Contracting for health and curative care use in Afghanistan between 2004 and 2005

Afghanistan has used several approaches to contracting as part of its national strategy to increase access to basic health services. This study compares changes in the utilization of outpatient curative services from 2004 to 2005 between the different approaches for contracting-out services to non-governmental service providers, contracting-in technical assistance at public sector facilities, and public sector facilities that did not use contracting. We find that both contracting-in and contracting-out approaches are associated with substantial double difference increases in service use from 2004 to 2005 compared with non-contracted facilities. The double difference increase in contracting-out facilities for outpatient visits is 29 (P < 0.01), while outpatient visits from female patients increased 41 (P < 0.01), use by the poorest quintile increased 68 (P < 0.01) and use by children aged under 5 years increased 27 (P < 0.05). Comparing the individual contracting-out approaches, we find similar increases in outpatient visits when contracts are managed directly by the Ministry of Public Health compared with when contracts are managed by an experienced international non-profit organization. Finally, contracting-in facilities show even larger increases in all the measures of utilization other than visits from children under 5. Although there are minor differences in the results between contracting-out approaches, these differences cannot be attributed to a specific contracting-out approach because of factors limiting the comparability of the groups. It is nonetheless clear that the government was able to manage contracts effectively despite early concerns about their lack of experience, and that contracting has helped to improve utilization of basic health services.