7.1.1. AFIAT Annual Report 2022.pdf

ASSISTANCE FOR FAMILIES AND INDIGENT

AFGHANS TO THRIVE (AFIAT)

Fiscal Year 2023 – Project Year 3 Annual Report Performance Period: October 1, 2022 – September 30, 2023

Submitted to

United States Agency for International Development (USAID)

Cooperative Agreement No: 72030620CA00006

Development Objective 2: Social Gains Advanced

Submitted by

Management Sciences for Health

Revised Submission Date

November 30, 2023

USAID AFIAT Project Year 3 Annual Report Page 2

Cover Photo Description

Service providers practicing insertion of implant in a skill lab in Herat under the supervision of AFIAT targeted support team (TST)

Photo credit: AFIAT project/Management Sciences for Health

Standard Disclaimer

This report is made possible by the generous support of the American people through the United States

Agency for International Development (USAID) under cooperative agreement No. 72030620CA00006.

The contents are the sole responsibility of Management Sciences for Health and do not necessarily reflect the views of USAID or the United States Government.

AFIAT Project

AFIAT is a consortium led by Management Sciences for Health, with local partner Afghan Midwives

Association and technical partners American College of Nurse-Midwives (ACNM) and Overseas

Strategic Consulting Ltd. (OSC).

Submitted by

Norio Kasahara nkasahara@afiat.org

For more information, please contact:

info@msh.org

Management Sciences for Health

4301 Fairfax Drive

Arlington VA 22203

Revision History

First draft submitted on October 30, 2023

Revised version submitted on November 30, 2023 mailto:nkasahara@afiat.org mailto:info@msh.org

USAID AFIAT Project Year 3 Annual Report Page 3

Table of Contents List of Tables

List of Figures

List of Abbreviations

Executive Summary

Objective 1

Objective 2

Objective 3

Objective 4

Project Management

Challenges and Way Forward

Introduction and Background

Project Overview

Operating Context

Project Reach

Accomplishments by Project Objective

Objective 1: Improve the Quality of Primary and Secondary Health and Nutrition Services in Targeted

Rural Areas

Sub-Objective (SO) 1.1 Quality standards updated based on global best practices and institutionalized at all levels

SO 1.2 Data-driven QI system established and scaled up nationally

SO 1.3 Health care providers’ core competencies to deliver integrated, quality services are improved

Objective 2: Increase Access to High-Impact, Evidence-Based Health and Nutrition Services

SO 2.1 Identify and scale up proven HIIs in maternal, neonatal, and child health (MNCH), FP, EPI, TB, and nutrition, including an integrated package of community-based MNCH and FP

SO 2.3 Reduce gender, cultural, age-related, physical, and financial barriers to accessing care

Objective 3: Enhance Adoption of Optimal Health and Nutrition Behaviors by Communities and

Households

SO 3.1 Identify and develop key messages based on perceptions, motivations, barriers, and opportunities to promote healthy behaviors

SO 3.2 Increase awareness of and demand for quality services and products related to HII

SO 3.3 Increase number of women and men seeking services and counseling from CHWs and at facilities

Objective 4: Collaborate with Partners to Plan, Finance, and Manage the Public Health System

SO 4.1 Collaborate with partners to plan for performance management of public service

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SO 4.2 Promote accountability and transparency systems in the health sector

Cross-Cutting Themes

Gender

Coordination with stakeholders

Monitoring and Evaluation

Project Management

Personnel

Coordination with the government agencies at central and provincial levels

Security management

FP compliance

Environmental compliance

Sustainability plan updates

Challenges and Strategies to Address Them

Way Forward: Key Priorities for PY4

List of Tables

Table 1. BPHS HFs supported by AFIAT, by wave

Table 2. Summary of training conducted in PY3, by topic and organization

Table 3. Results of RCA and PIP in Parwan and Helmand Provinces

Table 4. Summary of 1,898 QIC meetings in PY3, N = 249 HFs

Table 5. Comparison of clinical indicators & outcome measures post-AIM intervention (N = 15 HFs)

Table 6. TB core and operational indicators (121 out of 125 AFIAT HFs reporting)

Table 7. Treatment outcomes of all TB forms in 14 TST provinces (125 diagnostic HFs)

Table 8. Roll out of G-ANC

Table 9. Summary of 184 women in phase 1 & 2 provinces who completed G-ANC/G-PNC by

September 2023

Table 10. Trend of child morbidity and treatment, October 2020-September 2023

Table 11. Total number of participants in Safe CS surgery trainings (Faryab and Ghazni)

Table 12. Showing results of pre-intervention and post-intervention respondent data, Faryab and Ghazni

Table 13. Contribution of CB-DOTS in AFIAT TST HFs and national level, by year

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Table 14. Case detection and diagnosis through CB-DOTS in AFIAT TST HFs, PY3

Table 15. Contact screening and TPT in AFIAT-supported HFs, October 2021-June 2023 (86 diagnostic

HFs in Wave-1, 39 diagnostic HFs in Wave-2)

Table 16. GeneXpert module replacement in AFIAT-targeted provinces in PY3

Table 17: Result of Sputum Sample Transportation

Table 18. Trend of key nutrition indicators in TST-supported provinces (N = 249 HF)

Table 19. Number of clients who became fully vaccinated in PY3, by quarter, in 14 provinces

Table 20. UNFPA procurement of FP and HII commodities

Table 21: CHAMT Assessments and female health shura member participation

Table 22. Common gaps in Parwan and Ghazni Provinces

Table 23. Inventory management assessments show stock-outs of essential commodities during one-year period

Table 24. Summary of medicine distribution from the eight provinces that completed data entry on mSupply

Table 26. RMU assessments indicating compliance or non-compliance with RMU practice in 14 provinces in PY3

Table 27. HF staff trained on medicine quantification in PY3

Table 28. Key meetings AFIAT attended with national implications in PY3

Table 29. Number of HFs visited for DQA in PY3

Table 30. Data quality checking through databases

Table 31. AFIAT staffing changes in PY3 (October 2022-September 2023)

Table 32. Summary of coordination issues with the TIG in PY3

Table 33. AFIAT PY3 spending by line items

Table 34. Status of subawards and grants

Table 35. Summary of activities to support sustainability plan

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List of Figures

Figure 1. AFIAT TST-supported provinces, by wave

Figure 2. Average compliance with HQIP score in Wave-1 HFs and HPs

Figure 3. Average compliance with score in Wave-2 HFs and HPs

Figure 4. Change in average score of compliance by thematic area in HFs by assessment round for

Wave-1 and Wave-2 provinces.

