Balance Score Card Del Paquete de Servicios de Salud

AFGHANISTAN
BASIC PACKAGE OF HEALTH SERVICES

BALANCED SCORECARD
NATIONAL REPORT 2012-13
Ministry of Public Health

Islamic Republic of Afghanistan
Table of Contents
Executive Summary ........................................................................................................................ 3
Introduction ..................................................................................................................................... 6
Methodology ................................................................................................................................... 8
Sampling Frame .......................................................................................................................... 8
Data Collection ........................................................................................................................... 9
Revisions to the 2011-12 BPHS Balanced Scorecard............................................................... 11
Benchmarks............................................................................................................................... 11
Indicators................................................................................................................................... 12
NATIONAL LEVEL FINDINGS OF THE 2012-13 BPHS BALANCED SCORECARD ........ 16
Domain A: Client and Community ........................................................................................... 16
Domain B: Human Resources................................................................................................... 18
Domain C: Physical Capacity ................................................................................................... 24
Domain D: Quality of Service Provision .................................................................................. 29
Domain E: Management Systems ............................................................................................. 33
Domain F: Overall Mission ...................................................................................................... 35
PROVINCIAL LEVEL FINDINGS OF THE 2012-2013 BALANCED SCORECARD ............ 37
BADAKSHAN PROVINCE FINDINGS ................................................................................. 39
BADGHIS PROVINCE FINDINGS ........................................................................................ 41
BAGHLAN PROVINCE FINDINGS ...................................................................................... 43
BALKH PROVINCE FINDINGS ............................................................................................ 45
BAMYAN PROVINCE FINDINGS ........................................................................................ 47
FARAH PROVINCER FINDINGS.......................................................................................... 51
FARYAB PROVINCE FINDINGS.......................................................................................... 53
GHAZNI PROVINCE FINDINGS........................................................................................... 55
GHOR PROVINCE FINDINGS .............................................................................................. 57
HELMAND PROVINCE FINDINGS ...................................................................................... 59
HERAT PROVINCE FINDINGS ............................................................................................ 61
JAWZJAN PROVINCE FINDINGS ........................................................................................ 63
KABUL PROVINCE FINDINGS ............................................................................................ 65
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KANDAHAR PROVINCE FINDINGS ................................................................................... 67
KAPISA PROVINCE FINDINGS ........................................................................................... 69
KHOST PROVINCE FINDINGS ............................................................................................ 71
KUNAR PROVINCE FINDINGS............................................................................................ 73
KUNDUZ PROVINCE FINDINGS ......................................................................................... 75
LAGHMAN PROVINCE FINDINGS ..................................................................................... 77
NANGARHAR PROVINCE FINDINGS ................................................................................ 81
NIMROZ PROVINCE FINDINGS .......................................................................................... 83
NURISTAN PROVINCE FINDINGS...................................................................................... 85
PAKTIKA PROVINCE FINDINGS ........................................................................................ 87
PAKTIYA PROVINCE FINDINGS ........................................................................................ 89
PANJSHIR PROVINCE FINDINGS ....................................................................................... 91
PARWAN PROVINCE FINDINGS ........................................................................................ 93
SARIPUL PROVINCE FINDINGS ......................................................................................... 97
TAKHAR PROVINCE FINDINGS ......................................................................................... 99
URUZGAN PROVINCE FINDINGS .................................................................................... 101
WARDAK PROVINCE FINDINGS ...................................................................................... 103
ZABUL PROVINCE FINDINGS .......................................................................................... 105
Appendix 1: National Health Services Performance Assessment Sampling Frame, 2004 – 2013
..................................................................................................................................................... 106
Appendix 2: Basic Package of Health Services Sampling Frame, 2012-13 ............................... 107
Appendix 3: Comparison of BPHS Balanced Scorecard Indicators used in 2004 to 2009-10 with
Indicators used in 2012-13 .......................................................................................................... 108
Appendix 4: List of Items Included in Each Indicator for the 2012-13 BPHS Balanced Scorecard
..................................................................................................................................................... 109
Appendix 5: Change in Rank Order of Provinces between 2011/12 and 2012/13 Based on the
Overall Mean Score .................................................................................................................... 117
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EXECUTIVE SUMMARY
The Ministry of Public Health (MoPH) of the Islamic Republic of Afghanistan, with technical
assistance from the Johns Hopkins University Bloomberg School of Public Health (JHSPH) and
the Indian Institute of Health Management Research (IIHMR), has used the Balanced Scorecard
(BSC) as a means to measure and manage performance in delivery of the Basic Package of
Health Services (BPHS) throughout Afghanistan. This is the eighth BSC for the BPHS in
Afghanistan, and the third year that the BSC is based on assessments at Comprehensive Health
Centers (CHC), Basic Health Centers (BHC) and Sub-Health Centers (SHC), with district,
provincial, and regional or national level hospitals having a separate BSC based on the Essential
Package of Hospital Services (EPHS).
The 2012-13 BSC is based on data collected by an independent team led by JHSPH-IIHMR from
725 randomly selected BPHS health facilities in 34 provinces across the country, and involved
observations of 6,930 patient-provider interactions and patient exit interviews, along with 2,403
health worker interviews.
The indicators and methods used for their estimation in 2012-13 BSC are the same as those used
in 2011-12 BSC following the 2011 revisions recommended by the BSC Technical Working
Group, which was led by the MoPH and involving representatives of MoPH, implementing
agencies, donor agencies, and health providers. Thus, all results are comparable with 2011-12
round of assessment.
The composite average score is an arithmetic mean of 22 indicators that all have equal weight.
The percent of upper benchmarks met is estimated by dividing total number of indicators that
meet the upper benchmark by 22, which is the total number of indicators in the BSC. The same
approach is used for percent of lower benchmarks met, except the numerator is the sum of the
indicators that meet the lower benchmark. In 2012-13, the estimate of the national median score
for the composite average score was between Zabul (56.0) and Kapisa (56.1) and equaled 56.0.
Zabul met 9.1% of upper benchmarks and Kapisa met 27.3% of upper benchmarks. In 2011-12,
the estimate of the national median score for the composite average score was 55.0. Panjsher was
a province with a median performance as measured by the composite average score. It met 4.5%
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of upper benchmarks. The national median score for the average performance across the 22
indicators has increased from 55.0 % in 2011-12 to 56.0% in 2012-13, an increase of 1
percentage point. On average, 24.3% of upper and 75% of lower benchmarks have been met in
2012-13 as compared to 17.9% of upper and 77.8% of lower benchmarks met in 2011-12.
Overall, the 2012-13 national BSC results demonstrate good progress in the health sector with
more than one-third of indicators showing an increase of minimum five percentage points, all of
which are on a scale of 1-100. Moreover, there are no declines in any of the indicators nationally.
However, there are significant variations in levels of performance and changes in performance
across provinces and domains of the Scorecard. These suggest areas of focus that will require
further resources and attention of national policy-makers, implementing agencies and
international community.
Nationally, the 2012-13 BSC results point to sustained good performance in the domain of Client
and Community Responsiveness, with continuing high levels for the Client Satisfaction and
Perceived Quality of Care Index (national median score 75), as well as a high level of
Community Involvement in Decision-making at BPHS facilities (median score 86, an
improvement from 80 in 2011-12). Physical Capacity at BPHS facilities is improving and shows
relatively high results overall. Although deficiencies in health facility infrastructure remain,
results are higher compared to last year for three of the five indicators. The Quality of Service
Provision indicators show large variation. While health providers are following good practices in
assessing patients (median score of 80 for the Clinical Background and Physical Exam Index),
the scores for the Client Counseling Index (median score 33) and Time Spent with Clients
(median score 12) are yet to improve. The Human Resources domain shows large variation in
performance as well. Whereas the Health Worker Motivation Index remains high (median score
72), and there are improvements in the timeliness of salary payments (from 65 in 2011-12 to 72
in 2012-13) and Health Worker Knowledge Scores (raising from a median score of 64 in 2011-
12 to 70 in 2012-13), facilities are still struggling to meet the minimum staffing guidelines
(median score 24) and provide regular training opportunities for their staff (median score
showing 9% of health workers received training in the last year). Management systems indicators
show visible improvement in HMIS Use Index (rising from a median score of 75 in 2011-12 to
83 in 2012-13), which is also among the indicators with high scores. However, the results are
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very poor when it comes to financial systems (median score 3). The performance on this
indicator is the lowest in the Scorecard. There were no changes nationally in performance on the
Overall Mission indicators which focus on equity.
In 2012-13, Laghman led all provinces with the highest number of upper benchmarks achieved
(13), followed by Wardak and Kunar (12), and Nangahar (11). Daykundi, Khost and Sarepul,
and Uruzghan achieved the fewest number of upper benchmarks (1), followed by Bamyan, Ghor,
Samangan and Zabul (2).
The highest overall score in 2012-13 was in Wardak (69.2), which rose from 10th place in 2011-
12. The second highest score was in Kunar (67.7), which was 1st in 2011-12, followed by
Nangarhar (67.2), which was 2nd in 2011-12. The lowest overall score was found in Ghor
(48.0), followed by Samangan (49.1), and Khost (49.4). Last year, the lowest scoring province
was Zabul (which rose to 18th position in 2012-13), followed by Kabul and Ghor.
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INTRODUCTION
The purpose of the Afghanistan Health Sector Balanced Scorecard (BSC) is to summarize the
performance of Afghanistan’s provinces in the delivery of the Basic Package of Health Services
(BPHS), and to provide policymakers, health managers and the public with evidence concerning
areas of strength and weakness. The BSC provides a framework to efficiently look at several key
areas or domains of the health sector. Each domain is made up of several indicators that provide
information about performance in that domain, and the provincial results are color coded in a
“traffic light” pattern to draw attention to strong performance (green), weak performance (red),
and in-between (yellow), with benchmarks based on the performance found across the provinces
in Afghanistan. This allows the Ministry of Public Health (MoPH) and other stakeholders in the
health sector to quickly visualize the performance of each province for each indicator. Since its
inception in 2004, the BPHS BSC has provided an assessment of the performance made each year
of BPHS implementation in Afghanistan.
The BSC is used by the MoPH to clarify its vision and strategies, and to manage change through
a set of indicators that reflect the policies and strategies of the MoPH. It is intended to provide a
basis for problem-solving, programmatic change, or for rewarding good performance; the BSC
is not simply a tool used for measurement. The BPHS BSC was revised substantially in 2011
to reflect the changing policies and conditions in the country. Six domains comprising 22
indicators, plus three summary indicators, were identified to summarize the performance of
health providers across the country to deliver the BPHS (Figure 1). The province remains the
main unit of analysis, so the BSC report is largely organized to show how each province
performs. The revision was carried out through a participatory process that was led by the
MoPH and with active involvement of various other stakeholders in the Afghan health sector
including the non-governmental organization (NGO) implementing partners, donors, health
worker association representatives, and other stakeholders, including a MoPH led BSC
Technical Working Group. The Third Party Evaluation team from the Johns Hopkins
Bloomberg School of Public Health (JHSPH) and the Indian Institute of Health Management
Research (IIHMR) facilitated the process.
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The BSC domains summarize the health sector from the following six perspectives:
1. Client and Community

2. Human Resources
3. Physical Capacity
4. Quality of Service Provision
5. Management Systems
6. Overall Mission
Figure 1: Domains and Indicators Framework of the Revised BPHS BSC
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METHODOLOGY
Sampling Frame
The data for the BSC are taken from the National Health Services Performance Assessment
(NHSPA), which is conducted each year, using a stratified random sample of all health facilities
providing the BPHS from the provinces of Afghanistan and systematic random samples of
patients and health workers. The 2004 NHSPA included all provinces except Daykundi, which
was newly formed and had no BPHS facilities when the 2004 NHSPA was conducted. In 2005,
2006 and 2007, the NHSPA included Daykundi, but did not include Kandahar, Helmand, Zabul
and Uruzgan since security conditions prevented assessment teams from reaching facilities in
these provinces. In 2008, the NHSPA also did not include Farah province, in addition to
Kandahar, Helmand, Zabul and Uruzgan due to poor security conditions at the time. In 2009-10,
the NHSPA included all 34 provinces. In 2011-12, except for Nuristan, all provinces were
included. Nuristan could not be surveyed due to security-related reasons. In 2012-13, all 34
provinces of Afghanistan have been included in the survey.
A sampling frame of BPHS health facilities was created for each province by compiling a list of
health facilities from MoPH in Kabul and updating them with the Provincial Public Health
Directors (PPHD), HMIS officers and key informants from NGOs and the MoPH in each
province. A stratified random sample of 25 facilities providing BPHS services was taken from
each province. After finalizing the list of functional facilities, in consultation with the PPHDs,
HMIS officers and NGOs, facilities were stratified into three groups: Comprehensive Health
Centers (CHC), Basic Health Centers (BHC) and Sub-Health Centers (SHC). For each province,
facilities were then randomly selected from each stratum according to the following distribution
by facility type: five CHCs, fifteen BHCs and five SHCs. If fewer than the above number of a
particular facility type were available for survey in any province, other facility types were
substituted.
From 2004 to 2008, District Hospitals had been included in the sample for the BPHS BSC, and
SHCs were not included in the sample. Starting in 2009-10, SHCs were included in the BPHS
sample, and District Hospitals were included in the Essential Package of Hospital Services
(EPHS) Balanced Scorecard. Further details about the samples for NHSPA 2004, 2005, 2006,
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2007, 2008, 2009-10, 2011-12 and 2012-13 for each province are presented in Appendix I.
Appendix II presents a summary of the BPHS facility types surveyed in each province for the
2012-13 annual round.
A summary of the national sample for NHSPA 2004, 2005, 2006, 2007, 2008 and 2009-10,
2011-12 and 2012-13 annual rounds is shown below (Table 1).
Table 1: National NHSPA Sample, 2004 - 2013
UNIT 2004 2005 2006 2007 2008 2009- 2011- 2012-

