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ASSESSMENT OF DECENTRALIZATION FEASIBILITY OPTIONS WITHIN THE HEALTH SYSTEM OF AFGHANISTAN

REPORT

By

GOVERNANCE INSTITUTE –

AFGHANISTAN December 2014

A GOVERNANCEINSTITUTE

AFGHANISTAN

I G یمؤسسھ تقویھ حکومتدار

Report on Decentralization in the Health Sector by the Governance Institute – Afghanistan (GI-A), December 2014

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Table of Contents

Cover ............................................................................................................... 1

Acknowledgments ............................................................................................ 4

Executive Summary ......................................................................................... 5

Key Overall Conclusions and Recommendation .......................................... 5

Introduction .................................................................................................. 6

Approach ...................................................................................................... 6

Key Findings................................................................................................. 6

Realities of Capacity Building (see Section 3.2) ........................................... 7

Capacity for Decentralization by PPHOs ...................................................... 7

Conclusions .................................................................................................. 8

Options ......................................................................................................... 8

Key Recommendations ................................................................................ 9

1. Introduction ............................................................................................. 11

1.1 Report Structure ............................................................................... 11

1.2 Background and Objectives .............................................................. 11

Overall Objective .................................................................................... 11

Sub-Objectives ....................................................................................... 12

1.3 Approach and Methods ..................................................................... 12

Factors Influencing the Approach ........................................................... 12

Methods .................................................................................................. 13

1.4 Strengths and Limitations ................................................................. 15

2. Wider Context to Decentralization to the Provincial Level ...................... 16

2.1 New Political Context ........................................................................ 16

2.2 Policy and Legal Framework ............................................................. 16

2.3 Relevant Challenges to Decentralization in Literature Review .......... 16

2.4 Lessons Learned on Capacity Building ............................................. 18

3. Findings .................................................................................................. 21

3.1 Wider Context ................................................................................... 21

Political, Policy, and Legal Framework ................................................... 21

Governmental Institutional Functioning ................................................... 21

3.2 Current Facilitating Factors and Challenges to Decentralization ...... 22

3.3 The Realities of Capacity Building .................................................... 23


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3.4 Capacity for Decentralization in Seven Provincial Public Health Directorates ..................................................................................... 24

The Context ............................................................................................ 24

Strengths and Weaknesses of, and Issues Common to, PPHOs ........... 25

Provincial Public Health Directors and Officers on Decentralization .............. 25

Meetings with Mastofiats on Decentralization in Health .......................... 25

Focus Group Discussions with NGOs at the Provincial Level ................. 25

Findings from Reviewing Meeting Minutes of PPHCC Meetings ............ 26

4. Conclusions, Options, Implications, and Risks ....................................... 27

4.1 Conclusions ...................................................................................... 27

4.2 Options ............................................................................................. 28

Option 1 .................................................................................................. 28

Option 2 .................................................................................................. 29

Option 3 .................................................................................................. 29

4.3 Implications and Risks ...................................................................... 31

Values of the MoPH ................................................................................ 31

5. Recommendations .................................................................................. 33

Annex A. Extract from the ‘Statement of Work’ .......................................... 35

Annex B. Additional Documents Consulted ............................................... 37

Annex C. Interview List .............................................................................. 38

Annex D. Wider Context Questions and Issues ......................................... 40

Annex E. Findings: Self-ranking at the Provincial Level on Capacity ........ 41

Annex F. Strengths and Weaknesses of the Seven Provinces .................. 45

Annex G. Reviews and Summaries (sent separately) ................................ 47

Annex H. International Literature Review (sent separately) ....................... 47

Annex I. PPHOs Performance Monitoring Checklist (sent separately) ...... 47

List of Tables Table 1. Clarifying the Meaning of Decentralization Table 2. Criteria for Choice of the Seven Provinces Table 3. Challenges to Decentralization from International Literature Table 4. Facilitating Factors and Challenges Table 5. Delegation to Provincial Health Offices Table 6. Authority Delegated to Provincial Public Health Offices Funding was provided by the United States Agency for International Development (USAID) under Cooperative Agreement AID-OAA-A-11-00015. The contents are the responsibility of the Leadership, Management, and Governance Project and do not necessarily reflect the views of USAID or the United States Government.


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Acknowledgments We would like to acknowledge the Ministry of Public Health (MoPH), Management Science for Health’s Leadership Management, and Governance (MSH-LMG) Project, and USAID for their oversight, financial, and technical support to this project. Additionally, the Governance Institute of Afghanistan (GIA) team would also like to acknowledge the contributions of the oversight committee to this assignment, particularly Dr. Zeliakha Ansari and Dr. Ataullah Saeedzai, who provided regular support throughout the life of this project. The collaboration of all NGOs, donors, stakeholders, and other technical partners who offered their time to provide the information required by our interviewers is recognized and highly appreciated. We would also like to mention the names of the GIA team for their dedication and hard effort to accomplish the assigned tasks and obligations, including: Ms. Stephanie Simmonds as principle investigator, Dr. Ajmal Sabawoon for his effective project management and technical contributions, and the technical involvement and contributions of Dr. Ferozuddin Feroz, Dr. Abdul Wali Ghayur, and Dr. Shafiqullah Shahim. Finally, we would like to appreciate efforts undertaken by the Administration and Finance teams for facilitating all logistic aspects of the project. Lastly, we hope that this piece of work will support decision making processes at the policy level for the betterment of the health of Afghan people. With best regards, The GIA team


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Executive Summary Key Overall Conclusions and Recommendation There was remarkable consistency in the opinions of stakeholders when assessing the present capacity of Ministry of Public Health (MoPH) Provincial Public Health Offices (PPHOs) in Afghanistan to function as effective and efficient decentralized offices. Stakeholders, at both central and provincial levels, highlighted the need for the health sector to be cautious about implementing decentralization in the absence of wider supportive government will, commitment, laws, and regulations. In addition, it is recognized that central level cannot transfer skills and knowledge related to governance and public health if it is itself not effectively demonstrating such capacity. Delegation was often mentioned of one form of decentralization that could be addressed. Stakeholders thought that there would be better ownership of programs, more appreciation of the need to have better oversight of the values of the MoPH, and more interest in getting positive result if various functions (see Tables 5, 6, and Section 4) were effectively delegated. However, decisions and implementation on the ‘what’ and the ‘how’ need to be incremental and independent of the wider new governmental context. In a self-ranking exercise, PPHOs identified several functions that they had strong capacity in, including leadership, coordination, communication, supportive supervision, oversight of health service delivery, and monitoring and evaluation (M&E). Pharmaceutical management, measuring disease burden and trends, referral system, and inter-sectorial collaboration were identified as needing capacity strengthening. There are high levels of awareness and open discussion about the challenges of effective and efficient delegation. The most mentioned challenges were corruption, nepotism, ambiguity in procedures and level of authority, long bureaucratic procedures, poor capacity of staff related to low pay, insecurity, and lack of coordination among different governmental departments. Our overall conclusion about capacity building in the health sector is that the MoPH and a number of donors have fallen into the category of stakeholders who see capacity building as little more than the ‘training’ of individuals with attendance at workshops, seminars, and conferences. In formal and informal discussions during this study the words ‘mentoring,’ ‘coaching,’ and ‘institutional capacity’ never came up. Our key recommendation is as follows: before there is any delegation from the national to the provincial level in the health sector, the central MoPH should focus on strengthening its institutional functioning over a minimum of the next six months. Meanwhile, the values and the political context of the new government, including national policy, legal, and provincial framework, will emerge; and decentralization and perhaps re-centralization issues will become more explicit. Concurrently, the MoPH, with PPHOs, can develop a plan to specify: a) an incremental approach to greater delegation of authority and some functions to the provincial level; b) the timing, location, and way in which capacity strengthening will be undertaken.


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Introduction The Governance Institute – Afghanistan (GI-A) undertook a USAID-funded capacity assessment of PPHOs in Afghanistan between June and October 2014. The study was commissioned following discussions with the MoPH regarding the decentralization of the health sector to the provincial level. The ministry recognized that one factor determining the success of any such decentralization would be the capacity of PPHOs. The overall objective of the assessment was to assess the present capacity of PPHOs in performing key stewardship and public health functions. Sub-objectives included diagnosing the relative strengths and weaknesses of the provincial health systems, ranking key weaknesses in order of priority, and giving specific recommendations that could guide a MoPH strategy on decentralization that might include a capacity development plan. Approach The approach by GI-A to the assessment was primarily one of looking at the current strengths of PPHOs that could be built upon, not just the capacity weaknesses. At the outset, we agreed to be clear about 3 things: 1) the term ‘decentralization’ as applied to, and within, the country context – see Table 2; 2) the purpose of decentralization (that it is not an end in itself); and 3) the seven provinces selected by the MoPH are so few of the total 34 in the country, that our recommendations must be used with caution (see Section 1). Other factors that influenced our approach included the importance of recognizing that provincial health offices are only one element of a much wider health system, not underestimating the very real progress that has been made in some aspects of governance and in health service delivery since 2002, and the crucial recognition that options for decentralization in the health sector must not be developed in isolation of wider contextual factors (see Section 2). A number of relevant challenges to decentralization found during a literature review influenced the design of the methodological tools for this assessment. Such challenges include the complexity of the process of decentralization, the evidence that, for example, the impact of decentralization on equity is mixed and inconclusive, and that there are a number of pre-determining factors in the wider context to successful decentralization including the quality of state and institutional governance (see Table 3). Both qualitative and quantitative methods were used to assess the feasibility of options for decentralization within the health system of Afghanistan. These included: a) desk research of international literature and local relevant documents (see Table 2, footnotes, Annexes B and E and the international literature review for references); b) secondary data analysis of national surveys and existing data sources; c) in-depth interviews of a variety of stakeholders; d) focus group discussions with PPHOs provincial key stakeholders and provincial liaison directorate (PLD); e) an assessment of the capacity of PPHOs; and f) direct observation of provincial health coordination committee meetings (see Section 1).

Key Findings The Wider Context (see Section 3.1) There is currently a new political context as a result of the very recent change of government. This could mean a period of rapid change in the country that is also a window of opportunity - an opportunity to build upon the successes to date while addressing the very real constraints to state building and institutional transformation.


