title: Assessing the pro-poor effect of different contracting schemes for health services on health facilities in rural Afghanistan.
abstract: BACKGROUND
  Despite progress in improving health outcomes in Afghanistan by contracting public health services through non-governmental organizations (NGOs), inequity in access persists between the poor and non-poor. This study examined the distributive effect of different contracting types on primary health services provision between the poor and non-poor in rural Afghanistan.
  
  
  METHODS
  Contracts to NGOs were made to deliver a common set of primary care services in each province, with the funding agencies determining contract terms. The contracting approaches could be classified into three contracting out types (CO-1, CO-2 and CO-3) and a contracting-in (CI) approach based on the contract terms, design and implementation. Exit interviews of patients attending randomly sampled primary health facilities were collected through systematic sampling across 28 provinces at two time points. The outcome, the odds that a client attending a health facility is poor, was modelled using logistic regression with a robust variance estimator, and the effect of contracting was estimated using the difference-in-difference approach combined with stratified analyses.
  
  
  RESULTS
  The sample covered 5960 interviews from 306 health facilities in 2005 and 2008. The adjusted odds of a poor client attending a health facility over time increased significantly for facilities under CO-1 and CO-2, with odds ratio of 2.82 (1.49, 5.36) P-value 0.001 and 2.00 (1.33, 3.02) P-value 0.001, respectively. The odds ratios for those under CO-3 and CI were not statistically significantly different over time. When compared with the non-contracting facilities, the adjusted ratio of odds ratios of poor status among clients was significantly higher for only those under CO-1, ratio of 2.50 (1.32, 4.74) P-value 0.005.
  
  
  CONCLUSIONS
  CO-1 arrangement which allows contractors to decide on how funds are allocated within a fixed lump sum with non-negotiable deliverables, and actively managed through an independent government agency, is effective in improving equity of health services provision.
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Suite E8622, 615 N Wolfe Street, Baltimore, MD 21205, USA and oalonge@jhsph.edu.
authors.forename: Olakunle
authors.initials: O
authors.lastname: Alonge
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Suite E8622, 615 N Wolfe Street, Baltimore, MD 21205, USA and.
authors.forename: Shivam
authors.initials: S
authors.lastname: Gupta
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Suite E8622, 615 N Wolfe Street, Baltimore, MD 21205, USA and.
authors.forename: Cyrus
authors.initials: C
authors.lastname: Engineer
authors.affiliation: Department of Health Economics and Finance, Afghanistan Ministry of Public Health, Kabul, Afghanistan.
authors.forename: Ahmad Shah
authors.initials: AS
authors.lastname: Salehi
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Suite E8622, 615 N Wolfe Street, Baltimore, MD 21205, USA and.
authors.forename: David H
authors.initials: DH
authors.lastname: Peters
mesh_terms: D000346:Afghanistan; D003150:Community Health Workers; D003284:Contract Services / Q000145:classification / Q000191:economics*; D032982:Contracts; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data*; D006306:Health Surveys; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D015233:Models, Statistical; D011203:Poverty; D011320:Primary Health Care; D019035:Rural Health Services
keywords: Contracting; community health workers; facility-based services; health inequity; performance-based financing