Authors: Susan Stout, Ipsita Parida

This case study examines the revival of the health care system in Afghanistan after 2001. At the start of the period all measures of health status and service delivery were extremely low. The government concluded that contracting out to NGOs was the best means of delivering primary health care services. Carefully chosen staff developed a Basic Package of Health Services that the NGOs contracted to deliver. Independent evaluators collected and reviewed data on health care system performance, which enabled the government to assess the performance of NGOs and to revise policies and service delivery priorities based on need. Data suggested rapid improvement in the infant, under-five, and maternal mortality in the period 2002–2010 indicating relative success of the contracting out modality for service delivery. Recent data suggest a leveling off of improvements in service delivery, indicating a need to further strengthen the contracting out mechanism and to more fully engage external stakeholders, particularly Parliamentarians and leadership at the provincial levels, to re-invigorate the model and further improve capacity to monitor and evaluate performance of the health system.

Key contextual conditions: In 2002, Afghanistan was among the poorest countries in the world. Coverage of basic health care services was, to the degree it had been documented, very low. The health care workforce was fragmented across skill levels and insufficient in terms of geographic distribution and gender. About 80 percent of existing health care facilities were either operated or supported by various international and some local NGOs with no policy guidance or oversight from the government. The low status afforded women has a significant impact on their health and that of their families, and there are gaps in the availability of female providers.

Key stakeholders: Government of Afghanistan; Ministry of Public Health; Ministry of Finance; Grants and Contracts Management Unit; Provincial Health Departments; Provincial Health Officers; members of Parliament; World Bank; USAID; European Union; NGO health care providers; third-party monitoring and evaluation organizations; citizens and consumers.

Lessons Learned

  • Use of a contracting-out system enabled the government to quickly provide health care services while gradually building up its capacity to manage the sector.
  • Setting explicit priorities and standards for basic health care ensured that all NGOs were working toward common goals.
  • Donors used similar procedures and contracts enabling the focus on consistent service provision at the provincial level.
  • Lump-sum contracts enabled NGOs and government to be flexible in programming and focus on performance. The intermediate transition to least-cost contracts in some insecure areas led to greater emphasis on input management which was not beneficial and there was a return to the lump-sum approach in the most recent program of support.
  • Allowing NGOs to bypass government procurement regulations enabled them to more quickly hire and place staff and purchase drugs at the local level.
  • Strong monitoring and evaluation mechanisms provide crucial information on delivery performance, which can be used to identify coverage gaps and assess NGO effectiveness. Mechanisms like the BSC (balance score card) provided robust measures of six areas of health care service delivery, including patient and provider satisfaction, and its reports encouraged cross-province benchmarking of service delivery performance and faster iteration and course-correction.
  • There was a strong focus on using data-backed information at key inflection points in the project to enable addressing delivery challenges. For example the Basic Package of Health services were formulated of the results of the Afghanistan National Health Resources Assessment and so implementers were able to use evidence to encourage stakeholder collaboration.

Development challenges

  • Rebuilding Afghanistan’s weak health infrastructure after the fall of the Taliban government.
  • Improve infant, under-five, maternal and adult mortality rates
  • Extend health care services to rural areas
  • Increase the number of female health care providers to address cultural barriers to women’s use of services and improve access to basic health care services like skilled birth attendance, family planning services, etc.

Delivery challenges

  • The need to build stakeholder support for, and establish leadership to develop and manage the process of, mobilizing and engaging NGOs in expanding their efforts for health care service delivery at a province-wide level.
  • The management of universal, primary, secondary, and district level hospital care under the scheme.
  • The design of both contracting mechanisms and the means of enabling the government to hold NGOs accountable for the delivery of services, while simultaneously developing their own capacity in terms of improving health-care.