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Publications

Filtering by Category: Afghanistan

Key Message Brief 6: Lessons from results-based financing to improve health services in Afghanistan

Future Health Systems

The Afghanistan experience of nearly 15 years of contracting for health services has demonstrated both how results-based financing (RBF) can serve to increase utilisation of health services and the equity in use, as well as the limitations and failings of RBF approaches to work consistently.

Future Health Systems (FHS) findings, generated through robust experimental and quasi-experimental studies in a rapidly changing context, suggests that attention to scheme design (especially to address demand side concerns, supply side capabilities, and the size and mechanisms of payments) and implementation (timeliness and communication about payments) are critical.

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Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda

Future Health Systems

Bennett S, Mahmood SS, Edward A, Tetui M and Ekirapa-Kiracho E (2017) Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda, Health Research Policy and Systems, 15(Suppl 2):108, DOI: 10.1186/s12961-017-0270-0

Many effective innovations and interventions are never effectively scaled up. Implementation research (IR) has the promise of supporting scale-up through enabling rapid learning about the intervention and its fit with the context in which it is implemented. We integrate conceptual frameworks addressing different dimensions of scaling up (specifically, the attributes of the service or innovation being scaled, the actors involved, the context, and the scale-up strategy) and questions commonly addressed by IR (concerning acceptability, appropriateness, adoption, feasibility, fidelity to original design, implementation costs, coverage and sustainability) to explore how IR can support scale-up.

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Enhancing social accountability for health care in Afghanistan

Future Health Systems

In the United States and parts of Africa and Asia, community scorecards (CSCs) have improved accountability and responsiveness of services. Work supported by Future Health Systems (FHS) sought to evaluate CSC feasibility in a fragile context (Afghanistan) through joint engagement of service providers and community members in the design of patient-centred services, to assess impact on service delivery and perceived quality of care.

FHS Key Message Brief 3: Unlocking community capability: key to more responsive, resilient and equitable health systems

Future Health Systems

In Future Health Systems, we focused on communities as active service delivery participants across a wide variety of contexts. In this brief, we reflect on the process of unlocking community capabilities, the key actors involved, and the productive tensions within community partnerships forged to build more responsive, resilient and equitable health systems.

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Effectiveness of a pay-for-performance intervention to improve maternal and child health services in Afghanistan: a cluster-randomized trial

Future Health Systems

Engineer C, Dale E, Agarwal A, Agarwal A, Alonge O, Edward A, Gupta S, Schuh H, Burnham G, Peters DH (2016) Effectiveness of a pay for performance intervention to improve maternal and child health services in Afghanistan: A cluster-randomized trial, International Journal of Epidemiology, doi: 10.1093/ije/dyv362

A cluster randomized trial of a pay-for-performance (P4P) scheme was implemented in Afghanistan to test whether P4P could improve maternal and child (MCH) services. The authors found that the intervention had minimal effect, possibly due to difficulties communicating with health workers and inattention to demand-side factors. P4P interventions need to consider management and community demand issues.

 

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Bypassing Primary Care Facilities for Childbirth: Findings from a Multilevel Analysis of Skilled Birth Attendance Determinants in Afghanistan

Future Health Systems

Tappis H, Koblinsky M, Doocy S, Warren N, Peters DH (2016) Bypassing primary care facilities for childbirth: findings from a multilevel analysis of skilled birth attendance determinants in Afghanistan, Journal of Midwifery and Women’s Health, Volume 61, Issue 2, pages 185–195, DOI: 10.1111/jmwh.12359

The objective of this study was to assess the association between health facility characteristics and other individual/household factors with a woman's likelihood of skilled birth attendance in north-central Afghanistan. The study finds that assumptions that women who give birth with a skilled attendant do so at the closest health facility may mask the importance of supply-side determinants of skilled birth attendance. More research based on actual utilization patterns, not assumed catchment areas, is needed to truly understand the factors influencing care-seeking decisions in both emergency and nonemergency situations and to adapt strategies to reduce preventable mortality and morbidity in Afghanistan.

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Assessing the pro-poor effect of different contracting schemes for health services on health facilities in rural Afghanistan

Future Health Systems

Alonge O, Gupta S, Engineer C, Salehi AS, Peters DH, (2015) Assessing the pro-poor effect of different contracting schemes for health services on health facilities in rural Afghanistan, Health Policy & Plannning, 30 (10): 1229-1242, doi: 10.1093/heapol/czu127

Despite progress in improving health outcomes in Afghanistan by contracting public health services through non-governmental organizations (NGOs), inequity in access persists between the poor and non-poor. This study examined the distributive effect of different contracting types on primary health services provision between the poor and non-poor in rural Afghanistan.

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Toward universal coverage in Afghanistan: A multi-stakeholder assessment of capacity investments in the community health worker system

Future Health Systems

Edward, A., Branchini, C., Aitken, I., Roach, M., Osei-Bonsu, K., & Arwal, S. H. (2015) Toward universal coverage in Afghanistan: A multi-stakeholder assessment of capacity investments in the community health worker system, Social Science & Medicine, Vol 145, pp 173-183, doi:10.1016/j.socscimed.2015.06.011

Global efforts to scale-up the community health workforce have accelerated as a result of the growing evidence of their effectiveness to enhance coverage and health outcomes. Reconstruction efforts in Afghanistan integrated capacity investments for community based service delivery, including the deployment of over 28,000 community health workers (CHWs) to ensure access to basic preventive and curative services. The study aimed to conduct capacity assessments of the CHW system and determine stakeholder perspectives of CHW performance. 

