hospital),each with its own recommended staffing pat-tern and defined catchment area. Althoughmental health and disability were included in

22


6 The mandate of the Health Coordination Task Force was to among other things, serve as a forum for discussion of policy issues to becommunicated to the MOH leadership. Membership composed representatives from the MOH, UN agencies, NGOs, ICRC, anddonors. This task force was later defined as the Consultative Group for Health and Nutrition, which is now currently under amend-ment again (Pavignani and Colombo 2002).

7 Experience with a similar cadre of health workers in the 1995 national health plan revealed difficulties with supervision, monitoringand supply which resulted in CHWs setting up as village doctors in some areas. Fears of similar results prompted suggestions to cre-ate a working group to explore the role of CHWs in the BPHS. Stakeholders involved, however, neglected to devote time to the issue.

8 Just 7 months into the roll out of the BPHS, a review process of the contents of the BPHS began due to concerns raised by implement-ing NGOs.

the BPHS, they were excluded in the initialrounds of funding. While deemed importantproblems specific to Afghanistan, these twocomponents have been relegated to second tierservices.

One of the consequences of defining apackage of health services, and an importantpolicy development within the formulation ofthe contents of the package, was the redesignand reclassification of the Afghan health sys-tem. Previously, the taxonomy of health facili-ties was inconsistent and ill-defined, with anarray of different names floating around to de-scribe the same facility. Causing confusionabout the type of services signified by differentnames, staffing patterns and the function of dif-ferent facilities in the referral chain, the healthsystem’s current nomenclature reflects an at-tempt to alleviate this problem and standardiseservices by facility level.

It is interesting to note that while this re-structuring of the system represents a signifi-cant policy development, little ‘air time’ wasgiven to the issue. Indeed, the implications ofsuch a change are far reaching with all PPAs,performance-based grants and building pro-grams based on this model. These changes alsoimpact on the future sustainability of the sys-tem. The consequences of this restructuringwill only become evident in years following theinitial contract periods. While the new struc-ture is not unreasonable and is based on expe-riences from the reconstruction process inMozambique, it has been the replacement ofthe old confusing terminology rather than evidence that it is the right structure that has fa-cilitated its easy acceptance.

4.2 MOH in the Driver’s Seat (June 2002 – March 2003)

This period of time in the process of iden-tifying Afghanistan’s health deliverystrategy was characterised by hot de-

bate, conflict, confusion, and camp building.Opinion regarding the PPA proposal forAfghanistan’s health system was divided alongboth NGO and donor camps. Donor and MOHconcern regarding the PPA approach revolvedaround the implementation capacity of NGOsto deliver the BPHS on a provincial scale, asproposed by the WB. Disagreements reached aclimax following the release of a WB aide-memoire which donors felt did not reflect deci-sions and compromises made at a series ofmeetings during a WB mission in early 2003.

Also under discussion was the possibilityof direct provision of the BPHS in a limitednumber of provinces through a MOHStrengthening Mechanism (MOH-SM) usingIDA/WB monies.

Despite conflict and disagreement thisphase was ended by a clear choice on the wayforward both at the end of the second JDM andthe WB mission in April 2003. The MOH waseffectively in the ‘driver’s seat’ from this mo-ment onwards, pushing consistently for the im-plementation of the BPHS and subcontractingservice delivery to NGOs. Moreover, this peri-od of time is significant, as it heralded the endof the discussion phase and work was startedon implementation modalities.

4.2.1 Pushing the agenda forward: the second JointDonor Mission (July 2002)

The objectives of the second JDM were to fol-low up on issues and next steps that had beenraised during the first visit, continue policy di-alogue regarding the mechanism by which theMOH would work with NGOs, and to assessthe costs to deliver services outlined in the

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MOH in the Driver’s Seat (June 2002 – March 2003)

9 Although the initial proposal from the WB was for NGOs to cover entire provinces, negotiations took place over a 10-month periodwith the final agreement allowing for both provincial and cluster-based coverage. A cluster constitutes a group of districts that forma logical entity in terms of geography, access, referral patterns etc (EC 2003)

10 DFID funded 5 short term consultancies between August 2002 and March 2003 addressing key areas such as policy, strategy and insti-tutional development, health financing, budgeting and financial management, and human resource development (Simmonds 2003).

BPHS and the resources available with whichto finance it (WB 2002b). Despite the fact thatthe government had still not made a decisionpertaining to their role in health, the PPAs re-mained the sole strategy on the agenda.

Participation in this JDM had expanded toinclude GTZ, KfW, JICA, and the FrenchCooperation. While GTZ and KfW did not havean active presence in the health sector duringthe first JDM, there were other actors who werepresent and had been providing funds forhealth activities for several years that were notincluded (e.g. SIDA). Although some of thesedonors, such as SIDA and NORAD were pro-gressively phasing out of the health sector dueto the perceived abundance of funds available,other donors such as KOICA were interested incontributing to areas in health other than theBPHS. This was primarily due to funding avail-ability and a desire to program funds on theirown terms, based on past experiences, at theirown pace (interview data).

Despite scepticism generated by the pres-entation of evidence on the use of PPAs andother performance-based payment systems inCambodia and Haiti, a number of importantdecisions had been taken by the end of the sec-ond JDM that would drive the policy processonward. Even though some stakeholders wereuncertain of the WB’s agenda it was generallyagreed that the PPAs represented an interestingoption for healthcare delivery. Given the lack ofevidence of its efficacy in practice however, itwas expressed that implementation on a pilotbasis would be more advisable in the initialstages of the roll out of the BPHS. Perceived asa show of support the MOH endorsed contract-

ing-out in unserved areas and contracting-in inunderserved areas.

In addition, a list of guidelines was devel-oped to facilitate a unified approach to man-agement of PPAs for the MOH and a commonapproach (i.e. the World Bank approach) fordonors to follow. Some of the key points in-cluded that provinces or clusters of districtswould be the geographical area covered by aPPA9, donors would adhere to common termsof reference based on the BPHS, and that agree-ments should be established for at least 2–3years (WB 2002b). However, while all donorshave more or less based their contracts/grantson the BPHS, implementation mechanismsevolved to be quite variable and only the WBhas adopted the term PPA for its project areas(see section 3.3.2).

4.2.2 Development of an interim health strategyAlthough a policy direction had been outlined,the next challenge for the MOH was how totranslate the policy into a strategy for thehealth sector. Supported by a series of visitsconducted by a DFID funded institutional de-velopment consultant the MOH began workingon an interim health strategy in August 2002 inorder to clearly define priorities for health serv-ice delivery and strengthening of the healthsystem10. The process was helped alongthrough a series of seminars held by the con-sultant, which introduced international experi-ences in health systems development and re-form and facilitated brainstorming sessions onpriority steps for strategic development of thehealth sector (Simmonds 2002). In addition tothese seminars, daily sessions were held in a

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11 The objectives of the GCMU are: (i) expansion of the BPHS through NGOs and the private sector, (ii) strengthen the stewardship roleof the MoH, (iii) integrate NGO and donor efforts in the reconstruction of the health system, (iv) develop MoH capacity to work withNGOs and the private sector to encourage use of domestic resources in future partnerships (Draft terms of reference in Daly 2003).

second visit in November 2002 on topics suchas the role, values and purpose of the MOH,setting priorities and development of options,and the value of thinking strategically whiledealing with the everyday (Sondorp et al 2004).This practical approach to capacity buildingnot only supported the development of an in-terim health strategy, but provided guidanceon day-to-day issues that the MOH was deal-ing with. Faced with demands and expecta-tions from an ever growing international com-munity, the seminars provided an opportunityfor MOH staff to discuss their positions on keyissues, and receive advice on matters that werebecoming part of their daily routine such ashow to chair a meeting effectively.

By December 2002 a draft of the interimhealth strategy had been formulated and a se-ries of position papers had been developed thatdescribed the MOH’s position on various is-sues such as capacity building, coordination,and construction of health facilities. ByFebruary 2003 the final interim health strategywas agreed and circulated. In line with theNDF which identified health and nutrition as apriority, the interim policy outlined 12 strate-gies for delivery of health care including capac-ity building of institutional and managementfunctions within the MOH. The strategy in-cludes a revised organisational structure for theMOH and outlines a series of indictors and out-puts to achieve priorities. A commitment to theprovision of the BPHS for the next 3–7 yearswas also included in the strategy.

