IslamicRepublic of Afghanistan
Ministry of Public Health
General Directorate of Policy,Planning and International Relations
Health Economics and Financing Directorate
Annual Report
Reporting Period: Mar 21- Dec 20, 2012
Contents
Acronyms...... 3
Foreword...... 4
Summary of main achievements during 21/03/2012 – 20/12/2012...... 6
1 Overview...... 7
2 Health Financing Unit (HFU)...... 8
2.1 Program Budgeting...... 8
2.2 Financial Risk Protection/Health Insurance...... 8
2.3 Revenue Generation Strategic Framework (RGSF)...... 9
2.4 Mobile Health (M-Health) Initiative...... 9
2.5 Results Based Financing (RBF)...... 9
3 Health Economics Unit (HEU...... 10
3.1 Resource Tracking Subunit...... 10
3.1.1 National Health Accounts (NHA)...... 10
3.1.2 Expenditure Management Information System (EMIS)...... 10
3.2 Economic Evaluations...... 11
3.2.1 Economic Evaluation of the Potential for Intravenous (IV) Fluids Local Production in Afghanistan11
3.2.2 Benefit Incidence Analysis (BIA)...... 11
3.2.3 Cost Analysis of Kabul’s National Hospitals...... 11
3.2.4 Costing of the Basic Package of Health Services (BPHS)...... 11
3.2.5 Comparison study of the strengths and weaknesses of contracting-in and out modalities for delivering BPHS in Afghanistan: Cost, Quality, and Equity 12
3.2.6 Cost Analysis of the Essential Package of Hospital Services (EPHS)...... 12
3.2.7 Cost Analysis of Kabul Medical University (KMU)...... 12
4 Aid Coordination and Sector Wide Approach (SWAp)...... 12
5 Challenges...... 13
6 Lessons Learnt...... 13
7 HEFD Work Plan for 2013...... 14
Acronyms
BIA Benefit Incidence Analysis
BPHS Basic Package of Health Services
CCT Conditional Cash Transfer
CSO Central Statistics Office
DSF Demand Side Financing
EGGI Economic Growth and Governance Initiative
EMIS Expenditure Management Information System
EPHS Essential Package of Hospital Services
EU European Union
GCMU Grants and Contracts Management Unit
GIRoAGovernment of the Islamic Republic of Afghanistan
HEFD Health Economics and Financing Directorate
HEU Health Economics Unit
HFU Health Financing Unit
HMIS Health Management Information System
M-Health Mobile Health
M&E Monitoring and Evaluation
MoEcMinistry of Economy
MoFMinistry of Finance
MoPH Ministry of Public Health
NHA National Health Accounts
PETS Public Expenditure Tracking Survey
PPR Provider Payment Reform
RBF Results-Based Financing
RGSFRevenue Generation Strategic Framework
USAID United States Agency for International Development
Foreword
This report reflects the main accomplishments of the Health Economics and Financing Directorate (HEFD) of the Afghanistan Ministry of Public Health (MoPH)during the last three quarters of 2012. The main functions of HEFD include: conducting economic evaluations in priority areas; developing health financing policies and strategies;implementing innovative health financing mechanisms; and planningprogram budgets.
In 2012,HEFD conductedcost analysis studies of Kabul’s National Hospitals, the Basic Package of Health Service (BPHS), and Essential Package of Health Services (EPHS). Thesestudies have provided concrete evidence for decision makers at various levels for useto strengthen the health system and to improve different aspects of health financing in Afghanistan. Findings fromthe studies justifythe MoPHleadership’s public funding requestto the Ministry of Finance(MoF) for an incremental increase in theoperational budget of national hospitals. Apart from the costing exercises, HEFD conducted three significanteconomic evaluations: Economic Evaluation of the Potential for Intravenous Fluids – Local Production in Afghanistan;Benefit Incidence Analysis (BIA) of Health ServicesProvision in Afghanistan; and Afghanistan BPHS Contracting Study:Cost, Quality and Equity. It is worth mentioning that most of these studies are the first their kind in Afghanistan.
In addition,HEFD has developed key health financing documents – AfghanistanHealth Financing and Sustainability Policy 2012-2020; the Revenue Generation Strategic Framework (RGSF); the Capacity Building Strategic Approach and Work Plan; and the Health Insurance Feasibility Concept Note. These documents guide HEFD’s future activities. As per the Capacity Building Strategic Approach and Work Plan, HEFD is striving to enhance the capacity of its staff through short and long term training courses to equip them with the requisite skills. Included in this plan was the enrolment of three additional staff members[1]in the Master of Science (MSc) in Health Economics and Healthcare Management at Chulalongkorn University in Thailand and training of two female interns in health economics and financing for six months. Both the MSc program and the internshipsare supported by the United States Agency for International Development (USAID) through the Health Policy Project (HPP) of the Futures Group International (FGI) and the Economic Growth and Governance Initiative (EGGI), respectively.
