Transcript Implementation of Pharmaceutical Pricing and

Some Practical Lessons
on Implementing RBF from
Afghanistan
Benjamin Loevinsohn
World Bank
October 2008
Outline
1.
2.
3.
4.
Background on Afghanistan
What the Government tried to do
Some of the results accomplished
Practical lessons about implementation
Very conservative society where social
obstacles impede women’s access to
services
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
Afghanistan in 2002Reasons to Worry

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
Little physical infrastructure
MOPH had limited capacity
Health workers afflicted by the “3 wrongs”

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

wrong gender
wrong skills
wrong location
Little coordination of NGO activities
Distribution of NGO Health Centers
was Chaotic and Unequal – 1 HF per
50,000
Road
un-served
Inequalities were very serious, MMR much
worse in rural and remote areas
8000
6507
6000
4000
2182
2000
418
774
0
Kabul (urban)
Alishen,
Laghman
(semirural)
Maywand,
Kandahar
(rural)
Ragh,
Badakshan
(rural, most
remote)
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
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
Results-Based Contracting - PPAs


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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
Results-based Aspects of
PPAs

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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
Setting up a Grants and
Contract Management Unit
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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
Health Facility Surveys
JHU worked with stakeholders to
develop a health facility assessment
 Carried out annually since 2004
 600+ facilities per year
 Formulated a “balanced score-card”
(BSC) that rated facilities on a scale of
0-100

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

80
32% Improvement in Quality of
Care from facility survey (BSC)
75
70
65
MOPH Alone
60
PPA Median
Non-PPA Median
55
50
45
40
2004
2005
2006
2007
Improvements in Reproductive Health
– Household Surveys 2003 to 2006
35
30
25
20
2003
2005
2006
15
10
5
0
Skilled Birth Attendance
Contraceptive Prevalence
Rate
Antenatal Care
Changes in Routine Immunization
Coverage
80
70
60
50
2003
2005
2006
40
30
20
10
0
BCG
OPV3
DPT3
U5MR in Afghanistan: Actual
and MDG4 Target
300
260
250
191
200
Target
Actual
150
100
50
0
1990
1995
2000
2005
2010
2015
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
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 NGOs
c. Hold NGOs accountable for obligations
d. Track performance using available data
e. Keep MOPH leadership informed
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 rate
c. Household surveys to verify HMIS data – found
big differences for vaccination & ANC coverage
d. Field visits using checklists
e. Involve community
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
Per capita outpatient visits per year in
Secure and Insecure Provinces with
PPAs by same NGO
1
0.8
0.6
Saripul
Helmand
0.4
0.2
0
2004
2005
2006
2007
Introduction of Conditional
Cash Payment by NGO
60%
50%
40%
Introduction
of new
approaches
30%
20%
10%
13
86
M
1
M
2
M
3
M
4
M
5
M
6
M
7
M
8
M
9
M
10
M
11
M
13 12
87
M
1
M
2
0%
OPD
delivery
Family Planning
THANK YOU!