4.2.3 3rd World Bank pre-appraisal missionIn January – February 2003, a pre-appraisalmission was conducted by the WB (also at-tended by MSH and DFID) to assess and fi-

nalise the design of the PPA project compo-nents, and come to an agreement with otherdevelopment partners on their involvementand coordination mechanisms (WB 2003a).During the mission the following agreementswere arrived at:

● 10 provinces would be designated to thePPA model; 7 contracted out to NGOs and 3 in which the MOH would deliver servicesitself using WB/IDA monies through aMOH Strengthening Mechanism (MOH-SM), which would provide technical expert-ise and advice on proposal development,management systems, etc. It was envisagedthat the MOH-SM would operate as tradi-tional government provision and serve as acontrol group to compare against the con-tracting out of service delivery to NGOs,similar to the pilot design in Cambodia;

● In order to ensure efficient use of resourcesand prevent duplication of efforts a leaddonor was proposed for each province;

● The establishment of a Grants and ContractManagement Unit11 to coordinate donor as-sistance coming into the health sector andserve as a focal point for the PPAs;

● The mandate to finalise work on a nationalsalary policy.

The aide memoire presented another checklistof ‘things to do’ in the coming months thatstakeholders felt the MOH did not have the ca-pacity to do alone, and would take a substan-tial amount of time, over and above otherpressing matters that they had to deal with.Donors felt that they were being pushed intoproviding support for preparations for theWB’s project who wasn’t around to chip in.

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They also felt the time schedules given to com-plete tasks were simply unrealistic given thatthe PPAs were neither the only thing the MOH,nor other donors had to devote attention to.

In this early part of 2003 debate over imple-mentation mechanisms continued and tensionwas exacerbated amongst donors with the release of the aide memoire. Some of the reactions and concerns of key stakeholders areoutlined below to illustrate the array of opin-ions and some of the blockages preventing con-sensus.

Donor/UN reactions and concernsAlthough eventually donors were able come toan agreement on how to program their funds ina coordinated way there was a period of heateddebate where irritations began to brewamongst stakeholders. Below some of these ‘irritations’ are highlighted to illustrate some ofthe issues that can derail the process of strate-gy development. Rather than pointing fingers,this section should be read from a lessonslearned perspective.

The four main donors in health are USAID,WB, EC and UNICEF. While the WB was re-sponsible for introducing the PPA concept,there was general consensus among the maindonors regarding the overall principles neces-sary for implementation of the mechanism,which consisted of subcontracting NGOs forservice provision, with the Afghan governmentacting as a regulator and policy-maker. Therewas considerable controversy, however, re-garding implementation strategies.

The main points of contention have re-volved around the following technical issues:

1) Evidence-based policy: given the lack of evidence and field experience with the PPAs,implementation on such a large scale posesan ethical and moral dilemma.

2) Scale of coverage: based on the Cambodiaevaluation the WB advocated strongly forprovince-wide PPAs in at least 10 provinces,with one NGO responsible for delivery ofthe BPHS. Other donors were morefavourable of a cluster approach with only alimited number of province-wide PPAs as apilot. Concerns were that with only 1 NGOproviding the entire BPHS in a provincethere would be no safety net if the approachfailed. Moreover, the number of NGOs withthe capacity to implement at a province-wide scale was felt to be limited, especiallygiven that many of the lead NGOs workingin the health sector were also working inother sectors such as education, and receiv-ing substantial injections of funding to ex-pand these services at the same time.

3) NGO and government capacity: the capaci-ty of NGOs to provide the scope of servicesin the BPHS in the context of Afghanistan isnot certain, and many have argued, is notpossible without a more phased approach.Government capacity at all levels is under-standably weak and PPAs would occupymost of their time, preventing capacitybuilding in other areas.

Disagreements came to a boiling point with therelease of the pre-appraisal aide memoire. Thereport triggered the exchange of very frank let-ters between the WB and donors who had par-ticipated in various meetings throughout themission. Donors claimed “it (the aide memoire)does not reflect … discussion with the MoH anddonors nor the points of view expressed and appar-ent compromises made by the various health sectorpartners, including the WB, during the appraisalmission” (USAID et al 2003). This perception thatall views were not taken into account createdfriction and slowed down policy decisionseven longer.

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While the debate amongst the donors listedabove had continued ardently since mid 2002,other donors had chosen to opt out of partici-pation in JDMs as well as the PPA scheme.Some felt they didn’t have enough funds to getinvolved and have instead invested in other ar-eas in the health sector such as hospital con-struction. Others were of the opinion that whilethe PPAs represented a viable option, theywere more comfortable with programmingtheir funds based on their own past experi-ences. An additional complication was theMOFs request for donors to choose three sec-tors for support, which limited them in spread-ing their resources and caused smaller donorsto opt out altogether. In contrast, while theFrench Cooperation steered away from sup-porting the BPHS financially, they remainedfully engaged in the policy process, contribut-ing an additional perspective which, due tolack of involvement from other donors, was inshort supply.

Another issue that donors were debatingwas the funding of district hospitals. Despitethe inclusion of district hospitals in the BPHS,both the WB and USAID were seriously con-templating not funding this component. TheWB eventually agreed to include them after itwas estimated that a 50 bed hospital would

cost approximately $150,000 per year. USAIDstood by their decision at this point in time buthave since taken a more relaxed attitude, fund-ing a limited number of district hospitals.

MOH reactions and concernsThere was general consensus among the inter-national community that the MOH was ex-tremely open to suggestions and criticismthroughout the policy process, and were opento taking risks and trying new things in deter-mining the best way to deliver health servicesin Afghanistan. While the MOH was primarilyconcerned with the proposed scale of the PPAsit seems they acted within the confines of‘bounded rationality’ (Walt 1994), having limit-ed information and making decisions based onoptions which offered a better solution to theway services were being delivered.

A position paper released at approximatelythe same time as the pre-appraisal mission re-inforces the notion that the MOH was in favourof a more considered approach in delivery ofthe BPHS: “At this point in time we think a mixof … the 3 options is the way to move forward.There is no one right way to deliver services inour country. We need to be flexible, be preparedto do things differently from the past, if thehealth of our people, especially mothers andchildren is to improve” (MOH 2003a). Althoughthere were discussions regarding direct govern-ment provision through the MOH-SM the bal-ance of these policy options tipped in favour ofcontracting NGOs for service provision.According to key informants, there was, andcontinues to be considerable speculation overthe degree of choice that the MOH has had inmaking these decisions. The literature continu-ally points out that involvement of internation-al organisations is more likely to lead to coer-cive adoption of policy (Dolowitz and Marsh2000; Stone 2001), and with the energetic approach used to promote to the merits of the

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12 The Program Secretariat was to be responsible for overall coordination in the health and nutrition sector.

PPA approach, many actors feel that some de-gree of pressure has influenced policy.

NGO reactions and concernsMost NGOs had serious concerns about thePPA proposal put forth by the WB. As newsspread that PPAs were on the menu and wouldbe the only policy served for discussion, shockwaves were sent through the NGO community.PPAs represented a shift from traditional formsof humanitarian assistance to a more business-oriented approach geared towards privatisationwhich didn’t sit well with some. Indeed, NGOsfeared losing their traditional identity to be seenas merely ‘contractors’. While some fiercely op-posed the PPA approach, most NGOs weresomewhere in the middle, confused and unsureof what position or strategy to adopt. Despitepresentations on the PPA concept made duringthe second JDM many NGOs seemed to remainunclear on the specifics and implications ofsuch an approach. Some organisations made therounds in an effort to join forces and raise con-cerns, however they didn’t manage to rallyamongst themselves to present a common opin-ion. While papers and letters were written re-garding perceived flaws of the approach (for ex-ample see Ridde and Bonhour 2002; Daly 2003) theydidn’t have much success in raising any highprofile question marks pertaining to their con-cerns before decisions were taken.

Some organisations who had been receiv-ing funds from donors other than USAID, WBor the EC were slow in responding to the PPAs.Confident that their current support for healthactivities would continue they didn’t pay muchattention to the ensuing debate and remainedsomewhat indifferent. However, as funding forthe BPHS became available, donors who hadbeen supporting health projects on a smallerscale made plans to phase out of health and

into other sectors such as education. This tran-sition caught organisations off guard and trig-gered a rush to develop proposals for subse-quent rounds of funding.

