7.1.2. AFIAT Annual Report 2023.pdf

ASSISTANCE FOR FAMILIES AND INDIGENT

AFGHANS TO THRIVE (AFIAT)

Fiscal Year 2024 – Project Year 4 Annual Report Performance Period: October 1, 2023–September 30, 2024

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 (MSH)

Revised Submission Date

December 05, 2024

USAID AFIAT Project Year 4 (PY4) Annual Report Page 2

Cover Photo Description

An AFIAT mentor is demonstrating newborn resuscitation to midwives at a district hospital in Kabul province. 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 (AMA) and technical partner American College of Nurse-Midwives (ACNM).

Submitted by

Norio Kasahara nkasahara@afiat.org

For more information, please contact:

info@msh.org

Management Sciences for Health

4201 Wilson Boulevard, Suite 500

Arlington VA 22203

Revision History

First draft submitted on October 30, 2024

Revised draft submitted on December 04, 2024 mailto:nkasahara@afiat.org mailto:info@msh.org

USAID AFIAT Project Year 4 (PY4) Annual Report Page 3

Table of Contents

List of Abbreviations

Executive Summary

Introduction and Background

Accomplishments by Project Objective

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

Rural Areas

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

Objective 3: Enhance Adoption of Optimal Health and Nutrition Behaviors by Communities and HHs . 41

