Does contracting of health care in Afghanistan work? Public and service-users' perceptions and experience

Anne Cockcroft,Neil Andersson,Amir Khan,Noor Md Ansari,Khalid Omer,Candyce Hamel

doi:10.1186/1472-6963-11-s2-s11

Abstract

BackgroundIn rebuilding devastated health services, the government of Afghanistan has provided access to basic services mainly by contracting with non-government organisations (NGOs), and more recently the Strengthening Mechanism (SM) of contracting with Provincial Health Offices. Community-based information about the public's views and experience of health services is scarce.MethodsField teams visited households in a stratified random sample of 30 communities in two districts in Kabul province, with health services mainly provided either by an NGO or through the SM and administered a questionnaire about household views, use, and experience of health services, including payments for services and corruption. They later discussed the findings with separate community focus groups of men and women. We calculated weighted frequencies of views and experience of services and multivariate analysis examined the related factors.ResultsThe survey covered 3283 households including 2845 recent health service users. Some 42% of households in the SM district and 57% in the NGO district rated available health services as good. Some 63% of households in the SM district (adjacent to Kabul) and 93% in the NGO district ordinarily used government health facilities. Service users rated private facilities more positively than government facilities. Government service users were more satisfied in urban facilities, if the household head was not educated, if they had enough food in the last week, and if they waited less than 30 minutes. Many households were unwilling to comment on corruption in health services; 15% in the SM district and 26% in the NGO district reported having been asked for an unofficial payment. Despite a policy of free services, one in seven users paid for treatment in government facilities, and three in four paid for medicine outside the facilities. Focus groups confirmed people knew payments were unofficial; they were afraid to talk about corruption.ConclusionsHouseholds used government health services but preferred private services. The experience of service users was similar in the SM and NGO districts. People made unofficial payments in government facilities, whether SM or NGO run. Tackling corruption in health services is an important part of anti-corruption measures in Afghanistan.

Highlights

In rebuilding devastated health services, the government of Afghanistan has provided access to basic services mainly by contracting with non-government organisations (NGOs), and more recently the Strengthening Mechanism (SM) of contracting with Provincial Health Offices
The sample In consultation with the MOPH, we purposively selected two districts for the demonstration social audit, one with government health services run by a contracted NGO and one with these services run by the Provincial Health Office contracted to do so under the Strengthening Mechanism
A group drawn from the project steering committee and district representatives estimated 35% of the population in the SM district and 10% in the NGO district lived in urban communities, with a small nomad population in each district

Summary

Introduction

In rebuilding devastated health services, the government of Afghanistan has provided access to basic services mainly by contracting with non-government organisations (NGOs), and more recently the Strengthening Mechanism (SM) of contracting with Provincial Health Offices. Community-based information about the public’s views and experience of health services is scarce. According to official policy in 2008, services in government health facilities (including those run directly by the MOPH, and those provided under contract by the SM or by a contracted NGO) were provided free of charge. Given the difficult security situation in many parts of the country, reliable representative community-based data about use and experience of health services in Afghanistan are hard to collect. Most of the information about the functioning of the health services is facilities-based (collected from the facility staff and records and from the users of the facility). Repeated cycles of a survey of facilities across the country have shown improvements over time in many functions and in staff views and experience, as well as high and improving ratings of the service from patients using the facilities [5]. The people who do not make use of available public health services are often the most disadvantaged

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Conclusion