After the collapse of the Taliban in 2001, Afghanistan’s health system was in a state of crisis. The maternal mortality ratio was 1600 deaths per 100,000 live births, the highest ever recorded, and less than 10% of the population lived within a one hour walking distance to a health facility.¹ In conjunction with other stakeholders, the Ministry of Public Health drafted a Basic Package of Health Services (BPHS) to strengthen the health system. The services incorporated in the BPHS included maternal and newborn health, child care and immunization, public nutrition, communicable diseases, mental health, disability, and regular supply of essential drugs. However, the MOPH lacked the facility infrastructure necessary to provide these services, and its capacity was insufficient to deliver the breadth and dose of care needed to improve access and outcomes. To remedy this gap, the MOPH partnered with NGOs to provide the BPHS. NGOs were chosen through a bidding process after which the selected organizations received 1-3 year contracts with payment contingent upon meeting pre-specified goals. In addition to these partnerships, the MOPH instituted community-based care delivered by CHWs at rural health posts. These efforts resulted in enhanced access and utilization, with a marked increase in annual patient visits from 2.0 million to 44.8 million.¹

In 2008 the government of Lesotho, recognizing the need to rebuild the only tertiary hospital in the country, entered a public-private integrated partnership with the goal of improving quality of care without compromising patient cost.² Through a competitive bidding process, the government selected the organization Tsepong to design and build a hospital and gateway clinic, update filter clinics, and provide all services for an 18-year contract. Central to the commitment was improving quality and access, specifically to accomplish the goals of a 24% increase in outpatient visits and a 21% increase in inpatient visits. Tsepong comprises community groups, funders, and providers and as such has been committed to social accountability.³ Local businesses, women’s groups, and physicians comprise 40% of Tsepong, ensuring that service delivery is accountable to patient needs and that adequate working conditions and career development are in place. Additionally, the Government of Lesotho has worked to ensure that services are high-quality through quarterly audits conducted by an independent management company and required accreditation of all providers. The hospital has been serving patients since 2011.