10 12 13
Number of Provinces 33 30 30 30 29 34 33 34
Number of Facilities 617 629 630 636 618 726 738 725
Number of Observations
of Patient-Provider 5719 5856 5964 6089 5970 7979 6826 6930
Interactions
Number of Exit Interviews 5597 5862 5964 6087 5950 7979 6826 6930
Number of Health
1553 1452 1723 1940 2233 2281 2393 2403
Workers Interviewed
Data Collection
Contracts for the recent set of BPHS BSC work were signed in September 2009, although data
collection for the annual BSC rounds was usually completed by September in each year. Since it
was not possible to collect all the BSC data for the first round in 2009, a decision was made to
move to a year-round data collection process covering 2009-10 (November 2009 to September
2010). There had been an intention to amend the BSC in 2009, but because of the need to start
data collection quickly, it was decided to postpone most changes till the 2011-12 round.
Because of concerns about the lack of data in insecure provinces in 2009-10, it was also decided
to test new methods to collect date in insecure and inaccessible areas. The new method for
collecting data in insecure areas involved a community-based data collection approach. In the
community-based data collection approach, local school teachers were trained on a concise
version of NHSPA data collection instruments. The trained school teachers collected data while
other school teachers were trained to do supervision and monitoring of the data collection
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activities under supervision of the regular teams. The community-based approach was
conducted in eight provinces in 2009-10, including Badghis, where both methods were used to
test for reliability of the new approach. Moving to year-round data collection and adding
community based data collectors improved nationwide coverage, so that far higher numbers of
facilities were assessed in 2009-10 compared to previous years. This also resulted in higher
number of observations of patient-provider interactions, exit interviews and health worker
interviews being conducted.
In mid 2011, it was determined that the year-round data collection would not continue, because
information was needed earlier in 2012 than would be available through a year-round schedule.
So the data collection schedule was compressed, with data collection for the BSC 2011-12
round commencing in August 2011, and was completed by March 2012. The 2011-12 NHSPA
continued to use the community-based data collection methods in insecure areas to generate a
more representative assessment of the Afghanistan health sector. We found a high level of
reliability with most items collected by the community-based data collectors in 2009-10
compared to the usual data collection method (overall concordance of 91% between the two
methods), but there were problems with reliability of specific items in the health worker
interview and the observation of medical care. In response to this, in the 2011-12 round, the
health worker interviews were changed to a self-assessment form that did not require
interviews, and increased training was provided for observation tasks. Because of increased
insecurity, the community based data collectors were used in all or part of 26 provinces in the
2011-12 round. Despite the addition of community-based data collectors, data could not be
collected from Nuristan province because of heightened insecurity in the province throughout
the data collection period.
Encouraged with the survey coverage attained through the use of community-based data
collection, Ministry of Public Health requested JHU to continue using it in 2012-13 round as
well. The approach was employed in a total of four provinces (Badghis, Zabul, Uruzgan,
Nuristan). There was high insecurity in these provinces at the time of data collection. Without
community-based data collection, these provinces would have been dropped this year.
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Revisions to the 2011-‐12 BPHS Balanced Scorecard
In addition to changes in the sampling and data collection methods described above, there were
also changes in the set of domains and indicators selected to be included in the Balanced
Scorecard. There were also concomitant changes in the benchmarks for the new indicators. The
comprehensive revision exercise of Balanced Scorecard was led by the Ministry of Public
Health, and has resulted in a substantially different BPHS BSC for 2011-12 compared to
previous rounds. The original BSC in 2004 was comprised of six domains and twenty nine
indicators, in addition to three summary indicators. The revised BSC also has six domains, but
they have been restructured, and each domain has indicators which have either undergone
revision or are completely new. Similar indicators from the previous rounds have been grouped
together in the revised BSC, so that the information and trends of the previous rounds of BSC is
possible, but not with exact comparisons. BSC 2012-13 presents a comparable data point for
BSC 2011-12. Appendix III provides a description of the change for each of the original BSC
indicators, and the degree of comparability from old and the revised BPHS BSC.
Benchmarks
Since the measurement of many indicators was changed in 2011-12, new benchmarks had to be
created for each of them, as the 2004 benchmarks were no longer relevant. For each indicator of
the BSC, upper and lower benchmarks were set to indicate levels that are currently achievable
in Afghanistan. The upper benchmark was set at a level that is currently being achieved by at
least six provinces and the lower benchmark by 27 provinces out of a total of 33 provinces
which were surveyed in 2011-12 annual round. This means that the upper level of performance
was set at level achieved by the top 20th percentile (quintile) of the provinces, whereas the
lower benchmark was set at the level achieved by the bottom quintile.
There were exceptions to setting the benchmarks based on 2011-12 data for four indicators.
Two Indicators – Salary Payments Current (Indicator 5) and Time Spent with Client (Indicator
17) – remain exactly the same as the earlier versions of the Balanced Scorecard. The
benchmarks for these two indicators are kept the same as those established in 2004, so the
baseline year for these two indicators is 2004. The two concentration indices – Outpatient Visit
Concentration Index (Indicator 21) and Client Satisfaction Concentration Index (Indicator 22) –
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were revised during the previous round of BPHS BSC (2009-10) and are kept the same in 2011-
12. The benchmarks that were established in 2009-10 have been maintained for the 2011-12
round and 2012-13 round. It is worth noting that despite the methodology remaining the same,
these scores are not perfectly comparable across the years because of the changes in population
levels and distribution.
The Provincial BSC tables are color-coded to be easier to read. Numbers in green colored cells
indicate that the score is above the upper benchmark (i.e., the score would have placed the
province in the top quintile in the baseline year). Scores shown in red cells indicate that the
score would have placed the province in the bottom quintile of performers in the baseline
year. All results between the top and bottom quintiles are shown in yellow cells, representing
the performers in the middle three quintiles.
Indicators
The indicators are classified according to one of six domains. Each indicator is measured as a
percentage or score from 0 to 100. In some cases, the number shows the percentage of results in
a province that met a certain standard. For example, the Revised Staffing Index (Indicator 6)
shows the percentage of health facilities meeting the minimum BPHS staffing guidelines as
prescribed by the Ministry of Public Health. Indicator 17 (Time Spent with Patients) shows the
percentage of patient consultations in which the health worker was observed to spend at least
nine minutes with the patient. For some indicators, such as the Revised Equipment Functionality
Index (Indicator 13), the score reflects the unweighted percentage of items in the index that are
present and functional.
Most of the indicators are comprised of indexes that are made up from a number of items. For
example, the Overall Client Satisfaction and Perceived Quality of Care Index (Indicator 1) is
comprised of 12 items that are asked of patients or caretakers of child patients after they are
finished at the health facility. The Revised Equipment Functionality Index is comprised of a
standardized list of equipment items expected at each type of health facility. A complete list of
items for each indicator is shown in Appendix V. Items within a scale are weighted equally, and
for the provincial score, they are weighted according to the sampling frame that stratifies by
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each level of health facility (CHC, BHC, and SHC), so that comparisons can be made across
provinces even when some provinces do not have a full set of health facilities of each type.
11 Indicators 21 and 22 require special mention. A Concentration Index is a measure of relative

equity for each attribute (outpatient visits for Indicator 21 and satisfaction with services for
Indicator 22). The Concentration Index calculates how well the attribute is distributed across the
population with regard to wealth status. The original Concentration Indices have been converted
into 100-point scales in order to make the results easier to interpret. In the converted scale, a
score of 0 is equal to a score of (+1) on the original Concentration Index (indicating an extreme
pro-rich orientation where the wealthiest segment of the population has all of the attribute in
question) and a score of 100 is equal to a score of (-1) on the original scale (indicating an
extreme pro-poor orientation, where the poorest segment has all of the attribute in question). A
score of 50 on the converted scale is equal to a score of (0) on the Concentration Index,
indicating complete equality between the poor and non-poor in service utilization or satisfaction
with services. On the converted index, scores above 50 represent a positive (that is, pro-poor)
result from the perspective of the MoPH. As a result of the conversion of the Concentration
Indices, all indicators in the BSC are now based on a scale of 0-100, with a higher score
representing a more positive result from the perspective of MoPH.
The last three indicators in the BSC are composite measures of performance. The first is “the
percent of upper benchmarks achieved” and the second is “the percent of lower benchmarks
achieved”. The “percent of upper benchmarks achieved” demonstrates how well provinces have
done in meeting the upper benchmarks across the indicators on the BSC. This can be viewed as
the percentage of indicators for which the province is achieving a high level of performance
relative to the level of health service performance in Afghanistan.
The second composite indicator measures how well provinces have done in meeting the lower
benchmarks across the indicators. For those indicators for which a province does not meet the
lower benchmark (i.e., the scores are colored red), the province can be viewed as demonstrating
a low level of performance relative to other provinces in Afghanistan at the baseline. Indicators
in the “red zone” should be targeted by managers as priority areas for improvement.
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The final composite indicator is an overall mean score. This is calculated by taking an average
of each indicator in each province, weighted by the sampling weights for the proportion of each
type of health facility in a province. Otherwise, each indicator is given the same weight.
Because of changes in the sampling of facilities, the data collection instruments, the methods of
data collection, and the revision of indicators and benchmarks, most indicators in the BSC are
not directly comparable from previous years, though they are comparable across provinces. Two
indicators – Salary Payments Current (Indicator 5) and Time Spent with Client (Indicator 17) –
remain exactly the same as the earlier version of the Balanced Scorecard, and are more directly
comparable across the years. The two Concentration Indexes (Indicators 21 and 22) are also
estimated in the same way as in 2009-10, and so are more directly comparable with that year.
In the next section, we describe the main findings for the National level BPHS BSC, which is
shown in Table 2. The first column on the left is the serial number of the indicator. The next
column to its right is the name of the indicator listed according to the six domains. The next
eight columns contain the median values from 2004, 2005, 2006, 2007, 2008, 2009-10, 2011-
12 and 2012-13, respectively. This represents the middle value among the provinces, with half
the provinces having results above the median, and the other half of the provinces having scores
below that value. The next seven columns show the percentage of provinces meeting the lower
benchmarks each year and the final seven columns show the same information for the upper
benchmarks.
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Table 2: National Results for the Basic Package of Health Services Balanced Scorecard, 2004 - 2013
AFGHANISTAN HEALTH SECTOR National Medians Provinces m eeting low er benchm ark (%) Provinces m eeting upper benchm ark (%)
2009 2011 2012 2009 2011 2012 2009 2011 2012
BPHS Balanced Scorecard 2011/12 LB UB 2004 2005 2006 2007 2008 2004 2005 2006 2007 2008 2004 2005 2006 2007 2008
/10 /12 /13 /10 /12 /13 /10 /12 /13
Dom ain A: Client and Com m unity
Overall Patient Satisfaction 66.4 90.9 83.1 86.3 86.0 77.7 81.0 76.0 - - 81.3 96.7 96.7 93.3 93.1 97.1 - - 18.8 26.7 20.0 3.3 20.7 0.0 -
1 Patient Perception of Quality Index 66.2 83.9 76.0 76.2 80.3 77.6 77.5 77.2 - - 81.8 96.7 96.7 96.7 100.0 94.1 - - 18.2 10.0 33.3 10.0 44.8 23.5 -
Client Satisf action & Perceived Quality of Care Index 73.3 81.3 - - - - - - 77.2 75.3 - - - - - - 81.8 64.7 - - - - - - 18.2 23.5
Written Shura-e-sehie activities in community 18.1 66.5 34.2 54.5 66.4 86.0 94.3 82.9 - 81.8 83.3 93.3 100.0 100.0 100.0 - 18.2 26.7 50.0 90.0 93.1 79.4
2
Community Involvement and Decision Making Index 72.4 90.0 - - - - - - 80.4 86.3 - - - - - - 81.8 85.3 - - - - - - 18.2 32.4
Dom ain B: Hum an Resources
Health Worker Satisfaction Index 56.1 67.9 63.5 64.1 68.1 69.0 69.1 68.4 - 81.8 86.7 93.3 93.3 96.6 94.1 - 18.2 33.3 53.3 56.7 62.1 55.9 -
3
Revised Health Worker Satisf action Index 61.7 66.6 - - - - - - 64.5 63.5 - - - - - - 81.8 73.5 - - - - - - 18.2 29.4
4 Health Worker Motivation Index 66.7 72.8 - - - - - - 69.3 72.1 - - - - - - 81.8 94.1 - - - - - - 18.2 44.1
5 Salary Payment Current 52.4 92.0 76.7 90.0 81.3 90.7 82.7 70.8 64.5 71.9 81.8 96.7 83.3 83.3 82.8 67.6 60.6 67.6 18.2 43.3 33.3 46.7 41.4 29.4 27.3 23.5
Staffing Index -- Meeting minimum staff guidelines 10.1 54.0 39.3 58.0 66.9 63.9 72.1 90.2 - - 81.8 93.3 96.7 100.0 100.0 100.0 - 18.2 60.0 76.7 76.7 79.3 100.0
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Revised Staf f ing Index -- Meeting minimum staf f guidelines 11.4 33.3 - - - - - - 25.4 24.4 - - - - - - 81.8 70.6 - - - - - - 18.2 14.7
Provider Knowledge Score 44.8 62.3 53.5 69.0 68.7 68.7 - - - - 81.8 100.0 100.0 100.0 - - - 18.2 86.7 76.7 80.0 - - -
Revised Provider Knowledge Score 71.5 86.0 - - - - 79.3 - - - - - - - 82.7 - - - - - - 20.7 - -
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Revised Revised Provider Knowledge Score 61.9 77.7 - - - - - 70.6 - - - - - - - - - - - - - - - -
New Provider Know ledge Score 59.4 67.6 - - - - - - 64.4 69.5 - - - - - - 81.8 97.1 - - - - - - 18.2 61.8
Staff received training in last year 30.1 56.3 39.0 74.3 68.9 68.5 71.1 47.2 - - 81.8 93.3 96.7 100.0 96.6 82.4 - 18.2 90.0 70.0 73.3 72.4 41.2 -
8
Revised Staf f Received Training (in the past 12 months) 7.1 14.9 - - - - - - 11.1 8.8 - - - - - - 81.8 61.8 - - - - - - 18.2 8.8
Dom ain C: Physical Capacity
Equipment Functionality Index 61.3 90.0 65.7 67.0 78.7 83.8 88.4 86.6 - - 81.8 73.3 86.7 100.0 100.0 97.1 - 0.0 0.0 3.3 30.0 41.4 29.4 -
9
Revised Equipment Functionality Index 67.4 85.0 - - - - - - 74.5 81.2 - - - - - - 81.8 94.1 - - - - - - 18.2 29.4
Drug Availability Index 53.3 81.8 71.1 83.7 85.7 81.0 86.3 90.0 - - 81.8 100.0 100.0 96.7 100.0 94.1 - 18.2 56.7 53.3 46.7 58.6 76.5 -
10
Pharmaceuticals and Vaccines Availability Index 71.8 88.6 - - - - - - 76.6 78.6 - - - - - - 81.8 85.3 - - - - - - 18.2 14.7
Laboratory Functionality Index (Hospitals & CHCs) 5.6 31.7 18.3 36.3 43.3 58.5 64.5 63.0 - - 81.8 100.0 100.0 100.0 100.0 100.0 - 18.2 66.7 83.3 100.0 96.6 97.1 -
11
Laboratory Functionality Index (CHCs only) 53.1 76.3 - - - - - - 66.3 71.2 - - - - - - 81.8 91.2 - - - - - - 18.2 14.7
Clinical Guidelines Index 22.5 51.0 34.8 48.9 61.6 78.3 83.9 80.3 - - 81.8 93.3 100.0 100.0 100.0 97.1 - 18.2 46.7 70.0 93.3 100.0 94.1 -
12
Revised Clinical Guidelines Index 64.3 85.9 - - - - - - 70.3 78.9 - - - - - - 81.8 91.2 - - - - - - 18.2 35.3
Infrastructure Index 49.3 63.2 55.0 44.6 48.7 54.6 54.1 64.1 - - 81.8 33.3 46.7 70.0 69.0 88.2 - 18.2 10.0 6.7 16.7 24.1 52.9 -
13
Revised Inf rastructure Index 48.9 73.4 - - - - - - 55.6 62.1 - - - - - - 81.8 79.4 - - - - - - 18.2 38.2
Dom ain D: Quality of Service Provision
Patient History and Physical Exam Index 55.1 83.5 70.6 73.5 82.2 83.1 83.9 74.3 - - 81.8 100.0 96.7 100.0 96.6 100.0 - 18.2 26.7 43.3 50.0 51.7 14.7 -
14
Client Background and Physical Assessment Index 66.7 81.5 - - - - - - 73.8 80.2 - - - - - - 81.8 97.1 - - - - - - 18.2 41.2
Patient Counseling Index 23.3 48.9 29.6 35.1 36.6 48.7 48.0 30.0 - - 81.8 90.0 93.3 96.7 96.6 73.5 - 18.2 16.7 13.3 46.7 44.8 8.8 -
15
Client Counselling Index 31.7 58.5 - - - - - - 30.0 33.4 - - - - - - 81.8 52.9 - - - - - - 18.2 5.9
Proper sharps disposal 34.1 85.0 62.2 52.0 77.5 84.4 75.4 71.3 - - 81.8 76.7 73.3 90.0 93.1 88.2 - 18.2 10.0 33.3 50.0 31.0 23.5 -
16
Universal Precautions 51.8 70.4 - - - - - - 61.6 62.1 - - - - - - 81.8 79.4 - - - - - - 18.2 23.5
17 Time Spent w ith Client 3.5 31.2 18.0 6.2 7.0 18.4 19.7 9.6 16.1 11.8 81.8 70.0 80.0 83.3 86.2 73.5 90.9 61.8 18.2 3.3 3.3 23.3 41.4 14.7 15.2 2.9
Dom ain E: Managem ent System s
HMIS Use Index 49.6 80.7 67.7 65.8 74.9 91.5 92.4 77.3 - - 81.8 70.0 76.7 100.0 100.0 97.1 - 18.2 16.7 43.3 70.0 82.8 44.1 -
18
Revised HMIS Use Index 66.1 86.2 - - - - - - 75.1 82.9 - - - - - - 81.8 82.4 - - - - - - 18.2 35.3
19 Financial Systems 2.2 20.3 - - - - - - 3.8 2.7 - - - - - - 81.8 50.0 - - - - - - 18.2 23.5
20 Health Facility Management Functionality Index 40.0 57.6 - - - - - - 50.4 48.0 - - - - - - 81.8 91.2 - - - - - - 18.2 20.6
Dom ain F: Overall Mission
Outpatient visit concentration index 48.0 52.7 50.5 50.6 51.2 50.0 50.0 - - - 81.8 79.3 86.2 82.8 82.1 - - 18.2 31.0 27.6 27.6 89.3 - -
21
New Outpatient visit concentration index 46.2 56.9 - - - - - 49.4 44.5 43.8 - - - - - 82.4 36.4 29.4 - - - - - 17.6 9.1 5.9
Patient satisfaction concentration index 49.0 50.9 49.9 49.8 49.8 49.6 49.6 - - - 81.8 96.6 82.8 96.6 89.3 - - 18.2 3.4 3.5 0.0 7.1 - -
22
New Patient satisf action concentration index* 49.6 50.8 - - - - - 50.0 49.9 49.6 - - - - - 82.4 72.7 50.0 - - - - - 17.6 15.2 5.9
Com posite Scores
23 Percent of Upper Benchmarks Achieved 16.4 33.5 40.1 49.7 51.7 42.2 17.9 24.3
24 Percent of Low er Benchmarks Achieved 78.6 85.0 87.5 93.9 92.2 88.7 77.8 75.0
25 Median f or the average coomposite score 52.0 59.9 62.4 68.7 71.9 67.5 55.0 56.0
15
NATIONAL LEVEL FINDINGS OF THE 2012-‐13 BPHS BALANCED
SCORECARD
Domain A: Client and Community

