Too good to be true? An assessment of health system progress in Afghanistan, 2002–2012

Abstract

The bold decision was taken in Afghanistan in 2002 to provide donor-funded public health services by means of contracting-out of predefined health care packages. This study seeks to identify the extent to which progress has been made in public health services provision in the context of broader state-building agendas. The article argues that the provision of public health services was also intended to generate a peace dividend and to legitimize the newly established government. The widely portrayed success of the contracting model is backed up by very high official figures for health service coverage. This contrasts with evidence at household level, which suggests limited utilization of public health services, and perceptions that these offer inferior quality, and a preference for private providers. The dissonance between these findings is striking and confirms that public health care cannot remain immune from powerful market forces, nor from contextual determinants outside the health field.

An assessment of the barriers to accessing the Basic Package of Health Services (BPHS) in Afghanistan: was the BPHS a success?

“…The same report states that 2200 midwives had been trained before 2010, with 1000 more to be trained between 2012 and 2014, with further claims that efforts so far have been a success [43]. There is a high attrition rate of health professionals and therefore any estimate of success given in government documents is very likely to be overly optimistic [9]. Hiring female health workers in rural areas has proven extremely difficult [9].…”

“…Studies that undertake primary data collection are limited by the security situation so frequently conduct small scale surveys or interviews. Studies that utilise secondary data collection are usually reliant on government data that has come under criticism for lack of plausibility [9]. The overall quality of evidence is therefore taken to be low.…”

“…Collectively, they invested more than $820 million in the health sector between 2003 and 2008/09 which is particularly high when compared with investments in health sectors of other post-conflict countries [7, 8]. Each of the three main donors funded the BPHS in roughly a third of Afghanistan’s 34 provinces [9]. From 2004 to 2008 the donors provided financial and technical support, with the majority of the construction funding coming from USAID, for the renovation of 451 health facilities and the construction of 312 health facilities [10].…”

“…The BPHS and the EPHS are delivered using a contacting-out model through which local and international NGOs bid for health service contracts which last between 12 and 36 months and are designed to fulfil a standardised package of care [11]. The rapid scale up of the BPHS has been attributed to the successful implementation of the NGO contracting mechanism [9]. The BPHS is delivered by NGOs in 31 of the 34 Afghan provinces and by the MOPH in three provinces using a contracting-in initiative entitled Strengthening Mechanisms (SM) [12].…”

Conflict and Health: seven years of advancing science in humanitarian crises

“…In particular, one of the articles takes a comprehensive view through the use of a case study framework to analyze the impact of the success of health sector reforms during the health sector reconstruction period in Kosovo [63]. Comprehensive studies of health sector reform in general are rarely found even elsewhere, but in general are now needed to document and inform current debates [64-66]. …”