While the majority of NGOs (and interna-tional organisations), albeit reluctantly, eventu-ally decided to participate in the biddingprocess, some opted out of the process from thebeginning as a result of clashes with organisa-tional principles and mandates. MSF, for exam-ple, while officially supporting the PPA initia-tive have chosen not to participate due to theirposition on neutrality and independence.Moreover, their emergency mandate preventsthem from engaging in development relatedactivities such as provision of a basic package.Also strictly upholding the core humanitarianprinciples, ICRC has chosen not to engage.Apart from these agencies however, on thewhole, relatively few have opted out of theprocess completely.

4.2.4 Developments in health coordinationIn April 2002 WHO was installed as lead in thehealth sector, with responsibility for policy andplanning and overall sector coordination.However in the same month a new approachintroducing ‘programme secretariats’ and ‘pro-gramme groups’ emerged, endorsed throughthe NDF. WHO was again announced as headof the Program Secretariat12 in June 2002 withthe responsibility for overall coordination inthe health and nutrition sector.

In order to improve the effectiveness andefficiency of aid coordination, the MOF an-nounced that sectoral coordination mecha-nisms called Consultative Groups were to beestablished for each of the 12 national pro-grams in the NDF. In line with this wider gov-ernment move the MOH created the Consulta-tive Group for Health and Nutrition (CGHN),

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13 The CGHN is not officially an NGO coordination mechanism. The few NGOs that do participate have been invited by the MOH anddo not necessarily represent the NGO community as a whole.

14 In order to improve input of technical expertise a Technical Advisory Group will be established. A group of permanent and floatingmembers will be appointed to advise on 4 main priorities in the health sector: (1) decrease in infant mortality rate, under five morbid-ity and mortality, malnutrition, and communicable diseases, (2) decrease in maternal mortality rate, (3) improve equitable distributionof quality health services, and (4) enhanced capacity of MOH to implement effective and efficient health services (MOH 2004b).

15 PHCC: Provincial Health Coordination Committee. The terms of reference for the PHCCs include: (i) Information sharing, (ii) coor-dinate regular reporting system for HMIS, (iii) draft annual provincial workplan, (iv) coordinate expansion of services, (v) identifysites for new health facilities, (vi) assign catchment areas, (vii) review and approve proposals (viii) participate in emergency responseand special activities, (viiii) mediate among stakeholders, and (x) coordinate with MoH and governor. Membership will include thePHD as chair, the provincial health deputy director, provincial HMIS focal person, and a representative from EPI management. Nomore than 7 other members may be chosen from: other relevant line ministries, NGOs providing services, 1 representative from theprivate sector and international agencies with an office in the province or region (MOH 2003a).

replacing the Program Secretariat which to datehad failed to function effectively. While theProgram Secretariat was criticised for havingtoo many expatriates involved and not enoughAfghan leadership, the MOF stressed thatAfghan ownership of the CG process would bekey for development and change. The CGHN isheld once a month and chaired by the MOH,with USAID and the EC serving as joint focalpoints. The meeting includes representativesfrom other ministries as well as the donor, UNand a few select NGOs13. A smaller version ofthe CGHN was also formed (WCGHN) whichserves as a venue to discuss technical and pol-icy issues. The meeting is chaired by theTechnical Deputy Minister and include mem-bers from select NGOs, donors, and the UN14.

In addition to the CGHN, six managementtask forces and twelve general taskforces havebeen created to allow for focused technical in-put on specific topics with the aim to providerecommendations or develop interventionstrategies. Membership of task forces includestechnical experts and donor, UN, NGO, andMOH representatives based on involvement inthe topic. There are also several workinggroups that are in operation such as the capac-ity building working group.

One of the main sources of problems in theCambodia pilot was that provincial health de-partments did not have a stake in the success ofthe intervention districts. To avoid this problem

in Afghanistan, coordination mechanisms havebeen established at the provincial level in theform of a Provincial Health CoordinationCommittee (PHCC)15. The PHCC has been cre-ated with the objective “…to coordinate the ac-tivities of all stakeholders in achieving MOHpriorities, particularly the expanded delivery ofthe basic package of health services (BPHS)”(MOH 2003c). However the role that the PHCCand the Provincial Health Office would play inthe different flavours of contracting adopted bydonors was suggested to be unclear amongstakeholders. For example, the function of thePHCC would be much different in a WBprovince with one provider compared to a US-AID province where there may be as many as 5 providers. Although this mechanism may gosome way towards building relationships be-tween provincial authorities and NGOs, somedonors have suggested that the lack of inclu-sion of provincial hospitals and ProvincialHealth Directors (PHD) into the BPHS has ledto a lack of buy-in to the process in someprovinces. Indeed the current lack of a decen-tralised system may create the potential forconflict given that many PHDs are politicalrather than technical appointees who are large-ly concerned with controlling resources.Whether this situation will improve over timeas PHDs become more familiar with policiesand the NGOs operating in their provinces willbe key to the success of BPHS projects.

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4.2.5 The influence of assessments and studies onthe policy process

Several studies took place during 2002 and2003 to establish a base of information whichcould inform planning and resource allocation.Those which have had a significant impact onthe health policy process specifically are de-scribed below.

UNICEF/CDC Maternal Mortality StudyAlthough it was widely recognised that the ma-ternal mortality ratio in Afghanistan was ex-tremely high, accurate figures were not avail-able. In Afghanistan’s first ever national studyon maternal mortality, a staggering MMR of1,600 per 100,000 live births (95% CI 1,100 –2,000) was revealed, one of the highest in theworld. Even more disturbing was the discoveryof an MMR gauged at 6,500 maternal deathsper 100,000 live births (95% CI 5,000 – 8,000) inBadakhshan province, the highest MMR everreported globally. While the MOH recognisedmaternal mortality was responsible for a highproportion of preventable deaths, these stag-gering figures ensured that conquering mater-nal mortality was included as a top priority inAfghanistan’s health strategy. One of the mainaims of the strategy is to reach the MillenniumDevelopment Goal for maternal mortalitywhich is a reduction by three quarters by 2015.

Afghanistan National Health ResourceAssessmentAt a provincial planning workshop in March2002 it became apparent that there was ex-tremely limited up to date information on thestatus of health resources available in the coun-try to address pressing health needs. In order tofacilitate rational planning and direct the equi-table allocation of resources the AfghanistanNational Health Resource Assessment was con-ducted by MSH and HANDS in April –September 2002 funded by USAID, EC,

UNFPA, and JICA. The objectives of the assess-ment were to (i) conduct an inventory of exist-ing resources and their distribution, (ii) estab-lish an up to date database of information to fa-cilitate rational planning, and (iii) establish thebasis for development of data sets for humanresources and health service infrastructure thatcould be routinely updated (MOH/MSH 2002).

Main findings showed that there was ex-treme inequity in the distribution of health fa-cilities, an acute shortage of services dealingwith pregnancy and delivery and a need to en-sure availability of community-based healthworkers due to poor accessibility health facili-ties, particularly in rural areas.

The ANHRA has played an important rolein the expansion of the BPHS. First, it under-scored the shortage of female health workersand the need to initiate training for midwivesas quickly as possible. Second, data collectedon the distribution of facilities was used to de-

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termine whether provinces were underservedand therefore a priority for the expansion of theBPHS. This assisted the MOH and donors togauge where resources should be directed as apriority. Particularly for donors such as USAID,who focus on districts as geographical unitsrather than whole provinces, the data allowedthem to determine which districts should becovered before others. The data collected in theANHRA was also used to facilitate health facil-ity planning during several provincial plan-ning workshops held with PHDs from acrossthe country in Kabul. The workshops repre-sented the first time that all provincial stake-holders were brought together in a systematicway and provided an effective means to dis-seminate information and policies developed atthe central level (MOH 2004). Some feel, how-ever, that distorted estimates of the quantity,quality and location of existing facilities haveled to inaccurate planning. For example, largediscrepancies have been reported between thenumber of ANHRA reported health facilitiesand those found in situational analyses con-ducted by NGOs (differences as large as 50%).

Although initial data analysis was flawed itwas corrected and a final version of the assess-ment was circulated in April 2003. While the as-sessment document admits that the informa-tion was not 100% accurate, it was stated that itrepresented the most comprehensive dataavailable for planning. Despite requests tomaintain the database, updating it with new in-formation as it became available, with the ex-ception of areas where USAID is working, thishas not been done due the perceived inaccura-cy of the data. So, while the ANHRA has serveda purpose, its usefulness has waned.

Costing of the BPHSConducted in March 2003, this study has theaim to cost the recently developed BPHS in or-der to be “used by MOH and donors for grants and

contracts with NGOs to extend health service to therelevant areas and provide a benchmark for opera-tion of government health services” (MSH 2003).To determine the costing, data was collectedfrom 6 NGOs over a total of 10 facilities at BasicHealth Centre or Comprehensive HealthCentre level, which were sampled from across9 provinces. Hospital costs were based on oneestimate of a 50 bed hospital.

