Some Practical Lessons on Implementing RBF from

Afghanistan

Benjamin Loevinsohn

World Bank

October 2008

Outline

1. Background on Afghanistan

2. What the Government tried to do

3. Some of the results accomplished

4. Practical lessons about implementation

Very conservative society where social Very conservative society where social obstacles impede women’s access to obstacles impede women’s access to

servicesservices

Country Context

Pop’n = 25 Million 650 000 km2 34 provinces One of the poorest countries in the world (GDP ~ 300 dollars/ capita/year Civil War since 1978 1-2 million people died, >5 million refugees 80% rural

Afghanistan in 2002-Reasons to Worry

Little physical infrastructure MOPH had limited capacity Health workers afflicted by the “3 wrongs”

wrong gender wrong skills wrong location

Little coordination of NGO activities

Distribution of NGO Health Centers was Chaotic and Unequal – 1 HF per 50,000

un-servedRoad

Inequalities were very serious, MMR much worse in rural and remote areas

418774

2182

6507

0

2000

4000

6000

8000

Kabul (urban) Alishen,Laghman

(semirural)

Maywand,Kandahar

(rural)

Ragh,Badakshan(rural, most

remote)

What the Government did: Established the “Basic Package of Health

Services” – priority health interventions Signed Results-Based Contracts with NGOs

on a very large scale – 90% of rural Afghans live in areas served by contracted NGOs

Competitively recruited Afghans to work in MOPH at market wages

Invested heavily in monitoring & 3rd party evaluation including HFSs, HHSs, HMIS

Results-Based Contracting

EC, USAID, MOPH (with WB funding) signed contracts/grants with NGOs

Similarities: focused on BPHS; same indicators & M&E process; clear geographic responsibility (provinces); competitive recruitment; move towards MOPH management of all grants

and contracts

Results-Based Contracting - PPAs MOPH signed “performance-based partnership

agreements” (PPAs) using WB funds 46% local NGOs, 27% INGOs, 29% with

consortia credible threat of sanctions – one INGO was

terminated for poor performance, one local NGO’s contract not extended

considerable autonomy – lump sum instead of line item budgets

Results-based Aspects of PPAs

Credible threat of termination Bonuses for NGOs: annual 1% of contract

value for 10 point increase in BSC, 5% for increase in coverage at the end of the contract

Could have been better designed (+23% in year 1, less bonus than 10% and 10%)

bonuses also paid to provincial health officials to align incentives

Setting up a Grants and Contract Management Unit

Competitive recruitment of local consultants Transparent recruitment thru involvement of

external stakeholders Paid market wages but on contract Caused considerable resentment in MOPH However, attracted very capable people, many

from NGO sector Much appreciated by senior management Much cheaper than international consultants

Health Facility Surveys

JHU worked with stakeholders to develop a health facility assessment

Carried out annually since 2004 600+ facilities per yearFormulated a “balanced score-card”

(BSC) that rated facilities on a scale of 0-100

Health Facility Surveys – An Important M&E Tool

BSC looked at 29 areas of care including: (i) equity; (ii) patient satisfaction; (iii) availability of drugs, equipment, & staff; (iv) knowledge of providers; (v) quality of patient-provider interaction; (vi) patient load, etc.

Costs about $300,000 per year

32% Improvement in Quality of Care from facility survey (BSC)

40

45

50

55

60

65

70

75

80

2004 2005 2006 2007

MOPH Alone

PPA Median

Non-PPA Median

Improvements in Reproductive Health – Household Surveys 2003 to 2006

0

5

10

15

20

25

30

35

Skilled Birth Attendance Contraceptive PrevalenceRate

Antenatal Care

2003

2005

2006

Changes in Routine Immunization Coverage

0

10

20

30

40

50

60

70

80

BCG OPV3 DPT3

2003

2005

2006

U5MR in Afghanistan: Actual and MDG4 Target

0

50

100

150

200

250

300

1990 1995 2000 2005 2010 2015

Target

Actual

260

191

Implementation Lessons Learned

1. Have clear objectives: The MOPH focused on the BPHS in rural areas and ensured all DPs did too!!

2. Have explicit contracts: The MOPH spent time and effort to ensure contracts were clear on what was expected but left how to NGOs. Used a checklist in designing them

3. Have an explicit plan: PIP dealt with NGO selection, contract management, M&E

Implementation Lessons Learned

4. Clear Arrangements for Contract Mgt: MOPH set up GCMU: 10 people with proper budget – look after all DP contracts/grants

a. Field visits to assess progress, ID issues, and diagnose causes

b. Ensure prompt payment of NGOsc. Hold NGOs accountable for obligationsd. Track performance using available datae. Keep MOPH leadership informed

Implementation Lessons Learned

5. Monitor Carefully: Used different sources of information to assess performance on explicit indicators:

a. Health facility surveys – very useful to do yearly by 3rd party

b. HMIS – insisted on high reporting ratec. Household surveys to verify HMIS data – found

big differences for vaccination & ANC coveraged. Field visits using checklistse. Involve community

Implementation Lessons Learned

6. Give Implementers Autonomy: MOPH gave NGOs substantial autonomy by:

a. Use of lump-sum (not line item budgets)

b. Allowing NGOs to procure their own drugs, supplies, and equipment

c. Focusing on what not how; e.g. insisted on female health workers

d. Encouraging NGOs to innovate

Per capita outpatient visits per year in Secure and Insecure Provinces with PPAs by same NGO

0

0.2

0.4

0.6

0.8

1

2004 2005 2006 2007

Saripul

Helmand

Introduction of Conditional Cash Payment by NGO

0%

10%

20%

30%

40%

50%

60%

OPD

delivery

Family Planning

Introduction of new approaches

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