Project Description

Project name: Health Sector Emergency Reconstruction and Development Project
Project Status: Open
Project Approval Date: June 5, 2003
Project ID: P078324

When the Taliban fell, Afghanistan had some of the worst health indicators in the world. It had an estimated under-five mortality rate of 256 per 1,000 births, compared to 92 for South Asia. This project aims to improve primary health care which in turn, will decrease child and maternal mortality rates. It focuses on rural areas, many of which have never had functioning health services. It builds on the work of local and international NGOs that were already providing some 80% of health services at the time of the Taliban. The Project finances contracts between the Ministry of Public Health and ten NGOs to deliver health services in 12 provinces. Another four provinces are covered directly by the Ministry with project funds. Volunteer community health workers are being trained, the number of health centers is increasing, and the quality of care is improving. Performance is monitored by a third party. Based on successful results so far, supplementary financing was provided in early 2006.

Highlights

• • The number of people visiting a health center in rural areas has increased fourfold since 2004. In most low income countries the average is 0.3 visits per person per year, whereas in Afghanistan it is approaching 1.0 in areas covered by the project
• • The number of people visiting a health center in rural areas has increased fourfold since 2004. In most low income countries the average is 0.3 visits per person per year, whereas in Afghanistan it is approaching 1.0 in areas covered by the project
• • The Ministry of Public Health has contracted with NGO service providers in districts where 80% of the population are living - boosting access to health care in rural areas."
• • An independent assessment of quality of care shows a 40% increase in patient satisfaction, provider knowledge, quality of the patient-provider interaction, and utilization by the poor.
• • There has been a 60% increase in the number of functional health centers in the 11 provinces financed by the project during Phase I. Third party evaluations show that the centers are fully supplied, equipped, and staffed. There is almost no absenteeism, which compares well with up to 40% absenteeism among public sector doctors elsewhere in South Asia.
• • The number of pregnant women receiving prenatal care per year has increased from 8,500 in 2003 (5% of pregnant women, based on the baseline household survey) to 123,000 in 2006 (63%, based on health management information system data). An ongoing household survey to be available by March 2007 should confirm these numbers.
• • NGOs maintained and even expanded services in unstable areas. In Helmand, one of the more insecure provinces, the number of patients seen more than doubled, from 157,000 in 2004 to 338,000 in 2006, despite the assassination of four health workers and the destruction of 15% of health centers.
• • The TB case detection rate—the number of patients diagnosed as a proportion of the expected number of TB cases—has increased from less than 10% to almost 50% in less than 2 years, but it is still a long way towards the international standard of 70%.
• • 8,000 patients have been diagnosed and are receiving effective TB treatment.
• • More than 10,000 community health workers—half of whom are women—have been trained and deployed. They have helped increase family planning and childhood vaccination. The number of couples using modern methods of family planning has increased from 47,000 to 115,000 in 11 provinces, in part thanks to supplies distributed by these workers.
• • The number of facilities with trained female health workers has increased from 25% before the project to 85% today.

Total Financing

IDA has provided a total of $95 million in grant financing since 2003, including supplementary financing of $30 million that was approved in February, 2006 and which will end in 2008. Total public sector health care financing is estimated at $180 million per year, of which about 90% is from external sources and 78% is off-budget.

IDA Contribution

IDA helped design the project and strengthen the capacity of the Ministry of Public Health to tender and manage contracts. It has brought experience from other post-conflict situations such as Cambodia, Timor Leste, and the Democratic Republic of Congo to Afghanistan. For example, IDA financed the trip of a Cambodian government official to share experiences working with NGOs with his Afghan counterparts. IDA has also encouraged other donors to adopt a similar approach. The EU is now channeling its financing through the ministry. Both USAID and the EU have also moved towards having the ministry monitor performance and to insist on performance-based financing for NGOs.

Linkages

By providing virtually free health services, the project has helped increase access to preventive, promotive and curative care. It has, thereby, reduced the health-induced financial shocks that frequently push poor families deeper into poverty. Discussions with people in the community consistently show that their satisfaction with the health services has increased significantly. People associate the improvement with actions taken by the democratically-elected government.

Next Steps

Physical access to services needs to be further improved and it will also take bold approaches to get communities to fully use the services. For example, despite a huge increase in obstetrical services, increasing the proportion of deliveries that are attended by skilled health workers will have to overcome serious social obstacles. The approaches that have been successful in Afghanistan are now being applied in other post-conflict settings such as South Sudan and Liberia.

Evaluation

IEG evaluation will happen after closure. Independent evaluations have been done by Johns Hopkins University, the London School of Hygiene and Tropical Medicine, and Afghanistan Research and Evaluation Unit (AREU).

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