Open Access Research article

Perspectives on reproductive healthcare delivered through a basic package of health services in Afghanistan: a qualitative study

Natasha Howard1*, Aniek Woodward12, Dhrusti Patel3, Ahmad Shafi4, Lisa Oddy5, Annemarie ter Veen16, Nooria Atta7, Egbert Sondorp16 and Bayard Roberts1

Author Affiliations

1 London School of Hygiene and Tropical Medicine, London, UK

2 King’s College London, London, UK

3 Duke University, Durham, North Carolina, USA

4 Rumi Consultancy, Kabul, Afghanistan

5 McGill University, Montreal, Canada

6 Royal Tropical Institute, Amsterdam, the Netherlands

7 Kabul Medical University, Kabul, Afghanistan

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BMC Health Services Research 2014, 14:359  doi:10.1186/1472-6963-14-359

Published: 28 August 2014



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.


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.


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.


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.

BPHS; SRH; Reproductive health; Health-system framework; Afghanistan