Results showed that the BPHS could beprovided for a total of $4.55 per capita per year.Since the costing, the figure of $4.55 has beenused substantially, cited in several documentsand used by most donors as a benchmark indetermining appropriate financial require-ments for grants/contracts. It has been particu-larly useful in that all donors, and NGOs in thepreparation of proposals, have been workingoff the same figure. However, considering theinformation constraints in conducting this ex-ercise it would seem that $4.55 can only be avery vague indication of what costs might be,which is clearly acknowledged by the authorsthemselves: “the data required for this study didnot exist…the quality of data that did exist wasquestionable” (Ibid). Other weaknesses in thestudy are the small sample size, the data usedwas based on 2001 and 2002 when a lot ofchanges were occurring and lack of clarity onhow to do economic costing of CHWs andTBAs. Despite these weaknesses and the time-frame over which the study was conducted, thestudy is a valiant attempt to produce an initialbenchmark for planning.

While some argue that $4.55 is too low toinclude quality services up to the district hos-pital level and despite the weaknesses in thestudy, initial analysis of winning proposalsshow that per capita costs are hovering aroundthis figure (see section 3.3). It will be importanthowever, to examine whether NGOs have cutcorners in an attempt to be competitive andwithin reason of the $4.55 benchmark. This is

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16 Construction was only included in grants awarded in the first round and has been removed from subsequent rounds of funding

particularly true for rural provinces where thelogistics of access alone constitute significantcosts. The trade off between lower costs andquality of care is also another issue whichshould remain on the radar of policy-makers.

4.2.6 Infrastructure developmentProviding the bulk of funds for reconstructionof health facilities, the USAID REFS programofficially started in September 2003. The plan-ning process and site assessment however,started at the beginning of 2003. At a provincialplanning workshop held in early 2003 one ofthe priorities was to establish priority areas forfacility construction. Given that there was nofunding envelope attached to this planningprocess, what emerged was a construction‘wish list’ with gross overestimations of healthfacility requests. Nonetheless, this process wasused to assist in identifying priority sites forconstruction of health facilities, based on theavailability of funding from USAID. The LouisBerger Group (LBG), a U.S-based constructionfirm, was contracted by USAID to manage thereconstruction process. Over 300 health facili-ties were planned for construction bySeptember 2004.

While the REFS program was established atapproximately the same time as the WB andUSAIDs first tenders for delivery of the BPHSwere issued, the EC announced their firstround of funding in late 2002 with awardsgranted in mid 2003. With the REFS programnot yet foreseen there was much more empha-sis on infrastructure development within thefirst tender round16. In contrast, constructionunder USAID REACH and the WB PPAs wasan unallowable cost. This is one difference thatexists between the project activities conductedunder each of the three major donors.

4.3 Expanding Coverage of the BPHS (April – December 2003)

Debate, discussion and negotiation overapproaches to implementation hadtaken place over a period of 10 months

by this point in time. Given that the tenderingprocess was supposed to begin by June, specif-ically for the MOH/WB PPAs, consensus hadto be reached and decisions taken. Althoughthe MOH was more favourable of a cluster ap-proach and continually expressed concern overthe scale of the PPAs, they formally agreed toNGO provision throughout the country and amix of the cluster and province-wide approach-es in May 2003.

The concept of a lead donor in eachprovince evolved from this process wherebyspecific donors would be responsible for specif-ic provinces, creating fewer coordination prob-lems with having multiple donors in one area.In line with this idea the country was split upand provinces assigned to each donor (see Map1). While the EC and USAID finally agreed toprovince-wide and cluster-wide projects, theiragreement was conditional on being able to se-lect the provinces in which their projects wouldbe implemented. Essentially the EC and USAIDchose the provinces they wanted and the WBwas left with the rest of the country.

A third JDM was held from April 21–23chaired by the MOH. A two day workshop washeld in Kabul with a variety of stakeholdersfrom the UN, NGOs, donor agencies, and dif-ferent levels of the MOH. Numerous issueswere presented and discussed amongst smallworking groups including implementation ofthe BPHS at the provincial level, integration ofvertical programs, and piloting of health fi-nancing mechanisms. The MOH also presented

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17 Due to some coordination problems in Badghis province both KfW and the WB have NGOs under contract providing the BPHS.However the province has been split into 2 clusters with each NGO covering half of the province.

developments in the new interim health stra-tegy including the restructuring of the MOH,capacity building, strengthening of provincialhealth departments, human resource develop-ment strategies, and future directions for healthsector reform (e.g. civil service reform, healthfinancing options, health facility construction).

4.3.1 ProcurementThe WB issued requests for Expressions ofInterest in April 2003 and NGOs were given amonth to respond. A Request for Proposal wasthen issued to shortlisted NGOs between Mayand August 2003 who had 45 days to submittechnical and financial proposals. USAID issueda Request for Applications on June 10th, 2003

with a closing date of July 24th, 2003. The EC’sfirst Call for Proposals (CFP) came in December2002, before the finalisation of the BPHS. Theirsecond CFP was issued on May 15th, 2003 withthe same closing date as USAID. The biddingprocess went smoothly, although there wassome indecisiveness caused by high costs forprovinces that were initially tendered out asclusters under the WB PPA model (see box 4).High overhead costs with more than one NGOin a province caused the MOH to rethink theirstrategy and it was decided to eliminate thecluster approach and expand all contracts toprovince-wide coverage under one NGO17.

The competitive bidding process has been anew experience for many NGOs. As one con-

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Expanding Coverage of the BPHS (April – September 2003)

Map 1: BPHS funding status by donor as of July 2004

Herat

Farah

Nimroz

HilmandKandahar

Badghis

Ghor

Uruzgan

Zabul Paktika

Faryab

JawzjanBalkh

SamanganBaghlan

Kunduz

Bamyan

WardakLogar

Ghost

Kapisa

Kabul

Takhar Badakhshan

Paktya

Nangarhar

NuristanKunarParwan

Laghman

Sari Pul

Ghazni

IDA/WB/MOH

MOH-SM

USAID

EC

Source: MOH presentation 2004*The ADB funds the BPHS in 4 district in Ghor and 5 districts in Badakhshan, KfW funds half of Badghis province, andUSAID funds 1 district in Ghor.

sultant states the process differs in that “…be-fore, NGOs submitted a proposal and thenstarted talking, now they have to get it right thefirst time around or they get eliminated”. Thischange in procedures coupled with the speedin which the tendering process was initiatedput pressure on NGOs to produce proposalsfor entire provinces within 1–2 months time.Furthermore, it put pressure on them to designstrategies for implementing an entire districthealth system, including management of hos-

pitals which many had little to no experiencedoing. Some organisations thought ahead andbrought in experienced consultants to writeproposals three months in advance. Others,who were either unsure of whether they wouldbid or simply didn’t have the resources to hireexpensive consultants, had to struggle throughwith the capacity they had in country.According to one evaluator of the bids “Themarket was favourable for NGOs so nobody really lost out, but the proposals fundedweren’t great”. Indeed, it is evident that someNGOs have not fully understood the idea of theMOHs new role as a policy-maker versus serv-ice provider. Describing a strategy to servicedelivery, one proposal submitted for northernAfghanistan explained that “this is seen a gapfiller until the MOH can take over fully”.

Although many NGO’s initial response tothe PPAs was negative there are few thathaven’t participated in the bidding, primarilydue to two main reasons. While still not neces-sarily agreeing with the PPA approach, manyfeel it will be impossible to change things orhave an impact on policy if they opt out of theprocess. They feel that being involved in imple-mentation will enable them to remain engaged,and allow them to raise flags and concernsfrom the field which might not otherwise beheard. The second reason arises out of the sim-ple need to stay afloat. Given that all fundingfor primary health care is being channelledthrough WB/MOH, USAID and the EC healthNGOs with little access to private sources offunding have little choice in the matter.However, in general, this all or nothing ap-proach has excluded few organisations and hasserved to establish coordinated service deliverywithin a clearly defined national policy frame-work.

