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Afghanistan Health Sector
Balanced Scorecard
National Results 2004 - 2008
L P Singh1, Olakunle Alonge2, Anubhav Agarwal1,
...
Overview
1. Afghanistan public health sector and BPHS
2. Introduction to the Afghanistan Health Sector Balanced
Scorecard
...
Afghanistan Public Health Sector
Source:
A Basic Package of Health Services for Afghanistan – 2010/1389 – MoPH, Afghanistan
Basic Package of Health Services (BPHS)
o Developed in 2002 by MoPH in consultation with major
stakeholders of Afghanistan...
What is a Balanced Scorecard?
o Philosophy of Balanced Scorecard
• Translating strategy into action
o Classic definition b...
o Alternative definition:
“A strategic planning and management system that is used
extensively in business and industry, g...
 Enables MoPH and partners to view a snapshot of several domains of
health system performance and track trends over time
...
 Promotes focus on attainment of measurable results
 Provides actionable evidence on areas of strength and weakness at
m...
Benchmarking in the BSC
 Benchmarks established using 2004 data and applied to
subsequent annual rounds
 Upper Benchmark...
Color Coding in the BSC
Score meeting Upper Benchmark
Score between Lower and Upper Benchmarks
Score below Lower Benchmark
 Health worker satisfaction
 Salary payments current
 Equipment functionality
 Drug availability
 Family planning ava...
Kabul province BSC (2004 – 08)
An example
Benchmarks Kabul
Lower Upper 2004 2005 2006 2007 2008
A. Patients & Community
1 Overall Patient Satisfaction 66.4 90.9 84....
D. Service Provision
18 Patient History and Physical Exam Index 55.1 83.5 70.6 79.7 92.4 92.6 63.6
19 Patient Counseling I...
Sample
Unit
2004 2005 2006 2007 2008
Number of Provinces 33 30 30 30 29
Number of facilities 617 629 630 636 618
Number of...
National results 2004-2008
Domain A: Patients and Community
34.2
54.5
66.4
86.0
94.3
83.1
86.3 86.0
77.7
81.0
76.0 76.2
80.3
77.6 77.5
0.0
10.0
20.0
...
34.2
54.5
66.4
86.0
94.3
83.1
86.3 86.0
77.7
81.0
76.0 76.2
80.3
77.6 77.5
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90....
60
5
1.5
0
10
20
30
40
50
60
70
80
90
100
Shura guidelines overall patient satisfaction Patient perception quality
Progres...
76.7
90.0
81.3 90.7
82.7
63.5 64.1
68.1 69.0 69.1
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 20...
76.7
90.0
81.3 90.7
82.7
63.5 64.1
68.1 69.0 69.1
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2004 2005 2006 20...
6 5.6
0
5
10
15
20
25
30
35
40
45
50
Salary payment current Health worker satisfaction index
Progress (2004-08) –Percentag...
65.7
67.0
78.7
83.8
88.4
71.1
83.7
85.7 81.0
86.3
34.8
48.9
61.6
78.3
83.9
39.3
58.0
66.9
63.9
72.1
18.3
36.3
43.3
58.5
64...
65.7
67.0
78.7
83.8
88.4
71.1
83.7
85.7 81.0
86.3
34.8
48.9
61.6
78.3
83.9
39.3
58.0
66.9
63.9
72.1
18.3
36.3
43.3
58.5
64...
61.4
70.0
82.9
93.7 94.9
67.7
65.8
74.9
91.5 92.4
39.0
74.3
68.9
68.5
71.1
53.5
69.0
68.7
68.7
79.3
65.6
63.2
69.4 70.0 69...
61.4
70.0
82.9
93.7 94.9
67.7
65.8
74.9
91.5 92.4
39.0
74.3
68.9
68.5
71.1
53.5
69.0
68.7
68.7
79.3
65.6
63.2
69.4 70.0 69...
