Basic Package Of Health Services Research Articles

Afghanistan's health system under the Taliban: key challenges

Before the Taliban takeover on Aug 15, 2021, Afghanistan had made considerable progress over two decades in increasing the coverage of health services and improving some health indicators. Article 52 of the 2004 Afghanistan constitution states that “The state shall provide free preventative healthcare and treatment of diseases as well as medical facilities to all citizens in accordance with the provisions of the law”.1 The scope of the country's health services is defined by the Basic Package of Health Services (BPHS) and the Essential Package of Hospital Services (EPHS).

Calculating the Cost and Financing Needs of the Basic Package of Health Services in Afghanistan: Methods, Experiences, and Results

The Basic Package of Health Services (BPHS) is the basis for primary health care in Afghanistan and should be accessible to all citizens. Most of these health services have been provided by nongovernmental organizations with support from donors. Studies before 2018 found that utilization and quality of services were lower than they should be, partly due to insufficient resources, leading the Ministry of Public Health to conduct a costing study to determine the level of funding required for the BPHS.We expanded and refined that data analysis in this article. The main findings show that the total recurrent expenditure on BPHS interventions in 2018 was US$281 million (US$8.93 per capita)-only 62% of the US$452 million (US$14.34 per capita) required for good quality of care. It also showed that the need for services was probably not fully met by public facilities, with actual utilization less than 50% of the need in some cases. Furthermore, scaling up to entirely meet the need could require 2 to 3 times the resources used in 2018.Following the change of government in 2021, economic problems, food shortages, reductions in donor funding, and other factors have increased the need for public health services while the capacity and quality of those services have deteriorated. Nongovernmental organizations continue to provide the BPHS, which remains the main platform for primary health care services in Afghanistan, and international organizations are working to rebuild and support these health services. But additional donor support is needed. The results of this study provide important information on the cost and financing needs of the BPHS that can be used for advocacy and for financing and planning services. We also describe the methodology, challenges, and solutions that can be helpful to other countries interested in conducting similar analyses.

Efficiency analysis of primary healthcare facilities in Afghanistan

BackgroundAfghanistan’s health system is unique in that primary healthcare is delivered by non-governmental organizations funded by multilateral or bilateral donors, not the government. Given the wide range of implementers providing the basic package of health services, there may be performance differences in service delivery. This study assessed the relative technical efficiency of different levels of primary healthcare services and explored its determinants.MethodData envelopment analysis was used to assess the relative technical efficiency of three levels of primary healthcare facilities (comprehensive, basic, and sub-health centers). The inputs included personnel and capital expenditure, while the outputs were measured by the number of facility visits. Data on inputs and outputs were obtained from national health information databases for 1263 healthcare facilities in 31 provinces. Bivariate analysis was conducted to assess the correlation of various elements with efficiency scores. Regression models were used to identify potential factors associated with efficiency scores at the health facility level.ResultsThe average efficiency score of health facilities was 0.74 when pooling all 1,263 health facilities, with 102 health facilities (8.1%) having efficiency scores of 1 (100% efficient). The lowest quintile of health facilities had an average efficiency score of 0.36, while the highest quintile had a score of 0.96. On average, efficiency scores of comprehensive health centers were higher than basic and sub-health centers by 0.11 and .07, respectively. In addition, the difference between efficiency scores of facilities in the highest and lowest quintiles was highest in facilities that offer fewer services. Thus, they have the largest room for improvement.ConclusionsOur findings show that public health facilities in Afghanistan that provide more comprehensive primary health services use their resources more efficiently and that smaller facilities have more room for improvement. A more integrated delivery model would help improve the efficiency of providing primary healthcare in Afghanistan.

The cost-effectiveness of using performance-based financing to deliver the basic package of health services in Afghanistan

Performance-based financing (PBF) is a mechanism to improve the quality and the utilisation of health benefit packages. There is a dearth of economic evaluations of PBF in the ‘real world’....

