Delivering Strong and Sustained Health Gains in Afghanistan: The Sehatmandi Project

Challenge

Afghanistan’s health system faces a critical shortage of key ingredients – qualified healthcare workers, especially female healthcare workers to ensure that women can seek health services; safe and equipped facilities, particularly in areas that are experiencing active conflicts; and supplies of medicines, equipment and vaccines. Insecurity, gender imbalances, and lack of government revenue severely limit the availability of even the most basic healthcare for most Afghans – and the situation has become particularly acute during the COVID-19 Pandemic.

Approach

The Sehatmandi program builds on the innovative approach of contracting out the provision of virtually all basic and essential health services to service provider non-governmental organizations (NGOs). The project takes a pay-for-performance (P4P) approach that directly links the payment of service providers to their performance on the delivery of 11 key health-related services such as immunization, skilled birth attendance, family planning visits, and growth monitoring of infants and children.  The performance is verified by an independent third-party monitor before payment is made. The expected outcomes are clearly spelled out and quantified and customized for each province of the country through a contract between the MOH and the NGO with set terms for service standards.

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“While cooking in the kitchen, I stopped breathing and my vision went dark. When I woke up, I was on a hospital bed. Every time I come here, doctors are so respectful and care about us. My neighbors and I are so pleased. It is five days that I am here in hospital and I have had a very good experience. I appreciate the hospital’s management system. There are so many patients, but the doctors are always doing their best.”

Gulab Zarin, Kama district, Nangarhar province

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The project focuses on improving the value-for-money by enhancing accountability and transparency in the health sector and is a cutting-edge model for service delivery in fragile and conflict-affected settings.

The project has effectively served as a platform to channel the resources of key development partners in a common results framework to finance basic and priority health services across the country with minimal management cost, including in highly insecure and conflict-affected areas which are difficult to serve.

Results

The program made notable achievements despite the rising insecurity and the COVID-19 pandemic.

• Health facility visits per capita per year in 2019 reached 2.1, which translates into provision of health, nutrition and population services to more than 60 million individual visits.
• More than 4,073,000 children have been immunized from 2018 – 2020.
• The volume of services delivered under the Sehatmandi project has increased for 10 out of 11 payment indicators. For example, the number of couple-years of contraceptive protection provided by Sehatmandi facilities increased by 49% between 2018 and 2019, and the number of women giving birth at a health facility increased by 21% over the same period.

Since 2002, international development aid, including support from the World Bank and the Afghanistan Reconstruction Trust Fund, has been a critical part of Afghanistan's development.

Overall health outcomes in Afghanistan have improved markedly since the first decade of the 2000s:

• The newborn mortality rate fell from 53 to 23 per 1,000 live births from 2003 to 2018.
• The under-5 mortality rate dropped from 191 to 50 per 1,000 live births from 2006 to 2018, while at the same time the proportion of facilities with female staff has increased.
• Births attended by skilled health personnel among the lowest income quintile increased to from 14.9% to 58.8% between 2003 to 2018.
• PENTA 3 immunization coverage (a combination of five vaccines in one covering polio, diphtheria, Pertussis, tetanus, haemophilus influenzae type b, and hepatitis B) doubled between 2002 – 2018 from 29% to 61% among children ages 12-23 months in the lowest income quintile.

Bank Group Contribution

The Sehatmandi Project is supported by grant of $140 million from the International Development Association (IDA), a $425 million grant from the Afghanistan Reconstruction Trust Fund (ARTF). The ARTF is a multi-donor trust fund administered by the World Bank on behalf of 34 donor partners which have contributed almost $12 billion.

Partners

The Afghanistan Sehatmandi Project is implemented by the Ministry of Public Health of Afghanistan in close cooperation with the donors to the Afghanistan Reconstruction Trust Fund (ARTF), WHO and UN agencies. Afghan and international NGOs support the project as service providers.

The Global Financing Facility for Women, Children and Adolescents (GFF) supports the project with a $35 million grant. The GFF supports low- and lower-middle-income countries to accelerate progress on reproductive, maternal, newborn, child and adolescent health and nutrition, and strengthen financing and health systems for universal health coverage (UHC).

Moving Forward

Building on the program’s success and to further enhance health service delivery, additional financing for the project is under preparation to make further investments in health facilities and the capacity of the healthcare system and healthcare providers and expand the menu of health services provided.