Does contracting of health care in Afghanistan work? Public and service-users' perceptions and experience (original) (raw)
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Health policy and planning, 2014
Despite progress in improving health outcomes in Afghanistan by contracting public health services through non-governmental organizations (NGOs), inequity in access persists between the poor and non-poor. This study examined the distributive effect of different contracting types on primary health services provision between the poor and non-poor in rural Afghanistan. Contracts to NGOs were made to deliver a common set of primary care services in each province, with the funding agencies determining contract terms. The contracting approaches could be classified into three contracting out types (CO-1, CO-2 and CO-3) and a contracting-in (CI) approach based on the contract terms, design and implementation. Exit interviews of patients attending randomly sampled primary health facilities were collected through systematic sampling across 28 provinces at two time points. The outcome, the odds that a client attending a health facility is poor, was modelled using logistic regression with a rob...
Public health care in Afghanistan: An investigation in suboptimal utilization of facilities
Afghanistan has made strides in increasing access to health care services since 2001 however it is still battling with poor utilization of services. In order to enhance demand for services a study was conducted to explore answers to the questions on knowledge, attitude and practices of communities in relation to healthcare services. The study design was cross-sectional qualitative spanning in six provinces representing geographical and ethno cultural regions of the country. In each of the six provinces, two districts were selected through mixed sampling technique representing urban-rural population. A total of 48 villages were selected in twelve districts. The study was conducted from September 2009 to March 2010. The study highlights poor heath seeking behavior associated with physical accessibility including high cost of transportation, socio-cultural barriers for women, awareness and trust for public health facilities. The system based issues adds to prevailing access related barriers such as privacy, efficiency and availability within health facilities; lack of female physicians and, aspects of behavior and attitude, and governance issues. Afghanistan mandates the requirement of women friendly health services and unavailability of female physicians and para medics is the biggest roadblock in achieving it. Many respondents associated with community men-
An experiment with community health funds in Afghanistan
Health Policy and Planning, 2009
As Afghanistan rebuilds its health system, it faces key challenges in financing health services. To reduce dependence on donor funds, it is important to develop sustainable local financing mechanisms. A second challenge is to reduce high levels of out-of-pocket payments. Community-based health insurance (CBHI) schemes offer the possibility of raising revenues from communities and at the same time providing financial protection. This paper describes the performance of one type of CBHI scheme, the Community Health Fund (CHF),
Bulletin of The World Health Organization, 2008
Objective To research the effects of changes in health service utilization and quality on the costs of the Basic Package of Health Services (BPHS) in 13 provinces of Afghanistan. Methods The study grouped data from 355 health facilities and more than 4000 health posts into 21 data points that represented 21 different nongovernmental organization contracts for service delivery between April 2006 and March 2007. Data were pooled from five data sets on expenditure, service utilization, quality (i.e. client satisfaction and the availability of essential medicines and female health-care providers), pharmaceuticals, and security and remoteness scores. Pearson's partial correlation and multiple linear regression models were used to examine correlations between expenditure and other study variables. Findings Fixed costs were found to comprise most of the cost of BPHS contracts. There was no correlation between cost and utilization rate or security. The distance to the health facility was negatively correlated with costs (R ² = 0.855, F-significance < 0.001). The presence of female health workers, indicative of good quality in this cultural context, was negatively correlated with security (r =-0.70; P < 0.001). There was a significant correlation between the use of curative services and client satisfaction but not between the use of preventive services and client satisfaction (R ² = 0.389 and 0.272 for two types of health facilities studied). Conclusion Access to health services can be extended through contracting mechanisms in a post-conflict state even in the presence of security problems. Service characteristics, geographical distance and the security situation failed to consistently explain, alone or in combination, the observed variations in per capita costs or visits. Therefore, using these parameters as the basis for planning does not necessarily lead to better resource allocation.