Perception of basic package of health services’ impact on health service delivery and mortality among residents of Wulu County, South Sudan

A populations’ perception of health service delivery is critical to the understanding of the relationship between quality of care and utilization of health services and has been increasingly treated as an outcome of health care delivery. This study aimed to assess the perceived impact of a basic package of health services on health service delivery and mortality in Wulu County, South Sudan. A cross-sectional survey of 396 eligible adults aged 18 years and above who had benefitted from the services of health facilities within communities of Wulu County and equally resided in the community during the years 2014 to 2016 was conducted. A structured questionnaire was used to determine respondents’ perceived mortality and health service delivery ratings. Most respondents expressed moderate overall perceptions of health service delivery (62.4%) and mortality (84.1%) during 2014–2016. In 2016 significantly lower (p < 0.05) mortality perception scores and significantly higher perceived scores of health service delivery were recorded than in 2014 and 2015. In 2015, however, significantly lower mortality perception scores were recorded than in 2014. Respondents from the most urban area, Wulu Payam, expressed significantly higher health service satisfaction scores than those from other payams. The perception of a basic package of health services provided by health care agencies in South Sudan as expressed by the residents of Wulu County was satisfactory and considered to have achieved a significant reduction in the population’s mortality rate. However, the rural payams appeared to be lagging behind.

Experiences of Caretakers Seeking Care for Their Under-five Children Related to Public Primary Health Care in Sharg-Alneel Locality, 2015

Sudan public sectors’ has three levels of services delivery: primary, secondary and tertiary care. Primary level intended for health facilities that provide the basic package of health services and supposed to be the first contact for seeking medical help, advices and referral to high specialized services. Therefore, coordination between these three levels is important. As well as bypassing primary care level results in overburdening of referral facilities, increasing cost for the patients and depreciating health care system in terms of manpower, equipment and resources. Information about the health services utilizations’ and it’s the associated factors will be useful for improving service delivery to achieve universal health coverage. This paper intended to explore the experiences of caretakers seeking care for their under-five children related in public PHC facilities in Sharg-Alneel Locality, 2015. The study was descriptive cross-sectional applied qualitative research methods. Focus group discussions were conducted with caretakers who had experience with PHC services. Qualitative data was manually analyzed using thematic content analysis. This paper revealed that the main reasons that force the respondents to bypass the primary health facilities and seek care directly from the hospitals were related to the quality of the provided services. Accessibility issues, affordability issues, lack of knowledge of existing services, inadequacy of drugs, health staff competency and proper referrals system which is crucial to a functioning PHC, also reported to be lacking. Also, in this paper the respondents recommend the expansion of health insurance services coverage, provision of ambulances to all PHC facilities. Therefore, this paper recommends to educate and sensitize the individuals, families and community on PHC services role as the first line of health services to increase their knowledge and create awareness of services provided at the PHC facilities. This will increase demand for and improve access to PHC services. Also, to strengthen the implementation and facilitate the monitoring and evaluation by the authorities at the different levels. To enhance role of health insurance fund as purchaser rather than services provider and breach of free health care policy jeopardized affordability of PHC services need urgent actions, and continuous professional development for the PHC healthcare providers which will contribute in improving performance and providing quality PHC, and building their capacity on management of the under-5 common illness and by strengthen the supportive supervision and monitoring.

Exploring the health system for sustainable and integrated acute malnutrition services applying a systems lens: the case of Afghanistan

Introduction: Afghanistan has an estimated annual burden of severe acute malnutrition in children under five of over 600,000, with less then 30% accessing care. Since 2009, acute malnutrition has been part of the country’s Basic Package of Health Services, which is outsourced for implementation to local partners and regulated by the Ministry of Public Health. A gradual transition to government implementation is expected to change the dynamics of health system functions and actors, with unpredictable outcomes. Building competencies in applying systems thinking by taking into account tacit knowledge may strengthen adaptive management and leadership for improving sustainable and integrated acute malnutrition interventions. We explored the dynamics of the health system with a systems lens to identify opportunities for improving sustainable and integrated acute malnutrition services to inform policies. Methods: A mixed method design involved over 70 health actors to explore the health system capacity through participatory system dynamics mapping based on rapid observation, key informant interviews, group discussions and document review. The policy analysis investigated acute malnutrition coverage. A network analysis explored involvement and influences of health actors. A framework approach appraised key health system functions and explored the level of integration of acute malnutrition. System changes over time and causal loop analyses explored system dynamics to identify leverages for improving and sustaining health outcome. Results: Key policies and strategies were in place but did not consistently recognise severe acute malnutrition as a major childhood illness. Narrow involvement of health actors missed opportunities for ‘learning together’ and developing sustainable and broad-based technical leadership. The health actors network showed two scale free hubs of the Public Nutrition Directorate and health workers of health facilities making the link between government and partners at and between the national/provincial and community levels. The Basic Package of Health Services left community-based nutrition underdeveloped and 40% of the hard-to-reach population uncovered. Most funding remained emergency based, and quality and ownership were limited despite major training efforts. The extent of integration was stronger at implementation level than at policy and organisational level. Behaviour-over-time, mapping the effects of financial and technical support on effective coverage, showed late but fast expansion of coverage. Causal loop analysis, building on tacit knowledge to describe the complexity of interactions and influences, found reinforcing effects from policy, competency and community involvement and dumping effects from financial and technical support on improving quality. Based on the learning from the change mechanisms, an initial theory of change identified assumptions that should be tested and refined in evaluations. Conclusion: The exploration of health system capacity and dynamics uncovered strengths and missed opportunities for sustaining integrated acute malnutrition services in Afghanistan. This study is an initial step in applying systems thinking using tacit knowledge through participative approaches to explain unpredictable behaviour and foster dialogue and ‘learning together’ for improving sustainable and integrated acute malnutrition services. Further research should encourage applying systems thinking to further understand dynamic complexity by opening the black box to understand why change happens, how and under what circumstances, and design effective interventions.

