Health Policy and Planning
Volume 30 Issue 10 December 2015
http://heapol.oxfordjournals.org/content/current

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Assessing the pro-poor effect of different contracting schemes for health services on health facilities in rural Afghanistan
Olakunle Alonge1,*, Shivam Gupta1, Cyrus Engineer1, Ahmad Shah Salehi2 and David H Peters1
Author Affiliations
1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Suite E8622, 615 N Wolfe Street, Baltimore, MD 21205, USA and
2Department of Health Economics and Finance, Afghanistan Ministry of Public Health, Kabul, Afghanistan
Accepted October 30, 2014.
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.
Method 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.

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Use of health care among febrile children from urban poor households in Senegal: does the neighbourhood have an impact?
Georges Karna Kone1,*, Richard Lalou2, Martine Audibert3, Hervé Lafarge4, Stéphanie Dos Santos2, Alphousseyni Ndonky2 and Jean-Yves Le Hesran5
Author Affiliations
1Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CR CHUM) et Université de Daloa (Cote d’ivoire), 850 rue saint Denis Montréal, Canada,
2UMR 151 IRD/AMU, Laboratoire Population–Environnement–Développement, Aix-Marseille Université, centre Saint-Charles, Case 10, 3, place Victor-Hugo, 13331 Marseille cedex 3, France,
3CERDI, CNRS, 65 Boulevard François Mitterrand, 63000 Clermont-Ferrand, France,
4University of Paris Dauphine 32, avenue Henri Varagnat 93143 Bondy cedex, France
Accepted December 31, 2014.
Abstract
Urban malaria is considered a major public health problem in Africa. The malaria vector is well adapted in urban settings and autochthonous malaria has increased. Antimalarial treatments prescribed presumptively or after rapid diagnostic tests are also highly used in urban settings. Furthermore, health care strategies for urban malaria must comply with heterogeneous neighbourhood ecosystems where health-related risks and opportunities are spatially varied. This article aims to assess the capacity of the urban living environment to mitigate or increase individual or household vulnerabilities that influence the use of health services. The data are drawn from a survey on urban malaria conducted between 2008 and 2009. The study sample was selected using a two-stage randomized sampling. The questionnaire survey covered 2952 households that reported a case of fever episode in children below 10 years during the month before the survey.
Self-medication is a widespread practice for children, particularly among the poorest households in Dakar. For rich households, self-medication for children is more a transitional practice enabling families to avoid opportunity costs related to visits to health facilities. For the poorest, it is a forced choice and often the only treatment option. However, the poor that live in well-equipped neighbourhoods inhabited by wealthy residents tend to behave as their rich neighbours. They grasp the opportunities provided by the area and adjust their behaviours accordingly. Though health care for children is strongly influenced by household socio-economic characteristics, neighbourhood resources (facilities and social networks) will promote health care among the poorest and reduce access inequalities. Without being a key factor, the neighbourhood of residence—when it provides resources—may be of some help to overcome the financial hurdle. Findings suggest that the neighbourhood (local setting) is a relevant scale for health programmes in African cities.