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Health systems do not thrive in war zones. Little wonder, then, that after roughly three decades of virtually continuous warfare, Afghanistan’s was a shambles when reconstruction of the country began following the fall of the Taliban government in 2001. Since then, many dedicated efforts—increasingly led by the nation’s Ministry of Public Health (MoPH), though still technically and financially supported by donors—have made remarkable headway in rebuilding health services across the devastated nation.

Yet the challenges remain daunting. Children have a roughly 10 percent probability of dying before the age of five, and the maternal mortality ratio in the country suggests that  one in every 50 Afghan women will die from pregnancy-related causes. Immunization remains spotty, and serious infectious diseases are endemic—the nation is among the last holdouts of polio; tuberculosis rates clock in at twice the regional average.

Although dire resource constraints and persistent warfare challenge progress, many of the main causes of morbidity and mortality in Afghanistan are eminently preventable. Improving the management and leadership of health service delivery can be a potent and cost-effective means of addressing such problems.

The United States Agency for International Development (USAID) has contracted with a variety of nongovernmental organizations (NGOs) to implement programs to that end. One of them is Management Sciences for Health (MSH), which has since 2006 partnered with USAID and the MoPH through its Tech-Serve project to introduce a hands-on management and leadership development program (LDP) across all strata of Afghanistan’s health system. In that time, some 149 teams of health service delivery personnel working at the provincial level, and 12 teams from the central bureaucracy, have participated in LDP training.

LDP and its Benefits

Health services in Afghanistan are primarily delivered by NGOs and supported through the MoPH by programs funded by USAID, which covers 13 provinces, and the World Bank and European Commission (EC), which cover the remainder. NGOs supported by USAID—mostly local—sign contracts with the MoPH and are expected to deliver services defined by a Basic Package of Health Services (BPHS).

First approved by the Ministry in 2003, BPHS covers seven broad health indicators ranging from child nutrition and maternal health to immunizations and communicable diseases. In each province, a Provincial Public Health Coordination Committee (PPHCC) typically comprising representatives from NGOs, United Nations and the public and private sectors oversees service delivery. Each of these provincial bodies established its own subcommittees to oversee the leadership development program.

The LDP’s approach is notably hands-on and, in a variety of ways, tailored to the practical needs of health systems of developing countries. It is conducted with small teams that attend four short workshops, each lasting two to three days, over a six-month period. More importantly, the teams apply what they are learning in these workshops to existing public health or service delivery challenges that they face.

Beginning in 2005, teams of four or five individuals selected by the PPHCC—often including provincial government personnel, NGO staff and a provincial MSH representative—were trained by Tech-Serve as facilitators using materials in Pashto and Dari, the primary local languages. These facilitators then returned to their provinces and invited staff from health service facilities to attend LDP training. At the central government level, a parallel system recruited national health system and agency managers to LDP training.

Whether their primary responsibilities are service delivery at the provincial level, or health system administration and policy at the central level, the teams attending the training are guided through the same processes. They work through a series of steps, driven by a methodology that is aspirational yet systematic in guiding the acquisition of management skills. The LDP’s central tool is the “challenge model,” a heuristic device that asks each team to create a vision for a desired result, one that all stakeholders—facility staff, health care providers, religious and community leaders—can share.

“You set up a tension between where you are now and where you want to be,” explains Sylvia Vriesendorp, Principal Program Associate at MSH. “This creates a need for resolution. We don’t tell them what to work on because this is an empowerment process. They learn that leadership is about taking on a challenge and making it your own. That creates a huge amount of energy. I am a firm believer that it is not money that is the scarce resource, it is human energy. It is there, but often not harnessed at all.”

Having determined where they are in relation to their vision, the teams pinpoint the root causes of that gap. This requires that they not only chart out the dimensions of their chosen challenges, but to learn how to appropriately collect and record credible data that verifies their impressions. That, in turn, establishes a quantifiable baseline that they can later use to monitor their own progress and refine remedial measures. Through all this, facilitators trained and paid by Tech-Serve provide instruction, guidance and mentorship.

