Public-private partnerships have proven successful in implementing Afghanistan’s Basic Package of Health Services

Against the backdrop of prolonged war and civil strife, the Afghan health sector has made significant progress toward achieving the Millennium Development Goals. Since 2001, the number of functioning primary healthcare facilities has doubled, coverage of basic health services reached all 34 provinces, the quality of services in publicly-financed facilities improved, the infant mortality rate fell 22 percent, and the under-five mortality rate fell 26 percent. Though significant challenges remain, strengthening the country’s Basic Package of Health Services—in part through the introduction of public-private partnerships—has resulted in major health improvements.

Afghanistan’s health system was in very poor condition in late 2001, with few preventive and curative health services. The prolonged civil war, the shortage of staff in rural areas, and the absence of explicitly articulated national priorities all resulted in the limited availability and poor quality of services. Life expectancy was only 45 years for women and 47 for men. Coverage of services such as skilled birth attendance, antenatal care, and vaccination was very low, with severe consequences for health outcomes. In 2001 the infant mortality rate (IMR) was estimated at 165 per 1,000 live births, and the under-five mortality rate (U5MR) was estimat-ed at 257 per 1,000 live births. The maternal mortality ratio was 1,600 per 100,000 live births (reaching as high as 6,500 in some parts of the country).

In 2003, the Afghan Ministry of Public Health (MOPH) launched, with donor assistance, a far-ranging reform program to improve basic healthcare services. The Ministry adopted the role of steward, rather than direct provider, of service delivery; established a Grant and Contract Management Unit to function as a purchasing unit; divided the provinces among donors for accountability; and defined a Basic Package of Health Services.

Public-private partnerships

Through public tenders, NGOs (Non-Governmental Organizations) were then contracted to provide basic health services throughout the country. The services were provided in three levels of care facilities: basic health centers, comprehensive health centers, and district hospitals. The initial three-year contracts were lump-sum, with a performance bonus linked to specified performance targets. The contracts included baseline indicators and three-year targets for such health aspects as the number of functioning health centers, number of new outpatient visits, equipment functionality, availability of essential drugs and family planning supplies, and medical staffing. Almost all NGOs contracted under the program received a performance bonus.

The average cost of the basic health services provided by the NGOs under these PPP arrangements was $4-5 per capita, with an additional 10 percent for monitoring and evaluation and 0.5 percent for the cost of establishing and operating the Ministry’s purchasing unit.

Striking results

Because of the success of the initial contracting, another round of contracting was implemented in 2009. Key achievements from 2002-2009, as measured through independent assessments, include:

  • A near-doubling of functioning health facilities from 934 (2002) to 1775 (2009).
  • An increase in the number of facilities with skilled female health workers from 25 percent to 84 percent.
  • An increase in the number of facilities providing delivery care from 41 percent to 80 percent for basic health centers, 51 percent to 95 percent for comprehensive health centers, and 51 percent to 100 percent for district hospitals.
  • An increase in the number of women delivering with the assistance of a skilled birth attendant from six percent to more than 24 percent.
  • An increase in the number of pregnant rural women receiving at least one antenatal care consultation from less than 5 percent to 36 percent and an increase in deliveries in rural areas with skilled birth attendance from six percent to 24 percent.
  • An increase in the percent of children receiving DTP3 immunization from 21 percent to 43 percent.
  • An improvement in TB case detection rates.
  • A drop in infant mortality from 165 per 1,000 live births to 111, and the under-five mortality rate from 257 to 166.

Public-private partnerships have been key to implementing the Basic Package of Health Services. Most health services in Afghanistan are being delivered by NGOs under contracts with the Ministry or through grants from a small number of donors. In three provinces near Kabul and parts of rural Kabul province, the Ministry is contracting managers to help strengthen service delivery using its own staff.

This effort, known as the Strengthening Mechanism, involves the competitive recruitment of managers, the provision of a level of funding similar to that provided to NGOs, and the use of the same monitoring and evaluation mechanisms. Both of these approaches have been considered successful based on facility assessments and administrative data.

Government stewardship

The Ministry’s stewardship role has been central to the success of the Basic Package of Health Services. Before its introduction, NGOs often focused on a variety of priorities. Some emphasized infectious disease control, others reproductive health, and others non-communicable disease control. The various NGOs also established different types of facilities and utilized different types of staff. The Basic Package has helped ensure that there is a standard national set of priorities and a common overall approach, with a particular focus on key health interventions.

These efforts help to mobilize resources. External assistance to the sector in support of public-private partnerships grew from less than $100 million in 2003 to more than $277 million in 2008 and is increasingly “on budget.” Moreover, the proportion of external finance coming through Afghanistan’s government budget has increased dramatically.