Figure 5. Change in average score of compliance by thematic area in HPs by assessment round for

Wave-1 and Wave-2 provinces

Figure 6. PROGRES average score by 11 domains, AMA

Figure 7. PROGRES baseline sustainability score of AMA

Figure 8. Trend of dropout from Penta-1 to Penta-3 in TST HFs, October 2021-September 2023

Figure 9. Trend of CHW referrals for a few services (N = all HPs in the catchment area of 249 HFs, 14 provinces)

Figure 10. Trend of CHW referrals for immunization (N = all HPs in the catchment area of 249 HFs, 14 provinces)

Figure 11. Findings from 642 HF-level CHAMT assessments

Figure 12. Findings from 1,841 HP-level CHAMT assessments

Figure 13. Average score by domain for the NGO respondents, N = 13

Figure 14. APTOS score comparison from PY2 and PY3, by tracer medicine

Figure 15. Average data consistency of AMELP indicators, N = 72 assessments

Figure 16. Trend of data consistency of mentorship

Figure 17. Power BI dashboard view of an AMELP indicator

Figure 18. Power BI dashboard view of overall HQIP results

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List of Abbreviations

AADA Agency for Assistance and Development of Afghanistan

AAIWO Afghan Alfouz Innovational Welfare Organization

ACNM American College of Nurse-Midwives

AFDA Afghanistan Food and Drug Authority

AFGA Afghanistan Family Guidance Association

AFIAT Assistance for Families and Indigent Afghans to Thrive

AFSOG Afghan Society of Obstetricians and Gynecologists

AHDS Afghan Health and Development Society

AHO Alliance of Health Organization

AHS Afghan Health Survey

AIM Alliance for Innovation on Maternal Health

AKF Aga Khan Foundation

AKHS Aga Khan Health Services

AMA Afghan Midwives Association

AMELA Afghanistan Monitoring, Evaluation, and Learning Activity

AMELP Activity Monitoring, Evaluation, and Learning Plan

AMTSL active management of the third stage of labor

ANC antenatal care

ANMC Afghan Nurses and Midwives Council

APHA Afghan Private Hospitals Association

APTOS average percentage of time out of stock

ARI acute respiratory infection

BARAN Bu Ali Rehabilitation and Aid Network

BCC behavior change communication

BDN Bakhtar Development Network

BHC basic health center

BP blood pressure

BPHS basic package of health services

BS birth spacing

BSC balanced scorecard

CAF Care of Afghan Families

CB-DOTS community-based DOTS

CBHC community-based health care

CD+ Community Dialogue Plus

CHA Coordination of Humanitarian Assistance

CHAMT Community Health Accountability Monitoring Tool

CHC comprehensive health center

CHO community health officer

CHS community health supervisor

CHW community health worker

COC combined oral contraceptive

CS Cesarean section

CYP couple years of protection

DH district hospital

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DHIS2 District Health Information Software 2

DIC drop-in center

DMPA depot medroxyprogesterone acetate

DMPA-SC sub-cutaneous depot medroxyprogesterone acetate

DOTS directly observed treatment, short course

DQA data quality assessment

DR-TB drug-resistant TB

DS-TB drug-sensitive TB

EMMP Environment Monitoring and Mitigation Plan

EPHS essential package of hospital services

EPI Expanded Program on Immunization

EUD European Union Delegation

FHAG family health action group

FHH family health house

FP family planning

FPC fixed-price contract

G-ANC group ANC

G-PNC group PNC

GF Global Fund

GMP growth monitoring and promotion

HER Health Emergency Response

HF HF

HFM HF management

HII high-impact intervention

HMIS health management information system

HNTPO Health Net Transcultural Psychosocial Organization

HP health post

HPD Health Promotion Department

HPRO Health Protection and Research Organization

HQIP Harmonized Quality Improvement Program

IEA Islamic Emirate of Afghanistan

IEC information, education, and communication

IFA iron and folic acid

IFRC International Federation of Red Cross and Red Crescent Societies

IMAM integrated management of acute malnutrition

IMAT Inventory Management Assessment Tool

IMNCI integrated management of neonatal and childhood illness

IP infection prevention

IPC infection prevention and control

IPCC interpersonal communication and counseling

IUD intrauterine device

IV intravenous

IYCF infant and young child feeding

JACK Just for Afghan Capacity and Knowledge

KII key informant interview

LAM lactation amenorrhea method

LARC long-acting reversible contraceptive

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LDHF low-dose high-frequency

LHSS Local Health System Sustainability Project

LQAS lot quality assurance survey

LS learning sessions

LWG logistics working group

M&E monitoring and evaluation

MA management accompaniment

MAM moderate acute malnutrition

MCC Media Communication Committee

MCH maternal and child health

MDS managing drug supply

MFL master facility list

MIAR monthly integrated activity report

MICS Multiple Indicator Cluster Survey

MMoC midwifery model of care

MMRCA Medical Management and Research Courses for Afghanistan

MNCH maternal, neonatal, and child health

MNDSR maternal and neonatal death surveillance and response

MOC management of obstetric complications

MOEc Ministry of Economy

MOPH Ministry of Public Health

MOU memorandum of understanding

MSH Management Sciences for Health

MUAC mid upper-arm circumference

ND normal delivery

NEPI National EPI

NGO nongovernmental organization

NSIA National Statistics and Information Authority

NSP national strategic plan

NSTG national standard treatment guideline

NTP National TB Control Program

OFAC Office of Foreign Assets Control

OHPM Organization for Health Promotion and Management

OPD outpatient department

OPHA Organization for People’s Health in Action

ORS oral rehydration salts

P4P pay for performance

PC patient competent

PH provincial hospital

PIO performance improvement officer

PIP performance improvement plan

PMO program monitoring office

PNC postnatal care

PND Public Nutrition Department

POP progestin-only pill

PPE personal protective equipment

PPH postpartum hemorrhage

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PROGRES Program for Organizational Growth, Resilience, and Sustainability

PSCM pharmaceutical supply chain management

PY project year

Q quarter

QBL quantification of blood loss

QI quality improvement

QIC QI committee

QoC quality of care

QQC quantified quality checklist

QQM quantified quality metrics

RCA root cause analysis

RH regional hospital

RH reproductive health

RHDO Relief Humanitarian Development Organization

RMC respectful maternity care

RMNCH reproductive, maternal, neonatal, and child health

RMNH reproductive, maternal, and newborn health

RMU rational medicine use

RR rifampicin-resistant

SAF Solidarity for Afghan Families

SAM severe acute malnutrition

SB safety bundle

SBCC social and behavior change communication

SG sub-group

SHC sub-health center

SMART Standardized Monitoring and Assessment of Relief and Transitions

SO sub-objective

SOP standard operating procedure

SP service provider

SPM senior provincial manager

TB tuberculosis

TBIS TB information system

TF task force

TIG Taliban government

TOR terms of reference

TOT training of trainers

TPM third-party monitoring

TPT TB preventive treatment

TSR treatment success rate

TST targeted support team

TWG technical working group

UHI Urban Health Initiative

UN United Nations

UNDP United Nations Development Programme

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

USAID US Agency for International Development

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USG US Government

WB World Bank

WFP World Food Programme

WHO World Health Organization

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Executive Summary

The US Agency for International Development (USAID)-funded Assistance for Families and Indigent

Afghans to Thrive (AFIAT) project is a five-year cooperative agreement implemented by a consortium led by Management Sciences for Health (MSH) from July 10, 2020 to July 9, 2025. AFIAT aims to improve the health outcomes of the Afghan people—particularly women of childbearing age and preschool children—in rural and peri-urban parts of Afghanistan where health services are provided by nongovernmental organizations (NGOs).

Operating within the parameters of the absence of an internationally recognized government, AFIAT continues to adapt to regulations invoked by the Taliban entity. AFIAT, with concurrence from USAID, is in the process of entering into a memorandum of understanding (MOU) with the Ministry of Public

Health (MOPH) and is waiting for MOPH response at the time of the submission of this report.

AFIAT continues to strengthen health worker capacity to deliver the best possible care in a resource-limited environment. AFIAT also engaged in national level activities to support health systems components, including health management information system (HMIS), pharmaceutical supply chain management (PSCM), Afghan Health Survey (AHS), tuberculosis (TB) and nutrition services, and midwifery pre-service education. Furthermore, through a targeted support team (TST) and a fixed-price contract (FPC) with the Health Emergency Response (HER) project service providers (SPs), AFIAT supported 14 target provinces to strengthen key high-impact facility and community-based interventions.

In February 2023, the HER project replaced the Sehatmandi project, and in seven provinces1 new SPs took over the implementation responsibilities.

All 14 target provinces were engaged in various levels of activities during project year (PY) 3 (October

2022-September 2023). Key accomplishments within each of AFIAT’s four objectives are below.

Objective 1

In PY3, AFIAT—jointly with NGOs—conducted two rounds of assessments using the Harmonized

Quality Improvement Program (HQIP) tools in the 14 TST provinces. For the 165 health facilities (HFs) of 7 Wave-12 provinces, the average compliance with standards in the 14 assessment areas was 77% in

February 2023 and 87% in September 2023, a considerable improvement from the baseline 47% estimated in November 2021. For the 84 HFs of 7 Wave-23 provinces, the average compliance with standards improved from 36% in baseline conducted in December 2022 to 69% in August 2023. The HFs develop performance improvement plans (PIPs) that are monitored on a monthly basis by a quality improvement (QI) committee. In PY3, 1,898 QI committee (QIC) meetings took place, averaging 1.9 meetings per quarter in the 249 HFs. In quarter (Q) 4, 62% of the meetings reviewed corrective actions and engaged health shuras in their action.

Across 14 provinces with TSTs, AFIAT conducted competency-based training sessions for 349 members of the TSTs (156 female, 193 male) to improve provider skills in clinical competency and counseling.

These TSTs made 4198 visits to 249 target HFs and 7,131 visits to 910 health posts (HPs) using a low-

1 Provinces where the NGO changed: Faryab, Ghor, Herat, Kabul, Nangarhar, Parwan and Takhar 2 Wave-1 provinces: Balkh, Bamyan, Herat, Kabul, Kandahar, Nangarhar, and Parwan 3 Wave 2 provinces: Faryab, Ghazni, Ghor, Helmand, Jawzjan, Khost, and Takhar

USAID AFIAT Project Year 3 Annual Report Page 2 dose, high-frequency approach to mentor a total of 3,162 active health SPs (1,782 female, 1,380 male) and 1,843 community health workers (CHWs) (958 female, 885 male) in various thematic areas.

The Alliance for Innovation on Maternal Health (AIM) safety bundle (SB) program introduced a set of interventions to identify and manage postpartum hemorrhage (PPH) in 2 phases in 18 HFs in 5 provinces. In PY3 after training, among 36,312 births in 18 HFs, 99.9% of the women received active management of the third stage of labor (AMTSL) and oxytocin, and blood loss was quantified for 93% of the instances. PPH was confirmed for 906 women (2.5%), among which 894 cases’ (98%) cause of PPH was recognized and recorded, and 3 women died from PPH in Nangarhar (case fatality rate of 0.3%).

