Rebuilding health systems in post-conflict countries: estimating the costs of basic services

Health system evaluation in conflict-affected countries: a scoping review of approaches and methods

INTRODUCTION

Strengthening health systems in conflict-affected settings has become increasingly professionalised. However, evaluation remains challenging and often insufficiently documented in the literature. Many, particularly small-scale health system evaluations, are conducted by government bodies or non-governmental organisations (NGO) with limited capacity to publish their experiences. It is essential to identify the existing literature and main findings as a baseline for future efforts to evaluate the capacity and resilience of conflict-affected health systems. We thus aimed to synthesise the scope of methodological approaches and methods used in the peer-reviewed literature on health system evaluation in conflict-affected settings.

METHODS

We conducted a scoping review using Arksey and O'Malley's method and synthesised findings using the WHO health system 'building blocks' framework.

RESULTS

We included 58 eligible sources of 2,355 screened, which included examination of health systems or components in 26 conflict-affected countries, primarily South Sudan and Afghanistan (7 sources each), Democratic Republic of the Congo (6), and Palestine (5). Most sources (86%) were led by foreign academic institutes and international donors and focused on health services delivery (78%), with qualitative designs predominating (53%). Theoretical or conceptual grounding was extremely limited and study designs were not generally complex, as many sources (43%) were NGO project evaluations for international donors and relied on simple and lower-cost methods. Sources were also limited in terms of geography (e.g., limited coverage of the Americas region), by component (e.g., preferences for specific components such as service delivery), gendered (e.g., limited participation of women), and colonised (e.g., limited authorship and research leadership from affected countries).

CONCLUSION

The evaluation literature in conflict-affected settings remains limited in scope and content, favouring simplified study designs and methods, and including those components and projects implemented or funded internationally. Many identified challenges and limitations (e.g., limited innovation/contextualisation, poor engagement with local actors, gender and language biases) could be mitigated with more rigorous and systematic evaluation approaches.

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

We present a methodology for calculating the funds necessary to provide primary health care services and apply it to the Basic Package of Health Services in Afghanistan.

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.

Rebuilding child health in South Kivu, Democratic Republic of Congo (DRC): evaluating the Asili social enterprise program

BACKGROUND

The Democratic Republic of Congo (DRC) has a long history of conflict and ongoing local instability; the eastern provinces, including South Kivu, have been especially affected. Health systems and livelihoods have been undermined, contributing to massive inequities in access to health services and high rates of internal displacement. Asili, an innovative social enterprise program, aimed to provide essential community services and improve the health of under-five children in two South Kivu communities, Mudaka and Panzi, via provision of small-format, franchisable health clinics and clean water services.

METHODS

We evaluated utilization and acceptance of Asili services in two study sites, Mudaka and Panzi. Data collected included questions on housing conditions, food security, and at follow up, Asili membership and use, satisfaction with services, and recommendations for improvement. Structured pre- and post-interviews with primary caregivers of families with under-five children were the primary source of data with additional community input collected through focus group discussions.

RESULTS

At baseline, we enrolled 843 households in Mudaka and 890 in Panzi. Market segmentation analysis illuminated service usage patterns, showing Asili services were well received overall in both Mudaka and Panzi. Families reporting higher levels of proxy measures of socioeconomic status (SES), such as electricity, land ownership, and education, were more likely to use Asili services, findings that were further supported by focus group discussions among community members.

CONCLUSIONS

Rebuilding health infrastructure in post-conflict settings, especially those that continue to be conflict-affected and very low SES, is a challenging prospect. Focus group results for this study highlighted the positive community response to Asili, while also underscoring challenges related to cost of services. Programs may need, in particular, to have different levels of costs for different SES groups. Additionally, longer follow-up periods and increased stability may be needed to assess the potential of social enterprise interventions such as Asili to improve health outcomes, especially in children.

TRIAL REGISTRATION

Institutional Review Board approval for this study was obtained at Stanford University (IRB 35216) and the University of Kinshasa, DRC. Further, this study has been registered on Clinicaltrials.gov (record NCT03536286), retrospectively registered as of 4/23/2018.

