Background
Health service contracting
BPHS in Afghanistan
Study objectives
Methods
Setting
Study design
Data collection
Levels and demographic characteristics | 18 interviews (face-to-face) | 8 interviews (phone) | 4 FGDs (face-to-face) |
---|---|---|---|
Policy-makers/Donors/Advisors (Level 4)
|
7
|
3
| - |
Government | 3 | - | - |
UN/Bilateral | 3 | 1 | - |
CSO/NGO | 1 | 2 | - |
Supervisors/Managers (Level 3)
|
7
|
3
| - |
Government | 3 | - | - |
UN | 1 | - | - |
CSO/NGO | 3 | 3 | - |
Frontline providers (Level 2)
|
4
|
2
| - |
Government/NGO | 4 | 2 | - |
SRH service-users (Level 1)
a
| |||
(a) Bamyan women at a BPHS facility | - | - | 1 |
(b) Bamyan women 2 hrs from a BPHS facility | - | - | 1 |
(c) Non-educated lower-income Kabul women | - | - | 1 |
(d) Educated higher-income Kabul women | - | - | 1 |
Data analysis
Ethics
Results
Service delivery
Coverage and access
“With the introduction of the BPHS, that was simultaneous with the attention of the international community to Afghanistan…There were areas, districts, where we did not have even a single vaccinator, but now they have 45 health centres in those districts”. (Donor-level 4)
“Half of the work of the clinic involves deliveries. When you ask people ‘why don’t you go to the clinic?’ they say it’s too far”. (BPHS provider-level 2)
“But during the winter, the roads are blocked…Nothing can go there except helicopters. Even helicopters cannot go there sometimes”. (BPHS manager-level 3)
“In winter-time for IMCHN we even go by horse in some cases. We change our plan if we cannot go to some of those blocked villages…The idea now is to train some midwives for every 1,000-1,500 people…They will stay there”. (BPHS provider-level 2)
Demand and usage
“They are willing to come to the health facilities, almost all of them are not sick. Most of them need the services, the reproductive health services…They come because they are aware these are useful for them”. (BPHS provider-level 2)
“Let’s say someone has bleeding. She somehow thinks it’s related to her taking birth-control. That scares many more women to sign up for family planning…Some people even think that using birth control will prevent them from having sex or that it reduces their drive”. (BPHS manager-level 3)
“Most of the patients that come here have some form of STIs. NGOs and the aid community have not really paid any attention to this particular issue…” (BPHS provider-level 2)
“Even when there is a skilled birth attendant in the health facility they prefer to stay home”. (BPHS manager-level 3)
“Women should be working for their family members like going to the land to harvest, taking important daily activities of their family, and even bringing income to the family. Condemned to stay at home and still not go to school. And if they graduate from school, not to university”. (BPHS provider-level 2)
Service-user perspectives
“If the BPHS clinic was not there we would have to walk for hours to get to another health facility or hospital” (BPHS user-level 1)
“People are poor and they have to stay at home…” (Potential BPHS user-level 1)
“The daya is not as knowledgeable as the clinic”. (Potential BPHS user-level 1)
“My child is three months old. I was very ill during my pregnancy…, but I was not able to go to the clinic because I do not have anybody to watch my children”. (Higher-income service-user, Kabul-level 1)
Workforce
Gender and numbers
“I think one of the best things that the partners and the MoPH have done is promoting services of women by a woman”. (Donor-Level 4)
“At the BPHS level in a BHC [Basic Health Centre] we find the midwives 24-hours on duty. These midwives need rest, but she cannot leave at all because she’s the only one at the health facility…” (Civil society leader-level 4)
Training and standards
“Right now there are specific standards covering antenatal care, prenatal care, postnatal care, safe delivery or complicated cases. This is only good for staff, right now they know what to do and how to apply it”. (Donor-level 4)
“In 2002 in our country we had 467 midwives, but now we have more than 2,600…” (MoPH trainer-level 3)
Role and workload
“I think there are a lot of problems with the CHW. It has its benefits of course. In a situation where you have nothing, this is a very good network, but most of the CHWs, if you see their education background, they are very low and they don’t have this much ability to recognise the need of the patient or to give the medicine”. (MoPH senior manager-level 3)