Poverty, vulnerability, and provision of healthcare in Afghanistan
Social Science & Medicine, 2010
This paper presents findings on conditions of healthcare delivery in Afghanistan. There is an ongoing debate about barriers to healthcare in low-income as well as fragile states. In 2002, the Government of Afghanistan established a Basic Package of Health Services (BPHS), contracting primary healthcare delivery to non-state providers. The priority was to give access to the most vulnerable groups: women, children, disabled persons, and the poorest households. In 2005, we conducted a nationwide survey, and using a logistic regression model, investigated provider choice. We also measured associations between perceived availability and usefulness of healthcare providers. Our results indicate that the implementation of the package has partially reached its goal: to target the most vulnerable. The pattern of use of healthcare provider suggests that disabled people, female-headed households, and poorest households visited health centres more often (during the year preceding the survey interview). But these vulnerable groups faced more difficulties while using health centres, hospitals as well as private providers and their out-of-pocket expenditure was higher than other groups. In the model of provider choice, time to travel reduces the likelihood for all Afghans of choosing health centres and hospitals. We situate these findings in the larger context of current debates regarding healthcare delivery for vulnerable populations in fragile state environments. The 'scaling-up process' is faced with several issues that jeopardize the objective of equitable access: cost of care, coverage of remote areas, and competition from profit-orientated providers. To overcome these structural barriers, we suggest reinforcing processes of transparency, accountability and participation.
Bulletin of the World Health Organization, 2008
Objective To research the effects of changes in health service utilization and quality on the costs of the Basic Package of Health Services (BPHS) in 13 provinces of Afghanistan. Methods The study grouped data from 355 health facilities and more than 4000 health posts into 21 data points that represented 21 different nongovernmental organization contracts for service delivery between April 2006 and March 2007. Data were pooled from five data sets on expenditure, service utilization, quality (i.e. client satisfaction and the availability of essential medicines and female health-care providers), pharmaceuticals, and security and remoteness scores. Pearson's partial correlation and multiple linear regression models were used to examine correlations between expenditure and other study variables. Findings Fixed costs were found to comprise most of the cost of BPHS contracts. There was no correlation between cost and utilization rate or security. The distance to the health facility was negatively correlated with costs (R ² = 0.855, F-significance < 0.001). The presence of female health workers, indicative of good quality in this cultural context, was negatively correlated with security (r : = -0.70; P < 0.001). There was a significant correlation between the use of curative services and client satisfaction but not between the use of preventive services and client satisfaction (R ² = 0.389 and 0.272 for two types of health facilities studied). Conclusion Access to health services can be extended through contracting mechanisms in a post-conflict state even in the presence of security problems. Neither the per capita cost nor the number of visits per capita appeared to be a good predictor of the cost of covering different population groups and geographical areas. Bulletin of the World Health Organization 2008;86:xxx-xxx. Une traduction en français de ce résumé figure à la fin de l'article. Al final del artículo se facilita una traducción al español. املقالة. لهذه الكامل النص نهاية يف الخالصة لهذه العربية الرتجمة
Background: In 2002 Afghanistan's Ministry of Public Health (MoPH) and its development partners initiated a new paradigm for the health sector by electing to Contract-Out (CO) the Basic Package of Health Services (BPHS) to non-state providers (NSPs). This model is generally regarded as successful, but literature is scarce that examines the motivations underlying implementation and factors influencing program success. This paper uses relevant theories and qualitative data to describe how and why contracting out delivery of primary health care services to NSPs has been effective. The main aim of this study was to assess the contextual, institutional, and contractual factors that influenced the performance of NSPs delivering the BPHS in Afghanistan. Methods: The qualitative study design involved individual in-depth interviews and focus group discussions conducted in six provinces of Afghanistan, as well as a desk review. The framework for assessing key factors of the contracting mechanism proposed by Liu et al. was utilized in the design, data collection and data analysis.
BMC Health Services Research, 2011
Background: Unofficial payments in health services around the world are widespread and as varied as the health systems in which they occur. We reviewed the main lessons from social audits of petty corruption in health services in South Asia (Bangladesh, Pakistan), Africa (Uganda and South Africa) and Europe (Baltic States). Methods: The social audits varied in purpose and scope. All covered representative sample communities and involved household interviews, focus group discussions, institutional reviews of health facilities, interviews with service providers and discussions with health authorities. Most audits questioned households about views on health services, perceived corruption in the services, and use of government and other health services. Questions to service users asked about making official and unofficial payments, amounts paid, service delivery indicators, and satisfaction with the service. Results: Contextual differences between the countries affected the forms of petty corruption and factors related to it. Most households in all countries held negative views about government health services and many perceived these services as corrupt. There was little evidence that better off service users were more likely to make an unofficial payment, or that making such a payment was associated with better or quicker service; those who paid unofficially to health care workers were not more satisfied with the service. In South Asia, where we conducted repeated social audits, only a minority of households chose to use government health services and their use declined over time in favour of other providers. Focus groups indicated that reasons for avoiding government health services included the need to pay for supposedly free services and the non-availability of medicines in facilities, often perceived as due to diversion of the supplied medicines. Conclusions: Unofficial expenses for medical care represent a disproportionate cost for vulnerable families; the very people who need to make use of supposedly free government services, and are a barrier to the use of these services. Patient dissatisfaction due to petty corruption may contribute to abandonment of government health services. The social audits informed plans for tackling corruption in health services.