Cost of provision of essential health Services in Public Health Centers of Jimma zone, Southwest Ethiopia; a provider perspective, the pointer for major area of public expenditure

BACKGROUND

Provision of up-to-date cost information is crucial for not only addressing knowledge gap on the cost of essential health services (EHS) but also budgeting, allocating adequate resources and improving institutional efficiency at public health centers where basic health services are delivered the most.

OBJECTIVE

To analyze the costs of essential health services at public health centers in Jimma Zone.

METHODS

A facility based cross-sectional study was conducted in public health centers of Jimma zone from April 10, 2018 to May 9, 2018. The study was conducted from a provider perspective using retrospective standard costing approach of one fiscal year time horizon. Step-down allocation was used to allocate costs to final services. All costs for provision EHS were taken into account and expressed in United States dollar (USD). Sixteen public health centers located in eight districts were randomly selected for the study.

RESULTS

The Average annual cost of providing essential health services at health centers in Jimma zone was USD 109,806.03 ± 50,564.9. Most (83.7%) of the total Annual cost was spent on recurrent items. Nearly half (45%) of total annual cost was incurred by personnel followed by drugs and consumables that accounted around one third (29%) of the total Annual cost. Around two third (65.9%) of the total annual cost was incurred for provision of EHS at the final cost center. The average overall unit cost was USD 7.4 per EHS per year.

CONCLUSION

Cost providing an EHS at public health centers was low and so, necessitating funding of significant resources to provide standard health care. The variability in unit costs and cost components for EHS also suggest that the potential exists to be more efficient via better use of both human and material resources.

How does health literacy affect the utilization of basic public health services in Chinese migrants?

Previous studies have focused on the determinants of basic public health services utilization, such as socioeconomic status and mobility characteristics, rather than on health literacy. Thus, this study aimed to estimate the effect of health literacy on the utilization of basic public health services among Chinese migrants. Based on the 2016 China Migrants Dynamic Survey data (N = 2335), this study used propensity score matching approach to estimate the effect of health literacy on the utilization of basic public health services, including the establishment of health records and receipt of health education, and to explore heterogeneity in this effect based on educational attainment and urban-rural status. The findings show that high levels of health literacy increased the probability of establishing health records and receiving more health education. Also, high levels of health literacy had a positive effect on the utilization of basic public health services among Chinese migrants, especially those with less education or living in urban areas. Policy makers should more carefully consider the actual situation and needs of migrants who are living in urban areas or have less education, constructing more targeted service programs.

Flexibility of deployment: challenges and policy options for retaining health workers during crisis in Zimbabwe

BACKGROUND

Zimbabwe experienced a socio-economic crisis from 1997 to 2008 which heavily impacted all sectors. In this context, human resource managers were confronted with the challenge of health worker shortage in rural areas and, at the same time, had to operate under a highly centralised, government-centred system which defined health worker deployment policies. This study examines the implementation of deployment policies in Zimbabwe before, during and after the crisis in order to analyse how the official policy environment evolved over time, present the actual practices used by managers to cope with the crisis and draw lessons. 'Deployment' here was considered to include all the human resource management functions for getting staff into posts and managing subsequent movements: recruitment, bonding, transfer and secondment. The study contributes to address the existing paucity of evidence on flexibility on implementation of policies in crisis/conflict settings.

METHODS

This retrospective study investigates deployment policies in government and faith-based organisation health facilities in Zimbabwe before, during and after the crisis. A document review was done to understand the policy environment. In-depth interviews with key informant including policy makers, managers and health workers in selected facilities in three mainly rural districts in the Midlands province were conducted. Data generated was analysed using a framework approach.

RESULTS

Before the crisis, health workers were allowed to look for jobs on their own, while during the crisis, they were given three choices and after the crisis the preference choice was withdrawn. The government froze recruitment in all sectors during the crisis which severely affected health workers' deployment. In practice, the implementation of the deployment policies was relatively flexible. In some cases, health workers were transferred to retain them, the recruitment freeze was temporarily lifted to fill priority vacancies, the length of the bonding period was reduced including relaxation of withholding certificates, and managers used secondment to relocate workers to priority areas.

