Elgar Companion to Health and the SDGs – pre publication proof
Najibullah Safi, Ahmad Jan Naeem, and Palwasha Anwari
Introduction
Worldwide, over 274 million people will need humanitarian assistance, and this is the
highest in decades. As a result of the humanitarian crisis affecting access to healthcare
services, women and children bear ample additional morbidity and mortality. The impact of
armed conflict on the health of women and children surpasses the effects on those directly
affected by conflict (E. Bendavid et al., 2021). Children are the first victims of all types of
emergencies and pay the highest price (UNICEF, 2022).
Since the Soviet Union invasion in 1979, Afghanistan has suffered from ongoing conflict and
humanitarian crises. The last political transition in mid-August 2021 was triggered by the
sudden military withdrawal of the United States and its allies, resulting in the collapse of the
elected government, and put at severe risk all development gains made over the last two
decades. Following the political turnover, much of the development funding, including
financing for health, was paused. This created substantial risks for the provision of basic
health services and negatively impacted access to health care, particularly for women,
children, and other vulnerable groups.
The United Nations estimates that out of a population of close to forty-one million 22.1
million people in Afghanistan need life-saving humanitarian support in 2022. (World Bank
(WB), 2023) This shows around a 20% increase compared to 2021. The increase in the
number of people needing assistance is driven by multiple shocks: from the takeover of
government; recurrent natural disasters; poor recovery from previous disasters; reduced
donor funding; worsening economic conditions; increased food insecurity; and lack of access
to basic services, including healthcare. The health needs are immense; more than 14.5
million people, including 2.9 million women of reproductive age (15-49 years old), 700,000
displaced people, and 1.2 million people with disability, need urgent support in 2022 (UNOCHA,
2022).
In this study, we focus on the last 20 years (2002-2022) of Afghanistan’s health system and
its path to achieving the sustainable development goals in the context of ongoing conflict
and humanitarian crises.
Approach and Objectives
The World Health Organization’s (WHO) health system’s building blocks serve as the study’s
analytical framework and shapes the analysis. The blocks are: Health service delivery; Health
workforce; Health information systems; Access to essential medicines; Health systems
financing; and Leadership and governance (WHO, 2010).
Drawing on national documents, regional and international published literature, we first
examine the achievements of the health system over the last two decades (2002- 2021) and
Elgar Companion to Health and the SDGs – pre publication proof
the factors that led to constrained access to health services with the pausing of donor funds.
Then we assess potential approaches to sustain the gains and prevent excessive morbidity
and mortality, particularly among women, children, and other vulnerable groups.
As the case of Afghanistan demonstrates, many challenges are technical, and indicators
have seen significant improvement with evolving the system and its performance. The main
challenge to improving access of Afghan people to health care, however, is adaptive, i.e.,
requiring a fundamental rethink about how to engage with the situation post-Taliban
takeover in 2021. The chapter ends with some reflections on this, particularly considering
the obligations of the international community.
Definition of terms
Health system - A health system consists of all organizations, people, and actions whose
primary intent is to promote, restore or maintain health. This includes efforts to influence
determinants of health as well as more direct activities that improve health (WHO, 2007).
Power- the recent feminist theory of power by Luttrell and colleagues categorizes four types
of power: (Cecilia Luttrell et al., 2009)
1- Power over (ability to influence or coerce)
2- Power to (organize and change existing hierarchies)
3- Power with (power from collective action)
4- Power within (power from the individual)
Healthcare access is a complex concept and is measured in terms of availability,
affordability, physical accessibility, and acceptability of services (M. Gulliford et al., 2002). In
other words, healthcare access is the ability to obtain healthcare services such as
prevention, diagnosis, treatment, and management of diseases, disorders, and other healthimpacting
conditions. Healthcare must be affordable and convenient to be accessible.
Four aspects must be evaluated (M. Gulliford et al., 2002):
1- If services are available
2- If there is an adequate supply of services
3- If opportunities to obtain healthcare exists
4- If a population may “have access” to services.
Gender refers to those characteristics of women and men which are socially constructed,
whereas “sex” designates those characteristics that are biologically determined (WHO,
2002).
Health equity, also referred to as socioeconomic health equity, is defined as “the absence of
unfair and avoidable or remediable differences in health among population groups defined
socially, economically, demographically or geographically” (Karien Stronks et al., 2016).
In other words, health inequities are health differences that are socially produced,
systematic in their distribution across the population, and unfair. (Whitehead M. Dahlgren
G, 2006)
Elgar Companion to Health and the SDGs – pre publication proof
The evolution of the Afghanistan health system
Afghanistan is a landlocked country located in South Asia that shares borders with Pakistan,
Iran, Turkmenistan, Uzbekistan, Tajikistan, and China. It has an estimated population of
approximately forty-one million and growing at 2.9%, but no formal census since 1979. Over
the last four decades, the country has gone through numerous difficulties at various points.