Contracting for health and curative care use in Afghanistan between 2004 and 2005
Health Policy and Planning, 2009
Afghanistan has used several approaches to contracting as part of its national strategy to increase access to basic health services. This study compares changes in the utilization of outpatient curative services from 2004 to 2005 between the different approaches for contracting-out services to non-governmental service providers, contracting-in technical assistance at public sector facilities, and public sector facilities that did not use contracting. We find that both contracting-in and contracting-out approaches are associated with substantial double difference increases in service use from 2004 to 2005 compared with non-contracted facilities. The double difference increase in contracting-out facilities for outpatient visits is 29% (P < 0.01), while outpatient visits from female patients increased 41% (P < 0.01), use by the poorest quintile increased 68% (P < 0.01) and use by children aged under 5 years increased 27% (P < 0.05). Comparing the individual contracting-out approaches, we find similar increases in outpatient visits when contracts are managed directly by the Ministry of Public Health compared with when contracts are managed by an experienced international non-profit organization. Finally, contracting-in facilities show even larger increases in all the measures of utilization other than visits from children under 5. Although there are minor differences in the results between contracting-out approaches, these differences cannot be attributed to a specific contracting-out approach because of factors limiting the comparability of the groups. It is nonetheless clear that the government was able to manage contracts effectively despite early concerns about their lack of experience, and that contracting has helped to improve utilization of basic health services. Keywords Contracting, health services, health systems, Afghanistan, performance-based payment KEY MESSAGES Large-scale contracting for health services in Afghanistan has been associated with substantial increases in curative care use. Curative care at contracted facilities is reaching the poor and female patients.
Journal of Hospital Management and Health Policy
Background: Afghanistan has made significant progress in improving the health status of its population by improving access, coverage, and quality of health services since 2002. As a result, child and maternal mortality rates have considerably decreased. Despite this progress, however, concerns have been increasing over inequity in the utilization of health care. Methods: Data from the Afghanistan Living Conditions Survey (ALCS 2016/17) were analyzed to examine inequities in using health care. Wealth was measured using consumption of both consumables and durable goods. Key health services studied were inpatient and outpatient care use in the public and private sectors. The use of inpatient and outpatient care was compared by wealth status, marriage status, age group, gender, and education level using F tests. Logistic and negative binomial regression models were used to examine factors associated with the utilization of outpatient and inpatient care, respectively. Concentration indexes (CIs), the composite measure of inequalities, were generated for both outpatient and inpatient services, and CIs were broken down by potential drivers of the inequalities. Results: The study shows that households in the wealthiest quintile used more outpatient and inpatient health care compared to those in the poorest quintile. Overall utilization of inpatient and outpatient care was pro-rich, with a CI of 0.123 and 0.174, respectively. There was greater inequality in utilization of health services provided by private health facilities, with a CI of 0.288 and 0.234 for outpatient and inpatient care, respectively. The use of health services in public facilities was more evenly distributed among the population, with CIs close to zero (0.014 and 0.093 for outpatient and inpatient services, respectively). The breakdown of CIs shows that location was one of key drivers of inequalities in utilization of care, which prevailed in both inpatient and outpatient health services. Conclusions: There is significant inequality in the use of inpatient and outpatient care in Afghanistan. Although the utilization of health services in public facilities is more equal, the utilization of care in private facilities is pro-rich. As the private sector provides more than half of outpatient care services, it is critical to address this inequality. Improving physical access and quality of care in public facilities, and expanding programs that address potential financial barriers, could help reduce the inequity.