Not many people know about a large-scale programme that is bringing basic health improvements to the population of Afghanistan. Talk to an average person in Europe or English speaking countries and chances are not one will tell you that Afghanistan has been making substantial progress thanks to some novel approaches. Between 2002 and 2016 Afghanistan’s under-5 mortality rate dropped 60 percent to 55 per 1,000 live births, reflecting substantial investments in healthcare since the end of the Taliban regime.

Key to the improvements is the way in which they were implemented: through partnerships between NGOs with experience of working in Afghanistan’s dispersed regions, and the Ministry of Public Health (MoPH) in a stewardship role. That’s one of the conclusions of the World Bank, the programme’s executing agency, in its most recent assessment.

System Enhancement for Health Action in Transition (SEHAT)

The programme began in 2002 when an international group of donors working together with the MoPH, pooled their resources and expertise together to establish the Afghanistan Reconstruction Trust Fund (ARTF), with US$408 million in donor funding. It may seem like a substantial amount, but Afghanistan’s population is estimated at 30 million and great efficiency is required to bring lasting benefits.

The programme, System Enhancement for Health Action in Transition (SEHAT), is being carried out at the country level by several local and international NGOs, on behalf of the MoPH. It’s backed by a soft loan from the World Bank and donations from a multitude of bilateral development agencies. As of 2015, KIT Royal Tropical Institute has acted as the third-party evaluation partner for the programme.

The partnership structure with the Ministry of Health was chosen in order to overcome major obstacles to establishing a well-functioning health system covering Afghanistan’s vast territory. The biggest of these obstacles was a general break-down in trust at all levels except the most local, as well as widespread corruption in the health system.

Low ranking health system

In 2002, Afghanistan’s health system ranked among the lowest quality in the world. The country was second from the bottom of countries ranked by UNDP’s Human Development Index that year. Life expectancy was 43. Nearly three quarters of the population was undernourished (70 percent). Only 13 percent had access to safe or improved water sources. Only 36 percent of the population could read and write. Only 30 percent had some form of schooling.

Health centre visits were hampered by fear and distrust of all authorities, the country’s inhospitable terrain, its great distances, poor transport infrastructure, decadent hospitals and medical staff. The health ministry did not have the resources or know-how to establish a well-functioning system.

Train individuals in rural areas

The solution was to have NGOs established in rural areas train individuals in the delivery of basic healthcare, essential hospital services and health system management. The performance element was deemed necessary given the country context and is highly novel: it’s a ‘results-based financing’ system whereby health workers are remunerated according to completed output objectives, such as the number of women receiving early antenatal care and delivering their babies in health facilities, rather than according to inputs — such as the construction of health centres and staff training. Budgets and financing are also tightly linked to results.

According to the World Bank, the approach is working: the performance on quality of care of all contracted health facilities jumped by 32 percent in the early stages of the programme. The Bank ascribes this to the significant freedom the performance-based system gives NGOs, allowing them to decide how to use resources innovatively to reach their intended results. The results-based financing system runs parallel to a new programme appraisal system similar to one used in widely human resource management in industrialised countries — another novel feature of the SEHAT health programme. The ‘balanced score card” system uses red, orange, and green traffic lights to show health system managers what’s working and what’s not. This performance monitoring component aims to make Afghanistan’s health system quality and coverage transparent at a glance, by showing progress in terms of the key health statistics that are most relevant to Afghanistan’s health situation.

Independent evaluator

But are all those figures correct? As an essential part of the overall checks and balances, KIT Royal Tropical Institute was appointed as the independent evaluator of the results-based financing programme. KIT was also asked to verify the household statistics estimates, and in 2015 it started with a household nationwide survey in order to provide a-baseline, which was performed by KIT’s health unit. In 2018 KIT will repeat and extend this through a survey (sample) of 24,000 households in 34 provinces. Afghani households are estimated to have around 10 members each, meaning 240,000 people need to be extensively interviewed and so that their vital statistics and health status can be recorded. A mountainous task.