AFIAT implemented TB activities across 249 HFs in 14 targeted provinces, of which 125 are TB diagnostic facilities. In PY3, 6,891 cases were all forms TB cases and 4,568 were pulmonary bacteriologically confirmed TB cases and subsequently received treatment. The treatment success rate

(TSR) for all forms of TB cases stood at 97%. There has been a 7% increase in bacteriological diagnosis for pulmonary TB from PY2, an increase in TSR for DS TB from 96% to 97%, TSR for DR TB from 70% to 72%, an increase in contact investigation coverage from 45% to 51%, and an increase of TPT in children under 5 by 8%, and contribution of CB DOTS. At the same time there has been a 9% decline in

TB case notification from PY2, a 6% decline in DR TB case notification, and a 43% decline in TB cases in children. This situation can be attributed to stock out of GeneXpert cartridges or political instability.

These declines have affected the country as a whole, and AFIAT, together with GF and its partners, is working to address the challenges in PY4.

AFIAT and its partner Afghan Midwives Association (AMA) introduced group antenatal care and postnatal care (G-ANC/G-PNC) in 22 HFs, where 34 cohorts of 10-12 women of similar gestation age were enrolled for group counseling and care. In Bamyan, Kabul, Kandahar, and Nangarhar, early results from 184 women who completed the 4 G-ANC and 2 G-PNC sessions showed promising high retention; early screening and referral for anemia, hypertension, malnutrition, and depression; 97% institutional delivery; and 26% acceptance of modern contraceptives. All 146 women who were interviewed expressed satisfaction with the model.

AFIAT has been integrating nutrition interventions within G-ANC and midwifery models and trained 68 midwives from 11 provinces on nutrition interventions.

Objective 2

AFIAT introduced Safe Cesarean Surgery in provincial hospitals (PHs) of Ghazni and Faryab and conducted 4 batches of training for 102 participants (65 female, 37 male). Implementation began in

August 2023 with 436 Cesarean sections (CSs) supported in these hospitals. Preliminary data recorded shows in 27% of cases the surgical safety checklist was used and prophylactic intravenous (IV) antibiotic was provided in 82% of cases. In 55% of cases, vaginal cleansing was performed prior to operation and foley catheter was also applied. It is expected that by changing hospital practices, post-operative complications could be avoided.

AFIAT has been integrating nutrition interventions within G-ANC and midwifery models and trained 68 midwives from 11 provinces on nutrition interventions. AFIAT has also been supporting the national nutrition program to revise guidelines, advocate for dedicated position and shorter training curriculum, and addressing gaps of iron folate supply. Because of tailored support, growth monitoring and promotion (GMP) and counseling on infant and young child feeding (IYCF) increased 10% over PY2 at

HF level, and 3% at HP level.

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The CB-DOTS program notified 854 TB cases across all forms, contributing 12% to the overall TB case notification in the 14 provinces. AFIAT supported the installation of three new GeneXpert machines procured by the project in three district hospitals (DHs) and three GeneXpert machines procured by the Global Fund (GF) in three more AFIAT-supported diagnostic HFs. AFIAT also engaged 26 basic health centers (BHCs) in specimen (sputum) transport mechanism.

Objective 3

In PY3, AFIAT reproduced and distributed 214,567 information, education, and communication (IEC) materials. AFIAT also printed 147,000 new materials on TB and integrated management of neonatal and childhood illness (IMNCI). Tiahrt posters (promoting voluntary informed choice of family planning ) were printed in Dari and Pashto and distributed to the HFs as well. AFIAT TSTs organize learning sessions (LS) on interpersonal communication and counseling (IPCC) to ensure that these new materials are incorporated into the health education sessions at different levels of the HFs.

AFIAT also engaged health shuras to hold the providers and outreach workers accountable through the

Community Health Accountability Monitoring Tool (CHAMT). These shura members conducted 642 visits to HFs and 1,841 visits to HPs. In Q4, 18% of the HF visits and 28% of HP visits included female shura members.

Due to delays in obtaining MOPH approval, Community Dialogue Plus (CD+) implementation resumed in Q2 and in PY3 training of trainers (TOT) was conducted for 102 participants (42 female and 60 male), who in turned trained 613 (196 female, 417 male) individuals from HFs, which included shuras and family health action groups (FHAGs). Subsequently, at the 72 HPs where CD+ is implemented, 1,689 individuals (937 female, 752 male) were trained. These community individuals will work together to increase demand for maternal and neonatal health and immunization services in underserved communities.

Objective 4

AFIAT supported the HER NGOs to conduct a baseline self-assessment of their organizational capacity using the Program for Organizational Growth, Resilience, and Sustainability (PROGRES) tool. This information will be used to plan capacity building activities in PY4. AFIAT integrated the PROGRES tool into the management accompaniment (MA) support to the HER project and helped the MA firms apply the tool for the NGOs in the 20 provinces not directly supported by AFIAT in Q4.

AHS was delayed due to MOPH and National Statistics and Information Authority (NSIA) negotiations.

AFIAT upgraded the District Health Information Software 2 (DHIS2) data warehouse and updated the modules for compatibility with the new HMIS package rolled out in Q4.

AFIAT TSTs used the Inventory Management Assessment Tool (IMAT) to measure the average percentage of time out of stock (APTOS) for tracer medicines in 265 HFs. For commodities included in the basic package of health services (BPHS) procurement list, the score was 9% (below the 10% threshold). However, for high-impact intervention (HII) commodities, the score was 53%.

AFIAT introduced mSupply in 14 provinces where NGOs began to enter pharmaceutical data. In 8 provinces the data entry has been completed.

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AFIAT also trained 108 NGO staff on medicine quantification. NGOs, in turn, trained 830 staff (21 female, 809 male) from 828 HFs in 13 provinces. This helps NGOs to rationally allocate medicine from provincial stocks and minimize stockouts.

Project Management

MSH conducted an internal mid-term review of the project. The mid-term review included project document review, key informant interviews (KIIs) of 25 internal and external stakeholders, and review of tools developed by AFIAT. The main findings and recommendations were used to inform PY4 work planning.

In PY3, 86 national staff and one expatriate staff left MSH, while 132 national staff joined the project.

Challenges and Way Forward

In 7 out of 14 provinces where AFIAT TSTs operate, a new NGO took over the HER implementation responsibilities in February 2023, creating a challenge to reengage the technical staff in TST activities. In the HER project, medicine procurement delay led to NGOs not providing medicine to the HPs until

August, reducing community access to contraceptives and commodities. In addition, in December 2022, the Taliban announced a ban on women working for NGOs. Even though an exception was made for health personnel, the uncertainty led to gaps in program monitoring and capacity building support.

Finally, lack of an MOU led to provincial-level customized negotiation with different departments, which took up a significant amount of staff time. High-level negotiations between MOPH and NSIA also held up

AHS.

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Introduction and Background

Project Overview

The USAID-funded AFIAT project is a five-year project implemented by a consortium led by MSH from

July 10, 2020 to July 9, 2025. The consortium also includes Afghan Midwives Association (AMA), American College of Nurse-Midwives (ACNM), and Overseas Strategic Consulting Ltd. The aim of the project is to improve the health outcomes of the Afghan people—particularly women of childbearing age and preschool children—in rural and peri-urban parts of Afghanistan where health services are provided by NGOs. AFIAT applies an evidence-based, human-centered, systems thinking approach to work toward its four objectives:

1. Improving the quality of primary and secondary health and nutrition services in targeted rural areas

2. Increasing access to high-impact and evidence-based health and nutrition services

3. Enhancing the adoption of optimal health and nutrition behaviors by communities and households

4. Collaborating with partners to plan and manage the public health system

Working across all levels of the health system, AFIAT supports PSCM and the national data warehouse

(including HMIS, TB, Expanded Program on Immunization [EPI], and COVID-19) and provides targeted technical support for QI service delivery at the provincial level through TSTs. In 2020, AFIAT’s provincial-level TST activities focused on seven Wave-1 provinces: Balkh, Bamyan, Herat, Kabul, Kandahar, Nangarhar, and Parwan. In 2022, the project expanded to seven Wave-2 provinces: Faryab, Ghazni, Ghor, Helmand, Jawzjan, Khost, and Takhar, with full TST interventions in PY3 Q2. These provinces are depicted in figure 1.

Figure 1. AFIAT TST-supported provinces, by wave

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Operating Context

Since November 2021, AFIAT has been operating through limited engagement with the MOPH under the US Department of Treasury’s Office of Foreign Assets Control (OFAC) guidance for NGOs. A ban on women working for NGOs was introduced in December 2022, followed by the ban on employment of Afghan women in the United Nations (UN) agencies in April 2023, remains in effect for non-health sectors, and AFIAT continues to operate under customized negotiation with provincial authorities for the movement and safety of their provincial female staff and their mahrams (male companions). Of 14 provincial project offices, the female staff are able to work in the office in 11 provinces. The Taliban government (TIG) keeps insisting on an MOU, and in Q3 USAID reviewed and provided feedback on the draft MOU submitted by AFIAT in Q4.

The HER project, initiated in February 2023, experienced medicine stockout due to delay in the

UNICEF procurement process, and the first shipment of medicine was distributed in late Q3. The

United Nations Population Fund (UNFPA) also procured contraceptives that are inadequate for the national need.

Project Reach

According to the HMIS/DHIS2 of the MOPH, there are 3,313 HFs that provide BPHS and essential package of hospital services (EPHS) in Afghanistan, 2,228 of which are contracted out. However, uneven capacity building support to these facilities has resulted in inequitable access to high-quality care, particularly in rural areas where more than 70% of the population live. Table 1 illustrates the proportion of service delivery points benefiting from AFIAT TST support.

Table 1. BPHS HFs4 supported by AFIAT, by wave

Level HFs HPs

Total in target provinces

Supported by

AFIAT

Total in target provinces

Supported by

AFIAT

Wave-1 623 165 (26%) 5,205 375 (7%)

Wave-2 496 84 (17%) 3,529 389 (11%)

Total 1,119 249 (22%) 8,734 764 (9%)

The following section describes the key achievements in PY3 (October 2022-September 2023) by project objective.

4 HFs included in this calculation consist of those that are covered under HER and the types are sub-health center

(SHC), basic health center (BHC), comprehensive health center (CHC), and district hospital (DH): Data source, WHO/UNICEF shared HF list

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Accomplishments by Project Objective

Objective 1: Improve the Quality of Primary and Secondary Health and

Nutrition Services in Targeted Rural Areas

Sub-Objective (SO) 1.1 Quality standards updated based on global best practices and institutionalized at all levels

HQIP tool refinement

The HQIP is a nationally approved approach for QI that utilizes the Plan-Do-Study-Act cycle in continuous improvement of quality of care (QoC) in HFs. AFIAT implemented this approach for 14 technical areas.5

Based on the implementation lessons from Wave-1 provinces, where HQIP was introduced in

November 2021 (PY2), AFIAT updated the standards and verification criteria in PY3 to match the scope of primary care HFs. This included adding two new TB verification criteria to reflect the national guideline, removing neonatal tetanus and neonatal jaundice from the sick newborn care checklist, and replacing a verification criterion for managing drug supply (MDS).