This domain captures the viewpoints of clients of BPHS facilities and community members
through two indicators:
• Overall Client Satisfaction and Perceived Quality of Care Index
• Community Involvement in Decision-making
Both indicators were revised in 2011 and therefore, they are only strictly comparable to 2011-
2012 BSC results, although many of the items forming these indicators have been retained from
previous years.
Indicator 1: Overall Client Satisfaction and Perceived Quality of Care Index

The Overall Client Satisfaction and Perceived Quality of Care Index is a composite indicator
consisting of twelve items measuring overall client satisfaction and perception of different
aspects of the quality of care they received at a particular visit. The items include various
important aspects of care, including cleanliness of the health facility, waiting time, privacy
during the visit, respectfulness of the provider, and availability of prescribed medicine. The
national median score for the indicator was 75.3, compared to 77.2 in 2011-12.
Indicator 1: Client Sa5sfac5on & Perceived

Quality of Care Index Proportion of provinces
100.0 meeting the lower benchmark
Provinces mee6ng
80.0 lower benchmark (%)
has decreased from 81.8% in
77.2 75.3 Provinces mee6ng 2011-12 to 64.7% in 2012-
60.0 upper benchmark (%)
Na6onal Medians
13. There was no change in
40.0
proportion of provinces
20.0 meeting the upper benchmark
0.0 (18.2% in 2011-12 and
2011 /12 2012 /13
23.5% in 2012-13). Nuristan
province had the highest level of client satisfaction and perceived quality of care, with a score of
89.1, followed by Laghman (87.0), whereas Kunar and Nangahar had the highest scores in 2011-
16
12. The lowest scores were found in Paktya (63.2) and Khost (66.0), replacing Takhar and
Saripul at the bottom of the provincial tables from the previous year.
Indicator 2: Community Involvement and Decision Making

Community Involvement and Decision Making is an indicator composed of five items measuring
the level of involvement of community in decision making process of the facility. The national
median score for the indicator was 86.3, an increase of 5.9 percentage points from the score
observed in 2011-12.
Indicator 2: Community Involvement and
Decision Making Index
There was no change in 100.0
proportion of provinces 80.0

Provinces mee6ng
meeting the lower benchmark. 80.4
Provinces mee6ng
In 2011-12, 81.8% met the
Na6onal Medians
40.0
lower benchmark as compared
to 85.3% this year. There was 20.0
an increase in proportion of 0.0

2011 /12 2012 /13
provinces meeting the upper
benchmark from 18.2% to 32.4%. Nangarhar province achieved the highest score for the
indicator in the country with a score of 98.1, followed by Kunar (96.8). These were also the two
top provinces last year. The lowest scores were recorded in Paktika (55.5) and Kabul (56.2). The
latter was also at the bottom of the list during the previous round.
17
Domain B: Human Resources
This domain focuses on one of the key elements of health service delivery, the human resources.
It assesses main aspects of the working environment and conditions of the BPHS facility staff of
through the following indicators:
• Health Worker Satisfaction
• Health Worker Motivation
• Salary Payment Current
• Minimum Staffing Index
• Provider Knowledge Score
• Staff Received Training
Of these six indicators, Salary Payments Current is the only indicator which has not changed
since it was first defined in the 2004 BSC, and thus, it is a good indicator to observe long term
trends in this domain. The Health Worker Motivation was introduced in 2011. The remaining
four indicators were revised in 2011, but they had similar counterparts in BSCs 2004 – 2010.
Indicator 3: Health Worker Satisfaction Index

Job satisfaction is defined as the attitude towards one’s work and the related emotions and
beliefs. Health Worker Satisfaction Index consists of thirty six items that cover the main
determining factors of job satisfaction, and includes all types of health workers. The national
median score for the indicator has remained around the same level since the last round: in 2011-
12 it was 64.5, and in this round it is estimated to be 63.5.
There was no substantial
Indicator 3:Revised Health Worker Sa5sfac5on change in the proportion of
Index
100.0 provinces meeting the lower
Provinces mee6ng benchmark (81.8% and
80.0 64.5 lower benchmark (%)
63.5
73.5% in 2011-12 and 2012-
Provinces mee6ng
60.0 upper benchmark (%) 2013, respectively). There
Na6onal Medians
40.0 was an increase of 11
20.0 percentage points in
0.0
2011 /12 2012 /13 meeting the upper benchmark
in 2012-13 (29.4%) as compared to 2011-12 (18.2%). Wardak and Baghlan, both with a score of
18
72.0, appear to have the highest health worker satisfaction. They were closely followed by
Nuristan (70.0); Nangarhar and Samangan had the highest levels in 2011-12. Khost (54.6) and
Paktya (55.3) appear at the opposite end of the spectrum. Khost (58.4) was also among the
lowest performing provinces in the country during 2011-12.
Indicator 4: Health Worker Motivation Index

Motivation is defined in terms of intent to act or engage in particular type of behavior. Items in
this index are aimed at measuring the degree to which health workers are intent to perform their
duties as well as potential reasons for it, such as financial rewards or desire to serve their
communities. Together these nineteen items measure the level of motivation among the BPHS
health workers of all types, including clinical as well as support staff. The national median score
for this indicator was 72.1, noticeably higher than the median score for satisfaction, but about the
same as last year’s national
Indicator 4: Health Worker Mo5va5on Index
median (69.3).
100.0
There was an increase in 80.0 69.3 72.1 Provinces mee6ng

lower benchmark (%)
proportion of provinces Provinces mee6ng
meeting the lower benchmark
Na6onal Medians
40.0
this year. In 2011-12, 81.8%
of provinces met the lower 20.0
benchmark as compared to 0.0

94.1% in 2012-13. There was 2011 /12 2012 /13
a substantial increase in proportion of provinces meeting the upper benchmark, which increased
from 18.2% last year to 44.1% this year. Wardak province was estimated to have the highest
level of health worker motivation with a score of 84.0. It was followed by Nangarhar (77.5) and
Faryab (77.4). The lowest scores were found in Khost (63.9) and Bamyan (66.5). It is interesting
to note that last year Wardak had the lowest level on this indicator with a score of 61.9, followed
by Zabul.
Indicator 5: Salary payment current

This indicator consists of one simple question asking a health worker whether or not their
salaries have been paid on time. Similar to Indicators 3 and 4, it covers all types of health
workers. As noted above, this indicator did not undergo any changes during the BSC revision
19
since 2004. After achieving a peak score of 90.7 in 2007, this indicator had been declining ever
since, reaching its lowest point in 2011-12 (64.5). This year it has increased (71.9) compared to
last year, but it is yet to achieve the levels observed in earlier years.
Indicator 5: Provinces mee6ng lower benchmark (%)

Salary Payment Current Provinces mee6ng upper benchmark (%)
Na6onal Medians
100 90.0 90.7
90 81.3 82.7
76.7
80 70.8 71.9
70 64.5
60
50
40
30
20
10
0
2004 2005 2006 2007 2008 2009 /10 2011 /12 2012 /13
There were no changes in proportion of provinces meeting the lower (60.6% and 67.6% in 2011-
12 and 2012-2013, respectively) or upper benchmarks (27.3% and 23.5% in 2011-12 and 2012,
respectively). Nuristan and Wardak received perfect scores on this indicator, implying that all
health workers in these two provinces had been paid on time. They are followed by Kunduz
(98.8) and Laghman (98.5). The lowest score was observed in Ghor (6.1). It is followed by
Bamyan (22.1) and Jawzjan (24.0), but there is a large gap between Ghor and the other two low
performing provinces. It seems that for timely payment of salaries, unlike for any other indicator,
there is an extremely large variation among provinces.
Indicator 6: Meeting minimum staffing guidelines

This indicator assesses whether BPHS health facilities meet the minimum staffing requirements
as determined by the BPHS Guidelines. These requirements vary by health facility type: (i) Sub-
Health Centers, (ii) Basic Health Centers, and (iii) Comprehensive Health Centers. To receive a
high score on this indicator a particular health facility must have the required number of health
workers in each position as it is determined by the BPHS Guidelines. For example, a SHC must
20
have both, a nurse and a midwife, either regular or community. If it is a BHC, it must have a
nurse, a midwife (either regular or community), a community health supervisor, a physician, and
two vaccinators. If it is a CHC, it must have two nurses, two midwives (regular or community),
two vaccinators, two physicians, a community health supervisor, a laboratory technician, and a
pharmacy technician.
Indictor 6:Revised Staffing Index -‐ Mee5ng

Minimum Staff Guidelines The national median for this
100.0 indicator was estimated to be
Provinces mee6ng
24.4, which was similar to
60.0
Provinces mee6ng the 2011-12 estimate (25.4).
upper benchmark (%)
Na6onal Medians
Proportion of provinces
40.0 25.4 24.4 meeting the lower benchmark
20.0 declined from 81.8% last
0.0 year to 70.6% this year.
2011 /12 2012 /13
There was no change in
proportion of provinces meeting the upper benchmark (18.2% in 2011-2012 and 14.7% in 2012-
2013). Parwan province was the best performing province in the country for this indicator with a
score of 56.4, followed by Kunduz (44.8) and Farah (44.5). Kunduz was also among the top
performers for this indicator in 2011-12. The lowest scores were found in Badghis (0.0) and
Khost (2.1). The latter was among the bottom two last year also.
It should be noted that comparison of results prior to 2011 will not be entirely correct. New
staffing requirements have been introduced in 2010. Moreover, the method for estimating this
indicator was revised substantially in 2011.
21
Indicator 7: Provider Knowledge Score
This indicator assesses the knowledge of health workers by questions about practical knowledge
concerning the management of common conditions covered by the BPHS. These are common
childhood illnesses and nutrition, maternal health, and infectious disease such as tuberculosis,
malaria and HIV/AIDS. It also covers key aspects of infection control at facility level. Specific
questions are revised each year, but their content areas remain the same. Only results from the
clinical staff are included in this indicator.
Indicator 7: Revised Provider Knowledge Score

The national median score for
the indicator was 69.5 as 100.0
compared to 64.4 in 2011-12. 80.0 69.5 Provinces mee6ng

There was an increase in Provinces mee6ng
Na6onal Medians
40.0
meeting the lower benchmark
from 81.8% in 2011-12 to 20.0
97.1% this year. There was a 0.0

2011 /12 2012 /13
substantial increase in
proportion of provinces meeting the upper benchmark, which increased from 18.2% to 61.8%
between the two rounds. The top three provinces are Kunar (79.7), Nangarhar (79.0), and
Wardak (78.9). The lowest scores are observed in Helmand (55.9), Bamyan (60.7), and
Daykundi (61.6). It appears that both highest performing provinces and lowest performing
provinces have improved their knowledge scores since the last round: This year’s lowest
performer Helmand still has a higher score than the last year’s lowest performer Zabul (55.9 and
45.5, respectively).
Indicator 8: Staff Received Training

This indicator assesses whether facility staff have received relevant training in the past twelve
months. A total of nine items are used to form this indicator, including areas such as IMCI,
maternal and neonatal health, family planning methods, nutrition, malaria, HIV/AIDS,
tuberculosis, and universal precautions. It covers all clinical staff, plus the CHW supervisors.
22
The national median for this
Indicator 8: Revised Staff Received Training
year was 8.8, compared to
100.0 11.2 in 2011-12. There was a
Provinces mee6ng decline in proportion of
Provinces mee6ng provinces meeting the lower

benchmark from 81.8% to
Na6onal Medians
40.0
61.8% between the two
20.0 11.1 8.8 rounds. There was also a
0.0 decline in proportion of
2011 /12 2012 /13
provinces meeting the upper
benchmark from 18.2% to 8.8%. The highest scores were recorded in Kunar (27.8), Nuristan
(16.7) and Farah (16.4). Kunar was also a top performer last year with a score of 32.0. Ghazni
(1.9), Bamyan (2.2), and Takhar (4.2) had the lowest scores for this indicator. The latter was
among the bottom provinces in the last round also and its score has stayed practically the same
this year (4.1).
23
Domain C: Physical Capacity
This domain assesses the physical capacity of BPHS facilities, including infrastructure,
equipment and medicine, to provide health care services. It consists of the following five
indicators, although the indicator on laboratory functionality applies only to CHCs:
• Equipment Functionality
• Pharmaceuticals and Vaccines Availability
• Laboratory Functionality
• Clinical Guidelines Index
• Infrastructure Index
All five indicators were revised in 2011 and therefore, they are only strictly comparable to 2011-
2012 BSC results, although many of the items forming these indicators have been retained from
previous years.
Indicator 9: Equipment Functionality Index

This indicator is comprised of twenty-three items for Sub-health centers and Basic Health
Centers, and of twenty-six items for Comprehensive Health Centers. It assesses presence and
functioning of basic equipment that is required for different types of facilities to provide services
as required by the BPHS
Indicator 9: Revised Equiplment Func5onality
Guidelines. These include Index
children’s scales, 100.0
81.2
74.5 Provinces mee6ng
thermometer, stethoscope, 80.0 lower benchmark (%)
sterilizer, vaccine Provinces mee6ng
refrigerator, delivery kit and Na6onal Medians
40.0
other basic equipment.
Microscope, centrifuge and 20.0
hemoglobinometer are 0.0

2011 /12 2012 /13
included only for CHCs.
The national median score for the indicator increased from 74.5 in the 2011-12 round to 81.2 in
this round. There was an increase in proportion of provinces meeting the lower benchmark from
81.8% in 2011-12 to 94.1% in 2012-13. There was a substantial increase in proportion of
provinces meeting the upper benchmark, which increased from 18.2% to 29.4% between the two
rounds. Kunar (97.0), Wardak (95.5), and Laghman (94.7) had the highest scores for this
24
indicator, while Kabul (63.8), Parwan (67.3), and Ghor (68.3) had the lowest scores. For this
indicator, Kabul was also among the bottom ranking provinces last year.
Indicator 10: Pharmaceuticals and Vaccines Availability Index