Working through a local KIT Kabul office, KIT’s health unit has trained 400 Afghanis to become public health enumerators and designed a new, extended survey of up to 300 questions.

Survey

KIT designed the survey so as to provide an accurate snapshot of health coverage in the 34 provinces. Over the next few months, groups of three newly-trained enumerator couples will be visiting four households per day, in one car, together with a supervisor/editor.

The questions asked go beyond the basics of names, date of birth, sex, and medical history and recent health centre visits of all household inhabitants. Children are measured and weighed and their parents asked if they have been vaccinated. They are asked whether there have been any deaths or health problems. In the case of a death, a ‘verbal autopsy’ is performed, whereby the enumerators will try to ascertain the likely cause of death based on standard questions.

The whole process is expected to be completed in two hours — a demanding schedule in Afghanistan’s rugged and badly connected rural areas, especially considering the distances that need to be covered. It’s also a laborious process because of the volume of paperwork that needs to be completed, then checked by the supervisor, before it is finally inputted manually by the editor when the teams return to base.

A digital approach

In practice to date, the paper work was often delivered incomplete or with errors and was slowing down progress. Which is why KIT has decided to try a digital approach in 2018. In a pilot project in two provinces, enumerators will be equipped with tablets with GPS trackers. “Not in all provinces can tablets be used, since local authorities often do not allow them, out of fear that they may be used to collect and transmit other ‘intelligence’ that could be used for military purposes,” explains Egbert Sondorp, a health systems strengthening expert at KIT who is in charge of KIT’s programme work in Afghanistan.

SEHAT aims to expand the scope, quality, and coverage of health services provided to the population, particularly for the poor. It provides a package of basic health services and of essential hospital services across the country through NGOs  The procurement and contract management for NGO services are carried out by the Ministry of Public Health’s Grants and Contract Management Unit, and service provision is monitored through the regular health management information system and through facility and community surveys carried out by KIT Royal Tropical Institute.

The results

In June 2017, the World Bank announced the results of a review of progress achieved in the health sector in Afghanistan from 2002-2017, which was conducted by World Bank experts and an independent group from the University of Toronto.

The review found that many key health indicators had improved more rapidly in Afghanistan than in most other countries that had started at a similar level of development. The under-5 mortality rate dropped 60 percent to 55 per 1,000 live births in 2016 from 137 in 2002. Births attended by skilled health personnel increased to 58 percent from 14.3 per cent over the same period.

“Afghanistan has set a new benchmark against which to judge other countries affected by conflict, and even more so low income countries that are not facing conflict,” said Dr. Timothy Evans, Senior Director for Health Nutrition and Population at the World Bank, when announcing these results at a Presidential Summit on Health Care in Afghanistan in Kabul.

Over the period 2002-2016, the number of functioning health facilities increased five-fold while the proportion of facilities with female staff increased from 22 percent to 87 percent. The review links the programme’s success to the government’s contracting of NGOs to provide health services.

Health care challenges

Despite its impressive progress — by 2016 Afghanistan had moved up 19 positions on the UNDP Human Development Index — but the country still faces major health care challenges relative to the rest of the world. The World Bank notes that the use of family planning remains low, resulting in high fertility rates that could prevent Afghanistan from achieving its economic development goals. Malnutrition remains a serious problem that is exacerbated by declining levels of exclusive breast feeding and poor infant and child feeding practices.

The Afghanistan Reconstruction Trust Fund (ARTF) was set up in 2002 to provide a coordinated financing mechanism for the Government of Afghanistan’s budget and priority investment projects. Today, the ARTF remains the vehicle of choice for pooled funding, thanks to its “excellent transparency and high accountability,” and moreover provides a well-functioning arena for policy debate and consensus creation, according to external evaluators in 2012.

It is the largest single source of on-budget financing for Afghanistan’s development and is delivering important results within key sectors including education, health, agriculture, rural development, infrastructure, and governance. The ARTF is supported by 34 donors and administered by the World Bank.