System Enhancing for Health Actions in Transition (SEHAT) Program
The development objectives of the System Enhancement for Health Action in Transition Project for Afghanistan are to expand the scope, quality and coverage of health services provided to the population, particularly to the poor, in the project areas, and to enhance the stewardship functions of the ministry of public health (MOPH). Financing is needed for implementation of the basic package of health services (BPHS) and essential package of hospital services (EPHS) through contracting out and contracting in arrangements both in rural and urban areas in provinces supported by the European union (EU), the Afghanistan Reconstruction Trust Fund (ARTF) and the World Bank, covering a total of twenty one provinces in the country (out of thirty four provinces). System enhancement for health action in transition (SEHAT) will be a platform nation-wide project, which will allow for financing health services in more provinces if additional resources become available. The project will also strengthen the national health system and ministry of public health's capacity at central and provincial levels, so it can effectively perform its stewardship functions in the sector.
SEHAT has three components which are i) Component 1: Sustaining and improving BPHS and EPHS services; ii) component II: Building the stewardship capacity of MoPH and system development and component III: Strengthening program management
For a decade, the European Union (EU), the United States Agency for International Development (USAID) and the World Bank (WB) have been supporting health service delivery in Afghanistan, each targeting a specific set of provinces. The World Bank provided financing for 11 provinces through Strengthening Health Activities for the Rural Poor (SHARP), which ended on September 30, 2013. Similarly, the EU provided financial support for the provision of Basic Package of Health Services (BPHS) and Essential Package of Hospital Services EPHS in 10 provinces, and USAID provides financing for the same service packages in the remaining 13 provinces. The support has been well coordinated by the Ministry of Public Health (MoPH) and the package of services provided was very similar in each of the provinces. Central functions were also supported by these three development partners in a complementary fashion. Under this arrangement, the WB supported a Service Procurement and Contract Management Department (SPCMD/ GCMU), third party monitoring and results based financing for improved service delivery. Besides financing BPHS and EPHS, EU and the USAID also financed SPCMD and capacity building activities both for the MOPH and the NGOs. The bilateral EU support to the Basic Package of Health Services (BPHS) and the Essential Package of Hospital Services (EPHS) finished on December 30, 2013.
The SEHAT Project finances the implementation of the BPHS and EPHS through contracting out and contracting in arrangements both in rural and urban areas in provinces supported by the EU, the ARTF and the World Bank, covering 21 of the 34 provinces in the country and urban Kabul. With the USAID joining SEHAT, it will be a platform nation-wide project that allows for financing health services in all 34 provinces of the country. In addition, financial support for implementation of Results-Based Financing will continue under SEHAT project through June 30, 2018.
The project will also strengthen the national health system and MOPH’s capacity at central and provincial levels. In an effort to effectively perform its stewardship function the MoPH in collaboration with the development partners identified ten thematic areas to be supported under SEHAT. The groups, assigned to develop thematic areas proposals, have already started their work and the progress to date is slow as it is a new experience for the MoPH departments.
Download the SEHAT EPP (Emergency Project Paper) here
Component 1: Sustaining and improving BPHS and EPHS services (estimated total cost of US$307 million): This component will support the implementation of the BPHS and EPHS through performance-based partnership agreements (PPAs), i.e. contracts between MOPH and NGOs which will deliver health services as defined in these packages. It will also support the government’s efforts in delivering the BPHS and EPHS through contracting in management services in designated provinces, and the implementation of an urban version of the BPHS in Kabul city and possibly to other cities. It will include support to improve access to and quality of BPHS/EPHS services, as well as training of additional community midwives and community nurses. In addition, financing will be made available for contracted services specifically for marginalized populations such as prisoners and nomads. HIV/AIDS prevention services will be contracted out for targeted population sub-groups who are at an elevated risk for HIV-infection, if funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria is insufficient.
The RBF scheme, piloted under the current SHARP project, will be mainstreamed. This will involve the completion of ongoing pilot in 14 provinces as well as an in-depth impact evaluation to inform future direction and mainstreaming of the RBF in Afghanistan under SEHAT. This will help to further refine the performance-based contracts with NGOs. The RBF scheme has been under implementation for the past 24 months. Preliminary results are promising and show increasing coverage of key maternal and child health services, besides higher equity of service utilization and quality of services. Furthermore, the implementation arrangements for the scheme will be mainstreamed so that it is embedded in the arrangements for BPHS and EPHS implementation. As such, the contract management, monitoring and supervision of the scheme by MOPH will be within those of BPHS/EPHS. The impact evaluation under SEHAT will supplement the impact evaluation of a more limited scope to be completed under SHARP to measure the results of the RBF implementation in the selected provinces. The impact evaluations will be financed by the HRITF.