CONCLUSION

Flexibility in the implementation of deployment policies during crises may increase the resilience of the system and contribute to the retention of health workers. This, in turn, may assist in ensuring coverage of health services in hard-to-reach areas.

Assessment of progress towards universal health coverage for people with disabilities in Afghanistan: a multilevel analysis of repeated cross-sectional surveys

BACKGROUND

Since 2002, Afghanistan has made much effort to achieve universal health coverage. According to the UN Sustainable Development Goal 3, target eight, the provision of quality care to all must include usually underserved groups, including people with disabilities. We investigated whether a decade of international investment in the Afghan health system has brought quality health care to this group.

METHODS

We used data from two representative household surveys, one done in 2005 and one in 2013, in 13 provinces of Afghanistan, that included questions about activity limitations and functioning difficulties, socioeconomic factors, perceived availability of health care, and experience with coverage of health-care needs. We used multilevel modelling and tests for interaction to investigate factors associated with differences in perception between timepoints and whether village remoteness affected changes in perception.

FINDINGS

The 2005 survey included 334 people, and the 2013 survey included 961 people. Mean age, employment, and asset levels of participants with disabilities increased slightly between 2005 and 2013, but the level of education decreased. Formal education and higher asset level were associated with improved availability of health care and positive experience with coverage of health-care needs, whereas being employed was only associated with the latter. Perceived availability of health care and positive experience with coverage of health-care needs significantly worsened in 2013 compared with in 2005 (227 [69%] perceived that services were available in 2005 vs 405 [44%] in 2013, p<0·0001; 255 [78%] perceived a positive experience in 2005 vs 410 [45%] in 2013, p<0·0001). Village remoteness increased in 2013 (no connectivity by paved road 186 [57%] in 2005 vs 797 [87%] in 2013, p<0·0001; mean time to reach health-care facility 64·3 min [SD 167·7] vs 84·4 min [107·7], p<0·0001) and negatively affected perception of health-care availability.

INTERPRETATION

Perceived availability of health care and experience with health-care coverage have not greatly improved for people with disabilities in Afghanistan, particularly in remote areas. Health policy in Afghanistan will need to address attitudinal, social, and accessibility barriers to health care.

FUNDING

Swedish International Development Agency.

Improving health care costing with resource consumption accounting

Purpose - The purpose of this paper is to explore the differences between a traditional costing system (TCS) and resource consumption accounting (RCA) based on a case study carried out in a hospital. Design/methodology/approach - A descriptive case study was first carried out to identify the current costing system of the case hospital. An exploratory case study was then conducted to reveal how implementing RCA within the case hospital assigns costs differently to gallbladder surgeries than the current costing system (i.e. a TCS). Findings - The study showed that, in contrast to a TCS, RCA considers the unused capacity, which is the difference between the work that can be performed based on current resources and the work that is actually being performed. Therefore, it assigns lower total costs to open and laparoscopic gallbladder surgeries. The study also showed that by separating costs into fixed and variable RCA allows managers to benefit from a pricing strategy based on the difference between the service's selling price and variable costs incurred in providing that service. Research limitations/implications - The limitation of this study is that, because of time constraints, the implementation was performed in the general surgery department only. However, since RCA is an advanced system that has the same application procedures for any department inside in a hospital, managers need only time gaps to implement this system to all parts of the hospital. Practical implications - This study concluded that RCA is better than a TCS for use in health care settings that have high overhead costs because it accurately assigns overhead costs to services by considering unused capacities incurred by a hospital. Consequently, this study provides insight into both measuring and managing unused capacities within the health care sector. This study also concluded that RCA helps health care administrators increase their competitive advantage by allowing them to determine the lowest service price. Originality/value - Since the literature review found no study comparing RCA with TCS in a real-life health care setting, little is known about differences arising from applying these systems in this context. Thus, the current study fills this gap in the literature by comparing RCA with TCS for both open and laparoscopic gallbladder surgeries.