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Under the previous government there was no publicly stated political will and commitment to decentralization. It is too soon after the change of government to know whether there will be the political will to have decentralization as a state-owned process that has a policy and legal framework. Furthermore, if the political will does exist, there still remains the question if that translates into the long-term political commitment that is required to make decentralization a success. There is no national policy on decentralization, nor is there any legislation. Perhaps in the absence of a crucial supportive context, we were unable to find any evidence that any other line ministry has formally adopted and implemented decentralization. There are some facilitating factors to enable successful decentralization. These include the growing evidence of strong leadership and the possibility of building upon some sound foundations, successes, and strengths to transform governmental institutions towards achieving sustainable results. Some of the current challenges include the lack of strong national unity, lack of willingness among some in management to transfer power, and the extensive and institutionalized corruption. Decentralization could either facilitate further corruption or it could, by tightening up procedures and accountability, help to reduce it. Realities of Capacity Building (see Section 3.2) A number of issues came to light when looking at capacity building in the health sector. Disappointingly, the MoPH and a number of donors have fallen into the category of stakeholders who see capacity building as little more than the formal training of individuals, and the attendance at workshops, seminars, and conferences - many overseas. The words ‘mentoring,’ ‘coaching,’ and ‘institutional capacity’ never arose during discussions. There is also no focal point in the MoPH for the oversight of the quality of technical assistance (TA). There are now an undoubtedly significant number of highly trained and experienced Afghan health professionals in public health, unlike in 2002. However, little of their capacity is being channeled by the MoPH into enabling the ministry to function as an effective institution that generates sustainable results across a wide range of functions and services. Capacity for Decentralization by PPHOs (see Section 3.3) Our analyses has highlighted that there are variable degrees of knowledge and skills in PPHOs. Various factors play a role in this including pay scales not being an incentive to attract capable staff, lack of authority, poor support from MoPH central level, and too few resources to be able to function effectively. All of these factors contribute to low morale and retention of qualified staff. The quality, type, and amount of continuing education and capacity building available can also affect staff retention. We were not able to find a sound strategy developed and implemented over the past 10 years to develop the capacity of PPHOs. Such a strategy would include the transfer of knowledge and skills from the central level of the MoPH to the provincial level and the use of mentoring, coaching, fora such as roundtables, and coordinated and formal workshops/seminars. We analyzed the interviews with all seven provincial health directors for any capacity-related issues that are common to all provinces. We found five; they are as follows:

• A lack of authority – everything has to be referred to the MoPH central level; • Perceived lack of confidence by the MoPH central level in PPHOs; • Insufficient capacity for planning;


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• Too few resources available to undertake M&E; and • Too few administrative staff for efficient, quality financial management.

The only other common issue that four of the seven provincial health directors expressed was that of good coordination. Coordination also ranked number two in the capacity self-reporting by provincial health offices (see Annex E). Conclusions (see Section 4.1) Stakeholders, at both the central and provincial levels, highlighted the need for the health sector to be cautious about implementing decentralization in the absence of wider supportive government will, commitment, laws and regulations. In addition, it is recognized that the central level cannot transfer skills and knowledge related to governance and public health if it is itself not effectively demonstrating such capacity. At the start of the capacity assessment, we were informed that that MoPH currently has three priorities for building the capacity of PPHOs. They are: 1) budget management, 2) expenditure management, and 3) procurement. Results from our assessment indicate that the capacity for financial management in provincial health offices is weak. This is due to vacant posts, as well as lack of knowledge and skills about current (somewhat complicated) financial practices, which are determined by the Ministry of Finance. Capacity building for PPHOS surrounding the topic of procurement does not need to be addressed, as there is a provincial procurement committee whose role is mandated by decree or by the central government. However, there is a need for PPHOs to have increased awareness of procurement issues and procedures. Options (see Section 4.2)

1. MoPH Statement of Intent and Capacity Building Issue a MoPH ‘Statement of Intent’ to clarify both the values and the emerging political framework of the new government (including at the provincial level) prior to any definitive decision(s) regarding decentralization in the health sector. Meanwhile, the opportunity will be taken to strengthen the institutional functioning of the MoPH for effective governance, including for the possibility of process oversight for incremental decentralization.

2. Collaborate with Ministry of Finance

In the light of the possible devolution of some financial authority to the offices of provincial governors, clarify with the Ministry of Finance the extent to which this will affect the health sector at the provincial level. Collaborate with the finance ministry on getting an explicit list of the functions and procedures that a PPHO will have to undertake. Once the functions and procedures are clarified, the MoPH should then write a “MoPH Statement” about this context, the functions that need capacity strengthening, how the process will be undertaken, and how it will be monitored and reviewed, including lessons learned. Meanwhile, work concurrently within the framework of Option 1.

3. Proceed Without Intervention

The final option is to proceed with decision making regarding which functions of the government to decentralize. This should be combined with finalizing the draft health strategy on decentralization and beginning the implementation of PPHO capacity development. The GI-A is not in favor of this option, as it ignores both the crucial wider context addressed in this report and the need to re-visit governance capacity and the transfer of skills in the central level of the MoPH.


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Implications and Risks (see Section 4.3) As part of the process of developing the options, we considered both the implications and risks for any option, both for the current values of the MoPH and for the potential objectives of decentralization. For example, population size of a province should not be the only factor in deciding the allocation of resources, as is the case now. A risk is that the Governor and his/her Office would not see health as priority in the allocation of resources and inequities (geographical, gender, etc.) would persist or worsen.

Key Recommendations (see Section 5 for details on each recommendation)

1. Focus on strengthening institutional capacity: Prior to any formal decentralization from national to provincial level in the health sector, we recommend that the central MoPH focus on strengthening its institutional functioning over a minimum of the next six months. Concurrently, the MoPH and PPHOs can develop a plan to specify: a) An incremental approach to greater delegation of authority and of some functions to the provincial level; and b) The timing, location, and way in which capacity strengthening will be undertaken.

2. Improve communication: While strengthening aspects of the institutional

functioning of the MoPH and developing a plan (as outlined in Recommendation 1), improve communication between the central and provincial levels of the health system.

3. Create a focal point at the central level of the MoPH: A focal point should be created to assess the need for and coordination, monitoring, and review of, technical assistance. The focal point would also promote and ensure the implementation of mentoring and coaching approaches by technical assistance.

4. Promote cohesion within the PPHOs: The approach to strengthening of the

capacity of PPHOs should be one of viewing the PPHOs as mini-institutions. A PPHO should be strengthened to work as a team with shared values and working principles towards common objectives and targets.

5. Review the PPHO structures: The PHO structures are similar in all provinces, with the exception of the existence of few extra positions in MoPH-Strengthening Mechanism (SM) provinces. There are some officers within the provinces that are not part of the PPHO organogram. The PPHO’s structure has never been evaluated for its adequacy to discharge its public health functions. It is recommended that a review of the structures be conducted that takes into account different provincial contexts.

6. Review or develop PPHO Terms of Reference (ToRs): During our review, we were unable to locate any PPHO ToRs. If they are in existence, they should be reviewed and revised following a discussion on delegation and authority. If the ToRs are not pre-existing, then they should be developed within the next six months. Additionally, the provincial health annual plans for the next year should include locally set service delivery targets.

7. Determine key priority areas: From the sample of 7 provinces, it can be concluded that PPHOs are all different. They need to be treated as such when determining key priority areas to support them towards strengthening


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the health system at the provincial level and below. The 7 PPHOs were found to have five issues in common. However, we recommend caution in presuming the occurrence of, or applying a blanket approach to, addressing the following five issues in all 34 provinces in the country:

• A lack of authority; • Perceived lack of confidence in PPHOs by the MoPH central level; • Insufficient capacity for planning; • Too few resources available to undertake M&E; and • Lack of capacity and too few administrative staff for financial

management.

8. Streamline Contract Management: Contracting NGOs at the provincial level would be neither efficient nor cost-efficient. However, the role of the provinces could be strengthened in the current process of selecting and monitoring NGOs. In addition, sending a copy of the NGO report to the province is not sufficient; rather, the payment of the NGOs against their reports could be jointly determined between the Grants and Contract Management Unit (GCMU) and the PPHO.

9. Reduce effort required to enhance PPHO capacity in procurement, while building capacity in the area of Financial Management: Current training for PPHO staff on procurement at the provincial level is not recommended, as there is a legally mandated provincial procurement committee. However, capacity building is needed in the area of Financial Management.

10. Place efforts to change the selection process of the high level staff, i.e. PHDs: The recruitment and selection of the key staff should be through the MoPH and its partners. The role of Civil Service Commission (CSC) should be limited to a mere presence in the selection panels.

11. Review the payment scales of PPHOs: The payment scales are neither similar across provinces nor sufficient to attract qualified staff to the PPHOs. This needs to be revisited either on fixed- or performance-based payment schemes.


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1. Introduction 1.1 Report Structure Section 1 provides the study background, its objectives, the assessment study approach, and the main strengths and limitations encountered during the study. Section 2 crucially takes a look at the wider context to decentralization of the provincial level. It first gives a snapshot of the new political context as of September 2014. Secondly, it highlights the need for a supportive national policy and legal framework for decentralization. The section also offers an overview of decentralization challenges, gathered from an international literature review. Lastly, this section contains a brief summary of lessons learned on capacity building. Section 3 of this report presents wider-context findings, including the political, policy, and legal framework and the institutional functioning of the MoPH at the national level as the key supportive institution within the health sector for the success of decentralization. This is followed by an assessment of current facilitating factors and challenges to decentralization within Afghanistan. The section then presents the results of the PPHO capacity assessment, conducted in seven sample provinces. Section 4 highlights conclusions, options, implications, and risks, while Section 5 provides our recommendations for decentralization. The Annexes provide an extract from the current contract’s ‘Statement of Work’ and the work plan (Annex A), references to the documents used during the study (Annex B), a list of people interviewed (Annex C), and a list of the questions and issues considered when examining the wider context to decentralization at the provincial level (Annex D). Annexes E and F provide detail on the findings of this assessment study. 1.2 Background and Objectives During a strategic health retreat in January 2012, the MoPH and its partners came to a consensus that systematic decentralization could help the MoPH improve efficiency and transparency. Additionally, the MoPH concluded that decentralization would not work, especially in terms of its impact on efficiency and quality of services, if the approach is poorly designed and/or implemented. The United States Agency for International Development (USAID) and its implementing partner, Management Sciences for Health (MSH), commissioned the Governance Institute Afghanistan (GI-A) to undertake a capacity assessment on the current performance of provincial health systems their transition needs for a more decentralized system. The intention of this assessment was to provide the MoPH with an assessment as to the capacity of its provincial management teams from functional, service delivery, and outcome perspectives. The study had an overall objective and specific sub-objectives, as summarized below (see Annex A for a detailed description).

Overall Objective The main aim of the study was ‘to assess the present capacity of provincial public health offices in performing key stewardship and public health functions.’


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Sub-Objectives

• To assess the capacity of provincial public health offices in carrying out specific stewardship/management and public health functions.

• To assess provincial health systems so that a scoring and ranking mechanism be institutionalized for continuous assessment.

• Diagnose the relative strengths and weaknesses of the provincial health systems, and prioritize key weakness areas.

• Develop specific recommendations that could guide a decentralization strategy inclusive of a capacity development plan.

1.3 Approach and Methods

Factors Influencing the Approach In undertaking the assessment, the GI-A was mindful of five things: First, the need to be clear at the outset about the statement of work; this included the wording and the link between the objective and sub-objectives and the expected deliverable of the study. Second, the importance of bearing in mind that PPHOs are only one element of a much wider health system. The institution of the MoPH at the central level of government bears much responsibility for the ability of PPHOs to be able to function effectively and efficiently and to be transparent and accountable. This is particularly important when considering the need by provincial level to achieve sustainable, positive health results. Third, it is important not to underestimate the very real progress that has been made in some aspects of governance and in health service delivery since 2002. Additionally, it is key not to underestimate the difficulties that Afghanistan is facing in terms of security, variable leadership ability, and the relative lack of impact of the considerable quantity of technical assistance to date on institutional capacity. Fourth, an analysis of the wider context and the institutional function of the central level ministry was not part of the contractual statement of work; however, the GI-A felt it crucial that this be considered. The review of the international literature as part of the study (see Table 31) highlighted that options for decentralization must not be developed in isolation of wider contextual factors such as:

• The political will and commitment to decentralization both within the national government and in the ministry of health or equivalent;

• A national policy on decentralization with supportive legislation that gives the type and extent of decentralization, and the sectors and functions to be decentralized;

• The process of developing a national sector policy which includes wide consultation with provincial level authorities and other stakeholders;

• A national health policy or strategy on decentralization that highlights the ‘why’, ‘what’ and ‘how’ of decentralization in the health sector including ‘how’ capacity on aspects of decentralization will be strengthened; and

• Clear, stated roles and responsibilities of the national ministry of health with particular reference as to how the national level will help strengthen the role

1 Note – as well as Table 3, there is a full international literature review available from MSH and from the GI-A.


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and capacity of the provincial levels. Decentralization to a lower level of government stands little or no chance of success if the central level ministry itself does not have the institutional leadership, organization and management, structure, and skills to support decentralization.