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

Cross-Cutting Themes

Project Management

Challenges and Strategies to Address Them

Way Forward: Key Priorities for PY5

USAID AFIAT Project Year 4 (PY4) Annual Report Page 4

List of Abbreviations

AAC AIM action committee

AADA Agency for Assistance and Development of Afghanistan

ACNM American College of Nurse-Midwives

ADB Asian Development Bank

AFDA Afghanistan Food and Drug Authority

AFGA Afghanistan Family Guidance Association

AFIAT Assistance for Families and Indigent Afghans to Thrive

AHS Afghanistan 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

APTOS average percentage of time out of stock

ARI acute respiratory infection

AYSO Afghan Youth Services Organization

BARAN Bu Ali Rehabilitation and Aid Network

BCC behavior change communication

BDN Bakhtar Development Network

BHC basic health center

BPHS basic package of health services

BSC balanced scorecard

CAF Care of Afghan Families

CB-DOTS community-based DOTS

CBHC community-based health care

CCN cooperating country national

CD+ Community Dialogue Plus

CHAMT Community Health Accountability Monitoring Tool

CHC comprehensive health center

CHO community health officer

CHS community health supervisor

CHW community health worker

CS cesarean sections

DFA de facto authorities

DH district hospital

DHIS2 District Health Information Software 2

DMPA depot medroxyprogesterone acetate

DoEc Department of Economy

DoF&MDO Department of Follow-Up and Monitoring of Decrees and Orders

DOTS directly observed treatment, short course

DQA data quality assessment

DR-TB drug-resistant TB

DS-TB drug-sensitive TB

ECEB essential care for every baby

USAID AFIAT Project Year 4 (PY4) Annual Report Page 5

ECSB essential care for small babies

EMMP Environment Monitoring and Mitigation Plan

EPHS essential package of hospital services

EPI Expanded Program on Immunization

FHAG family health action group

FHH family health house

FP family planning

FPC fixed-price contract

GANC group ANC

GPNC group PNC

GF Global Fund

HBB helping babies breathe

HER Health Emergency Response

HF health facility

HH household

HII high-impact intervention

HMIS health management information system

HNTPO Health Net Transcultural Psychosocial Organization

HP health post

HPD Health Promotion Department

HQIP Harmonized Quality Improvement Program

IEC information, education, and communication

IMAM integrated management of acute malnutrition

IMAT Inventory Management Assessment Tool

IMNCI integrated management of neonatal and childhood illness

IPC infection prevention and control

IPCC interpersonal communication and counseling

IRB Institutional Review Board

ISQua International Society for Quality in Health Care

IUCD intrauterine contraceptive device

IV intravenous

IYCF infant and young child feeding

JACK Just for Afghan Capacity and Knowledge

LDHF low-dose high-frequency

LMIS logistics management information system

LQAS lot quality assurance survey

LRP Learning Resource Package

LS learning sessions

M&E monitoring and evaluation

MA management accompaniment

MCH maternal and child health

MDS managing drug supply

MEO mission environmental officer

MFL Master Facility List

MIAR monthly integrated activity report

MIYCN maternal, infant, and young child nutrition

MLMG midwifery leadership, management, and governance

MMoC midwifery model of care

MNCH maternal, neonatal, and child health

MPDSR maternal and perinatal death surveillance and response

USAID AFIAT Project Year 4 (PY4) Annual Report Page 6

MOC management of obstetric complications

MOEc Ministry of Economy

MoF Ministry of Finance

MOJ Ministry of Justice

MOPH Ministry of Public Health

MOU memorandum of understanding

MSH Management Sciences for Health

MTaPS Medicines, Technologies, and Pharmaceutical Services

ND normal delivery

NEPI National EPI

NGO non-governmental organization

NSIA National Statistics and Information Authority

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

ORS oral rehydration salts

P4P pay for performance

OSCE objective structured clinical examination

PEE pre-eclampsia/eclampsia

PH provincial hospital

PII personally identifiable information

PIO performance improvement officer

PIP performance improvement plan

PMH perinatal mental health

PMO program monitoring office

PNC postnatal care

PND Public Nutrition Department

PPE personal protective equipment

PPH postpartum hemorrhage

PPHD Provincial Public Health Directorate

PRIS Pharmaceutical Registration Information System

PROGRES Program for Organizational Growth, Resilience, and Sustainability

PSCM pharmaceutical supply chain management

PY project year

Q quarter

QBL quantification of blood loss

OFAC US Department of Treasury’s Office of Foreign Assets Control

QI quality improvement

QIC quality improvement committee

QIO quality improvement officer

QoC quality of care

QQM quantified quality metrics

RCA root-cause analysis

RCCE risk communication and community engagement

RI Relief International

RH reproductive health

RHCS reproductive health commodity security

RHO reproductive health officer

USAID AFIAT Project Year 4 (PY4) Annual Report Page 7

RMC respectful maternity care

RMNCH reproductive, maternal, neonatal, and child health

RMNCAH reproductive, maternal, newborn, child, and adolescent health

RMU rational medicine use

RUTF ready to use therapeutic foods

SAF Solidarity for Afghan Families

SAM severe acute malnutrition

SB safety bundle

SHC sub-health center

SIV Special Immigration Visa

SNC sick newborn care

SO sub-objective

SOP standard operating procedure

SP service provider

SS safe surgery

TB tuberculosis

TBIS TB information system

TCN third country national

TF task force

TOR terms of reference

TOT training of trainers

TPM third-party monitoring

TPT TB preventive treatment

TSFP Targeted Supplementary Feeding Program

TSR treatment success rate

TST targeted support team

TWG technical working group

UHI Urban Health Initiative

UNDP United Nations Development Programme

UNFPA United Nations Population Fund

USAID US Agency for International Development

USG US Government

VSU Vetting Support Unit

WB World Bank

WFP World Food Programme

WHO World Health Organization

WRA women of reproductive age

USAID AFIAT Project Year 4 (PY4) Annual Report Page 8

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 non-governmental organizations (NGOs) contracted under the Afghanistan Health Emergency Response

(HER) project.

AFIAT, with concurrence from USAID, entered a memorandum of understanding (MOU) with the

Ministry of Public Health (MOPH) on March 10, 2024.

AFIAT continues to strengthen health worker capacity to deliver the best possible care in a challenging environment. AFIAT also engaged in national level activities to support health systems components, including Afghanistan Health Survey (AHS), health management information system (HMIS), pharmaceutical supply chain management (PSCM), tuberculosis (TB) and nutrition services, and midwifery pre-service education by Afghan Midwives Association (AMA) members. Furthermore, through a targeted support team (TST) and a fixed-price contract (FPC) with the HER project service providers (SPs), AFIAT expanded support in two phases to cover 397 health facilities (HFs) and 1,251 health posts (HPs) in 14 target provinces to strengthen key high-impact facility and community-based interventions.

In project year 4 (PY4), the focus of AFIAT has been to advocate for replication and institutionalization of several AFIAT-initiated interventions within the HER phase 2 (HER2) project, including the Alliance for Innovation on Maternal Health (AIM) safety bundle (SB), Safe Cesarean Surgery, mSupply for logistics information management, group antenatal/postnatal care (GANC/GPNC), and the SP NGOs’ performance management through the management accompaniment (MA) approaches.

In four provinces – Faryab, Ghazni, Kandahar and Parwan – the HER2 project led to new NGOs taking implementation responsibilities in March 2024 (Q2). In two other provinces—Helmand and Herat—

UNICEF notified the implementing NGO of the discontinuation of the service provision contract in

April 2024 and was in the process of hiring two other NGOs. The agreements with the new NGOs were signed in September 2024.

All 14 TST target provinces were involved in various activities during PY4. Key achievements within each of AFIAT's four objectives are described in the sections below.

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

Services in Targeted Rural Areas

AFIAT conducted two rounds of Harmonized Quality Improvement Program (HQIP) assessments in 397

HFs and 1,251 HPs. After the assessment round in PY4Q1, the HF staff developed performance improvement plans (PIPs) to address identified issues. The score improved in all 397 HFs at the August

2024 assessment.

The facility level plans were monitored monthly by a quality improvement committee (QIC). In PY4, 3,585 of the expected 4,764 QIC meetings (75%) took place, averaging 2.3 meetings per facility per quarter. In 82% of the meetings, data were discussed and reviewed. Meeting minutes indicated that

NGO management and health shuras were involved in corrective actions in 66% and 51% of the meetings, respectively, in the month prior to the meeting.

USAID AFIAT Project Year 4 (PY4) Annual Report Page 9

AFIAT supported TSTs—comprising of AFIAT, AMA, and NGO staff—made 5,681 visits to 397 target

HFs using a low-dose high-frequency (LDHF) approach to mentor a total of 4,362 active health workers

(2,316 female, 2,046 male) in various thematic areas.

With support from AFIAT and AMA, the AIM SB program introduced a set of interventions to identify and manage postpartum hemorrhage (PPH) in 45 HFs in 14 provinces in three phases. In PY4, among

76,374 births across these 45 HFs, 100% of the women received active management of the third stage of labor (AMTSL) and oxytocin administration, and blood loss was quantified for 99% of the instances. PPH was confirmed for 686 women (2%) from all births, with the cause recognized and recorded in 685 of these cases.

AFIAT supported TB activities across 397 HFs in 14 targeted provinces, including 197 TB diagnostic centers, of which 194 submitted their Q4 data at the time of report submission. In PY4, 12,605 all form

TB cases were reported (7,265 in the 249 HFs of PY3), representing a 7% increase compared to the same period of the previous year. A total of 7,795 pulmonary bacteriologically confirmed TB cases were reported, all of whom subsequently received treatment. The treatment success rate (TSR) for all TB cases was 96%. Comparing PY4 data to the data in the previous year, several improvements were noted:

bacteriological diagnosis for pulmonary TB increased by 14%. Drug-resistant TB (DR-TB) cases increased by 32% over last year because of new GX machines being operational.