Technical assistance for health in non-conflict fragile states: challenges and opportunities

The paper examines how best technical assistance (TA) for health might be implemented in post-conflict fragile states. It does so in the light of current development trends such as harmonization and alignment and moves towards aid instruments that favour country-led approaches. A number of key issues are addressed. The first of these considers which core principles for ethical TA might apply in post-conflict fragile states; the second reviews thematic challenges, such as the need to balance 'good enough governance' with effective attention to equity, rights and working with local health capacity. A third area for discussion is how best to plan for, and implement, long-term health TA inputs in often volatile and insecure environments, while a fourth topic is the engagement of civil society in rebuilding health systems and service delivery post-conflict. Attention to gender issues in post-conflict fragile states, including the importance of acknowledging and acting upon women's roles in peacekeeping and maintenance, the necessity to apply and sustain more gender equitable approaches to health in such contexts and how TA might facilitate such participation, represents the fifth issue for debate.

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

Background

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 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.

Methods

Twenty-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.

Results

Improvements 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.

Conclusions

By 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.

Too good to be true? An assessment of health system progress in Afghanistan, 2002-2012

The bold decision was taken in Afghanistan in 2002 to provide donor-funded public health services by means of contracting-out of predefined health care packages. This study seeks to identify the extent to which progress has been made in public health services provision in the context of broader state-building agendas. The article argues that the provision of public health services was also intended to generate a peace dividend and to legitimize the newly established government. The widely portrayed success of the contracting model is backed up by very high official figures for health service coverage. This contrasts with evidence at household level, which suggests limited utilization of public health services, and perceptions that these offer inferior quality, and a preference for private providers. The dissonance between these findings is striking and confirms that public health care cannot remain immune from powerful market forces, nor from contextual determinants outside the health field.

Measuring equity in disability and healthcare utilization in Afghanistan

This paper analyses equity in health and healthcare utilization in Afghanistan based on a representative national household survey. Equitable access is a cornerstone of the Afghan health policy. We measured socioeconomic-related equity in access to public health care, using disability--because people with disabilities are poorer and more likely to use health care--and a concentration index (CI) and its decomposition. The socioeconomic-related equity in healthcare utilization was measured using a probit model and compared with an OLS model providing the horizontal inequity index (HI). We found a low rate of healthcare facilities utilization (25%). Disabled persons are using more healthcare facilities and have higher medical expenses. Disability is more frequently associated with older age, unemployed heads of household and lower education. The Cl of disability is 0.0221 indicating a pro-rich distribution of health. This pro-rich effect is higher in small households (CI decreases with size of the household, -0.0048) and safe (0.0059) areas. The CI of healthcare utilization is -0.0159 indicating a slightly pro-poor distribution of healthcare utilization but, overall, there is no difference in healthcare utilization by wealth status. Our study does not show major socioeconomic related inequity in disability and healthcare utilization in Afghanistan. This is due to the extreme and pervasive poverty found in Afghanistan. The absence of inequity in health access is explained by the uniform poverty of the population and the difficulty of accessing BPHS facilities (a basic package of health services), despite alarming health indicators.

How much does it cost to achieve coverage targets for primary healthcare services? A costing model from Aceh, Indonesia

Despite significant investment in improving service infrastructure and training of staff, public primary healthcare services in low-income and middle-income countries tend to perform poorly in reaching coverage targets. One of the factors identified in Aceh, Indonesia was the lack of operational funds for service provision. The objective of this study was to develop a simple and transparent costing tool that enables health planners to calculate the unit costs of providing basic health services to estimate additional budgets required to deliver services in accordance with national targets. The tool was developed using a standard economic approach that linked the input activities to achieving six national priority programs at primary healthcare level: health promotion, sanitation and environment health, maternal and child health and family planning, nutrition, immunization and communicable diseases control, and treatment of common illness. Costing was focused on costs of delivery of the programs that need to be funded by local government budgets. The costing tool consisting of 16 linked Microsoft Excel worksheets was developed and tested in several districts enabled the calculation of the unit costs of delivering of the six national priority programs per coverage target of each program (such as unit costs of delivering of maternal and child health program per pregnant mother). This costing tool can be used by health planners to estimate additional money required to achieve a certain level of coverage of programs, and it can be adjusted for different costs and program delivery parameters in different settings.

