London School of Hygiene and Tropical Medicine, London, UK.
The University of Arizona, Tucson, AZ, USA.
Int J Equity Health. 2018 Oct 5;17(1):128. doi: 10.1186/s12939-018-0847-4.
In 2002 Afghanistan's Ministry of Public Health (MoPH) and its development partners initiated a new paradigm for the health sector by electing to Contract-Out (CO) the Basic Package of Health Services (BPHS) to non-state providers (NSPs). This model is generally regarded as successful, but literature is scarce that examines the motivations underlying implementation and factors influencing program success. This paper uses relevant theories and qualitative data to describe how and why contracting out delivery of primary health care services to NSPs has been effective. The main aim of this study was to assess the contextual, institutional, and contractual factors that influenced the performance of NSPs delivering the BPHS in Afghanistan.
The qualitative study design involved individual in-depth interviews and focus group discussions conducted in six provinces of Afghanistan, as well as a desk review. The framework for assessing key factors of the contracting mechanism proposed by Liu et al. was utilized in the design, data collection and data analysis.
While some contextual factors facilitated the CO (e.g. MoPH leadership, NSP innovation and community participation), harsh geography, political interference and insecurity in some provinces had negative effects. Contractual factors, such as effective input and output management, guided health service delivery. Institutional factors were important; management capacity of contracted NSPs affects their ability to deliver outcomes. Effective human resources and pharmaceutical management were notable elements that contributed to the successful delivery of the BPHS. The contextual, contractual and institutional factors interacted with each other.
Three sets of factors influenced the implementation of the BPHS: contextual, contractual and institutional. The MoPH should consider all of these factors when contracting out the BPHS and other functions to NSPs. Other fragile states and countries emerging from a period of conflict could learn from Afghanistan's example in contracting out primary health care services, keeping in mind that generic or universal contracting policies might not work in all geographical areas within a country or between countries.
2002 年，阿富汗公共卫生部（MoPH）及其发展伙伴通过选择将基本医疗服务包（BPHS）外包给非国家提供者（NSPs），为卫生部门开创了一个新的范例。这种模式通常被认为是成功的，但很少有文献探讨实施背后的动机以及影响计划成功的因素。本文利用相关理论和定性数据，描述了将初级卫生保健服务外包给 NSPs 的实施方式以及原因，并探讨了这种方式为何如此有效。本研究的主要目的是评估影响在阿富汗提供 BPHS 的 NSPs 表现的背景、制度和合同因素。
本定性研究设计包括在阿富汗六个省进行的个人深入访谈和焦点小组讨论，以及一次案头审查。采用了 Liu 等人提出的评估承包机制关键因素的框架，用于设计、数据收集和数据分析。
虽然一些背景因素促进了外包（例如 MoPH 的领导力、NSP 的创新和社区参与），但在一些省份，恶劣的地理环境、政治干预和不安全局势产生了负面影响。合同因素，如有效的投入和产出管理，指导了卫生服务的提供。制度因素很重要；承包 NSP 的管理能力影响其交付成果的能力。有效的人力资源和药品管理是促成 BPHS 成功交付的显著因素。背景、合同和制度因素相互作用。
有三组因素影响 BPHS 的实施：背景、合同和制度。MoPH 在将 BPHS 及其他职能外包给 NSP 时应考虑所有这些因素。其他脆弱国家和刚刚摆脱冲突的国家可以借鉴阿富汗在将初级卫生保健服务外包方面的经验，但应牢记，通用或普遍的承包政策在一个国家或国家之间的所有地理区域内可能并不适用。