Through FPCs, AFIAT also rapidly scaled up GANC/GPNC interventions to reach a total of 50 HFs, introducing cumulatively 125 cohorts of 1,273 women of similar gestational age. The experience of care for these women, based on exit interviews, have been very positive, and AFIAT is seeing a high retention of enrolled women throughout the 6–8-month intervention period.

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

Services

In PY3, AFIAT began implementing safe Cesarean surgery in two provincial hospitals (PHs) and two district hospitals (DHs) in Ghazni and Faryab provinces, with full implementation starting in August 2023.

In PY4, across these four hospitals, 2,419 reported CSs were supported.

The CB-DOTS program continued to operate within the catchment area of the 397 HFs. The 196 diagnostic HFs notified 1,843 TB cases across all forms referred by CB-DOTS, contributing 6% to the overall TB case notifications in these HFs.

AFIAT supported the installation of 18 new 10-color GeneXpert machines, procured by the Global Fund

(GF), in AFIAT-supported diagnostic HFs. This added to the seven machines procured directly by the project. The GeneXpert utilization rate remained steady at 70%. Additionally, AFIAT continued to support the specimen (sputum) transport mechanism to 54 isolated basic health centers (BHCs).

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

Communities and HHs

AFIAT engaged health shuras to hold the facility-based health workers and community health workers

(CHWs) accountable using the Community Health Accountability Monitoring Tool (CHAMT) in HFs receiving TST support. In PY4, shura members conducted 939 visits to 378 HFs and 2,768 visits to 1,154

HPs. Female shura members participated in 23% of the HF visits and 42% of the HP visits.

The implementation of Community Dialogue Plus (CD+) continued in 140 HPs, leading to increased utilization. In three provinces, improvements in the uptake of maternal and neonatal interventions were celebrated, and HER NGOs, along with CD+ committee members, officially committed to continuing this approach in the future.

USAID AFIAT Project Year 4 (PY4) Annual Report Page 10

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

Health System

AFIAT conducted three rounds of MA workshops in the 14 provinces based on the findings from the third-party monitoring (TPM) findings and service utilization and quality related data (HQIP and

Quantified Quality Metrics [QQM]). All the provinces developed a PIP based on the discussions. Due to a delay in the TPM contracting mechanism from UNICEF, AFIAT was unable to conduct MA activities in

Q4.

AFIAT supported the nationwide rollout of the new HMIS in November 2023, and supported NGOs in improving data quality, particularly for new indicators of interest to the project.

AFIAT TSTs used the Inventory Management Assessment Tool (IMAT) in 390 HFs to measure the average percentage of time out of stock (APTOS) in the past 90 days for tracer commodities. For commodities included in the basic package of health services (BPHS) procurement list, the score was

14% (with an acceptable threshold of less than10%). In contrast, the average score for the five high-impact intervention (HII) commodities was 27%, which is higher than the acceptable benchmark level of

10%.

AFIAT continued to support HER SP NGOs in entering pharmaceutical data into mSupply and using the platform for distributing medicine to HFs. Among the 32 provinces where mSupply is functional, 25 provinces recorded medicine distribution through mSupply. UNICEF provided NGOs with $24.7 million in cash advances to procure 40 of the 140 medicine items agreed upon by the stakeholders from the local suppliers over a six-month period (January-June 2024)1. As of June 30, $16 million, or 65% of the funds were spent by NGOs.

AFIAT commenced training of trainers (TOT) for AHS in late June. The survey is coordinated with the

National Information and Statistics Authority (NSIA) and the MOPH. The household (HH) listing is expected to begin in Q1 of PY5.

Project Management

In anticipation of reduced funding in PY5, AFIAT began scaling down its provincial operations in Q4. In

PY4, 394 national staff and one third country national (TCN) left MSH (including 27 due to the Special

Immigration Visa [SIV]), while 53 national staff joined the project. AFIAT closed 13 provincial offices

(except for Kabul) in September, and the remaining provincial staff will work from home in PY5.

Challenges and Way Forward

UNICEF did not finalize the contract for TPM until June 2024, resulting in no TPM HMIS verification or

QQM data being collected for the January-March 2024 performance period in Q3, and no management accompaniment (MA) support could be provided in Q4.

The discussion on the nutrition component for the AHS delayed the start of the survey. However, AFIAT was able to conduct TOT for data enumerators in late June, and data collection is expected to commence in PY5Q1 in tandem with the household listing.

In PY5, the focus will be on completing investments in TB, RMNH and MA, while continuing to advocate for institutionalization.

1 UNICEF presentation slide deck for the ISM meeting in Dubai September 2024

USAID AFIAT Project Year 4 (PY4) Annual Report Page 11

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 included AMA and American College of Nurse-Midwives

(ACNM). 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 HER SP 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 HHs

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 provinces (Wave-1 provinces): Balkh, Bamyan, Herat, Kabul, Kandahar, Nangarhar, and Parwan. In 2022, the project expanded to an additional seven provinces (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

USAID AFIAT Project Year 4 (PY4) Annual Report Page 12

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 HER SP

NGOs. A ban on women working for HER SPs was introduced in December 2022, followed by the ban on employment of Afghan women in the United Nations 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 were able to work in the office in 11 provinces, excluding Helmand, Kandahar, and Nangarhar.

In Q1 of PY4 USAID approved the draft MOUs that were being negotiated with the MOPH by AFIAT.

On March 10, the MOU was signed by the Minister of Public Health and countersigned by AFIAT two days later.

