M&E contracting afghanistan

Monitoring basic health services contracts in a conflict affected setting: experience from Afghanistan

1. Contracting Governance Monitoring basic health services contracts in a conflict affected setting: experiences from Afghanistan Najibullah Safi, MD, MSc. DMS Program Manager, Health System Development WHO – Country Office, Afghanistan Fifth Global Symposium on Health Systems Research: Advancing health systems for all in the SDG era

2. Presentation outline 10/3/2018 Fifth Global Symposium on Health Systems Research, Liverpool, UK 2

3. Contracting system: overview Fifth Global Symposium on Health Systems Research, Liverpool, UK Afghanistan is the only country in the world using contracting-out of health services to NGOs on a large scale (31 out of 34 provinces) The Basic Package of Health Services (BPHS) and the Essential Package of Hospital Services (EPHS) are contracted-out to NGOs since 2003 and 2005 respectively NGOs are selected through a competitive bidding process BPHS and EPHS are mainly financed by EU, USAID and WB through a basket fund (ARTF) The cost of BPHS and EPHS is roughly US$ 5 per capita per year Ministry of Public Health manages all the contracts 10/3/2018 3 MMR CPR

4. M&E system Its complex and various departments and organizations are engaged Grant and Contract Management Unit (GCMU): responsible for contract management M&E directorate: is using national monitoring checklist to monitor BPHS and EPHS facilities Technical departments: using their own checklists or sometimes jointly with M&E are monitoring health services Provincial Public Health Directorates: being increasingly engaged in M&E Third party (currently KIT): is responsible for Two rounds of HMIS data verification per year Health facilities functionality assessment National health facility assessment: Balanced Score Card (BSC) Afghanistan Health Survey (AHS) 10/3/2018 Fifth Global Symposium on Health Systems Research, Liverpool, UK 4

5. M&E system cont. 1. National monitoring checklist Comprised of 377 indicators which are summarized in 11 composite index indicators 2. HMIS data verification and functionality assessment Verify the performance of NGOs, and Strengthening Mechanism (SM) against specific output indicators; availability of staff, drugs, and functionality of equipment 3. National health facility assessment (BSC) BPHS BSC is comprised of 23 indicators organized in five domains Client and community  Human resource Physical capacity Quality of services Management system 4 . Afghanistan Health Survey Nationally representative household survey Sample size: 23,460 households (23 households per cluster, 30 clusters per province) Sample size yields provincial estimates with at least 95% level of confidence Use two-stage stratified cluster sampling First stage sampling: 30 clusters Probability Proportion to Size (PPS) method Second stage sampling: 23 households per cluster Conducted by third party and monitor by MoPH and NSIA* AHS report large number of outcome and impact level indicators Conducted every 2-3 years 10/3/2018 Fifth Global Symposium on Health Systems Research, Liverpool, UK 5

6. M&E resources Most of the M&E activities are undertaken by third party (previously Johns Hopkins University (JHU) and currently KIT – Netherland) Technical assistance is an inbuilt component of each activity related to M&E GCMU staff/consultants hired from the project fund On average GCMU spent an amount of US$ 52,000 per year for monitoring contracted NGOs across the country On average third party (KIT) spent around US$ 3,200,000 per year for carrying out M&E activities (around 2% of the total SEHAT budget) In addition some investment is done by GAVI and GFATM in monitoring vertical programs using national M&E checklist 10/3/2018 Fifth Global Symposium on Health Systems Research, Liverpool, UK 6 Third part activities Actual expenditures US$ (2015-17) Drop-in centers functionality 35,336 HMIS Verification 2,030,632 Health Facility Functionality 191,808 National Health Survey 3,568,660 National Health Facility Survey 2,945,872 Drug Quality Assessment 58,669 Impact Evaluation of RBF 795,080 Total budget 9,626,057

7. Client relationship GCMU is responsible for contract management 20% of NGOs payment is linked with their performance confirmed by the third party In principle GCMU/MoPH can terminate the contracts of poor performing NGOs – but it hardly happened Managements letters, monitoring missions reports, face to face meetings, joint monitoring with NGOs are the commonly used approaches for endorsing corrective measures and improved performance External forces, beyond MoPH and NGOs, and personal interest can play critical role in shaping the relationship between both parties 10/3/2018 Fifth Global Symposium on Health Systems Research, Liverpool, UK 7

8. Discussion and conclusion The M&E system is comprehensive but complex Overlap of various M&E approaches Large amount of data is collected, but utilization remains inadequate Insufficient engagement of the MoPH technical departments in M&E Delay in availability of reports for decision making and payment of NGOs Absence of agreed platform for sharing M&E findings within MoPH department and relevant stakeholders Resources Inadequate capacity at the national and provincial levels for monitoring the activities of NGOs and third party M&E findings can directly affect client relationship Security and ongoing conflict overshadow M&E activities and so does mutual accountability 10/3/2018 Fifth Global Symposium on Health Systems Research, Liverpool, UK 8

9. 10/3/2018 Fifth Global Symposium on Health Systems Research, Liverpool, UK 9 Thanks