This presentation was given at the Global Symposium on Health System Research in November 2010. The authors are L P Singh, Olakunle Alonge, Anubhav Agarwal, Kayhan Natiq, S D Gupta and David Peters.

1. Afghanistan Health Sector
Balanced Scorecard
National Results 2004 - 2008
L P Singh1, Olakunle Alonge2, Anubhav Agarwal1,
Kayhan Natiq2, S D Gupta1 and David Peters2
1 Indian Institute of Health Management Research (IIHMR)
2 Johns Hopkins Bloomberg School of Public Health

2. Overview
1. Afghanistan public health sector and BPHS
2. Introduction to the Afghanistan Health Sector Balanced
Scorecard
3. National results – Discussion by domains and indicators
4. Summary
5. Looking Ahead…

3. Afghanistan Public Health Sector
Source:
A Basic Package of Health Services for Afghanistan – 2010/1389 – MoPH, Afghanistan

4. Basic Package of Health Services (BPHS)
o Developed in 2002 by MoPH in consultation with major
stakeholders of Afghanistan Health sector
o Provides clear guidelines on the various aspects of health
services delivery
o BPHS Implementation
• MoPH = Stewardship role
• Implementation through contracting (NGOs, MoPH-SM)
o Third-party monitoring using the Balanced Scorecard
approach, annually since 2004.

5. What is a Balanced Scorecard?
o Philosophy of Balanced Scorecard
• Translating strategy into action
o Classic definition by Kaplan and Norton
• “A multi-dimensional framework for describing, implementing and
managing strategy at all levels of an enterprise by linking
objectives, initiatives, and measures to an organization’s strategy”

6. o Alternative definition:
“A strategic planning and management system that is used
extensively in business and industry, government, and
nonprofit organizations worldwide to align organizational
activities to the vision and strategy of the organization,
improve internal and external communications, and
monitor organizational performance against strategic
goals.”
Source: http://www.balancedscorecard.org
What is a Balanced Scorecard?

7.  Enables MoPH and partners to view a snapshot of several domains of
health system performance and track trends over time
 Enables provinces and agencies to benchmark performance
• Achievable performance targets appropriate for Afghanistan
 Management innovation
• Afghanistan is one of the pioneers in LMIC to apply BSC to manage national
health system
Why a Balanced Scorecard for Afghanistan?

8.  Promotes focus on attainment of measurable results
 Provides actionable evidence on areas of strength and weakness at
multiple levels: national, provincial
 Provides a basis for corrective action
 Measurement of performance essential for effective management
and accountability
Why a Balanced Scorecard for Afghanistan?

9. Benchmarking in the BSC
 Benchmarks established using 2004 data and applied to
subsequent annual rounds
 Upper Benchmark: Minimum level of performance achieved
by provinces in the top quintile in 2004
 Lower Benchmark: Minimum level of performance achieved
by provinces above the bottom quintile in 2004

10. Color Coding in the BSC
Score meeting Upper Benchmark
Score between Lower and Upper Benchmarks
Score below Lower Benchmark

11.  Health worker satisfaction
 Salary payments current
 Equipment functionality
 Drug availability
 Family planning availability
 Laboratory functionality
 Staffing levels
 Provider knowledge score
 Staff received training in last year
 HMIS use
 Clinical guidelines
 Infrastructure
 Patient record keeping
 Monitoring of TB treatment
• Facilities with user fee guidelines
• Facilities with exemptions for
poor patients
• Overall patient satisfaction
• Patient perceptions of quality
• Shura-e-sehie activity in
community
• Equity of service delivery
• Equity of patient satisfaction
• Females as % of new outpatients
Staff
Financial
Systems
Patients
&
Community
Overall
Vision
Service
Provision
Capacity
for
Service
Provision
DOMAINS
• Patient history and physical
exam
• Patient counseling
• Proper sharps disposal
• Average new outpatient visits
per month (BHC>750 visits)
• Time spent with patient
(> 9 minutes)
• Provision of antenatal care
• Provision of delivery care
The Framework of the Balanced Scorecard