The report outlines activities in the areas of health economics, health financing, and aid coordination. HEFD is committed to supporting the MoPH in improving the quality of healthcare and ensuring universal coverage in Afghanistan.
Taking the opportunity, I would like to thank Husnia Sadat, Mohammad Saber Perdes, and Nasratullah Rasa for leading their pertinent units and achieving the Directorate’s shared objectives. I also acknowledge the support of the European Union (EU) Technical Cooperation Program implemented by EPOS and the USAID funded HPP. Finally, I am thankful to the leadership of MoPH for the overall support provided to HEFD.
Ahmad Shah Salehi
Director
Health Economics and Financing Directorate
January 2013
Summary of main achievements during 21/03/2012 – 20/12/2012
-National Health Financing and Sustainability Policy 2012 – 2020 developed
-Revenue Generation Strategic Framework developed
-BPHS Costing Study conducted
-EPHS Costs and Efficiency Study conducted
-Kabul Hospitals Costs and Efficiency Study conducted
-Benefit Incidence Analysis of Health Services in Afghanistan conducted
-Economic evaluation of the Potential for Intravenous (IV) Fluids Local Production in Afghanistan conducted
-Comparison Study of costs, quality, efficiency, and equity of the BPHS contracting modalities conducted
-National Priority Program proposal costed
-ACOMAT private hospital costed
In addition, HEFD took leading role in some other activities assigned by the leadership of MoPH. The main activities are as following:
-Health Sector Strategic Planning Retreat 2012 organized
-National Health and Nutrition Policy 2012-2020 Working Group meetings facilitated
-Workshop on Health and Nutrition Policy 2012-2020 organized
-National Health and Nutrition Policy 2012-2020 drafted and presented to many fora in order to finalize it
-Significantly contributed to National Priority Program proposal
1Overview
Since its establishment in mid2009, HEFD has expanded its role to provide important economic and financing data analyses to key policy decisionmakers and service provision partners. HEFDhad three functional units during 2012: Health Financing Unit (HFU), Health Economics Unit (HEU), and Aid Coordination Unit (ACU).[2]Each unit is comprised of subunitsthat are responsible for fulfilling key functions such aseconomicevaluations, production of National Health Accounts(NHA), health insurance,Public Expenditure Tracking Survey (PETS), program budgeting, resource mobilization,and innovative health financing modalities, such as ResultsBased Financing(RBF) and Demand Side Financing (DSF). In mid 2012, the ACU was separated from the structure of HEFD and started working under the umbrella of GD Policy and Planning.
Current HEFD’s organizational chart is elaborated in Figure 1 below.
1
2Health Financing Unit (HFU)
HFU is responsible for developing key financing policies and strategies; managing annual MoPH program budget; implementing various health financing innovation;,designing a context specific health insurance scheme; and studying the feasibility of several supply and demand side financing schemes (including implementation of Result Based Financing and Mobile Health Initiatives). The Unit is led by Dr. Husnia Sadat.
2.1Program Budgeting
Team / Abdul Aziz Sharifi and Mohammad Fahim AhmadiObjectives / -To ensure effective implementation and alignment of MoPH projects with the approved budget
-To ensure overall investment programs meet MoPH priorities
Achievements / -1391 Chart of Account (CoA) developed
-Budget statement for 1391 developed
-1392 Budget submitted according to Ministry of Finance (MoF) program budget guidelines
-Budget Circular 2 (BC2) prepared and submitted according to MoF program budget guidelines
-Capacity increased of seventeen national hospitals directorsin program budgeting reform
-Forty-two MoPH project managers trained in Budget Circular 1 (BC1)
-Forty-two MoPH project managers trained in financial planning
-A Mid-Term Budget Framework (MTBF) developed
-MoPH budget 1391 prepared and submitted to MoF for approval of the parliament
-Performance indicators report developed and submitted to MoF on quarterly basis
-Projects’ physical progress report developed and submitted to Ministry of Economy (MoEc) on quarterly basis
-Activelyparticipatedin budget execution meetings in MoF and MoEc
2.2Financial Risk Protection/Health Insurance
Team / Sayed Mohammad Karim Alawi, Faridoon Joyenda and Ajmal BehzadObjectives /
1.1.1To examine the possibilities of designing, developing and implementing successful Afghan-specific health insurance schemes by studying enabling environments for a health insurance scheme and recommending options to the GoIRA to initiate a scheme given the context and health system landscape.