The HER second phase (HER-2) project continued to experience medicine stockouts into PY4 due to intermittent supply from UNICEF. This PY, over the last two quarters, NGOs were allowed to procure

45 items of medicine and contraceptives from local markets. AFIAT supported medicine quantification for BPHS/essential package of hospital services (EPHS) in calendar year 2024 to alleviate this issue in

PY4.

Project Reach

According to the HMIS/Master Facility List (MFL) of the MOPH, there are 4,508 HFs that provide BPHS and EPHS services in Afghanistan, 2,405 of which are contracted out under the HER2 project. Table 1 illustrates the proportion of service delivery points benefiting from AFIAT TST support. In PY3, the HER

SPs took on leading the implementation of the QI processes in 104 HFs, thus permitting AFIAT to add

104 new HFs in Q1 and 44 additional HFs for QI support in PY4 Q3. These new 44 HFs were jointly assessed in Q2 of PY4, and the mentorship support began immediately. By the end of PY4Q3, in 136 of the 397 facilities receiving AFIAT support, the HER NGOs had started taking the lead in the QI processes.

Table 1. BPHS HFs2 and HPs supported by AFIAT, by wave (% share of total HFs/HPs)

Level Wave Total in

Target

Province

Supported by

AFIAT in PY3

HFs added for support in PY4Q1

HFs newly added for support in

PY4Q3

Total supported by AFIAT- in

PY4

HFs Wave-1 682 165 49 17 231

Wave-2 561 84 55 27 166

Total 1,243 249 (20%) 104 (8%) 44 (4%) 397 (32%)

HPs Wave-1 5,198 370 175 56 601

Wave-2 3,567 388 182 80 650

Total 8,765 758 (9%) 357 (4%) 136 (2%) 1,251 (14%)

2 HFs included in this calculation are those that are covered under HER, and the types are SHC, BHC, CHC, and DH.

Data source: WHO/UNICEF shared HF list

USAID AFIAT Project Year 4 (PY4) Annual Report Page 13

AFIAT expanded support to 90% of the planned 1,383 HPs. Handover of QI leads to some of the HPs were not possible due to: OHPM suspension in Herat and Helmand (affecting FPC plan), CHW transition (new CHW recruitment) or not meeting the 75% HQIP threshold needed for consideration.

The following section describes the accomplishments in PY4 (October 2023 – September 2024) by project objective.

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

Activity 1.1.1.a Support UN partners and Management Accompaniment (MA) firms to in utilizing QQC data for QI of service delivery

The HER project TPM began collecting QQM data in July 2023, with the first set of results presented in the quarterly performance review meetings in October 2023. AFIAT has been collaborating with the MA contractors MgtWell and Health Protection and Research Organization (HPRO) to review HMIS verification and QQM data and support NGO capacity strengthening. Two additional assessments were conducted in PY4 Q1 and Q2. However, due to a delay in UNICEF’s re-contracting for TPM, the assessment results for July-September 2024 were unavailable at the time of this report’s submission.

To see the differences of AFIAT support on the quality of care, the scores for the content of care element of QQM are compared between health facilities with and without AFIAT support over 3 rounds of TPM during the PY4 period. Because of AFIAT’s larger focus, the QQM content of care element is selected for comparison. While understanding the unavailability of QQM data prior to the

AFIAT interventions and the existence of other underlying differences at baseline, including the selection criteria of health facilities by AFIAT, the below graph indicates that the mean QQM scores are higher in the health facilities supported by AFIAT by on average 2.9% points than those without AFIAT between

October 2023 and June 2024.

USAID AFIAT Project Year 4 (PY4) Annual Report Page 14

Figure 2: Difference in QQM content of care scores between HFs with and without AFIAT support

AFIAT has supported UNICEF and the World Bank in PY3 and prior quarters in developing the quantified quality metrics (QQM) to assess quality of care during third-party verification each quarter.

AFIAT analyzes the data and includes the recommendation in the provincial performance review of MA.

The findings are used in developing provincial performance improvement plan (PIP) and addressing the gaps. This has been described in detail in Objective 4: Management Accompaniment (MA) section.

Integrate QI component in the HER contracts

AFIAT continued to participate in Quality of Care (QoC) technical working group (TWG) meetings to update the QQM tool. In early June, AFIAT presented the feedback from the MA workshops to the

TWG. More details on the QQM assessments have been described in Objective 4: MA section.

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

1.2.4 Support the institutionalization of TSTs in targeted provinces

1.2.4.a HQIP assessments to measure progress in compliance with quality standards

The HQIP assessment has been rolled out at various points in time and across different geographical locations. Within two groups of the provinces that initiated QI activities at different times (Wave), the cohorts of prioritized HFs and HPs are selected at a specific point in time (selection phase) and implement the assessment in a 4 to 7-month interval (rounds). Table 2 summarizes the timing of the assessment by wave and phase.

USAID AFIAT Project Year 4 (PY4) Annual Report Page 15

Table 2: Number of HFs and HPs assessed by Wave, phase and times of assessment rounds

Wave Selection phase

Number of HFs and HPs assessed Assessment rounds

HFs HPs Baseline 2 3 4 5 6

Wave I Phase 1 172* 423 Nov 2021 Jun 2022 Mar 2023 Sep 2023 Mar 2024 Aug 2024

Phase 2 49 180 Oct 2023 Mar 2024 Aug 2024

Phase 3 17 41 Apr 2024 Aug 2024

Wave 2 Phase 1 84* 421 Dec 2022 Aug 2023 Mar 2024 Aug 2024

Phase 2 55 185 Aug 2023 Mar 2024 Aug 2024

Phase 3 27 81 Apr 2024 Aug 2024

Total 405 1,331

* Note: 8 HFs were replaced in PY3: 6 in Wave-1 (UHI overlap in Herat), and 2 in Wave-2 provinces. The first assessments of the replacement are counted in Baseline.