Factors influencing performance by contracted non-state providers implementing a basic package of health services in Afghanistan

BackgroundIn 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.MethodsThe 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.ResultsWhile some contextual factors facilitated the CO (e.g. MoPH leadership, NSP innovation and community participation), harsh geography, political interference and insecurity in some provinces had negative effects. Contractual factors, such as effective input and output management, guided health service delivery. Institutional factors were important; management capacity of contracted NSPs affects their ability to deliver outcomes. Effective human resources and pharmaceutical management were notable elements that contributed to the successful delivery of the BPHS. The contextual, contractual and institutional factors interacted with each other.ConclusionThree sets of factors influenced the implementation of the BPHS: contextual, contractual and institutional. The MoPH should consider all of these factors when contracting out the BPHS and other functions to NSPs. Other fragile states and countries emerging from a period of conflict could learn from Afghanistan’s example in contracting out primary health care services, keeping in mind that generic or universal contracting policies might not work in all geographical areas within a country or between countries.

Routine Immunization Service Delivery Through the Basic Package of Health Services Program in Afghanistan: Gaps, Challenges, and Opportunities.

Background.The Basic Package of Health Services (BPHS) program has increased access to immunization services for children living in rural Afghanistan. However, multiple surveys have indicated persistent immunization coverage gaps. Hence, to identify gaps in implementation, an assessment of the BPHS program was undertaken, with specific focus on the routine immunization (RI) component.Methods.A cross-sectional survey was conducted in 2014 on a representative sample drawn from a sampling frame of 1858 BPHS health facilities. Basic descriptive analysis was performed, capturing general characteristics of survey respondents and assessing specific RI components, and χ2 tests were used to evaluate possible differences in service delivery by type of health facility.Results.Of 447 survey respondents, 27% were health subcenters (HSCs), 30% were basic health centers, 32% were comprehensive health centers, and 12% were district hospitals. Eighty-seven percent of all respondents offered RI services, though only 61% of HSCs did so. Compared with other facility types, HSCs were less likely to have adequate stock of vaccines, essential cold-chain equipment, or proper documentation of vaccination activities.Conclusions.There is an urgent need to address manpower and infrastructural deficits in RI service delivery through the BPHS program, especially at the HSC level.

