Long and short Integrated Management of Childhood Illness (IMCI) training courses in Afghanistan: a cross- sectional cohort comparison of post-course knowledge and performance

Background: In 2003 the Afghan Ministry of Public Health (MoPH) adopted the Integrated Management of Childhood Illness (IMCI) for delivering child health services in primary care facilities. Key problems were subsequently identified: high cost of training, frequent health worker turnover and poor quality of IMCI implementation by those trained – specifically in the use of job aids and protocols for assessment, classification, treatment and counselling. The high financial, human resources and opportunity costs of implementing IMCI spurred the MoPH to prioritize developing a shortened IMCI course of comparable quality to the 11-Day training. Methods: This cross-sectional evaluation compared knowledge before and after training, and health worker performance in assessment, classification and treatment of sick children in two similar cohorts, eight months post-training. Results: The mean increase in knowledge scores of the thirty 7-Day course trainees was 29 [95% Confidence Interval (CI): 24, 34] compared to 23 (95% CI: 18, 28) in the 31 trained in the 11-Day course. During assessment visits, mean scores in the 7-Day course trainees and the 11-Day course trainees were 93% (95% CI: 91, 95) versus 94% (95% CI: 91, 96) in assessment; 95% (95% CI: 89, 100) versus 96% (95% CI: 91, 100) in classification; 95% (95% CI: 92, 100) versus 97% (95% CI: 95, 100) in treatment; and 81% (95% CI: 76, 86) versus 80% (95% CI: 75, 85) in counselling. The 7-Day course was 36% less expensive than the 11-Day course. For each course opportunity costs, measured as numbers of children who potentially received poorer care than usual during trainee absence, were 3,160 for the 11-Day course and 2,016 for the 7-Day course. This measure was chosen because trainee absence commonly resulted in higher patient volumes per remaining provider or complete closure of a health facility with one single health worker. Conclusion: Given similar performance and knowledge of health workers trained in both courses, potential cost savings, the possibility of training more health workers and the relative ease with which health workers in remote settings might participate in a shorter course, it seems prudent to standardize the 7-Day course in Afghanistan where child mortality rates remain unacceptably high

Lessons from the development process of the Afghanistan integrated package of essential health services

In 2017, in the middle of the armed conflict with the Taliban, the Ministry of Public Health decided that the Afghan health system needed a well-defined priority package of health services taking into account the increasing burden of non-communicable diseases and injuries and benefiting from the latest evidence published by DCP3. This leads to a 2-year process involving data analysis, modelling and national consultations, which produce this Integrated Package of Essential health Services (IPEHS). The IPEHS was finalised just before the takeover by the Taliban and could not be implemented. The Afghanistan experience has highlighted the need to address not only the content of a more comprehensive benefit package, but also its implementation and financing. The IPEHS could be used as a basis to help professionals and the new authorities to define their priorities

The Effects on Va Hospital Performance of a Prospective Resource Allocation System Based on a Case-Mix Weighted Measure of Workload (Veterans Administration).

The system by which resources are allocated to Veterans Administration (VA) hospitals includes explicit and implicit incentives. If a new allocation system changes the incentives, it is expected that hospital performance will be affected. In fiscal year 1981 the VA introduced a new resource allocation method which used a case-mix weighted measure of workload--Prospective Reimbursement Intradistrict Methodology (PRIME)--to four hospitals. The problem for this study was to determine whether VA hospital behavior had changed as a result of PRIME and , if so, how. The objectives were: (1) to develop an economic model that identified possible effects of PRIME, and (2) to document and measure these effects. Initially, the economic model specified that the objective function of VA hospitals is composed of two goods: (1) extra workload, and (2) "other preferred expenses" (the allocation of resources to other than productivity increasing inputs or expenses). The VA hospitals' objective function is constrained, however, by the discretionary budget. Analysis determined that PRIME would result in two simultaneously occurring changes: (1) a change in the relative prices of the two goods, and (2) a change in the means of measuring workload for purposes of reimbursement. These, it was hypothesized, would affect hospital behavior by increasing workload, the reimbursable expenses, and decreasing "other preferred expenses," the nonreimbursable expenses. Specific variables were identified and constructed to detect changes in workload. These were (1) case-mix index, (2) intensity of service index, (3) length of stay index, (4) one day lengths of stay, and (5) number of treated cases. These dependent variables, as well as the hospital control, trend, and treatment variables, were measured directly, or by their surrogates, in three experimental and three control hospitals for the pre- and post-treatment periods. The analysis led to three conclusions: (1) PRIME, the new resource allocation method, did alter hospital behavior in the expected direction; (2) hospital specific characteristics strongly influence workload levels; and (3) seasonal time and trend factors affect hospital behavior but to a lesser extent than do hospital specific characteristics.Ph.D.Health care managementUniversity of Michiganhttp://deepblue.lib.umich.edu/bitstream/2027.42/159800/1/8402345.pd

Contracting for health services: effects of utilization and quality on the costs of the Basic Package of Health Services in Afghanistan

