The role of contractual arrangements in improving health sector ...

INTRODUCTION
Background
Afghanistan
Afghanistan’s history of the past two decades is characterized by war, anarchy,
insecurity, political instability and international neglect. During this time drastic changes in
regimes have disabled the country from making strides towards structural development.
Although peace has prevailed since 2002, the country faces real challenges in the form of
extreme poverty, insecurity, political instability, lack of infrastructure and large gender
disparities. In addition, the lack of social and human capital, absence of government income
through taxation or natural resources and the volatile political system are adding to the
complexity of health sector development. Civil society (non-profit) organizations in
Afghanistan have had a major role in provision of mainly primary health care in rural parts of
the country for more than two decades.
The Government of Afghanistan, in the post-conflict period, has embarked on a policy
of contracting out primary health care services to the nongovernmental organizations instead
of directly providing essential health services, which has been a subject of debate in the
country and outside. The purpose of this study is to document the experience of outsourcing
publicly financed health services to the private or nongovernmental organization sector in
Afghanistan, identify strengths and weaknesses and apply the lessons learnt within and in
other post-conflict countries.
Health system in Afghanistan
Current health and social indicators
The overall health and social indicators, including life expectancy and infant mortality,
are among the worst in the world. In addition, maternal mortality and the literacy rate among
women are particularly bad. Table 1 shows some of the main health and social indicators.
Table 1. Selected health and social indicators for Afghanistan
Total population 23.85 million
Life expectancy at birth (average) 44.5 years
Total fertility rate 6.3%
Contraceptive prevalence rate (modern methods) 22%
Maternal mortality ratio (per 100 000 live births) 1600 deaths
Delivery assisted by health professional 14%
Under 5 mortality rate (per 1000 live births) 257 deaths
Infant mortality rate (per 1000 live births) 165 deaths
Stunting due to chronic malnutrition 45%–59%
Literacy among women 12.7%
Household access to safe drinking water 13%
Households with adequate sanitation facilities 12%
Sources: Afghanistan Health and Social Indicators Fact Sheet (Updated March 2005), Ministry of Public Health
Afghanistan Human Development Report, United Nations Development Programme, February 2005
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