An interesting point to note is that despitethe marked differences in donor approaches,many NGOs are viewing all 3 as one and the

34


In the final agreement over the geographical unit

that each WB PPA would cover the MOH decided to

opt for a mix of the cluster and province-wide ap-

proaches; 4 provinces would be province-wide and

3 would be based on the cluster approach. However,

after receiving bids for 2 of the cluster provinces the

MOH felt that the overhead costs involved with hav-

ing more than one NGO in a province were too high

and not an efficient use of resources. NGOs were

asked to bid again, but this time for the entire

province. After receiving bids for the second time,

the MOH decided they should have some experience

with implementation and wanted to experiment

with other contracting models, so they designated

the provinces as those that would fall under the

MOH-SM. USAID and the EC have gone on to estab-

lish several cluster grants in their responsible areas.

Per capita costs in the clusters range from $1.75 - $48

USD* whereas in provinces they range from $2.95 –

$6.25 USD. An important issue to examine in upcom-

ing performance assessments will be whether lower

cost has an impact on the quality of services, and

whether NGO capacity is sufficient to provide the

BPHS at a provincial level. Moreover, the different

mix of costs in NGO budgets (e.g. construction, ca-

pacity building, etc.) should also be considered.

*It should be noted that drugs are provided in kind

Box 4: Higher costs with the cluster approach?

18 A bonus of 1% of the contract value will be paid every six months in the case of exceptional performance, defined as a 10 percentagepoint or more improvement from the previous highest score on a health facility assessment carried out by a third party using a stan-dard quantitative checklist. 5% of the contract value will be paid at the end of the contract based on exceptional performance, definedas 50 percentage point increase in the combined score on the indicators listed in the terms of reference as measured by household andhealth facility surveys (WB 1997).

same. NGOs contemplating their role in thisnew initiative feel that if they reject the WB orUSAID model, it would be hypocritical to ac-cept an EC grant as all donors are working to-wards the same objective, which these NGOsconsider to be privatisation.

4.3.2 Implementation mechanismsDespite the plea for a unified approach in theimplementation of the PPA mechanisms, thethree major donors have each adopted some-what divergent modifications on the WorldBank’s ‘Proposed Common Approach to PPAs’outlined in the aide memoire from the secondJDM. The main features of each of the maindonors are described below. For a broader pic-ture of similarities and differences see annex 1.

World Bank: The perceived success of the con-tracting-out model in the Cambodia pilot is re-flected heavily in the World Bank’s design forAfghanistan. The competitive tendering pro-cess involves 3 main steps: (i) issuance of a re-quest for expression of interests (EOI) fromprospective bidders (both for-profit and not-for-profit agencies), (ii) request for proposalsfrom 3–6 shortlisted bidders and, (iii) bid eval-uation involving a two envelope system wherea technical and financial proposal are submit-ted separately. Much the same as Cambodia,the contracts are performance-based with fi-nancial bonuses of up to 10% for meeting andexceeding predetermined targets18. Contractsare based on lump sum remuneration whichgives considerable flexibility to NGOs to adjustthe budget as necessary to accommodatechanging situations during implementation.Moreover the lump sum contracts represent a

much lighter burden in terms of managementas NGOs are free to provide services as they seefit and spend funds according to how they feelwill best benefit the project, without having toget approval for changes.

One of the major differences in the WB ap-proach is that funding is channelled through theMOF, albeit under tight controls, and it is theMOH that establishes contracts with NGOs.The GCMU is the focal point for all negotiationsand contract management, including the ten-dering, evaluation and implementation process.In contrast USAID and EC establish agreementsdirectly with NGOs and channel funds throughthem rather than the government.

USAID: Successful experiences with their im-plementing partner, MSH, in the performance-based payment pilot in Haiti led USAID toadopt a similar approach in Afghanistan. TheREACH program brings in elements of per-formance-based payment based on submissionof deliverables on a monthly basis, but uses agrant as opposed to a contract and does not of-fer financial incentives for good performance.Payment mechanisms are based on cost-reim-bursement which is another significant differ-ence from the WB approach. Moreover, the geo-graphical area covered by REACH program isclusters of districts and in some cases single dis-tricts. As a result some provinces have up to 4 NGOs delivering the BPHS in different clus-ters of districts. Moreover, although the processwas competitive it differed from the WB processin that competition was not over a pre-definedgeographical area; instead NGOs could deter-mine the geographical units they wanted to bidon e.g. one district, a cluster of districts, etc.

35

Expanding Coverage of the BPHS (April – September 2003)

19 Infrastructure is a large component of many of the EC’s initial grants (awarded in early 2003) as USAID’s REFS program had not yetmaterialised.

Unlike the WB, performance indicators areproposed by the applicant and negotiated uponaward based on capacity to implement theBPHS. Preference is given to national NGOs orinternational NGOs partnering with nationalagencies. Although a similar evaluation processis carried out as in the WB model with scoresallocated for both technical and financial as-pects of the proposal, the scores are only usedas a tool and NGOs with the highest score donot necessarily win the grants. In order to en-sure decisions were as informed as possible,discussions were held amongst evaluation pan-el members after the scoring process. Panelmembers included representatives from US-AID, MSH technical staff and the MOH (bothcentral and provincial authorities). Taking intoaccount information from the scoring processand discussions, a vote was then taken to deter-mine the winning bid.

The scope of services is also different asREACH does not require NGOs to support dis-trict hospitals, which are included in the BPHS.Instead, it is stated that “One of the main pur-poses of the grants program is to help in devel-oping an integrated, comprehensive communi-ty-based delivery system that at a minimum in-cludes Health Posts, Basic Health Centers andComprehensive Health Centers in the initialphase” (USAID/MOH 2003). Considerable ef-fort is invested in capacity building activitiesfor all NGO partners, however a specific em-phasis is placed on national NGOs in order toimprove their ability to prepare and managegrants according to international standards andregulations.

It is interesting to note that the REACHprogram has evolved to include more elementsof the PPA model than the previous AHSEP,where proposals were submitted rather than

solicited through a competitive process andgrants were only commissioned for 6–8 monthsduration (USAID/MSH 2002). Funding howev-er, remains channelled through USAIDs imple-menting partner MSH rather than through theMOF which represents another significant dif-ference to the WB strategy.

EC: A more phased approach has been adoptedin order to “pave the way to new contractualforms between the Ministry of Health and theNGOs for the delivery of the BPHS(Performance-based Partnership-like Agreements)”(EC 2002 italics added). In this sense the currentEC grants are not performance-based. One ofthe expected outcomes of the project is to beginto define measurable performance-based indi-cators for delivery of the BPHS. In the initialgrants, NGOs have submitted logical frame-works and defined their own indicators. Insubsequent projects it is envisioned that nation-al indicators will be adhered to. In line with thisphased approach some EC projects are only 21months in duration in comparison to 36 underthe WB contracts and construction of health fa-cilities is a focal activity19.

While the WB and USAID remain at oppo-site sides of the spectrum in terms of the geo-graphical unit of coverage, the EC has opted fora more considered approach adopting a mix ofboth the province-wide and cluster-wide proj-ects. Although the EC has a much more relaxedapproach to monitoring and evaluation thanthe WB or USAID, their projects will be includ-ed in the JHU/IIHMR nationwide assessments.Results from these assessments will constitutethe only monitoring data that the EC will re-ceive apart from midterm and annual activityreports and spontaneous monitoring visits.

36


20 An international advisor was first seconded through UNICEF. Since then, one international advisor has been recruited using WBmonies and a second has been placed in the GCMU through the EC. The EC advisor is located in the GCMU for strategic reasons withsupport to the GCMU being part of a wider working framework.

4.4 A Brief Overview of the Current State of Affairs

4.4.1 Delivery of the BPHS: Contracts and GrantsThe GCMU has functioned very effectively sinceits establishment in March 2003. Comprised of 2international advisors20, 5 local consultants and8 local consultants working both in the GCMUand other parts of the MOH, they have dis-cussed and finalised bidding documents with alldonors and carried out complex procurementprocedures including the tendering, evaluationand negotiation of numerous contracts in a verytransparent manner. The GCMU initially con-sisted of only 4 national consultants, however itwas agreed that more staff were required in or-der to strengthen other MOH departments thatweren’t progressing as quickly as the GCMUsuch as monitoring and evaluation and healthcare financing, which were deemed important inthe successful functioning of the contractingprocess and the final outcomes. Although thiswas a valiant attempt to build capacity amongstthose staff that weren’t as experienced as the na-tional consultants, MOH representatives admitthat policy development and procedures sur-rounding contracting happened so quickly thatthere wasn’t time to include these departmentsin the process.