“Each health post covers 100–150 families…[and] two CHWs. They are volunteers. Not all of them are able to leave their life and work for these numbers of families. So it was not as much effective as it was thought”. (BPHS manager-level 3)
Retention
“But now the market is better, quite better than before…You see as soon as a person is qualified, he is not willing to work in that position anymore. And one of the major problems in the health facilities, the competent staff, specially the high level staff like female MD is quite scarce”. (BPHS manager-level 3)
“…there are also people that move from one province to the other because they want to get to a province where, for example, the family is better off, there are better schools, etc.” (Donor-level 4)
Health information
Monitoring and evaluation
“Because from 9 indicators, most of them are about reproductive health”. (BPHS provider-level 2)
“So these different types of tools are coming and going. This is a little boring, so we need to have a fixed tool because time is wasting…” (MoPH manager-level 3)
Quality measurement
“It is six months or more that nobody has come from MoPH…Sometimes, you see, people do not provide the real information and the real feedback because he has connection with somebody”. (BPHS provider-level 2)
Financing
Financial information
“From the level of funding that we had in 2003, now it's increased tremendously…” (MoPH senior manager-level 4)
“We don’t have a health financing information system…[and] don’t know exactly which percentage will move to the specific lines in the reproductive health”. (NGO manager-level 3)
“Of course, if we [donors] all had the same budget headings, it will be much easier, so I think it is possible but it has not been looked at”. (Donor-level 4)
Incentives
“If you ask a women to go and provide services to a rural area, they may hesitate to go. But if they have an internal mechanism that they go for three or four years and they receive high compensation they go and the condition will be that they train local women in that area in three years, so after three years they have another person in place”. (NGO manager-level 3)
“Incentives like material and blankets for the newborn baby, like a kit for a woman that comes to postnatal care for the second and third visits. Now almost all of them do not come for the second or third visits”. (BPHS provider-level 2)
Service-user perspectives
“Even if I go to the public hospital or clinic, I cannot afford to buy the medicine. Money is needed for doctors’ fees, medicine, and travel”. (Higher-income service-user, Kabul-level 1)
Stewardship
Prioritisation
“If the RH component was not there, I'm not sure we would have got the commitment of donors. So…BPHS got funding because of RH. I can say RH got funding because of BPHS”. (MoPH senior manager-level 4)
“Because only talking about the problem is not enough, you have to provide evidence”. (MoPH senior manager-level 4)
Coordination
“I think both [MoPH and Ministry of Education] should work together. [For example] if teenagers receive sex education [SRH curriculum] only in schools but not in the clinics, then there will still be a gap”. (BPHS manager-level 3)
“So there’s the BPHS and the EPHS and they should complement one another in that there should be a functional referral system but there’s still a lot of work to be done on that…I’ve seen women carried for four days by men from the village to come to the hospital for obstructed labour”. (NGO provider-level 2)
“The referral system still is weak, referral from the health facilities to the district hospital, specifically for major obstetric complications”. (NGO manager-level 3)
“Coordination is always difficult, especially now with the different donors funding it, every donor having its own procedures and its own reporting requirements”. (MoPH senior manager-level 4)
Accountability
“I think the implementers are more accountable because they are contracted…” (Donor-level 4)
“It’s a good mechanism for accountability towards the donors, towards the MoPH, towards the institutions, how much this is accountable to the beneficiaries, I don’t know”. (Donor-level 4)
Service-user perspectives
“I am uneducated and I can’t read and write. First we go to God. But if we know someone can help us, then we would go to him. Maybe the head of Shura or whoever…” (BPHS user-level 1)