Lastly, part of looking at the wider context includes an understanding of the functioning of the key responsible institution (in this case the MoPH) for the health sector. As defined in this report, an institution is a lead governmental facility that sets policy and strategy. Whereas an organization is independent and can consist of any grouping which either argues for different, innovative approaches or helps achieve the governmental policy and strategy. Institutional (and organizational) capacity strengthening is about team work. For example, in-house collaborative diagnosis and treatment of strengths and challenges, developing a shared vision and shared cultures (such as of learning and accountability), a systematic approach to change management including planning, M&E and feedback, and the development of ownership are all activities that require a strong team approach.

Methods Before finalizing the approach to the study, the GI-A identified three issues that needed clarification. First, we needed an internal common agreement as to what we understood by the term ‘decentralization’ as applied to, and within, the country context (see Table 1). Second, to have clarity about the purpose of decentralization, we agreed that decentralization is not an end in itself but is undertaken to better achieve broader objectives such as equity, effectiveness, efficiency, quality, transparency, and accountability. The third issue was to get agreement that the seven provinces of the total 34 in the country represented a good selection of the variety of factors influencing the ability to deliver services – see Table 2. However, because they were so few provinces, our recommendations must be used with caution. Indeed, we think the word ‘suggestions’ would be more appropriate. Furthermore, because of the small sample size, it would not be wise to discern any difference between contracting in and contracting out provinces, between secure and insecure provinces, or differences between the provinces funded by the different donors. The sample had been determined by a MoPH committee and agreed upon by both the GI-A and MSH (the contractor). An indication of the approach and methods used can be seen in the study work plan in Annex A. There are references to some of the documents consulted in Annex B. The list does not include the references used in the writing of the main body of this report, as they are given as footnotes. Additionally, other references can be found in Table 3. There are yet more references in the international literature review that can be obtained from MSH or the GI-A. A list of the persons met during the study is included in Annex C. Stakeholders included staff at the MoPH and the Ministry of Finance at the national level, staff of the seven provincial health offices, staff from the Governor’s Office, UNICEF, the World Bank, and NGOs at both the national and provincial levels. Annex D includes questions and issues considered when looking at the wider context to decentralization to provincial level. Both qualitative and quantitative methods were used to assess the feasibility of options for decentralization within the health system of Afghanistan. These included:

• Desk research of international literature and local relevant documents (see Annex B for the references for the national documents and footnotes and Table 3 for other references).


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• Other qualitative and also quantitative tools such as: 1) secondary data analysis of national surveys and existing data sources; 2) in-depth interviews with a variety of stakeholders; 3) focus group discussions with PPHOs and provincial key stakeholders; 4) an assessment of the capacity of PPHOs; 5) direct observation of PPHCC meetings and/or other relevant committees; and 6) self-reporting ranking of provincial functions and skills.

The interviews and focus group discussions were conducted at both the national and provincial levels. The assessment of the capacity of PPHOs was undertaken in the seven sample provinces.

In the statement of work in the contract for the assessment, some key areas of assessment were given for the existing organizational and managerial capacities in the provincial public health offices. These guided the development of the interview forms – see Annex A. Table 1. Clarifying the Meaning of Decentralization* The word decentralization** is a commonly used term. However, coming under its umbrella are other terms, such as those in the left hand column. But ‘decentralization’ is often the only term used when the focus is actually for example, delegation, within the framework of decentralization.

Terms Clarification of the term Delegation Handing over or allocating defined specific power to certain

individuals or groups of people. In health, such as provincial health offices, NGOs or the board of a provincial hospital.

De-concentration Giving power for select functions to provinces.

Devolution Handing powers over to local government; for example, if the national budget were devolved to The Office of the Governor at the provincial level.

Privatization A form of privatization is the allocation of public (or in the case of this country for health, donor funds managed by government) for the purposes of divesting responsibility for services and products formerly provided by government to agencies, organizations, or private enterprises through fixed contracts as sole providers and/or in partnership with government.

Re-concentration When power that has been decentralized is transferred back to state/central level. This is sometimes done because of macroeconomic instability, because of concerns over inequities, and/or obvious fragmentation. This can also occur when state decides to play a greater role in health care and be the main financial contributor. Instead of direct taxes, the health sector is to be financed by the state and e.g. municipalities. Currently in Afghanistan, the Office of the President is contemplating if the purchase of medicines should be re-concentrated at national level to enable the bulk purchase of quality medicines.

*There is commonly what is termed ‘functional decentralization’ (authority for performing particular functions, e.g. health is transferred to a specialized office, like the PPHO) and ‘areal decentralization’ (broad responsibilities for public functions are transferred to a local organization or office that has a well-defined geographical boundary e.g. Office of a Governor). ** Decentralization can also take many forms, political, administrative and financial.


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Table 2. Criteria for Choice of the Seven Provinces Provinces Security Contracting

Grade Donor

Secure Semi- secure

Insecure In Out 1 2 3 EC USAID World Bank

Balkh √ √ √ √ Dikundi √ √ √ √ Farah √ √ √ √ Kandahar √ √ √ √ Kapisa √ √ √ - - - Lagman √ √ √ √ Takhar √ √ √ √ 1.4 Strengths and Limitations The key advantage of the methods and tools is that they are internationally proven and have been adapted to the context of Afghanistan by Afghans with a sound knowledge of, and extensive work experience in, the country as a whole and the health sector in particular. In addition, Afghan nationals undertook all the interviews and conducted the analysis. The role of the international principal investigator was one of mentor, adding quality to what had been developed, for example, during the design of the interview forms and the questions for the focus group discussions. The principal investigator also assisted during a visit to the country towards the end of the study by brainstorming the interpretation of the findings and subsequent development of the options with GI-A staff. Her presence also brought a perspective of international experience in decentralization, including the international desk review for this study. The main limitation of this study is that the seven provinces may not be a large enough sample to fully represent all of the 34 provinces in the country. While the GI-A has made every effort to ensure sound results from the assessment of the seven provinces, the extrapolation of the findings must be done with caution. Security concerns both in Kabul and in the provinces did not limit the ability of the GI-A to undertake the work. However, the presidential elections did limit access to many stakeholders in Kabul. But eventually, all key persons were interviewed.


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2. Wider Context to Decentralization to the Provincial Level 2.1 New Political Context At the time of the writing of this report, there was a wider context of rapid change in the country as a result of the very recent change in government. In his inauguration speech on 30th September 2014 (and subsequently), President Ashraf Ghani has made reference to, and expressed:

• A strong commitment and will to fight corruption while reducing bureaucratic red tape;

• A determination to appoint people on merit to senior governmental positions; • The willingness and determination to implement widespread reforms to

promote good governance including effective and efficient government and its bureaucracy; and

• The need for a greater focus on the role of women in society and the establishment of a special Office for Women and Children.

2.2 Policy and Legal Framework The international literature is clear on the usefulness and necessity of having a national decentralization policy with supportive legislation. Indeed, a book on health system decentralization published in 1990, but still highly relevant today, states that ‘Decentralization policies are usually initiated by central governments and only subsequently are they adopted by the health sector’…..‘before the health sector becomes involved in decentralization, the central government has initiated a national policy by issuing a decree or by adopting constitutional changes that set the pattern for the reforms to be adopted by different ministries.’ 2 It is also stated that ‘Decentralization takes place within a particular historical context and is implemented by governments with different political beliefs and policies’ and that some of the complex reasons why governments are interested in decentralization include in response to more autonomy by regions or provinces, political ideologies, and the need to rationalize overburdened and outdated administration.

2.3 Relevant Challenges to Decentralization in Literature Review Table 3 below lists some of the challenges to successful decentralization found in the international literature; these challenges were identified during a literature review.3 Table 3. Challenges to Decentralization from International Literature

Type of challenge

Notes Reference

Complexity Decentralization is an extremely complex topic; it is very dangerous to make generalizations on why such policies were adopted and how they evolved. It is probably even more difficult to draw conclusions on how decentralization should be undertaken. Each country has its own experiences and their relevance to other countries is fairly limited. For every potential advantage to decentralization there is a corresponding disadvantage. Decentralization may provide opportunities for improving services, but at the same time it can create

Health system decentralization: concepts, issues and country experience. Edited by Mills A et al., 1990, World Health Organization, Geneva Martineau T et al 2003, Decentralisation and the

2 Patrick Vaughan, 1990, in Health system decentralization: concepts, issues and country experience. Edited by Mills A et al, World Health Organization, Geneva 3 The international literature review undertaken as part of this study can be obtained from MSH and from GI-A, Kabul


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Type of challenge

Notes Reference

problems and challenges, such as developing sufficient managerial capacity, and risks. For example, the local capture of resources – in particular the political area of staffing.

impact on Human Resource Management in China and South Africa. Liverpool School of Tropical Medicine/DFID, UK

Evidence mixed and inconclusive

Evidence from the empirical literature on the outcomes of decentralization in the context of health is mixed and inconclusive. Khaleghian found that decentralized child immunization programs performed better in low-income countries, while the opposite occurs in middle-income countries. The impact of administrative decentralization on equity in health and health care is an important unresolved issue in the health policy debate. Predictions from the limited theoretical literature and the relevant empirical research are insufficient to draw any firm conclusions. Available evidence does not confirm that decentralized governments perform better in delivering services to the poor, despite the fact they often are their largest constituency. In Africa, decentralization has been essentially used to consolidate alliances with local elites and thereby reinforce central power, rather than to pursue pro-poor policies. Institutional weaknesses and fiscal constraints have also limited the success of decentralization.

Khaleghian P 2004 Decentralisation and public service: the case of immunization. Social Science and Medicine, (59) 1, 163-183 Jime Nez-Rubio D et al 2008 Equity in Health and Health Care in a Decentralised Context: Evidence from Canada. Health Economics 17: 377–392 Cabral L 2011 Decentralisation in Africa: Scope, Motivations and Impact on Service Delivery and Poverty. Overseas Development Institute, Working Paper no 020 www.future-agriculture.org

Resistance to change

Decentralized service delivery must expect some resistance along the way. A change management strategy must be carefully designed with the idea of assessing and controlling the risks of failure. To be effective, the change management strategy will need to address at least 7 issues identified in the policy discussion in the paper.

Republic of Rwanda 2006 Making Decentralized Service Delivery Work: Putting the people at the centre of service provision, Policy note. Government of the Republic of Rwanda, Kigali May 2006

Contextual - need pre-determining factors to be functioning

The transfer of power and responsibility from the central to the local level should help the poor if local resources, accountability, and governance are in good shape. The process in China and India had negative effects because local governments remained under-funded and health was not seen as their priority. Effective governance enables successful decentralization and helps health leaders achieve better health service performance. Thailand’s 1997 Constitution included a move towards a decentralized system. The country’s approach to decentralization is categorized as a “cautious mover” since there has been limited progress - especially in health-care decentralization during the past decade. Although there are multiple causes of delay, lack of political leadership is the most crucial. The process and the policy context are crucial. The key is less choosing a “big bang” approach (the Philippines and Indonesia) over a gradual one (China and India) than ensuring that these changes are accompanied by reform of healthcare funding.