Integrate QI component in the HER contracts

AFIAT supported development, translation and proofreading of the HER quantified quality checklists

(QQC) in Dari and Pashto in Q1 and Q2 and submitted to UNICEF for finalization. AFIAT also oriented

NGOs on the QQCs in Q3 and supported some of them to apply it at the HF level as a complementary measurement. The HER project third-party monitoring (TPM) began data collection of quantified quality metrics (QQM) in July 2023, and the results will be presented in the quarterly performance review meeting in October 2023.

SO 1.2 Data-driven QI system established and scaled up nationally

Support the establishment of TSTs in targeted provinces

AFIAT has a three-pronged approach to capacity building of TSTs (project, NGO, and AMA staff), a comprehensive onboarding training for new staff, formal training/orientation for topics that require a longer duration, and post-training follow-up through virtual tele-mentoring sessions. The TST in turn conducts LS for the HF staff through on-site mentorship visits.

Onboarding training and post-training follow-up for new hires and NGOs

AFIAT organizes a 10-day in-person onboarding training on the technical areas and the QI approach for newly hired staff (performance improvement officers [PIOs] and community health officers [CHOs]).

This training helps the newly hired staff to start their jobs smoothly and provide high-quality mentorship to the HF staff. In PY3, four batches of on-boarding training were conducted—two batches for AFIAT

5 14 HQIP areas: ANC, FP, normal delivery and immediate newborn care, management of obstetric complications

(MOC), PNC, sick newborn care, IMNCI, EPI, Infection Prevention (IP), Health Facility Management (HFM);

Managing Drug Supply (MDS} & Rational Medicine Use (RMU), TB, Nutrition

USAID AFIAT Project Year 3 Annual Report Page 8 staff and two batches for NGO staff hired through fixed-price contract (FPC) arrangement. A total of

147 participants (65 female, 82 male) completed the training.

The onboarding training is followed by regular post-training follow-up virtual (tele-mentoring) sessions where practical challenges are discussed as a group. In PY3, AFIAT—with technical support from

ACNM— assisted in facilitating 30 tele-mentoring sessions held for 88 and 13 male TST members (42

PIOs, 46 CHOs) from the 14 targeted provinces, 9 AMA mentors, 2 AFIAT central midwifery officers, and 2 AFIAT central RMNH officers.

Training of the TSTs

Following onboarding training, AFIAT organized trainings at the central and provincial level to ensure capacity strengthening of NGO and HF staff. In PY3, 3,102 individuals (1,249 female, 1,808 male) participated in various training sessions. Table 2 below summarizes the participants by topic and organization.

Table 2. Summary of training conducted in PY3, by topic and organization

S#

Thematic area AFIAT AMA NGO OtherNote1

Total of unique numberNote

3 F M F F M F M

1 ANC 18 0 13 33 6 0 0 70

2 FP 2 3 0 0 0 0 0 5

3 MOC 39 3 5 139 84 6 0 276

4 PNC 0 0 0 10 1 0 0 11

5 SNC 19 1 4 6 0 0 0 30

6 IMNCI 3 33 1 0 4 0 0 41

7 MDS/RMU 5 23 0 13 246 4 8 299

8 BCC 23 19 2 3 79 1 0 127

9 TB 33 40 1 380 643 0 2 1,099

10 Nutrition 36 45 4 293 342 4 0 724

11 OtherNote2 101 132 8 257 385 5 66 954

Total of unique numberNote3 148 181 24 1,102 1,551 20 76 3,102

Note 1: Other participants (MOPH, Other institutions, private)

Note 2: Other areas (Data use, community health, Progress tool, PIP, RCT, etc.)

Note 3: Total number of participants are based on the participant’s unique ID number and is 3,102. Some participants attended multiple sessions.

Support the functioning of TSTs in targeted provinces

In PY3, AFIAT conducted 2 rounds of HQIP assessments (Round 3 and 4, in March and September

2023) for 165 HFs and 367 HPs of Wave-1 provinces and two rounds (baseline and Round 2, in

December 2022 and August 2023) for 84 HFs and 384 HPs of Wave-2 provinces. The average score of compliance with HQIP standards observed in the Round 3 and 4 assessments in Wave-1 provinces were much higher than in the baseline and Round 2 assessment in HFs and HPs. Similarly, the average score of compliance in Wave-2 HFs were higher in Round 2 compared to baseline. Figures 2 and 3 summarize the scores of these achievements at different rounds.

USAID AFIAT Project Year 3 Annual Report Page 9

Examining the average rate of change between baseline and 6-month assessment by thematic area across the provinces, maternal care services, sick newborn care and family planning show slower progress as compared to other thematic areas. Based on the findings, AFIAT has been adapting the TST approaches to address these priority areas. The HQIP findings in Wave-1 provinces in the later assessments suggest that greater focus on these areas has contributed, in part, to the increased scores over time.

Figure 2. Average compliance with HQIP score in Wave-1 HFs and HPs

Note: Wave-1 provinces: Balkh, Bamyan, Herat, Kabul, Kandahar, Nangarhar, and Parwan

Figure 3. Average compliance with score in Wave-2 HFs and HPs

Note: Wave-2 provinces: Faryab, Ghazni, Ghor, Helmand, Jawzjan, Khost, and Takhar

Figure 2 allows to compare rate of change in average HQIP score between round 1 and round 2 for the

Wave-1 and Wave-2 provinces. The overall increase in the average scores of all thematic areas in health facilities between round 1 and 2 assessment is 15 percentage points in Wave-1 and 33 percentage points in Wave-2 provinces.

Figure 4 and 5 compare changes in the average HQIP scores in the health facilities (HFs) and health posts (HPs) in Wave-1 and Wave-2 provinces by thematic areas and by round of assessment. The rates of change between round 1 and 2 in Wave-2 are greater in all 14 thematic areas compared to Wave-1.

This may suggest that AFIAT’s adaptative implementation of the tool, which includes fine-tuning of the

QI approaches and tool as the findings from the field team come out and systematic and continuous capacity strengthening of the assessors over the course of the QI process, appears to work.