When they return to their base of operations, the LDP teams transfer what they have learned to their colleagues. They then align relevant personnel with the task at hand and work together to mobilize all stakeholders—traditional councils, health providers, religious leaders and so on—whose involvement is essential to obtaining the result desired. The issues might touch on anything from vaccination to family planning at the provincial level to policy development and advocacy at the central level. If a team represents a particularly demoralized facility, it might choose something as simple as improving cleanliness at its facility, or setting up a sheltered waiting area for patients.

“You do have groups who go for the low hanging fruit,” says Dr. Hedayatullah Saleh, Technical Director for Primary Health Care, Tech-Serve project. “But many teams used this methodology to address complex problems. For example, reproductive health is a complex issue in Afghanistan, especially in rural areas. Such efforts are complicated by challenges related to security, lack of female staff, traditional attitudes and social barriers.”

In any case, the LDP process, with its emphasis on hands-on learning, instills and reinforces skills essential to better management, such as communication, staff and community alignment, planning skills and coordination. It also establishes accountability, since the LDP teams are asked to chart out the steps they must take to close the gap between their situation and their aspirations.

Over a six-month course, the teams plan their interventions, organize resources, implement their strategies and, ultimately, evaluate outcomes using data they have gathered or that exist in the MoPH’s Health Management Information System, which was established in partnership with USAID and MSH. Over that period, they return for three more skills-building workshops, report on their progress and apply what they learn back at their facilities. In the end, they present their strategies and results before superiors and peers and, if necessary, return to the drawing board to refine their interventions.

One team from a comprehensive health center in a remote, mountainous and extremely conservative area in eastern Afghanistan used its LDP training to address maternal health. In an account submitted to MSH, a midwife explained how her LDP team began to address the reluctance of people to bring women to health facilities for deliveries and postnatal care. They met with the Community Health Shura, the local traditional council, and with community elders and religious leaders to educate them about the potentially life-saving benefits of such things as antenatal and postnatal care. They persuaded female community health workers to refer women to their facility. These efforts, she reports, helped save the life of a woman who was in hemorrhagic shock, after an informed neighbor urged her husband to take her to the health center.

The LDP approach has scored successes within the central health bureaucracy as well. The Afghanistan National Blood Safety and Transfusion Services Directorate (ANSBSTS) in Kabul, for example, addressed two issues in its LDP training, which it began in 2010. At a higher, administrative level, the LDP team identified the US$30 cost of providing a pint of blood as a prime target for savings. By streamlining processes for ordering and managing supplies and executing the first fixed-term, two-year contract for their procurement in the agency’s history, the team reduced targeted costs by three percent. On the service delivery front, meanwhile, staff identified the relative rarity of voluntary blood donation in Kabul and its surrounding districts as being a significant challenge.

The LDP team, made up of staff from every level of the agency, did a quick assessment and estimated that only about 30 percent of their blood supply was collected from voluntary donors—the rest being obtained as required from family members of those in need. It sought to increase that proportion to 50 percent. A quick analysis suggested that two major factors accounted for the low rate of voluntary blood donation in the region. The first was fear. “In this part of the world,” explains Dr. Ahmad Masoud Rahmani, National Director of ANSBSTS, “a lot of people believe that blood donation will harm their health.” Second, many others had simply not been informed of the significant contribution they could make to public health simply by donating blood.

To address both of these issues, the LDP team launched a major publicity campaign addressing these issues. It also solicited VIPs—including President Hamid Karzai, other political leaders and foreign dignitaries—to publically donate their own blood. Further, the Directorate trained its staff in infection prevention and helped them revamp the services offered to donors to boost public confidence in their professionalism. These steps, says Masoud, helped the LDP team increase blood donation coverage in Kabul and its surrounding areas to 50 percent.

