Annual Results and Impact Evaluation Workshop for RBF - Day Four - Learning from RBF Implementation
Some Practical Lessons on Implementing RBF from Afghanistan
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Transcript of Some Practical Lessons on Implementing RBF from Afghanistan
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Some Practical Lessons on Implementing RBF from
Afghanistan
Benjamin Loevinsohn
World Bank
October 2008
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Outline
1. Background on Afghanistan
2. What the Government tried to do
3. Some of the results accomplished
4. Practical lessons about implementation
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Very conservative society where social Very conservative society where social obstacles impede women’s access to obstacles impede women’s access to
servicesservices
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Country Context
Pop’n = 25 Million 650 000 km2 34 provinces One of the poorest countries in the world (GDP ~ 300 dollars/ capita/year Civil War since 1978 1-2 million people died, >5 million refugees 80% rural
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Afghanistan in 2002-Reasons to Worry
Little physical infrastructure MOPH had limited capacity Health workers afflicted by the “3 wrongs”
wrong gender wrong skills wrong location
Little coordination of NGO activities
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Distribution of NGO Health Centers was Chaotic and Unequal – 1 HF per 50,000
un-servedRoad
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Inequalities were very serious, MMR much worse in rural and remote areas
418774
2182
6507
0
2000
4000
6000
8000
Kabul (urban) Alishen,Laghman
(semirural)
Maywand,Kandahar
(rural)
Ragh,Badakshan(rural, most
remote)
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What the Government did: Established the “Basic Package of Health
Services” – priority health interventions Signed Results-Based Contracts with NGOs
on a very large scale – 90% of rural Afghans live in areas served by contracted NGOs
Competitively recruited Afghans to work in MOPH at market wages
Invested heavily in monitoring & 3rd party evaluation including HFSs, HHSs, HMIS
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Results-Based Contracting
EC, USAID, MOPH (with WB funding) signed contracts/grants with NGOs
Similarities: focused on BPHS; same indicators & M&E process; clear geographic responsibility (provinces); competitive recruitment; move towards MOPH management of all grants
and contracts
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Results-Based Contracting - PPAs MOPH signed “performance-based partnership
agreements” (PPAs) using WB funds 46% local NGOs, 27% INGOs, 29% with
consortia credible threat of sanctions – one INGO was
terminated for poor performance, one local NGO’s contract not extended
considerable autonomy – lump sum instead of line item budgets
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Results-based Aspects of PPAs
Credible threat of termination Bonuses for NGOs: annual 1% of contract
value for 10 point increase in BSC, 5% for increase in coverage at the end of the contract
Could have been better designed (+23% in year 1, less bonus than 10% and 10%)
bonuses also paid to provincial health officials to align incentives
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Setting up a Grants and Contract Management Unit
Competitive recruitment of local consultants Transparent recruitment thru involvement of
external stakeholders Paid market wages but on contract Caused considerable resentment in MOPH However, attracted very capable people, many
from NGO sector Much appreciated by senior management Much cheaper than international consultants
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Health Facility Surveys
JHU worked with stakeholders to develop a health facility assessment
Carried out annually since 2004 600+ facilities per yearFormulated a “balanced score-card”
(BSC) that rated facilities on a scale of 0-100
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Health Facility Surveys – An Important M&E Tool
BSC looked at 29 areas of care including: (i) equity; (ii) patient satisfaction; (iii) availability of drugs, equipment, & staff; (iv) knowledge of providers; (v) quality of patient-provider interaction; (vi) patient load, etc.
Costs about $300,000 per year
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32% Improvement in Quality of Care from facility survey (BSC)
40
45
50
55
60
65
70
75
80
2004 2005 2006 2007
MOPH Alone
PPA Median
Non-PPA Median
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Improvements in Reproductive Health – Household Surveys 2003 to 2006
0
5
10
15
20
25
30
35
Skilled Birth Attendance Contraceptive PrevalenceRate
Antenatal Care
2003
2005
2006
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Changes in Routine Immunization Coverage
0
10
20
30
40
50
60
70
80
BCG OPV3 DPT3
2003
2005
2006
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U5MR in Afghanistan: Actual and MDG4 Target
0
50
100
150
200
250
300
1990 1995 2000 2005 2010 2015
Target
Actual
260
191
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Implementation Lessons Learned
1. Have clear objectives: The MOPH focused on the BPHS in rural areas and ensured all DPs did too!!
2. Have explicit contracts: The MOPH spent time and effort to ensure contracts were clear on what was expected but left how to NGOs. Used a checklist in designing them
3. Have an explicit plan: PIP dealt with NGO selection, contract management, M&E
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Implementation Lessons Learned
4. Clear Arrangements for Contract Mgt: MOPH set up GCMU: 10 people with proper budget – look after all DP contracts/grants
a. Field visits to assess progress, ID issues, and diagnose causes
b. Ensure prompt payment of NGOsc. Hold NGOs accountable for obligationsd. Track performance using available datae. Keep MOPH leadership informed
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Implementation Lessons Learned
5. Monitor Carefully: Used different sources of information to assess performance on explicit indicators:
a. Health facility surveys – very useful to do yearly by 3rd party
b. HMIS – insisted on high reporting ratec. Household surveys to verify HMIS data – found
big differences for vaccination & ANC coveraged. Field visits using checklistse. Involve community
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Implementation Lessons Learned
6. Give Implementers Autonomy: MOPH gave NGOs substantial autonomy by:
a. Use of lump-sum (not line item budgets)
b. Allowing NGOs to procure their own drugs, supplies, and equipment
c. Focusing on what not how; e.g. insisted on female health workers
d. Encouraging NGOs to innovate
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Per capita outpatient visits per year in Secure and Insecure Provinces with PPAs by same NGO
0
0.2
0.4
0.6
0.8
1
2004 2005 2006 2007
Saripul
Helmand
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Introduction of Conditional Cash Payment by NGO
0%
10%
20%
30%
40%
50%
60%
OPD
delivery
Family Planning
Introduction of new approaches
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