47% 38%

62% 64%

77% 81% 87%

82%

0%

20%

40%

60%

80%

100%

HF (N=165) HP (N=368)P

e rc e n ta ge c o m p lia n ce w it h st an d ar d

Wave-1 Provinces

Nov-21 (BL)

Jun-22 (R-2)

Mar 23 (R3)

Sep-23 (R4)

36%

24%

69% 61%

0%

20%

40%

60%

80%

100%

HF (N=84) HP (N=384)

P e rc e n ra ge c o m p lia n ce w it h st an d ar d

Wave-2 Provinces

Dec-22 (BL)

Aug-23 (R-2)

USAID AFIAT Project Year 3 Annual Report Page 10

Figure 4. Change in average score of compliance by thematic area in Health Facilities by assessment round for Wave-1 and Wave-2 provinces.

USAID AFIAT Project Year 3 Annual Report Page 11

Figure 5. Change in average score of compliance by thematic area in Health Posts by assessment round for Wave-1 and Wave-2 provinces.

USAID AFIAT Project Year 3 Annual Report Page 12

Further analysis adjusted for potential confounding variables is required to understand the difference.

Confounding variables may include:

● Round 1 and round 2 in Wave-1 provinces took place soon after the Taliban take-over and during the Sehatmandi-HER transition, while in Wave-2 HER projects were being implemented.

● The interval between assessment rounds in Wave-1 and II is not necessarily consistent across the provinces, less than 6 months in some provinces.

● The AFIAT provincial office set-up in the Wave-2 provinces was more efficient than in Wave-1 provinces, which may have influenced better scores in those provinces.

Based on the findings of HQIP assessments in PY3 and more in-depth analysis of the data, AFIAT will continue to apply the QI approaches in new health facilities and health posts in PY4.

Medicine stockouts contributed to lower overall HP scores in the latest rounds. Because of lower allocation in HER and supply delays, many HER SPs chose not to supply commodities to the HP, resulting in a widespread stockout.

Each round of HQIP assessments is followed by a participatory workshop at each facility where, for each of the three priority areas, a root cause analysis (RCA) is performed, and a PIP is developed. The following table describes two results from this exercise in Parwan (Wave-1) and Helmand (Wave-2)

Provinces.

Table 3. Results of RCA and PIP in Parwan and Helmand Provinces

Provinc e

Gaps and RCA Action taken

1 Parwan During ANC in Round 2 (June 2022), the midwives didn’t meet the criteria that assessed whether they ask or screen for danger signs. The RCA revealed that the midwives did not have the knowledge of danger signs. Further deep dive found that there were not enough supervisors from

NGOs to provide supportive supervision visits.

The HER SP NGO hired one additional RMNH supervisor to address this gap and developed a comprehensive supervision plan which included specified number of visits and skill assessment of all midwives. In Round-4 assessment, this gap was found to be addressed.

2 Helman d

In baseline (December 2022) it was found that HPs do not have active FHAG and health shuras, and CHWs did not receive initial or refresher training in the past seven years.

The RCA revealed that the CHWs were not aware of having FHAG and health shuras.

Further deep dive revealed that the NGOs did not budget for community activities as they did not see the value and importance of having them.

HER SP established/revitalized health shuras and FHAGs, allocated budget for CHW training, and linked them with the HFs. All CHWs have now been trained after seven years.

A female CHW mentioned that because of health promotion activities of FHAG and health shuras, there has been a change in attitude on institutional deliveries, and mothers are expressing interest in giving birth at an HF.

USAID AFIAT Project Year 3 Annual Report Page 13

Implement a tailored capacity building approach for TST-supported facilities and communities

TST intervention to improve capacity of SPs

In PY3, the TSTs conducted 16,929 visits to 249 HFs, supporting 3,237 HF staff. The team also conducted competency confirmation using competency checklists 9,756 times. At the HP level, 1,839

CHWs from 1,044 HPs were visited 12,946 times.

Build the capacity of TST members in mentoring for core clinical and non-clinical competencies through formal training workshops

During PY3, three batches of capacity building training were conducted on the management of obstetric and newborn complications, FP/birth spacing (BS), and respectful maternity care (RMC) (table F.3 in annex

F for details of participants from 14 TST provinces). The training focused on the facility and community-based aspect of the competencies and interventions to improve maternal and newborn health and referrals. A comparison of pre- and post-test averages shows a 31% improvement in overall participants’ knowledge and skills. Detail of the results have been included in annex F, box F.1.

Establishment of skills simulation mini-labs at the AFIAT provincial offices

To facilitate the practice sessions and enhance the skills of the PIOs and CHOs, AMA mentors, and

NGO reproductive health (RH) and QI officers, AFIAT established skills simulation labs at its 14 provincial offices.

AFIAT also established 10 additional provincial-level skills labs outside the AFIAT offices: 4 have been established in collaboration with AMA and HER NGO in PHs of Faryab, Ghazni, Kabul, and Khost

Provinces and 6 have been established in 6 AIM sites (5 DHs, 1 PH) managed by the AIM sites’ staff.

The skills labs have the mannequins and supplies for practicing AMTSL, PPH management, immediate newborn care, neonatal resuscitation, IUD insertion and removal, implant insertion and removal, GMP, etc. AFIAT also provided job aids for calculating expected date of delivery; FP medical eligibility criteria;

shock management; RMC charter; flip charts on PPH, helping babies breathe, essential care for every baby, essential care for small baby; and counseling book on FP messages.

AFIAT has provided logbooks to track use of the materials and skills practice sessions. NGOs schedule visits from other facilities. For example, in Kama DH of Nangarhar Province, providers from the four nearby HFs come every Thursday for formal practice sessions.

Strengthen Quality Improvement Committees (QICs)

In the 249 TST facilities, AFIAT introduced a QIC with specific terms of reference (TOR) for the committee introduced from May 2023. This committee is expected to meet on a monthly basis, review the HQIP scores, gaps, PIP, logbook of mentorship activities of the HF, and record of health shura meetings and assess progress against the PIP.