National and sub-national analysis of the health benefits and cost-effectiveness of strategies to reduce maternal mortality in Afghanistan

BACKGROUND

Afghanistan has one of the highest rates of maternal mortality in the world. We assess the health outcomes and cost-effectiveness of strategies to improve the safety of pregnancy and childbirth in Afghanistan.

METHODS

Using national and sub-national data, we adapted a previously validated model that simulates the natural history of pregnancy and pregnancy-related complications. We incorporated data on antenatal care, family planning, skilled birth attendance and information about access to transport, referral facilities and quality of care. We evaluated single interventions (e.g. family planning) and strategies that combined several interventions packaged as integrated services (transport, intrapartum care). Outcomes included pregnancy-related complications, maternal deaths, maternal mortality ratios, costs and cost-effectiveness ratios.

FINDINGS

Model-projected reduction in maternal deaths between 1999-2002 and 2007-08 approximated 20%. Increasing family planning was the most effective individual intervention to further reduce maternal mortality; up to 1 in 3 pregnancy-related deaths could be prevented if contraception use approached 60%. Nevertheless, reductions in maternal mortality reached a threshold (∼30% to 40%) without strategies that assured women access to emergency obstetrical care. A stepwise approach that coupled improved family planning with incremental improvements in skilled attendance, transport, referral and appropriate intrapartum care and high-quality facilities prevented 3 of 4 maternal deaths. Such an approach would cost less than US$200 per year of life saved at the national level, well below Afghanistan's per capita gross domestic product (GDP), a common benchmark for cost-effectiveness. Similar results were noted sub-nationally.

INTERPRETATION

Our findings reinforce the importance of early intensive efforts to increase family planning for spacing and limiting births and to provide control of fertility choices. While significant improvements in health delivery infrastructure will be required to meet Millennium Development Goal 5, a paced systematic effort that invests in scaling up capacity for integrated maternal health services as the total fertility rate declines appears feasible and cost-effective.

Costs of addressing heroin addiction in Malaysia and 32 comparable countries worldwide

OBJECTIVE

Develop and apply new costing methodologies to estimate costs of opioid dependence treatment in countries worldwide.

DATA SOURCES/STUDY SETTING

Micro-costing methodology developed and data collected during randomized controlled trial (RCT) involving 126 patients (July 2003-May 2005) in Malaysia. Gross-costing methodology developed to estimate costs of treatment replication in 32 countries with data collected from publicly available sources.

STUDY DESIGN

Fixed, variable, and societal cost components of Malaysian RCT micro-costed and analytical framework created and employed for gross-costing in 32 countries selected by three criteria relative to Malaysia: major heroin problem, geographic proximity, and comparable gross domestic product (GDP) per capita.

PRINCIPAL FINDINGS

Medication, and urine and blood testing accounted for the greatest percentage of total costs for both naltrexone (29-53 percent) and buprenorphine (33-72 percent) interventions. In 13 countries, buprenorphine treatment could be provided for under $2,000 per patient. For all countries except United Kingdom and Singapore, incremental costs per person were below $1,000 when comparing buprenorphine to naltrexone. An estimated 100 percent of opiate users in Cambodia and Lao People's Democratic Republic could be treated for $8 and $30 million, respectively.

CONCLUSIONS

Buprenorphine treatment can be provided at low cost in countries across the world. This study's new costing methodologies provide tools for health systems worldwide to determine the feasibility and cost of similar interventions.