Uchimura H and Jutting J, 2006 Decentralisation in Asian Health Sectors: Friend or Foe? Policy Insights No 18, OECD Development Centre, May 2006 MSH, 2013, Five Smart Strategies to Govern Decentralised Health Systems, USAID Leadership, Management and Governance Project, June 2013 Jongudomsuk P, and Srisasalux J, 2012, A decade of health-care decentralization in Thailand: what lessons can be drawn? Uchimura H and Jutting J, 2006 Decentralisation in Asian Health Sectors: Friend or Foe? Policy Insights No 18, OECD Development Centre, May 2006

Quality of Success of decentralization ultimately rests on the van der Wal B et al (undated)


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Type of challenge

Notes Reference

state governance

quality of state governance’, its ability to be strong and impartial. This means the state should take responsibility for a) equitable policies; b) professional standards; c) and regional inequalities. The state has not been able to deliver on any of these criteria. Health-care decentralization could not be implemented effectively without the support of the central ministry. Local government staff needs to have their capacity strengthened to handle the new responsibilities; this could be best done by the central ministry staff that was previously responsible for these capacities.

Will patients be better off with a decentralised basic health service? SNV Netherlands Development Organisation Jongudomsuk P, and Srisasalux J, 2012, A decade of health-care decentralization in Thailand: what lessons can be drawn?

2.4 Lessons Learned on Capacity Building One of the most useful papers among the international literature on capacity building is authored by Potter and Brough.4 They state that ‘Capacity building is the objective of many development programmes and a component of most others. However, satisfactory definitions continue to elude us, and it is widely suspected of being too broad a concept to be useful. Too often it becomes merely a euphemism referring to little more than training.’ The final statement in the paper maintains that ‘It is surely time for governments of countries struggling to improve their health services, and for development partners ostensibly trying to support their efforts, to move beyond the mantra of ‘lack of capacity’ and the ineffective placebos of equipment, training and construction.’ The authors go on to say that ‘By addressing systemic capacity building as a hierarchy of components in which the less tangible are the most important…significant improvements could come about in the way development aid resources are used.’ Internationally, one of the key functions of technical assistance is generally presumed to be capacity building. There are mixed results in the health sector, but increasingly the impression is that there needs to be re-think about aspects of technical assistance. These aspects include donor coordination, approaches used in technical assistance, how quality is monitored, and establishing exit strategies. A common approach has been to benefit a particular department or unit in a ministry, often for a specific technical subject such as HIV/AIDS or maternal and child health. This has resulted in islands of excellence within a wider institutional context that still has weak managerial capacity and lack of effective governance. A paper written for a Heads of State Special Summit on HIV/AIDS, TB, and Malaria in Africa looks at institutional factors and states that ‘The move to results-based institutions by focusing on outputs and outcomes is for the better. However, we still need to rigorously examine the quality of inputs that the increasing availability of funds is being used on. This is especially so in relation to needing a better balance between aid for health services and that for institutional and health systems development. In addition, technical advisers from development partners need to work more across a ministry of health on institutional and management change to have a greater impact on achieving targets.’5

4 Potter C and Brough R, 2004, Systemic capacity building: a hierarchy of needs. Health Policy and Planning; 19(5): 336–345 5 Stephanie Simmonds, 2008, Institutional factors and HIV/AIDS,TB and Malaria, International Journal of Health Planning and Management 2008;23: 139-151


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According to a paper authored by the World Bank in 2007,6 between 2002 and 2006 an estimated US$1.6 billion was spent on technical assistance in Afghanistan. Despite this significant sum of money the paper goes on to state that there was widespread dissatisfaction in Afghanistan among both the government and donors with the high cost of technical assistance and its limited impact in terms of capacity building. A key message in the paper is that ‘In Afghanistan, unless specific care is taken to firmly establish Afghan ownership of technical assistance activities and to use technical assistance with a strategic vision to support public administration reform, little progress will be achieved to foster capacity and institution building.’ The author goes on to say that ‘In addition, such efficient use of technical assistance for capacity building will require: a) institution wide medium term approaches instead of narrowly focused random and fragmented projects and b) much more effective donor coordination in the context of the Afghanistan National Development Strategy.‘ A paper written in 20067 on the experiences of the MoPH in capacity building states that:

• Core basic skills such as English language, report writing, and computer skills had never been offered by any of the agencies that had provided training in the MoPH.

• Some organizations had conducted management training in specialized areas but there was little evidence of these programs being tailored to meet the needs of different levels of staff.

• There was a good ministry capacity building plan but implementation needed effective coordination between the MoPH and its partners. A wide range of organizations were providing training on similar topics leading to duplication in some areas and gaps in others. Few agencies had used the plan as a basis for conducting capacity building.

• In order to fulfill the large unmet learning needs among provincial public health office staff, a dedicated cadre of Afghan trainers should be established and tasked with imparting core skills and knowledge such as HMIS, M&E, knowledge of public health, computer and English language to both MoPH and provincial public health office staff.

To build individual capacity and for it to contribute to institutional development, it is important that a person knows what they are expected to be doing in their daily work. However, a finding cited in the 2006 paper was that ‘A large number of ministry and provincial health staff reported they were not aware of the job description for their current post’. It would seem that there are similar experiences between the health and education sectors in capacity building in the country. A paper published in 20108 states that ‘Although the technical assistance in terms of funding the national technical advisors has helped in achieving programme objectives it has not helped much in systems development. Progress made on programmes overwhelmingly relied on the 6 Serge Michaela, 2007, Review of Technical Assistance and Capacity Building in Afghanistan: Discussion Paper for the Afghanistan Development Forum, World Bank, 26 April 26 2007 7 MoPH with Johns Hopkins University and The Indian Institute of Health Management Research, December 2006. The capacity building and lessons learned assessment, General Directorate of Human Resources, Ministry of Public Health, Kabul 8 Sayed Muhammad Shah, Is capacity being built? A Study of Policymaking Process in the Primary and Secondary Education Subsector, July 2010. Afghanistan Research and Evaluation Unit Case Study Series.


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performance of individual advisors rather than teams and the system.’

The paper goes on to say ‘As a whole, capacity building through induction of technical advisors in the education system lacked a strategy under which the technical advisors would transfer their skills to civil servants. In addition, the trainings that were provided were short term without a proper system for the civil servants to be able to apply the learnt skills to their jobs. Apparently, the system and trainings provided did not have much connection in practice. There are significantly different perceptions between the ministry and some donors on the current pattern of technical assistance in terms of funding national advisors for the long term without any exit strategy.’

Finally, in 2004 the MoPH drafted a capacity building plan. The 2006 paper previously cited in this report mentions the availability of a ‘good ministry capacity building plan’ 9 According to the MoPH 2008 Human Resource Policy, 10 the first comprehensive needs assessment and capacity building plan was undertaken September-December 2008; it is stated that ‘the final report is being finalized in January 2009.’ In the Policy on Capacity Building Plan’ document, there is mention that ‘a Capacity Building Plan will be drafted each year under the supervision of the Capacity Building Planning Steering Committee.’ We were unable to find these documents.

9 MoPH with Johns Hopkins University and The Indian Institute of Health Management Research, December 2006. The capacity building and lessons learned assessment, General Directorate of Human Resources, Ministry of Public Health, Kabul 10 MoPH, Human Resources for Health Policy 2008 – 2012, Strategy 2008 – 2010, Indicative Plan to Implement Priority Activities: 2008 – 2010. Government of the Islamic Republic of Afghanistan


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3. Findings 3.1 Wider Context

Political, Policy, and Legal Framework Under the previous government, there was no publicly stated political will and commitment to decentralization. With the new government only constituted within months of this report (September 2014), it is too soon to know if there will be any such commitment from the new government leaders. A long-term political commitment is required to make decentralization a success.11 There is no national policy framework within which line ministries, especially service ministries, could design decentralization in their sector. 12 The first national policy framework that addressed the functioning of provinces was the 2008-2013 Afghanistan National Development Strategy (ANDS). There was also the 2010-2013 Sub-National Governance Policy. Neither document specifically outlines the context, role of stakeholders, or possible process of decentralization. At the time of this report writing, the President was only discussing the devolution of some of the operational budget funds to the Office of a Governor, but not any other aspects of decentralization. Currently, it is not clear whether there will be the political will to have a process of decentralization, and therefore a national policy and legal framework developed in the near future. There is also no national law on decentralization.13 To have such a law is essential if there is to be clarity about the purpose, roles of stakeholders, and political, administrative, and financial functions of a decentralized province. These elements make it explicit as to what would and would not be legal when considering the different forms of decentralization.

Governmental Institutional Functioning Perhaps because there is no supporting legal and policy framework, we were unable to find any evidence that other line ministries are actively pursuing the implementation of forms of decentralization. The office of governors and four line ministries, including the MoPH, were planning 2013 onwards for devolution of funds from the Ministry of Finance as part of a capacity building for results (CBR) facility with a grant from the World Bank.14 In the health sector, the funds were intended to benefit the BPHS and EPHS programs. There was a specific Ministry of Finance policy statement developed to provide the framework for the use of the funds by all five planned recipients of the money. However, the funds were never materialized.15 Following a re-think by donors in discussion with the Ministry of Finance, a revised draft policy statement has been produced and discussions are ongoing as to the amount, target programs, and route for channeling the funds. Meanwhile, the President has recently announced that he is considering devolution of approximately 40 percent of the national operational budget to the offices of provincial governors. This may affect the health sector at provincial level. Should either or both these

11 Patrick Vaughan, 1990, in Health system decentralization: concepts, issues and country experience. Edited by Mills A et al, World Health Organization, Geneva 12 Aarya Nijat Governance in Afghanistan: An Introduction. Afghanistan Research and Evaluation Unit Issues Paper, March 2014 13 Aarya Nijat Governance in Afghanistan: An Introduction. Afghanistan Research and Evaluation Unit Issues Paper, March 2014 14 Note - MoF, World Bank, ARTF 2011-2015, US$100 million grant 15 Interview with a Deputy Minister of Finance, 11 October 2014


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initiatives take place, the MoPH will need to considerably strengthen its ability to deal efficiently with the various procedures required by the Ministry of Finance. In addition, a senior official at the Ministry of Finance has admitted that financial management in the Ministry of Finance is not efficient and is very bureaucratic.16 As previously mentioned, the MoPH is the key governmental institution at the central level for the health of the people of Afghanistan and, as such, bears much responsibility for the ability of provincial health offices to be able to function effectively and efficiently and to be transparent and accountable. For example, a PPHO must be able to oversee the active enforcement of anti-corruption measures in the provincial health sector. Additionally, the director of a PPHO must have the ability to detect and deal with any corruption within the PPHO office. Yet the MoPH seems not to be specifically developing capacity to address corruption. This is despite a key aspect of good governance being transparency about anti-corruption measures at the central level and their active enforcement at all levels of the system. Currently, there are measures in place within the MoPH, but they are not in writing and so everyone has their own interpretation as to what they are. Another topic not currently formalized in writing is the important subject of aid effectiveness. It is not mentioned in the current national health strategy, which is particularly where it needs to be. The result of this is there being little mention, and no active pursuit of, this topic in discussion with partners and other stakeholders. Nor does knowledge about the subject seem to have translated into there being a focal point in the ministry responsible for monitoring adherence to, for example, the Paris Principles. This begs the question: is this a reflection of lack of capacity to establish systems and practices to help ensure aid effectiveness is effectively addressed or is it a lack of the will to give visibility to a subject that can be uncomfortable to deal with because of its link with donors and their funds? Accountability is another key aspect of governance. When looking for any link between planning and accountability for results, we learned that there is no one annual plan for the MoPH as an institution. Each unit produces its own plan and there is no indication that, for example, one of the deputy ministers has responsibility for overseeing the achievement of results. 3.2 Current Facilitating Factors and Challenges to Decentralization We explored what factors in the environment might help with the process of decentralization and its implementation. Because it is well known that the design of any new policy or strategy can meet with opposition and interference, we also identified, through the experience of GI-A personnel working on this assessment study and a brainstorming session with other colleagues, some key prevailing challenges to successful decentralization (see Table 4).