Pharmaceuticals and Vaccines Availability Index assesses whether BPHS health facilities
possess thirty-one important
Indicator 10: Pharmaceu5cals and Vaccine
Availability Index pharmaceutical products and
100.0 vaccines that are on the
80.0
Provinces mee6ng Essential Drugs List. Among
lower benchmark (%)
76.6 78.6 Provinces mee6ng these are such items as
paracetamol, anti-malarial
Na6onal Medians
40.0
drugs, oral contraceptive
20.0 pills, oxytocin, and childhood
0.0 vaccines.
2011 /12 2012 /13
The national median score for the indicator was 78.6, compared to 76.6 in 2011-12. There was
no change in proportion of provinces meeting the lower benchmark (81.8% in 2011-12 and
85.3% in 2012-13). Also, there was no change in proportion of provinces meeting the upper
benchmark (18.2% in 2011-12 and 14.7% in 2012-13). Logar (95.3), Kunar (93.6), and
Nangarhar (91.1) were the top three performers for this indicator. Kunar was also among the top
ranking provinces in 2011-12. The lowest scores were observed in Parwan (59.9), Farah (62.1),
and Nimroz (65.0). In the previous year, Badakhshan and Kapisa had the lowest scores.
25
Indicator 11: Laboratory Functionality Index
The Laboratory Functionality
Indicator 11: Revised Labroratory Func5onality
Index is comprised of sixteen Index (CHCs only)
laboratory tests targeting most 100.0
common diseases and 80.0 71.2 Provinces mee6ng

conditions in Afghanistan. It Provinces mee6ng
includes a range of tests, from
Na6onal Medians
40.0
pregnancy testing to TB
smears and HIV testing. 20.0
Importantly, it assesses 0.0

whether a facility can carry out 2011 /12 2012 /13
these tests regularly. This indicator is implemented for CHCs only, as SHCs and BHCs are not
mandated to provide such testing services.
The national median for this indicator was 66.3 in 2011-2012, compared to 71.2 in 2012-2013.
There was an increase in proportion of provinces meeting the lower benchmark from 81.8% to
91.2% between the two rounds. However, there was no change in proportion of provinces
meeting the upper benchmark, which was 14.7% this year compared to 18.2% in 2011-12.
Bamyan (85.0), Paktika (78.1), Helmand (77.5), and Takhar (77.5) were the top ranking
provinces for Laboratory Functionality Index; Khost and Paktya had the highest scores in 2011-
12. Uruzgan (43.8), Parwan (46.3), and Nimroz (53.1) had the poorest performing CHCs when it
comes to laboratory tests, compared to Baghlan and Ghor in 2011-12.
26
Indicator 12: Clinical Guidelines Index
The Clinical Guidelines Index assesses the presence of clinical guidelines in BPHS health
facilities for management of most common conditions and illnesses. These are the following: (i)
IMCI, (ii) TB, (iii) Malaria, (iv) Immunization, (v) Family planning, and (vi) HIV counseling
and testing. The latter applies only to CHCs as facilities below this level are not expected to
provide such services.
Indicator 12: Revied Clinical Guidelines Index
indicator was 78.9, showing
100.0 an increase of 8.6 percentage
78.9
70.3 Provinces mee6ng points compared to last year
Provinces mee6ng
(Table 2). Proportion of
provinces meeting the lower
Na6onal Medians
40.0 benchmark increased from
20.0 81.8% to 91.2%, or slightly
0.0
more than 10%. Proportion
2011 /12 2012 /13 of provinces meeting the
upper benchmark increased substantially from 18.2% to 35.3% between the two rounds.
Nangarhar (96.4), Baghlan (96.3), Laghman (95.4) were the highest ranking provinces for this
indicator, whereas Kandahar and Kunar had the highest scores last year. Ghor (44.5), Uruzgan
(61.6), and Kabul (63.9) had the lowest scores in Clinical Guidelines Index, although there is a
noticeable gap between Ghor and the two other low ranking provinces. The lowest scoring
provinces in 2011-12 were Zabul and Paktika.
27
Indicator 13: Infrastructure Index
The Infrastructure Index assesses whether BPHS facilities have basic infrastructure, including
the following ten items: windows, doors, roof, interior and exterior walls, grounds, water source,
heating, electricity, and toilets. All of these items have to be present and functioning for the
facility to receive a full score on this index.
The national median for this indicator was estimated to be 62.1 in this round, an increase from
55.6 in the 2011-12 round.
There was no change in Indicator 13: Revised Infrastructure Index
proportion of provinces 100.0

meeting the lower benchmark Provinces mee6ng
(81.8% in 2011-12 and 62.1
79.4% in 2012-13). However,
Na6onal Medians
in the same period there was 40.0
a substantial increase in 20.0

0.0
meeting the upper benchmark 2011 /12 2012 /13
from 18.2% to 38.2%. Wardak (89.9), Herat (87.6), and Kunar (85.7) had the most well
functioning infrastructure in BPHS facilities, while Samangan (28.6), Balkh (28.6), and Khost
(38.9) were at the other end of the spectrum with the lowest scores when it comes to basic
infrastructure. Nangahar and Nimroz were at the top of the table in 2011-12, whereas Ghor and
Takhar were at the bottom.
28
Domain D: Quality of Service Provision
This domain measures the technical aspects of service delivery and the patient provider
interaction through the inclusion of four indicators:
• Client Background and Physical Assessment,
• Client Counseling,
• Universal Precautions, and
• Time Spent with Clients.
Time Spent with Clients has not undergone any methodological changes during BSC revision
and is a good indicator to observe the long term changes. The other three indicators in this
Domain have been revised and are strictly comparable only to 2011-12 results.
Indicator 14: Client Background and Physical Assessment Index

This indicator assesses how well health workers follow the basic steps that are required for all
visits, regardless of the nature of a complaint. It consists of a set of seven items that include
whether a health worker greets the client, asks their age, registers the reason for visit, asks for
details such as the nature and duration of a complaint, asks about previous interventions,
performs a physical examination, and ensures privacy.
Indicator 14: Client Background and Physical indicator is 80.2, observably
Assessment Index
100.0 higher than the score for
80.2
73.8 Provinces mee6ng 2011-12 (73.8). There was an
increase in proportion of
Provinces mee6ng
60.0 upper benchmark (%) provinces meeting the lower
Na6onal Medians
40.0 benchmark from 81.8% to
20.0 97.1% between the two
rounds. There was a
0.0
2011 /12 2012 /13 substantial increase in
proportion of provinces meeting the upper benchmark from 18.2% to 41.2% between the two
rounds. Nuristan (97.4), Herat (93.2), and Nangarhar (92.6) had the highest scores for this
indicator, while Bamyan (63.8), Khost (67.3), and Saripul (70.7) were at the bottom of the
ranking on this aspect of quality of services. Kunar and Nimroz had the highest levels in 2011-
12; whereas Badghis and Takhar had the lowest.
29
Indicator 15: Client Counseling Index
This index is composed of eight
items. Together they measure Indicator 15: Client Counseling Index
how well a health worker 100.0

communicates with the client Provinces mee6ng
and provides basic information
Provinces mee6ng
concerning their condition,
30.0 33.4 Na6onal Medians
including home care and 40.0
precautions, correct ways to 20.0

take medicine and potential
0.0
adverse reactions, signs and 2011 /12 2012 /13
symptoms that should prompt re-visit.
The national median for this indicator has increased not changed substantially from the last
round, from 30.0 to 33.4, and remains at relatively low levels compared to other indicators in this
Domain. There was a visible decline in proportion of provinces meeting the lower benchmark
from 81.8% in 2011-12 to 52.9% in 2012-13. Moreover, there was a decline in proportion of
provinces meeting the upper benchmark from 18.2% in 2011-12 to 5.9% in 2012-13. Similar to
the previous indicator, the highest score was observed for Nuristan (72.2). It was followed by
Nangarhar (60.0), which is also one of the top three performing provinces for Indicator 14, and
Kunar (57.2). Paktya (16.4), Daykundi (20.3) and Khost (20.5) had the lowest scores;
Badahkshan and Takhar had the lowest scores in 2011-12.
Indicator 16: Universal Precau5ons Indicator 16: Universal
100.0
Precautions
Provinces mee6ng
This indicator provides
61.6 62.1 comprehensive assessment of
Provinces mee6ng
60.0 upper benchmark (%) the precautions and safety
Na6onal Medians
40.0 measures followed at BPHS
20.0 health facilities to prevent

infection and injury of health
0.0
2011 /12 2012 /13 workers as well as their clients.
30
It has nine items related to use of disposable syringes for all injections, presence of water and
soap, regular use of sterilizers, disinfectants and incinerators, and proper disposal of sharps.
The national median for this indicator is 62.1, which is approximately at the same level as last
year (61.6). There was no change in proportion of provinces meeting the lower benchmark,
which was 81.8% in 2011-12 and 79.4% this year. Also, there was no change in proportion of
provinces meeting the upper benchmark between the two rounds. It was 18.2% last year and
23.5% this year. The highest levels of universal precautions are found in Kunar (95.1) and
Nangarhar (92.2). These are the same two provinces that received highest score in 2011-12.
Daykundi (31.9) and Badakhshan (34.2) were the lowest scoring provinces. The latter was
among the lowest ranking provinces in 2011-12, along with Zabul.
Indicator 17: Time Spent with Client

To provide good quality care a health worker must spend sufficient time with his or her clients.
This indicator assesses whether the time spent with each client in BPHS facilities is greater than
nine minutes. This was estimated as the minimum time needed to complete a history, physical
examination, diagnosis and counseling in an outpatient setting.
Indicator 17: Provinces mee6ng lower benchmark (%)

Time spent with Client Provinces mee6ng upper benchmark (%)
Na6onal Medians
100
80
60
40
18.0 18.4 19.7

16.1
20 9.6 11.8
6.2 7.0
0
2004 2005 2006 2007 2008 2009 /10 2011 /12 2012 /13
As noted above, this indicator has not been revised since 2004, which makes it comparable with
years prior to 2011. The national median for this year was 11.8%, compared to 16.1% in 2011-
31
12,, but still higher than the lowest score observed in 2009-10 (9.6%). There was a visible
decline in proportion of provinces meeting the lower benchmark from 90.9% to 61.8% between
the two rounds. There was also a decline in proportion of provinces meeting the upper
benchmark from 15.2% to 2.9% between the two rounds. Baghlan (47.8), Panjsher (30.1), and
Nangarhar (24.6) were the top performing provinces for this indicator. Kabul (0.0) and Paktya
(0.0) were at the other end of the spectrum, showing that none of the providers surveyed in these
two provinces were recorded as spending more than nine minutes with their clients. For this
indicator, Kabul was among the two lowest performing provinces in 2011-12 as well (0.8).
32
Domain E: Management Systems
This domain assesses various aspects related to the management of health facilities. It consists
of three indicators:
• HMIS Use Index
• Financial Systems
• Health Facility Management Functionality.
The HMIS Use Index was revised in 2011-12, and is based on a similar indicator used in the
BSC prior to 2011. The other two indicators were newly introduced in 2011-12.
Indicator 18: Revised HMIS Use Index

This index consists of five questions related to various HMIS forms being used in BPHS health
facilities, including
Indicator 18: Revised HMIS Use Index
Notifiable Diseases Report,
100.0 TB register and others.
82.9
Provinces mee6ng
index was estimated to be
Na6onal Medians
40.0 82.9 an increase over last
20.0 year’s score (75.1). There
was no change in proportion
0.0
2011 /12 2012 /13 of provinces meeting the
lower benchmark between the two rounds: it was 82.4% in 2012-13, almost the same as in 2011-
12 (81.8%). However, there was an increase in proportion of provinces meeting the upper
benchmark from 18.2% to 35.3% between the two rounds. Farah (96.5), Baghlan (94.3), and
Takhar (94.0) were the top performers in this category, while Kabul (44.7), Uruzgan (47.5), and
Helmand (49.9) had the least developed HMIS at facility level this year. In 2011-12, Kunar and
Balkh had the highest scores, whereas Zabul and Ghor had the lowest scores.
33
Indicator 19: Financial Systems
This indicator consists of three items related to existence of petty cash system in the facility,
current availability of petty cash
and maintenance of expenditure Indicator 19: Financial Systems
records. It is the indicator with the 100.0

lowest national median scores in Provinces mee6ng
both years: it was 3.8 in 2011-12
Provinces mee6ng
and 2.7 this year. There was a
Na6onal Medians
decline in proportion of provinces 40.0
meeting the lower benchmark from 20.0

3.8 2.7
81.8% in 2011-12 to 50% this
0.0
year. There was no change in 2011 /12 2012 /13
proportion of provinces meeting the upper benchmark between the two rounds. It was 23.5% in
2012-13 compared to 18.2% in 2011-12.
Indicator 20: Health Facility Management Functionality Index

This index assesses the BPHS health facilities on various aspects of management functions and
includes nine items related to health facility staff meetings, supervisory visits from Provincial
Public Health Directorate or Implementing NGO, up-to-date inventory of drugs, furniture and
equipment, and the use of National Monitoring Checklist to improve the functioning of health
facility.
Indicator 20: Health Facility Management The national median this year
Func5onality Index
was estimated to be 48.0,
100.0
similar to last year’s national
Provinces mee6ng
median (50.4). There was a
60.0 48.0 upper benchmark (%) small change in proportion of
Na6onal Medians
40.0 provinces meeting the lower
20.0
benchmark, which increased
from 81.8% to 91.2%. There
0.0
2011 /12 2012 /13 was no change in proportion
of provinces meeting the upper benchmark (18.2% in 2011-12 and 20.6% in 2012-13). Nuristan
(77.6), Logar (65.3), and Nangarhar (63.5) were the top three performing provinces for this
34
indicator. Nangarhar was also among the top performers last year, although its score was
substantially higher (82.9). Samangan (36.2), Balkh (36.6), and Daykundi (37.2) had the least
well functioning management systems measured in this year’s BSC, compared to Zabul and
Kabul last year.
Domain F: Overall Mission

Domain F reflects the mission of Ministry of Public Health to promote equity and protect the
right to health by all citizens of the country. This domain incorporates two indicators: (i)
Outpatient Visit Concentration Index, and (ii) Client Satisfaction Concentration Index.
Concentration Index is a measure of socioeconomic-related inequality in a health variable. It is
bounded between -1 and 1, and if there is perfect equality, the CI is zero. A negative value for
the CI means a particular health variable is higher among the poor, while a positive value for the
CI means the health variable is higher among the rich.
The index has been rescaled to match the scale of other indicators of the BSC. A score of 50
indicates perfect equality. Hence, if a score is above 50, it indicates that a particular health
variable is higher among the poor, and if a score is below 50, it suggests that this health variable
is higher among the rich.
Indicator 21: Outpatient Visit Concentration Index

This indicator assesses equity in access to outpatient services by measuring the wealth status of
health facility clients at exit interviews. The wealth status is measured through a series of
questions on assets, sources of income, access to water, electricity and other necessities. In
2009-10 methodological
Indicator 21: New Outpa5ent visit concentra5on
changes were made for the Index
calculation of this index. It 60.0
did not undergo any change Provinces mee6ng

lower benchmark (%)
during the 2011 BSC 40.0 44.5 Provinces mee6ng
revisions.
Na6onal Medians
20.0
indicator was estimated to be 0.0
2011 /12 2012 /13
43.8, which is practically the
35
same level as in 2011-12 level (44.5). There was no change in proportion of provinces meeting
the lower benchmark between the two rounds. It was 29.4% in 2012-13 compared to 36.4% in
2011-12. There was also no change in proportion of provinces meeting the upper benchmark
between the two rounds (9.1% in 2011-12 and 5.9% in 2012-13). Logar (60.1), Ghazni (57.0),
and Kabul (55.9) had the most pro-poor outpatient visits concentrated among the poorer groups.
Kapisa (34.9), Saripul (35.3), and Nuristan (36.6) were at the bottom of this ranking, which
suggests that in these provinces the richer groups use the outpatient services more.
Indicator 22: Client Satisfaction Concentration Index