OBJECTIVE: To research the effects of changes in health service utilization and quality on the costs of the Basic Package of Health Services (BPHS) in 13 provinces of Afghanistan. METHODS: The study grouped data from 355 health facilities and more than 4000 health posts into 21 data points that represented 21 different nongovernmental organization contracts for service delivery between April 2006 and March 2007. Data were pooled from five data sets on expenditure, service utilization, quality (i.e. client satisfaction and the availability of essential medicines and female health-care providers), pharmaceuticals, and security and remoteness scores. Pearson's partial correlation and multiple linear regression models were used to examine correlations between expenditure and other study variables. FINDINGS: Fixed costs were found to comprise most of the cost of BPHS contracts. There was no correlation between cost and utilization rate or security. The distance to the health facility was negatively correlated with costs (R² = 0.855, F-significance < 0.001). The presence of female health workers, indicative of good quality in this cultural context, was negatively correlated with security (r = -0.70; P < 0.001). There was a significant correlation between the use of curative services and client satisfaction but not between the use of preventive services and client satisfaction (R² = 0.389 and 0.272 for two types of health facilities studied). CONCLUSION: Access to health services can be extended through contracting mechanisms in a post-conflict state even in the presence of security problems. Service characteristics, geographical distance and the security situation failed to consistently explain, alone or in combination, the observed variations in per capita costs or visits. Therefore, using these parameters as the basis for planning does not necessarily lead to better resource allocation

Long and Short Integrated Management of Childhood Illness (IMCI) Training Courses in Afghanistan: A Cross-sectional Cohort Comparison of Post-Course Knowledge and Performance

Background: In 2003 the Afghan Ministry of Public Health (MoPH) adopted the Integrated Management of Childhood Illness (IMCI) for delivering child health services in primary care facilities. Key problems were subsequently identified: high cost of training, frequent health worker turnover and poor quality of IMCI implementation by those trained – specifically in the use of job aids and protocols for assessment, classification, treatment and counselling. The high financial, human resources and opportunity costs of implementing IMCI spurred the MoPH to prioritize developing a shortened IMCI course of comparable quality to the 11-Day training. Methods:This cross-sectional evaluation compared knowledge before and after training, and health worker performance in assessment, classification and treatment of sick children in two similar cohorts, eight months post-training. Results:The mean increase in knowledge scores of the thirty 7-Day course trainees was 29 [95% Confidence Interval (CI): 24, 34] compared to 23 (95% CI: 18, 28) in the 31 trained in the 11-Day course. During assessment visits, mean scores in the 7-Day course trainees and the 11-Day course trainees were 93% (95% CI: 91, 95) versus 94% (95% CI: 91, 96) in assessment; 95% (95% CI: 89, 100) versus 96% (95% CI: 91, 100) in classification; 95% (95% CI: 92, 100) versus 97% (95% CI: 95, 100) in treatment; and 81% (95% CI: 76, 86) versus 80% (95% CI: 75, 85) in counselling. The 7-Day course was 36% less expensive than the 11-Day course. For each course opportunity costs, measured as numbers of children who potentially received poorer care than usual during trainee absence, were 3,160 for the 11-Day course and 2,016 for the 7-Day course. This measure was chosen because trainee absence commonly resulted in higher patient volumes per remaining provider or complete closure of a health facility with one single health worker. Conclusion:Given similar performance and knowledge of health workers trained in both courses, potential cost savings, the possibility of training more health workers and the relative ease with which health workers in remote settings might participate in a shorter course, it seems prudent to standardize the 7-Day course in Afghanistan where child mortality rates remain unacceptably high

Rebuilding and strengthening health systems and providing basic health services in fragile states

The international community has compelling humanitarian, political, security and economic reasons to engage in rebuilding and strengthening health systems in fragile states. Improvements in health services and systems help to strengthen civil society and to restore legitimacy to governments. Effective engagement with fragile states to inform the design of health programmes and selection of interventions depends on donor coordination and an understanding of health system challenges. Planning requires consideration of allocation (services to be delivered), production (organisation of services), distribution (beneficiaries of services) and financing. The criteria for selecting interventions are: their impact on major health problems; effectiveness; the possibility of scale-up; equity; and sustainability. There are various options for financing and models of engagement, but support should always combine short-term relief with longer-term development. Stakeholders should aim not only to save lives and protect health but also to bolster nations\u27 ability to deliver good-quality services in the long run. © 2011 The Author(s). Disasters © Overseas Development Institute, 2011

Developing countries' health expenditure information: what exists and what is needed?

In the past decade, the scarcity of financial resources for the health sector has increasingly led countries to take stock of national health resources used, review allocation patterns, assess the efficiency of existing resource use, and study health financing options. The primary difficulties in undertaking these analyses have been 1) the lack of information on health expenditures and 2) not using existing information to improve the planning and management of health sector resources. The principle sources of available health expenditure information are reported by organizations such as the World Bank, WHO, UNICEF and OECD. Special studies and non-routine information are a second major source of information. This existing data has a number of difficulties, including being sporadic, incon-sistency, inclusion of only national level public expenditure, high opportunity and maintenance costs, quantitative and qualitative differences across countries, and validity and interpretability problems. Reliable health expenditure data would be useful not only for in-country, national purposes, but also for cross-national comparisons and for development agencies. Country uses of health expenditure data include policy formulation and planning and management, while international uses would facilitate examination of cross-national comparisons, reviews of existing pro-grammes and identification of funding priorities. Collaborative efforts between countries and internationa