In PY3, 1,898 meetings took place—68% of the expected meetings (12 per HF for 165 HFs) in Wave-1 and 76% of expected meetings (9 per HF for 84 HFs) for this period.

USAID AFIAT Project Year 3 Annual Report Page 14

Table 4 summarizes some of the key achievements from QIC meetings.

Table 4. Summary of 1,898 QIC meetings in PY3, N = 249 HFs

Sl Indicator Wave-1

(Oct 2022-

Sep 2023)

Wave-2

(Jan-Sep

2023)

Remarks/total

1 Total number of HFs 165 84 249 in 14 provinces

1.a Expected number of QIC meetings

1,980 720* Khost and Takhar HF meetings introduced in March 2023

2 Total number of QIC meetings held

1,352 546

3 Proportion of QIC meetings that took place as scheduled

68% 76%

Due to workload on HF staff and scheduling conflicts with client’s flow into the HF, the meetings get delayed. AFIAT team prepared a specific plan to strengthen QIC meetings including scheduling on the convenient time of day for all

HF staff to participate.

4 Proportion of meetings where previous months’ meeting minutes was available 80% 65%

Meeting minutes recording has been improved up to 73%.

Recording minutes of the meetings and reviewing the minutes in the next meeting is in AFIAT’s specific action plan for strengthening the

QIC meetings.

5 Proportion of meetings where performance data was discussed

48% 46%

Data use has been a challenge at HF level due to limited data understanding and limited availability of data presentation tools. AFIAT introduced wallcharts for quality indicators beside pay for performance (P4P) indicators with providing support to improve plotting, reading, and interpreting the charts. Promoting data use at

HF level needs further focus work which is part of the TST monthly visit plan to strengthen data use further.

USAID AFIAT Project Year 3 Annual Report Page 15

6 Proportion of meetings where the mentorship logbook was reviewed

94% 61%

7 Proportion of meeting minutes where record indicates NGO involvement in corrective actions (according to PIP) in the previous month

58% 42%

Due to high workload, NGO provincial technical staff were not able to attend in the QIC, but the

HF staff attended QIC to review the action points when they could.

During the RCA and PIP development NGO technical staff and HF staff were actively involved in the process.

8 Proportion of meetings where the QIC met health shura

68% 58%

9 Proportion of meeting minutes where record indicate health shura involvement in corrective actions (according to PIP) in the previous month 50% 42%

Health shura involvement in the

QIC meetings has been proposed by AFIAT to strengthen community engagement in the QIC activities.

So far the data indicates health shura involvement in 47% of the meetings which is a good midway result. AFIAT TST members working with QIC members to encourage health shura involvement in QIC meetings.

Costing of TST interventions

To assess replicability, AFIAT has introduced a simple tracking system at AFIAT and NGO level to capture the costs associated with the TST operations. These expenses include salary and benefits, transportation costs, meals and incidental expenses, cost of procuring equipment and supplies, cost of printing recordkeeping and reporting tools, mobile phone top-ups, and any other relevant costs.

AFIAT has entered into FPCs with HER-implementing NGOs in 14 provinces. As part of the contract, NGOs are tracking TST expenses from July 2023 as well. NGOs are also expected to track in logbooks to understand the time spent by TSTs on site, topics covered, competency assessments conducted, etc.

These will be eventually triangulated with other contextual information, including but not limited to number of clients post-mentorship utilizing the HFs, distance of HFs from the provincial offices, and catchment area and staffing structure of the HFs.

USAID AFIAT Project Year 3 Annual Report Page 16

SO 1.3 Health care providers’ core competencies to deliver integrated, quality services are improved

Build core competencies for midwives and nurses

Support AMA strategic plan implementation

In November 2022, two rounds of workshops were facilitated by AMA in Kabul for the development of the AMA strategic plan 2023-2025 by the support of AFIAT. The technical inputs for this strategic plan were provided by 30 participants from the AMA central and provinces. The workshops’ outputs included a revised AMA vision and mission, identified strategic priority areas considering the current political and economic instabilities, strategies and strategic goals, and objectives followed by the detailed implementation plan for the defined strategic objectives. The workshop also provided learning opportunities for AMA members in prioritization.

In Q2 of PY3, the final strategic plan reviewed by MSH experts was presented to the AMA Board of

Directors for approval, and the implementation plan derived from the strategic plan is implemented by

AMA from Q3 onwards. The strategy focuses on strengthening the organization's capacity to promote evidence-base high impact interventions in line with the AFIAT's priorities, more efficient advocacy and greater collaboration with partners.

AFIAT also applied the PROGRES tool to conduct baseline assessment of AMA organization capacity.

Figures 7 and 8 show the key results from the self-assessment. The result of AMA assessment indicates that this association obtained good scores in finance, resource mobilization, communication, and service delivery, while there were capacity gaps in the seven other domains. AFIAT plans to undertake customized capacity building initiatives in PY4 to address different gaps.

Figure 6. PROGRES average score by 11 domains, AMA

Note: AMA does not sub-grant to other organizations, so that domain was not considered.

Figure 7. PROGRES baseline sustainability score of AMA

3 3

4 4

Average score by domain (AMA)

(Range 1-5)

USAID AFIAT Project Year 3 Annual Report Page 17

Midwifery model of care (MMoC)

In 2021 (PY1), AFIAT integrated the Midwifery Model of Care (MMoC), trauma-informed care, and psychological safety into the Midwifery Pre-service Educational Program Curriculum. MMoC is a person-centered, evidence-based approach, and respectful care for maternal and newborn health is introduced to midwifery professionals with the technical support of ACNM.

In PY3, 10 midwifery champions (3 AFIAT and 7 AMA, all female) were trained within 3 months on the concept of MMoC. From June to August 2023, the ACNM trained the champions through a weekly two-hour virtual sessions.