title: Does contracting of health care in Afghanistan work? Public and service-users' perceptions and experience.
abstract: BACKGROUND
  In rebuilding devastated health services, the government of Afghanistan has provided access to basic services mainly by contracting with non-government organisations (NGOs), and more recently the Strengthening Mechanism (SM) of contracting with Provincial Health Offices. Community-based information about the public's views and experience of health services is scarce.
  
  
  METHODS
  Field teams visited households in a stratified random sample of 30 communities in two districts in Kabul province, with health services mainly provided either by an NGO or through the SM and administered a questionnaire about household views, use, and experience of health services, including payments for services and corruption. They later discussed the findings with separate community focus groups of men and women. We calculated weighted frequencies of views and experience of services and multivariate analysis examined the related factors.
  
  
  RESULTS
  The survey covered 3283 households including 2845 recent health service users. Some 42% of households in the SM district and 57% in the NGO district rated available health services as good. Some 63% of households in the SM district (adjacent to Kabul) and 93% in the NGO district ordinarily used government health facilities. Service users rated private facilities more positively than government facilities. Government service users were more satisfied in urban facilities, if the household head was not educated, if they had enough food in the last week, and if they waited less than 30 minutes. Many households were unwilling to comment on corruption in health services; 15% in the SM district and 26% in the NGO district reported having been asked for an unofficial payment. Despite a policy of free services, one in seven users paid for treatment in government facilities, and three in four paid for medicine outside the facilities. Focus groups confirmed people knew payments were unofficial; they were afraid to talk about corruption.
  
  
  CONCLUSIONS
  Households used government health services but preferred private services. The experience of service users was similar in the SM and NGO districts. People made unofficial payments in government facilities, whether SM or NGO run. Tackling corruption in health services is an important part of anti-corruption measures in Afghanistan.
authors.affiliation: CIET Trust Botswana, PO Box 1240, Gaborone, Botswana. acockcroft@ciet.org
authors.forename: Anne
authors.initials: A
authors.lastname: Cockcroft
authors.forename: Amir
authors.initials: A
authors.lastname: Khan
authors.forename: Noor
authors.initials: N
authors.lastname: Md Ansari
authors.forename: Khalid
authors.initials: K
authors.lastname: Omer
authors.forename: Candyce
authors.initials: C
authors.lastname: Hamel
authors.forename: Neil
authors.initials: N
authors.lastname: Andersson
mesh_terms: D000346:Afghanistan; D016001:Confidence Intervals; D003258:Consumer Behavior; D003284:Contract Services / Q000191:economics / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D003415:Crime / Q000191:economics / Q000331:legislation & jurisprudence* / Q000523:psychology; D003695:Delivery of Health Care / Q000191:economics* / Q000592:standards; D005260:Female; D017144:Focus Groups; D019538:Health Care Surveys; D006291:Health Policy; D006296:Health Services / Q000191:economics* / Q000592:standards; D006801:Humans; D008297:Male; D008485:Medical Audit; D015999:Multivariate Analysis; D016017:Odds Ratio; D009938:Organizations; D010465:Perception; D012922:Social Change