Performance-based partnership Agreements for the reconstruction of the health system in Afghanistan

The reconstruction of the health system in Afghanistan is in its early stages, and donors have proposed Performance-based Partnership Agreements (PPAs) through which to subcontract the delivery of health services to private organisations, both for-profit and not-for-profit. Beyond ideological debates, this article sets out to explain the model underlying the PPA initiative and sheds light on empirical data concerning the assumed benefits of such an approach. The article studies privatisation and the contracting-out of health services, though there is as yet no information that can demonstrate the superiority of private over public service provision. Similarly, the merits of subcontracting have not been fully proven and such arrangements raise several ethical issues. Where PPAs are to be attempted, it is important to remain cautious and to ensure that operations are organised in such a way as to permit proper comparison. The paper concludes with recommendations to organisations involved in or considering the advantages of PPAs.Editor's note: This paper was translated from French by Grace Toleque and Deborah Eade. The original paper will be available free of charge on our website at www.developmentinpractice.org. Valéry Ridde is a PhD candidate in community health and a research/teaching assistant at Laval University in Canada. He has been responsible for humanitarian programmes in countries including Afghanistan, Iraq, and Mali and is an independent consultant in international health and programme evaluation.