Too good to be true? An assessment of health system progress in Afghanistan, 2002–2012

Abstract

The bold decision was taken in Afghanistan in 2002 to provide donor-funded public health services by means of contracting-out of predefined health care packages. This study seeks to identify the extent to which progress has been made in public health services provision in the context of broader state-building agendas. The article argues that the provision of public health services was also intended to generate a peace dividend and to legitimize the newly established government. The widely portrayed success of the contracting model is backed up by very high official figures for health service coverage. This contrasts with evidence at household level, which suggests limited utilization of public health services, and perceptions that these offer inferior quality, and a preference for private providers. The dissonance between these findings is striking and confirms that public health care cannot remain immune from powerful market forces, nor from contextual determinants outside the health field.

Keywords:

• Afghanistan
• health service development
• health system analysis
• contracting-out
• state building

Acknowledgements

The research was undertaken as part of the project ‘Providing Health Care in Severely Disrupted Environments: A Multi-country Study’, largely funded through the Danish Government Ministry of Foreign Affairs. The authors thank Maurizio Murru for contributions from his own fieldwork and to the research as a whole, and Althea-Maria Rivas for details from her field research. Gyuri Fritsche, Egbert Sondorp, Lindsay Morgan and Ilkhom Gafurov made helpful comments on a draft of an earlier report.