Insecurity and lack of funds hamper progress on Afghan health service

Ambitious Afghan Government plans to provide basic health-care services to 25 million Afghan people who have one of the lowest health standards in the world are being hampered by a lack of funds and mounting insecurity, government and humanitarian officials said. Abdullah Sherzai, Deputy Minister of Public Health, told the Bulletin that his ministry was still waiting for almost half the funds needed for this year's budget alone. Donors, like USAID and The World Bank, have approved the Afghan Government plan. But some donors are not providing enough funds for this, preferring more visible projects with more immediate results, such as building a big hospital in Kabul and other cities, officials say. Out of a total US$ 200 million we budgeted for the provision of the Basic Package of Health Services (BPHS) this year, only 50-60% of the money has been disbursed, Mr Sherzai said, speaking from Kabul in August. The Basic Package initiative, developed by the Afghan Government in cooperation with nongovernmental organizations (NGOs), and United Nations agencies including WHO, aims to provide a standardized set of basic health services at primary level to improve the health status of Afghans. Maternal mortality is alarmingly high, with about 1700 women dying for every 100 000 live births because of complications that could easily be prevented. The situation is worse in remote areas. The country has one of the highest infant mortality rates in the world--with 165 deaths per 1000 live births. One in four children die before their fifth birthday. Life expectancy at birth is only 46 years. Most Afghans, particularly those in rural areas, do not have access to health care because more than two decades of war have destroyed or damaged the majority of health facilities and educational institutions, and many health-care workers have been displaced or killed. Dr Khalid Shibib of WHO's Emergency and Humanitarian Action Department said that although access to health care in Afghanistan has been improving slowly, it is not very different to many other underdeveloped countries. A serious problem is a lack of mental health resources and a shortage of professional mental health care workers. A team of researchers warned in August that the prevalence of mental disorders in Afghanistan was alarming and required immediate attention by donors and policy-makers (JAMA 2004;292:575-93). With decades of war, the people of Afghanistan have gone through uniquely traumatic experiences that have affected their mental health, said Dr Barbara Lopes Cardozo, a psychiatrist at the Centers for Disease Control and Prevention in Atlanta. …

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

Afghanistan is one of the most fragile and conflict-affected countries in the world. It has experienced almost uninterrupted conflict for the last thirty years, with the present conflict now lasting over a decade. With no history of a functioning healthcare system, the creation of the Basic Package of Health Services (BPHS) in 2003 was a response to Afghanistan’s dire health needs following decades of war. Its objective was to provide a bare minimum of essential health services, which could be scaled up rapidly through contracting mechanisms with Non-Governmental Organisations (NGOs). The central thesis of this article is that, despite the good intentions of the BPHS, not enough has been done to overcome the barriers to accessing its services. This analysis, enabled through a review of the existing literature, identifies and categorises these barriers into the three access dimensions of: acceptability, affordability and availability. As each of these is explored individually, analysis will show the extent to which these barriers to access are a critical issue, consider the underlying reasons for their existence and evaluate the efforts to overcome these barriers. Understanding these barriers and the policies that have been implemented to address them is critical to the future of health system strengthening in Afghanistan.

The successes and the challenges of Egyptian Health Sector Reform Program

Objective The aim of this study was to evaluate the effectiveness and the efficiency of the Egyptian Health Sector Reform Program in achieving universal coverage for all citizens with high-quality basic health services. Background The Government of Egypt launched the Health Sector Reform Program in 1997. The program introduces the family health model as the principle for reform, and aims to insure universal coverage of all citizens with a basic package of health services. Participants and methods A simple random sample of 10 family health units was selected from the total 220 units in Menoufia Governorate. Each selected unit was subjected to data collection and analysis of infrastructure, resources management, quality indicators, referral system, coverage, and utilization, and questionnaire was administered for a sample of patients and providers to measure their satisfaction. Results Coverage with family health fund was 83% for insured, 86% for uninsured, and 77% for exempted. Active enrollment was 44% for insured, 60% for uninsured, and 14% for exempted. The average utilization visit of the population was 1.1 visits per year. The percentage of different curative utilization visits as regards total curative visits was 47% for insured, 49% for uninsured, and 4% for exempted. There was low utilization of medical instruments. The overall patient satisfaction was 66%, and only 11% of providers were satisfied with their salaries. The final evaluation of all aspects of quality indicators according to the Egyptian Accreditation Program was 55%. The average total cost per visit was 33 LE, and the average revenue per visit was 6 LE. Conclusion Our study results show that the rate of active enrollment was low. There is underutilization among coverage people and low-quality indicators. Thus, there is a need for regular monitoring and evaluation to improve these indicators and increase customer satisfaction.

SWOT analysis of program design and implementation: a case study on the reduction of maternal mortality in Afghanistan.