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Unlocking community capabilities to improve health service delivery

Future Health Systems

FHS's 'unlocking community capabilities' (UCC) theme systematically examines how communities can be active participants in the planning, delivery, monitoring and evaluation of their health system, by identifying and mobilising individual and collective capabilities in different social, political, and institutional environments. This brief explores current activities and initial findings from the theme.
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FHS Podcast 2: A visit to Kabul

Future Health Systems

In the second podcast from Future Health Systems, Jeff Knezovich visits the FHS Afghanistan team in Kabul to find out what sort of research they're currently undertaking, what challenges they face in attempting research in an insecure environment, and what it's like living and working in difficult security situations. He interviews Kojo, Melissa Roach and Anubhav Agarwal, who tell him about the community scorecard that FHS is in the process of piloting in several provinces in Afghanistan.
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Removing user fees for basic health services: a pilot study and national roll-out in Afghanistan

Future Health Systems

User fees for primary care tend to suppress utilization, and many countries are experimenting with fee removal. Studies show that additional inputs are needed after removing fees, although well-documented experiences are lacking. This study presents data on the effects of fee removal on facility quality and utilization in Afghanistan, based on a pilot experiment and subsequent nationwide ban on fees.
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Targeting accuracy and impact of a community-identified waiver card scheme for primary care user fees in Afghanistan

Future Health Systems

User fees are a known common barrier to using health services, particularly among the poor. When fees are present, many facilities have waiver systems for poor patients to exempt them from paying. Targeting waivers to patients who need them most has been a challenge, especially in fragile states, where relevant data are limited and trust in institutions is low. An analysis of the asset index of beneficiaries indicated that although targeting was progressive, significant leakage and high levels of under-coverage occurred; 42% of cards were used by people in the wealthiest three quintiles, and only 19% of people in the poorest quintile received a card. Households with waiver cards reported higher rates of care-seeking for recent illnesses compared to those without cards (p = 0.02).
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Association between health workforce capacity and quality of care for children under five in Afghanistan

Future Health Systems

This presentation by Dr Anbrasi Edward at the 28th ISQua conference in Hong Kong was informed by a study to determine the association between health workforce capacity and quality of care in primary care facilities providing a basic package of health services (BPHS) in Afghanistan.
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Can community health workers increase coverage of reproductive health services?

Future Health Systems

Health services were severely affected during the many years of instability and conflict in Afghanistan. In recent years, substantial increases in the coverage of reproductive health services have been achieved, yet absolute levels of coverage remain very low, especially in rural areas. One strategy for increasing use of reproductive health services is deploying community health workers (CHWs) to promote the use of services within the community and at health facilities. Results show that presence of a female CHW in the community is associated with higher use of modern contraception, antenatal care services and skilled birth attendants but presence of a male CHW is not. Community-level random effects were also significant.
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Configuring Balanced Scorecards for Measuring Health System Performance: Evidence from 5 Years' Evaluation in Afghanistan

Future Health Systems

n 2004, Afghanistan pioneered a balanced scorecard (BSC) performance system to manage the delivery of primary health care services. This study examines the trends of 29 key performance indicators over a 5-year period between 2004 and 2008.
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Determinants of Skilled Birth Attendant Utilization in Afghanistan: A Cross-Sectional Study

Future Health Systems

This article seeks to identify characteristics associated with use of skilled birth attendants where health services exist in Afghanistan. It is based on a cross-sectional study in all 33 provinces in 2004.
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Determinants of primary care service quality in Afghanistan

Future Health Systems

This article identifies factors associated with service quality provided by agencies implementing a basic package of health services in Afghanistan and is based on a cross-sectional survey of outpatient health facilities, health workers, patients and caretakers.
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Client perceptions of the quality of primary care services in Afghanistan

Future Health Systems

This article identifies factors associated with client perceptions of the quality of primary care services in Afghanistan through a cross-sectional survey of outpatient health facilities, health workers, patients and caretakers.
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Infant and under-five mortality in Afghanistan: current estimates and limitations

Future Health Systems

The objective of this article is to examine historical estimates of infant and under-five mortality in Afghanistan, provide estimates for rural areas from current population-based data, and discuss the methodological challenges that undermine data quality and hinder retrospective estimations of mortality.
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An experiment with community health funds in Afghanistan

Future Health Systems

Community-based health insurance (CBHI) schemes offer the possibility of raising revenues from communities and at the same time providing financial protection. This paper describes the performance of one type of CBHI scheme, the Community Health Fund (CHF), which was piloted for the first time in five provinces of Afghanistan between June 2005 and October 2006. The performance of the CHF programme demonstrates that complex community-based health financing schemes can be implemented in post-conflict settings like Afghanistan, except in areas of high insecurity.
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