The desire to extend access to basic health services to as much of the population as possible is shared by many post-conflict countries, where morbidity and mortality are often high. While controlling disease outbreaks and reducing mortality must be the immediate focus in many post-conflict states, it is also imperative to plan for the longer-term development of the health system and to help restore civil society and the legitimacy of the government by providing basic services, including health services. (1) This often involves developing the health system so that it can provide basic services to many more people. (2) In Afghanistan, for instance, less than 10% of the population had access to basic health services in 2003, according to government estimates. (3)
After the fall of the Taliban in 2001, Afghanistan had some of the worst health indicators ever recorded in the world. In 2002 the maternal mortality rate exceeded 1600 per 100 000 live births, reaching 2200 per 100 000 in some parts of the country. (4) The infant mortality rate was estimated to be 165 per 1000 live births, and 257 children per 1000, more than one in four, died before the age of 5 years. (5) Health facilities had been damaged or destroyed during the years of fighting and, in many rural areas, neither facilities nor trained health workers were available. (6)
To improve the health situation rapidly, the Ministry of Public Health (MOPH) of Afghanistan developed the Basic Package of Health Services (BPHS) to deal with those areas in which the country faced its most pressing health-related problems: maternal and neonatal health, child health and immunization, nutrition, communicable diseases, mental health, disabilities and the regular supply of essential medicines. The package reflected priorities for promoting health and rebuilding the health system. A central principle of the BPHS was equity, meaning that the BPHS would be extended to as many people as possible throughout the country.
Because of high maternal, infant and child mortality rates and lack of access to basic services, the MOPH and major donors in the health sector--the United States Agency for International Development (USAID), the European Commission and The World Bank--were most interested in helping to extend access to primary health care, especially for women and children. The BPHS was viewed as the best way to achieve this in a planned and coordinated manner that would address the major health problems faced by Afghanistan. At the MOPH's direction, the donors took responsibility for funding health services and development activities in different provinces, thereby covering the entire country. The MOPH remained the steward and overseer of the health system and directed efforts to improve it.
When donors were considering funding for this major undertaking, they needed an estimate of costs to determine the feasibility of extending access to the BPHS. In 2002, despite a paucity of data, a cost analysis was conducted to determine how much funding the donors would need to provide. Newbrander et al. estimated the cost of the BPHS to be 4.50 US dollars (US$) per capita, (7) which the donors considered reasonable.
In USAID-funded provinces, the non-profit international health organization Management Sciences for Health (MSH) worked with the MOPH and USAID to help establish the BPHS through contracting with national and international nongovernmental organizations (NGOs). Liu et al. found that contracting out has enabled various countries, including post-conflict states, to improve access to health services. (8) They concluded, however, that the information available on the performance and universality of access under such contracts was inadequate for evaluating the effectiveness of contracting. Loevinsohn & Harding found, on the other hand, that contracting out health services in developing countries had positive results, including the expansion of access. …