Achievements / -Health Financing Policy (2012-2020) developed-A Concept note on Social Health Insurance developed
-Terms of reference (ToR) for the health insurance working group developed
-A health insurance working group established with active regular meetings
-ToR for Health insurance feasibility study developed
-HEFD staff capacity built in the area of health insurance
-ToR for an international technical expert on health insurance regulation developed
2.3Revenue Generation Strategic Framework (RGSF)
Team / Sayed Mohammad Karim Alawi, Faridoon Joyenda and Ajmal BehzadObjectives / To increase public allocation and mobilize domestic resources.
Achievements / -RGSF developed
-Advocacy plan for the strategy developed
-Advocacy plan costed
-RGSF and advocacy plan coordinated with stakeholders
2.4Mobile Health (M-Health) Initiative
Team / Abo Ismael Foshanji, Najibullah AabedObjectives / To improve utilization of key maternal health services by empowering community health workers to provide timely and quality counseling services; improving access to clinics through the use of transportation vouchers; and strengthening the referral system.
Achievements / The project is designed and contracted with a BPHS implementing partner. Project implementation has just started.
2.5Results Based Financing (RBF)
Team / Najibullah Hoshang, KalemullahNiazi, SafidinHemat, Ahmad NawidShamsObjectives / -To ensure that patients and communities are increasingly involved and satisfied with the publicly financed health services they receive;
-To improve the quality of health care services; and
-To increase key maternal and child health outputs.
Achievements / -RBF Indicators Performance: On average, the RBF intervention health facilities under BPHS coverage show 28% improvement in HMIS indicators compared to the baseline. However, control health facilities show only 10% improvement on average compared to the baseline.
-Balanced Scorecard (BSC) performance 2011/2012: Hospitals covered by RBF improved 7.8% in infection prevention and 7.2% in overall quality of care, while control hospitals have shown no progress during the reporting period.
-Revision of the Unit Costs: Unit cost for the main RBF indicators were revised based on private sector prices.
-Regular RBF Coordination Meetings: Quarterly coordination meetings between MoPH and provincial managers of NGOs were conducted for information sharing, learning from achievements, and troubleshooting.
-RBF Contracts Amendment: The RBF contracts with NGOs were amended in collaboration with GCMU.
-HMIS Data Quality Improvement: The quality improvement of health services provision is a key objective of the RBF project. Third party reports show that the HMIS data quality improved by 27% (67% in 2010, 94% in 2012).
3Health EconomicsUnit (HEU)
HEU is responsible for conducting economic evaluations including the Public Expenditure Tracking Survey (PETS) and Benefit Incidence Analysis (BIA).In addition HEU plays a vital role in the production ofNational Health Accounts (NHA) andthe institutionalization of Expenditure Management Information System (EMIS). The unit is led by Dr. Mohammad Saber Perdes.
3.1Resource Tracking Subunit
3.1.1National Health Accounts (NHA)
Team / Mir Najmuddin Hashimi, Shuhrat MunirObjectives / To use a comprehensive approach for estimating the total national health expenditure including public, private, and donor contributions,which can be easily understood by policymakers in order to take appropriate actions.
Achievements / -Data were collected for producing second round of NHA
-Health expenditure questionnaire related to inpatient and outpatient services incorporated into the National Risk and Vulnerability Assessment (NRVA) survey tool
-NHA findings presented at national and international events
-NHA report 2011 disseminated to relevant MoPH stakeholders
-Steering committee meeting held for the second round of NH
-Capacity building training conducted for BPHS implementers
3.1.2Expenditure Management Information System (EMIS)
Team / HEFD teamObjectives / To harmonize financial reporting systems among MoPH stakeholders,especially BPHS implementers.
Achievements / -EMIS databse developed
-EMIS pilot tested among a number of BPHS implementing partners
-EMIS team established in HEFD
3.2Economic Evaluations
3.2.1Economic Evaluation of the Potential for Intravenous (IV) FluidsLocal Production in Afghanistan
Team / Husnia Sadat, Ahmad Reshad Osmani, and Mohammad Yonus Zawoli with technical and financial support of HPPObjectives / To evaluate the potential costs and benefits of investing in the production of IV fluids relative to importation.