12. Kabul province BSC (2004 – 08)
An example

13. Benchmarks Kabul
Lower Upper 2004 2005 2006 2007 2008
A. Patients & Community
1 Overall Patient Satisfaction 66.4 90.9 84.8 75.6 94.8 76.3 82.6
2 Patient Perception of Quality Index 66.2 83.9 86.9 72.8 86.5 80.9 71.6
3 Written Shura-e-sehie activities in community 18.1 66.5 33.3 80.1 59.8 53.7 29.6
B. Staff
4 Health Worker Satisfaction Index 56.1 67.9 68.8 66.1 78.4 62.3 60.2
5 Salary payments current 52.4 92.0 52.4 91.4 94.8 93.3 50.3
C. Capacity for Service Provision
6 Equipment Functionality Index 61.3 90.0 75.6 80.8 80.8 83.2 74.3
7 Drug Availability Index 53.3 81.8 76.8 71.3 86.8 69.6 66.5
8 Family Planning Availability Index 43.4 80.3 65.4 76.7 89.4 89.1 97.8
9 Laboratory Functionality Index (Hospitals & CHCs)
5.6 31.7 30.4 44.1 43.7 41.6 51.7
10 Staffing Index -- Meeting minimum staff guidelines
10.1 54.0 54.0 79.7 85.3 77.2 73.4
11 Provider Knowledge Score* 44.8 62.3 59.1 73.8 78.5 73.3 N/A
11a Revised Provider Knowledge Score
71.5 86.0 N/A N/A N/A N/A 82.2
12 Staff received training in last year 30.1 56.3 36.6 76.5 68.0 66.8 45.0
13 HMIS Use Index 49.6 80.7 80.7 63.6 62.8 61.0 60.3
14 Clinical Guidelines Index 22.5 51.0 38.4 64.9 60.7 77.7 62.3
15 Infrastructure Index 49.3 63.2 56.5 55.1 53.4 41.2 39.5
16 Patient Record Index 56.1 92.5 59.5 79.2 71.3 62.0 51.0
17 Facilities having TB register 8.3 26.6 10.7 7.8 38.0 51.2 51.8

14. D. Service Provision
18 Patient History and Physical Exam Index 55.1 83.5 70.6 79.7 92.4 92.6 63.6
19 Patient Counseling Index 23.3 48.9 37.5 52.0 64.8 65.4 35.0
20 Proper sharps disposal 34.1 85.0 54.4 59.7 66.1 65.9 44.6
21
Average new outpatient visit per month (BHC >
750 visits)
6.7 57.1 11.1 90.9 69.2 85.7 46.7
22 Time spent with patient (> 9 minutes) 3.5 31.2 31.2 19.0 25.1 5.9 0.7
23 BPHS facilities providing antenatal care 28.9 82.8 80.2 87.9 85.0 100.0 91.7
24 Delivery care according to BPHS 10.5 39.3 27.9 27.3 30.6 58.3 42.2
E. Financial Systems
25 Facilities with user fee guidelines* 80.3 100.0 100.0 91.3 100.0 100.0 0.0
26 Facilities with exemptions for poor patients* 64.4 100.0 64.0 47.5 100.0 100.0 100.0
F. Overall Vision
27 Females as % of new outpatients 46.5 59.7 62.6 64.7 61.8 64.3 61.0
28 Outpatient visit concentration index 48.0 52.7 51.9 50.6 50.0 49.9 55.3
29 Patient satisfaction concentration index 49.0 50.9 49.9 50.9 50.6 50.0 49.3
* Indicators not included in composite scores
Revised Composite Scores
32 Percent of Upper Benchmarks Achieved 7.7 26.9 23.1 38.5 61.5 50.0 34.6
33 Percent of Lower Benchmarks Achieved 69.2 88.5 100.0 96.2 100.0 96.2 84.6
Mean scores across 26 indicators 46.2 54.9 53.4 64.2 67.3 66.4 56.1
Benchmarks Kabul
Lower Upper 2004 2005 2006 2007 2008