The function of the GCMU has not beenconfined to dealing with contracts and the unithas become very involved in other sector poli-cy initiatives. Dubbed ‘the ministry within theministry’ the GCMU has been a driving forcebehind many policy initiatives, such as the PRRprocess. Relationships between the GCMU(both national and international staff) and oth-er components of the ministry have been re-markably horizontal with trust established

through previous work ties. These strong rela-tionships have facilitated the GCMUs involve-ment in policy related issues. Although the na-tional MOH consultants are funded throughWB monies, who some argue handle thingsfrom a WB perspective, the GCMU has servedas an effective way to bring service deliverycloser to the government. Indeed, with a na-tional consultant heading the GCMU it isAfghan staff that are dealing with day to dayissues and have been actively involved in thecontracting process. Moreover, GCMU mem-bers stress that they represent the MOH anddeal with all donors from this perspective.

37

A Brief Overview of the Current State of Affairs

The roll out of the BPHS is well underwaythroughout the country with 43 contracts oper-ating in 33 out of 34 provinces (see table 3).

The rapid expansion of the BPHS has re-sulted in 59% coverage of the BPHS country-wide. An attempt will be made in autumn of2004 to fill some of these gaps through a thirdround of funding from both USAID (approxi-mately 10M USD) and the EC (13M Euros).Both will fill the gaps in their cluster-wide provinces, and the EC has includedNuristan which remains the only uncoveredprovince in the country and Ghor province,which currently has funding from USAID andthe ADB.

Per capita costs vary amongst the differentdonor approaches. This is due to a number offactors including the mix of costs included inbudgets. For example, construction costs have

been included in the EC and ADB projects butnot in USAID and WB projects. In addition thecost of medicine has not been included in US-AID per capita costs as they are provided inkind. At any rate per capita costs through US-AID REACH will not actually be known untilthe end of the grant period as project budgetsare revised every 6 months and any unspentfunds can be taken back and used for subse-quent rounds of funding. The MOH-SM percapita costs are higher than the otherMOH/WB projects as they will provide someservices, but will employ a mix of contracting-out and contracting-in for certain parts of theproject such as CHW and midwifery training,based on the Cambodia experience. Finally, US-AID, ADB, and some EC per capita costs reflecta cluster-wide approach, in which economies ofscale cannot be exploited.

38


Donor Total no. Total no. No. Total funds Total pop’n Average pop’n Total pop’n Duration of Per capitaprovinces districts contracts/ awarded ($) served coverage in covered by contract/ costs ($)

grants responsible contracts/ grant (months)awarded areas (%) grants (%)*

USAIDRound 1(06/03) 9 60 16 37,410,957 2,927,700 33 14 30 5.11Round 2(11/03) 5 33 9 15,472,800 1,870,757 40 9 26 3.82SUB-TOTAL 14 93 25 grants 52,883,757 4,798,457 40 23 28 4.72

(19 NGOs)

ID/WBRound 1(05/03) 8 73 8 37,017,073 3,585,000 100 17 33 3.78

1 contract withMOH under

3 17 MOH-SM 10,635,941 1,104,300 100 5 24 4.829 grants

(7 NGOs andSUB-TOTAL 11 90 MOH) 47,653,014 4,689,300 100 22 28 4.30

ECRound 1(12/02) 4 27 4 11,552,359 1,718,300 100 8 21 3.84Round 2(05/03) 4 22 3 10,116,163 913,300 43 4 30 4.43SUB-TOTAL 8 49 7 grants 21,668,522 2,631,600 68 13 26 3.87

(7 NGOs)

ADBRound 1(04/04) 3** 11 3 2,868,006 294,500 24 1 12 4.83SUB-TOTAL 3 11 3 grants 2,868,006 294,500 24 1 12 4.83

(3 NGOs)

TOTAL 33 243 44 (30 NGOs) 125,073,299 12,413,857 58 59 27 4.55

* The total population was extracted from the MOH’s ‘BPHS Project Update Information by Districts’ spreadsheet as of March 22, 2004

** These provinces are also funded by USAID

Table 3: Contract/Grant Summary for Expansion of the BPHS as of July 2004

21 These calculations include funds disbursed through the ECs third round of funding.

Another issue that the MOH is raising is thecosts of contracting incurred through the differ-ent donor approaches. While the GCMU claimsto cost only $1.5 million over three years tomanage 11 contracts worth $47,653,014, over-head costs for the REACH program may be ashigh as $23 million to manage 25 contractsworth $58,419,407. However, it should be not-ed that the costs of the REACH program in-clude several individuals providing muchneeded TA to the ministry. Moreover, it hasbeen suggested that although the USAID ap-proach to contracting is more costly due tomanagement intensive cost reimbursementprocedures and monitoring, these mechanismsmay be what the MOH need to adopt in the fu-ture to keep a closer eye how NGOs are spend-ing funds and the details of implementation.

The profile of the NGOs contracted to deliv-er the BPHS varies significantly across the 3 donors. While the formation of consortiumsbetween national and international organisa-tions was emphasised in all three donor tenderdocuments, only 4 of the current contracts/grants are operating under this means (2 underEC and 1 each under USAID and WB). Thisseems to be as a result of the constraints in-volved in forming a consortium over the shorttime period between the issuance of a call forbids and the deadline for submission of a pro-posal, and due to the implications of partneringwith agencies under a performance-based mod-el where the lead NGO will assume a financialrisk.

Looking at the involvement of nationalNGOs in the delivery of the BPHS, 48% ofREACH grants have been awarded to AfghanNGOs, 43% under the WB, and 29% under theEC (as part of a consortium with internationalagencies). Only REACH however, is working

with new national NGOs on a large scale, with67% of the total number of Afghan NGOsawarded grants being new. For the most partthe EC and WB agreements have been estab-lished with 3 of the most well known and reputable national NGOs in health, with the ex-ception of one consortium including a new na-tional NGO under the WB scheme. In total, national NGOs have been awarded 43% ofavailable donor funds. In addition 2 of the morewell established national NGOs have beenawarded a total of $37.5 million, representingalmost 30% of total funds awarded to date21.

The MOH-SM was formally agreed upon inDecember 2003 and the GCMU has been work-ing full time on submitting proposals for ap-proval by the WB. Several site visits have beenconducted over the last 3 – 4 months in order todiscuss the project with provincial health direc-tors and identify sites for health facilities.Currently, all sites have been identified, all pro-posals have recently been approved and mostkey staff positions have been recruited.

The ADB established a full time presence inthe MOH in October 2003 with the establish-ment of a Project Implementation Unit (PIU) inthe MOH. The PIU has a similar function of theGCMU to manage the tendering, evaluation,award and monitoring of the contracts.Although the majority of their assistance is con-centrated in the agriculture and transportationsectors, they are programming $3 million USDfor expansion of the BPHS for 4 districts inBadahkshan and Ghor provinces. A RFP was is-sued in April 2004 and proposals were award-ed in August 2004.

The MOH is taking the performance ofNGOs seriously and have been proactive inconducting site monitoring visits in all 8 PPAprovinces. Warning letters have already been

39


22 All branches of MSF withdrew from Afghanistan after the incident in Badghis province. This was in part due to the perceived lack ofaction taken by the government to address the crime. It is believed that those responsible for the killings are publicly known and walk-ing free in the communities of Badghis.

issued to two NGO who have failed to fill keypositions in the field, ensure adequate supplyof drugs and initiate CHW training programsamong other things. The MOH intends to con-duct monitoring visits each quarter to keep aclose eye on progression, in addition to month-ly meetings with PPA NGOs. Monthly meet-ings have taken place for all PPA NGOs sinceJune in order to allow discussion of problemsencountered during implementation thus far.USAID/REACH also recently conducted asimilar review forum. The four most commonproblems for NGOs operating under REACHincluded cost recovery, clarity on the role ofCHWs and the health posts, EPI, and BPHSstaffing patterns.

The MOH is currently strategising to deter-mine the best way to finance further expansionof the BPHS to achieve 100% coverage. TheMOH will use leftover project resources fromthe AHEAD program and, if necessary, tap intoa programmatic structural adjustment credit of$20 million USD provided by the WB. Howeverthe gap is filled, it is evident that the MOH isfully committed to ensuring the BPHS reachesas many as possible in line with the priorities ofthe interim health strategy.

Monitoring and evaluation will be conduct-ed by Johns Hopkins University (JHU) and theIndian Institute of Health ManagementResearch (IIHMR) who have been contracted tofunction as an independent third party evalu-ator. Annual health facility assessments will beconducted in addition to semi-annual rapidsurveys in areas where province-wide contractsexist. The first annual survey got underway inJuly and results are scheduled to be ready byearly 2005. Part of the third party’s terms of ref-erence includes building the capacity of the

MOH to conduct similar monitoring activitiesin the future.

