2. Motivation
In 2002, the health system was in a 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
• Few functioning health facilities
2
3. Motivation…
Reflected in health indicators that 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
3
4. • Focus on stewardship functions
o Define the package of services: BPHS and EPHS
o Define the beneficiaries: service areas defined for each provider
o Define the standard of services: inputs requirements for BPHS and EPHS
defined
• Partner with the private sector
o that has been serving 80% during the conflict
• Use its purchasing power effectively to register results
• The approach is largely along the lines of current thinking on
service delivery in fragile states (e.g. Collier)
Strategy: Afghanistan’s Approach to
Health Service Delivery
4
11. ...but not enough
11
Coverage of important services remains low by
global standards e.g.
o CPR 15%,
o ANC 36%
o SBA 24 %
Additional effort to increase coverage needed
12. Results-Based Financing (RBF)
• Since 2010:
o 14 provinces: gradually scaled up
o Primary care and hospitals
• RBF means:
o Payment for additional services
o Payments for improved quality
o Payments for serving the poor
• Rigorously assessed with a gold standard IE design
12
23. The longer RBF is in place, the better
(ANC 1-4)
(highest after 12 months ~ control for seasonality)
9.9
13.5
21.8
6.9
1.4
4.3
0
5
10
15
20
25
3months** 12 Months*** 19 months***
Treatment
Control
23
24. The longer RBF is in place, the better
(PNC 1-2)
3.9
7.7
16.5
3.1
1.5
6
0
2
4
6
8
10
12
14
16
18
3months** 12 Months*** 19 months***
Treatment
Control
24
25. The longer RBF is in place, the better
(SBA)
-0.3
1.2
5.4
0.5
-0.2
2.6
-1
0
1
2
3
4
5
6
3mohths 12 Months 19 months**
Treatment
Control
25
26. Quality improved in most hospitals
with RBF in place
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
1 2 3 4 5 6 7 8 9 10 11 12 13
Score
Hospitals
Overall Score
Before
After
26
