The Ministry of Public Health (MOPH) in Afghanistan has developed a balanced scorecard (BSC) to regularly monitor the progress of its strategy to deliver a basic package of health services. Although frequently used in other health-care settings, this represents the first time that the BSC has been employed in a developing country. The BSC was designed via a collaborative process focusing on translating the vision and mission of the MOPH into 29 core indicators and benchmarks representing six different domains of health services, together with two composite measures of performance. In the absence of a routine health information system, the 2004 BSC for Afghanistan was derived from a stratified random sample of 617 health facilities, 5719 observations of patient-provider interactions, and interviews with 5597 patients, 1553 health workers, and 13 843 households. Nationally, health services were found to be reaching more of the poor than the less-poor population, and providing for more women than men, both key concerns of the government. However, serious deficiencies were found in five domains, and particularly in counselling patients, providing delivery care during childbirth, monitoring tuberculosis treatment, placing staff and equipment, and establishing functional village health councils. The BSC also identified wide variations in performance across provinces; no province performed better than the others across all domains. The innovative adaptation of the BSC in Afghanistan has provided a useful tool to summarize the multidimensional nature of health-services performance, and is enabling managers to benchmark performance and identify strengths and weaknesses in the Afghan context. Une traduction en français de ce résumé figure à la fin de l'article. Al final del artículo se facilita una traducción al español.
This paper presents findings on conditions of healthcare delivery in Afghanistan. There is an ongoing debate about barriers to healthcare in low-income as well as fragile states. In 2002, the Government of Afghanistan established a Basic Package of Health Services (BPHS), contracting primary healthcare delivery to non-state providers. The priority was to give access to the most vulnerable groups: women, children, disabled persons, and the poorest households. In 2005, we conducted a nationwide survey, and using a logistic regression model, investigated provider choice. We also measured associations between perceived availability and usefulness of healthcare providers. Our results indicate that the implementation of the package has partially reached its goal: to target the most vulnerable. The pattern of use of healthcare provider suggests that disabled people, female-headed households, and poorest households visited health centres more often (during the year preceding the survey interview). But these vulnerable groups faced more difficulties while using health centres, hospitals as well as private providers and their out-of-pocket expenditure was higher than other groups. In the model of provider choice, time to travel reduces the likelihood for all Afghans of choosing health centres and hospitals. We situate these findings in the larger context of current debates regarding healthcare delivery for vulnerable populations in fragile state environments. The 'scaling-up process' is faced with several issues that jeopardize the objective of equitable access: cost of care, coverage of remote areas, and competition from profit-orientated providers. To overcome these structural barriers, we suggest reinforcing processes of transparency, accountability and participation.
The present paper attempts to analyse some of the shortcomings that have impeded efforts in the field of disability policy in Afghanistan. After an overview of recent disability initiatives, this paper attempts to explain why they have had a limited impact. The context of a Conflict-Affected Fragile State makes the development of state capacity to deliver basic services for the population particularly difficult. To help overcome these shortcomings, it is argued that Amartya Sen's Capability Approach constitutes a relevant framework for designing disability policy and implementation. Although the definition of human development has evolved considerably over the past decade, the transition from theory to action has been disappointing. Through the example of the National Disability Survey in Afghanistan we argue that one reason for this is the paucity of knowledge and the insufficient focus placed on enhancing the agency of vulnerable groups.Cet article constitue une tentative d'analyse de certains manquements qui ont ralenti les efforts mene´s dans le champ du handicap en Afghanistan. Apres le passage en revue des initiatives re´centes, l'article pre´sente les e´le´ments qui ont contribue´a`limiter leur impact. Le de´veloppement des services publics de base est particulie`rement difficile dans les Etats fragiles. Afin de surmonter les insuffisances identifie´es, les auteurs estiment que l'approche par les capabilite´s de Amartya Sen offre un cadre d'analyse approprie´pour de´finir une politique du handicap et la mettre en oeuvre. Bien que la de´finition du de´veloppement humain ait beaucoup e´volue´au cours de la dernie`re de´cennie, sa traduction dans les faits demeure insuffisante, sans aucun effet visible sur le processus d'e´laboration des politiques publiques ni meˆme en terme de bien-eˆtre. En s'appuyant sur l'exemple de l'enqueˆte nationale sur le handicap en Afghanistan, les auteurs de´battent du besoin de connaissances scientifiques ainsi que des de´fis pose´s par un travail de recherche fondeś ur l'approche par les capabilite´s pour de´finir et mettre en oeuvre une politique publique du handicap.
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