Institutional Analysis of the Ministry of Public Health at Central and

Provincial Levels

First Global Symposium on Health System ResearchNovember 18, 2010

Overview• Background

• Objectives

• Methodology

• Stewardship functions

• Strengths and challenges by stewardship functions

• Recommendations

Background• Dilapidated health system and extremely poor health status

• MOPH assumed a stewardship role in the health sector and left direct service provision to NGOs

• The division contributed to important gains in health for the Afghan population

• At the central level, the Grants and Contracts Management Unit (GCMU) provided a strong role in overseeing contracts and coordinating donor inputs

Objectives• To identify the strengths and weaknesses of MOPH at central

and provincial levels

• To help the Ministry to effectively carry out its stewardship functions

Methodology• Semi-structured Interviews with Ministry’s officials at the

central and provincial levels

• Field visits to Parwan, Baghlan, Samangan and Balkh provinces

• Review of Ministry’s key documents

Stewardship Functions

– Setting strategies and objectives

– Development of technical guidelines

– Coordination

– Regulation and promotion of the private sector

– Budgeting and resource mobilization

– Accountability and public relations

– Monitoring and evaluation

– Human resource development

– IEC/BCC

– Emergency response

Setting Strategies and Objectives

Strengths Challenges1. Clear and known

mechanisms for developing strategies

2. Many guiding documents developed by the MOPH

3. Senior MOPH officials heavily involved

4. Documents widely shared with development partners

1. Lack of an effective mechanism for dissemination and explanation of key documents to central and provincial staff

2. Lack of involvement of provincial officials

Technical Guidelines and Supervision

Strengths Challenges1. Relevant technical

guidelines developed for several components of the Basic Package of Health Services

2. Guidelines made available to the NGOs

3. Staff of the health facilities trained on how to use the technical guidelines

1. Lack of technical guidelines for mental health, disability, and IEC components of the BPHS and treatment guidelines for the EPHS

2. Inconsistencies in the training of provincial staff

Coordination

Strengths Challenges1. Several coordination

mechanisms exist at the central and provincial levels

2. Results presented to and discussed in certain coordination mechanisms

1. Variations among coordination meetings at the central and provincial levels in terms of discussing the results, decision making and follow up

2. Some NGOs not sharing their reports with provincial officials

Private Sector

Strengths Challenges1. Central and provincial

officials have a positive view about the private sector

2. Private sector rapidly growing in the cities

3. Signs of its expansion in rural areas

1. Lack of updated policies, strategies, quality assurance guidelines, monitoring checklists, etc

2. Low capacity of departments dealing with the private sector

Budgeting & Resource MobilizationStrengths Challenges1. Many central and provincial

officials involved in mobilizing external resources

2. Managers have adequate knowledge about their development budgets

3. Budget expenditure relatively high compared to other ministries

1. Lack of specific operational budget for departments

2. Limited involvement in operation budget preparation

3. Complicated administrative and procurement procedures

4. Centralized financial authority

5. Delay in the reform of the General Directorate of Administration

Accountability & Public Relation

Strengths Challenges1. Extensive presence of

leadership in media

2. Availability of relatively extensive information on MOPH website

3. Regular meetings with community representatives at the national and provincial levels

1. Lack of formal policies and guidelines about accountability and public relations

2. Unavailability of MOPH website in local languages

3. No disclosure of MOPH datasets and financial figures on the website

Monitoring & EvaluationStrengths Challenges1. Existence of national

M&E mechanism

2. Unified HMIS across the country

3. Extensive use of data at certain departments of the MOPH

1. Variations in data use at the central and provincial levels

2. No regular feedback to provincial officials

3. Concerns about the BSC: (i) known timing; (ii) prolonged gap between data collection and report; (iii) potential conflicts of interest; (iv) still not understood and used by many officials

Human Resources

Strengths Challenges1. Draft national human resource

policy and strategy available

2. Provincial and several central departments reformed

3. Many officials paid salaries close to market rates

4. Community midwifery training program implemented in many provinces

1. Same level of provincial staffing and salaries regardless of population size, number of health facilities, and remoteness

2. Too long recruitment process

3. Lack of a strategic plan for addressing human resource issues

4. Issues with the gender, location and knowledge of health workers

IEC/BCC

Strengths Challenges1. Draft policy and strategy

available

2. IEC/BCC an integral part of the BPHS

3. External resources available for IEC/BCC

1. Shortage of technical expertise

2. Delay in finalization of strategies and guideline

Emergency

Strengths Challenges1. National plans available for

Avian Influenza

2. DEWS established

1. Lack of national documents for other emergencies

2. No preparation for certain emergencies

3. The function divided among several directorates

4. Emergency subcommittees not present in some provinces

Conclusions– Good progress in strengthening the stewardship functions

required for rapid expansion of services

– Many key areas still need to be reformed for sustaining the momentum

• Budget and financial management

• Capacity building for peripheral levels

• …

– Need for a systematic approach to strengthening the stewardship functions

Recommendations

Setting Strategies and Objectives– Establish a formal mechanism for the distribution and

explanation of guiding documents to staff

– Consider reinitiating the provincial health quarterly workshop

– Involve the provinces in the development and revision of documents

– Finalize and publish the draft list of health indicators and summary sheets

Technical Guidelines and Supervision

– Develop guidelines for mental health, disability, and IEC parts of the BPHS and treatment guidelines for EPHS

– Conduct training need assessment and training on technical guidelines at the provincial level

Coordination– Make available the national and provincial profiles on

regular basis and make sure they are always part of agenda

– Make sure NGOs are submitting their activity and financial reports to provincial offices

– Hire provincial consultants

Private Sector– Establish a technical and coordination mechanism among

the departments dealing with private sector

– Develop norms and standards

– Reform and strengthen the capacity of concerned departments

Budgeting & Resource Mobilization– Build on program budgeting initiative

– Decentralize budgeting and financial authority

– Reform the General Directorate of Administration

– Simplify procedures

– Develop resource mobilization strategy and guidelines

– Improve the negotiation and proposal writing skills of the officials at the provincial level

Accountability & Public Relation– Finalize and publish the draft public relation strategy and

guidelines

– Publish the website in local languages (requires more staff, translators, and IT equipment; could be contracted out)

– Make the datasets and financial figures publicly available

Monitoring & Evaluation– Finalize, prepare, and disseminate summary national and

provincial profiles on regular basis

– Conduct training need assessment and provide tailored training on HMIS, BSC, etc

– Increase the salary of HMIS officers to levels paid by NGOs

– Evaluate the feasibility of: (i) making BSC entirely independent; (ii) using M&E staff only for quality control and double check; (iii) doing continuous on demand data collection and analysis through out the year.

Human Resources– Evaluate the feasibility of introducing differential staffing

and market rate salaries depending on size and remoteness of provinces

– Introduce incentives, organize informal events, etc to boost morale

– Translate the human resource strategy to an action plan with a focus on developing local human resources

– Expedite recruitment by strengthening and authorizing the General Directorate of Human Resources

IEC/BCC– Hire a short-term consultant to finalize the documents

– Reform the department

– Integrate the IEC with health care delivery departments

Emergency– Bring the function under one reformed umbrella

– Develop general guidelines and instructions

– Conduct regular assessment of potential emergencies and resources

– Make sure subcommittees exist in all provinces