Similar to Indicator 21, this indicator focuses on equity by measuring the wealth status of health
facility clients at exit interviews. However, unlike the previous indicator, it focuses on
satisfaction among those who have used the services. It measures whether the poor are satisfied
with health services when compared to non-poor groups. Similar to Indicator 21, the responses
are measured on a four-point Likert scale but it is not a composite index and consists of only one
item on overall satisfaction.
Indicator 22: New Pa5ent sa5sfac5on
concentra5on Index
80.0 The national median was
Provinces mee6ng estimated to be 49.6, and it
60.0 49.9 lower benchmark (%)
49.6
Provinces mee6ng
appears that it has not
upper benchmark (%)
40.0 changed much since 2009-10
Na6onal Medians
(Table 2). There was a
20.0
decline in proportion of
0.0
provinces meeting the lower
2011 /12 2012 /13 benchmark from 72.7% in
2011-12 to 50% this year. There was also a decline in proportion of provinces meeting the upper
benchmark from 15.2% to 5.9% between the two rounds. Kunduz (51.1), Samangan (50.8), and
Farah (50.6) had higher satisfaction among the poorer populations, while Faryab (48.7), Kabul
(48.8), and Jawzjan (49.0) had slightly higher satisfaction among the richer groups. It seems that
there are little socio-economic differences in client satisfaction with outpatient health services in
Afghanistan, although it is likely to be due to the differences in expectations as much as actual
quality of services that different groups receive.
36
PROVINCIAL LEVEL FINDINGS OF THE 2012-‐2013 BPHS BALANCED
SCORECARD
The write-up on each provincial finding is divided into four sections:
Summary
This describes the percentage of the indicators that attained the upper benchmark in a province. It
also compares the rank order of that province in 2011-2012 and 2012-2013 rounds based on the
overall mean provincial score (Appendix VI). However, it should be noted that the 2011-12
national assessment was limited to 33 provinces and excluded Nuristan due to security reasons,
while in 2012-13 all 34 provinces were surveyed and ranked. While adding Nuristan makes the
ranking between two years not directly comparable, excluding it would limit use of results for
this province. Moreover, it may well be expected that all 34 provinces will be ranked in the
future and thus, leaving this one province out this year may have a negative impact on future
rankings.
Areas of Concern
These are indicators that are in the Red Zone for the 2012-2013 round.
Falling Trend
These are indicators that have transitioned from the Green Zone to the Yellow Zone or from the
Yellow Zone to the Red Zone. They also include indicators that fell by 20 or more percentage
points from the previous round.
Areas of Achievement
These are indicators that are in the Green Zone for the 2012-2013 round.
Rising Trend
These are indicators that have transitioned from the Red Zone to the Yellow or Green Zone or
from the Yellow Zone to the Green Zone. They also include indicators that increased by 20 or
more percentage points from the previous round.
37
AFGHANISTAN HEALTH
AFGHANISTAN HEALTH SECTOR
SECTOR B E N C H M A R K S BADAKHSHAN
2009 2011 2012
BPHS
BPHS Balanced SScorecard
Balanced corecard 2004
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
Overall Patient Satisfaction 66.4 90.9 86.4 94.2 86.8 87.6 85.5 67.5 - -
1 Patient Perception of Quality Index 66.2 83.9 77.6 82.9 77.5 86.1 76.6 70.3 - -
Overall Client Satisfaction and Perceived Quality of Care Index 73.3 81.3 - - - - - - 73.3 76.1
Written Shura-‐e-‐sehie activities in community 18.1 66.5 35.6 8.4 73.4 96.0 95.6 51.4 - -
2
Community Involvement and Decision Making Index 72.4 90.0 - - - - - - 85.0 90.0
Health Worker Satisfaction Index 56.1 67.9 63.5 64.8 70.6 73.0 68.0 67.7 - -
3
Revised Health Worker Satisfaction Index 61.7 66.6 - - - - - - 63.5 62.6
4 Health Worker Motivation Index 66.7 72.8 - - - - - - 68.8 71.7
5 Salary Payment Current 52.4 92.0 54.9 83.0 75.2 98.8 58.8 45.5 84.6 77.3
Staffing Index -‐-‐ Meeting minimum staff guidelines 10.1 54.0 38.0 37.2 66.3 73.4 86.9 85.5 - -
6
Revised Staffing Index -‐-‐ Meeting minimum staff guidelines 11.4 33.3 - - - - - - 22.8 29.5
Provider Knowledge Score 44.8 62.3 48.6 67.3 61.8 60.3 - - - -
Revised Provider Knowledge Score 71.5 86.0 - - - - 79.2 - - -
7
Revised Revised Provider Knowledge Score 61.9 77.7 - - - - - 71.2 - -
New Provider Knowledge Score 59.4 67.6 - - - - - - 63.0 68.0
Staff received training in last year 30.1 56.3 68.9 87.3 53.7 70.0 71.1 40.0 - -
8
Revised Staff Received Training (in l ast year) 7.1 14.9 - - - - - - 6.0 7.3
Equipment Functionality Index 61.3 90.0 69.6 49.5 73.3 82.3 93.3 76.9 - -
9
Revised Equipment Functionality Index 67.4 85.0 - - - - - - 72.8 82.1
Drug Availability Index 53.3 81.8 52.9 81.5 74.0 75.3 78.3 49.4 - -
10
Pharmaceuticals and V accines Availability Index 71.8 88.6 - - - - - - 63.9 79.1
Laboratory Functionality Index (Hospitals & CHCs) 5.6 31.7 31.7 32.3 38.2 62.9 76.6 24.1 - -
11
Revised Laboratory Functionality Index (CHCs only) 53.1 76.3 - - - - - - 62.5 75.0
Clinical Guidelines Index 22.5 51.0 18.3 40.2 48.1 78.1 85.4 60.6 - -
12
Revised Clinical Guidelines Index 64.3 85.9 - - - - - - 66.1 77.9
Infrastructure Index 49.3 63.2 63.2 35.5 38.9 42.0 41.1 43.9 - -
13
Revised Infrastructure Index 48.9 73.4 - - - - - - 54.2 44.1
Patient History and Physical Exam Index 55.1 83.5 54.2 67.7 72.6 86.7 73.9 70.8 - -
14
Client Background and Physical Assessment Index 66.7 81.2 - - - - - - 60.8 77.9
Patient Counseling Index 23.3 48.9 23.3 31.1 35.0 55.8 34.3 20.8 - -
15
Client Counselling Index 31.7 58.5 - - - - - - 25.8 30.9
Proper sharps disposal 34.1 85.0 64.4 34.4 75.6 88.4 70.5 43.2 - -
16
Universal Precautions 51.8 70.4 - - - - - - 42.1 34.2
17 Time Spent with Client 3.5 31.2 21.0 12.0 23.1 16.9 3.4 10.4 7.8 13.2
HMIS Use Index 49.6 80.7 60.9 27.6 72.0 83.7 96.0 51.6 - -
18
Revised HMIS Use Index 66.1 86.2 - - - - - - 77.4 89.8
19 Financial Systems 2.2 20.3 - - - - - - 0.0 1.6
20 Health Facility Management Functionality Index 40.0 57.6 - - - - - - 50.6 47.2
Outpatient visit concentration index 48.0 52.7 48.9 49.0 49.8 46.7 48.2 - - -
21
New Outpatient visit concentration i ndex 46.2 56.9 - - - - - 56.9 40.1 36.7
Patient satisfaction concentration index 49.0 50.9 50.9 50.0 50.0 49.6 49.5 - - -
22
New Patient satisfaction concentration i ndex* 49.6 50.8 - - - - - 49.8 47.8 50.2
COMPOSITE SCORES
Percent of Upper Benchmarks Achieved - 20.0 20.0 20.0 60.0 40.0 15.0 0.0 13.6
Percent of Lower Benchmarks Achieved - 85.0 80.0 95.0 90.0 90.0 80.0 63.6 77.3
Overall Means (Provincial) - 51.6 51.8 60.8 70.7 68.6 52.9 51.8 55.6
38
BADAKSHAN PROVINCE FINDINGS
Summary
Badakhshan province attained the upper benchmarks in three of the twenty-two BSC indicators
in 2012-2013. For the overall BSC score, the province has risen from the 28th in 2011-12 among
the 33 provinces to the 20th rank in 2012-13 among the 34 provinces.
Areas of concern
13. Revised Infrastructure Index
15. Client Counseling Index
16. Universal Precautions Index
21. New Outpatient Visits Concentration Index
Falling trend
Areas of achievement
2. Community Involvement and Decision Making Index
7. New Provider Knowledge Score
18. Revised HMIS Use Index
Rising trend
8. Revised Staff Received Training (over the past 12 months)
10. Pharmaceuticals and Vaccines Availability Index
14. Client Background and Physical Assessment Index
22. New Patient Satisfaction Concentration Index
39
AFGHANISTAN HEALTH
SECTOR B E N C H M A R K S BADGHIS
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 62.7 80.2 44.8 100.0 78.2 61.3 - -
18
21
22
COMPOSITE SCORES
40
BADGHIS PROVINCE FINDINGS
Summary
Badghis province attained the upper benchmarks in one of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has fallen from the 20th in 2011-12 among
the 33 provinces to the 23rd rank in 2012-13 among the 34 provinces.
Areas of concern
1. Overall Client Satisfaction and Perceived Quality of Care Index
3. Revised Health Worker Satisfaction Index
6. Revised Staffing Index -- Meeting minimum staff guidelines
Falling trend
17. Time Spent with Client
Rising trend
9. Revised Equipment Functionality Index
41
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S BAGHLAN
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
BPHS Balanced Scorecard
Balanced Scorecard 2004
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 40.0 68.7 86.9 81.4 96.3 81.6 - -
18
21
22
COMPOSITE SCORES
42
BAGHLAN PROVINCE FINDINGS
Summary
Baghlan province attained the upper benchmarks in thirteen of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has risen significantly from the 27th rank in
2011-12 among the 33 provinces to the 6th rank in 2012-13 among the 34 provinces, as it has
seen an improvement in fifteen of the twenty-two indicators.
Areas of concern
Falling trend
4. Health Worker Motivation Index
12. Revised Clinical Guidelines Index
16. Universal Precautions
20. Health Facility Management Functionality Index
Rising trend
5. Salary Payment Current
11. Revised Laboratory Functionality Index (CHCs only)
12. Revised Clinical Guidelines Index
43
AFGHANISTAN HEALTH
SECTOR B E N C H M A R K S BALKH
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 72.9 90.6 88.6 100.0 90.1 76.1 - -
18
21
22
COMPOSITE SCORES
44
BALKH PROVINCE FINDINGS
Summary
Balkh province attained the upper benchmarks in only a single indicator of the twenty-two BSC
indicators in 2012-2013. For the overall BSC performance ranking, the province has fallen from
the 3rd in 2011-12 among the 33 provinces to the 24th place in 2012-13 among the 34 provinces.
Areas of concern
Falling trend
Rising trend
45
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S BAMYAN
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 67.7 85.0 77.7 98.8 80.0 91.8 - -
18
21
22
COMPOSITE SCORES
46
BAMYAN PROVINCE FINDINGS
Summary
Bamyan province attained the upper benchmarks in only two of the twenty-two BSC indicators
in 2012-2013. For the overall BSC performance ranking, the province has slid down from the
30th in 2011-12 among the 33 provinces to the 31st place in 2012-13 among the 34 provinces.
Areas of concern
Falling trend
Areas of Achievement
Rising Trend
47
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S DAYKUNDI
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2005 2006 2007 2008
/10 /12 /13
Overall Patient Satisfaction 66.4 90.9 81.9 81.1 71.6 80.5 72.3 - -
1 Patient Perception of Quality Index 66.2 83.9 69.7 68.5 66.8 77.5 65.2 - -
Overall Client Satisfaction and Perceived Quality of Care Index 73.3 81.3 - - - - - 80.1 72.1
Written Shura-‐e-‐sehie activities in community 18.1 66.5 0.0 0.0 67.4 79.2 68.8 - -
2
Community Involvement and Decision Making Index 72.4 90.0 - - - - - 78.9 92.9
Health Worker Satisfaction Index 56.1 67.9 61.4 66.1 48.7 53.6 58.4 - -
3
Revised Health Worker Satisfaction Index 61.7 66.6 - - - - - 65.6 62.0
4 Health Worker Motivation Index 66.7 72.8 - - - - - 75.1 71.3
5 Salary Payment Current 52.4 92.0 100.0 82.4 27.4 17.4 8.9 1.7 57.1
Staffing Index -‐-‐ Meeting minimum staff guidelines 10.1 54.0 93.2 91.4 85.9 72.9 94.6 - -
6
Revised Staffing Index -‐-‐ Meeting minimum staff guidelines 11.4 33.3 - - - - - 28.5 7.1
Provider Knowledge Score 44.8 62.3 63.1 64.5 61.9 - - - -
Revised Provider Knowledge Score 71.5 86.0 - - - 79.0 - - -
7
Revised Revised Provider Knowledge Score 61.9 77.7 - - - - 59.9 - -
New Provider Knowledge Score 59.4 67.6 - - - - - 66.9 61.6
Staff received training in last year 30.1 56.3 13.0 72.2 46.8 71.9 18.7 - -
8
Revised Staff Received Training (in l ast year) 7.1 14.9 - - - - - 7.5 13.8
Equipment Functionality Index 61.3 90.0 73.6 80.5 64.0 81.6 72.3 - -
9
Revised Equipment Functionality Index 67.4 85.0 - - - - - 69.3 74.3
Drug Availability Index 53.3 81.8 84.6 88.9 57.6 76.2 54.0 - -
10
Pharmaceuticals and V accines Availability Index 71.8 88.6 - - - - - 71.7 78.1
Laboratory Functionality Index (Hospitals & CHCs) 5.6 31.7 25.3 40.9 52.7 41.9 39.3 - -
11
Revised Laboratory Functionality Index (CHCs only) 53.1 76.3 - - - - - 59.4 70.8
Clinical Guidelines Index 22.5 51.0 64.0 51.2 47.6 70.3 55.7 - -
12
Revised Clinical Guidelines Index 64.3 85.9 - - - - - 56.9 73.6
Infrastructure Index 49.3 63.2 71.0 50.2 31.5 46.6 81.7 - -
13
Revised Infrastructure Index 48.9 73.4 - - - - - 56.2 46.6
Patient History and Physical Exam Index 55.1 83.5 84.5 72.5 66.9 74.4 73.7 - -
14
Client Background and Physical Assessment Index 66.7 81.2 - - - - - 72.7 76.0
Patient Counseling Index 23.3 48.9 25.5 25.9 34.1 37.8 20.5 - -
15
Client Counselling Index 31.7 58.5 - - - - - 52.2 20.3
Proper sharps disposal 34.1 85.0 93.2 82.0 83.7 77.9 70.8 - -
16
Universal Precautions 51.8 70.4 - - - - - 56.2 31.9
17 Time Spent with Client 3.5 31.2 11.6 12.3 20.1 5.8 0.8 16.9 0.9
HMIS Use Index 49.6 80.7 63.4 18.2 65.9 84.7 62.2 - -
18
Revised HMIS Use Index 66.1 86.2 - - - - - 73.6 79.6
19 Financial Systems 2.2 20.3 - - - - - 0.0 0.0
20 Health Facility Management Functionality Index 40.0 57.6 - - - - - 40.0 37.2
Outpatient visit concentration index 48.0 52.7 - - - - - - -
21
New Outpatient visit concentration i ndex 46.2 56.9 - - - - 50.5 36.6 39.9
Patient satisfaction concentration index 49.0 50.9 - - - - - - -
22
New Patient satisfaction concentration i ndex* 49.6 50.8 - - - - 50.5 49.2 49.4
COMPOSITE SCORES
Percent of Upper Benchmarks Achieved - 44.4 33.3 16.7 33.3 25.0 4.5 4.5
Percent of Lower Benchmarks Achieved - 88.9 88.9 83.3 77.8 70.0 72.7 54.5
Overall Means (Provincial) - 59.9 58.3 55.6 62.7 53.9 50.7 50.8
48
DAYKUNDI PROVINCE FINDINGS
Summary
Daykundi province attained the upper benchmarks in only one of the twenty-two BSC indicators
in 2012-2013. For the overall BSC score, the province has slid down from the 26th in 2011-12
among the 33 provinces to the 30th rank in 2012-13 among the 34 provinces.
Areas of concern
6. Staffing Index
13. Functional Infrastructure Index
19. Financial Systems
21. Outpatient Visit Concentration Index
22. Client Satisfaction Concentration Index
Falling trend
6. Staffing Index
Rising trend
12. Clinical Guidelines Index
49
AFGHANISTAN HEALTH
SECTOR B E N C H M A R K S FARAH
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007
/10 /12 /13
Overall Patient Satisfaction 66.4 90.9 82.8 81.9 74.5 87.8 81.6 - -
1 Patient Perception of Quality Index 66.2 83.9 69.4 81.4 77.4 84.9 81.2 - -
Overall Client Satisfaction and Perceived Quality of Care Index 73.3 81.3 - - - - - 70.2 81.7
Written Shura-‐e-‐sehie activities in community 18.1 66.5 73.2 31.0 11.5 80.0 82.8 - -
2
Community Involvement and Decision Making Index 72.4 90.0 - - - - - 85.6 80.2
Health Worker Satisfaction Index 56.1 67.9 54.4 69.3 55.9 82.8 69.2 - -
3
Revised Health Worker Satisfaction Index 61.7 66.6 - - - - - 68.1 65.5
4 Health Worker Motivation Index 66.7 72.8 - - - - - 68.9 71.8
Staffing Index -‐-‐ Meeting minimum staff guidelines 10.1 54.0 57.1 41.9 77.0 92.6 88.7 - -
6
Revised Staffing Index -‐-‐ Meeting minimum staff guidelines 11.4 33.3 - - - - - 22.8 44.5
Provider Knowledge Score 44.8 62.3 45.5 71.9 60.3 78.0 - - -
Revised Provider Knowledge Score 71.5 86.0 - - - - - - -
7
Revised Revised Provider Knowledge Score 61.9 77.7 - - - - 74.7 - -
New Provider Knowledge Score 59.4 67.6 - - - - - 59.4 77.8
Staff received training in last year 30.1 56.3 37.2 76.4 69.0 100.0 78.5 - -
8
Revised Staff Received Training (in l ast year) 7.1 14.9 - - - - - 19.1 16.4
Equipment Functionality Index 61.3 90.0 66.3 63.5 53.1 89.6 92.9 - -
9
Revised Equipment Functionality Index 67.4 85.0 - - - - - 85.0 88.9
Drug Availability Index 53.3 81.8 9.8 83.7 91.7 100.0 97.0 - -
10
Pharmaceuticals and V accines Availability Index 71.8 88.6 - - - - - 86.2 62.1
Laboratory Functionality Index (Hospitals & CHCs) 5.6 31.7 0.0 42.4 47.0 95.6 59.1 - -
11
Revised Laboratory Functionality Index (CHCs only) 53.1 76.3 - - - - - 73.6 55.2
Clinical Guidelines Index 22.5 51.0 59.5 52.2 45.5 82.9 83.3 - -
12
Revised Clinical Guidelines Index 64.3 85.9 - - - - - 82.4 92.9
Infrastructure Index 49.3 63.2 76.7 53.0 33.6 88.5 68.6 - -
13
Revised Infrastructure Index 48.9 73.4 - - - - - 74.4 80.5
Patient History and Physical Exam Index 55.1 83.5 52.0 65.6 56.7 84.2 69.7 - -
14
Client Background and Physical Assessment Index 66.7 81.2 - - - - - 68.6 80.4
Patient Counseling Index 23.3 48.9 16.0 32.4 10.3 48.7 32.6 - -
15
Client Counselling Index 31.7 58.5 - - - - - 33.5 29.5
Proper sharps disposal 34.1 85.0 67.8 51.9 17.3 80.0 81.5 - -
16
Universal Precautions 51.8 70.4 - - - - - 70.4 66.3
HMIS Use Index 49.6 80.7 72.4 68.0 26.9 77.9 88.7 - -
18
Revised HMIS Use Index 66.1 86.2 - - - - - 73.1 96.5
19 Financial Systems 2.2 20.3 - - - - - 0.0 0.0
20 Health Facility Management Functionality Index 40.0 57.6 - - - - - 52.1 61.1
Outpatient visit concentration index 48.0 52.7 51.8 49.2 48.3 54.6 - - -
21
New Outpatient visit concentration i ndex 46.2 56.9 - - - - 44.9 40.6 39.3
Patient satisfaction concentration index 49.0 50.9 49.0 48.9 50.5 49.5 - - -
22
New Patient satisfaction concentration i ndex* 49.6 50.8 - - - - 50.9 49.0 50.6
COMPOSITE SCORES
50
FARAH PROVINCER FINDINGS
Summary
Farah province attained the upper benchmarks in nine of the twenty-two BSC indicators in 2012-
2013. For the overall BSC score, the province has risen from the 13th in 2011-12 among the 33
provinces to the 11th rank in 2012-13 among the 34 provinces.
Areas of concern
Falling trend
3. Health Worker Satisfaction Index
6. Staffing Index
7. Provider Knowledge Score
8. Staff Received Training (in last year)
9. Equipment Functionality Index
18. HMIS Use Index
Rising trend
6. Staffing Index
18. HMIS Use Index
51
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S FARYAB
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 73.2 78.3 62.0 98.7 100.0 83.0 - -
18
21
22
COMPOSITE SCORES
52
FARYAB PROVINCE FINDINGS
Summary
Faryab province attained the upper benchmarks in four of the twenty-two BSC indicators in
Areas of Concern
Falling Trend
6. Staffing Index
18. HMIS Use Index
Rising trend
18. HMIS Use Index
53
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S GHAZNI
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 82.5 71.6 85.8 100.0 93.1 75.8 - -
18
21
22
COMPOSITE SCORES
54
GHAZNI PROVINCE FINDINGS
Summary
Ghazni province attained the upper benchmarks in five of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has risen from the 21st in 2011-12 among
Areas of concern
6. Staffing Index
Falling trend
6. Staffing Index
Rising trend
18. HMIS Use Index
55
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S GHOR
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 81.0 68.2 46.8 59.0 67.6 73.1 - -
18
21
22
COMPOSITE SCORES
56
GHOR PROVINCE FINDINGS

