Table 2.

Afghanistan: interventions, scale-up strategy and implementation research

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)
Context	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

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