AFIAT assessed 397 HFs and 1,251 HPs using the full HQIP tools for 14 areas in two rounds, February-

March 2024 and August 2024.

Figure 3. Trend of HQIP scores, November 2021-September 2024

As outlined above, the overall HQIP scores have demonstrated an upward trajectory, on average, in the course of the successive rounds of the assessments. The graph below offers a different perspective on the same results in terms of how the cohort of health facilities transitioned from the baseline (BL) to the higher scores.

The baseline scores across the waves and selection phases show a similar distribution, with health facilities spread across the scores and exhibiting significantly low skewness and kurtosis. The majority of the cohort gradually moves towards the higher score after the baseline assessment, and by the third round of the assessment, the distribution skews towards the higher scores.

The number of outperforming health facilities continues to increase after the third round of assessment.

While negative deviance exists, a group of underperforming facilities appears to be pulled up to higher score over time. This is presumably attributable to the provision of less intensive but continuous mentorship by AFIAT in collaboration with NGOs following 12 months of intervention. The graph also suggests that the minimum timeframe for achieving a mass of health facilities attaining higher scores is 18 to 24 months, given the prevailing operational context.

Figure 4: Trend of HF HQIP scores since 2021, by Wave and selection phase

USAID AFIAT Project Year 4 (PY4) Annual Report Page 16

Transition of the TSTs

Under the FPC contracts, AFIAT started transitioning the lead of QI activities of 136 HFs and 493 HPs to HER SP NGOs. In addition to the QI visits to HFs and HPs performed by AFIAT staff, AFIAT deployed two strategies to facilitate the transfer of QI capacity to HER SPs:

1. Joint visits (AFIAT and HER SPs’ teams) to transitioned HFs fostered a smooth exchange of knowledge and expertise, ensuring a seamless transition.

2. Independent QI visits by HER SPs to the transitioned HFs allowed them to familiarize themselves with operational nuances, strengthening their ownership of QI activities.

Figure 5 below shows a distinct shift, with HER SPs now taking the lead in driving QI activities within the

136 transitioned HFs in PY4 through FPCs. The transfer of responsibility, along with backup technical support from AFIAT, marks an important step towards sustainability of QI activities led locally by HER

SPs. Figure 5 indicates the proportion of HF visits performed by teams of different composition, indicating an increase in the proportion of HFs visited by the NGOs without direct AFIAT presence.

This, combined with support for the new 44 HFs resulted in a higher presence of AFIAT-only visits.

USAID AFIAT Project Year 4 (PY4) Annual Report Page 17

Figure 5. Trend of joint AFIAT-NGO and only NGO visits, October 2021-September 2024

The FPC contracts were terminated in August 2024 due to budget constraints. However, prior to this, NGO involvement for both FPC and HER staff increased, and NGOs continued to support these HFs in

Q2 and Q3.

1.2.3.a Capacity strengthening of TSTs

AFIAT continued to support the TSTs as needed to ensure the TST members (NGO, AMA and AFIAT staff) have the necessary competencies and skills to provide mentoring during facility visits. Out of the

400+ TST members (excluding MA participants), 100% of the TSTs were trained to support the relevant activities through onboarding training in PY3-4, formal training on MOC, SNC and data use, quarterly data/performance review, and weekly tele-mentorship sessions.

Table 3 below summarizes the participants by topic and organization.

Table 3. Number of TST members participating in formal training sessions conducted in

PY4, by topic and organization

SN Thematic Area

AFIAT AMA NGO Total

Number of

Unique

Participants F M F F M

1 ANC 5 0 0 17 0 22

2 FP 0 0 0 0 0 0

3 Delivery 0 0 0 0 0 0

4 MOC 39 8 3 33 1 84

5 PNC 16 0 1 29 1 47

6 SNC 8 26 0 7 24 65

7 IMNCI 12 21 0 10 16 59

8 EPI 8 20 0 1 15 44

9 IP 2 0 0 3 10 15

10 HFM 0 0 0 0 0 0

11 RMU 0 14 0 0 9 23

12 BCC 6 10 0 2 5 23

13 TB 2 2 0 8 17 29

14 Nutrition 45 43 6 21 56 171

15 Other* 31 33 1 22 104 191

1,692

3,632 3,644

512 677

1,360

1,000

2,000

3,000

4,000

5,000

6,000

PY2 PY3 PY4

N o o f m e n to rs h ip v is it s

Only NGOs

AFIAT + NGO

Only AFIAT

USAID AFIAT Project Year 4 (PY4) Annual Report Page 18

Total Number of

Individuals Participating 109 117 7 77 191 500

* Other includes onboarding training of FPCs, Midwifery Model of Care (MMoC), and provincial quarterly performance review workshop (which includes orientations on QQM and data use).

Note: SNC: sick newborn care; MDS/RMU: managing drug supply/rational medicine use; BCC: behavior change communication.

1.2.2 Support the functioning of TST members in mentoring for core reproductive, maternal, neonatal, and child health (RMNCH) competencies through formal training workshops

A Perinatal Mental Health (PMH) module was drafted by ACNM in PY4 for the orientation of AFIAT, AMA, and NGO technical officers and mentors. The module is based on recently developed materials from World Health Organization (WHO) and USAID MOMENTUM PMH Community of Practice. It focuses on the integration of PMH in maternal and child health (MCH) services and the role of midwives in identifying risk factors and symptoms of PMH conditions. Midwives are also trained to provide screening, education, support, and referrals as appropriate. This material was presented to TST members through tele-mentorship sessions beginning in Q4, and TST members then introduced learning sessions for the HF midwives.