This case study analyzes the design and implementation of the Basic Package of Health Services (BPHS) in Afghanistan by synthesizing the literature with a focus on maternal health services. The authors are a group of graduate students in the Brandeis University International Health Policy and Management Program and Sustainable International Development Program who used the experience in Afghanistan to analyze an example of successfully implementing policy; two of the authors are Afghan physicians with direct experience in implementing the BPHS. Data is drawn from a literature review, and a unique aspect of the case study is the application of the business-oriented SWOT analysis to the design and implementation of the program that successfully targeted lowering maternal mortality in Afghanistan. It provides a useful example of how SWOT analysis can be used to consider the reasons for, or likelihood of, successful or unsuccessful design and implementation of a policy or program. Copyright © 2015 John Wiley & Sons, Ltd.

Community health workers of Afghanistan: a qualitative study of a national program.

BackgroundAfghanistan is a country that has been in conflict for decades, resulting in the destruction of much of its social infrastructure including the health system. In 2003, after the intervention of US-led NATO forces, the new government with support from its international partners designed a Basic Package of Health Services to provide services to the majority rural population; its specific focus is on women and children. The workforce to deliver these services consists of Community Health Workers (CHWs). In this paper we aim to 1) describe the CHW program, 2) explore the gender dynamics of the workforce, and 3) identify facilitators and challenges to the program.MethodOur descriptive, qualitative study involved an analysis of policy and administrative documents, in-depth interviews and focus groups, and non-participant observation. Ethical approval for the fieldwork was obtained from the University of Ottawa, and the Afghanistan National Public Health Institute.ResultsThere are more than 20,000 CHWs across the country serving as village primary care providers, functioning as a liaison between the community and health-care facilities, and working as community developers; more than half are women. Noteworthy is a gender hierarchy: as one moves up the hierarchy of supervision and training, management and decision-making, the ratio of women to men diminishes. We found that female CHWs accomplished their tasks vis-à-vis maternal child health with greater ease than their male counterparts, as societal gender dynamics influences task allocation. Volunteerism helps to deploy a larger number of CHWs, but also makes their retention difficult. Community participation facilitates tasks of CHWs, but also poses challenges to the program, such as traditional leaders influencing the recruitment of CHWs that may not be the best choice for the community. Drug supply and support for CHWs is vital to the effectiveness of the program.ConclusionsThis case study of the decade-long, rural health workforce CHW program in Afghanistan suggests that CHWs play an important role in post-conflict, developing countries, potentially contributing to health system strengthening.

Evaluating the use of locally-based health facility assessments in Afghanistan: a pilot study of a novel research method.

BackgroundThrough the Balanced Scorecard program there have been independent, annual and nationwide assessments of the Afghan health system from 2004 to 2013. During this period, Afghanistan remained in a dynamic state of conflict, requiring innovative approaches to health service evaluation in insecure areas. The primary objective of this pilot study was to evaluate the reliability of health facility assessments conducted by a novel, locally-based data collection method compared to a standard survey team.MethodsIn this cross-sectional study, one standard survey team of clinicians and multiple rapidly trained locally-based survey teams of teachers conducted health facility assessments in Badghis province, Afghanistan from March – August, 2010. Outpatient facilities covered under the country’s Basic Package of Health Services were eligible for inclusion. Both approaches attempted to survey as many health facilities as safely possible, up to 25 total facilities per method. Each facility assessed was scored on 23 health services indicators used to evaluate performance in the annual Balanced Scorecard national assessment. For facilities assessed by both survey methods, the indicator scores produced by each method were compared using Spearman’s correlation coefficients and linear regression analysis with generalized estimating equations.ResultsThe standard survey team was able to assess 11 facilities; the locally-based approach was able to assess these 11 facilities, as well as 13 additional facilities in areas of greater insecurity. Among the 11 facilities assessed by both approaches, 19 of 23 indicators were statistically similar by survey method (p < .05). Spearman’s coefficients varied widely from (−0.39) to (0.71). The differences were greatest for items requiring specialized data collector knowledge on reviewing patient records, patient examination and counseling, and health worker reported satisfaction.ConclusionsThis pilot study of a novel method of data collection in health facility assessments showed that an approach using locally-based survey teams provided markedly increased access to areas of insecurity. Though analysis was limited by small sample size, indicator scores used for facility evaluation were relatively comparable overall, but less reliable for items requiring clinical knowledge or when asking health worker opinions, suggesting that alternative approaches may be needed to assess these parameters in insecure environments.

Perspectives on reproductive healthcare delivered through a basic package of health services in Afghanistan: a qualitative study

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.

