Implementing people-centred health systems governance in 3 provinces and 11 districts of Afghanistan: a case study

Background Previous studies show that health systems governance influences health system performance and health outcomes. However, there are few examples of how to implement and monitor good governing practices in fragile and conflict affected environments. Good governance has the potential to make the health system people-centered. More research is needed on implementing a people-centered governance approach in these environments. Case description We piloted an intervention that placed a people-centred health systems governance approach in the hands of multi-stakeholder committees that govern provincial and district health systems. We report the results of this intervention from three provinces and eleven districts in Afghanistan over a six month period. This mixed-methods exploratory case study uses analysis of governance self-assessment scores, health management information system data on health system performance, and focus group discussions. The outcomes of interest are governance scores and health system performance indicators. We document the application of a people-centred health systems governance conceptual model based on applying four effective governing practices: cultivating accountability, engaging with stakeholders, setting a shared strategic direction, and stewarding resources responsibly. We present a participatory approach where health system leaders identify and act on opportunities for making themselves and their health systems more accountable and responsive to the needs of the communities they serve. Discussion and evaluation We found that health systems governance can be improved in fragile and conflict affected environments, and that consistent application of the effective governing practices is key to improving governance. Intervention was associated with a 20% increase in antenatal care visit rate in pilot provinces. Focus group discussions showed improvements across the four governing practices, including: establishment of new sub-committees that oversee financial transparency and governance, collaboration with diverse stakeholders, sharper focus on community health needs, more frequent presentation of service delivery data, and increased use of data for decision making. Conclusions Our findings have implications for policy and practice within and beyond Afghanistan. Governance is central to making health systems responsive to the needs of people who access and provide services. We provide a practical approach to improving health systems governance in fragile and conflict affected environments. Electronic supplementary material The online version of this article (doi:10.1186/1752-1505-9-2) contains supplementary material, which is available to authorized users.

Directions: For each item, note briefly the internal strengths and weaknesses within the PPHCC as well as the opportunities and threats that exist in the current environment. You will rate performance on a scale of from 1 to 10, with 10 being the best possible rating. Meeting the MOPH policies, priorities, objectives, strategies, and standards: a. Overall b. In relation to the BPHS c.
In relation to the EPHS 2 Coordination of all stakeholders: a. At the provincial level b. In the districts and the communities c.
With the MOPH 3 Improvement of services: a.
Overall quality b. Accessibility c.
Sustainability 4 Input into provincial planning, consolidation of the provincial plan, and monitoring of its implementation 5 Oversight: Development and implementation of a joint supervision plan 6 Coordinate an emergency response and participate in it 7 Coordinate and participate in immunization campaign 8 Provide technical and consultation support to the PPHD 9 Sharing of information related to service delivery, MOPH policies, strategies, standards, new initiatives, and any problems and challenges 10 Identify sites for new health facilities 11 Mediate disputes that arise among stakeholders and ensure shared understand-ing between governmental organizations and NGOs ( Greater than zero, but no more than 25% of the activity described within the standard is met Greater than 25%, but no more than 50% of the activity described within the standard is met Greater than 50%, but no more than 75% of the activity described within the standard is met Greater than 75% of the activity described within the standard is met

Practices of Health Governance Self-Assessment Tool
This self-assessment tool is intended for use by individual members and is based on practices of effective governance.
Instructions: Please circle the choice that represents the extent to which you agree that the statement accurately describes your governance decision-making.

Scoring criteria
Questions 2 and 22 are reverse coded and receive a minus score, i.e., the score is subtracted from the total score. The maximum score that can be earned is 280. Greater than zero, but no more than 25% of the activity described within the ToR is met Greater than 25%, but no more than 50% of the activity described within the ToR is met Greater than 50%, but no more than 75% of the activity described within the ToR is met Greater than 75% of the activity described within the ToR is met Instrument # ToR 0% 1%-25% 26%-50% 51%-75%

76%-100%
A General 1 Knows the provincial health system's strategic purpose of community service, goals, policies, programs, services, strengths, and needs 2 Performs the duties of PPHCC responsibly and conforms to the level of competence expected from PPHCC members 3 Suggests possible nominees to the PPHCC or advisory bodies who are clearly women and men of achievement and distinction and who can make significant contributions to the work of the PPHCC and the provincial health system 4 Serves in leadership positions and undertakes special assignments willingly and enthusiastically 5 Helps establish and nurture exemplary relationships with various provincial and community stakeholder organizations and associations so as to inform the plans of the provincial health system, and also helps ensure the cost-effective implementation of those plans via influence with these other organizations 6 Follows and stays informed about trends in the provincial health system and the PPHO and the MOPH, especially trends in public health, service quality and patient safety, health care economics, medical technologies, physician and health worker issues, regulatory frameworks for health programs, and community aspirations

B Meeting Related
1 Prepares for and participates in PPHCC and subcommittee meetings, including appropriate PPHCC activities 2 Asks timely and substantive questions at PPHCC and subcommittee meetings, while at the same time supporting the majority decision on issues decided by the PPHCC