16 Interview with a Deputy Minister of Finance, 11 October 2014


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Table 4. Facilitating Factors and Challenges (not in order of priority)

Facilitating Factors Challenges Strong leadership by the new President and Chief Executive.

Parliamentary interference. The political appointment of provincial staff. Absence of a national law on decentralization. Little or no accountability.

Emerging strong commitment to fight corruption.

Extensive and institutionalized corruption.

A window of opportunity to build upon what is working while making changes to some of the core constraints to moving out of the ’fragile state’ category

Lack of national unity yet feeling of dependency on central level in light of financial and administrative authority being at central level. Perception that decentralization will lead to further fragmentation.

Greater number of well trained and highly experienced professionals in the country who could be motivated to return to working on contributing to state building and institutional development.

Provincial public health directorate structure and staffing, e.g. most do not have adequate numbers of people for financial management and procurement. Additionally, there is a lot of bureaucracy in procurement and financial management. Variable capacity to institutionalize and implement decentralization at provincial level.

An opportunity to build upon the foundations laid in the MoPH already to facilitate the institutional transformation needed in the ministry to get more results.

Poor links between the MoPH central level Provincial Health Directorate, technical departments, and the PPHOs. Combined with poor ability to transfer knowledge and skill from central to provincial level.

Provincial level interest in, and willingness to see, decentralization in many provincial governors offices and in PPHOs.

The high level of insecurity in some areas of the country.

The possible devolution of funds, e.g. some of the national operational budget, means that PPHOs will be able to put into practice their newly developed capacity to manage financial related issues.

Unwillingness to transfer power as it is seen as losing authority. Lack of know-how on the transfer of authority and of relevant skills.

Communities are more vocal and active about seeing that their needs are met.

PPHOs often do not have the funds to get out to communities and to sit down with them and listen.

3.3 The Realities of Capacity Building Capacity building within the MoPH seems to have become little more than training for individuals. In formal and informal discussions during this study, the words ‘mentoring’, ‘coaching,’ and ‘institutional capacity’ never came up, unless raised by a GI-A staff member. Training - and only training - dominated discussions. In the last few years, this has resulted in a human resource strategy for capacity building 2014-2018 that has in its title the words ‘with focus on in‐ service training;’17 the Capacity Building and Organization Development Directorate within the MoPH seems to have

17 MoPH, 2014, National Strategy on Human Resource for Health (HRH) Capacity‐ Building with focus on In‐ service Training. General Directorate of Human Resources, Ministry of Public Health, Kabul


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been focusing exclusively on aspects of training,18 including an electronic package of training opportunities. It is intended that all these aspects of training will contribute to an integrated in-service training plan. The plan is intended to be a first step in developing a continuing education program for health professionals. There is no doubt that, in contrast to the situation in 2002, a significant number of individuals within the MoPH have postgraduate qualifications from internationally, world-recognized academic institutions, some through distance learning. But such training does not seem to have benefited the MoPH to help it function as a well- governed institution. Indeed, we could find no evidence that since 2004 there have been attempts at developing the capacity of the MoPH to function as a well-managed governmental institution. There is one or two outstanding ‘Islands of Excellence,’ such as the GCMU, but all the technical assistance that the unit has benefited from has created what many Afghans nickname a ‘mini MoPH’. Much power and expertise is based in the unit that should actually be spread across other units and departments in the ministry. Capacity building seems to be somewhat fragmented in the ministry. There is a human resources directorate with another directorate, the ‘Capacity Building and Organization Development Directorate,’ under its auspices. The title of this latter directorate is interesting in that to date, no work has been done on organizational development. The focus has been only on training as part of capacity building. It also became evident during the study that there is no strategy to address technical assistance, especially ‘how’ technical assistance personnel should work, rather than just ‘what’ they work on, and their approach to the work and any exit strategy. Furthermore, no one directorate in the ministry is the focal point for technical assistance, so there is currently no oversight. 3.4 Capacity for Decentralization in Seven Provincial Public Health Directorates

The Context One crucial aspect of the functioning, and related capacity, of PPHOs is the leadership and support provided by the Provincial Liaison Directorate (PLD) in the central-level MoPH. We asked a number of people for the terms of reference for the PLD and always got the same answer - there are none. Focus group discussions highlighted varying opinions as to the quality of support provided by the PLD and others within the MoPH central level. For example, the “MoPH superiors do not accept to meet PPHO authorities” (Takhar province), “the response to our reports is too slow” (Kapisa province), “between the MoPH and PPHOs there is not good coordination” (Balkh province), and “if the MoPH took care of the problems we inform them about, then we would not be faced with so many problems” (Laghman province). We also could not find terms of reference or a job description for PPHOs. There only seems to be the description of a package of PPHO core functions and tasks in a framework document. The purpose of the 2012 package is stated as being ‘to establish a framework for the function of PPHOs, to identify gaps in the performance

18 MoPH, 2014, National In-Service Training Guide; Development of Guidelines for In-Service Training; and Mapping of In-Service Training Providers. Capacity Building and Organizational Development Directorate, General Directorate of Human Resources, Ministry of Public Health, Kabul


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of PPHOs, to build the capacity of PPHOs to undertake their stewardship functions, and to further develop the concept of a focus on health outcomes.’19

Strengths and Weaknesses of, and Issues Common to, PPHOs Annex F lists the strengths and weaknesses of PPHOs. It was developed from an analysis of interviews and focus group discussions in each of the seven provinces with a variety of stakeholders. Interestingly, for each of the provinces, the number of weaknesses identified is longer than the strengths. The most outstanding issues common in all seven provinces, as identified through interviews with provincial health directors, are:

• A lack of authority; • Perceived lack of confidence in PPHOs by the MoPH central level; • Insufficient capacity for planning; • Too few resources available to undertake M&E; and • Lack of capacity/too few administrative staff for financial management.

Four20 of the seven provincial health directors expressed during their interviews that they are good at coordination. Coordination also ranked number two in the capacity self-reporting by provincial health offices (see Annex E). Provincial Public Health Directors and Officers on Decentralization21 All provincial public health directors and officers interviewed were in favor of decentralization. However, a few of them had concerns about poor capacity at the provincial level. According to them, it needs to be strengthened prior to any delegation of more responsibilities and authorities. They believe that decentralization will help PPHOs to better address provincial health problems, engage communities in health services delivery, encourage innovation and ownership of the programs, minimize workload at the central level, speed up program implementation and improve quality and coverage of health services. Meetings with Mastofiats on Decentralization in Health22 The Mastofiat plays the role of controller in financial management at the provincial level. During interviews with Mastofiat staff in all 7 provinces, the common problems cited were related to fund release to PPHOs and other departments. Issues include incomplete documentation, delays in communicating allotments from the MoF, and lack of adequate capacity at the PPHOs. According to many of the 7 Mastiofiats, decentralization should be gradual with clear guidelines on the role and responsibilities at various levels. Improved working conditions, regular reporting to the MoPH and other related departments, and deployment of capable directors and other staff at PPHOs with ongoing supervision/monitoring were also mentioned being crucial elements of decentralization. Focus Group Discussions with NGOs at the Provincial Level23 NGO partners have diverse views on the functions to be delegated to provincial levels across the target provinces. They range from limited delegation of power to complete delegation of all functions of the central ministry. Functions such as monitoring, 19 MoPH, 2012, Framework of PPHO Core Functions, Tasks, Standards and Self-assessment, Ministry of Public Health, Kabul 20 Kandahar, Balk, Laghman and Takhar 21 Also see summary of interviews with public health directors and offices sent separately to MSH with this report 22 Also see summary of interviews with Mastofiats sent separately to MSH with this report 23 Also see summary of interviews with NGOs sent separately to MSH with this report


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recruitment of staff, BPHS/EPHS contract management, financial autonomy, regular review of service delivery, and establishment of new health facilities/procurement (including services) should be done at provincial level. Decentralization of these functions would, in their opinion, help in needs-based planning, micro-planning at the district level, community involvement, effective monitoring, contract management, and the training and recruitment of local staff - all of which will improve health service delivery. However, local capacity building, especially the filling of all vacant positions with qualified staff and adequate remuneration, are necessary prerequisites. Pressure from local forces, especially influential individuals, and nepotism in recruitment and award of contracts (services and supplies) are considered as potential drawbacks.

Findings from Reviewing Meeting Minutes of PPHCC Meetings 1. All meeting minutes reviewed included an agenda of follow-up actions.

However, follow-up at the next meeting as to the result of any action was evident in only one province; in most of the provinces, such follow-up was not completed in a systematic way. There was no indication of the current status of actions, or whether it had been achieved.

2. Most of PPHCCs minutes identified real needs of the community. For example, the establishment of a trauma center alongside the Kabul Jalal-Abad road.

3. All provinces have to analyze HMIS data and should present the HMIS top ten indicators to PPHCC members on a quarterly basis. One province listed the top ten indicators on a monthly basis for three consecutive meetings. Just one province listed the top ten in just one of the PPHCC meetings.

4. Some decisions, particularly related to quality control, are not taken by the PPHO. For example, one PPHCC meeting reported on the construction of a health facility but was not able to oversee the quality and had to refer any decision to the MoPH central level.