Afghanistan's Basic Package of Health Services: Its development and effects on rebuilding the health system

In 2001, Afghanistan's Ministry of Public Health inherited a devastated health system and some of the worst health statistics in the world. The health system was rebuilt based on the Basic Package of Health Services (BPHS). This paper examines why the BPHS was needed, how it was developed, its content and the changes resulting from the rebuilding. The methods used for assessing change were to review health outcome and health system indicator changes from 2004 to 2011 structured along World Health Organisation's six building blocks of health system strengthening. BPHS implementation contributed to success in improving health status by translating policy and strategy into practical interventions, focusing health services on priority health problems, clearly defining the services to be delivered at different service levels and helped the Ministry to exert its stewardship role. BPHS was expanded nationwide by contracting out its provision of services to non-governmental organisations. As a result, access to and utilisation of primary health care services in rural areas increased dramatically because the number of BPHS facilities more than doubled; access for women to basic health care improved; more deliveries were attended by skilled personnel; supply of essential medicines increased; and the health information system became more functional.

Prospects for the sustainability of delivering the basic package of health services in Afghanistan: a stakeholder analysis

This study explored the readiness of stakeholders in Afghanistan for sustaining delivery of the Basic Package of Health Services (BPHS) without external technical and financial assistance. A stakeholder analysis was applied using qualitative methods. Fifteen stakeholders were purposively drawn from the Afghanistan ministries of public health and finance, political representatives, development partners, nonprofit organizations and public health experts. Data were collected through in-depth interviews with the stakeholders and desk review of pertinent documents. We found that sustainability of the BPHS in Afghanistan is questionable as stakeholders are suboptimally organized to come up with effective alternatives. Uneven ownership and divisive positioning are bottlenecks to the evolution of a realistic continuation plan. Those with the most significant influence are lukewarm, while those who are most supportive have the least influence. Sustainability needs to be tackled at the start in designing the BPHS rather than in the wake of eventual donor withdrawal.

A cost and technical efficiency analysis of two alternative models for implementing the basic package of health services in Afghanistan

Since 2003, the Afghan Ministry of Public Health (MoPH) and international partners have directed a contracting-out model through which non-governmental organisations (NGOs) deliver the Basic Package of Health Services (BPHS) in 31 of the 34 Afghan provinces. The MoPH also managed health service delivery in three provinces under an alternative initiative entitled Strengthening Mechanisms (SM). In 2011, under the authority of the MoPH and Delegation of the European Union to Afghanistan, EPOS Health Management conducted a cost and technical efficiency study of the contracting-out and SM mechanisms in six provinces to examine economic trade-offs in the provision of the BPHS. The study provides analyses of all resource inputs and primary outputs of the BPHS in the six provinces during 2008 and 2009. The authors examined technical efficiency using Data Envelopment Analysis (DEA) at the BPHS facility level. Cost analysis results indicate that the weighted average cost per BPHS outpatient visit totalled $3.41 in the SM provinces and $5.39 in the NGO-led provinces in 2009. Furthermore, the data envelopment analyses (DEAs) indicate that facilities in the three NGO-led provinces scored 0.168 points higher on the DEA scale (0–1) than SM facilities. The authors conclude that an approximate 60% increase in costs yielded a 16.8% increase in technical efficiency in the delivery of the BPHS during 2009 in the six provinces.

Success in reducing maternal and child mortality in Afghanistan

After the collapse of the Taliban regime in 2002, Afghanistan adopted a new development path and billions of dollars were invested in rebuilding the country's economy and health systems with the help of donors. These investments have led to substantial improvements in maternal and child health in recent years and ultimately to a decrease in maternal and child mortality. The 2010 Afghanistan Mortality Survey (AMS) provides important new information on the levels and trends in these indicators. The AMS estimated that there are 327 maternal deaths for every 100,000 live births (95% confidence interval = 260–394) and 97 deaths before the age of five years for every 1000 children born. Decreases in these mortality rates are consistent with changes in key determinants of mortality, including an increasing age at marriage, higher contraceptive use, lower fertility, better immunisation coverage, improvements in the percentage of women delivering in health facilities and receiving antenatal and postnatal care, involvement of community health workers and increasing access to the Basic Package of Health Services. Despite the impressive gains in these areas, many challenges remain. Further improvements in health services in Afghanistan will require sustained efforts on the part of both the Government of Afghanistan and international donors.