Objective-oriented verses participant-oriented approach to develop a monitoring and evaluation tool for mental health program in Afghanistan

Date of Award


Document Type


Degree Name

Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)


Community Health Sciences


Introduction: Afghans have been coping with the psychological impact of conflict over the past three decades. To respond to increased mental health (MH) needs; Ministry of Public Health (MoPH), Afghanistan, has sought to integrate MH services into the basic package of health services (BPHS) and the essential package of hospital services (EPHS) since 2003. The establishment of a monitoring and evaluation (M&E) system is one of the strategic priorities of the program. A need exists to develop a tool for monitoring and evaluating the program. Utilizing objective-oriented and participant-oriented evaluation approaches, this study aims to develop a comprehensive and responsive tool for M&E of the MH program and to answer the question "Which approach would better serve to develop a tool for M&E of the MH program in Afghanistan?" Methodology: During July-September 2010, we conducted an exploratory qualitative study in Kabul and Baghlan provinces using two evaluation approaches. In objectiveoriented approach, in addition to document review, we conducted ten in-depth interviews (IDI) with heads of departments in the MoPH and members of mental health taskforce. In participant-oriented approach, a total of 14 focus group discussion (FGD) and 26 IDIs were held with six groups of stakeholders ranging from decision makers to patients. Participants were asked to describe the program and propose M&E criteria for it. Result: The main theme identified in the description of the program, both in documents and by participants, was provision of integrated MH services through the BPHS and EPHS. The program currently focuses on identification and treatment of common mental disorders at all the levels of health care system. None of the stakeholders described inter sectorial collaboration and preventive interventions though these were described in project documents. We were unable to identify any, precise and commonly-agreed upon pre-defined goals and objectives for the program. Thus the objective-oriented approach had to be modified to a goal free approach to evaluation. Although each of the tools developed by the two approaches emphasized different domains for program M&E, common domains were recognized in both tools. Stewardship capacity of the MoPH was specific in objective-oriented approach whereas community-based referral and provision of psychosocial counseling were specific to participant-oriented approach. Evaluating availability of trained staffs and psychotropic medicines at health facilities were common and highly repeated in both approaches. Conclusion: The absence of explicit programmatic objectives hampered the use of the objective-oriented approach. Perhaps the reason for the absence of clear programmatic goals is that Mil is a new field of health care for the MoPH and its partners in Afghanistan. In contrast to the objective-oriented, the participant-oriented approach provided a wide range of indicators proposed by all potential stakeholders. The tool developed through this study will facilitate responsive evaluation of nationally-wide program with numerous stakeholders. Participant-oriented approaches should guide M&E of the MH program in Afghanistan. The study results could be used to devise objectives for the MH program. Construct validity and consensus building with stakeholders is required to reduce the number of indicators and shape up the final tool. Few of the indicators could also be part of the routine HMIS and M&E system.

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