It has long been said—and REACH agrees: "You cannot manage what you cannot measure."

Since October 2002, REACH has awarded over $68 million in USAID-funded grants to 25 Afghan and international NGOs to train health providers and to deliver the Basic Package of Health Services (BPHS), which addresses Afghanistan's most critical health problems, especially those of women and children. These REACH NGO-grantees now operate 332 health facilities, including 15 district hospitals and 5 provincial hospitals, and 3,400 health posts, in 14 Afghan provinces.

REACH has used a number of tools to measure the process, progress and outcomes of the implementation of the BPHS. The two most important are the Health Management Information System (HMIS) and the REACH Household Surveys.

HMIS: Monitoring The Expansion And Use Of BPHS
Early on and even before inception of REACH, the need for carefully monitoring progress of the BPHS implementation became clear. In 2002, service statistics of barely 5% of health facilities were available at the national level. REACH provided intensive technical assistance to the Ministry of Public Health and the partners for developing a new routine reporting system (Health Management Information System or HMIS) focused on BPHS that would ensure the availability and adequate use of data on national, provincial and local levels. The new HMIS was developed in 2003 and rolled out in early 2004. The HMIS Procedures Manual was revised and updated in 2006.

Using HMIS, NGOs regularly report data on the expansion of BPHS services and their use by women and children:

• From over 3000 village health posts comes data on the use of family planning and mother and child health services as recorded in pictorial tally sheets by non- and semi-literate, REACH-trained Community Health Workers (CHWs).
• From NGO-operated Basic and Comprehensive Health Centers, and from district and provincial hospitals, comes data on the use of clinic services, availability of staff and equipment, stock of pharmaceuticals, etc.

HMIS indicators measuring progress of BPHS implementation are now being reported by 99% of the 332 health facilities operated by REACH NGO grantees and by nearly three-quarters of all health facilities in Afghanistan. This data, shared and analysed at both provincial and central levels, helps shape both local and national health planning and response.

REACH Household Surveys: Evaluating Outcomes
Early in the implementation of BPHS, REACH began to prepare NGOs to conduct a series of household surveys in their catchment areas, where health outcomes are most accurately measured. At a series of workshops, NGOs not only learned how to collect the data but also how to computerize it on a database designed for this purpose.

Most importantly, REACH taught NGO staff how to analyse the data and helped them begin to develop action plans based upon that analysis. The NGOs then designed a dissemination plan through which findings and analysis would be shared with provincial authorities and health facilities on the frontlines of the healthcare system.

A baseline household survey, undertaken in late 2003 and early 2004, was followed a year later by a midterm survey. As the REACH Program neared its September 2006 conclusion, the NGO end-of-project household survey was undertaken. Results comparing the baseline and end-of-project findings have been presented in a number of forums, most recently for key stakeholders in Washington, D.C.

In each NGO catchment area, the REACH household survey gathers data on key health indicators, including:

• The use of contraceptives
• The percentage of deliveries assisted by skilled professionals
• Vaccination rates
• The prevalence of appropriate care-seeking behavior—knowing what to do to treat childhood illness

The REACH household surveys are not centralized. NGOs gather and analyse the results themselves before submitting the data to REACH for provincial and national consolidation, significantly speeding the initiation of actions based upon that data. The findings of the household survey provide a good measure of REACH's program results. These results will also be useful to the Ministry of Public Health as they reveal the status of key health indicators in a large segment of Afghanistan population.

The success of this decentralized approach has led several USAID-funded REACH NGOs to replicate the household survey methodology in non-REACH provinces where they operate health facilities funded by other donors. Moreover, MOPH has asked for REACH help in replicating the household survey methodology with the next round of USAID grantees and in the provinces where the MOPH itself operates clinics.

Accurate, systematically gathered and carefully analyzed data is a valuable tool in meeting the health needs of the men, women, and children whose lives the numbers represent. REACH is proud to have introduced and implemented the HMIS and the household survey, two major monitoring and evaluation tools that are helping NGOs develop action plans and program activities that respond to the healthcare needs of the people they serve and enabling the MOPH, at all levels, to establish evidence-based strategies, policies and guidelines that are bettering the health of the Afghan people.