title: Implementing people-centred health systems governance in 3 provinces and 11 districts of Afghanistan: a case study.
abstract: BACKGROUND
  Previous studies show that health systems governance influences health system performance and health outcomes. However, there are few examples of how to implement and monitor good governing practices in fragile and conflict affected environments. Good governance has the potential to make the health system people-centered. More research is needed on implementing a people-centered governance approach in these environments.
  
  
  METHODS
  We piloted an intervention that placed a people-centred health systems governance approach in the hands of multi-stakeholder committees that govern provincial and district health systems. We report the results of this intervention from three provinces and eleven districts in Afghanistan over a six month period. This mixed-methods exploratory case study uses analysis of governance self-assessment scores, health management information system data on health system performance, and focus group discussions. The outcomes of interest are governance scores and health system performance indicators. We document the application of a people-centred health systems governance conceptual model based on applying four effective governing practices: cultivating accountability, engaging with stakeholders, setting a shared strategic direction, and stewarding resources responsibly. We present a participatory approach where health system leaders identify and act on opportunities for making themselves and their health systems more accountable and responsive to the needs of the communities they serve.
  
  
  RESULTS
  We found that health systems governance can be improved in fragile and conflict affected environments, and that consistent application of the effective governing practices is key to improving governance. Intervention was associated with a 20% increase in antenatal care visit rate in pilot provinces. Focus group discussions showed improvements across the four governing practices, including: establishment of new sub-committees that oversee financial transparency and governance, collaboration with diverse stakeholders, sharper focus on community health needs, more frequent presentation of service delivery data, and increased use of data for decision making.
  
  
  CONCLUSIONS
  Our findings have implications for policy and practice within and beyond Afghanistan. Governance is central to making health systems responsive to the needs of people who access and provide services. We provide a practical approach to improving health systems governance in fragile and conflict affected environments.
authors.affiliation: Leadership, Management and Governance Project - Afghanistan (LMG-AFG), Management Sciences for Health (MSH), House # 24, Darul Aman Road, Kabul, Afghanistan.
authors.forename: Zelaikha
authors.initials: Z
authors.lastname: Anwari
authors.affiliation: Management Sciences for Health, 4301 N. Fairfax Drive, Suite 400, Arlington, VA 22203 USA.
authors.forename: Mahesh
authors.initials: M
authors.lastname: Shukla
authors.affiliation: Wardak Provincial Public Health Office, Maidan Shahr, Afghanistan.
authors.forename: Basir Ahmad
authors.initials: BA
authors.lastname: Maseed
authors.affiliation: Wardak Provincial Public Health Office, Maidan Shahr, Afghanistan.
authors.forename: Ghulam Farooq Mukhlis
authors.initials: GF
authors.lastname: Wardak
authors.affiliation: Khost Provincial Public Health Office, Khost, Afghanistan.
authors.forename: Sakhi
authors.initials: S
authors.lastname: Sardar
authors.affiliation: Herat Provincial Public Health Office, Herat, Afghanistan.
authors.forename: Javid
authors.initials: J
authors.lastname: Matin
authors.affiliation: Herat Provincial Public Health Office, Herat, Afghanistan.
authors.forename: Ghulam Sayed
authors.initials: GS
authors.lastname: Rashed
authors.affiliation: Ministry of Public Health, Great Masoud Square, Kabul, Afghanistan.
authors.forename: Sayed Amin
authors.initials: SA
authors.lastname: Hamedi
authors.affiliation: Ministry of Public Health, Great Masoud Square, Kabul, Afghanistan.
authors.forename: Hedayatullah
authors.initials: H
authors.lastname: Sahak
authors.affiliation: Ministry of Public Health, Great Masoud Square, Kabul, Afghanistan.
authors.forename: Abdul Hakim
authors.initials: AH
authors.lastname: Aziz
authors.affiliation: Center for Leadership and Management, Management Sciences for Health, Medford, MA USA.
authors.forename: Mariah
authors.initials: M
authors.lastname: Boyd-Boffa
authors.affiliation: Management Sciences for Health, 4301 N. Fairfax Drive, Suite 400, Arlington, VA 22203 USA ; Center for Leadership and Management, Management Sciences for Health, Medford, MA USA.
authors.forename: Reshma
authors.initials: R
authors.lastname: Trasi
keywords: Fragile and conflict affected environments; Governance; Health; Health systems; Health systems governance; Health systems performance