Abstract
In 2004, Afghanistan pioneered a balanced scorecard (BSC) performance system to manage the delivery of primary health care services. This study examines the trends of 29 key performance indicators over a 5-year period between 2004 and 2008. Independent evaluations of performance in six domains were conducted annually through 5,500 patient observations and exit interviews and 1,500 provider interviews in >600 facilities selected by stratified random sampling in each province. Generalized estimating equation (GEE) models were used to assess trends in BSC parameters. There was a progressive improvement in the national median scores scaled from 0-100 between 2004 and 2008 in all six domains: patient and community satisfaction of services (65.3-84.5, p<0.0001); provider satisfaction (65.4-79.2, p<0.01); capacity for service provision (47.4-76.4, p<0.0001); quality of services (40.5-67.4, p<0.0001); and overall vision for pro-poor and pro-female health services (52.0-52.6). The financial domain also showed improvement until 2007 (84.4-95.7, p<0.01), after which user fees were eliminated. By 2008, all provinces achieved the upper benchmark of national median set in 2004. The BSC has been successfully employed to assess and improve health service capacity and service delivery using performance benchmarking during the 5-year period. However, scorecard reconfigurations are needed to integrate effectiveness and efficiency measures and accommodate changes in health systems policy and strategy architecture to ensure its continued relevance and effectiveness as a comprehensive health system performance measure. The process of BSC design and implementation can serve as a valuable prototype for health policy planners managing performance in similar health care contexts. Please see later in the article for the Editors' Summary.
Highlights
Emerging from decades of conflict, in 2002, Afghanistan had some of the worst health indicators in the world, with more than 30% of its population living below the poverty line
The balanced scorecard (BSC) has been successfully employed to assess and improve health service capacity and service delivery using performance benchmarking during the 5-year period
To address the exceptionally high disease burden, the Under Five Mortality Rate estimated to be 257 deaths per 1,000 live births and the Maternal Mortality Ratio estimated at 1,600 deaths per 100,000 births [2,3,4,5], the Ministry of Public Health (MOPH) designed a Basic Package of Health Services (BPHS) delivered primarily through contracting mechanisms with nongovernmental organization (NGO) and MOPH implementing agencies [6]
Summary
Emerging from decades of conflict, in 2002, Afghanistan had some of the worst health indicators in the world, with more than 30% of its population living below the poverty line. Nowadays, with increased demand for improved governance and accountability, policy makers are seeking comprehensive performance measures that show in detail how innovations designed to strengthen health systems are affecting service delivery and health outcomes. One such performance measure is the ‘‘balanced scorecard,’’ an integrated management and measurement tool that enables organizations to clarify their vision and strategy and translate them into action. The researchers examine the trends between 2004 and 2008 of the 29 key performance indicators in six domains included in this balanced scorecard, and consider the potential and limitations of the scorecard as a management tool to measure and improve health service delivery in Afghanistan and other similar countries
Sign-in/Register to view highlights & summary 
Published Version (
Free)
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call