5. The lack of staff and the stock-out of clinics for some medicines are challenges for most of the provinces.


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4. Conclusions, Options, Implications, and Risks 4.1 Conclusions There was remarkable consistency in the opinions of stakeholders when assessing the present capacity of the MoPH PPHOs in Afghanistan to function as effective and efficient decentralized offices. Stakeholders, at both the central and provincial levels, highlighted the need for the health sector to be cautious about going ahead with decentralization in the absence of wider supportive government will, commitment, laws and regulations. In addition, it is recognized that the central level cannot transfer skills and knowledge related to governance and public health if it is itself not effectively demonstrating such capacity. Delegation was often mentioned as a form of decentralization. If various functions (see Table 5) were effectively delegated, then stakeholders thought that there would be better ownership of programs, more appreciation of the need to have better oversight of the values of the MoPH, and more interest in getting positive results. But decisions and implementation on the ‘what’ and the ‘how’ need to be incremental and dependent of the wider new governmental context. There are high levels of awareness and open discussion about the challenges to effective and efficient delegation. Among those most frequently mentioned corruption, nepotism, ambiguity in procedures and level of authority, long bureaucratic procedures, poor capacity of staff related to low pay, insecurity and poor coordination among different governmental departments featured the most often. Our overall conclusion about capacity building in the health sector is that the MoPH and a number of donors have fallen into the category of stakeholders who see capacity building as little more than the formal training of individuals with attendance at workshops, seminars, and conferences. In formal and informal discussions during this study the words ‘mentoring,’ ‘coaching,’ and ‘institutional capacity’ never came up. During the design of the assessment, we learned that there are three key functions that the MoPH is interested in delegating to PPHOs. These are: budget management, expenditure management, and procurement. While not easy to discover the origin why these functions were decided upon for decentralization, we have concluded that the first two (budget management and expenditure management) is because of the possibility that some money, at some time, will be devolved from the Ministry of Finance at the central level to the Governor’s Office at the provincial level24. Regarding procurement, there seems to be a dream that the procurement of NGOs, as part of contracting-out, could be decentralized to each province. Contracting at the provincial level would be neither efficient nor cost-efficient. The government/MoPH could not afford to run more than three units, which would be replicates of the current central-level MoPH GCMU. Moreover, some would argue that decentralizing contracting could have a serious detrimental effect on equity because of variations in capacity of PPHOs and possibility of easy political influence over resource allocation to different districts. However, provinces could be more involved in the current process of both the selection and the payment of the contracted NGOs. For example, the public health director for a province for which a

24 As previously mentioned in Section 3.1


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NGO is being selected could be involved in the selection process. Verification of the performance of an NGO’s prior to payment could be determined jointly between the GCMU and the PPHO. It is notable that verification by the provinces also carries some risks, therefore, needs safeguarding measures. 4.2 Options The following options have been developed at a time when four important factors are in place: 1) Rapid change as a result of the change of government in September 2014, 2) Rumors about a possible change in leadership in various ministries, including the MoPH; 3) the MoPH at the central level needs to implement changes to its institutional functioning and ability to transfer knowledge and skills if decentralization to the provincial level is to be effective in improving issues such as efficiency, equity, quality, transparency and accountability. These changes would also assist them in being more responsiveness to the needs of the people; and 4) The President has recently announced that he is considering devolution of approximately 40 percent of the national operational budget to the offices of provincial governors. This may well include some of the health budget for the provincial level. 25 Additionally, there may be additional funds channeled through the offices of the provincial governors for the benefit of four sectors (including health) through an ARTF capacity building facility.26 In developing the options, we have recognized that decentralization can take many forms: political, administrative, and financial. Finally, there is a need to be clear as to whether we are really referring to delegation, de-concentration, devolution or privatization, and whether any re-concentration is needed.

Option 1 Issue a ‘Statement of Intent’ to the effect that both the values and the emerging political framework (including national policy and legal framework) under the new government (including at the provincial level) need to be clearer before any definitive decision(s) can be made about decentralization in the health sector. This might take about six months. Meanwhile, the opportunity will be taken to strengthen the institutional functioning of the MoPH to bring it to a level where there is relevant governance, including oversight, of a process of incremental decentralization. This would include:

• Evidence of strong leadership; • Clear vision, values, and mission of the MoPH; • The MoPH working as a team - the ministry working as a whole, as one.

There are no boundaries between units/departments, each is dependent on the other to achieve the vision common to all;

• An institutional culture that enables and encourages communication and consultation, as well as innovative, proactive decision making, efficient flow of information, and its use (such as from the HMIS) to achieve results;

• Management processes that enable efficiency, transparency, accountability, and internal delegation, as well as management skills that are relevant, practical, and facilitate the transfer of such skills the provincial level;

25 Note - It should be remembered that in the national operational budget there are budget lines with very detailed sub-codes. In health for example, 3 budget lines – wages and salaries, maintenance and purchasing assets - with a total of 220 sub-codes with no room for flexibility of spend. 26 Note – as mentioned earlier in this report this is a re-think on the anticipated devolution of funds from the Ministry of Finance as part of a capacity building for results (CBR) facility for which the funds were never forthcoming.


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• A rationalized structure; • Strengthened human resource management, including ensuring everyone is

clear about their role and that the appropriate people are in the right place with the right skills at the right time, with the right approaches and attitudes;

• Anti-corruption measures are explicit, in place, and are implemented effectively;

• A new health strategy that reflects the values and thinking of the new government and is based on a review or evaluation of the current strategy;

• Options 2 and 3 reviewed and decisions, including priorities, established regarding delegation, de-concentration, and/or re-centralization (see Table 5); and

• A few studies undertaken on issues that are key to making decisions about the future direction of the ministry.

Another aspect of a strengthened institution would be expressed in the confidence of the President and Chief Executive of the government to allocate more national funds to the sector, especially for health service delivery. Towards the end of the suggested six-month period, if there is evidence of more effective governance using the above list as criteria, and there are positive signs in the wider political and administrative context then the possibility of decentralization could be re-visited, it will be important to take time to agree and be clear and explicit as to what functions could - and should not be - decentralized within an incremental process that has priorities. Table 5 below could be used as guide as to functions that might be decentralized. Table 6 depicts a number of the functions and expresses the authority that would need to be delegated. Only then should any strategy document on decentralization in the heath sector be further considered.

Option 2 In the light of the possible devolution of some financial authority to governors, clarify with the Ministry of Finance the extent to which this will affect the health sector at the provincial level and the functions and procedures that a PPHO will need to be able to be able to efficiently implement. After this step is complete, MoPH statement on this context could be written, detailing the functions that need capacity strengthening, how the process will be undertaken, and how it will be monitored and reviewed (including lessons learned). Meanwhile, concurrently work within the framework of option 1.

Option 3 The final option is to proceed now with the finalization of the draft health decentralization strategy, make decisions about what to decentralize, and start implementation in the immediate future of the capacity development of PPHOs. The GI-A is not in favor of this option, as it ignores both the crucial wider context detailed about in this report and the need to re-visit governance within the central level of the MoPH. Table 5. Delegation to Provincial Health Offices

Delegation to Provincial Public Health Offices Could be delegated/given responsibility for:

(can act upon decisions made locally) Should not be delegated:

(cannot decide to) Setting provincial health priorities, developing provincial health strategy and annual plans with budget and financing gaps, human resource plan, and continuing education.

Include tertiary level interventions in provincial priorities and plans.


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Delegation to Provincial Public Health Offices Could be delegated/given responsibility for:

(can act upon decisions made locally) Should not be delegated:

(cannot decide to) Decisions related to aspects of the Paris Principles adapted to oversee the work of NGOs and other stakeholders. Aspects such as ownership, alignment, and managing for results. Decisions made and approved during PPPHCC meetings do not need to be sent to the MoPH central level for further approval. Responsibility for oversight of follow-up by PPHO.

*Medicines up to a given amount of US$ per annum.

Purchase medicines over a financial level.

*Medical and surgical equipment and supplies up to a given amount of US$ per annum.

Purchase medical and surgical equipment over a financial level.

Hiring and firing guards and cleaners

Develop a cadre of health personnel outside of the MoPH approved list of cadres. Contract NGOs or consultants in contracting out provinces.

Supervision and monitoring, especially of contract implementation by NGOs.

Emergencies, decisions about immediate response to e.g. disease outbreak, earthquake, and floods.

Innovative approaches to work. Collaborative, small operational research studies designed and implemented jointly by PPHOs and NGOs.

Purchase of food and of domestic equipment e.g. for cleaning, lighting.

*at the time this report was written, the Ministry of Finance informed us27 that the President is considering the need for the bulk purchase of medicines and the re-centralization of purchase of medicines for reasons of quality and cost-efficiency. It could also reduce corruption. So, this possible function for delegation may not be possible, except perhaps in the case of an emergency such as earthquake or sudden outbreak of a disease when an emergency local purchase of medicines is needed.

Table 6. Authority Delegated to Provincial Public Health Offices

PPHOs could be given authority to: Be involved in choosing NGOs in a contracting out province. Help verify performance of an NGO prior to payment. Act on feasible decisions made and approved during PPPHCC meetings. *Purchase medicines up to a given amount of US$ per annum. *Purchase medical and surgical equipment and supplies up to a given amount of US$ per annum. Hire and fire staff, excluding PHD. Monitor contract implementation by NGOs. Make decisions about immediate response (within 48 hour period) following an emergency e.g. disease outbreak, earthquake, floods. Act upon innovative approaches to work. Undertake collaborative small operational research studies designed and implemented jointly by PPHOs and NGOs. Purchase food and of domestic equipment e.g. for cleaning, lighting. 27 Interview with a deputy Minister of Finance, 11 October 2014


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4.3 Implications and Risks It will be important for stakeholders to rigorously consider the implications and risks for any option before a decision is made. Similarly, they must consider the implications and risks for the values of the MoPH and for what might be the objectives of decentralization such as efficiency, transparency, and accountability. A discussion of the implications and risks of decentralization to the current values of the MoPH (taken from the Health Strategic Plan 2011-201528) is detailed below.

Values of the MoPH

Equity Devolution: An implication is that should there be devolution; the population size of a province should not be the major factor in deciding the allocation of resources, as is the case now. A risk is that the governor and his/her office do not see health as priority in the allocation of resources and inequities persist or worsen. A further risk is that the devolution of finances and financial responsibility is not accompanied by institutional strengthening that addresses core behavioral issues that greatly impact getting results such as leadership, team work, attitudes, morale, and approaches to work.

Delegation: An implication is that the staff of a PPHO must have the relevant management knowledge and skills to effectively plan and set priorities to address equity and can monitor trends that take equity into account. A risk is the politics of staffing; nepotism could become more of a problem at the local level when there is delegation. Furthermore, with delegated priority planning and setting, the risk is that if known inequities (e.g. geographical, gender, and/or financial) are not rigorously addressed, then equity will remain a challenge and could possibly worsen. For example, service delivery in hard-to-reach geographical areas could worsen if not actively addressed as a priority.

Right to Health Devolution: As with equity, a risk is that the governor and his/her office do not see health as priority and the right of individuals and communities to health is either given a low priority or ignored when considering resource allocation.

Delegation: If through delegation PPHOs are no better than now at consulting communities about their health needs then there is the risk that provincial health strategies and annual plans will still not reflect the right to health.

Sustainability Devolution: A risk is that the Governor’s Office does not respect the budget lines and uses some of the money for his/her or others personal wishes. For example, the Governor’s Office could choose to build a new health center in his/her village. The PPHO may be put under serious pressure to staff and equip the new health center from existing resources, putting other facilities at risk of sustainability. Delegation: An implication of the delegation of monitoring and supervision with the necessary resources to undertake it efficiently is that the PPHO has direct responsibility to oversee the implementation of work by NGOs to ensure that their approach contributes to sustainability. For example the PPHO could oversee the number of NIDs to ensure they are reduced and routine immunization services are

28 MoPH, Strategic Plan for the Ministry of Public Health 2011-2015, Government of the Islamic Republic of Afghanistan


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functioning well. A risk is that a maintenance plan is not in place to ensure the sustainability of the equipment that is purchased by the PPHO.

Transparency Devolution: A risk is that a PPHO has no idea how decisions are made regarding the allocation of resources by the Governor’s Office because of the lack of transparency by the office. This could result in the unpredictability of funding.