Achievements / The study was conducted and the report is provided.
3.2.2Benefit Incidence Analysis (BIA)
Team / Khwaja Ahad Saeed, Ahmad Shah Salehi, Mohammad Saber PerdesObjectives / To analyze the extent of inequalities in healthcare utilization between the poor and the wealthy and to determine who is benefiting from publicly financed healthcare services across socio-economic groups.
The specific objectives of this study are listed below:
-To determine inequalities in the distribution of healthcare utilization across socioeconomic groups
-To determine whether the contribution of public spending in health services is appropriately distributed across socioeconomic groups
-To determine whether the distribution of healthcare utilization is different across household and individual characteristics.
Achievements / The study was conducted and the report is ready for dissemination.
3.2.3Cost Analysis of Kabul’s National Hospitals
Team / HEFD TeamObjectives / To provide a baseline overview of Kabul’s national hospitals’ actual costs, resources, and services.
Achievements / -The study was successfully conducted in 18 national hospitals
-Study findings were published in a comprehensive report
3.2.4Costing of the Basic Package of Health Services (BPHS)
Team / HEFD with the technical support of Health Systems 20/20 (USAID support)Objectives / -To understand major BPHS cost drivers and compare cost variations across facilities and provinces; and linking these to differences in service delivery and contracting mechanisms
-To inform decision makers about resource allocations across primary health care facilities and potential areas where additional resources/subsidies may be required.
Achievements / -The study was successfully conducted
-Study findings were published in a comprehensive report
3.2.5Comparison study of the strengths and weaknesses of contracting-in and out modalities for delivering BPHS in Afghanistan: Cost, Quality, and Equity
Team / HEFD with technical support of Futures Group (USAID support)Objectives / -To determine differences between the two BPHS implementation models with regard to cost, quality, and equity of services
Achievements / -The study was successfully conducted
-Study findings were published in a comprehensive report
3.2.6Cost Analysis of the Essential Package of Hospital Services (EPHS)
Team / HEFD StaffObjectives / -To provide a baseline overview of EPHS actual costs, resources, and services in 1390 (March 2011 to March 2012).
Achievements / -The study was successfully conducted
-Study findings were published in a comprehensive report
3.2.7Cost Analysis of Kabul Medical University (KMU)
Team / HEFD StaffObjectives / -To identify total cost of KMU and cost of each faculty
-To identify the cost of each student on the basis of study year at the faculty level
Achievements / -Designed study methodology and costing tool
-Questionnaire designed for collecting data
-Preliminary data collected
-Data analysis ongoing
4Aid Coordination and Sector Wide Approach (SWAp)
This unit was under HEFD during the first quarter and half of the second quarter of 1391. According to aMoPH decision, the unit was detached from the structure of HEFD. Currently, it is under the General Directorate of Policy and Planning.
Objectives / -To increase the efficiency and effectiveness of the provision of assistance by reducing the overlapping and duplication of aid efforts-To improve aid coordination in the financing and delivery of health services.
Achievements / -A formal discussion on health sector development has begun
-Institutional arrangements for SWAp established (SWAp Team, SWAp Taskforce, Steering Committee)
-Awareness on SWAp in MoPH raised
-Health Sector Development Partnership Arrangements developed and finalized
-Assessment of Coordination Mechanisms conducted
5Challenges
HEFD has identified the following specific challenges for 2012:
Capacity / -Limited capacity in MoPH departments in resource management-Limited practical experience in conducting PETS by local staff
-Lack of previous experience in conducting BIA
Coordination / -Poor coordination between MoPH project managers and MoF health sector department in releasing funds
-Unwillingness of stakeholders to share data with MoPH/HEFD
Bureaucracy / -Legislative obstacles including insurance law and limited capacity regarding risk pooling mechanisms
-Time-consuming procurement process
-Delays in paying RBF incentives to health facilities by implementing agencies
-Difficulties in accessing the required financial and HMIS data
Infrastructure / -Lack of unique computerized financial tracking system at the BPHS implementer level
-Poor data management system in national hospitals
6Lessons Learnt
The following lessons learnt will enable HEFD to move forward to address the abovementioned challenges and effectively reach program objectives:
-Properplanning will allow for rational use of resources and high project execution rate
-Political will andclose coordination are essential to designing a feasiblerisk pooling scheme for Afghanistan
-Institutional capacity building on risk pooling will help future plans
-Strongpolitical will is required to implement the RGSF