The benefits contracting health services in Afghanistan

Afghanistan has emerged from over twenty years of war with some of the worst health indicators in the world. It has the fourth highest rate of infant and child mortality, as well as one of the highest maternal mortality rates in the world. Access to basic health care is critical if the lives of Afghanistan’s war-affected people are to be improved.

Along with perinatal mortality and malnutrition, infectious diseases such as diarrhoea, acute respiratory infections and tuberculosis account for most of the deaths among children. Afghanistan’s women and girls are disadvantaged further due to a lack of female health staff and restrictive local traditions. To address this situation, three major donors—the European Commission (EC), USAID, and the World Bank—have invested large sums of money to rebuild Afghanistan’s health system. A report from The London School of Hygiene and Tropical Medicine, UK looks at the health policies of these donors in Afghanistan, and offers recommendations for other regions where primary health care is severely lacking.

New health policy, in Afghanistan and other developing countries, has focused on the delivery of health services to poor people in rural areas through contracting out health care to non-government organisations (NGOs). An example of this is the Performance-based Partnership Agreement (PPA) and other contracting models currently being implemented in Afghanistan on a large scale.

Evidence so far from other post-conflict and low-income countries on similar attempts is limited, inconsistent and mostly remains unpublished. The process of health policy development and implementation in Afghanistan, however, has been fairly successful. In the initial 18 months, the Afghan Ministry of Public Health and donors expanded coverage of basic primary health care to 59 percent of the population and more recently to 77 percent. Although there is currently no data to show how many are actually accessing services, the percentages indicate the population the awarded contracts cover. Nonetheless, the available evidence from Afghanistan shows:

• Contracting non-state providers to deliver basic health services has been successful to rapidly roll out basic health services in underserved areas.
• Establishing a basic package of health services has influenced priorities and the allocation of resources.
• Aligning and complementing donor strategies early in the programme was helpful.
• Proactive involvement of the Ministry of Public Health in contracting processes has increased government capacity and improved government-donor relations.
• NGOs have responded well to market forces and performance-based mechanisms.
• Technical assistance and systems to monitor progress have helped partners achieve high levels of success in meeting contract targets.

Despite this progress and the Ministry for Public Health taking overall responsibility, uncertainty regarding future donor support may cause problems for sustainability. Insecurity is also affecting NGO efforts to implement basic programmes. Learning from the Afghan experience, policymakers can:

• consider contracting arrangements for other fragile states and low-income countries, but pay more attention to communicating how contracting works
• adapt internal donor regulations to increase the effectiveness of the contracting approach
• identify and emphasise priorities for primary health care in the initial stages of resource allocation
• establish a framework for the alignment of donor requirements in the early stages of policymaking, as this will lead to a well organised health care system
• continue to experiment with performance-based measures to build the evidence
• encourage NGOs to be better prepared to respond to new strategies in post-conflict situations.

Source(s):
‘Contracting Health Services in Afghanistan: Can the twin objectives of equity and efficiency really be reached?’, London School of Hygiene and Tropical Medicine, by Lesley Strong, Abdul Wali and Egbert Sondorp, December 2005 (PDF) Full document.
Further details about this research project 'Contracting Health Services in Afghanistan: Can the twin objectives of efficiency and equity really be achieved' Full document.

Funded by: UK Department for International Development (EC-PREP)

id21 Research Highlight: 11 September 2006

Further Information:
Egbert Sondorp
London School of Hygiene and Tropical Medicine
Keppel Street London WC1E 7HT
UK

Tel: +44 (0)20 7636 8636
Fax: +44 (0)20 7436 5389
Contact the contributor: egbert.sondorp@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK