Project Information

Objective: The System Enhancement for Health Action in Transition (SEHAT) project seeks to expand the scope, quality and coverage of health services provided to the population, particularly to the poor, in the project areas, and to enhance the stewardship functions of the Ministry of Public Health.
Status: Active
Date Effective: 09/27/2013 to 06/30/2018
Financing: HRITF $12 million and IDA $100 million
Other Financial Contributions: US $517 million (Afghanistan Reconstruction Trust Fund)

Photo credit: World Bank/Graham Crouch


Since 2002, Afghanistan made remarkable progress in the health sector: infant mortality declined from 165 to 45 deaths per 1’000 live births in 2015; under-five mortality diminished from 257 to 55 deaths per 1’000 live births (Afghanistan Demographic and Health Survey, 2015); and maternal mortality dropped from 1’340 to 425 maternal deaths per 100’000 live births (World Bank, 2015). Despite such progress, services delivery challenges remain: the infant and under-five mortality rates in Afghanistan are still higher than the average for other low income countries; and about  42 percent of children under-five suffer from chronic malnutrition and both women. To address this situation, the Ministry of Public Health (MOPH) of Afghanistan – with the support of the World Bank – endeavored to scale-up its Basic Package of Health Services (BPHS) and its Essential Package of Hospital Services (EPHS) to all urban and rural areas in Afghanistan. 


RBF Payments

The SEHAT project includes a supply-side performance-based financing scheme. Under this scheme, the MPOH contracts-in MPOH providers and contracts-out international/national Non-Governmental Organizations (NGOs) to improve the coverage and quality of the BPHS and EPHS. Inherent RBF payments are disbursed every semester based on the quantity and the quality of services delivered. 


The verification function is led by a third party firm (i.e. a reputable University), which verified the quantity of services on a six monthly basis by reviewing self-reported data among a sample of facilities. It also oversees the verification of reported services within the community, ensuring that reported services were indeed delivered. The Third party is responsible to assess the quality of health care on annual basis using a Balanced Scorecard.  In addition, the Provincial health Office and a contracted NGOs assess the quality of care on a quarterly basis, using the National Monitoring Checklist (NMC).


Status and achievement – Fiscal Year 2016

The RBF mechanism implemented in Afghanistan builds on the RBF piloting experience carried out under the SHARP. Specifically, the 2015 survey indicated promising results, including enhanced health service coverage among and significantly improved performance, particularly with regard to community participation in decision-making, health worker satisfaction, staff training, and equipment functionality, heath facility management, pharmaceuticals and vaccine availability, and universal precautions. These results – as well as lessons drawn from the piloting experience – informed the scaling up process inherent to the SEHAT project.

Lessons Learned

Contracting-out for the delivery of health services has proven to be a powerful mechanism to deliver health services, particularly in poorly served areas and among poor and vulnerable populations, and improve health worker performance. 


The final impact evaluation of the RBF scheme was conducted in 2015. It included a household survey, a community leaders’ survey, a health facility assessment, and a qualitative assessment of health facility staff. The final report will be available at the beginning of 2017. 


Financing To Date


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