Perinatal mental health is part of GANC, and Midwifery Model of Care (MMoC) packages and has also been included in the revised midwifery curriculum developed by Aga Khan University (AKU). Many psychosocial counselors in the HFs are male and AFIAT cannot engage them in GANC, and thus midwives were oriented through TST. AFIAT will continue to support this through GANC and MMoC.

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

Strengthen Quality Improvement Committees (QICs)

In 249 TST supported facilities, AFIAT introduced specific terms of reference (TOR) for QICs starting in

May 2023, along with QICs of 104 new facilities in PY4 Q2 and 44 new facilities in PY4Q3. The QICs are expected to meet monthly, review HQIP scores, logbook of mentorship activities of the HF, identify gaps, assess PIP, and review records of health shura meetings to assess progress against the PIP.

In PY4, 3,585 QIC meetings took place—75% of the expected meetings (2.6 meetings per HF for both

249 original HFs and 148 new HFs) for this period.

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

This year, 2,353 CHWs including 52% (1,217) female, and 4,291 facility staff including 51% (2,282) female, participated in 78,624 learning sessions (LS) as detailed in Table 4.

Table 4. Number of HF staff and CHWs participating in LS in PY4.

SN

Thematic area

HP LS CHW HF LS HF staff Total

F M F M

1 ANC 6,280 968 709 4,361 819 70 2,566

USAID AFIAT Project Year 4 (PY4) Annual Report Page 19

2 FP 1,483 380 247 2,816 693 25 1,345

3 Delivery NA NA NA 3,033 678 10 688

4 MOC NA NA NA 3,442 850 8 858

5 PNC 4,143 793 546 1,568 485 37 1,861

6 SNC NA NA NA 2,947 739 111 850

7 IMNCI 6,059 742 774 3,679 193 620 2,329

8 EPI 2,486 400 455 2,446 275 299 1,429

9 IP NA NA NA 7,177 1,114 865 1,979

HF

Management

NA NA NA 2,722 233 594 827

11 MDS/RMU 1,439 296 316 2,525 48 462 1,122

12 BCC 697 58 109 2,597 205 568 940

13 TB 1,979 361 465 2,949 200 612 1,638

14 Nutrition 6,228 680 750 5,575 985 277 2,692

Total Number of

Individuals

Participating

30,794 1,217 1,136 47,830 2,282 2,009 6,644

Note: MOC curriculum includes PPH, PEE, neonatal resuscitation and care for small babies

In addition to the TST visits, AFIAT organized formal training for HF staff and CHWs in several thematic areas as indicated in Table 5.

Table 5. Formal training of HF staff and CHWs undertaken in PY4

SN Thematic area

Batch for

CHWs

CHW

Batch for HF

Staff

HF staff Total

F M F M

1 ANC 0 0 0 9 104 0 104

2 FP 0 0 0 2 31 0 31

3 Del NA NA NA 3 54 0 54

4 MOC NA NA NA 21 243 142 385

5 PNC 0 0 0 0 0 0 0

6 SNC NA NA NA 2 18 0 18

7 IMNCI NA NA NA 5 11 40 51

8 EPI NA NA NA 2 8 1 9

9 IP NA NA NA 2 35 25 60

10 HF Management NA NA NA 1 8 7 15

11 MDS/RMU NA NA NA 2 3 12 15

12 BCC 0 0 0 2 0 41 41

13 TB 54 631 644 55 301 201 1775

14 Nutrition 4 86 85 21 300 298 769

15 Other* 4 125 94 16 51 310 580

Total Number of

Participants 62 839 822 143 1,088 832 3,579

*Other training include: QQM and CBHC refresher and initial training, Onboarding training, etc

1.3.1 Strengthen core competencies for midwives and nurses

USAID AFIAT Project Year 4 (PY4) Annual Report Page 20

1.3.1.a Support AMA strategic plan implementation

In PY3Q3, AMA initiated the implementation of its updated strategic plan (2023–2025), focusing on strengthening the organization's capacity to promote evidence-based HIIs. In September 2023, AFIAT conducted the PROGRES assessment to identify areas for improvement to support the implementation of the AMA strategic plan. Based on the assessment results, AFIAT plans to conduct a leadership, management, and governance training for the AMA leaders and executive team in PY4Q2 (leadership training section below).

In PY4, AMA conducted two capacity-strengthening training sessions on IPC (infection, prevention and control) and preceptorship for AMA members including mentors, trainers, midwifery directors, HF midwives, and NGO reproductive health officers (RHO) in Kabul. A total of 54 participants were trained on IPC from 15 provinces. The preceptorship training was conducted for a total of 22 clinical midwives from 12 provinces.

Leadership training for midwives

AFIAT and AMA undertook the Midwifery Leadership, Management & Governance (MLMG) program for 17 female midwives from six provinces. The program includes online workshops, mentoring sessions, project development and implementation and dissemination of findings. In April 2024, a five-day workshop introduced the concepts of MLMG and governance structures of the health system. Following a strategic planning process using the MSH challenge model3, eight project teams were developed for implementation in their respective workplace. Ongoing mentorship and coaching support were provided, and the teams are expected to present lessons from their project in Q1 of PY5.

