Contracting for health services in Afghanistan: An analysis of the changes in outpatient services utilization and quality between 2004 and 2005

Afghanistan's health sector reconstruction relies on contracting for service delivery. Each major health sector donor funded different approaches to contracting. The key differences between the contracting-out approaches are whether NGOs receive performance incentives, the intensiveness and independence of monitoring from service providers and contract managers and NGO capacity building. Management support was contracted-in to the public sector under contracting-in. This thesis examines how different ways of specifying and monitoring contracts influence curative care utilization and structural, process and patient perceived quality.;Changes over 2004-2005 in curative outpatient visits and quality are compared between individual contracting and non-contracted groups. Curative care utilization is operationalized as new outpatient visits, visits from female patients and the poorest 20% of the population. Quality is operationalized with structural indices of staffing & service capacity, child health services, infrastructure & basic equipment and drugs & contraceptives, process indices of under-five patient assessment and caretaker counseling, and a scale of patient perceived quality.;Contracting-out and contracting-in have been effective policy tools for increasing curative care utilization, including utilization by female patients and the poor. All the contracting-out approaches show increases in curative care utilization relative to non-contracted facilities.;There are substantial differences in improvements in structural quality between contracting-out approaches. The pattern of differences suggests that rigorous contract monitoring is key to improving structural quality. Contracted NGOs have achieved large improvements in structural quality when given performance incentives, even without technical capacity building support. Contracts managed by the Afghan Ministry of Public Health (MoPH) show larger improvements in structural quality than contracts managed by an experienced international non profit organization. This allays concerns about the MOPH's contract management capacity.;Contracting-in facilities also show substantial improvements in two of the structural quality indices relative to non-contracted facilities. This indicates progress despite the lack of prior experience with service delivery.;The improvements in under-five patient assessment and caretaker counseling have been disappointing in all contracting groups and are a priority for future action. No contracting group demonstrates increases in patient perceived quality. However, since patient perceived quality is very high in 2004, there is less potential for improvement.