Monitoring of Private and Public Health Centers (AF0027)

What is the public problem that the commitment will address?
Low quality service delivery and ignoring the health standards in some health centers are problems in Afghanistan health sector and public trust in health sector has declined
This situation made our public pay lump sum amount of money for better and effective treatment outside Afghanistan whereas, economically deprived people cannot afford better and effective treatment outside Afghanistan.

What is the commitment?
A check list of minimal standards to scrutinize the quality of service delivery will be prepared by ministry of health. All health centers are obliged to comply with those minimal standards. Joint public and CSO experts monitor the health care centers to assess whether the standards are being met find out the bottle necks and difficulties and recommend solutions to the ministry of health within specific timeframe. Later the team re-monitors to check whether the recommendations have been implemented. In case the recommendations have not been considered or implemented, further steps according to law and procedures of ministry of health will be taken.

How will the commitment contribute to solving the public problem?
Identification and evaluation of health care problems in service delivery by ministry of health and implementation of recommendations in a specific time frame to bring reforms can uplift/improve quality of health services delivery.
Through supportive scrutiny, hospitals and health care centers will be obliged to work on quality service delivery.
The followings can also be considered:
1. Establish and publish minimal standards for health centers to aware citizens about the level of expectations in terms of facilities, medical equipment, staff from health centers.
2. By engaging CSOs in monitoring whether standards are being implemented, it instigates more accurate monitoring from health centers.
3. By conveying recommendations to health centers and existence of check list to examine implementation or nonoccurrence of minimal standards will promote accountability in health care services.
4. Minimal standards are developed by citizens and civil society in consultation with health care center staff, and other health professionals. This increases role of public in improvement of health care services.

Why is this commitment relevant to OGP values?
Quality improvement frame work (minimal standards) for health services delivery in participation with CSOs. It is related to civic participation and accountability

Additional information
National Health Policy
National Health Strategy

14. Developing and Implementing a Quality Improvement Framework for Civil Society and Citizen-Led Monitoring of Services Provided at Public and Private Health Centers

A checklist of minimal standards to scrutinize the quality of service delivery will be prepared by Ministry of Health. All health centers are obliged to comply with those minimal standards. Joint public and CSO experts monitor the healthcare centers to assess whether the standards are being met find out the bottle necks and difficulties and recommend solutions to the Ministry of Health within specific timeframe. Later the team re-monitors to check whether the recommendations have been implemented. In case the recommendations have not been considered or implemented, further steps according to law and procedures of Ministry of Health will be taken.

Main Objective

Identification and evaluation of health care problems in service delivery by Ministry of Health and implementation of recommendations in a specific time frame to bring reforms can uplift/improve quality of health services delivery.

Through supportive scrutiny, hospitals and healthcare centers will be obliged to work on quality service delivery. The followings can also be considered:

1. Establish and publish minimal standards for health centers to aware citizens about the level of expectations in terms of facilities, medical equipment, staff from health centers.
2. By engaging CSOs in monitoring whether standards are being implemented, it instigates more accurate monitoring from health centers.
3. By conveying recommendations to health centers and existence of check list to examine implementation or nonoccurrence of minimal standards will promote accountability in health care services.
4. Minimal standards are developed by citizens and civil society in consultation with healthcare center staff and other health professionals. This increases role of public in improvement of health care services.

Milestones

• Form a joint working group of experts from MOPH and CSOs to prepare the framework.
• Draft TOR for joint working group.
• Draft the framework (minimal standards) by joint working group.
• Convene a consultative meeting with CSOs to collect and incorporate the opinions into framework.
• Finalize the framework and approval by Ministry.
• Implement the first round of monitoring in partnership with CSOs in 20 health centers in five major cities as per the framework to identify the problems and recommend constructive changes.
• Implement the second round of monitoring in partnership with CSOs in 20 health centers in five major cities as per the framework to identify the problems and recommend constructive changes.
• Implement the third round of monitoring in partnership with CSOs in 20 health centers in five major cities as per the framework to identify the problems and recommend constructive changes.
• Implement the fourth round of monitoring in partnership with CSOs in 20 health centers in five major cities as per the framework to identify the problems and recommend constructive changes.
• Prepare a comprehensive report from the entire process, present specific recommendations for continuous health care quality improvement and identify the challenges in the implementation process and publicize the findings through website.

Editorial Note: For the complete text of this commitment, please see Afghanistan’s action plan at https://www.opengovpartnership.org/wp-content/uploads/2020/01/Afghanistan_Action-Plan_2019-2021_EN.pdf.