22.7
15.2
49.1
32.8
46.2 47.1
33.5
24.7
32.1
25.8
4.3 2.2 0.6
0
10
20
30
40
50
60
70
80
90
100
Progress (2004-08): Percent...
70.6 73.5
82.2
83.1
83.9
22.2
32.3
55.0
57.4
84.2
62.0
79.3
84.9
95.3 95.2
25.4
22.3
42.3
59.5
71.2
0.0
10.0
20.0
30.0
40....
70.6 73.5
82.2
83.1
83.9
22.2
32.3
55.0
57.4
84.2
62.0
79.3
84.9
95.3 95.2
25.4
22.3
42.3
59.5
71.2
0.0
10.0
20.0
30.0
40....
29.6
35.1 36.6
48.7
48.0
62.2
52.0
77.5
84.4
75.4
18.0
6.2 7.0
18.4 19.7
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
...
29.6 35.1 36.6
48.7
48.0
62.2
52.0
77.5
84.4
75.4
18.0
6.2 7.0
18.4 19.7
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
...
13.3
62.0
33.2
45.8
18.4
13.2
1.7
0
10
20
30
40
50
60
70
80
90
100
Patient history
and exam
index
Average new
patients
ANC...
o Two indicators on user fees
• Indicator 25: Facilities with user fee guidelines
• Indicator 26: Facilities with exemptio...
55.2 57.3 57.8 60.0 60.0
50.0 50.0 50.0 50.0 50.0
50.0 50.0 50.0 49.6 49.6
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90....
55.2 57.3 57.8 60.0 60.0
50.0 50.0 50.0 50.0 50.0
50.0 50.0 50.0 49.6 49.6
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90....
4.80
0.00 -0.40
-2
0
2
4
6
8
10
% female patients in OPD Overall patient visit Patient satisfaction
Progress (2004-08): Pe...
Summary
Summary of Performance: 2004 - 2008
Decrease (-2 or
less)
Patient satisfaction
Constant (+/- 2 pts)
Overall patient visit
...
Progress by Domains
64.4
70.1
48.5
41.4
51.9
72.3
77.1
57.5
43.0
52.6
77.6
74.7
65.3
55.1
52.9
80.4 79.9
72.5
63.8
53.2
84...
Usage of the Balanced Scorecard
o Over the years BSC has found extensive application in the
Afghanistan health sector such...
Looking Ahead
The Future Balanced Scorecard
o Domains largely sound, but:
• Rapidly changing health system
• Many benchmarks already ach...
Future BSC Features
Lower Upper National Median
2004 2005 2006 2007 2008
A. Patients & Community
1Overall Patient Satisfac...
Thank You!
Thank You!
Source:
National Geographic
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Afghanistan Health Sector Balanced Scorecard

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This presentation was given at the Global Symposium on Health System Research in November 2010. The authors are L P Singh, Olakunle Alonge, Anubhav Agarwal,
Kayhan Natiq, S D Gupta and David Peters.

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  • Decrease: - 8 pts.
    Large increase: both indicators in Domain D: Service Provision (# new OPD visits: + 26.8 pts.; Delivery care: + 11.7 pts.)
  • Rapidly changing health system, so some benchmarks are outdated (2004 targets have largely been achieved; it’s time to “raise the bar”)
    Some indicators, such as the CIs, need revision, to be more easily understood
    Several new indicators are proposed that will give a broader picture of BPHS delivery. For example, coverage is not really addressed by the current BSC, and this is something we’d like to add in the future, using data from biannual household surveys and other sources.
    ADDITIONS: Coverage (MCH services); access to care, OOPS, New goals/strategies: BPHS being revised (scope increasing), new H&N sector strategy, new National M&E strategy
  • We have been able to accomplish a lot in the last five years of the BSC in Afghanistan. Despite security and other challenges, we have consistently produced a timely measurement tool that is the first of its kind in a developing country.
