Impact of a Health Governance Intervention on Provincial Health System Performance in Afghanistan: A Quasi-experimental Study

Journal Article
  • Mahesh Shukla
Health Systems and Reform
July 2018; vol. 4 (3), pp. 249-66. DOI:


Poor governance contributes to poor health outcomes and may constrain a country’s progress in attaining its health goals. Yet, governance is not commonly used as a lever to improve the health sector or health system performance. Lack of a clear body of evidence linking governance interventions to better health system performance is one likely reason. This quasi-experimental study conducted in Afghanistan examines the causal impact of a provincial health governance intervention on the provincial health system’s performance. It compares health system performance indicators between 16 intervention provinces and 18 nonintervention provinces using a difference-in-differences analysis to draw inference. The intervention consisted of governance action planning, implementation of the governance action plan, and self-assessment of governance performance before and after the intervention.

The intervention had a statistically and practically significant impact on six indicators. Specifically, the intervention increased a province’s rate of outpatient department visits per person by an average of 18 percentage points and achievements in Penta 3 immunization, antenatal visits, postnatal visits, tuberculosis case detection, and facility delivery by 17, 14, 12, 11, and five percentage points, respectively (P < 0.01). No impact was detected on tetanus toxoid administration to pregnant mothers and tuberculosis cure; a marginally negative impact was seen in community health worker home visits and new family planning users.

Governing bodies provide an opportunity for governance reform. Improving health system governance is relevant to the current situation in low-income countries, where weak health systems are a significant barrier to addressing epidemics and providing high-quality health services.