15. Sample
Unit
2004 2005 2006 2007 2008
Number of Provinces 33 30 30 30 29
Number of facilities 617 629 630 636 618
Number of Observations of
Patient-Provider Interactions
5719 5856 5964 6089 5970
Number of Exit Interviews 5597 5862 5964 6087 5950
Number of Health Workers
Interviewed
1553 1452 1723 1940 2233

16. National results 2004-2008

17. Domain A: Patients and Community
34.2
54.5
66.4
86.0
94.3
83.1
86.3 86.0
77.7
81.0
76.0 76.2
80.3
77.6 77.5
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Written Shura-e-sehie
activities in
community
Overall Patient
Satisfaction
Patient Perception of
Quality Index

18. 34.2
54.5
66.4
86.0
94.3
83.1
86.3 86.0
77.7
81.0
76.0 76.2
80.3
77.6 77.5
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Written Shura-e-sehie
activities in
community
Overall Patient
Satisfaction
Patient Perception of
Quality Index
Domain A: Patients and Community

19. 60
5
1.5
0
10
20
30
40
50
60
70
80
90
100
Shura guidelines overall patient satisfaction Patient perception quality
Progress (2004-08) – Percentage points
Domain A: Patients and Community

20. 76.7
90.0
81.3 90.7
82.7
63.5 64.1
68.1 69.0 69.1
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Salary payments
current
Health Worker
Satisfaction Index
Domain B: Staff

21. 76.7
90.0
81.3 90.7
82.7
63.5 64.1
68.1 69.0 69.1
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Salary payments
current
Health Worker
Satisfaction Index
Domain B: Staff

22. 6 5.6
0
5
10
15
20
25
30
35
40
45
50
Salary payment current Health worker satisfaction index
Progress (2004-08) –Percentage points change
Domain B: Staff

23. 65.7
67.0
78.7
83.8
88.4
71.1
83.7
85.7 81.0
86.3
34.8
48.9
61.6
78.3
83.9
39.3
58.0
66.9
63.9
72.1
18.3
36.3
43.3
58.5
64.5
15.8
20.6
37.4
53.7
62.9
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Equipment
Functionality Index
Drug Availability Index
Clinical Guidelines
Index
Staffing Index --
Meeting minimum
staff guidelines
Laboratory
Functionality Index
(Hospitals & CHCs)
Facilities having TB
register
Domain C: Capacity for Service Provision

24. 65.7
67.0
78.7
83.8
88.4
71.1
83.7
85.7 81.0
86.3
34.8
48.9
61.6
78.3
83.9
39.3
58.0
66.9
63.9
72.1
18.3
36.3
43.3
58.5
64.5
15.8
20.6
37.4
53.7
62.9
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Equipment
Functionality Index
Drug Availability Index
Clinical Guidelines
Index
Staffing Index --
Meeting minimum
staff guidelines
Laboratory
Functionality Index
(Hospitals & CHCs)
Facilities having TB
register
Domain C: Capacity for Service Provision

25. 61.4
70.0
82.9
93.7 94.9
67.7
65.8
74.9
91.5 92.4
39.0
74.3
68.9
68.5
71.1
53.5
69.0
68.7
68.7
79.3
65.6
63.2
69.4 70.0 69.9
55.0
44.6
48.7
54.6 54.1
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Family Planning
Availability Index
HMIS Index
Staff received training in
last year
Provider Knowledge
Score
Provider Knowledge
Score- Revised
Patient Record Index
Infrastructure Index
Domain C: Capacity for Service Provision