    However, we have several ideas for how to make the BSC even more relevant and useful in the future. First, in addition to revised benchmarks for the current indicators, we would like to expand the scope of measurement to include areas not currently addressed in the BSC: the community’s role in health, in terms of CHW performance, as well as indicators of population health coverage, that go beyond facility quality and outputs. These will be captured through household surveys and other means, which will also allow us to look at the perspectives of non-users.
    In addition to the expanded scope of measurement, we feel there is lots of room for enhanced performance management. This would take place through improved communication and use of the BSC at peripheral levels; through documentation of best practices and information sharing, and really moving the BSC from a measurement tool to a performance improvement tool.
  • Transcript of "Afghanistan Health Sector Balanced Scorecard"

    1. 1. Afghanistan Health Sector Balanced Scorecard National Results 2004 - 2008 L P Singh1, Olakunle Alonge2, Anubhav Agarwal1, Kayhan Natiq2, S D Gupta1 and David Peters2 1 Indian Institute of Health Management Research (IIHMR) 2 Johns Hopkins Bloomberg School of Public Health
    2. 2. Overview 1. Afghanistan public health sector and BPHS 2. Introduction to the Afghanistan Health Sector Balanced Scorecard 3. National results – Discussion by domains and indicators 4. Summary 5. Looking Ahead…
    3. 3. Afghanistan Public Health Sector Source: A Basic Package of Health Services for Afghanistan – 2010/1389 – MoPH, Afghanistan
    4. 4. Basic Package of Health Services (BPHS) o Developed in 2002 by MoPH in consultation with major stakeholders of Afghanistan Health sector o Provides clear guidelines on the various aspects of health services delivery o BPHS Implementation • MoPH = Stewardship role • Implementation through contracting (NGOs, MoPH-SM) o Third-party monitoring using the Balanced Scorecard approach, annually since 2004.
    5. 5. What is a Balanced Scorecard? o Philosophy of Balanced Scorecard • Translating strategy into action o Classic definition by Kaplan and Norton • “A multi-dimensional framework for describing, implementing and managing strategy at all levels of an enterprise by linking objectives, initiatives, and measures to an organization’s strategy”
    6. 6. o Alternative definition: “A strategic planning and management system that is used extensively in business and industry, government, and nonprofit organizations worldwide to align organizational activities to the vision and strategy of the organization, improve internal and external communications, and monitor organizational performance against strategic goals.” Source: http://www.balancedscorecard.org What is a Balanced Scorecard?
    7. 7.  Enables MoPH and partners to view a snapshot of several domains of health system performance and track trends over time  Enables provinces and agencies to benchmark performance • Achievable performance targets appropriate for Afghanistan  Management innovation • Afghanistan is one of the pioneers in LMIC to apply BSC to manage national health system Why a Balanced Scorecard for Afghanistan?
    8. 8.  Promotes focus on attainment of measurable results  Provides actionable evidence on areas of strength and weakness at multiple levels: national, provincial  Provides a basis for corrective action  Measurement of performance essential for effective management and accountability Why a Balanced Scorecard for Afghanistan?
