Configuring balanced scorecards for measuring health system performance: evidence from 5 years' evaluation in Afghanistan.

BACKGROUND: In 2004, Afghanistan pioneered a balanced scorecard (BSC) performance system to manage the delivery of primary health care services. This study examines the trends of 29 key performance indicators over a 5-year period between 2004 and 2008. METHODS AND FINDINGS: Independent evaluations of performance in six domains were conducted annually through 5,500 patient observations and exit interviews and 1,500 provider interviews in >600 facilities selected by stratified random sampling in each province. Generalized estimating equation (GEE) models were used to assess trends in BSC parameters. There was a progressive improvement in the national median scores scaled from 0-100 between 2004 and 2008 in all six domains: patient and community satisfaction of services (65.3-84.5, p<0.0001); provider satisfaction (65.4-79.2, p<0.01); capacity for service provision (47.4-76.4, p<0.0001); quality of services (40.5-67.4, p<0.0001); and overall vision for pro-poor and pro-female health services (52.0-52.6). The financial domain also showed improvement until 2007 (84.4-95.7, p<0.01), after which user fees were eliminated. By 2008, all provinces achieved the upper benchmark of national median set in 2004. CONCLUSIONS: The BSC has been successfully employed to assess and improve health service capacity and service delivery using performance benchmarking during the 5-year period. However, scorecard reconfigurations are needed to integrate effectiveness and efficiency measures and accommodate changes in health systems policy and strategy architecture to ensure its continued relevance and effectiveness as a comprehensive health system performance measure. The process of BSC design and implementation can serve as a valuable prototype for health policy planners managing performance in similar health care contexts. Please see later in the article for the Editors' Summary.

A successful response to an outbreak of cholera in Afghanistan.

Although postconflict Afghanistan has some of the worst health indicators in the world, the government is working hard to rebuild the health infrastructure, extend services to underserved areas and improve the quality of health services. An outbreak of cholera ElTor O1 that struck Kabul and spread nationwide in 2005, prompted a collaborative response from the Afghan Ministry of Public Health, partner agencies, and the system established to provide the Basic Package of Health Services, of which diarrhoeal disease control is an essential component. This response illustrates that, with good preparation, it is possible to respond to an outbreak of cholera effectively. The very low mortality rate during the outbreak (0.1%) shows how a resource-poor country can succeed in providing high-quality health services with government commitment, coordinated action by partners, proper case management and treatment and expanded access to services.

An outbreak of hepatic veno-occlusive disease in Western afghanistan associated with exposure to wheat flour contaminated with pyrrolizidine alkaloids.

Pyrrolizidine alakloids (PAs) are known to cause hepatic veno-occlusive disease (VOD). Outbreaks have occurred in Western Afghanistan since 1974, the latest in February 2008. We conducted an outbreak investigation using a case-control design. Sixty-seven cases of VOD were compared with 199 community controls. Consumption of bread was strongly associated with disease (adjusted odds ratio: 35.8 [95%CI: 7.6-168.2]). Toxic doses of PA were found in plant extracts and in samples of wheat flour taken from the study area. Compared to wheat flour there was 1000 times less PA in milk and whey and in water samples the PA content was zero. Although direct analysis was not possible, contaminated wheat flour used to make bread was the likely source of PA causing the outbreak. Eating a more varied diet including meat and fruit may be protective. Prevention and control measures will rely on community awareness and agricultural interventions to ensure safety of the food supply.

Monitoring perinatal outcomes in hospitals in Kabul, Afghanistan: The first step of a quality assurance process.

OBJECTIVE: Afghanistan is one of the countries with highest maternal and perinatal mortality in the world. Lack of reliable data, however, makes it difficult to select and prioritise the interventions that would be most cost effective. To gain some evidence, we review and analyse perinatal outcomes in facilities in Kabul and examine the role of patient risk and clinical practice factors. METHODS: We used data for 2006 from a facility-based maternal and newborn surveillance system based on labour and delivery logbooks in the four government hospitals with maternity services in Kabul to analyse perinatal mortality and understanding potentially modifiable factors. RESULTS: Data was collected for 53,524 births during 2006. Perinatal mortality was 43.5 per 1000 total births and the stillbirth rate was 38. For babies with a birthweight of > or =2500 g, the risk of perinatal death if delivered by cesarean section was 3.57 (CI = 3.08-4.13) times the risk of those delivered vaginally. Babies born of mothers with risk factors were 6.49 (CI = 5.64-7.48) times more likely to die. The perinatal mortality rate in babies of women with risk factors undergoing cesarean section was 220.5 per 1000 total births. CONCLUSIONS: Facility-based monitoring of perinatal health is possible in resource-limited settings. The situation in hospitals in Kabul is precarious with high levels of perinatal mortality. Improved intrapartum care, especially for women with risk factors, is needed to positively impact perinatal health.

A balanced scorecard for health services in Afghanistan.

The Ministry of Public Health (MOPH) in Afghanistan has developed a balanced scorecard (BSC) to regularly monitor the progress of its strategy to deliver a basic package of health services. Although frequently used in other health-care settings, this represents the first time that the BSC has been employed in a developing country. The BSC was designed via a collaborative process focusing on translating the vision and mission of the MOPH into 29 core indicators and benchmarks representing six different domains of health services, together with two composite measures of performance. In the absence of a routine health information system, the 2004 BSC for Afghanistan was derived from a stratified random sample of 617 health facilities, 5719 observations of patient-provider interactions, and interviews with 5597 patients, 1553 health workers, and 13,843 households. Nationally, health services were found to be reaching more of the poor than the less-poor population, and providing for more women than men, both key concerns of the government. However, serious deficiencies were found in five domains, and particularly in counselling patients, providing delivery care during childbirth, monitoring tuberculosis treatment, placing staff and equipment, and establishing functional village health councils. The BSC also identified wide variations in performance across provinces; no province performed better than the others across all domains. The innovative adaptation of the BSC in Afghanistan has provided a useful tool to summarize the multidimensional nature of health-services performance, and is enabling managers to benchmark performance and identify strengths and weaknesses in the Afghan context.