26. 61.4
70.0
82.9
93.7 94.9
67.7
65.8
74.9
91.5 92.4
39.0
74.3
68.9
68.5
71.1
53.5
69.0
68.7
68.7
79.3
65.6
63.2
69.4 70.0 69.9
55.0
44.6
48.7
54.6 54.1
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Family Planning
Availability Index
HMIS Index
Staff received training in
last year
Provider Knowledge
Score
Provider Knowledge
Score- Revised
Patient Record Index
Infrastructure Index
Domain C: Capacity for Service Provision

27. 22.7
15.2
49.1
32.8
46.2 47.1
33.5
24.7
32.1
25.8
4.3 2.2 0.6
0
10
20
30
40
50
60
70
80
90
100
Progress (2004-08): Percentage points change
Domain C: Capacity for Service Provision

28. 70.6 73.5
82.2
83.1
83.9
22.2
32.3
55.0
57.4
84.2
62.0
79.3
84.9
95.3 95.2
25.4
22.3
42.3
59.5
71.2
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Patient History and
Physical Exam Index
Average new
outpatient visit per
month (BHC > 750
visits)
BPHS facilities
providing antenatal
care
Delivery care
according to BPHS
Domain D: Service Provision

29. 70.6 73.5
82.2
83.1
83.9
22.2
32.3
55.0
57.4
84.2
62.0
79.3
84.9
95.3 95.2
25.4
22.3
42.3
59.5
71.2
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Patient History and
Physical Exam Index
Average new
outpatient visit per
month (BHC > 750
visits)
BPHS facilities
providing antenatal
care
Delivery care
according to BPHS
Domain D: Service Provision

30. 29.6
35.1 36.6
48.7
48.0
62.2
52.0
77.5
84.4
75.4
18.0
6.2 7.0
18.4 19.7
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Patient Counseling
Index
Proper sharps disposal
Time spent with
patient (> 9 minutes)
Domain D: Service Provision

31. 29.6 35.1 36.6
48.7
48.0
62.2
52.0
77.5
84.4
75.4
18.0
6.2 7.0
18.4 19.7
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Patient Counseling
Index
Proper sharps disposal
Time spent with
patient (> 9 minutes)
Domain D: Service Provision

32. 13.3
62.0
33.2
45.8
18.4
13.2
1.7
0
10
20
30
40
50
60
70
80
90
100
Patient history
and exam
index
Average new
patients
ANC provision Provision of
delivery care
Patient
counseling
index
Proper sharp
disposal
Time spent
with patient
Progress (2004-08): Percentage points change
Domain D: Service Provision

33. o Two indicators on user fees
• Indicator 25: Facilities with user fee guidelines
• Indicator 26: Facilities with exemptions for poor patients
o No longer relevant - MoPH discontinued user fees at BPHS
facilities in 2008
o Only 16 of 618 facilities surveyed (2.6%) charged fees
o None of the surveyed facilities reported charging user fees in
22 of 29 provinces
Domain E: Financial Systems

34. 55.2 57.3 57.8 60.0 60.0
50.0 50.0 50.0 50.0 50.0
50.0 50.0 50.0 49.6 49.6
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Females as % of new
outpatients
Outpatient visit
concentration index
Patient satisfaction
concentration index
Domain F: Overall Vision

35. 55.2 57.3 57.8 60.0 60.0
50.0 50.0 50.0 50.0 50.0
50.0 50.0 50.0 49.6 49.6
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 2007 2008
Females as % of new
outpatients
Outpatient visit
concentration index
Patient satisfaction
concentration index
Domain F: Overall Vision

36. 4.80
0.00 -0.40
-2
0
2
4
6
8
10
% female patients in OPD Overall patient visit Patient satisfaction
Progress (2004-08): Percentage points change
Domain F: Overall Vision

37. Summary

38. Summary of Performance: 2004 - 2008
Decrease (-2 or
less)
Patient satisfaction
Constant (+/- 2 pts)
Overall patient visit
Infrastructure index
Patient perception quality
Time spent with patient
Mild Increase (2-10 pts)
Patient records index
Provider knowledge revised
% Female patients in OPD
Overall patient satisfaction
Health worker satisfaction
index
Salary payment current
Moderate increase
(10-25)
Proper sharp disposal
Patient history and exam
index
Drug availability
Patient counseling index
Equipment functionality
HMIS Guidelines
Provider knowledge
Large increase (26 or
more)
Staff training
Staffing index
ANC provision
FP Availability Index
Provision of delivery care
Lab functionality
Availability TB Registers
Clinical guidelines
Shura guidelines
Average new patients
Change in
median
scores