    9. 9. Benchmarking in the BSC  Benchmarks established using 2004 data and applied to subsequent annual rounds  Upper Benchmark: Minimum level of performance achieved by provinces in the top quintile in 2004  Lower Benchmark: Minimum level of performance achieved by provinces above the bottom quintile in 2004
    10. 10. Color Coding in the BSC Score meeting Upper Benchmark Score between Lower and Upper Benchmarks Score below Lower Benchmark
    11. 11.  Health worker satisfaction  Salary payments current  Equipment functionality  Drug availability  Family planning availability  Laboratory functionality  Staffing levels  Provider knowledge score  Staff received training in last year  HMIS use  Clinical guidelines  Infrastructure  Patient record keeping  Monitoring of TB treatment • Facilities with user fee guidelines • Facilities with exemptions for poor patients • Overall patient satisfaction • Patient perceptions of quality • Shura-e-sehie activity in community • Equity of service delivery • Equity of patient satisfaction • Females as % of new outpatients Staff Financial Systems Patients & Community Overall Vision Service Provision Capacity for Service Provision DOMAINS • Patient history and physical exam • Patient counseling • Proper sharps disposal • Average new outpatient visits per month (BHC>750 visits) • Time spent with patient (> 9 minutes) • Provision of antenatal care • Provision of delivery care The Framework of the Balanced Scorecard
    12. 12. Kabul province BSC (2004 – 08) An example
    13. 13. Benchmarks Kabul Lower Upper 2004 2005 2006 2007 2008 A. Patients & Community 1 Overall Patient Satisfaction 66.4 90.9 84.8 75.6 94.8 76.3 82.6 2 Patient Perception of Quality Index 66.2 83.9 86.9 72.8 86.5 80.9 71.6 3 Written Shura-e-sehie activities in community 18.1 66.5 33.3 80.1 59.8 53.7 29.6 B. Staff 4 Health Worker Satisfaction Index 56.1 67.9 68.8 66.1 78.4 62.3 60.2 5 Salary payments current 52.4 92.0 52.4 91.4 94.8 93.3 50.3 C. Capacity for Service Provision 6 Equipment Functionality Index 61.3 90.0 75.6 80.8 80.8 83.2 74.3 7 Drug Availability Index 53.3 81.8 76.8 71.3 86.8 69.6 66.5 8 Family Planning Availability Index 43.4 80.3 65.4 76.7 89.4 89.1 97.8 9 Laboratory Functionality Index (Hospitals & CHCs) 5.6 31.7 30.4 44.1 43.7 41.6 51.7 10 Staffing Index -- Meeting minimum staff guidelines 10.1 54.0 54.0 79.7 85.3 77.2 73.4 11 Provider Knowledge Score* 44.8 62.3 59.1 73.8 78.5 73.3 N/A 11a Revised Provider Knowledge Score 71.5 86.0 N/A N/A N/A N/A 82.2 12 Staff received training in last year 30.1 56.3 36.6 76.5 68.0 66.8 45.0 13 HMIS Use Index 49.6 80.7 80.7 63.6 62.8 61.0 60.3 14 Clinical Guidelines Index 22.5 51.0 38.4 64.9 60.7 77.7 62.3 15 Infrastructure Index 49.3 63.2 56.5 55.1 53.4 41.2 39.5 16 Patient Record Index 56.1 92.5 59.5 79.2 71.3 62.0 51.0 17 Facilities having TB register 8.3 26.6 10.7 7.8 38.0 51.2 51.8
    14. 14. D. Service Provision 18 Patient History and Physical Exam Index 55.1 83.5 70.6 79.7 92.4 92.6 63.6 19 Patient Counseling Index 23.3 48.9 37.5 52.0 64.8 65.4 35.0 20 Proper sharps disposal 34.1 85.0 54.4 59.7 66.1 65.9 44.6 21 Average new outpatient visit per month (BHC > 750 visits) 6.7 57.1 11.1 90.9 69.2 85.7 46.7 22 Time spent with patient (> 9 minutes) 3.5 31.2 31.2 19.0 25.1 5.9 0.7 23 BPHS facilities providing antenatal care 28.9 82.8 80.2 87.9 85.0 100.0 91.7 24 Delivery care according to BPHS 10.5 39.3 27.9 27.3 30.6 58.3 42.2 E. Financial Systems 25 Facilities with user fee guidelines* 80.3 100.0 100.0 91.3 100.0 100.0 0.0 26 Facilities with exemptions for poor patients* 