1.3.1.c Follow up on AMA’s PROGRES baseline assessment

In PY3Q4, AFIAT applied the PROGRES tool to conduct a baseline assessment of AMA’s organizational capacity and an action plan was developed to address the gaps found in the baseline assessment. During the present reporting period, AMA has initiated the implementation of the action plan with the following status: 66% of actions have started, 26% are in progress, and 8% of the action points are completed. The action points completed are related to the three following domains:

1. Human Resources Management/Organizational Structure and Job Descriptions

2. Finance, Operations, and Administration/Annual External Audit

3. Finance, Operations, and Administration/Payroll

In PY4Q1, AFIAT—with an AMA consultant—prepared the objectives, activities, and curriculum of the second batch of training for 16 young midwifery leaders of AMA on leadership, management, and advocacy to support AMA in its strategic objectives and in improving several low-performing PROGRES domains. The training objectives include:

● Improve leadership, management, advocacy skills and practices of midwifery leaders, supervisors, and managers.

● Apply leadership, management, and advocacy skills to improve management of reproductive, maternal, and newborn health (RMNH) services.

● Demonstrate strategic problem-solving skills while handling challenges.

● Demonstrate resource mobilization and management skills.

3 The MSH Challenge Model: https://msh.org/resources/the-challenge-model/#:~:text=The%20Challenge%20Model%20is%20a,their%20challenges%20and%20achieve%20results https://msh.org/resources/the-challenge-model/#:~:text=The%20Challenge%20Model%20is%20a,their%20challenges%20and%20achieve%20results https://msh.org/resources/the-challenge-model/#:~:text=The%20Challenge%20Model%20is%20a,their%20challenges%20and%20achieve%20results

USAID AFIAT Project Year 4 (PY4) Annual Report Page 21

● Apply monitoring and evaluation (M&E) skills to track results-based implementation of maternal and newborn health services.

● Improve teamwork and work climate.

In Q3, AFIAT M&E team supported AMA M&E focal point on developing an HMIS system for their various projects. AFIAT will continue to support M&E and IT capacity building for AMA staff.

Following AMA’s recommendations from the PROGRES assessment, AFIAT is reviewing their M&E system to provide further support. AMA has also requested assistance in building the capacity of their IT staff, which AFIAT will address in PY5.

1.3.1.d Implement Midwifery Model of Care (MMoC)

A cohort of 37 midwifery mentors and educators (all female) were trained by an AFIAT international consultant through virtual mentoring sessions. The six live sessions covered the following topics: optimal antenatal care (ANC); WHO intrapartum guidelines, assessment of maternal and fetal wellbeing using new partograph (WHO Labor Care Guide). The sessions included real case scenarios collected by the participants from their relevant clinical sites.

In addition, the Clinical Portfolio for Reflective Practice was finalized and is translated to be implemented first with the participants and who then will implement with trainees and junior midwives.

Participants in this portfolio received 12 sessions of virtual mentoring from the AFIAT international consultant and then performed practical assignment in the MSF supported Midwife Led Maternity Care

Center (MLMCC) in Ali Jinnah hospital in Kabul.

From September 29 to 30, 2024, AMA mentors utilizing the curriculum developed by AFIAT replicated the MMoC training for 20 midwives at Ahmad Shah Baba MLMCC with UHI funding through an extensive orientation session.

Capacity building of midwifery educators/preceptors through AMA

Organized by AMA, in PY4, three batches of preceptorship training (six days for each batch) were conducted in Helmand, Ghazni and Nangarhar provinces. All 76 female AMA midwifery mentors and educators participated in these training. The six-day program focused on the following topics: Respectful maternity care (RMC), ANC, PNC, management of obstetric complications, (PPH, shock, preeclampsia/eclampsia [PEE]), helping babies breathe (HBB], essential care for every baby (ECEB) and essential care for small babies (ECSB), FP (Long-Acting Reversible Contraception [LARC] methods, sub-cutaneous DMPA [Sayana Press®]), community-based aspects of competencies and interventions to improve maternal and newborn health at the community level.

AFIAT translated the updated WHO Labor Care Guide into Dari and Pashto. Midwives received orientation on the guide through mentorship and preceptorship training. The MoPH began adapting the

WHO Labor Care Guide using the translated versions, and the MNH National Technical Working

Group is meeting to finalize this adaptation process, with AFIAT as one of the key members

1.3.1.e Support AMA to collaborate with local partners to run MNH skills labs

AFIAT set up a total of 40 skill labs across 14 provinces, including 28 in AIM HFs, four in Safe Surgery

HFs, at provincial level seven and one at the AMA office. 140 AIM action committee members are regularly practicing their skills, with 100% demonstrating competency in PPH and other skills. AFIAT is working to handover the provincial skill labs to AMA and NGOs, with seven new skill labs planned for

PY5. AMA is utilizing the Kabul skill lab for their midwives and plans to enroll 40 midwives for regular sessions using their own budget. These labs are in addition to the already functional AIM skill labs. Due

USAID AFIAT Project Year 4 (PY4) Annual Report Page 22 to budget constraints, NGOs will lead the skill labs at the provincial level, and an orientation has been conducted during FPC.

1.3.2 Build core competencies at referral level

1.3.2.a AIM program on Postpartum Hemorrhage (PPH)

The AIM SB program introduces a set of interventions to identify and manage PPH and PEE. In PY4, AFIAT and AMA continued to support AIM PPH intervention in 45 HFs across 14 provinces. AIM PPH regular trainings were conducted for 187 health providers (102 female, 85 male) from seven provinces4.

In PY4, the comparison of the AIM PPH clinical indicators in the pre- and post-intervention periods, shows a maintained improvement in recognition of PPH through the quantification of blood loss (QBL)

(100% of deliveries—vaginal and CS—have blood loss quantified) and in identification of the cause of

PPH (in 100% of cases). The AIM intervention is building the confidence and proficiency of HF staff at the primary level through regular practice in the HF’s skill lab. This has led to a reduction in the number of referrals to higher-level facilities, and importantly, decreased the rate of severe PPH, thus reducing the need for life-saving advanced interventions. The management and communication between the referral (out and in) sites are facilitated and improved through a WhatsApp group for AAC members at each site.

