Afghanistan: Better Healthcare Saves Lives
Under-five mortality in Afghanistan has declined 26%
August 1, 2008—Access to health facilities used to be a major problem for rural communities in Balkh province in Northern Afghanistan. In 2003, the province had only 22 functioning health facilities serving a population of 950,000. People, especially in rural areas, often had to walk three or four hours to reach a medical facility. Few women visited a health facility during pregnancy and most babies were delivered at home.
Much has improved in the province since then. Today there are 86 facilities, and 93% of all facilities employ trained female staff. As a result, skilled birth attendance increased from 3.3% in 2003 to 23% in 2006, according to independent household surveys.
Improvements throughout Afghanistan
Despite continuing instability, similar progress has been achieved throughout Afghanistan.
When the Taliban fell in 2001, Afghanistan had some of the worst health indicators in the world. Today, despite continuing instability, health outcomes are vastly improved. The 2006 household survey indicates a 26% decline in under-five mortality since 2001. This translates into more than 80,000 lives being saved every year.
“The improvements in quality and coverage of health services in Afghanistan since 2002 are truly exceptional,” said Dr. Benjamin Loevinsohn, lead public health specialist and team leader for the Bank’s health projects in Afghanistan. “The number of functioning health facilities has tripled and there has been nearly a four fold increase in the number of out-patient visits. Third party assessments also show a large improvement in the quality of care.”
Loevinsohn said these results have been achieved largely thanks to performance-based contracts with local and international NGOs. With funding from the World Bank, the Ministry of Public Health contracted with NGOs to deliver a basic package of health services throughout the country. This basic package focuses on primary health care interventions such as child immunization, nutrition, tuberculosis and malaria control, prenatal, obstetrical, and post-partum care, family planning, and basic curative services.
NGOs Take the Lead
Currently 82% of the entire Afghan population lives in districts where primary health care services are provided by NGOs. In Balkh province, for instance, health services are provided by a consortium comprising BRAC and Bakhter Development Network, a Bangladeshi and Afghan NGO, respectively.
Other donors to the health sector also provide financing to NGOs. All the grants and contracts assign clear geographical responsibility to the NGOs and employ competitive selection. The Ministry of Public Health also invokes a credible threat of sanctions in case NGOs do not perform well and has terminated a few contracts. Performance is being reviewed by third party health facility assessments that are carried out each year in more than 600 facilities nationwide. The approximate cost of delivering the basic package of health services is US$4.00 per capita per year.
Loevinsohn—who recently published a report/toolkit on performance-based contracting for health services in developing countries—said this approach is one of the best mechanisms to rapidly secure improvements in the coverage and quality of publicly financed health services in developing countries. “In Afghanistan, we have seen that health facilities that are run by NGOs perform much better than facilities managed by the government,” Loevinsohn said. “They have more flexibility. There is little political interference, which means they can recruit the best qualified staff, and they don’t have to follow often rigid civil service rules and regulations.”
Government Involvement Needed for Success
But that does not mean the government does not have a role to play, he said. In fact, government involvement is critical to achieve success. By setting the priorities, allocating geographical responsibility, providing financing, and carefully monitoring performance, the Ministry of Public Health has been able to provide direction to what was previously an uncoordinated and chaotic system.
By giving NGOs a fair degree of autonomy but still holding them accountable for achieving national priorities, serious constraints such as scarce human resources, lack of physical facilities, and logistical challenges have been addressed.
Yet despite these encouraging improvements, the challenges are daunting. The health status of Afghans remains among the worst in the world. However, the progress that has made since 2002 shows that it is possible to achieve good results, even in challenging circumstances like those facing Afghanistan.