Summary
Ghor province attained the upper benchmarks in two of the twenty-two BSC indicators in 2012-
2013. For the overall BSC score, the province has further slid down from the 31st in 2011-12
Areas of concern
18. HMIS Use Index
Falling trend
Rising trend
6. Staffing Index
11. Laboratory Functionality Index (CHCs only)
57
AFGHANISTAN HEALTH SECTOR B E N C H M A R K S HELMAND
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004
/10 /12 /13
Overall Patient Satisfaction 66.4 90.9 66.4 53.4 - -
1 Patient Perception of Quality Index 66.2 83.9 70.4 63.4 - -
Overall Client Satisfaction and Perceived Quality of Care Index 73.3 81.3 - - 73.6 73.4
Written Shura-‐e-‐sehie activities in community 18.1 66.5 8.1 53.8 - -
2
Community Involvement and Decision Making Index 72.4 90.0 - - 81.3 88.4
Health Worker Satisfaction Index 56.1 67.9 61.4 50.9 - -
3
Revised Health Worker Satisfaction Index 61.7 66.6 - - 61.9 63.2
4 Health Worker Motivation Index 66.7 72.8 - - 66.8 74.9
5 Salary Payment Current 52.4 92.0 80.9 7.4 47.9 44.9
Staffing Index -‐-‐ Meeting minimum staff guidelines 10.1 54.0 40.3 66.4 - -
6
Revised Staffing Index -‐-‐ Meeting minimum staff guidelines 11.4 33.3 - - 25.4 28.3
Provider Knowledge Score 44.8 62.3 46.4 - - -
Revised Provider Knowledge Score 71.5 86.0 - - - -
7
Revised Revised Provider Knowledge Score 61.9 77.7 - 48.8 - -
New Provider Knowledge Score 59.4 67.6 - - 62.0 55.9
Staff received training in last year 30.1 56.3 36.1 29.0 - -
8
Revised Staff Received Training (in l ast year) 7.1 14.9 - - 19.7 14.6
Equipment Functionality Index 61.3 90.0 40.9 65.4 - -
9
Revised Equipment Functionality Index 67.4 85.0 - - 62.5 72.7
Drug Availability Index 53.3 81.8 81.6 88.0 - -
10
Pharmaceuticals and V accines Availability Index 71.8 88.6 - - 71.8 81.6
Laboratory Functionality Index (Hospitals & CHCs) 5.6 31.7 14.2 62.3 - -
11
Revised Laboratory Functionality Index (CHCs only) 53.1 76.3 - - 75.9 77.5
Clinical Guidelines Index 22.5 51.0 12.5 13.9 - -
12
Revised Clinical Guidelines Index 64.3 85.9 - - 73.1 70.5
Infrastructure Index 49.3 63.2 28.5 49.0 - -
13
Revised Infrastructure Index 48.9 73.4 - - 50.4 48.7
Patient History and Physical Exam Index 55.1 83.5 52.6 56.4 - -
14
Client Background and Physical Assessment Index 66.7 81.2 - - 74.0 89.7
Patient Counseling Index 23.3 48.9 16.7 6.5 - -
15
Client Counselling Index 31.7 58.5 - - 48.3 23.6
Proper sharps disposal 34.1 85.0 12.1 10.2 - -
16
Universal Precautions 51.8 70.4 - - 69.5 61.2
17 Time Spent with Client 3.5 31.2 11.7 0.0 24.8 3.4
HMIS Use Index 49.6 80.7 30.6 44.5 - -
18
Revised HMIS Use Index 66.1 86.2 - - 78.4 49.9
19 Financial Systems 2.2 20.3 - - 7.3 0.0
20 Health Facility Management Functionality Index 40.0 57.6 - - 51.3 53.1
Outpatient visit concentration index 48.0 52.7 50.2 - - -
21
New Outpatient visit concentration i ndex 46.2 56.9 - 47.3 39.1 43.4
Patient satisfaction concentration index 49.0 50.9 50.7 - - -
22
New Patient satisfaction concentration i ndex* 49.6 50.8 - 49.8 50.8 49.9
COMPOSITE SCORES
Percent of Upper Benchmarks Achieved - 0.0 15.0 9.1 13.6
Percent of Lower Benchmarks Achieved - 60.0 40.0 86.4 63.6
Overall Means (Provincial) - 40.6 43.3 55.3 53.1
58
HELMAND PROVINCE FINDINGS
Summary
Helmand province attained the upper benchmarks in three of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has considerably fallen down from the 15th
in 2011-12 among the 33 provinces to the 28th rank in 2012-13 among the 34 provinces.
Areas of concern
18. HMIS Use Index
Falling trend
18. HMIS Use Index
Rising trend
59
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S HERAT
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 42.9 54.4 60.5 91.0 94.5 96.9 - -
18
21
22
COMPOSITE SCORES
60
HERAT PROVINCE FINDINGS
Summary
Herat province attained the upper benchmarks in eight of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has considerably risen from the 18th in
2011-12 among the 33 provinces to the 9th rank in 2012-13 among the 34 provinces.
Areas of concern
Falling trend
Rising trend
61
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S JAWZJAN
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 53.4 52.8 52.1 100.0 97.0 78.6 - -
18
21
22
COMPOSITE SCORES
62
JAWZJAN PROVINCE FINDINGS
Summary
Jawzjan province attained the upper benchmarks in three of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has fallen down from the 14th in 2011-12
among the 33 provinces to the 21st rank in 2012-13 among the 34 provinces.
Areas of concern
Falling trend
Rising trend
63
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S KABUL
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 80.7 63.6 62.8 61.0 60.3 71.1 - -
18
21
22
COMPOSITE SCORES
64
KABUL PROVINCE FINDINGS
Summary
Kabul province attained the upper benchmarks in three of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has risen from the 32nd in 2011-12 among
Areas of concern
6. Staffing Index
18. HMIS Use Index
Falling trend
6. Staffing Index
Rising trend
65
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S KANDAHAR
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 44.2 51.9 - -
18
21
22
COMPOSITE SCORES
66
KANDAHAR PROVINCE FINDINGS
Summary
Kandahar province attained the upper benchmarks in five of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has fallen down from the 4th in 2011-12
Areas of concern:
Falling trend
18. HMIS Use Index
Rising trend
67
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S KAPISA
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 88.6 71.2 98.6 82.0 95.4 93.4 - -
18
21
22
COMPOSITE SCORES
68
KAPISA PROVINCE FINDINGS
Summary
Kapisa province attained the upper benchmarks in six of the twenty-two BSC indicators in 2012-
2013. For the overall BSC score, the province has fallen from the 12th in 2011-12 among the 33
Areas of concern
Falling trend
6. Staffing Index
Rising trend
6. Staffing Index
69
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S KHOST
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 79.0 43.9 100.0 100.0 85.1 64.5 - -
18
21
22
COMPOSITE SCORES
70
KHOST PROVINCE FINDINGS
Summary
Khost province attained the upper benchmarks in only one of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has considerably slid down from the 22nd in
2011-12 among the 33 provinces to the 32nd rank in 2012-13 among the 34 provinces.
Areas of concern
6. Staffing Index
Falling trend
Rising trend
71
AFGHANISTAN HEALTH
SECTOR B E N C H M A R K S KUNAR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 64.9 43.3 97.1 100.0 92.4 96.0 - -
18
21
22
COMPOSITE SCORES
72
KUNAR PROVINCE FINDINGS
Summary
Kunar province attained the upper benchmarks in twelve of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has slid down from the 1st in 2011-12
among the 33 provinces to the 2nd rank in 2012-13 among the 34 provinces.
Areas of concern
Falling trend:
18. HMIS Use Index
Rising trend
73
AFGHANISTAN HEALTH
SECTOR B E N C H M A R K S KUNDUZ
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 84.5 54.6 53.3 69.3 97.4 65.6 - -
18
21
22
COMPOSITE SCORES
74
KUNDUZ PROVINCE FINDINGS

Summary
Kunduz province attained the upper benchmarks in ten of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has risen from the 11th in 2011-12 among
Areas of concern
Falling trend
6. Staffing Index
18. HMIS Use Index
Rising trend:
18. HMIS Use Index
75
AFGHANISTAN HEALTH
SECTOR B E N C H M A R K S LAGHMAN
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 57.9 80.8 49.2 60.9 97.0 94.8 - -
18
21
22
COMPOSITE SCORES
76
LAGHMAN PROVINCE FINDINGS
Summary
Laghman province attained the upper benchmarks in thirteen of the twenty-two BSC indicators
in 2012-2013. For the overall BSC score, the province has maintained the 5th in 2011-12 among
Areas of concern
None
Falling trend
18. HMIS Use Index
Rising trend
77
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S LOGAR
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 61.8 75.9 84.4 100.0 90.7 93.6 - -
18
21
22
COMPOSITE SCORES
78
LOGAR PROVINCE FINDINGS
Summary
Logar province attained the upper benchmarks in nine of the twenty-two BSC indicators in 2012-
2013. For the overall BSC score, the province has risen from the 9th in 2011-12 among the 33
Areas of concern
6. Staffing Index
Falling trend
6. Staffing Index
18. HMIS Use Index
Rising trend
79
AFGHANISTAN HEALTH
SECTOR B E N C H M A R K S NANGARHAR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 54.7 42.2 82.5 92.0 91.7 79.1 - -
18
21
22
COMPOSITE SCORES
80
NANGARHAR PROVINCE FINDINGS
Summary
Nangarhar province attained the upper benchmarks in eleven of the twenty-two BSC indicators
in 2012-2013. For the overall BSC score, the province has slid down from the 2nd in 2011-12
among the 33 provinces to the 3rd rank in 2012-13 among the 34 provinces.
Areas of concern
Falling trend
6. Staffing Index
18. HMIS Use Index
Rising trend
81
AFGHANISTAN HEALTH
SECTOR B E N C H M A R K S NIMROZ
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 49.6 24.8 100.0 96.0 100.0 86.5 - -
18
21
22
COMPOSITE SCORES
82
NIMROZ PROVINCE FINDINGS
Summary
Nimroz province attained the upper benchmarks in four of the twenty-two BSC indicators in
Areas of concern
Falling trend
18. HMIS Use Index
Rising trend
18. HMIS Use Index
83
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S NURISTAN
AFGHANISTAN SECTOR
2009 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /13
Overall Patient Satisfaction 66.4 90.9 96.9 89.8 87.9 69.3 73.5 81.8 -
1 Patient Perception of Quality Index 66.2 83.9 81.5 86.9 84.6 73.5 75.7 78.3 -
Overall Client Satisfaction and Perceived Quality of Care Index 73.3 81.3 - - - - - - 89.1
Written Shura-‐e-‐sehie activities in community 18.1 66.5 58.7 11.6 71.9 83.8 80.9 87.3 -
2
Community Involvement and Decision Making Index 72.4 90.0 - - - - - - 89.6
Health Worker Satisfaction Index 56.1 67.9 64.2 51.0 64.0 64.4 71.6 67.1 -
3
Revised Health Worker Satisfaction Index 61.7 66.6 - - - - - - 70.0
4 Health Worker Motivation Index 66.7 72.8 - - - - - - 75.1
Staffing Index -‐-‐ Meeting minimum staff guidelines 10.1 54.0 17.5 0.0 90.6 91.9 100.0 100.0 -
6
Revised Staffing Index -‐-‐ Meeting minimum staff guidelines 11.4 33.3 - - - - - - 26.3
Provider Knowledge Score 44.8 62.3 67.0 68.8 50.3 82.6 - - -
Revised Provider Knowledge Score 71.5 86.0 - - - - 74.2 - -
7
Revised Revised Provider Knowledge Score 61.9 77.7 - - - - - 66.7 -
New Provider Knowledge Score 59.4 67.6 - - - - - - 67.0
Staff received training in last year 30.1 56.3 15.0 27.3 51.1 96.3 46.6 84.8 -
8
Revised Staff Received Training (in l ast year) 7.1 14.9 - - - - - - 16.7
Equipment Functionality Index 61.3 90.0 62.9 33.2 68.5 78.8 66.8 86.5 -
9
Revised Equipment Functionality Index 67.4 85.0 - - - - - - 84.3
Drug Availability Index 53.3 81.8 80.9 73.6 84.6 96.5 100.0 95.7 -
10
Pharmaceuticals and V accines Availability Index 71.8 88.6 - - - - - - 88.4
Laboratory Functionality Index (Hospitals & CHCs) 5.6 31.7 16.8 19.3 66.7 59.1 63.6 65.0 -
11
Revised Laboratory Functionality Index (CHCs only) 53.1 76.3 - - - - - - 65.6
Clinical Guidelines Index 22.5 51.0 38.1 10.2 52.0 63.2 61.6 91.3 -
12
Revised Clinical Guidelines Index 64.3 85.9 - - - - - - 84.9
Infrastructure Index 49.3 63.2 54.1 31.1 40.6 67.8 64.1 67.7 -
13
Revised Infrastructure Index 48.9 73.4 - - - - - - 49.9
Patient History and Physical Exam Index 55.1 83.5 87.4 67.5 88.4 82.0 74.1 81.8 -
14
Client Background and Physical Assessment Index 66.7 81.2 - - - - - - 97.4
Patient Counseling Index 23.3 48.9 55.9 31.2 48.5 32.4 38.5 55.3 -
15
Client Counselling Index 31.7 58.5 - - - - - - 72.2
Proper sharps disposal 34.1 85.0 53.0 5.8 11.5 16.2 42.6 79.6 -
16
Universal Precautions 51.8 70.4 - - - - - - 73.0
HMIS Use Index 49.6 80.7 70.2 4.9 26.4 75.6 84.9 83.2 -
18
Revised HMIS Use Index 66.1 86.2 - - - - - - 85.9
19 Financial Systems 2.2 20.3 - - - - - - 56.2
20 Health Facility Management Functionality Index 40.0 57.6 - - - - - - 77.6
Outpatient visit concentration index 48.0 52.7 46.1 63.2 54.4 51.8 55.3 - -
21
New Outpatient visit concentration i ndex 46.2 56.9 - - - - - 61.0 36.6
Patient satisfaction concentration index 49.0 50.9 49.8 50.0 48.8 49.6 50.1 - -
22
New Patient satisfaction concentration i ndex* 49.6 50.8 - - - - - 52.0 49.4
COMPOSITE SCORES
84
NURISTAN PROVINCE FINDINGS
Summary
In 2012-13 the data were collected for the first time in Nuristan province for the revised BPHS
Balanced Scorecard because in 2011-12 due to security conditions, this province was not
included in the assessment. Comparisons below are with 2009-10, although as described in
overall methodology, most of the indicators were revised in 2011 and hence, these comparisons
should be interpreted with caution.
Nuristan province attained the upper benchmarks in nine of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province ranked 4th in 2012-13 among the 34
provinces.
Areas of Concern
Falling Trend
Rising trend
None
85
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S PAKTIKA
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 70.0 30.6 22.6 58.8 77.6 75.5 - -
18
21
22
COMPOSITE SCORES
86
PAKTIKA PROVINCE FINDINGS
Summary
Paktika province attained the upper benchmarks in three of the twenty-two BSC indicators in
Areas of concern
6. Staffing Index
Falling trend
6. Staffing Index
Rising trend
18. HMIS Use Index
87
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S PAKTYA
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 67.2 45.3 79.0 84.0 91.7 66.7 - -
18
21
22
COMPOSITE SCORES
88
PAKTIYA PROVINCE FINDINGS
Summary
Paktiya province attained the upper benchmarks in three of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has considerably slid down from the 19th in
Areas of concern
6. Staffing Index
Falling trend
6. Staffing Index
Rising trend
89
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S PANJSHER
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
Overall Patient Satisfaction 66.4 90.9 N/A 92.5 94.4 84.4 83.6 75.0 - -
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 77.7 100.0 100.0 96.1 93.5 63.4 - -
18
21
22
COMPOSITE SCORES
90
PANJSHIR PROVINCE FINDINGS

Summary
Panjsher province attained the upper benchmarks in four of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has rose from the 17th in 2011-12 among the
33 provinces to the 15th rank in 2012-13 among the 34 provinces.
Areas of concern
6. Staffing Index
Falling trend
6. Staffing Index
18. HMIS Use Index
Rising trend
18. HMIS Use Index
91
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S PARWAN
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
Patient Counseling Index 23.3 48.9 59.2 38.7 47.3 45.5 55.6 37.9 -
15
16
HMIS Use Index 49.6 80.7 46.3 71.0 95.1 80.5 90.4 91.4 - -
18
21
22
COMPOSITE SCORES
92
PARWAN PROVINCE FINDINGS
Summary
Parwan province attained the upper benchmarks in four of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has considerably fallen from the 16th in
Areas of Concern
18. HMIS Use Index
Falling Trend
18. HMIS Use Index
6. Staffing Index
Rising trend
6. Staffing Index
93
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S SAMANGAN
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 69.4 40.9 92.2 93.2 98.3 95.1 - -
18
21
22
COMPOSITE SCORES
94
SAMANGAN PROVINCE FINDINGS
Summary
Samangan province attained the upper benchmarks in two of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has considerably fallen from the 8th in 2011-
12 among the 33 provinces to the 33rd rank in 2012-13 among the 34 provinces.
Areas of concern
18. HMIS Use Index
Falling trend
6. Staffing Index
18. HMIS Use Index
Rising trend
95
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S SARIPUL
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 53.8 75.1 72.1 87.4 92.8 86.6 - -
18
21
22
COMPOSITE SCORES
96
SARIPUL PROVINCE FINDINGS
Summary
SarIipul province attained the upper benchmarks in only one of the twenty-two BSC indicators in
2012-2013. For the overall BSC score, the province has risen from the 23rd in 2011-12 among
the 33 provinces to the 22nd rank in 2012-13 among the 34 provinces.
Areas of concern
Falling trend
Rising trend
6. Staffing Index
97
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S TAKHAR
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
Drug Availability Index 53.3 81.8 70.2 65.2 88.0 82.2 81.1 95.1 -
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 73.0 62.5 69.7 100.0 100.0 66.7 - -
18
21
22
COMPOSITE SCORES
98
TAKHAR PROVINCE FINDINGS
Summary
Takhar province attained the upper benchmarks in five of the twenty-two BSC indicators in
Areas of Concern
Falling Trend
18. HMIS Use Index
Rising trend
18. HMIS Use Index
99
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S URUZGAN
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 76.2 100.0 - -
18
21
22
COMPOSITE SCORES
100
URUZGAN PROVINCE FINDINGS
Summary
Uruzgan province attained the upper benchmarks in only one of the twenty-two BSC indicators
in 2012-2013. For the overall BSC score, the province has slid from the 24th in 2011-12 among
Areas of concern
6. Staffing Index
18. HMIS Use Index
Falling trend
Rising trend
101
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S WARDAK
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004 2005 2006 2007 2008
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 87.4 95.6 91.1 95.9 89.0 73.4 - -
18
21
22
COMPOSITE SCORES
102
WARDAK PROVINCE FINDINGS
Summary
Wardak province attained the upper benchmarks in twelve of the twenty-two BSC indicators in
2011-12 among the 33 provinces to the 1st rank in 2012-13 among the 34 provinces.
Areas of concern
Falling trend
Rising trend
6. Staffing Index
103
AFGHANISTAN HEALTH
HEALTH SECTOR B E N C H M A R K S ZABUL
AFGHANISTAN SECTOR
2009 2011 2012
BPHS
2004 -‐ 2–011/12
2012/13 LB UB 2004
/10 /12 /13
2
3
6
7
8
9
10
11
12
13
14
15
16
HMIS Use Index 49.6 80.7 14.5 53.6 - -
18
21
22
COMPOSITE SCORES
104
ZABUL PROVINCE FINDINGS
Summary
Zabul province attained the upper benchmarks in two of the twenty-two BSC indicators in 2012-
2013. For the overall BSC score, the province has considerably risen from the 33rd in 2011-12
Areas of concern
Falling trend
6. Staffing Index
18. HMIS Use Index
Rising trend
18. HMIS Use Index
105
Appendix 1: National Health Services Performance Assessment Sampling Frame, 2004 – 2013
106
Appendix 2: Basic Package of Health Services Sampling Frame, 2012-13
Province BHC CHC Sub center Total

