Salehi, Ahmad Shah

Background Lessons from polio eradication efforts and the Global Polio Eradication Initiative (GPEI) are useful for improving health service delivery and outcomes globally. The Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) is a multi-phase project which aims to map, package and disseminate knowledge from polio eradication initiatives as academic and training programs. This paper discusses initial findings from the knowledge mapping around polio eradication activities across a multi-country context. Methods The knowledge mapping phase (January 2018 – December 2019) encompassed four research activities (scoping review, survey, key informant interviews (KIIs), health system analyses). This paper utilized a sequential mixed method design combining data from the survey and KIIs. The survey included individuals involved in polio eradication between 1988 and 2019, and described the contexts, implementation strategies, intended and unintended outcomes...

For over a decade, investments have been made to revamp health infrastructure and service delivery to ensure access and quality for the rural poor in Afghanistan. Through contracting mechanisms the delivery of a basic package of health services has achieved significant improvements in coverage for reproductive and child health services. Employing multilevel probability sampling, 7057 households were selected in communities within the public health facility catchment areas in nine provinces, in 2010. Preferential careseeking for common pediatric conditions and average costs of payment were examined based on the wealth quintile of the respondents. Results: Commonly reported conditions were those targeted by IMCI: diarrhea (7%), fever (26%) and cough (30%), with significantly lower levels of careseeking for children in the poorest quintile, though a majority sought care from public facilities. Primary reasons for not seeking care were perceived seriousness of illness (35%), lack of tra...

Despite progress in improving health outcomes in Afghanistan by contracting public health services through non-governmental organizations (NGOs), inequity in access persists between the poor and non-poor. This study examined the distributive effect of different contracting types on primary health services provision between the poor and non-poor in rural Afghanistan. Contracts to NGOs were made to deliver a common set of primary care services in each province, with the funding agencies determining contract terms. The contracting approaches could be classified into three contracting out types (CO-1, CO-2 and CO-3) and a contracting-in (CI) approach based on the contract terms, design and implementation. Exit interviews of patients attending randomly sampled primary health facilities were collected through systematic sampling across 28 provinces at two time points. The outcome, the odds that a client attending a health facility is poor, was modelled using logistic regression with a rob...

Abstract Background Despite significant progress over the last decade in expanding coverage of a basic package of health services in Afghanistan, utilisation of maternal and child health services remain low, especially in rural areas. First introduced in Latin America and now expanding to Africa and Asia, conditional cash transfer (CCT) programmes, which provide monetary incentives to households meeting certain behavioural requirements, show promising results. While evidence in favour of CCT for low-income and middle-income countries is growing, little is known about the effects and challenges of CCT in post-conflict settings where resources are stretched, service provision is limited, systems are fragile, and security is tenuous. The objectives of this impact evaluation are (1) to assess the impact of CCT on utilisation of institutional delivery and DPT3 vaccination in Afghanistan and (2) to understand contextual and process factors that affect programme implementation. Methods A sequential mixed methods design was used. The first phase of the study involved analyses of baseline and end-line household survey and facility-based data collected through the Health Management Information System from 2009 to 2011. To assess the effects of incentives on service utilisation, we used two analytical approaches—difference-in-differences and interrupted time series. In the second phase of the study, we conducted a qualitative study to better understand operational factors that make certain districts more successful at implementing CCT, as well as to identify common challenges. Findings Results suggest that CCT may be an effective tool to stimulate demand for maternal and child health-service utilisation in Afghanistan. In comparison with intervention arms that provide monetary incentives only to the family, or only to community health workers, programmes that incentivise both families and community health workers show an 8 percentage point increase (p=0·047) in service utilisation from baseline. Interpretation CCT may be an effective policy tool to stimulate demand for health services in post-conflict settings. However, design, implementation, and evaluation of CCT programmes require careful consideration. Funding GAVI provided funding for programme implementation and USAID provided funding for the evaluation.

Afghanistan has made great strides in the coverage of health services across the country but coverage of key indicators remains low nationally and whether the poorest households are accessing these services is not well understood. We analyzed the Afghanistan Mortality Survey 2010 on utilization of inpatient and outpatient care, institutional delivery and antenatal care by wealth quintiles. Concentration indexes (CIs) were generated to measure the inequality of using the four services. Additional analyses were conducted to examine factors that explain the health inequalities (e.g. age, gender, education and residence). Among households reporting utilization of health services, public health facilities were used more often for inpatient care, while they were used less for outpatient care. Overall, the utilization of inpatient and outpatient care, and antenatal care was equally distributed among income groups, with CIs of 0.04, 0.03 and 0.08, respectively. However, the poor used more p...

Background. The knowledge and attitudes of healthcare workers regarding HIV infection are important factors influencing the readiness of people living with HIV to access care, and the quality of the care they receive. In addition to factors such as stigma and bias, how healthcare workers perceive their own risks in relation to caring for HIV-positive patients may potentially influence their willingness to provide care andtheir attitudes towards HIV-infected patients. In Afghanistan, there is a lack of information on the prevalence of HIV in general population. The country, however, has many risk factors that could facilitate HIV transmission.Objective. To assess HIV-related knowledge, attitudes, and risk perception amongst healthcare workers in Afghanistan national and regional hospitalsMethods. A cross-sectional survey among healthcare workers was conducted in five large hospitals selected in Afghanistan. Approval was obtained from the Institutional Review Board of the Ministry of ...