Component 2: Building the stewardship capacity of MOPH and system development (estimated total cost of US$90 million): This component includes:
- (a) Strengthening Sub-national Government (provincial health departments) by supporting: i) strengthening sub-national planning and budgeting; ii) strengthening operations and maintenance; and iii) building Provincial Health Directorates’ capacity to undertake their enhanced functions as envisaged in the sub-national governance policy and the provincial budgeting initiative.
- (b) Strengthening the Healthcare Financing Directorate through support for the MOPH to undertake analytical work, including the development and testing of appropriate financing models for the sector.
- (c) Developing Regulatory Systems and Capacities for Ensuring Quality Pharmaceuticals: Support will be provided to establish and operationalize a regulatory mechanism and quality assurance system for the pharmaceutical sub-sector.
- (d) Working with the Private Sector: This will include carrying out analytical work to understand and build knowledge about the potential role for better engagement of the private sector in the provision of health services.
- (e) Enhancing Capacity for Improved Hospital Performance: Based on the ongoing hospital assessment, the project will help to design a hospital provider payment mechanism that will enhance accountability of the autonomous hospitals. This sub-component will support the piloting of this new mechanism in two hospitals in Kabul.
- (f) Strengthening Human Resources for Health: This sub-component will strengthen the human resources capacities within the MOPH regular civil services staff. Hence, this subcomponent is directly linked with Capacity Building for Results (CBR) program proposal with a focus on ensuring availability of female health workers.
- (g) Governance and Social Accountability: This sub-component will support: i) streamlining and simplification of the MOPH internal procedures/processes and; ii) introducing a beneficiary feedback mechanism to enhance social accountability in the health sector. In addition, it will strengthen transparency of the system and communication capacity at MOPH to pro-actively reach out to the general public.
- (h) Strengthening Health Information System (HIS) and Use of Information Technology: The project will support key activities such as mainstreaming HIS activities and capacity
development at central and provincial levels along with improving data utilization at different levels of the health sector. Strengthening Health Promotion and Behavioral Change: This sub-component will strengthen the Health Promotion Unit to implement behavior change campaigns targeting specific behaviors to reduce malnutrition, promoting breastfeeding and appropriate complementary feeding for the children under two years, enhanced skilled and institutional deliveries, hygiene promotion and hand washing, compliance with anti-TB drugs, etc. The final list of behavior change campaigns will be discussed and agreed during project implementation.
Improving Fiduciary Systems: The project will support the MOPH in upgrading the financial management (FM) and procurement system to a web-based system. Improving fiduciary systems would include: i) simplification of payment procedures; ii) capacity building of finance and internal audit staff of the MOPH; iii) accreditation of the procurement department of the MOPH; iv) pilot e-GP (electronic Government Procurement); and v) strengthening of procurement capacity at PHDs.
Component 3: Strengthening program management (estimated total cost of USD 10 million)
This component will support and finance cost associated with system development and stewardship functions of the MOPH. It will finance incremental operating costs of the MOPH at the central and provincial levels. In addition, it will support and finance short term technical assistance in specific areas where immediate capacity development is required. SEHAT will adhere to the Government's National Technical Assistance salary guidelines, once it is approved by the GOIRA. Until such time, the project will adhere to the CBR salary scales on the maximum level that can be paid to contracted staff. The contracted staff will be embedded in MOPH departments to transfer knowledge and further develop ministry ownership. This component will also finance a comprehensive gender assessment in the MOPH.
20. MOPH will engage with the Capacity Building for Results Facility (CBR), a separate civil service reform project supported by IDA and ARTF. The aim of CBR project is to assist performance of line ministries including the MOPH. The SEHAT project will be coordinated with CBR to assist the government in improving the capacity and performance of MOPH in carrying out its mandates and delivering services through the implementation of specific capacity and institution building programs. CBR finances the recruitment of managerial and professional staff, as civil servants, for key positions and support targeted training programs. The MOPH is developing a CBR program proposal to the Ministry of Finance with its service delivery priorities and system development reforms and related staffing needs. It will seek assistance from CBR to help finance managerial and certain technical staff ensuring it retains skilled manpower to effectively manage the sector and undertake its stewardship functions. These staff will not be financed by SEHAT under Incremental Operating Costs (IOC).
Documents for download: COMPREHENSIVE HEALTH CARE WASTE MANAGEMENT PLAN
Health Care Waste Management Plan
As per the national legislation and regulation, MOPH has the responsibility to address environmental concerns in the project. Besides, development of a comprehensive Health Care Waste Management Plan (HCWMP) is a key covenant of SEHAT Project. Therefore, the MoPH developed a Preliminary HCWM Plan for the first 6 months of the SEHAT project in 2012. The major interventions that were recognized included development and adoption of guidelines for effective healthcare waste management, creating awareness and training to the end user/the waste producer/waste handler.
