Journey to Restoration: Strengthening the Health System in Afghanistan

For almost three years, the USAID-funded Leadership, Management, and Governance (LMG)-Afghanistan Project, led by Management Sciences for Health (MSH), has been offering technical assistance to support inspired leadership, sound management, and transparent governance within Afghanistan’s health system. As the $37 million project comes to a close in June 2015, the achievements and results of the project have been celebrated and recognized at two end-of-project events, one in Washington and one in Kabul.

The most recent event — Journey to Restoration: Stories from the LMG-Afghanistan Project — took place at the Afghan Ministry of Public Health (MOPH) in Kabul in May 2015. Key stakeholders in Afghanistan’s health system reform were in attendance, including participants from the MOPH, the United States Agency for International Development (USAID), the World Health Organization (WHO), and the Afghan Midwives Association. MSH Afghanistan Country Representative Dr. Mohammad Rashidi opened the event, noting that the first international mission of MSH was in Afghanistan, and that MSH and the MOPH have been partners for four decades.

One direct recipient of the LMG-Afghanistan Project’s technical assistance — which included coaching of MOPH senior leadership on how to improve accountability, transparency, and sustainability of health system strengthening (HSS) activities — is Dr. Said Habib Arwal, Community-Based Healthcare (CBHC) National Coordinator at the MOPH and the first of the MOPH’s Afghan Health Heroes. In a conversation with LMG Project Director Jason Taylor Wright in Kabul before the Journey to Restoration event, Dr. Arwal expressed appreciation for the project’s capacity building support to the MOPH. He described Afghanistan as providing “a model of community-based healthcare in the world.” He estimated that for every $1 spent in the community, $20 is saved, and indicated that Afghanistan now has more than 28,000 community health workers (CHWs), 55% of whom are otherwise uneducated. He went on to describe CHWs as “the foundation for the public health system of Afghanistan” and “the unknown soldiers of the Ministry of Public Health.” In referring to the CBHC, Dr. Arwal stated that although “most programs are not sustainable…this is a very sustainable program.”

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Local Ownership and Sustainability

Speaking during the Journey to Restoration event, USAID/Afghanistan Office of Social Sector Development (OSSD) Director Monique Mosolf cited excellent stewardship and leadership of the MOPH in advancing the “tremendous gains” in the health sector in Afghanistan, and noted that effective administrative structures, as well as the basic package of health services and entry of women into the workforce, were key elements in the success of HSS efforts in Afghanistan. The LMG-Afghanistan Project contributed to all three of these health system strengthening factors. Local ownership has been a priority in LMG-Afghanistan’s HSS strategies, and has been woven into all project activities. Strategies designed to strengthen health leadership are developed by Afghans, for Afghans, with international technical assistance – such as the support provided to Dr. Arwal and his unit – used to promote global knowledge exchange and quality oversight.

MOPH Deputy Minister of Public Health Ahmad Jan Naeem stated during the event that “community accountability will be a critical future priority for the government to make sure that communities are engaged in health planning.”

He further explained, “The Ministry is poised to take responsibility,” although “everything is not perfect,” and “we still have a long way to go.”

This focus on sustainability was echoed during a panel discussion moderated by MSH Deputy Country Portfolio Director for Project Management, Stephanie Cálves. The panel included the Deputy Minister of Public Health, EPOS Health Management Team Leader Caroline Fitzwarryne, WHO National Professional Officer, Health System Dr. Najibullah Safi, USAID/Afghanistan HSS Unit Lead Andrew Rebold, and LMG-Afghanistan Project Director Dr. Hedayatullah Saleh. During this discussion, Dr. Safi stressed the need for sustainability though the Transformation Decade (2015-2024), stating, “Afghanistan will still need donor funding for health for some time as there is still not enough funding within the Afghan government being put towards the health sector.“

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In his closing remarks after the panel discussion, Mr. Wright noted that the LMG-Afghanistan Project is the largest of the country buy-ins to the global LMG Project. He described Afghanistan as “invaluable as a proving ground for many of our leadership and governance interventions.” For example, in Afghanistan, the LMG Project has been able to develop governance guides for decentralized health authorities. He stated “These governance guides are not only being used in provinces and community shuras here; they are also being adapted in other countries.” He explained that LMG-Afghanistan supported the expansion of the LDP+ tool, an enhanced version of the USAID-funded Leadership Development Program. Governance bodies have been established to oversee how the tool is used to enhance health outcomes at the decentralized level. He concluded that “LMG-Afghanistan has been a crucial partner to the MOPH as it prepares to assume even greater ownership.”

The event was capped with a Storytelling Fair, which interactively described individual and organizational experiences of empowerment, as well as the health impact of LMG-Afghanistan Project activities. The individuals profiled during the Storytelling Fair are key pillars of the health systems and represented each of the nine LMG-Afghanistan Project program areas: Child and Adolescent Health (CAH); CBHC; Community Health Nursing Education (CHNE); Health Information Systems (HIS) and Monitoring and Evaluation (M&E); Hospital Management; Improving Quality in Health Care (IQHC); In-Service Training (IST); Leadership, Management, and Governance (L+M+G); and Provincial Health Systems Strengthening (PHSS). Their stories can be read in full in an End-of-Project booklet: Profiles of Courage: Stories of Impact from the LMG-Afghanistan Project (2012-2105), which can be found on the LMG website.

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