Results-based financing (RBF) has been introduced as a payment mechanism worldwide. RBF interventions provide incentives to healthcare providers based on health outcomes and quality of care. Previous literature reviews on RBF have mainly focused on the effectiveness of the interventions and have looked at unintended consequences as one of many outcomes of the RBF intervention. This systematic review aimed to include all papers that specifically assessed unintended consequences of RBF interventions, their impact, and recommendations for improved program designs. We conducted a search for published, unpublished, and grey literature up to July 2013. Two independent reviewers screened titles and abstracts of 190 studies for relevance against several inclusion and exclusion criteria. A total of 12 studies are included in this review, nine experimental or observational studies and three qualitative/ perception studies. Our findings show the lack of extensive empirical evidence on unintend...

Results-based financing (RBF) has been receiving increasing attention in recent decades. RBF involves a transfer of funds based on the attainment and verification of predetermined outcomes. Afghanistan has implemented RBF in the form of performance-based contracting (PBC) since 2003 and performance-based financing (PBF) between 2010 and 2015. The PBC experience was successful in delivering maternal and child health services. However, the PBF programme had minimal effect on the delivery of maternal and child health services. Using a political economy lens, this thesis answers the question of what factors shaped and affected the PBC and PBF programmes and their outcomes in Afghanistan. It also examines the cost-effectiveness of the PBF programme relative to standard practice. This thesis provides support for the assertion that both political economy factors and value for money are critical in the design, adoption and implementation of RBF programmes. RBF enforces different arrangement...

Vertical disease control programmes have enormous potential to benefit or weaken health systems, and it is critical to understand how programmes’ design and implementation impact the health systems and communities in which they operate. We use the Develop–Distort Dilemma (DDD) framework to understand how the Global Polio Eradication Initiative (GPEI) distorted or developed local health systems. We include document review and 176 interviews with respondents at the global level and across seven focus countries (Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, India, Indonesia and Nigeria). We use DDD domains, contextual factors and transition planning to analyse interactions between the broader context, local health systems and the GPEI to identify changes. Our analysis confirms earlier research including improved health worker, laboratory and surveillance capacity, monitoring and accountability, and efforts to reach vulnerable populations, whereas distortions include ...

The Government of Afghanistan has expressed a commitment to fight corruption, dating back to 2008 when the Independent AdministrativeReform and Civil Service Commission (IARCSC) and the United Nations Development Program (UNDP) Accountabilityand Transparency Project commissioned consultants to work with Afghan agencies to develop a Corruption Monitoring System.A subsequent workshop and report identifying indicators served as the basis for several strategies proposed by the Ministry ofPublic Health (MoPH). This paper discusses attempts to implement these strategies between 2008 and 2011, finding progress to besub-optimal. Proposed reasons range from tribal pressures to maintain the status quo at the level of government, to a preferentialfocus of donors on discrete health programs over institutional development. However, if sustainable services are to be providedby the Government in the long term, the Ministry cannot be circumvented and efforts need to be directed to strengthening pub...

Background Performance-based financing (PBF) has attracted considerable attention in recent years in low and middle-income countries. Afghanistan’s Ministry of Public Health (MoPH) implemented a PBF programme between 2010 and 2015 to strengthen the utilisation of maternal and child health services in primary health facilities. Methods We used a political economy analysis framework which aims to understand the main dynamics that influence the adoption and design of a policy and facilitates the exploration of policy processes and the roles played by key actors at various stages of implementation. Retrospective qualitative research methods were employed. The data comprised transcripts of key informant interviews and a review of PBF related documents. Results This study discovered a range of contextual factors contributing to the introduction of PBF in Afghanistan. In addition, the study identified the role, power, interest, and ideas of actors in relation to PBF and the extent to which...

In 2002 Afghanistan's Ministry of Public Health (MoPH) and its development partners initiated a new paradigm for the health sector by electing to Contract-Out (CO) the Basic Package of Health Services (BPHS) to non-state providers (NSPs). This model is generally regarded as successful, but literature is scarce that examines the motivations underlying implementation and factors influencing program success. This paper uses relevant theories and qualitative data to describe how and why contracting out delivery of primary health care services to NSPs has been effective. The main aim of this study was to assess the contextual, institutional, and contractual factors that influenced the performance of NSPs delivering the BPHS in Afghanistan. The qualitative study design involved individual in-depth interviews and focus group discussions conducted in six provinces of Afghanistan, as well as a desk review. The framework for assessing key factors of the contracting mechanism proposed by L...

