After a basic package of health services was introduced by Afghanistan's Ministry of Public Health, the development and performance of Afghanistan's health care services improved dramatically in many areas between 2004 and 2008, particularly in health service capacity and delivery of care. However, the editors of PLoS Medicine warn of the dangers of security issues for health staff and patients, which is seriously hampering progress, and argue that the likelihood of Afghanistan emerging from its fragile status is far from certain.
A study in this week's PLoS Medicine, led by Anbrasi Edward from the Johns Hopkins Bloomberg School of Public Health in Baltimore, USA, show through implementation of a balanced scorecard system--an integrated tool used to measure and manage the performance of health systems and services use--that over the five year period there was a progressive improvement in national average scores (scored 0-100) in six areas: patient and community satisfaction with services; provider satisfaction; capacity for service provision; quality of services; overall vision for pro-poor and pro-female health services; and financial systems.
In each year of the study, the authors selected a random sample of up to 25 health facilities in each of the 28 provinces included in the study. At each facility, 5 consultations involving children aged 5 and under, and 5 consultations involving patients older than 5, were observed, resulting in 5000 patient observations, 5000 interviews with patients or their caregivers on discharge, and 1500 health provider interviews over 5 years. The authors used this information to evaluate the key performance indicators in the balanced scorecard. By 2008, all provinces achieved the upper range of national average set in 2004. The authors used this information to evaluate the key performance indicators in the balanced scorecard. By 2008, all provinces achieved the upper range of national average set in 2004.
The authors report that use of the balanced scorecard helped to show the effects of investments, facilitate policy change, and create a more evidence-based decision-making culture in Afghanistan's primary healthcare system. However, the authors warn that the continuing success of the balanced scorecard in Afghanistan will depend on the ability of this tool to be revised to accommodate changes in health systems policy.
The authors say: "Emerging from decades of war and continued insecurity, Afghanistan has successfully pioneered the integration of the [balanced scorecard] BSC at the national and provincial levels, to improve the delivery of basic health services." They continue: "Despite the promising results so far, the successful execution of the [balanced scorecard] will depend on its adaptive ability and sustained efforts of the [Ministry of Public Health] leadership to accommodate dynamic and complex changes in the health care environment."
An accompanying editorial by the PLoS Medicine editors argues that the findings of the study are a best-case scenario of the current health situation in Afghanistan because five of the six provinces that were not included in the study--Helmand, Kandahar, Zabul, Uruzgan and Farah-- were excluded because of worsening security situations.
The editors say: "These security issues threaten not just the evaluation of health care provision, but the health care services and providers themselves--a complication virtually unknown in stable nations.: "In spite of these impressive gains, the future of health care in Afghanistan, and indeed the likelihood of Afghanistan emerging from its fragile status, is far from certain. "
The editorial continues: "Within the last year medical personnel have been attacked and killed in Afghanistan, even in the more peaceful areas within the country. Although banned by international humanitarian law, the targeting of health care infrastructure and personnel during armed conflict occurs with alarming regularity."
The editors point to an initiative which may help: "Events such as these have led to the establishment of a new resolution by the International Health Protection Initiative (http://ihpi.
Article by Edward and colleagues
Funding: The study was conducted through a Third Party Evaluation contract with the Afghanistan Ministry of Health and the Johns Hopkins University Bloomberg School of Public Health, in collaboration with the Indian Institute of Health Management Research. Support was also provided by DFID through the Future Health Systems Research Program Consortium (www.futurehealthsystems.org). No funding bodies had any role in study design, data collection and analysis or decision to publish or preparation of the manuscript.
Competing Interests: AE, BK, DHP, and GB were part of the team for the Third Party Evaluation contract awarded to Johns Hopkins University by the Ministry of Public Health. FK was the Deputy Minister of Public Health during the study and currently serves as the Minister for Advising the President on Health Affairs. ASS is the Director of Health Economics and Finance Department, Ministry of Public Health, Afghanistan. The authors declare that they have no other conflicts of interest.
Citation: Edward A, Kumar B, Kakar F, Salehi AS, Burnham G, et al. (2011) Configuring Balanced Scorecards for Measuring Health System Performance: Evidence from 5 Years' Evaluation in Afghanistan. PLoS Med 8(7): e1001066. doi:10.1371/journal.pmed.1001066
Johns Hopkins University
615 N Wolfe
Baltimore, MD 21205
United States of America
PLoS Medicine Editorial
Funding: The authors are each paid a salary by the Public Library of Science, and they wrote this editorial during their salaried time.
Competing Interests: The authors' individual competing interests are at http://www.
Citation: The PLoS Medicine Editors (2011) Health Care Systems and Conflict: A Fragile State of Affairs. PLoS Med 8(7): e1001065. doi:10.1371/journal.pmed.1001065