title: Poverty, vulnerability, and provision of healthcare in Afghanistan.
abstract: 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.
authors.affiliation: University College London, Leonard Cheshire Disability and Inclusive Development Centre, 1-19 Torrington Place, London WC1 E6BT, United Kingdom. j.trani@ucl.ac.uk
authors.forename: Jean-Francois
authors.initials: JF
authors.lastname: Trani
authors.forename: Parul
authors.initials: P
authors.lastname: Bakhshi
authors.forename: Ayan A
authors.initials: AA
authors.lastname: Noor
authors.forename: Dominique
authors.initials: D
authors.lastname: Lopez
authors.forename: Ashraf
authors.initials: A
authors.lastname: Mashkoor
mesh_terms: D000346:Afghanistan; D001294:Attitude to Health; D003284:Contract Services; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000458:organization & administration*; D006233:Persons with Disabilities; D005191:Family Characteristics; D005260:Female; D019538:Health Care Surveys; D005102:Health Expenditures; D006297:Health Services Accessibility; D006801:Humans; D016015:Logistic Models; D008297:Male; D010342:Patient Acceptance of Health Care; D010817:Physician-Patient Relations; D011203:Poverty; D035862:Vulnerable Populations