The preliminary HCWM plan was not purported to cover many issues in detail. To prepare a detailed plan based on the recommendation of the preliminary plan, MoPH recruited an international consultant to work on development of a comprehensive healthcare waste management plan.
The consultant along with the officials from the Environmental Health Directorate at Ministry of Public Health, undertook field visits in Kabul, Parwan, Panjshir, and Balkh provinces having detailed interactions with various stakeholders including the health care facilities (e.g. national hospitals, regional hospitals, provincial hospitals, district hospitals, comprehensive health centers, basic health centers), international funding agencies, various department of MoPH, non-governmental organizations, landfill sites, municipalities, regulatory bodies, and other relevant agencies.
The inputs from the desk research, and interaction with the stakeholders were useful in assessing the regulatory framework and its compliance in practice, present status of HCWM at different types of HCFs, quantities of health care waste (HCW) generated, current technology in use for treatment of HCW and its disposal, monitoring & evaluating mechanism, and training needs assessment. The specific issues such as segregation of HCW and color coding practices, type of equipment in use for collection & transportation, use and disposal of sharps, development of landfill facilities for HCW disposal, and status of infection control were addressed. The plans for management of HCW from rural areas have been worked out separately based on the interaction with the various stakeholders.
These inputs were useful in developing recommendations for the HCWMP. A gap analysis was also undertaken to compare the present status and the recommendations made. The Comprehensive HCWMP duly incorporates the gap analysis as well as the capacity of the various stakeholders to adopt and implement the proposed plan.
The plan contains major guidelines to be followed during the implementation stage-which by itself is another covenant of SEHAT- provision of pilot projects for CWTFs, alternate technologies for the remote and rural areas, third party monitoring and evaluation framework, format and contents of training programs, procurement policy for major treatment technologies and safety equipment, and construction guidelines for sharp and burial pits.
To review the full plan please click to the following link:
Sehat-Sehatmandi Environmental and Social Management Framework
BACKGROUND & PROJECT CONTEXT
Despite insecurity and unstable governance since 2001, Afghanistan has made notable progress in improving maternal, new-born, and child survival, nutrition, health interventions coverage and service availability to its population. The recent 2016 Demographic and Health Survey (DHS) shows a sharp reduction in under 5 mortality rate (U5MR) to 55 per 1,000 live births from 97 per 1000 live births in 2010. The large influx of financial assistance, strong local stewardship, development of sound and stable health policy frameworks, prioritization of investments in primary care and the introduction of a basic package of health services (BPHS) and essential package of hospital services (EPHS) delivered by non-governmental organizations (NGOs), have been among some of enablers of success. For the last 15 years, the European Union (EU), the United States Agency for International Development (USAID) and the World Bank have been supporting health service delivery in Afghanistan, initially each targeting a specific set of provinces. But under System Enhancement for Health Action in Transition (SEHAT) project 2013 - 2018 resources allocated for BPHS and EPHS (on and off -budget) came under one umbrella through Afghanistan Reconstruction Trust Fund (ARTF) platform covering the entire country. Therefore, SEHAT is a nation-wide project with similar procurement and implementation approach across different provinces, which is going to continue under the proposed Sehatmandi project.
The coverage of maternal, neonatal and child health services, the health outcomes remain sub-optimal in Afghanistan. Despite significant increases in skilled birth attendant deliveries maternal mortality ratio (MMR) remains very high, estimated to be 650 per 100,000 live births. Also, neo-natal mortality rates are persistently high, accounting for about 40 percent of the total under 5 mortality. The poor quality of care continues to hamper overall health improvements.
Given the socio-political environment, the demand side factors influencing preventive health care services and community engagement have been relatively underplayed in the past. As a result, critical interventions such as family planning and maternal and infant and young child nutrition related behaviours remain at low levels. With Government of Afghanistan’s effort in implementing an ambitious program to strengthen community engagement and empowerment through the Citizens’ Charter Afghanistan Program (CCAP), it offers an opportunity to scale up demand side interventions, and scale-up small-scale pilots, such as, conditional cash transfers, use of mini ambulances and wider use of Community Health Workers (CHWs)etc. to the whole country. They can play a critical role in making further progress for women and children in Afghanistan.
Over the last decade, the financing of health systems in Afghanistan has increased with the support of international community. However, the country still faces huge challenges in providing financing for the basic health services in the country. As per the National Health Accounts (NHA) of 2014, 72% of the health expenditures in Afghanistan relies on out-of-pocket (OOP) spending; 23% relies on external aid and only 5% depends on the financing of the central government. Some of the potential drivers of such high OOP include high drug costs and payments for hospital care.