Commitment Analysis

This commitment aims to develop a mechanism for joint monitoring of healthcare centers and involves civil society organizations and citizens to encourage compliance with service standards. The monitoring process in this commitment will result in a set of recommendations for the Ministry of Public Health to implement. The Ministry of Public Health will lead the implementation of this commitment, in collaboration with civil society organizations.

This commitment is intended as a continuation of the first action plan’s commitment 6, which led to the establishment and funding of The Health Service Accreditation Entity. ^[192] The Entity has not commenced activities. However, its collaborative formation process paved the way for greater CSO participation in monitoring health services. ^[193] In 2016, the Independent Joint Anti-Corruption Monitoring and Evaluation Committee published a Vulnerability to Corruption Assessment for the Afghanistan Ministry of Public Health. ^[194] This report identified gaps in the public health sector that could potentially leave room for corruption. Such corruption often led to illegal, unethical, and disturbing acts that are widespread and follow a specific pattern. ^[195] In most cases, the report showed that patients often have to pay bribes to receive healthcare services. The report also revealed a lack of political leadership within the sector, along with the absence of a complaints mechanism to provide citizens with a means to demand accountability. ^[196] Additionally, the committee found that there is a common practice of doctors referring patients to their private clinic to gain more benefit. ^[197]

Rampant corruption and lack of accountability have hampered the ability of the Ministry of Public Health to provide equitable, proper healthcare across Afghanistan. ^[198] This happens despite the healthcare sector being a key priority for the government since the fall of the Taliban regime. Another report from Integrity Watch Afghanistan made similar findings. ^[199] In that report, 184 healthcare facilities located across eight provinces were surveyed. The findings identified several key problems with healthcare centers, which include poor infrastructure, shortages in medicine and personnel, security threats, and managerial challenges. ^[200]

According to the World Health Organization, there are 3,135 healthcare facilities in Afghanistan as of 2018. This ensures access to a healthcare facility within a two-hour travel distance for almost 87 percent of Afghanistan’s population, ^[201] which is 38 million. ^[202] However, Integrity Watch Afghanistan’s study found that more than two-thirds of the healthcare centers it surveyed are located within two kilometers of the geospatial coordinates provided by the Ministry of Public Health. ^[203] This discrepancy potentially makes it more difficult for citizens to find their locations and makes it difficult for the ministry to monitor service delivery.

In monitoring healthcare service delivery, the Ministry of Public Health follows a specific service standard, but it has not been properly implemented. The standard is more of an internal guide and therefore is not available for public access. This limited availability also restricts the ability of the public to scrutinize it. Additionally, this monitoring process does not mandate the participation of civil society or citizens. Through this commitment, the ministry will work on institutionalizing a policy to improve the quality of the healthcare system that will see the incorporation of civil society participation in the monitoring process. ^[204] This would be done through the formation of a working group comprising the Ministry of Public Health and civil society stakeholders. The group would work to pilot joint monitoring of 20 healthcare centers in five major cities. ^[205]

Upon completion of joint monitoring exercises in the five cities, the working group would then develop a report with detailed recommendations for improving the quality of healthcare services. These recommendations will be developed based on a set of checklists. The working group would use those checklists to evaluate and assess the level of services provided by healthcare centers targeted through this commitment.

This commitment is relevant to the OGP value of civic participation. It proposes to increase civil society participation in the monitoring of healthcare service delivery.

If fully implemented as written, the commitment is expected to have a moderate potential impact on service delivery at public and private health centers. Civil society participation in the monitoring of healthcare service delivery is limited to certain groups within an official partnership program with the Ministry of Public Health. ^[206] This commitment could raise the level of civil society participation by institutionalizing such monitoring as part of the standard process. Furthermore, this commitment lacks specificity regarding the mechanism to guarantee the Ministry of Public Health’s compliance in responding to or providing a report on the recommendations delivered by the working group. Without clear provision for this, the commitment may suffer the same fate as the previous healthcare services accreditation commitment, which did not result in changes in government practice.

Going forward, the government could consider revisiting the objectives of the healthcare services accreditation commitment from the previous action plan with civil society stakeholders. While the commitment did not result in the desired outcome, its main objectives align well with this particular commitment. It could also be a powerful means of ensuring compliance with the recommendations that will be devised by the working group.

Civil society could also focus on ensuring that the checklists used in the joint monitoring process follow similar criteria and standards, as outlined by the accreditation commitment. Once the pilot project with the 20 healthcare facilities is completed, the working group could develop a strategy to roll out the improved service standards and expand the joint monitoring process for healthcare facilities nationwide.