A balanced scorecard for health services in Afghanistan

Abstract

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.

Long and short Integrated Management of Childhood Illness (IMCI) training courses in Afghanistan: a cross-sectional cohort comparison of post-course knowledge and performance

“…Their further conclusion that "Strategies for scaling up IMCI and other child-survival interventions might rely on health workers with shorter duration of pre-service training being deployed to underserved areas" was similar to the perspective of MoPH after 2008 to expand IMCI training to nurses and midwives in an attempt to increase availability of trained health workers in areas where nurses or midwives were the highest level of trained health worker. The fact that non-physicians performed less well in the counselling score is surprising in light of the literature and additional research would be necessary to elucidate this further (21). Previous studies in Afghanistan have also identified that female health workers performed better in counselling and providing quality care to children, findings not substantiated by this evaluation (10,19).…”

“…In Rowe et al 's review, however, the three studies that directly compared post-training performance between short and standard IMCI courses also concluded that there was no significance difference in post-training performance between groups (8,16). Our second finding -physicians trained in the 7-Day course did slightly better than physicians trained in the 11-Day course in providing three reasons to return to the health centre and in counselling about breastfeeding, increased liquid intake and the importance of follow-up -is remarkable because, poor counselling has been identified as typical of physicians (21). We highlight, however, that the statistical power in this study was insufficient to demonstrate a difference and that pursuing this line of inquiry requires a larger study.…”

“…The use of the validators as a gold standard caused some known biases inherent in this method of validation. Firstly, observation caused health workers to change their usual habits, an effect that was demonstrated by an average consultation time of 25 minutes during this evaluation when in fact, Afghan health workers spend an average of 7 minutes per visit (21,28). Thus, this evaluation did not clarify how health workers behaved in the absence of an observer.…”

Towards sustainable dilivery of health services in Afghanistan: options for the future

“…18,19 Two rounds of assessment have been completed since 2004. The exercise is aimed at monitoring and evaluating the delivery of basic health-care services in the 34 provinces covered by national and international NGOs and through internal contracts with the provincial tiers within the public health ministry (via the strengthening mechanism).…”

Assessing National Health Systems: Why and How

“…These types of assessments can be used for periodic review, evaluation, and course corrections, often integrating the assessments into a regular planning and budgeting cycle, so that problems can be identified and addressed through re-prioritization of efforts and re- 17,18 The trigger to take this approach has ranged from formation of a new government and new national health policy, to concerns from civil society organizations concerning poor quality or inequality in the performance of the national health system, or a planned evaluation of health reforms.…”