Non-governmental organisations are contracted to provide most of Afghanistan's health services. What can we learn from their approach and is it sustainable in the longer term?
Many Western health systems contract out healthcare services, including the NHS. Contracts are less common in low income countries, but contracts with non-governmental organisations (NGOs) to deliver health services are increasingly being promoted in so called fragile states—countries affected by conflict, emerging from conflict, or otherwise lacking the will or capacity to implement pro-poor policies.1 Contracts with NGOs are seen as an effective way to expand services quickly. This is important to reach many of the poorest people living in these countries and thus to make progress towards the millennium development goals for health, but many questions about contracting remain unanswered.