4.4.2 SecurityIncreasing insecurity in many parts of thecountry and upcoming presidential electionshave added to the challenges NGOs are facingin implementation of the BPHS. Previouslyconfined to the south-eastern parts of the coun-try, security has also become problematic in for-merly stable areas in the west. The death of 5MSF workers in Badghis province in June 2004has placed a new emphasis on the safety of re-lief workers in these areas. Other NGOs work-ing in this area have considered withdrawingtheir services due to continuing insecurity andhave requested the MOH to take action to re-duce their risks. Gaps in coverage with the de-parture of MSF22 has already placed stress onthe MOH to find funds. With 45% of the coun-try still uncovered, the MOH cannot afford thedeparture of more NGOs.

4.4.3 Policy developmentsPriority Reform and RestructuringThe Bonn agreement provided for the estab-lishment of the Independent AdministrationReform and Civil Service Commission (IARCSC), which was created in July 2003.Through the IARCSC, ministries can apply forPriority Reform and Restructuring (PRR) statuswhich allows for performance-based salarysupplementation for key MOH, based on re-cruitment of staff with relevant qualifications.As the MOH felt that a key threat to effectivepublic sector services was poor morale and mo-tivation caused by low staff salaries (Simmonds2003), the decision was made to apply for PRRstatus. Proposals for the PRR of Provincial

40


Health Departments and the Policy and Plan-ning General Directorate were submitted to theIARCSC and approved by the cabinet in late2003 and early 2004. There are plans for two additional General Directorates in the central Ministry under similar reforms this year (MOH2004).

Although the proposals have been ap-proved there has been significant delay in im-plementation due to high workloads at theIARCSC. In order to assist in the implementa-tion of the PRR process for the MOH, DFID an-nounced a tender for TA that would assist ingetting the process up and running. However,after the MOH had begun the recruitmentprocess of national consultants DFID suddenlywithdrew their support with the funding redi-rected to narcotics programs. As the PRRprocess had already started this placed theMOH in a difficult position. Fortunately the

WB agreed to provide 8 months worth ofsalaries for staff which has filled the void tem-porarily. The WBs assistance has been timely asthe MOH-SM provinces need to recruit staff assoon as possible. Several discussions have tak-en place with the IARCSC to try and fast trackthe process in these provinces. The MOH hasalready announced the positions for the MOH-SM, so recruitment will have to be pushedthrough by the IARCSC relatively soon.

While the PRR salary scales were approvedby the MOF the capital and running costs werenot approved and the MOH was told that thesecosts should be included in the recurrent budg-et of the ministry. However funds allocated tothe recurrent budget were already accountedfor at this point in time which has left the MOHwithout the funds to provide PHOs with thetools they need to fulfil their job descriptions,e.g. computers, buildings for offices, vehicles,

41


etc. This lack of equipment and running costsmay dampen any effects that more attractivesalaries have on motivation and morale.

Capacity building It is increasingly recognized that injecting mon-ey, for example through budget support, willbe insufficient to improve health systems with-out considerable support to other factors suchas human resources and management andservice delivery capacity (Mills 2002). As such,there has been considerable effort invested indeveloping a capacity building plan for thecentral and provincial MOH. In January 2004the MOH Public Administration CapacityBuilding Working Group (PACBWG) wasformed in order to develop a capacity buildingplan for the central and provincial MOH.Drafts of the plan were circulated in April–May2004. Although the PACBWG was comprisedof all major stakeholders it has been suggestedthat donor coordination has been poorest inthis area.

OPM, funded by the ADB, is also providingtechnical assistance in two main areas; generalpublic administration and management includ-ing personnel and financial management andprocurement and strengthening of the depart-ment of construction in terms of organization-

al arrangements, development of constructionstandards and a plan for upgrading health facilities (OPM 2003).

One component of the capacity buildingplan for the public health administration corestaff that has already started is a technicalroundtable discussion group which aims toprovide an opportunity for discussion of rele-vant technical information about health sys-tems and to keep the MOH up to date of healthsystem developments from around the worldand the literature. The roundtable will be facil-itated by various technical experts visitingAfghanistan on a different topic every twoweeks. Discussion leaders circulate an articlerelevant to their topic one week before theroundtable and facilitate discussion of the con-tents, raising key questions about findings andhow they relate to Afghanistan (MOH 2004a).This initiative represents an innovative way totake advantage of expertise coming in and outof the country and to expose MOH core staff toimportant health systems issues.

In addition to training capacity has alsobeen bought in through national consultants,staff seconded from international agencies suchas WHO and UNICEF and the placement ofpermanent international TA in various depart-ments of the ministry.

42


5 Concluding Remarksand Issues for Further Research

Policy in Afghanistan’s health sector was developed relatively quickly andwith few blockages between 2001 – 2003.

While there is scepticism surrounding theamount of choice the government had in selec-tion of policy options, they have been firmly es-tablished in the driver’s seat since mid to late2002. The MOHs main priority continues to beexpansion of the BPHS through subcontractingNGOs and resources are consistently being al-located to achieve their objective of 100% cov-erage; it is a lack of funds rather than strong po-litical commitment by the MOH that is frustrat-ing attempts to reach this goal.

Although there was no consensus reachedwithin the donor community on the best wayto provide the BPHS, there was agreement onthe overall principles of reform, namely the de-livery of a BPHS through contracts/grants withNGOs with the MOH refraining from servicedelivery in favour of a stewardship role.Whether the MOH views these reforms as along term strategy will only be revealed withtime. If the MOH’s enthusiasm regarding theMOH-SM is any indication however, a morebalanced approach of public provision and amix of contracting-in and contracting-out NSPsmay be on future policy agendas.

While policy development in Afghanistanoccurred with few obstacles, the published lit-erature on the achievement of the theoreticaladvantages of a basic package approach andcontracting is very limited (for example seeTarimo 1997, Ensor et al 2002, Palmer 2000). Giventhis lack of evidence and the international dif-fusion of health sector reform ideas regardless,there are many important questions to answer.The progression of Afghanistan’s health sectorreform presents an opportunity to documentthe development of health policy in a post-con-flict environment and the emergence of a novel method of service delivery. Moreover, anopportunity arises in which private provision

can be compared to that of public provisionthrough the MOH-SM, which is a source of on-going debate in the contracting literature (forexample see Brugha and Zwi 2000 and Mills 1997).The following questions can help to add to theevidence base:

What is the potential of the PPA mechanismto support and enhance health policy formulation and coordination of healthcaredelivery in post-conflict settings?Although not technically a coordination mech-anism PPAs can be seen as an innovative wayto facilitate development of a coherent nation-al framework with which to guide investmentand reconstruction efforts (Bornemisza andSondorp 2002). For example PPAs necessitatepolicy formulation regarding definition of serv-ices and targeted regions of operation, whichcan stimulate dialogue and the establishmentof priorities for the health sector. Do PPAs represent an effective mechanism with whichto coordinate the multitude of actors and inter-ests in post-conflict settings? In low-income set-tings? Can health policy formulation be en-hanced as a result?

What are the implications of a BPHS approach in Afghanistan?Given that many other countries have attempt-ed to provide a BPHS and failed due to re-source constraints, and given emerging signs ofdonor fatigue in Afghanistan, will a BPHS ap-proach be sustainable? Can an essential pack-age of services be provided of adequate qualityfor $4.55 per capita per year? What impact willAfghanistan’s BPHS have on health outcomes?

Is it possible to deliver a basic package of health services through contracts with private providers?The approaches taken by donors to implementthe basic package of health services in

44

Concluding Remarks and Issues for Further Research

Afghanistan are varied. The PPA mechanismused by the MOH/WB is much more flexiblethan the other approaches, particularly interms of budget flexibility. The geographicalarea of coverage is also different with theMOH/WB funding single NGOs to provide theentire BPHS in one province versus USAIDwho funds multiple NGOs. What is the mosteffective and efficient approach to contractservice delivery? Does one method have ad-vantages over the others? Is quality being sac-rificed to achieve efficiency gains (i.e. by fund-ing province-wide vs. cluster-wide projects)?Can delivery of a BPHS through contracts withprivate providers be accomplished in a cost-ef-fective and transparent way? What factors mayimpact on the delivery of a BPHS through con-tracts with private providers?

