Abstract
BackgroundContracting-out non-state providers to deliver a minimum package of essential health services is an increasingly common health service delivery mechanism in conflict-affected settings, where government capacity and resources are particularly constrained. Afghanistan, the longest-running example of Basic Package of Health Services (BPHS) contracting in a conflict-affected setting, enables study of how implementation of a national intervention influences access to prioritised health services. This study explores stakeholder perspectives of sexual and reproductive health (SRH) services delivered through the BPHS in Afghanistan, using Bamyan Province as a case study.MethodsTwenty-six in-depth interviews were conducted with health-system practitioners (e.g. policy/regulatory, middle management, frontline providers) and four focus groups with service-users. Inductive thematic coding used the WHO Health System Framework categories (i.e. service delivery, workforce, medicines, information, financing, stewardship), while allowing for emergent themes.ResultsImprovements were noted by respondents in all health-system components discussed, with significant improvements identified in service coverage and workforce, particularly improved gender balance, numbers, training, and standardisation. Despite improvements, remaining weaknesses included service access and usage - especially in remote areas, staff retention, workload, and community accountability.ConclusionsBy including perspectives on SRH service provision and BPHS contracting across health-system components and levels, this study contributes to broader debates on the effects of contracting on perceptions and experiences among practitioners and service-users in conflict-affected countries.
Highlights
Contracting-out non-state providers to deliver a minimum package of essential health services is an increasingly common health service delivery mechanism in conflict-affected settings, where government capacity and resources are constrained
72% were Afghan, 49% female, and they worked as UN/bilateral donors or technical advisors (19%), government staff (46%), and/or civil society/non-governmental organisation (CSO/NGO) staff (58%)
Perspectives of health-system practitioners (i.e. Reid et al’s levels 2–4) and sexual and reproductive health (SRH) service-users are reported separately, as authors found a natural dichotomy between these perspectives
Summary
Contracting-out non-state providers to deliver a minimum package of essential health services is an increasingly common health service delivery mechanism in conflict-affected settings, where government capacity and resources are constrained. One approach to improving access to healthcare services after armed conflict, and thereby contributing to the state-building process, is providing a Basic Package of Health Services (BPHS) for all citizens [13,14,15]. This package prioritises effective primary healthcare interventions (e.g. maternal health, communicable disease control) to address population-level disease burden cost-effectively and equitably [16]. First introduced nationally in Afghanistan in 2002, BPHS-centred approaches have been adopted in several countries since (e.g. South Sudan, Liberia, Somalia, Sierra Leone, the Democratic Republic of Congo, Timor Leste) [14,22]
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