The international strategic plan to implement health systems in Afghanistan has been successful and can serve as a model in other fragile states, argued Dr. Benjamin Loevinsohn of the World Bank at the fifth meeting of the Environmental Change and Security Program's Health, Population, and Fragility Series on October 24, 2006. Sallie Craig Huber of Management Sciences for Health (MSH) joined Loevinsohn to examine critical relationships between NGOs and governments in health care delivery, and also discuss the most efficient ways to accomplish health and stability goals in fragile settings.

Historically poor and devastated by decades of conflict, Afghanistan has some of the worst health statistics in the world. The country suffers from high child and maternal mortality rates, particularly in rural and remote areas. According to Loevinsohn, international assessments conducted after the fall of the Taliban in 2002 concluded that Afghanistan did not possess a functioning health system. The findings revealed the country's dire need to train female health workers, increase the number of health care professionals with knowledge of primary health care, and bolster the number of health care professionals in rural areas. Despite the presence of 65 health sector NGOs operating in Afghanistan at the time of the assessments, the country's health infrastructure lacked coordination, resulting in the duplication of services in some areas and the absence of clinics in underserved remote areas.

Building Something From Nothing

In close collaboration with the World Bank, which provided financial support, the Afghan Ministry of Public Health (MOPH) developed a comprehensive strategy to construct a functioning health system in eight provinces. Recognizing its limited resources, the MOPH was eager to partner with NGOs, but was cognizant of the need to coordinate their efforts to avoid the gaps in coverage that plagued the country in the past. To this end, the MOPH awarded performance-based partnership agreements (PPAs), as well as bonuses worth up to 10 percent of the contract, to NGOs that covered the selected eight provinces and provided clear objectives and performance indicators. NGOs were competitively selected over a seven-month period and were independently evaluated by The Johns Hopkins University.

The U.S. Agency for International Development, however, chose to issue grants directly to NGOs rather than channeling money through the MOPH. One of its largest contracts was awarded to MSH, which has more than three decades of experience in Afghanistan. Through the Rural Expansion of Afghan Community-Based Health Care (REACH) project, MSH aimed to provide basic health services, specifically maternal and child health care, to millions of Afghanis in 13 provinces. Reflecting on the challenges of implementing the project's primary goal, Huber said, "When you go into a post-conflict fragile state, there is a lot of pressure to…bridge the gap in the health care system all at once." She cited inadequate or damaged infrastructure, inexperienced leaders, and a lack of reliable population data as significant obstacles to realizing REACH's objectives. The strategy employed to overcome these challenges centered on training community health workers and midwives; offering continuous support to build management and leadership skills at the MOPH; and providing support for the MOPH to construct a national health management information system.

Indicators of Success

REACH's strategy has successfully improved access to health care in Afghanistan, according to Huber, increasing contraceptive prevalence, births attended by skilled attendants, and rates of immunization for rural children. Additionally, the training and deployment of more than 6,000 new community health workers has made a "major contribution" to REACH's success, she said. While conceding that the program's results are only small advances in the larger scheme, Huber said that progress made in the health sector will help foster stability and strengthen the relationship between Afghanis and their government: "They'll feel that the government is working for them and that they have hope for their future and their children's future."

Loevinsohn also touted Afghanistan's recent strides in the health sector. Recent studies indicate that areas with PPAs experienced the greatest percentage increases in antenatal care and the number of newly established health centers, as well as the highest number of facilities with trained female workers. In addition, PPAs—at a cost of approximately US$4 per capita annually—represent the most cost-effective contract scheme used in Afghanistan, he said. The success of PPAs in Afghanistan led Loevinsohn to conclude that having a clear package of services and indicators, as well as established geographical assignments and evaluation methods, will lead to success: "[This strategy] will get you where you want to go."

Lessons Learned

Loevinsohn maintains that the positive results obtained in Afghanistan using PPAs show that the scheme can be replicated in other fragile environments. He recommended that donors contract more systematically with NGOs, eliminate the use of short-term contracts, and issue performance bonuses to ensure that NGOs work toward the agreed indicators of success. In addition, he encouraged donors to channel money through the host country's government. Following these measures "leads to large and rapid improvements in health services," he said.

Despite Loevinsohn's recommendations, though, some attendees voiced skepticism over the prospects of replicating Afghanistan's results in other settings. One attendee argued that governments in stable countries have not been willing to hand over lucrative donor contracts to the NGO community. Loevinsohn agreed that stable governments often have a vested interest in "keeping things the way they are" and are often hesitant to forsake the power and prestige of international contracts, but he pointed to Bangladesh and India as two successful examples of stable countries that have agreed to contract with health sector NGOs. Serious progress can be achieved through partnerships in other settings, Loevinsohn said, but warned that the process of replicating Afghanistan's success will be challenging and ongoing: "This is an evolving story."

Drafted by Ken Crist.