The document discusses Afghanistan's experience monitoring basic health services contracts with NGOs in a conflict setting. It outlines Afghanistan's complex monitoring and evaluation (M&E) system involving multiple departments and organizations. Resources for M&E activities are substantial, with a third party responsible for most activities at a cost of $3.2 million per year. The relationship between contract managers and service-providing NGOs aims to improve performance through monitoring reports and meetings, though external factors sometimes interfere.

1. Contracting Governance
Monitoring basic health services contracts in a
conflict affected setting: experiences from
Afghanistan
Najibullah Safi, MD, MSc. DMS
Program Manager, Health System Development
WHO – Country Office, Afghanistan
Fifth Global Symposium on Health Systems Research: Advancing health systems for all in the SDG era

2. Presentation outline
• Introduction
• Monitoring and Evaluation (M&E) systems
• Resources for M&E and relationship with service providers
• Discussion and conclusion
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3. Introduction
• Afghanistan is the only country in the world using contracting-out of
health services to NGOs on a large scale (31 out of 34 provinces)
• The Basic Package of Health Services (BPHS) and the Essential
Package of Hospital Services (EPHS) are contracted-out to NGOs since
2003 and 2005 respectively
• NGOs are selected through a competitive bidding process
• BPHS and EPHS are mainly financed by EU, USAID and WB through a
basket fund (ARTF)
• The cost of BPHS and EPHS is roughly US$ 5 per capita per year
• Ministry of Public Health manages all the contracts
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4. Major progress over the years
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MMR
CPR

5. M&E system
• Its complex and various departments and organizations are engaged
Grant and Contract Management Unit (GCMU): responsible for contract
management
M&E directorate: is using national monitoring checklist to monitor BPHS and
EPHS facilities
Technical departments: using their own checklists or sometimes jointly with
M&E are monitoring health services
Provincial Public Health Directorates: being increasingly engaged in M&E
Third party (currently KIT): is responsible for
- Two rounds of HMIS data verification per year
- Health facilities functionality assessment
- National health facility assessment: Balanced Score Card (BSC)
- Afghanistan Health Survey (AHS)
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M&E system cont.
1. National monitoring checklist
• Comprised of 377 indicators which are summarized in 11 composite index
indicators
2. HMIS data verification and functionality assessment
• Verify the performance of NGOs, and Straighten Mechanism (SM) against
specific output indicators; availability of staff, drugs, and functionality of
equipment
3. National health facility assessment (BSC)
• BPHS BSC is comprised of 23 indicators organized in five domains
- Client and community
- Human resource
- Physical capacity
- Quality of services
- Management system

7. M&E system cont.
• Afghanistan Health Survey
Nationally representative household survey
- Sample size: 23,460 households (23 households per cluster, 30 clusters per province)
- Sample size yields provincial estimates with at least 95% level of confidence
Use two-stage stratified cluster sampling
- First stage sampling: 30 clusters Probability Proportion to Size (PPS) method
- Second stage sampling: 23 households per cluster
Conducted by third party and monitor by MoPH and NSIA*
AHS report large number of outcome and impact level indicators
Conducted every 2-3 years
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8. M&E resources
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Third part
activities
Actual
expenditur
es US$
(2015-17)
Drop-in centers
functionality
35,336
HMIS Verification 2,030,632
Health Facility
Functionality
191,808
National Health
Survey
3,568,660
National Health
Facility Survey
2,945,872
Drug Quality
Assessment
58,669
Impact Evaluation
of RBF
795,080
Total budget 9,626,057
• Most of the M&E activities are undertaken by third party
(previously Johns Hopkins University (JHU) and currently
KIT – Netherland)
• Technical assistance is an inbuilt component of each
activity related to M&E
• GCMU staff/consultants hired from the project fund
• On average GCMU spent an amount of US$ 52,000 per
year for monitoring contracted NGOs
• On average third party (KIT) spent around US$ 3,200,000
per year for carrying out M&E activities
• In addition some investment is done by GAVI and GFATM
in monitoring vertical programs using national M&E
checklist

9. Client relationship
• GCMU is responsible for contract management
• 20% of NGOs payment is linked with their performance confirmed by
the third party
• In principle GCMU/MoPH can terminate the contracts of poor
performing NGOs – but it hardly happened
• Managements letters, monitoring missions reports, face to face
meetings, joint monitoring with NGOs are the commonly used
approaches for endorsing corrective measures and improved
performance
• External forces, beyond MoPH and NGOs, and personal interest can
play critical role in shaping the relationship between both parties
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10. Discussion and conclusion
• The M&E system is comprehensive but complex
Overlap of various M&E approaches
Large amount of data is collected, but utilization remains inadequate
Insufficient engagement of the MoPH technical departments in M&E
Delay in availability of reports for decision making and payment of NGOs
Absence of agreed platform for sharing M&E findings within MoPH
department and relevant stakeholders
• Resources
Inadequate capacity at the national and provincial levels for monitoring the
activities of NGOs and third party
• M&E findings can directly affect client relationship
• Security and ongoing conflict overshadow M&E activities and so does
mutual accountability
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