How do key stakeholders respond and reactto PPAs and other donor approaches?PPAs represent a new funding mechanismwhich have significant differences from moretraditional forms of funding through introduc-tion of concepts such as competition and per-formance-based payment. These differencesmay necessitate changes in all key stakeholdersincluding donors, NGOs, multilateral agencies,and the MOH. What changes are required to fa-cilitate the successful implementation of thisapproach and are stakeholders willing to adjusttheir mandates and/or institutional arrange-ments? Do performance-based approaches in-fluence the way in which providers deliverservices? If so, in what ways?

How can government capacity to contract (at various levels) be established in a postconflict setting?It has been documented elsewhere that con-tracting requires government to learn an arrayof new skills compared to those required forpublic provision. Post-conflict environments

are typically fast moving and characterised bya large number of international actors. Is it fea-sible to build this kind of capacity in a post-conflict setting which is typically fast movingand characterised by large numbers of interna-tional actors, which demand a large amount ofthe government’s time and effort? Will govern-ment have enough time to learn these newskills in this type of setting? What is the mosteffective way to cultivate these skills?

Should NSPs be favoured for service provision above government?Mills (1998) points out that it is not clear thatthe private sector is more efficient provider ofservices than the public sector and contractingmay potentially represent a higher cost to thegovernment than direct provision (Mills 1997).It has also been noted that the same determina-tion is required to increase capacity to contractas is required to reverse public sector inefficien-cies, for which contracting has been prescribedto eliminate (Ibid). Based on these premises, re-searchers claim that government provisionshould not be ruled out (Mills 1998). However,supporters of health sector reform state thatpublic choice and property rights theory createinherent management deficiencies in the pub-lic sector (Mills 1997; Mills and Broomberg 1998;Palmer 2000; Walsh 1995). Indeed, findings fromthe Cambodia pilot showed that contractingout service delivery to private providers per-formed better than government and marginal-ly better than a contracting-in model (Bhushanet al 2001). However, an inconsistent evidencebase requires more research on the merits anddisadvantages of contracting health serviceswith NSPs. Should government be bypassedfor service delivery in post-conflict and low-in-come settings in favour of private providers?Do NGOs have more capacity to deliver servic-es than government?

45

Concluding Remarks and Issues for Further Research

References

Bhushan I, Keller S and Schwartz B. 2001. Evaluation Report:Contracting Health Services Pilot Project. Technical Assistance Report:Asian Development Bank.

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References

23 Information is current as of August 200424 In the most recent Request for Proposals NGOs must first pass an initial screening before they are eligible to submit a proposal. This

mechanism has been put in place to eliminate the submission of proposals from NGOs who are ineligible

Characteristics IDA/World Bank USAID/MSH EC

Annex 1: Similarities and Differences in Donor Procurement23

Afghanistan (AHEAD)

Funding flows from theMoF/MoH to NGOsNGOsFixed lump sum remunerationwith 100% budget flexibility

Performance-based contract:NGO performance judgedagainst progress and achieve-ment of measurable indicators.Failure to progress or achievetargets will result in terminationof contract.

Services are contracted out bythe MOH (i) Request for EOIs issued(ii) NGOs who submit an EOIare shortlisted(iii) RFP issued to shortlistedNGOsProposals submitted29 – 36 months$1,469,090 – $8,384,143 USD

16% at signing and 14% every 6 months based on submissionof quarterly reports and assess-ment of performance indicatorsthrough supervisory visits andthird party assessments

(i) 1% of contract value every 6 mths if an increase of 10 per-centage points or more from thehighest score in health surveysconducted by 3rd party.(ii) 5% of contract value at theend of the contract if an increaseof 50 percentage points in thecombined score of indicators Quality Cost Based Selection:Proposals are evaluated accord-ing to technical and financialcriteria. Those proposals with<60 points on the technical

Project name

Purchaser

ProviderType

Tender process

DurationSize of current contracts/ grantsPayment

Bonuses

Evaluation criteria

Rural Expansion ofAfghanistan’s Community-Based Healthcare (REACH)Funding flows directly fromMSH to NGOsNGOsFixed budget (input-based)

USAID contracts out to MSHwho then subcontracts NGOs

Performance-based grant: pay-ment (including initial advancepayment) will be tied to deliver-ables and achieving outputs.Payment is only made after re-view and acceptance of deliver-ables

(i) RFA issued (all eligible NGOscan bid)24

(ii) Proposals submitted

26 - 30 months$342,721 – $5,328,861 USD

Reimbursement of actual expen-ditures through submission ofquarterly invoices. Payment istied to achievement of deliver-ables agreed in grant

NO

Scoring system based on evaluation criteria plus a paneldiscussion system so the highestscore does not always win thebid.

Support to Health ServiceDelivery in Afghanistan

Funding flows from the EC directly to NGOsNGOsFixed budget (input-based)

EC establishes grants directlywith NGOs

Grants are used with a priority“to pave way to new contractualforms between the Ministry ofHealth (MoH) and the NGOs forthe delivery of the BPHS(Performance-based PartnershipAgreement-like contracts)”.

(i) International Call forProposals issued (all NGOs canbid but they must have theirheadquarters within the EU orin Afghanistan)(ii) Proposals submitted21 - 30 months4,341,840 – 1,704,289 Euros

If duration <12 mths or <100,000 Euros - 80% of budget forwardedIf >12 mths or >100,000 80% forthe first 12 mths forwarded

NGOs required to provide 10%of the overall cost of the grantfrom alternative fundingsources although exceptions canbe madeNO

Evaluation criteria are dividedin sections and subsectionswhich are rated on a scale of 1-5(1 = very poor 5 = very good).Evaluation criteria have less of

47

Annexes

25 Average coverage is 39% as of July 2004 with a range of 12 – 100%26 Average coverage in 4 cluster-wide provinces is 42%. Including province-wide project average coverage totals 73%

48

Annex

Characteristics IDA/World Bank USAID/MSH EC

Annex: Similarities and Differences in Donor Procurement

section are considered unre-sponsive and sent back. If >60points then financial proposal isopened. Scores are then tabulated with the followingweighting: Technical scores (80%) Financial scores (20%)

3 approaches:>7 province-wide PPAs>1 cluster-wide PPA>3 provinces designated asMOH strengthening mechanism(MOH-SM)

Entire BPHS in all contracts

Third party (JHU/IIHMR) willconduct rapid evaluationssemi-annually in province-wideprojects and more comprehen-sive evaluations annually nationwide

MOH will also conduct periodicmonitoring visits to PPA sites

Nationally defined core andmanagement indicators

Baseline figures will be extract-ed from a MICS conducted in2003

Geographical scope

Scope of services

Monitoring andEvaluation

Indicators

Budget/cost effectivenessweighted at 10% of overall score

Scores are weighted differentlydepending on whether the ap-plicant is a national NGO (newvs. experienced) or an INGO.Priority is given to nationalNGOs with 10% added to theirtechnical score13 provinces (+ 1 district of anEC province) are being fundedalthough most are not fully covered25

Both single districts and clustersof districts are funded, howeverpriority areas are defined as un-derserved areas rather than bydistrict or clusterThe minimum required servicelevels do not require NGOs toinclude district hospitals butthey can include them if theyhave the capacity and experienceQuarterly review of deliverablesthrough quarterly reports andspontaneous on-site monitoring

JHU/IIHMR will include US-AID provinces in annual nation-wide performance assessments

USAID has set standard indica-tors but the targets can be defined by the NGO and negoti-ated with the purchaser

Baseline figures are based onhousehold surveys conductedby the NGOs in the first quarterof the grant

an emphasis on quality of services and monitoring thanUSAID REACH but more emphasis on budgets and cost-effectiveness

Financial score weighted at 10%

Priority given to the highestscores

4 province-wide grants6 clusters in 4 provinces26

Entire BPHS plus constructionof facilities is included in someearly grants

Annual reports required

Financial management is considered as a proxy for management capacity

JHU/IIHMR will include all ECprovinces in annual nationwideperformance assessments andprovince-wide areas in semi-annual rapid surveysNGOs can define their own indicators and use a traditionallogical framework, however oneof the priorities of the programis to make a start in definingand measuring performance-based indicators related to theBPHS

Sources: WB Request for Proposals (2003), USAID Request for Application (2003), EC Call for Proposals (2002)

London School of Hygiene and Tropical Medicine (LSHTM)Keppel Street, London

WCIE 7HT, UKTel: +44(0)20 76 36 86 36http://www.lshtm.ac.uk

health policy in afghanistan two years of rapid change

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health coordination

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