Rebuilding and strengthening health systems and providing basic health services in fragile states

The international community has compelling humanitarian, political, security and economic reasons to engage in rebuilding and strengthening health systems in fragile states. Improvements in health services and systems help to strengthen civil society and to restore legitimacy to governments. Effective engagement with fragile states to inform the design of health programmes and selection of interventions depends on donor coordination and an understanding of health system challenges. Planning requires consideration of allocation (services to be delivered), production (organisation of services), distribution (beneficiaries of services) and financing. The criteria for selecting interventions are: their impact on major health problems; effectiveness; the possibility of scale-up; equity; and sustainability. There are various options for financing and models of engagement, but support should always combine short-term relief with longer-term development. Stakeholders should aim not only to save lives and protect health but also to bolster nations' ability to deliver good-quality services in the long run.

Health sector recovery in early post-conflict environments: experience from southern Sudan

Health sector recovery in post-conflict settings presents an opportunity for reform: analysis of policy processes can provide useful lessons. The case of southern Sudan is assessed through interviews, a literature review, and by drawing on the experience of former technical advisers to the Ministry of Health. In the immediate post-conflict phase, the health system in southern Sudan was characterised by fragmentation, low coverage of health services, dismal health outcomes and limited government capacity. Health policy was extensively shaped by the interplay of context, actors and processes: the World Bank and the World Health Organization became the primary drivers of policy change. Lessons learned from the southern Sudan case include the need for: sustained investment in assessment and planning of recovery activities; building of procurement capacity early in the recovery process; support for funding instruments that can disburse resources rapidly; and streamlining the governance structures and procedures adopted by health recovery financing mechanisms and adapting them to the local context.

Rebuilding the health care system in Afghanistan: an overview of primary care and emergency services

Developing nations have many challenges to the growth of emergency medical systems. This development in Afghanistan is also complicated by many factors that plague post-conflict countries including an unstable political system, poor economy, poor baseline health indices, and ongoing violence. Progress has been made in Afghanistan with the implementation of the Basic Package of Health Service (BPHS) by the Ministry of Public Health in an effort to provide healthcare that would have the most cost-effective impact on common health problems. Trauma and trauma-related disability were both identified as priorities under the BPHS, and efforts have begun to address these problems. Most of the emergency care delivered in Afghanistan is provided by the military sector and non-governmental organizations. Security, lack of infrastructure, economic hardship, difficult access to healthcare facilities, poor healthcare facility conditions, and lack of trained healthcare providers, especially women, are all problems that need to be addressed. The long-term goal of quality healthcare for all Afghan citizens will only be met by a combination of specific goal-oriented projects, foreign aid, domestic responsibility, and time.

Contracting for health services: effects of utilization and quality on the costs of the Basic Package of Health Services in Afghanistan

OBJECTIVE

To research the effects of changes in health service utilization and quality on the costs of the Basic Package of Health Services (BPHS) in 13 provinces of Afghanistan.

METHODS

The study grouped data from 355 health facilities and more than 4000 health posts into 21 data points that represented 21 different nongovernmental organization contracts for service delivery between April 2006 and March 2007. Data were pooled from five data sets on expenditure, service utilization, quality (i.e. client satisfaction and the availability of essential medicines and female health-care providers), pharmaceuticals, and security and remoteness scores. Pearson's partial correlation and multiple linear regression models were used to examine correlations between expenditure and other study variables.

FINDINGS

Fixed costs were found to comprise most of the cost of BPHS contracts. There was no correlation between cost and utilization rate or security. The distance to the health facility was negatively correlated with costs (R(2) = 0.855, F-significance < 0.001). The presence of female health workers, indicative of good quality in this cultural context, was negatively correlated with security (r = -0.70; P < 0.001). There was a significant correlation between the use of curative services and client satisfaction but not between the use of preventive services and client satisfaction (R(2) = 0.389 and 0.272 for two types of health facilities studied).

CONCLUSION

Access to health services can be extended through contracting mechanisms in a post-conflict state even in the presence of security problems. Service characteristics, geographical distance and the security situation failed to consistently explain, alone or in combination, the observed variations in per capita costs or visits. Therefore, using these parameters as the basis for planning does not necessarily lead to better resource allocation.