Contracting Out Health Service Delivery in Afghanistan Dr M.Nazir Rasuli General director Care of Afghan Families,CAF. Kathmando Nepal 12 Jun,2012
Outline 1. Background 2. BPHS 3. Contracting with NGOs, 4. Nutrition in BPHS 5. Results
Background: Country Context 26 million 34 provinces 70% rural Civil War since 1978
Background: Health System in 2002 The health system was in very poor condition Limited capacity in the Ministry of Public Health 80% of services provided by NGOs Lack of coordination among stakeholders Inequitable distribution of health services, with many rural areas extremely under-served
Background: Health Indicators in 2003 Health indicators were among worst in the world Life expectancy: women 45 years and men 47 years Under-five child mortality: 257 deaths per 1,000 live births Maternal mortality ratio: 1600 per 100,000 live births
MOPH approach to building the health system MOPH adopted stewardship over service delivery Defined the Packages of Services BPHS EPHS A unit was established Procure and Manage NGOs contracts Each province contracted for a single NGO Run all facilities within the province ( including hiring and firing of health workers)
3- The BPHS model framework Facility Level Key Staff Population Coverage Health Post Community Health Worker (CHW) 1,000-1,500 Basic Health Center Comprehensive Health Center Nurse (male), Midwife/Auxiliary Midwife, 2Vaccinator, Community Health Supervisor (CHS 2 Doctors (m/f); 2 Midwives; 2 nurses (m/f); Lab Tech Pharmacist, 2Vaccinator, Administrator, Community Health Supervisor (CHS 15,000-30,000 30,000-60,000 First Referral Hospital 2 Doctors (m/f), 1surgeon, anesthetist, Pediatrician, 4 Midwife, 10nurses, X-ray tech, Lab Tech, Pharmacist, 2Vaccinator, Dentist, Dental Tech, Care of Administrator,1CHS Afghan Families (CAF) 100,000-300,000
Health Facilities and Referral System in BPHS 30,000 people HP HP HP HP HP Comprehensive Health Center HP HP HP Basic Health Center Referrals HP HP HP HP HP HP HP Health Post Supervision & supplies from BHC Health Post District or Provincial Hospital
Types of Basic Health Facilities Health Post Basic Health Center Comprehensive Health Center District Hospital
Contracting with NGOs 1. PPA Performance-based Partnership Agreement (World Bank, 11 Provinces) 2. PCH Performance based Contract for Health (USAID, 13 Provinces) 3. PGC Performance based Grant Contract (EU 10 Provinces) MoPH role: Purchaser, stewardship, Policies, strategies, guidelines, standard, Monitoring, Evaluation Third Party Evaluation (JHU); Technical support (MSH);
BPHS Coverage by Donors 2011
BPHS components 1. Maternal and Newborn Care 2. Child Health and Immunization 3. Public Nutrition 4. Communicable Diseases Treatment and Control, 5. Mental Health, 6. Disability and Physical Rehabilitation Services 7. Regular Supply of Essential Drugs
Nutrition in BPHS /EPHS 1. Assessment of Nutritional status (population level) Estimate prevalence of malnutrition (z-score using indices of weight for height [wasting], weight for age [underweight], and height for age [stunting] as well as the underlying causes. Surveys conducted at district or provincial level for purposes of baseline, monitoring, and evaluation or in case of obvious deterioration in nutritional situation
Public Nutrition in BPHS /EPHS 2. Prevention of Malnutrition Vit A Supplementation to children 6-59 M Iodized Salt Promotion Balanced Micronutrient-rich foods promotion, Support and promote Exclusive Breast Feeding Promotion of appropriate Complementary feeding Community food demonstration Growth monitoring Iron-Folic acid supplementation for pregnant women Vitamin A supplementation -postpartum Control and prevention of diarrheal diseaseses Underlying causes: analysis of causes of malnutrition and support, advocate for relevant interventions
Public Nutrition in BPHS /EPHS 3. Treatment of Malnutrition Micronutrient deficiency disorders; Treatment of Acute Malnutrition in community and facilities; 4. Surveillance and referral Weight / Height, MUAC measurement and referral; Clinical signs of micronutrients deficiency;
Baby Friendly Village Initiative Village/Community Level Establish village Breast Feeding Support Group (BFSG) 10 members: 2 CHWs and 8 others; 50:50 male to female ratio All received IYCF training by Project Community Mobilizers BFSG members role: Promote IYCF in the village Refer mothers having difficulty breastfeeding to facility-based Counseling Corner Health Facility Level Establish IYCF counselor position (trained by master trainer trained by MoPH/PND IYCF specialists) Establish IYCF Counseling Corner (CC) Raise awareness of key staff about IYCF Implement policy to refer all pregnant & lactating mothers to CC for preventive and problematic IYCF counseling
Schematic presentation of general distribution of BFSG villages in relation to the District Hospital and Comprehensive Health Center (IYCF counseling corners) ~2 hr. walking distance to health facility Health Facility CHWs+8 Volunteers (BFSG) BFSG village Non-BFSG village
Breastfeeding Initiation Asked of Mothers of Infants <6 Mos. Old 100. 00 % 90. 00 % 80. 00 % 70. 00 % 60. 00 % 50. 00 % 40. 00 % 30. 00 % 20. 00 % 10. 00 % 0. 00 % within one hour within 6 hour within 24 hour After 24 hours Baseline End of Project
Fathers Knowledge of initiation of breastfeeding #5 father <24
Use of Colostrum #7
Fathers Responses re. Appropriate Length of Exclusive Breastfeeding
Results: U5MR - Actual and MDG4 Target
Results
Results (% of Facilities Providing Delivery Care)
Results (% of District Hospitals Doing CS)
Results (Quality of Care in Public Facilities)
Results: Immunization Coverage
How Does Afghanistan Compare? Under-five Mortality Afghanistan Mortality Survey 2010 Deaths per 1,000 live births for the 5- year period before the survey (Afghanistan excluding the South zone)
How does Afghanistan compare? Maternal Mortality Ratio: Deaths per 100,000 live births Data source: AMS 2010; Stratified et al. (2011) for Bangladesh 2010; and DHS Survey reports for Nepal and Pakistan
How Does Afghanistan Compare? Total Fertility Rate: TFR for women age 15-49 Afghanistan Mortality Survey 2010
How Does Afghanistan Compare? Contraceptive Use Percent of currently married women who are using any modern method
How Does Afghanistan Compare? Skilled Birth Attendants: Percent distribution of live births in the past 5 years assisted at delivery by a skilled provider
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