64.4 100.0 64.0 47.5 100.0 100.0 100.0 F. Overall Vision 27 Females as % of new outpatients 46.5 59.7 62.6 64.7 61.8 64.3 61.0 28 Outpatient visit concentration index 48.0 52.7 51.9 50.6 50.0 49.9 55.3 29 Patient satisfaction concentration index 49.0 50.9 49.9 50.9 50.6 50.0 49.3 * Indicators not included in composite scores Revised Composite Scores 32 Percent of Upper Benchmarks Achieved 7.7 26.9 23.1 38.5 61.5 50.0 34.6 33 Percent of Lower Benchmarks Achieved 69.2 88.5 100.0 96.2 100.0 96.2 84.6 Mean scores across 26 indicators 46.2 54.9 53.4 64.2 67.3 66.4 56.1 Benchmarks Kabul Lower Upper 2004 2005 2006 2007 2008
    15. 15. Sample Unit 2004 2005 2006 2007 2008 Number of Provinces 33 30 30 30 29 Number of facilities 617 629 630 636 618 Number of Observations of Patient-Provider Interactions 5719 5856 5964 6089 5970 Number of Exit Interviews 5597 5862 5964 6087 5950 Number of Health Workers Interviewed 1553 1452 1723 1940 2233
    16. 16. National results 2004-2008
    17. 17. Domain A: Patients and Community 34.2 54.5 66.4 86.0 94.3 83.1 86.3 86.0 77.7 81.0 76.0 76.2 80.3 77.6 77.5 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Written Shura-e-sehie activities in community Overall Patient Satisfaction Patient Perception of Quality Index
    18. 18. 34.2 54.5 66.4 86.0 94.3 83.1 86.3 86.0 77.7 81.0 76.0 76.2 80.3 77.6 77.5 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Written Shura-e-sehie activities in community Overall Patient Satisfaction Patient Perception of Quality Index Domain A: Patients and Community
    19. 19. 60 5 1.5 0 10 20 30 40 50 60 70 80 90 100 Shura guidelines overall patient satisfaction Patient perception quality Progress (2004-08) – Percentage points Domain A: Patients and Community
    20. 20. 76.7 90.0 81.3 90.7 82.7 63.5 64.1 68.1 69.0 69.1 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Salary payments current Health Worker Satisfaction Index Domain B: Staff
    21. 21. 76.7 90.0 81.3 90.7 82.7 63.5 64.1 68.1 69.0 69.1 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Salary payments current Health Worker Satisfaction Index Domain B: Staff
    22. 22. 6 5.6 0 5 10 15 20 25 30 35 40 45 50 Salary payment current Health worker satisfaction index Progress (2004-08) –Percentage points change Domain B: Staff
    23. 23. 65.7 67.0 78.7 83.8 88.4 71.1 83.7 85.7 81.0 86.3 34.8 48.9 61.6 78.3 83.9 39.3 58.0 66.9 63.9 72.1 18.3 36.3 43.3 58.5 64.5 15.8 20.6 37.4 53.7 62.9 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Equipment Functionality Index Drug Availability Index Clinical Guidelines Index Staffing Index -- Meeting minimum staff guidelines Laboratory Functionality Index (Hospitals & CHCs) Facilities having TB register Domain C: Capacity for Service Provision
    24. 24. 65.7 67.0 78.7 83.8 88.4 71.1 83.7 85.7 81.0 86.3 34.8 48.9 61.6 78.3 83.9 39.3 58.0 66.9 63.9 72.1 18.3 36.3 43.3 58.5 64.5 15.8 20.6 37.4 53.7 62.9 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Equipment Functionality Index Drug Availability Index Clinical Guidelines Index Staffing Index -- Meeting minimum staff guidelines Laboratory Functionality Index (Hospitals & CHCs) Facilities having TB register Domain C: Capacity for Service Provision
    25. 25. 61.4 70.0 82.9 93.7 94.9 67.7 65.8 74.9 91.5 92.4 39.0 74.3 68.9 68.5 71.1 53.5 69.0 68.7 68.7 79.3 65.6 63.2 69.4 70.0 69.9 55.0 44.6 48.7 54.6 54.1 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Family Planning Availability Index HMIS Index Staff received training in last year Provider Knowledge Score Provider Knowledge Score- Revised Patient Record Index Infrastructure Index Domain C: Capacity for Service Provision
