title: Perspectives on reproductive healthcare delivered through a basic package of health services in Afghanistan: a qualitative study.
abstract: BACKGROUND
  Contracting-out non-state providers to deliver a minimum package of essential health services is an increasingly common health service delivery mechanism in conflict-affected settings, where government capacity and resources are particularly constrained. Afghanistan, the longest-running example of Basic Package of Health Services (BPHS) contracting in a conflict-affected setting, enables study of how implementation of a national intervention influences access to prioritised health services. This study explores stakeholder perspectives of sexual and reproductive health (SRH) services delivered through the BPHS in Afghanistan, using Bamyan Province as a case study.
  
  
  METHODS
  Twenty-six in-depth interviews were conducted with health-system practitioners (e.g. policy/regulatory, middle management, frontline providers) and four focus groups with service-users. Inductive thematic coding used the WHO Health System Framework categories (i.e. service delivery, workforce, medicines, information, financing, stewardship), while allowing for emergent themes.
  
  
  RESULTS
  Improvements were noted by respondents in all health-system components discussed, with significant improvements identified in service coverage and workforce, particularly improved gender balance, numbers, training, and standardisation. Despite improvements, remaining weaknesses included service access and usage - especially in remote areas, staff retention, workload, and community accountability.
  
  
  CONCLUSIONS
  By including perspectives on SRH service provision and BPHS contracting across health-system components and levels, this study contributes to broader debates on the effects of contracting on perceptions and experiences among practitioners and service-users in conflict-affected countries.
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK. natasha.howard@lshtm.ac.uk.
authors.forename: Natasha
authors.initials: N
authors.lastname: Howard
authors.forename: Aniek
authors.initials: A
authors.lastname: Woodward
authors.forename: Dhrusti
authors.initials: D
authors.lastname: Patel
authors.forename: Ahmad
authors.initials: A
authors.lastname: Shafi
authors.forename: Lisa
authors.initials: L
authors.lastname: Oddy
authors.forename: Annemarie
authors.initials: A
authors.lastname: ter Veen
authors.forename: Nooria
authors.initials: N
authors.lastname: Atta
authors.forename: Egbert
authors.initials: E
authors.lastname: Sondorp
authors.forename: Bayard
authors.initials: B
authors.lastname: Roberts
mesh_terms: D000346:Afghanistan; D001291:Attitude of Health Personnel; D005260:Female; D017144:Focus Groups; D006282:Health Personnel; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D036301:Qualitative Research; D034121:Reproductive Health Services / Q000458:organization & administration*