Table 6. Comparison of clinical indicators and outcome measures post-AIM PPH intervention

SN Indicators

AFIAT (Phase 1- 3) AMA (Phase 1)

Baseline

(Apr

2022-

Nov

2023)

October

2023-

September

2024 (PY4)

Baseline

(Feb-

Apr

2023)

April-

September

2024 (PY4)

1 Number of HFs supported 39 39 6 6

2 Number of all births 23,695 66,920 2,723 9,454

3 AMTSL with oxytocin administered 100% 100% 100% 100%

4 % of births via CS 4% 4% 6% 7%

5 % of PPH from all births 1% 2% 1% 2%

6 % of deliveries with QBL performed 9% 100% 0% 99%

7 Number of transfers (in and out) due to PPH 51 157 45 87

7.a Average number of transfers (in and out) due to PPH per month 17 13 15 15

8 Number of maternal deaths due to PPH 1 5 0 1

Number of maternal deaths (transfers) due to all causes 0 6 0 1

% of PPH cases where causes of PPH were recognized 54% 99% 100% 100%

Number of advanced interventions performed 60 978 11 112

11.a Avg number of advanced interventions performed per month 20 82 4 19

4 Bamyan, Ghazni, Ghor, Khost, Kandahar, Herat, and Helmand.

USAID AFIAT Project Year 4 (PY4) Annual Report Page 23

A second post-intervention safety survey, conducted in PY4Q3 in the 9 phase-1 AIM HFs (Nangarhar, Balkh and Parwan) showed that increasing safety scores (Nangarhar and Balkh) were associated with a significant reduction in the incidence of postpartum hemorrhage while declining safety scores (Parwan) were associated with an increase in the rate of PPH. These observations suggest that a strong safety culture is essential for achieving clinical improvements in PPH, as also shown in Figure 6.a and 6.b..

Figure 6.a: Comparison of Hospital Survey on Patient Safety (HSOPS) score in three provinces, 3 months pre-AIM training (Aug 2022) and 15 months post-AIM training June

Figure 6.b: Comparison of PPH rates in three AIM sites, Aug 2022-June 2024

56% 72%

34%

88% 83%

24%

0% 20% 40% 60% 80%

100%

Balkh Nangarhar ParwanO ve ra ll

Sa fe ty S co re

Province

Baseline Post-Intervention

2.1% 2.4%

1.7%

1.1%

2.1%

2.5%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

Balkh Nangarhar Parwan

Baseline Post-intervention

USAID AFIAT Project Year 4 (PY4) Annual Report Page 24

1.3.2.b AIM Program on Pre-eclampsia/Eclampsia (PEE)

In PY4, AFIAT also initiated the AIM-PEE interventions in nine HFs in Balkh, Nangarhar, and Parwan provinces. The project conducted the AIM-PEE training of trainers (TOT) for 48 AIM action committee

(AAC) members (38 female, 10 male) in the nine HFs. AAC members oriented the other HF staff through LDHF approach in all nine HFs and in Balkh conducted training for eight HF staff (7 female, 1 male).

The AIM HFs that have implemented PPH for over 1 year were selected, given their familiarity with the safety culture, it was feasible to rapidly expand PEE services to outpatient and inpatient services without significant material input.

AIM PEE clinical indicators in the pre- and post-intervention periods in AIM HFs of the first two months of implementation in Balkh province show a rapid increase in recognition of PEE cases.

Table 7: Clinical Indicators of AIM PEE pre and post intervention, SN AIM PEE Indicators

AFIAT (Phase 1)

3-month baseline

May-

September

1 Number of HFs supported 9 9

2 Number of ANC visits recorded 11,305 17,357

2.a Avg monthly ANC visits 3, 768 3,471

3 Number of women who had their blood pressure taken (during ANC) 8,203 16,200

3.a Proportion of women who had their blood pressure taken (during

ANC)

73% 93%

Number of ANC women with pre-eclampsia diagnosed (BP>140/90, 2+ proteinuria)

NR* 92

5 Number of all births (logbook) (including PEE women referred in) 5,659 9,011

6 Number of births by vaginal delivery 5,459 8,666

7 Number (proportion) of births by c-section 200 345

7.a Proportion of births by C-section 4% 4%

Number of patients with pre-eclampsia in ANC clinic who required admission (admitted patients) 0 40

Number of patients with severe pre-eclampsia (SPE) at birth (including referrals in)

7 15

Number of patients with eclampsia coming from ANC, labor ward, or

PNC, or referred in)

3 22

Number of patients with chronic hypertension** with superimposed pre-eclampsia

NR 44

12 Number of gestational hypertension*** NR 15

*NR: Not recorded

** Pre-existing hypertension prior to 20 weeks gestation

***BP greater than 140/90 after 20 weeks gestation with no proteinuria that is resolved after 42 days postpartum

These HFs recorded 17 complications, five months post intervention due to severe pre-eclampsia (SPE) and eclampsia. These included two cases of pulmonary edema, eight cases of eclamptic seizures, two cases of thrombocytopenia, one case of posterior reversible encephalopathy syndrome (PRES), one case of renal failure, and three cases of intrauterine fetal deaths.

USAID AFIAT Project Year 4 (PY4) Annual Report Page 25

AFIAT continued to strengthen the PEE intervention through regular facilitation of the AIM Action

Committee meetings.

Monthly AIM Action Committee (AACs) to follow up on implementation issues

Based on the regular review of the monthly data of AIM PPH and PEE clinical indicators, AAC members are encouraging the maternal and…