As significantly, it accomplished this feat with minimal investment. “One of the good things about the LDP is that it encourages low resource approaches and the use of local resources,” says Dr. Abdul Ali, a consultant and leadership developer in charge of a newly formed Management and Leadership Development Department within the General Directorate for Human Resources to lead LDP in the country. “I really recommend this for any developing country, not only because it is sustainable but for the method.”That method, he says, has a lasting effect on trainees. Not only does it create a vision of what is possible through leadership and management, but it helps teams prove to themselves that they can solve seemingly intractable problems without resorting to outside help. That, he says, inspires managers to apply the methodology to new problems—including, in some cases, those in their personal lives.

Beyond that, the practical application of LDP training illustrates its benefits. This, in turn, creates a feedback loop, prompting leaders to build on their successes. If a team, say, increases its detection of TB from one case to five with minimal cost in just six months, its members can’t help but wonder whether they might with a little creativity and further analysis figure out a way to detect even more. Since the approach trains teams, rather than individuals, it builds a broader base of leadership capacity in individual facilities and agencies.

Conversely, trained individuals carry their skills with them when they move, and can seed LDP in other institutions of the health system. After some time, says Vriesendorp, this can create a critical mass of LDP-trained managers who, working independently across the health system, accelerate the pace of change.

But have the effects of LDP been verified? To some degree, they have. MSH conducted a study in Afghanistan beginning in 2010 that involved 56 teams that had completed the LDP. The teams came from a variety of health care facilities and each addressed one of nine indicators, measuring antenatal and postnatal care, normal deliveries, immunization, family planning, outpatient department use, TB detection and tetanus toxoid 2 vaccination.

Their performance was measured against statistics for equivalent facilities collected from the HMIS. The evaluators at MSH found that the LDP-trained teams increased coverage in the key indicator addressed from 37 percent at baseline to 58 percent on average. The matched comparison facilities, meanwhile, showed almost no change. Although no causative link between LDP and better outcomes can be established from such a retrospective, nonrandomized study of different indicators, MSH did find a statistically sound correlation between the two.

The Road Ahead

Yet monitoring LDPs in Afghanistan is challenging, and likely to remain so for some time. For one thing, the basic information on which evaluations depend is not always reliable in the country—baselines established from data collected in previous years might be misleading, as might current data collection processes. The MoPH is working to improve its Health Management Information System, established through a USAID-funded MSH program, but it has a long way to go. Further, as the LDP program expands, says Saleh, the central authorities who monitor progress will be hard pressed to keep up with the need for coordinating LDP monitoring and evaluation and providing mentoring where required

Security too continues to be a risk in this regard. “Despite huge security challenges in Afghanistan,” says Saleh, “the health sector and service providers are pretty well protected. But there are plenty of LDP teams located in areas where central teams, or even provincial facilitators, can’t visit.” Ali says that some of the LDP teams have addressed these challenges by appearing at provincial headquarters for mentoring and evaluation. Others have sought to make monitor visits safer. “One of the messages that we conveyed to the LDP teams,” says Ali, “is to involve the community, since the community is the main source of protection for health care providers.”

Still, the endlessly fluid and uniformly brutal warfare in Afghanistan will continue to challenge the execution and expansion of LDP—and the impending withdrawal of foreign forces is not likely to help. It is also unclear whether the European Commission and the World Bank will be willing to support the program in the provinces whose health systems they fund. As donors grapple with their own fiscal crises, talk of reducing funds for Afghanistan has caused much concern in the nation’s health sector.

Though LDP is a relatively low cost intervention, it does require human resources that have to be paid for by someone. On that count, the establishment of a Management and Leadership Development Department in the MoPH isn’t just a good sign for the future of this methodology in Afghanistan. Its champions hope that, with some luck, this institutionalization of LDP might expand the sources of funding for it as well. 

By Unmesh Kher