Decades of war and civil strife have adversely affected the delivery of health services to the population of Afghanistan. Until recently, the network of public service delivery had been disrupted by prolonged war and the lack of a central government. In response, many international and national nongovernmental organizations (NGOs) had assumed responsibility for the provision of essential primary health-care services via direct contracts with donor agencies.
After the end of the Taliban regime and during the evolution towards the election of a new parliament and government in 2002, health-care services continued to be provided mainly by NGOs. The network of public facilities was weak, and most qualified health professionals either left the country or left the public sector to look for better opportunities with NGOs. The limited national budget did not allow the ministry of public health to retain necessary staff or to provide medicines and other supplies required to offer basic services. Given its limited capacity in terms of human resources and the highly bureaucratic system, the new Afghan administration opted to pursue the delivery of health-care services through NGO contracting initiatives. External donors were equally influential in adopting this approach.
Since the public health sector was, and has remained, severely underfunded (the public health ministry's annual budget allows about US$ 1 per capita), it was unable to appropriately finance public health facilities. In addition, the experience of contracting in countries such as Cambodia (1) led major funding agencies, including the World Bank, the United States Agency for International Development (USMD) and the European Commission, to channel financial support to NGOs through contracting for a basic package of health services (BPHS). (2)
As in other countries such as Rwanda (3) and Timor-Leste, (4) the strategy has been to provide basic health services via contracting with national or international NGOs. However, after some years of contracting and in view of the gradual strengthening of the public health ministry at central and peripheral levels, alternatives are emerging--pursuing the contracting option or following the policy of increasing public provision of health services. This paper discusses these and other options in order to develop a sustainable health-care delivery system for Afghanistan.
Contracting for basic health services
Policy and process
Since 2002, the Afghan Ministry of Public Health has had an explicit policy on partnership with NGOs through contractual arrangements for the delivery of the BPHS. (2,5) As the ministry had inherited limited managerial capabilities in handling contracting activities, donor agencies invested in capacity-building through the establishment of an "elite" unit for management of grants and contracts. This unit, funded by the World Bank, has acquired experience in independently managing most aspects of the contracting process and has recently been expanded to manage funds channelled by donors other than the World Bank.
Contracting relies on capitation, payments made directly to health-care providers for each individual enrolled with that provider, by various national and international NGOs for a list of services based on the BPHS. Currently the three major donors listed above support contracting for the BPHS. The World Bank covers eight provinces and six clusters (a cluster being a specified area within a province assigned to the NGO for delivery of services) through contracting with NGOs, as well as three provinces and one duster through the Ministry of Public Health Strengthening Mechanism. USAID covers 13 provinces, of which seven are also covered by the World Bank. The European Commission covers 10 provinces (Fig. 1). The World Bank has a flexible incentive-led performance-based partnership agreement (6) and channels its funds through the finance ministry to the public health ministry's grants and contracts management unit, which is responsible for awarding and managing contracts to competing NGOs. …