Delegation: If a PPHO does not work as team, be consultative about the spending of available funds, and be open at coordination meetings as to how funds are planned to be spent and then have been spent, there the risk is that ‘transparency’ will be a buzzword rather than a concrete practice. Another risk is that, for example, while the power to select new staff is delegated to PPHOs, the signature of the governor of the province must be obtained for any final decision, similarly for the firing of staff; either of which could be obstructed for reasons that are not made transparent to the PPHO.


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5. Recommendations It can be seen from the following recommendations that we have placed the issue of PPHO capacity strengthening within the wider context of both the MoPH central level and that of the new government. This is important as PPHOs do not, and cannot, function in isolation. There would be no sustainable impact of any capacity strengthening if it is done ignoring wider factors, which can determine the effective and efficient functioning of PPHOs. We also highlight the need for a greater emphasis on the development of institutional capacity. Strengthening the capacity of individuals continues to be important and needed, but it should not be the dominant and sole approach. Key Recommendations:

1. Focus on strengthening institutional capacity: Prior to any formal decentralization from national to provincial level in the health sector, we recommend that the central MoPH focus on strengthening its institutional functioning over a minimum of the next six months. This would include strengthening leadership capacity and encouraging a sense of service, both at central and provincial levels, through a creative approach that promotes integrity, staff motivation, team working, and a culture of accountability. Meanwhile, the values and the political context of the new government, including national policy, legal, and provincial framework, will emerge and aspects of decentralization and perhaps re-centralization issues will be made more explicit. Towards the end of this period, a decision should be made as to whether a strategy on decentralization in the health sector is needed. Only then should any strategy document on decentralization in the heath sector be further considered. Concurrently, the MoPH and PPHOs can work together to develop a plan to specify: a) An incremental approach to greater delegation of authority and of some functions to the provincial level; and b) The timing, location, and way in which capacity strengthening will be undertaken.

2. Improve communication: While strengthening aspects of the institutional

functioning of the MoPH (see Option 1), concurrently improve communication between the central and provincial levels of the health system. Such improved communication could be reflected, for example, in discussing the desirability, feasibility, and capacity and other implications of the suggested aspects of delegation in Tables 5 and 6 with provincial health directors. Any necessary authority and implementation could then be jointly formalized on an incremental basis. In the absence of such improved communication, decisions the mentoring and training needed for issues such as planning, M&E, and financial management should not be made.

3. Create a focal point at the central level of the MoPH: A focal point should be created to assess the need for and coordination, monitoring, and review of, technical assistance. The focal point would also promote and ensure the implementation of mentoring and coaching approaches by technical assistance.

4. Promote cohesion within the PPHOs: The approach to strengthening of the

capacity of PPHOs should be one of seeing the PPHOs as mini-institutions. The emphasis needs to be on institutional capacity building. While strengthening the capacity of individuals is important, it should not be the


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dominant approach. A PPHO should be strengthened to work as a team with shared values and working principles towards common objectives and targets.

5. Review the PPHO structures: The PHO structures are similar in all provinces, with the exception of the existence of few extra positions in MoPH-Strengthening Mechanism (SM) provinces. There are some officers within the provinces that are not part of the PPHO organogram. The PPHO’s structure has never been evaluated for its adequacy to discharge its public health functions. It is recommended that a review of the structures be conducted that takes into account different provincial contexts.

6. Review or develop PPHO Terms of Reference (ToRs): During our review, we were unable to locate any PPHO ToRs. If they are in existence, they should be reviewed and revised following a discussion on delegation and authority. If the ToRs are not pre-existing, then they should be developed within the next six months. Additionally, the provincial health annual plans for the next year should include locally set service delivery targets.

7. Determine key priority areas: From the sample of seven provinces, it can be concluded that PPHOs are all different. They need to be treated as such when determining key priority areas to support them towards strengthening the health system at the provincial level and below. The seven PPHOs were found to have five issues in common. However, we recommend caution in presuming the occurrence of, or applying a blanket approach to, addressing the following five issues in all 34 provinces in the country: • A lack of authority; • Perceived lack of confidence in PPHOs by the MoPH central level; • Insufficient capacity for planning; • Too few resources available to undertake M&E; and • Lack of capacity and too few administrative staff for financial management.

8. Streamline Contract Management: Contracting NGOs at the provincial level would be neither efficient nor cost-efficient. However, the role of the provinces could be strengthened in the current process of selecting and monitoring NGOs. In addition, sending a copy of the NGO report to the province is not sufficient; rather, the payment of the NGOs against their reports could be jointly determined between the Grants and Contract Management Unit (GCMU) and the PPHO.

9. Reduce effort required to enhance PPHO capacity in procurement, while building capacity in the area of Financial Management: Current training for PPHO staff on procurement at the provincial level is not recommended, as there is a legally mandated provincial procurement committee. However, capacity building is needed in the area of Financial Management.

10. Place efforts to change the selection process of the high level staff, i.e. PHDs: The recruitment and selection of the key staff should be through the MoPH and its partners. The role of Civil Service Commission (CSC) should be limited to a mere presence in the selection panels.

11. Review the payment scales of PPHOs: The payment scales are neither similar across provinces nor sufficient to attract qualified staff to the PPHOs. This needs to be revisited either on fixed- or performance-based payment schemes.


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Annex A. Extract from the ‘Statement of Work’ C.1 Introduction: Decentralization to sub-national levels is seen as a common strategy to improve performance of health systems. Decentralization delineates the transfer of responsibilities and authorities from the central government to lower levels or autonomous/semiautonomous institutions. (Rondinelli et al. 1983) Governments pursue decentralization to improve administrative efficiency and service delivery, increase local participation, redistribute power, and reduce ethnic and regional tensions; decentralization is also used as a means of increasing cost efficiency, giving local units greater control over resources and revenues, and increasing accountability. (Brinkerhoff & Leighton 2002) In the recent Strategic Health Retreat held in January 2012, the MoPH and its partners came to a consensus that systematic decentralization could help the MoPH improve efficiency and transparency. It also concluded that Decentralization would not work, especially in terms of its impact on efficiency and quality of services, if the approach is poorly designed and/or implemented. In addition, the MoPH Strategic Plan (2011-2015) calls for a Decentralization Strategy in order to allow provinces greater authority and responsibility to play their stewardship role with regard to health sector activities and management of health services at the local level. In order to develop a practical and effective Decentralization Strategy, it is crucial that information be collected regarding how provincial health systems are currently performing and what needs to be done to assist them in their transition to a more decentralized system where important decisions are made at province level rather than at central level. The MoPH needs to carefully assess the capacity of its provincial management teams from functional, service delivery and outcome perspectives. To respond to this need, the MoPH formed a Working Group under the chairmanship of the Provincial Liaison Directorate to put together the Terms of Reference for such an assessment. The Working Group foresees that this will be an indicator based assessment measuring key organizational (primarily the PPHO), system and resources, services and health outcome indicators. It is also expected that this assessment should take account of the degree of decentralization currently implemented by the MoPH. Key Components of a Provincial Health System:

• Provincial Health Office (MoPH) • Health facilities managed by the MoPH and by NGOs • NGOs contracted to implement the Basic Package of Health Services (BPHS) and

the Essential Package of Hospital Services (EPHS) • Community-level component, including CHWs and Shura-e-Sehee • Governor’s office and Woleswali offices (including District Health Offices where they

exist) • Private sector, including traditional healers and small drug shops • Community Midwifery Education/Community Nursing School

C.2 Objectives 2.1 Overall Objective The aim of this assessment is to assess the present capacity of PPHOs in performing key stewardship and public health functions. The assessment shall identify individual and organizational capacity gaps and propose objective recommendations for a decentralization strategy that will eventually assist the MoPH to improve its support to Provincial Health Offices and to strengthen health systems at province level and below. It is also aimed that this exercise will conduct ranking of provincial health systems and as such will provide the MoPH with a scoring and ranking framework, which it (the MoPH) can apply for periodic assessment of the PHS performance.


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2.2 Sub-objectives:

• To assess the capacity of PPHOs in carrying out specific stewardship/management and public health functions

• To assess provincial health systems so that a scoring and ranking mechanism be institutionalized for continuous assessment

• Diagnose the relative strengths and weaknesses of the provincial health systems, and prioritize key weakness areas

• Develop specific recommendations that could guide a decentralization strategy inclusive of a capacity development plan

2.3 Key questions/areas of assessment PPHO Capacity: What are the existing organizational/managerial capacities at the Provincial Public Health Offices in terms of? a. Communication and Coordination b. Financial Management/procurement c. Planning and resource mobilization d. Supervision and Monitoring e. Management of public health services/Service delivery/Referral system f. HMIS (data collection, analysis, use/decision making) g. Human Resources management and development (Including authority, responsibility and available resources by level) h. Emergency Preparedness Response i. Public and private interaction j. Health Regulation and enforcement k. Infrastructure development l. Pharmaceutical and supplies management


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Annex B. Additional Documents Consulted (additional to the references in the footnotes and those in Table 3)

GOA, Minutes of Cabinet meeting, number 18, 15 August 2011 (only available in Farsi) GoA, 2006-2014, Circular numbers 01-64, Government of Afghanistan; available at www.ppu.gov.af GoA, 2008, Public Procurement law, Government of Afghanistan; available at www.ppu.gov.af GoA, 2009, Public Procurement Rules of Procedure, Government of Afghanistan; available at www.ppu.gov.af GoIRA, 2012, Treasury Accounting Manual Version_1.26’ Islamic Republic of Afghanistan’ Ministry of Finance; Treasury Department

MoPH, System Enhancement for Health Actions in Transition (SEHAT) Program: Afghanistan

MoPH, Sub-national Government: Presentation by PLD, MoPH to MoPH Leadership, Internal Review Meeting 10 and 16 September, 2014 MoPH, 2014, Financial Management Manual for The Ministry of Public Health, Islamic Republic of Afghanistan; Islamic Republic of Afghanistan, Ministry of Public Health’ GD of Admin/Finance, Development Budget Department

MoPH, Health Financing Policy, 2012 – 2020, Government of the Islamic Republic of Afghanistan MoPH, Draft Health Decentralisation Strategy, undated MoPH, Strategic Plan for the Ministry of Public Health, 2011-2015, Government of the Islamic Republic of Afghanistan MoPH, National Health Management Information System - Procedures Manual, Part I & II March 2011, Hoot 1389 MoPH, Hospital Sector Strategy, April 2011, Government of the Islamic Republic of Afghanistan MoPH, A Basic Package of Health Services for Afghanistan – 2010/1389, Revised July 2010, Government of the Islamic Republic of Afghanistan MoPH, Human Resources for Health Policy 2008 – 2012, Strategy 2008 – 2010, Indicative Plan to Implement Priority Activities: 2008 – 2010. Government of the Islamic Republic of Afghanistan MoPH, The Essential Package of Hospital Services for Afghanistan July 2005, Saratan 1384, Government of the Islamic Republic of Afghanistan Thomas J. Bossert, 2009 Module on Decentralization of Health Systems: Sharing Resources and Responsibilities. International Health Systems Group, Harvard School of Public Health (used in training in Afghanistan) Thomas Bossert, et al. "Transformations of Ministries of Health in the Era of Health Reform: The Case of Colombia," Health Policy and Planning, 13,1, pp. 59-77 (1998).

http://www.ppu.gov.af/




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Annex C. Interview List List of interviews and focus group discussions:

Number Applied tool Entity Respondent

Central Level 1 IDI MSH Principle Technical Advisor 2 IDI MSH LMG/HSS Program Manager 3 IDI MoPH Policy and Planning Directorate 3 IDI MoPH Policy and Planning Deputy Minister 4 IDI MoPH Head of GCMU 5 IDI MoPH/GCMU GAVI consultant 6 IDI MoPH/GCMU EC grant consultant 7 FGD MoPH/PLD Provincial public health directorate offices 8 IDI MoF Deputy Minister 9 IDI WB Public Health Specialist

10 IDI WHO PNO Health System Provincial level Daikundi

1 IDI MoPH/PPHD Director of PPHD 2 IDI Mostofiat Head of Mostofiat 3 IDI Procurement committee Members of procurement committee

4 FGD MoPH/PPHD All provincial public health officers including financial officer and procurement officer

5 FGD Provincial key stakeholders BPHS implementers, UNICEF and WHO Kapisa

1 IDI MoPH/PPHD Director of PPHD 2 IDI Mostofiat Head of Mostofiat


4 FGD Provincial key stakeholders BPHS implementers, UNICEF and WHO Takhar



5 FGD Provincial key stakeholders BPHS implementers, UNICEF and WHO Balkh



5 FGD Provincial key stakeholders BPHS implementers, UNICEF and WHO


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Laghman 1 IDI MoPH/PPHD Director of PPHD 2 IDI Mostofiat Head of Mostofiat 3 IDI Procurement committee Member of procurement committee

4 FGD MoPH/PPHD All provincial public health officer including financial officer and procurement officer

5 FGD Provincial key stakeholders BPHS implementers, UNICEF and WHO Kandahar



5 FGD Provincial key stakeholders BPHS implementer, UNICEF and WHO Farah



5 FGD Provincial key stakeholders BPHS implementers, UNICEF and WHO


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Annex D. Wider Context Questions and Issues • Political will expressed by new President at the end of September 2014– is it political

power, processes, stakeholders within the specific context of Afghanistan rather than line ministry systems and functions decentralization?

• Is the decentralization of the national budget to provincial level as mentioned very recently by the President part of a political process to devolve more power to Governors? What are the budget lines in the national budget?

• Is there a national policy on decentralization with supportive legislation that gives the type and extent of decentralization, and the sectors and functions to be decentralized?

• Will the proposed allocation of US$500,000 (? source of the money) to each province by central MoPH address core challenges such as leadership, attitudes and behavior (including corruption), management, decision making practices, planning etc. not just health activities and possibly construction

• The MoPH has asked each province to send in a proposal as to how they would spend the money. Is there a link with the annual plan by each province and the funding gaps in the plan?

• Have any other line ministries implemented systems and functions decentralization? If yes, any lessons learned?

• Does the national health strategy mention decentralization? Does the draft national strategy on decentralization in the health sector define the term and highlight the ‘why’, and ‘how’ of decentralization, not just the ‘what’. Plus ‘how’ capacity on aspects of decentralization will be strengthened at all levels of the health sector

• Are there stated clear role and responsibilities of the national ministry of health with particular reference as to how the national level will help strengthen the role and capacity at provincial level? Decentralization to a lower level of government stands little or no chance of success if the central level ministry itself does not have the institutional leadership, organization and management, structure and skills (including transfer of them) to support decentralization.

• Is there a need for a process of incremental steps to decentralization starting with institutional strengthening of the MoPH at central level?

• What are the origins of thinking about decentralization in MoPH? • What are the lessons learned in capacity building • What is present at the MoPH within framework of decentralization; is there delegation,

de-concentration and/or devolution? • Is there a need for the re-recentralization of any functions? • What are the implications and risks of decentralization for the values of the MoPH

especially equity • What is the feasibility of decentralization when e.g. when 3 donors fund circa 90 per

cent of the BPHS? • How were the current proposed functions for decentralization determined? • Which systems and what functions are most in need of efficiency and transparency? • From analysis of the study is there any discernable difference between secure, semi-

secure and insecure provinces?


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Annex E. Findings: Self-ranking at the Provincial Level on Capacity Summary Based on a self-ranking exercise by PPHOs, leadership, coordination, communication, supportive supervision, oversight of health service delivery and M&E are the functions they think they have the best capacity in. Pharmaceutical management, measuring disease burden and trends, referral system and inter-sectorial collaboration were identified as needing capacity strengthening. Method A self- ranking tool was developed and applied in all 7 provinces. The participants were given a copy of this instrument and requested to rank 23 different management, leadership and stewardship functions as shown in the table below. S/N Functions and skills Rank

1 Communication 2 Coordination 3 Leadership 4 Supportive supervision 5 Monitoring & Evaluation 6 Financial management 7 HMIS (data use, data processing and analysis, and informed decision making ) 8 Report writings skills 9 Oversight/monitoring of basic health service delivery

10 Oversight/monitoring of hospital service delivery 11 Oversight of equitable distribution of health services 12 Oversight of vulnerable groups 13 implementation and reinforcement of national health policy and/or strategy 14 Stewardship of public sector health services 15 Stewardship of private sector health services 16 Ensuring efficient functioning of referral system 17 Regular measurement of burden/trends of disease at province level 18 Emergency preparedness and response 19 Health regulation enforcement 20 Pharmaceutical and supply management 21 Ensuring accountability and transparency 22 Inter sectorial collaboration 23 Capacity building/critical thinking

Seventy-three PPHOs and key stakeholders (BPHS implementation organizations, UNICEF and WHO staff) completed the checklist. The results were analyzed by calculating means for each function then sorted from the lowest to the highest mean. The functions listed 1-6 are what PPHOs are determined to have good capacity in, numbers 7-13 medium capacity, and numbers 14-23 poor capacity. The areas of good capacity were leadership, coordination, communication, supportive supervision, oversight of basic health service delivery and M&E. Analyzing strength and weakness of seven provinces also suggest that almost all provincial health offices have established coordination and communication mechanism called PPHCC and meet regularly once in month. These qualitative data also suggest that all PPHOs are good in conducting supervision, monitoring and evaluation. Areas such as HMIS data use, equitable distribution of health services, financial management, reporting writing skills, monitoring of hospital services delivery, implementation and reinforcement of national health policy and strategy and stewardship of public health services identified as average or medium capacity areas. Finally areas such as


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stewardship of private sector health services; capacity building/ critical thinking; oversight of vulnerable groups; ensuring accountability and transparency; emergency preparedness and response; health regulation enforcement; pharmaceutical and supply management; regular measurement of burden/trends of disease at provincial level; ensuring efficient functioning of referral system; and Inter-sectorial collaboration.

S/N Functions and skills Total AS

PPHO AS

PPHO Ranking TP AS

TP Ranking

1 Leadership 5.19 4.60 1 7.31 2 2 Coordination 5.95 5.72 2 6.75 1 3 Supportive supervision 9.19 9.09 3 9.56 7 4 Communication 9.62 9.39 4 10.44 10 5 Oversight/monitoring of basic health service delivery 9.66 10.23 6 7.63 3 6 Monitoring & Evaluation 9.89 9.81 5 10.19 9 7 HMIS (data use, data processing and analysis, and informed decision

making ) 10.93 11.40 8 9.25 5

8 Financial management 10.99 11.28 7 9.94 8 9 Report writings skills 11.07 11.54 9 9.38 6 10 Oversight/monitoring of hospital service delivery 12.25 12.63 12 10.88 11 11 Oversight of equitable distribution of health services 12.26 13.56 13 7.63 4 12 implementation and reinforcement of national health policy and/or

strategy 12.30 12.23 10 12.56 13

13 Stewardship of public sector health services 12.56 12.60 11 12.44 12 14 Stewardship of private sector health services 13.64 13.95 14 12.56 14 15 Emergency preparedness and response 14.27 14.04 15 15.13 19 16 Health regulation enforcement 14.66 14.42 17 15.50 20 17 Pharmaceutical and supply management 14.97 15.63 18 12.63 15 18 Oversight of vulnerable groups 15.10 14.21 16 18.25 22 19 Ensuring accountability and transparency 15.15 15.79 19 12.88 16 20 Regular measurement of burden/trends of disease at province level 15.64 15.81 20 15.06 18 21 Ensuring efficient functioning of referral system 15.90 16.33 21 14.38 17 22 Inter sectorial collaboration 17.32 17.67 23 16.06 21 23 Capacity building/critical thinking 17.67 16.79 22 20.81 23 AS = Average Score, TP = technical partners

The data was further analyzed on the self-score ranking tools using partners’ scores and PPHOs score. It’s identified that some ranking are different between the groups, but generally their opinion are closed to each other. The overall mean of all 23 areas are less in partners ranking (12.05) compared to PPHOs (12.55) but no statistical differences are observed (P-value = 0.63). Statistics Total PPHO Technical Partners Mean 12.44 12.55 12.05 SD 3.29 3.37 3.64 P-Value using student's t-test (Two-sample equal variance) 0.63 Median 12.30 12.63 12.44

Annex F. Strengths and Weaknesses of the Seven Provinces The following list of strengths and weaknesses has been developed from an analysis of interviews and focus group discussions in each of the 7 provinces. Areas of strength and weakness Balkh Daikundi Farah Kandahar Kapisa Laghman Takhar Good Coordination (Functional PPHCC meeting) Yes Yes Yes Yes

Yes Yes

Functional Different Subcommittees Yes Yes

Yes

Yes Yes Availability of EPR committee Yes Yes

Yes

Poor coordination between PPHO and MoPH departments Yes

Yes Internet Availability Yes No Yes Yes

No Yes

Good quality internet No No No No

No Routine HMIS data collection Yes Yes Yes Yes Yes Yes Yes HMIS data Analysis and Use Yes No No Yes No No No No control on NGOs sending their HMIS data

Yes Yes

NA Yes Yes

Applying NMC Yes No Yes Yes Yes Yes Yes Not utilizing M&E data including no budget for M&E visit Yes Yes Yes Yes Yes Yes

All PPHOs position are occupied Yes No No No Yes Yes No Low capacity in planning

Yes Yes

Yes Yes Yes

Provincial Recruitment by PRR Yes Yes Yes Yes Yes Yes Yes Lengthy recruitment process at MoPH Yes

Yes Yes Yes Yes Yes

Low financial capacity Yes Yes Yes Yes Yes Yes Lengthy procurement and financial procedures Yes Yes Yes Yes Yes Yes Yes

Provincial annual budget developed by central MoPH Yes Yes Yes Yes Yes Yes Delay in payment (late allotment) Yes Yes Yes Yes Yes Yes Limited HR authority Yes Yes

Yes Yes Yes


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Areas of strength and weakness Balkh Daikundi Farah Kandahar Kapisa Laghman Takhar Incapable and low capacity provincial staff Yes Yes Yes No Yes Yes

Different salary scale between NGO and PHO Yes Yes Yes Yes

Yes Provincial decision making authority on health priorities

Yes

Decision on health priority taken at central level Yes Yes Yes Yes Yes Yes Yes Insecurity Yes

Yes Yes Yes Yes

Stock card and stock management information for emergency medicine

Yes

Yes Irregular supply management with stock outs

Yes

Different type of corruption Yes Yes Yes Yes Yes Interference of landlords, parliamentarians, provincial council members Yes

Yes Yes

Limited authority for law enforcement

Yes

Annex G. Reviews and Summaries (sent separately)

Annex H. International Literature Review (sent separately)

Annex I. PPHOs Performance Monitoring Checklist (sent separately)