    26. 26. 61.4 70.0 82.9 93.7 94.9 67.7 65.8 74.9 91.5 92.4 39.0 74.3 68.9 68.5 71.1 53.5 69.0 68.7 68.7 79.3 65.6 63.2 69.4 70.0 69.9 55.0 44.6 48.7 54.6 54.1 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Family Planning Availability Index HMIS Index Staff received training in last year Provider Knowledge Score Provider Knowledge Score- Revised Patient Record Index Infrastructure Index Domain C: Capacity for Service Provision
    27. 27. 22.7 15.2 49.1 32.8 46.2 47.1 33.5 24.7 32.1 25.8 4.3 2.2 0.6 0 10 20 30 40 50 60 70 80 90 100 Progress (2004-08): Percentage points change Domain C: Capacity for Service Provision
    28. 28. 70.6 73.5 82.2 83.1 83.9 22.2 32.3 55.0 57.4 84.2 62.0 79.3 84.9 95.3 95.2 25.4 22.3 42.3 59.5 71.2 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Patient History and Physical Exam Index Average new outpatient visit per month (BHC > 750 visits) BPHS facilities providing antenatal care Delivery care according to BPHS Domain D: Service Provision
    29. 29. 70.6 73.5 82.2 83.1 83.9 22.2 32.3 55.0 57.4 84.2 62.0 79.3 84.9 95.3 95.2 25.4 22.3 42.3 59.5 71.2 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Patient History and Physical Exam Index Average new outpatient visit per month (BHC > 750 visits) BPHS facilities providing antenatal care Delivery care according to BPHS Domain D: Service Provision
    30. 30. 29.6 35.1 36.6 48.7 48.0 62.2 52.0 77.5 84.4 75.4 18.0 6.2 7.0 18.4 19.7 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Patient Counseling Index Proper sharps disposal Time spent with patient (> 9 minutes) Domain D: Service Provision
    31. 31. 29.6 35.1 36.6 48.7 48.0 62.2 52.0 77.5 84.4 75.4 18.0 6.2 7.0 18.4 19.7 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Patient Counseling Index Proper sharps disposal Time spent with patient (> 9 minutes) Domain D: Service Provision
    32. 32. 13.3 62.0 33.2 45.8 18.4 13.2 1.7 0 10 20 30 40 50 60 70 80 90 100 Patient history and exam index Average new patients ANC provision Provision of delivery care Patient counseling index Proper sharp disposal Time spent with patient Progress (2004-08): Percentage points change Domain D: Service Provision
    33. 33. o Two indicators on user fees • Indicator 25: Facilities with user fee guidelines • Indicator 26: Facilities with exemptions for poor patients o No longer relevant - MoPH discontinued user fees at BPHS facilities in 2008 o Only 16 of 618 facilities surveyed (2.6%) charged fees o None of the surveyed facilities reported charging user fees in 22 of 29 provinces Domain E: Financial Systems
    34. 34. 55.2 57.3 57.8 60.0 60.0 50.0 50.0 50.0 50.0 50.0 50.0 50.0 50.0 49.6 49.6 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Females as % of new outpatients Outpatient visit concentration index Patient satisfaction concentration index Domain F: Overall Vision
    35. 35. 55.2 57.3 57.8 60.0 60.0 50.0 50.0 50.0 50.0 50.0 50.0 50.0 50.0 49.6 49.6 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2004 2005 2006 2007 2008 Females as % of new outpatients Outpatient visit concentration index Patient satisfaction concentration index Domain F: Overall Vision
    36. 36. 4.80 0.00 -0.40 -2 0 2 4 6 8 10 % female patients in OPD Overall patient visit Patient satisfaction Progress (2004-08): Percentage points change Domain F: Overall Vision
    37. 37. Summary
