Determinants of primary care service quality in Afghanistan

OBJECTIVE: To identify factors associated with service quality provided by agencies implementing a basic package of health services in Afghanistan. DESIGN: Cross-sectional survey of outpatient health facilities, health workers, patients and caretakers. SETTING: Primary health care facilities in every province of Afghanistan. MAIN OUTCOME MEASURES: Composite scale measuring the quality of clinical processes in four areas: patient histories, physical examinations, communication and time spent with patient. RESULTS: No difference in service quality was observed between male and female providers or between male and female patients, but when both the provider and patient were female quality was much higher. Overall, the quality of care at non-governmental organization and government-managed health facilities did not differ, but the poor received higher quality care at non-governmental facilities than at government facilities. Doctors provided higher quality care than lower level providers. Provision of six or more supervisory visits in the last 6 months was associated with higher service quality. Training doctors in integrated management of childhood illness was not associated with quality, but when lower level health workers received such training the quality of patient-provider communication was higher. Other recurrent inputs and geographic remoteness are not associated with the quality of care provided. CONCLUSIONS: The government's strategy to form partnerships with non-governmental organizations has led to higher quality of care provided to the poor. This represents a promising start in the reconstruction of Afghanistan's health system and provides useful evidence to other countries striving to increase access to quality care for the poor.