Badakshan 15 5 5 25
Badghis 10 2 5 17
Baghlan 12 7 6 25
Balkh 15 5 5 25
Bamyan 15 5 5 25
Daykundi 8 6 4 18
Farah 3 6 8 17
Faryab 8 10 2 20
Ghazni 14 5 5 24
Ghor 11 4 3 18
Helmand 10 5 5 20
Herat 12 5 3 20
Jawzjan 12 6 2 20
Kabul 13 6 4 23
Kandahar 14 10 1 25
Kapisa 10 6 9 25
Khost 6 11 7 24
Kunar 15 6 4 25
Kunduz 13 7 5 25
Laghman 11 4 4 19
Logar 13 5 5 23
Nangrahar 15 5 5 25
Nimroz 5 2 6 13
Nuristan 4 2 6 12
Paktika 10 2 2 14
Paktya 10 6 8 24
Panjsher 8 2 7 17
Parwan 15 5 5 25
Samangan 11 5 8 24
Saripul 10 5 10 25
Takhar 15 5 5 25
Uruzgan 8 5 4 17
Wardak 15 5 5 25
Zabul 5 6 5 16
Total 371 181 173 725
107
Appendix 3: Comparison of BPHS Balanced Scorecard Indicators used in 2004 to 2009-10
with Indicators used in 2012-13
108
Appendix 4: List of Items Included in Each Indicator for the 2012-13 BPHS Balanced
Scorecard
Means / Standard
S. No. Indicator / Sub-‐item Proportions Deviations
2012/13 2012/13
Overall Client Satisfaction and Perceived Quality of Care
Indicator 1
Index
SI # 1 How satisfied are you with cleanliness of the health facility? 78.0 21.6
SI # 2 How satisfied are you with respectfulness of health providers? 87.5 18.4
How satisfied are you with the way health workers explained
SI # 3 73.2 22.1
your illness?
How satisfied are you with the way health workers explained
SI # 4 74.5 21.4
your treatment?
How satisfied are you with the cost of this visit to the health
SI # 5 77.5 23.1
facility?
SI # 6 How satisfied are you with privacy during your visit? 85.5 20.2
How satisfied are you with amount of time a health worker
SI # 7 74.0 21.1
spent with you during your visit?
How satisfied are you with the hours during which the facility
SI # 8 77.5 21.0
is open?
How satisfied are you with the amount of time you spent
SI # 9 65.9 26.7
waiting to be seen by a health provider?
How satisfied are you with your visit to this health facility
SI # 10 80.2 18.5
overall?
How satisfied are you with the cleanliness of the toilets in this
SI # 11 63.3 27.7
HF?
How satisfied are you with the availability of the medicines
SI # 12 72.4 24.5
that the health worker prescribed? -‐ Include in analysis
Indicator 2 Community Involvement and Decision Making Index
SI # 1 Is there a Shura-‐e-‐sehie in this area? 94.1 23.7
Does the facility have written records of the activities carried
SI # 2 93.9 23.9
out by the Shura e Sehie in past 12 months?
Is a list of members and contact information of the Shura-‐e-‐
SI # 3 85.9 34.9
Sehie available? (Documentation needs to be produced)
Were there at least one person from the community present
SI # 4 94.3 23.3
in each Shura-‐e-‐Sehie meeting held in the past 6 months?
SI # 5 Does Shura-‐e-‐Sehie provide any support to CHWs? 73.6 44.1
Indicator 3 Health Worker Satisfaction Index
SI # 1 I know what is expected of me in this job -‐ WORK CONTENT 93.2 14.7
SI # 2 This job allows me to use all my skills -‐ WORK CONTENT 90.3 18.2
SI # 3 I understand my daily duties at this job -‐ WORK CONTENT 93.9 15.1
In this job management rarely interferes in my work -‐
SI # 4 36.1 36.7
AUTONOMY
This job allows me to use my personal judgment in carrying
SI # 5 73.4 32.2
out the work -‐ AUTONOMY
109
There are unnecessary procedures in this job that take time
SI # 6 69.7 33.6
away from my actual work -‐ WORK DEMANDS
I am often asked to do things that are not my duties -‐WORK
SI # 7 70.0 34.4
DEMANDS
SI # 8 I often have to work extra hours in this job -‐WORK DEMANDS 34.0 33.8
This job provides me with adequate opportunities to learn
SI # 9 77.1 28.4
new skills -‐ GROWTH & DEVELOPMENT
This job provides me with adequate opportunities to
SI # 10 76.2 29.3
participate in training programs -‐ GROWTH & DEVELOPMENT
I know how much I will get paid at the end of each month in
SI # 11 82.4 27.0
this job -‐ FINANCIAL REWARDS
I have to work extra to have enough money for my family -‐
SI # 12 26.9 33.1
FINANCIAL REWARDS
The benefits we receive are as good as most other jobs offer in
SI # 13 40.5 36.3
Afghanistan -‐FINANCIAL REWARDS
I understand the types of benefits that I am supposed to
SI # 14 73.2 31.5
receive in this job -‐ FINANCIAL REWARDS
There are few rewards for those who work here -‐ FINANCIAL
SI # 15 32.7 33.6
REWARDS
There is really too little chance for promotion in this job -‐
SI # 16 43.2 33.8
PROMOTION
Those who do well on the job stand a fair chance of being
SI # 17 50.3 33.3
promoted -‐ PROMOTION
People get ahead as fast here as they do in other organizations
SI # 18 71.1 32.1
-‐ PROMOTION
I can get help from my supervisor when I need it -‐
SI # 19 66.8 34.5
SUPERVISION & COMMUNICATION
When I do a good job, I receive the recognition from my
SI # 20 83.3 23.7
supervisor -‐ SUPERVISION & COMMUNICATION
My supervisor never gives me any feedback about how well I
SI # 21 62.4 35.4
am doing in my job -‐SUPERVISION & COMMUNICATION
In this job work assignments are not fully explained -‐
SI # 22 73.8 30.5
SUPERVISION & COMMUNICATION
I have good working relationships with my colleagues -‐ CO-‐
SI # 23 94.3 14.7
WORKERS
I find I have to work harder at my job because of the
SI # 24 31.7 33.7
incompetence of people I work with -‐ CO-‐WORKERS
I have all the necessary equipment and tools to do my job well
SI # 25 70.2 31.1
-‐ RESOURCE AVAILABILITY & INFRASTRUCTURE
This facility/hospital provides adequate medicine to provide
SI # 26 good quality of care -‐ RESOURCE AVAILABILITY & 69.3 30.4
INFRASTRUCTURE
Physical condition of the building I work in is adequate -‐
SI # 27 65.1 35.4
RESOURCE AVAILABILITY & INFRASTRUCTURE
I worry a lot about my family's and my own security living in
SI # 28 51.4 39.2
this community -‐ PHYSICAL SECURITY
110
There is adequate security in the hospital/facility to do my job
SI # 29 73.0 32.0
properly -‐ PHYSICAL SECURITY
SI # 30 I can keep this job as long as I want -‐ JOB SECURITY 61.5 34.2
People in this facility/hospital do not have to worry often
SI # 31 79.1 27.5
about getting fired -‐ JOB SECURITY
Staff in this facility/hospital have opportunities to participate
SI # 32 in developing facility/hospital's budget -‐ TRANSPARENCY & 43.8 36.9
PERCEPTION OF EQUITY
Staff in this facility/hospital have opportunities to express their
SI # 33 77.6 27.0
opinions -‐ TRANSPARENCY & PERCEPTION OF EQUITY
The rules for salary payments are fair -‐ TRANSPARENCY &
SI # 34 55.3 35.2
PERCEPTION OF EQUITY
My supervisor is unfair to me -‐ TRANSPARENCY & PERCEPTION
SI # 35 72.3 32.6
OF EQUITY
I feel like I am rewarded fairly for the work I do -‐
SI # 36 59.8 32.2
TRANSPARENCY & PERCEPTION OF EQUITY
Indicator 4 Health Worker Motivation Index
SI # 1 I sometimes feel my work here is meaningless 79.2 30.7
It is hard for me to care very much about whether or not the
SI # 2 82.2 29.4
work gets done right
SI # 3 I frequently think of quitting this job 70.6 33.3
SI # 4 I work here because of opportunities for promotion 76.8 26.1
SI # 5 I work here because it provides long term security for me 74.9 27.7
SI # 6 I only work here so that I get paid at the end of the month 61.4 33.9
I work here because of good benefits I receive (Note: all
SI # 7 35.6 31.7
benefits, think overall)
SI # 8 I work here because it is located in a safe area 64.9 34.1
Since I've heard about opportunities to receive performance-‐
SI # 9 60.9 34.7
based payments I've been working harder than before
I work in this facility/hospital because it has sufficient
SI # 10 resources I need to do my job (medicine, equipment, 61.9 32.2
infrastructure)
SI # 11 I do this job because it gives me respect in the community 69.2 32.6
SI # 12 I do this job because my family would be disappointed if I quit 58.2 35.3
I feel a very high degree of personal responsibility for the work
SI # 13 91.9 16.1
I do on this job
I feel I should personally take the credit or blame for the
SI # 14 84.0 21.8
results of my work on this job
I am glad that I work in this facility/hospital rather than other
SI # 15 87.9 20.9
facilities/hospitals in the country
I work in this job because it is part of the way in which I have
SI # 16 88.8 19.6
chosen to live my life
I work in this job because it allows me to decide how my work
SI # 17 79.6 21.7
is organized
SI # 18 I work in this job because it allows me to use my skills 82.2 21.8
I work in this job because I can accomplish something
SI # 19 89.8 18.2
worthwhile in this job
111
Indicator 5 Salary Payment Current
SI # 1 If the payment of your salary is up to date 64.8 47.8
Indicator 6 Staffing Index
Sub-‐Centers 53.8 50.0
SI # 1 Nurse (Male or Female) -‐ -‐
SI # 2 (Community) Midwife (Male or Female) -‐ -‐
-‐ -‐
BHC 8.1 27.3
SI # 2 Community Midwife (Male or Female) -‐ -‐
SI # 3 Community Health Supervisor (Male or Female) -‐ -‐
SI # 4 Vaccinators (Male or Female) -‐ -‐
SI # 5 Physician (Male or Female) -‐ -‐
-‐ -‐
CHC 18.2 38.7
SI # 2 Community Midwife (Male or Female) -‐ -‐
SI # 3 Community Health Supervisor (Male or Female) -‐ -‐
SI # 4 Vaccinators (Male or Female) -‐ -‐
SI # 5 Physician (Male or Female) -‐ -‐
SI # 6 Laboratory Technician (Male or Female) -‐ -‐
SI # 7 Pharmacy Technician (Male or Female) -‐ -‐
Indicator 8 Staff Received Training (in last year)
SI # 1 IMCI 8.0 27.1
SI # 2 HIV/AIDS 4.6 21.0
SI # 3 Tuberculosis 13.3 34.0
SI # 4 Malaria 9.6 29.5
SI # 5 FP methods 9.6 29.4
SI # 6 Maternal and neonatal health 9.8 29.7
SI # 7 Universal Precautions 4.6 21.0
SI # 8 Nutrition 14.1 34.8
SI # 9 CHW Refresher training 11.0 31.3
Indicator 9 Equipment Functionality Index
SI # 1 Children' Scale 89.9 30.1
SI # 2 Height Measure 88.3 32.2
SI # 3 Adult scale 90.5 29.4
SI # 4 Sphygmomanometer 60.7 48.9
SI # 5 Thermometer 93.6 24.4
SI # 6 Stethoscope 99.4 7.4
SI # 7 Otoscope 66.0 47.4
SI # 8 Sterilizer 83.5 37.1
SI # 9 Suction/aspiration device 77.8 41.6
SI # 10 Vision chart 69.0 46.3
SI # 11 Minor surgical set -‐ Include sub-‐items list 91.6 27.8
112
SI # 12 Fetoscope 95.5 20.8
SI # 13 Speculum 87.4 33.2
SI # 14 Watch (with seconds hand) 70.3 45.7
SI # 15 Flash light 64.6 47.9
SI # 16 Stretcher 72.2 44.8
SI # 17 Cold boxes[Separate from vaccine carrier] 90.8 28.9
SI # 18 Vaccine carriers -‐ Cold chain equipment [Separate] 98.5 12.2
SI # 19 Vaccine refrigerator 93.8 24.1
SI # 20 Ambu bag 71.4 45.2
SI # 21 Delivery Kit 87.6 33.0
SI # 22 Oxygen Gauge & Cylinder 44.4 49.7
SI # 23 MUAC / Tape measure 89.7 30.4
SI # 24 Microscope (Only CHCs) 97.1 16.7
SI # 25 Centrifuge (Only CHCs) 82.5 38.1
SI # 26 Hemoglobinometer (Only CHCs) 80.7 39.5
Indicator 10 Pharmaceuticals and Vaccines Availability Index
SI # 1 Paracetamol tabs 90.1 29.9
SI # 2 Magnesium Sulfate 82.4 38.1
SI # 3 Mebendazole 93.2 25.2
SI # 4 Amoxycillin / Ampicillin 89.8 30.2
SI # 5 INH 54.5 49.8
SI # 6 Rifampicin 54.9 49.8
SI # 7 Metronidazole 89.7 30.4
SI # 8 Chloroquine 88.9 31.5
SI # 9 Artesunate -‐ ACT 60.9 48.8
SI # 10 Co-‐trimoxazole 92.4 26.6
SI # 11 Salbutamol 84.8 35.9
SI # 12 Adrenaline 77.7 41.7
SI # 13 Ferrous Sulfate 86.0 34.8
SI # 14 Folic Acid 83.3 37.3
SI # 15 ORS packets 93.2 25.2
SI # 16 Depot Medroxy Progestrone Acetate (DMPA) 95.3 21.3
SI # 17 Oral Contraceptive Pills (OCPs) 97.1 16.9
SI # 18 Condoms 93.9 24.0
SI # 19 IUD 85.9 34.8
SI # 20 BCG 78.8 40.9
SI # 21 Measles 80.6 39.6
SI # 22 OPV 80.6 39.6
SI # 23 Tetanus Toxoid 81.2 39.1
SI # 24 Pentavalent DPTw -‐ HB Hib 81.0 39.2
SI # 25 Tetracycline ophthalmic ointment 83.4 37.2
SI # 26 Oxytocin 88.1 32.4
SI # 27 Sodium Lactate 76.8 42.3
SI # 28 Iodine 37.1 48.4
113
SI # 29 Retinol (Vitamin A) 88.3 32.1
SI # 30 Zinc 63.6 48.1
SI # 31 Vitamin K 52.2 50.0
Indicator 11 Laboratory Functionality Index (for CHCs only)
SI # 1 White cell and red cell counts 88.4 32.1
SI # 2 Malaria smears (thick and thin) 86.1 34.7
SI # 3 TB smears 94.8 22.3
SI # 4 Gram stains 40.7 49.3
SI # 5 Blood type and cross match 85.0 35.8
SI # 6 HIV testing 89.0 31.4
SI # 7 Liver function testing 3.5 18.4
SI # 8 Syphilis testing 73.8 44.1
SI # 9 Rapid diagnostic test for malaria 30.6 46.2
SI # 10 Urine dipstick tests 81.5 38.9
SI # 11 Pregnancy testing 96.0 19.8
SI # 12 Hepatitis B testing 90.8 29.1
SI # 13 Hepatitis C testing 89.0 31.4
SI # 14 Blood sugar 20.8 40.7
SI # 15 Stool tests for parasites 88.4 32.1
SI # 16 Stool tests for occult blood 39.9 49.1
Indicator 12 Clinical Guidelines Index
SI # 1 IMCI 83.9 36.7
SI # 2 Tuberculosis 76.3 42.6
SI # 3 Malaria 81.6 38.8
SI # 4 Immunization 78.0 41.5
SI # 5 Family planning 87.3 33.3
SI # 6 HIV Counseling and Testing guidelines -‐ Only for CHCs 47.2 50.0
Indicator 13 Functional Infrastructure Index
SI # 1 Windows -‐ Few or no repairs needed 82.5 38.0
SI # 2 Doors -‐ Few or no repairs needed 81.4 39.0
SI # 3 Roof -‐ Few or no repairs needed 76.9 42.2
SI # 4 Interior Walls -‐ Few or no repairs needed 78.4 41.2
SI # 5 Exterior Walls -‐ Few or no repairs needed 72.6 44.6
SI # 6 Grounds condition satisfactory 63.0 48.3
SI # 7 Functional water source 64.6 47.9
SI # 8 Reliable source of electricity 26.2 44.0
SI # 9 Heating in patient areas during winters 50.4 50.0
SI # 10 Toilets condition satisfactory 52.9 50.0
114
Indicator 14 Client Background and Physical Assessment Index
SI # 1 Consultations in which health worker greets the client 64.1 48.0
Consultations in which age was checked by the health worker
SI # 2 94.8 22.2
(HW)
Consultations in which the reason for visit was registered by
SI # 3 99.6 6.5
the HW
Consultations in which the details of the reason of visit was
SI # 4 92.9 25.6
asked?
Consultations in which HW asked about previous
SI # 5 38.4 48.6
intervention(s)
SI # 6 Consultations in which HW examined the client 86.5 34.2
SI # 7 Consultations in which privacy was observed 84.9 35.8
Indicator 15 Client Counseling Index
SI # 1 Tell mother/caretaker the name of the disease 33.0 47.0
SI # 2 Explain about the disease, its causes and/or course 22.4 41.7
SI # 3 The health worker explains home care or precautions 64.9 47.7
The health worker says the names of pharmaceutical products
SI # 4 21.4 41.0
to client (if applicable)
The health worker explains how to take medication (if
SI # 5 80.9 39.4
applicable)
The health worker explains the potential adverse reactions (if
SI # 6 6.6 24.9
applicable)
The health worker explains the signs and symptoms that
SI # 7 37.5 48.4
should prompt re-‐visit
SI # 8 The health worker asks the client if s/he has any queries 16.2 36.8
Indicator 16 Universal Precautions
Is there evidence that the safety boxes or closed containers
SI # 1 83.9 36.8
are being used properly for disposal of used sharps?
Is there evidence that syringes are being disposed of WITHOUT
SI # 2 66.5 47.2
being recapped?
Are there posted procedures for decontamination procedure
SI # 3 37.2 48.4
steps?
SI # 4 Is a basin with a water source and soap available in this room? 56.7 49.6
Is there evidence that disinfectants are being used in the
SI # 5 61.1 48.8
facility?
SI # 6 Is there evidence that the incinerator is being used regularly? 67.5 46.9
Use of Syringes: Disposable syringes are being used for all
SI # 7 99.7 5.3
injections
SI # 8 Is there evidence that the sterilizer is being used regularly? 70.4 45.7
Are there used needles, sharps, syringes, and other medical
SI # 9 10.1 30.2
waste lying on the ground inside or outside the facility.
Indicator 17 Time Spent with Client
How much time in total did the health worker spend in
SI # 1 10.6 30.8
consultation with patient?
115
Indicator 18 HMIS Use Index
SI # 1 MIAR analysis -‐ last month 92.9 25.6
SI # 2 MAAR analysis -‐ last month 81.2 39.1
SI # 3 Facility Status Report (FSR) 88.0 32.6
SI # 4 Notifiable Diseases Report 71.8 45.0
SI # 5 Is there a TB register? 67.2 47.0
Indicator 19 Financial Systems
SI # 1 Is there a petty cash system in this facility? 14.8 35.5
SI # 2 Is there any petty cash available for the facility expenses? 86.7 34.2
SI # 3 Are there any records of expenditures for the last month? 90.3 29.8
Indicator 20 Health Facility Management Functionality Index
Are there minutes from the HF staff meeting in the last 3
SI # 1 83.5 37.2
months ?
Has there been at least one supervision visit received from the
SI # 2 88.4 32.1
higher level (PHD or NGO office or CHS) in past 3 months?
Were recommendations written in a supervision book from
SI # 3 95.7 20.3
last supervision?
Is there a CHW supervision schedule created by health facility
SI # 4 44.7 49.8
staff?
SI # 5 Is there an up to date furniture inventory present? 9.4 29.2
SI # 6 Is there an up to date inventory of equipment? 10.1 30.1
SI # 7 Is there an up to date inventory record on essential drugs? 23.1 42.2
Has the national monitoring checklist been administered in
SI # 8 22.9 42.0
this facility in the last 12 months?
Is there a summary scoring sheet for results from the NMC
SI # 9 96.5 18.3
present in this facility? (Actual sighting needed)
116
Appendix 5: Change in Rank Order of Provinces between 2011/12 and 2012/13 Based on
the Overall Mean Score
Overall Mean Scores Rank Order Rank Order Change*

Province
2011/12 2012/13 2011/12 2012/13 2012/13 minus 2011/12
BADAKHSHAN 51.8 55.6 27 20 7
BADGHIS 52.8 54.4 22 23 -1
BAGHLAN 51.8 65.0 26 6 20
BALKH 61.1 53.7 5 24 -19
BAMYAN 50.4 49.8 30 31 -1
DAYKUNDI 50.7 50.8 28 30 -2
FARAH 57.1 60.3 13 11 2
FARYAB 58.6 57.3 11 13 -2
GHAZNI 52.8 55.8 24 19 5
GHOR 48.8 48.0 31 34 -3
HELMAND 55.3 53.1 16 28 -12
HERAT 53.7 62.1 20 9 11
JAWZJAN 56.8 54.8 14 21 -7
KABUL 48.2 52.1 32 29 3
KANDAHAR 62.1 60.9 4 10 -6
KAPISA 57.8 56.1 12 17 -5
KHOST 53.2 49.4 21 32 -11
KUNAR 72.7 67.7 1 2 -1
KUNDUZ 59.2 63.2 7 7 0
LAGHMAN 62.3 65.9 3 5 -2
LOGAR 60.7 62.3 6 8 -2
NANGARHAR 69.1 67.2 2 3 -1
NIMROZ 58.8 57.3 10 12 -2
NURISTAN 66.9 4
PAKTIKA 52.2 56.6 25 16 9
PAKTYA 54.7 53.3 18 27 -9
PANJSHER 55.0 57.0 17 14 3
PARWAN 55.5 53.5 15 25 -10
SAMANGAN 58.9 49.1 9 33 -24
SARIPUL 54.1 54.8 19 22 -3
TAKHAR 50.7 57.0 29 15 14
URUZGAN 52.5 53.4 23 26 -3
WARDAK 59.2 69.2 8 1 7
ZABUL 44.0 56.0 33 18 15
* GREEN = Improvement in rank RED = Drop in rank
Note: Nuristan is excluded in this analysis, as data were not collected in 2011-12
117

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AFGHANISTAN

BASIC PACKAGE OF HEALTH SERVICES

Ministry of Public Health

1. Client and Community

Figure 1: Domains and Indicators Framework of the Revised BPHS BSC

Table 1: National NHSPA Sample, 2004 - 2013

UNIT 2004 2005 2006 2007 2008 2009- 2011- 2012-

11 Indicators 21 and 22 require special mention. A Concentration Index is a measure of relative

Domain A: Client and Community

Indicator 1: Overall Client Satisfaction and Perceived Quality of Care Index

Indicator 1: Client Sa5sfac5on & Perceived

Indicator 2: Community Involvement and Decision Making

proportion of provinces 80.0

an increase in proportion of 0.0

Indicator 3: Health Worker Satisfaction Index

Indicator 4: Health Worker Motivation Index

There was an increase in 80.0 69.3 72.1 Provinces mee6ng

benchmark as compared to 0.0

Indicator 5: Salary payment current

Indicator 5: Provinces mee6ng lower benchmark (%)

Indicator 6: Meeting minimum staffing guidelines

Indictor 6:Revised Staﬃng Index -­‐ Mee5ng

Indicator 7: Revised Provider Knowledge Score

compared to 64.4 in 2011-12. 80.0 69.5 Provinces mee6ng

97.1% this year. There was a 0.0

Indicator 8: Staff Received Training

Provinces mee6ng provinces meeting the lower

Indicator 9: Equipment Functionality Index

hemoglobinometer are 0.0

Indicator 10: Pharmaceuticals and Vaccines Availability Index

common diseases and 80.0 71.2 Provinces mee6ng

Importantly, it assesses 0.0

proportion of provinces 100.0

a substantial increase in 20.0

Indicator 14: Client Background and Physical Assessment Index

how well a health worker 100.0

precautions, correct ways to 20.0

symptoms that should prompt re-visit.

Indicator 16: Universal Precau5ons Indicator 16: Universal

20.0 health facilities to prevent

Indicator 17: Time Spent with Client

Indicator 17: Provinces mee6ng lower benchmark (%)

18.0 18.4 19.7

Indicator 18: Revised HMIS Use Index

records. It is the indicator with the 100.0

meeting the lower benchmark from 20.0

Indicator 20: Health Facility Management Functionality Index

Domain F: Overall Mission

Indicator 21: Outpatient Visit Concentration Index

did not undergo any change Provinces mee6ng

Indicator 22: Client Satisfaction Concentration Index

The write-up on each provincial finding is divided into four sections:

Province BHC CHC Sub center Total

Overall Mean Scores Rank Order Rank Order Change*

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Indictor 6:Revised Staﬃng Index -‐ Mee5ng