Background. The knowledge and attitudes of healthcare workers regarding HIV infection are important factors influencing the readiness of people living with HIV to access care, and the quality of the care they receive. In addition to factors such as stigma and bias, how healthcare workers perceive their own risks in relation to caring for HIV-positive patients may potentially influence their willingness to provide care andtheir attitudes towards HIV-infected patients. In Afghanistan, there is a lack of information on the prevalence of HIV in general population. The country, however, has many risk factors that could facilitate HIV transmission.Objective. To assess HIV-related knowledge, attitudes, and risk perception amongst healthcare workers in Afghanistan national and regional hospitalsMethods. A cross-sectional survey among healthcare workers was conducted in five large hospitals selected in Afghanistan. Approval was obtained from the Institutional Review Board of the Ministry of Public Health of Afghanistan and interviews were voluntary. Data analysis was conducted using STATA 11.0 to calculate frequencies and to perform cross-tabulation and logistic regressions with adjusted odd ratio and 95%confidence interval in order to detect statistical significance on differences in knowledge and attitude among healthcare workers in the targeted hospitals.Results. Among 741 healthcare workers who participated in the study, 34.4% (255) correctly identified all correct modes of HIV transmission and 32.1% (238) correctly identified all incorrect modes of HIV transmission. Only 10.4% (77) correctly identified both correct and incorrect modes of HIV transmission. Nurses 12.3% (27) were most knowledgeable by correctly identifying all correct and incorrect modes of HIV transmission. The majority of healthcare workers expressed a willingness to care for people living with HIV. While 88% of healthcare workers believed that it is necessary to take extra infection precautions for people living with HIV, 76% presumed that people living with HIV should be nursed separately from other patients.Conclusion. Nearly 2 of every 3 Afghan healthcare workers in this sample lacked basic knowledge about the routes of transmission of HIV.These findings provide support for both improving the education of current healthcare workers, and integrating teaching modules that include the topics of disease transmission, clinical care, and universal precautions into curricula of health educational institutions.

In 2004, Afghanistan pioneered a balanced scorecard (BSC) performance system to manage the delivery of primary health care services. This study examines the trends of 29 key performance indicators over a 5-year period between 2004 and 2008. Independent evaluations of performance in six domains were conducted annually through 5,500 patient observations and exit interviews and 1,500 provider interviews in >600 facilities selected by stratified random sampling in each province. Generalized estimating equation (GEE) models were used to assess trends in BSC parameters. There was a progressive improvement in the national median scores scaled from 0-100 between 2004 and 2008 in all six domains: patient and community satisfaction of services (65.3-84.5, p<0.0001); provider satisfaction (65.4-79.2, p<0.01); capacity for service provision (47.4-76.4, p<0.0001); quality of services (40.5-67.4,…

Since 2003, the Afghan Ministry of Public Health (MoPH) and international partners have directed a contracting-out model through which non-governmental organisations (NGOs) deliver the Basic Package of Health Services (BPHS) in 31 of the 34 Afghan provinces. The MoPH also managed health service delivery in three provinces under an alternative initiative entitled Strengthening Mechanisms (SM). In 2011, under the authority of the MoPH and Delegation of the European Union to Afghanistan, EPOS Health Management conducted a cost and technical efficiency study of the contracting-out and SM mechanisms in six provinces to examine economic trade-offs in the provision of the BPHS. The study provides analyses of all resource inputs and primary outputs of the BPHS in the six provinces during 2008 and 2009. The authors examined technical efficiency using Data Envelopment Analysis (DEA) at the BPHS facility level. Cost analysis results indicate that the weighted average cost per BPHS outpatient visit totalled $3.41 in the SM provinces and $5.39 in the NGO-led provinces in 2009. Furthermore, the data envelopment analyses (DEAs) indicate that facilities in the three NGO-led provinces scored 0.168 points higher on the DEA scale (0-1) than SM facilities. The authors conclude that an approximate 60% increase in costs yielded a 16.8% increase in technical efficiency in the delivery of the BPHS during 2009 in the six provinces.

BACKGROUND Afghanistan has one of the highest rates of maternal mortality in the world. We assess the health outcomes and cost-effectiveness of strategies to improve the safety of pregnancy and childbirth in Afghanistan. METHODS Using national and sub-national data, we adapted a previously validated model that simulates the natural history of pregnancy and pregnancy-related complications. We incorporated data on antenatal care, family planning, skilled birth attendance and information about access to transport, referral facilities and quality of care. We evaluated single interventions (e.g. family planning) and strategies that combined several interventions packaged as integrated services (transport, intrapartum care). Outcomes included pregnancy-related complications, maternal deaths, maternal mortality ratios, costs and cost-effectiveness ratios.Findings Model-projected reduction in maternal deaths between 1999-2002 and 2007-08 approximated 20%. Increasing family planning was the ...

Human resources for health are self-evidently critical to running a health service and system. There is, however, a wider set of social issues which is more rarely considered. One area which is hinted at in literature, particularly on fragile and conflict-affected states, but rarely examined in detail, is the contribution which health staff may or do play in relation to the wider state-building processes. This article aims to explore that relationship, developing a conceptual framework to understand what linkages might exist and looking for empirical evidence in the literature to support, refute or adapt those linkages. An open call for contributions to the article was launched through an online community. The group then developed a conceptual framework and explored a variety of literatures (political, economic, historical, public administration, conflict and health-related) to find theoretical and empirical evidence related to the linkages outlined in the framework. Three country c...