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Table 2 Afghanistan: interventions, scale-up strategy and implementation research

From: Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda

Scaling-up dimensions informed by IR

Nature of intervention and scale-up strategy

Findings from IR

Implementing team

FHS team (Johns Hopkins with local hires), in collaboration with three local NGOs and the community-based healthcare department of the MOPH

Research aim and design

Aim to explore feasibility and effectiveness of community scorecards in Afghan context

Three rounds of structured community and facility engagement processes involving identification and measurement of quality and performance indicators, and collective development of work plans; quarterly longitudinal data on indicators and qualitative evaluation using focus group discussions; findings on other dimensions emerged organically

Attributes of the innovation or service

Community level balanced scorecard

Aims: to enhance community engagement, accountability & responsiveness to users at the local level so as to improve quality of primary care services

Appropriateness: It was found easier for MOPH and NGO stakeholders to understand and appreciate the intervention if framed as an extension of the balanced scorecard, implemented in hospitals and health facilities; the Partnership Defined Quality strategy, similar to the Community Score Card, was also being implemented in Afghanistan, though community members were not involved in generating indicators or scores and therefore the scorecard was more readily accepted by the NGO teams

Fidelity: Not assessed

Attributes of the target community

Initially implemented in Takhar and Bamyan provinces with ethnic Hazara, Uzbek and Tajik communities. Later (post-FHS) expanded to a Pashtun community in Nangarhar. History of conflict, and security issues meant low levels of trust within communities

Acceptability: While the intervention was acceptable in more progressive regions, in conservative areas it was problematic for men and women to sit together in community meetings to score health centres; the implementation team sought to circumvent by developing processes to feed women’s views into community meetings

Intention to adopt: Not assessed (not individual-level intervention)

Coverage: Not assessed (project remained on pilot scale until recently)


Post-conflict environment, low levels of trust in public healthcare system. Balanced scorecard used at national level to monitor health services, therefore government officials were familiar with the use of scorecards in general

Feasibility: Initial substantial scepticism on the part of providers and local council members about the ability of the community to identify indicators and score performance, but their ability to do so was demonstrated over time

Scaling-up strategy

Vertical scaling up – influence MOPH to establish community scorecard as a national policy for community healthcare in Afghanistan

Implementation cost: Cost analysis not done, but recognised importance of highly skilled facilitators to effectiveness of intervention and need to train facilitators well

Sustainability: Initial project documentation gave little role to Provincial Public Health Directors, but by end of Year 1 the project had learnt of their importance in coordination and was making efforts to work closely with them so as to facilitate institutionalisation

  1. FHS Future Health Systems, IR implementation research, MOPH Ministry of Public Health, NGO non-governmental organisation