University College London, Leonard Cheshire Disability and Inclusive Development Centre, 1-19 Torrington Place, London WC1 E6BT, United Kingdom.
Soc Sci Med. 2010 Jun;70(11):1745-55. doi: 10.1016/j.socscimed.2010.02.007. Epub 2010 Mar 9.
This paper presents findings on conditions of healthcare delivery in Afghanistan. There is an ongoing debate about barriers to healthcare in low-income as well as fragile states. In 2002, the Government of Afghanistan established a Basic Package of Health Services (BPHS), contracting primary healthcare delivery to non-state providers. The priority was to give access to the most vulnerable groups: women, children, disabled persons, and the poorest households. In 2005, we conducted a nationwide survey, and using a logistic regression model, investigated provider choice. We also measured associations between perceived availability and usefulness of healthcare providers. Our results indicate that the implementation of the package has partially reached its goal: to target the most vulnerable. The pattern of use of healthcare provider suggests that disabled people, female-headed households, and poorest households visited health centres more often (during the year preceding the survey interview). But these vulnerable groups faced more difficulties while using health centres, hospitals as well as private providers and their out-of-pocket expenditure was higher than other groups. In the model of provider choice, time to travel reduces the likelihood for all Afghans of choosing health centres and hospitals. We situate these findings in the larger context of current debates regarding healthcare delivery for vulnerable populations in fragile state environments. The 'scaling-up process' is faced with several issues that jeopardize the objective of equitable access: cost of care, coverage of remote areas, and competition from profit-orientated providers. To overcome these structural barriers, we suggest reinforcing processes of transparency, accountability and participation.
本文介绍了阿富汗医疗服务提供状况的调查结果。在低收入国家和脆弱国家，人们一直在争论医疗保健的障碍。2002 年，阿富汗政府制定了基本医疗服务一揽子计划（BPHS），将初级医疗服务承包给非国家提供者。其优先事项是让最弱势群体（妇女、儿童、残疾人和最贫困家庭）获得医疗服务。2005 年，我们进行了一次全国范围的调查，并使用逻辑回归模型，调查了服务提供者的选择。我们还测量了感知到的医疗服务提供者的可及性和有用性之间的关联。我们的结果表明，该一揽子计划的实施部分实现了其目标：针对最弱势群体。服务提供者的使用模式表明，残疾人、女性户主家庭和最贫困家庭更频繁地去卫生中心（在调查访谈前一年）。但这些弱势群体在使用卫生中心、医院以及私人提供者方面面临更多困难，其自付费用也高于其他群体。在服务提供者选择的模型中，旅行时间降低了所有阿富汗人选择卫生中心和医院的可能性。我们将这些发现置于当前关于脆弱国家环境中弱势人群医疗服务提供的辩论的大背景下。“扩大规模”进程面临着一些危及公平获取目标的问题：护理费用、偏远地区的覆盖范围以及营利性提供者的竞争。为了克服这些结构性障碍，我们建议加强透明度、问责制和参与的进程。