39. Progress by Domains
64.4
70.1
48.5
41.4
51.9
72.3
77.1
57.5
43.0
52.6
77.6
74.7
65.3
55.1
52.9
80.4 79.9
72.5
63.8
53.2
84.3
75.9 76.4
68.2
53.2
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
A. Patients &
Community
B. Staff C. Capacity for
Service Provision
D. Service
Provision
F. Overall Vision
2004 2005 2006 2007 2008
+ 19.8
+ 27.9
+ 26.8
+ 1.3+ 5.8

40. Usage of the Balanced Scorecard
o Over the years BSC has found extensive application in the
Afghanistan health sector such as:
• General monitoring tool by the leadership for tracking
progress of the provinces and NGO implementing BPHS
during quarterly meetings
• The development partners used it as an instrument for
awarding performance bonuses (The World Bank)
• The NGOs used it to showcase their performance
• The provincial leadership used it to request additional
supplies and human resources

41. Looking Ahead

42. The Future Balanced Scorecard
o Domains largely sound, but:
• Rapidly changing health system
• Many benchmarks already achieved
• Need for revised indicators
o Revision of BSC underway
• Several new indicators proposed
• Broader picture of BPHS delivery
• Better adapted to goals of new health strategies

43. Future BSC Features
Lower Upper National Median
2004 2005 2006 2007 2008
A. Patients & Community
1Overall Patient Satisfaction 66.4 90.9 83.1 86.3 86.0 77.7 81.0
2
Patient Perception of Quality
Index
66.2 83.9 76.0 76.2 80.3 77.6 77.5
3
Written Shura-e-sehie
activities in community
18.1 66.5 34.2 54.5 66.4 86.0 94.3
B. Staff
4
Health Worker Satisfaction
Index
56.1 67.9 63.5 64.1 68.1 69.0 69.1
5Salary payments current 52.4 92.0 76.7 90.0 81.3 90.7 82.7
C. Capacity for Service
Provision
6
Equipment Functionality
Index
61.3 90.0 65.7 67.0 78.7 83.8 88.4
7Drug Availability Index 53.3 81.8 71.1 83.7 85.7 81.0 86.3
8
Family Planning Availability
Index
43.4 80.3 61.4 70.0 82.9 93.7 94.9
9
Laboratory Functionality
Index (Hospitals & CHCs)
5.6 31.7 18.3 36.3 43.3 58.5 64.5
1
0
Staffing Index -- Meeting
minimum staff guidelines
10.1 54.0 39.3 58.0 66.9 63.9 72.1
1
1Provider Knowledge Score
44.8 62.3 53.5 69.0 68.7 68.7
1
2
Staff received training in last
year
30.1 56.3 39.0 74.3 68.9 68.5 71.1
1
3HMIS Index
49.6 80.7 67.7 65.8 74.9 91.5 92.4
1
4Clinical Guidelines Index
22.5 51.0 34.8 48.9 61.6 78.3 83.9
1
5Infrastructure Index
49.3 63.2 55.0 44.6 48.7 54.6 54.1
1
6Patient Record Index
56.1 92.5 65.6 63.2 69.4 70.0 69.9
1
7Facilities having TB register
8.3 26.6 15.8 20.6 37.4 53.7 62.9
D. Service Provision
Expanded Scope of Measurement
 Community’s role in health
 Coverage indicators
 Perspectives of non-users
Enhanced performance management
 Communication and use at
peripheral levels
 Documentation of best practices
 Performance improvement tool

44. Thank You!
Thank You!
Source:
National Geographic
Channel