In October 2003, REACH awarded $35 million in USAID funds to 13 national and international NGOs for delivery of Afghanistan's Basic Package of Health Services (BPHS) in clinics and health facilities in rural and underserved areas of 14 Afghan provinces.

Among the recipients was an NGO established in Bangladesh in 1972: the Bangladesh Rural Advancement Committee (BRAC). BRAC registered as an NGO in Afghanistan in 2002, determined to use its 30 years of experience working with the poor in Bangladesh to help the Afghan people recover from decades of war. BRAC received a grant of $1.3 million to deliver the BPHS in the Paghman district of Kabul province.

The award of USAID-funded grants, however, is only the first step in achieving the REACH goal of lowering Afghanistan's high maternal and child mortality rate by increasing access to health care services. REACH grants are contingent on performance—REACH technical assistance is provided with every award to help NGOs like BRAC meet the highest possible standards in carrying out their mandate.

Regular visits by REACH monitors are especially important. Known to travel on horseback to visit health facilities in extremely isolated, rugged parts of the country, REACH monitoring teams use carefully developed criteria to assess NGO delivery of the BPHS. Using a checklist to identify areas needing improvement, monitors inspect NGO facilities, evaluate operational capacity, observe staff performance, and share their findings with the NGO field staff.

Alerted by monitoring reports, REACH grant officers hold discussions with the NGO and, in coordination with REACH technical staff, develop an action plan with specific targets and deadlines, arranging technical assistance the NGO may need. The REACH provincial public health advisor posted to the field office nearest the NGO also lends his support. During follow-up visits, monitors gauge the NGO's progress.

In addition to providing regularly scheduled technical assistance to all its NGO grantees, REACH has also formed an NGO development team that cuts across all REACH program areas to provide and coordinate highly focused technical assistance for selected NGOs. To identify those NGOs needing greater technical assistance, the team examines the NGO's capacity to deliver service, the quality of that service, and the extent of community involvement in clinic activities.

Using a scorecard that allows objective decision-making, the team makes use of monitoring reports, findings from other assessment tools, feedback from program units, and, not least, the deliverables, or reports, the NGO itself has submitted. With this information in hand, REACH is ready to assist NGOs at the central, provincial, or health facility level.

Approximately 120 Afghans staff BRAC's four comprehensive and four basic health centers in Paghman district. Together, these facilities provide 117,900 people access to sorely-needed health services. BRAC staff are busy. Between January and June 2005, an average of 12,631 patients visited the eight clinics each month; BRAC also fields 87 community health workers, who operate first-line health posts in villages throughout the clinics' catchment areas.

Identified by the NGO development team as needing focused technical assistance, BRAC worked hard to successfully upgrade several important areas of clinic operation. With support from Dr. Huymayoon Safi, REACH Provincial Public Health Advisor for Kabul and Ghazni provinces; guidance from a REACH monitoring team, supervised by Dr. Najib Naimi; and assistance from REACH grant officers and technical staff, BRAC raised the level of its services throughout the Paghman district.

To bring infrastructure and equipment in targeted clinics up to acceptable standards, BRAC prepared a waiting room for female patients, completely renovated a delivery room, and created a bright, private space for antenatal and postnatal consultations, complete with REACH-produced health education posters and flip charts. [BRAC waiting rooms before and after]

To dispose of clinic waste, BRAC had pits dug and saw to it that furnaces made of steel and baked brick were locally constructed and properly installed, along with lidded concrete receptacles for discarded needles and other sharps. The NGO also assigned one of its own staff to regularly monitor the safety of waste disposal. [BRAC waste disposal before and after]

To improve drug management in all eight clinics, BRAC recruited a new pharmacist, had metal shelves erected, made sure cold boxes were used to store temperature-sensitive pharmaceuticals, and provided locks to safeguard narcotics and psychotropic drugs. [BRAC drug storage before and after]

To generate increased demand for family planning services, BRAC staff launched a series of meetings with local health committees (Shura-e-sehi) to fully engage their support. Within six months, 102 health committees were created at the health post level, of which 23 were made up entirely of women.

Each BRAC clinic also established a health committee to serve as a bridge between the clinic and communities in the area. Eligible BRAC staff—doctors, midwives, and nurses—received more technical training in family planning; with heightened supervision, each BRAC CHW now holds daily sessions to educate her community on birth spacing and factors related to maternal mortality.

To encourage villagers to act to prevent disease before it starts, BRAC trained community health workers in techniques to motivate villagers to improve nutrition and make sure they and their children receive needed immunizations.

And to ensure effective use of survey data identifying specific needs in clinic coverage areas, REACH taught BRAC staff how to create charts, tables, and target indicators, and how to use them.

Since BRAC received its grant in October 2003, REACH has distributed 46 additional grants, providing a total of 21 NGOs with more than $68 million for the delivery of primary health care that emphasizes the needs of women and children.

Drawing on professional staff and advisors based in Kabul and the provinces as well as on consultants from Management Sciences for Health, REACH builds the capacity of its NGO grantees to deliver high-quality health services.

Technical assistance ranges from instruction in financial and service-related record-keeping, drug management, and effective use of information systems, to training in ways to improve community outreach and workshops to refresh and upgrade the knowledge and skills of clinic staff. REACH master trainers also prepare designated clinic staff to teach and supervise community health workers, whose health posts in the villages and connections with local shuras play an important role in mobilizing and maintaining community support for clinics and promoting the use of the BPHS.

REACH is especially proud of NGOs like BRAC, which, with REACH technical assistance, are meeting the challenge of operating well-managed, well-staffed, and well-maintained clinics that enjoy the respect and support of the Afghan communities they serve.

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