    38. 38. Summary of Performance: 2004 - 2008 Decrease (-2 or less) Patient satisfaction Constant (+/- 2 pts) Overall patient visit Infrastructure index Patient perception quality Time spent with patient Mild Increase (2-10 pts) Patient records index Provider knowledge revised % Female patients in OPD Overall patient satisfaction Health worker satisfaction index Salary payment current Moderate increase (10-25) Proper sharp disposal Patient history and exam index Drug availability Patient counseling index Equipment functionality HMIS Guidelines Provider knowledge Large increase (26 or more) Staff training Staffing index ANC provision FP Availability Index Provision of delivery care Lab functionality Availability TB Registers Clinical guidelines Shura guidelines Average new patients Change in median scores
    39. 39. Progress by Domains 64.4 70.1 48.5 41.4 51.9 72.3 77.1 57.5 43.0 52.6 77.6 74.7 65.3 55.1 52.9 80.4 79.9 72.5 63.8 53.2 84.3 75.9 76.4 68.2 53.2 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 A. Patients & Community B. Staff C. Capacity for Service Provision D. Service Provision F. Overall Vision 2004 2005 2006 2007 2008 + 19.8 + 27.9 + 26.8 + 1.3+ 5.8
    40. 40. Usage of the Balanced Scorecard o Over the years BSC has found extensive application in the Afghanistan health sector such as: • General monitoring tool by the leadership for tracking progress of the provinces and NGO implementing BPHS during quarterly meetings • The development partners used it as an instrument for awarding performance bonuses (The World Bank) • The NGOs used it to showcase their performance • The provincial leadership used it to request additional supplies and human resources
    41. 41. Looking Ahead
    42. 42. The Future Balanced Scorecard o Domains largely sound, but: • Rapidly changing health system • Many benchmarks already achieved • Need for revised indicators o Revision of BSC underway • Several new indicators proposed • Broader picture of BPHS delivery • Better adapted to goals of new health strategies
    43. 43. Future BSC Features Lower Upper National Median 2004 2005 2006 2007 2008 A. Patients & Community 1Overall Patient Satisfaction 66.4 90.9 83.1 86.3 86.0 77.7 81.0 2 Patient Perception of Quality Index 66.2 83.9 76.0 76.2 80.3 77.6 77.5 3 Written Shura-e-sehie activities in community 18.1 66.5 34.2 54.5 66.4 86.0 94.3 B. Staff 4 Health Worker Satisfaction Index 56.1 67.9 63.5 64.1 68.1 69.0 69.1 5Salary payments current 52.4 92.0 76.7 90.0 81.3 90.7 82.7 C. Capacity for Service Provision 6 Equipment Functionality Index 61.3 90.0 65.7 67.0 78.7 83.8 88.4 7Drug Availability Index 53.3 81.8 71.1 83.7 85.7 81.0 86.3 8 Family Planning Availability Index 43.4 80.3 61.4 70.0 82.9 93.7 94.9 9 Laboratory Functionality Index (Hospitals & CHCs) 5.6 31.7 18.3 36.3 43.3 58.5 64.5 1 0 Staffing Index -- Meeting minimum staff guidelines 10.1 54.0 39.3 58.0 66.9 63.9 72.1 1 1Provider Knowledge Score 44.8 62.3 53.5 69.0 68.7 68.7 1 2 Staff received training in last year 30.1 56.3 39.0 74.3 68.9 68.5 71.1 1 3HMIS Index 49.6 80.7 67.7 65.8 74.9 91.5 92.4 1 4Clinical Guidelines Index 22.5 51.0 34.8 48.9 61.6 78.3 83.9 1 5Infrastructure Index 49.3 63.2 55.0 44.6 48.7 54.6 54.1 1 6Patient Record Index 56.1 92.5 65.6 63.2 69.4 70.0 69.9 1 7Facilities having TB register 8.3 26.6 15.8 20.6 37.4 53.7 62.9 D. Service Provision Expanded Scope of Measurement  Community’s role in health  Coverage indicators  Perspectives of non-users Enhanced performance management  Communication and use at peripheral levels  Documentation of best practices  Performance improvement tool
    44. 44. Thank You! Thank You! Source: National Geographic Channel
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