The monarchy was ended in 1973, which was followed by a series of military coups that
resulted in the establishment of a communist regime in 1978. With the support of the Soviet
military invasion, the regime sustained its power until 1991. Then, the country went through
a civil war (from 1992-1996) when different factions of Mujahidin, who carried out a holy
fight (Jehad) against the communist regime, fought against each other for power. The
situation continued by the first round of the Taliban regime (1996-2001), which was ended
by the military intervention of the international community led by the United States. Over
the last 20 years (2002-2021), after an interim government, the first elected government
came into power in 2004, which was supported by the upper and lower house parliaments.
The Taliban came into power for the second time in mid-August 2021 with the sudden
withdrawal of the United States military and its allies. It resulted in the collapse of the
democratic administration. Since then, the Taliban administration has not been recognized
by any single country, while some levels of diplomatic interactions are happening with the
Taliban militant group as a de-facto government.
Over the last forty years, the provision of social services, including health, has experienced
drastic changes impacted by the type and degrees of conflict and the interest of the central
government. Throughout this period, the engagement of the international community
indicated considerable variation from supporting the state, to supporting rebels and refugee
camps in neighbouring countries, to deliberate non-engagement.
Traditional medicine has an ancient history, and it was the only treatment practice until the
early 20th century in Afghanistan. The first group of Afghan doctors was trained in Turkey in
the 1920s. The physician assistant program and the first medical college were established in
1931 and 1932, respectively. Throughout the 1960s, the health system was limited to a few
hospitals in large urban areas. Health services in rural areas were restricted to vertical
programs such as malaria, leishmaniasis, and tuberculosis (TB) control. After the Soviet
Union invasion in 1979, the health system was limited to major national and provincial
hospitals, polyclinics and mother and child health (MCH) clinics. On the other hand, nongovernmental
organizations (NGOs) initiated cross-border activities in rural areas. Following
the withdrawal of the Soviets troops, gradually, more areas were accessible to NGOs to
establish a network of primary healthcare facilities.
Between 1992 – 1996 Mujahidin-led government and then the Taliban’s first regime (1996-
2001) showed minimum interest in the health sector. Imposed strict gender segregation,
bans on girls’ education, and women’s social participation all further constrained access to
health services for women and children. However, during the first Taliban regime, with
improved security, the network of NGOs was further expanded. Overall, the country had a
Elgar Companion to Health and the SDGs – pre publication proof
fragmented health system until 2001. After the collapse of the Taliban in 2001, the Ministry
of Public Health (MoPH) of the new government developed a national health policy and
strategy stating to deliver primary health care (PHC) through a Basic Package of Health
Services (BPHS) across the country. The BPHS was further amended in 2005 and 2010. In
addition, the MoPH introduced the Essential Package of Hospital Services (EPHS) in 2005 to
provide referral support to BPHS facilities.
The state of the Afghan health system in 2021 (until the second Taliban
administration)
Health Services Delivery
The rebuilding of Afghanistan’s health system started in 2002 with the support of the
international community. In the initial phase, the MoPH introduced the contract-out to nongovernmental
organizations (NGOs) for delivering the Basic Package of Primary Health
Services (BPHS) and Essential Package of Hospital Services (EPHS). The system was financed
by donors’ funds managed through different mechanisms by the World Bank (WB),
European Union (EU), and the United States Agency for International Development (USAID).
Initially, it featured disparate and fragmented contract management, with each donor had
its own preferred performance indicators. The health donors collectively financed the
System Enhancement for Health Action in Transition (SEHAT) project, spanning from 2013-
2018. However, after 12 years of supporting the health system, in May 2015, donors agreed
to adapt a harmonized approach. This unified strategy was managed by the World Bank
under the Afghanistan Reconstruction Trust Fund (ARTF) scheme (World Bank (WB), 2018).
In Afghanistan, health services are provided through a network of 3,231 public health
facilities. On average, each facility covers a population of 13,000, but coverage varies from
4,100 in Nuristan province to 20,400 people per health facility in Kandahar province (MoPH,
2020). Overall, 93% of the population can access health facilities within 2 hours of travel by
any means of transportation (Central Statistics Organization, 2016-2017). However, the
range of services available to people may vary. In reference to Afghanistan Demographic
and Health Survey 2015 (DHS), Afghanistan Health Survey (AHS) 2018, Multiple Indicator
Clusters Survey (MICS)2022-2023, substantial inequity exists in the access to and utilization
of health services. This is evident, for instance, in illustration of the unequal distribution of
coverage by immunization services shown in Figure 1 (Afghanistan National Statitics and
Information Authories (NSIA) KIT the Royal Tropical Institue (KIT), and Ministry of Public
Health, April 2019)
Figure 1 Proportion of children 12-23 months who were fully immunized according to vaccine cards or mother’s
recall by province, Afghanistan. The darker the color the lower the immunization coverage.
Source: Afghanistan Multiple Cluster Indicators (MICS) 2022-2023(UNICEF, 2023)
Elgar Companion to Health and the SDGs – pre publication proof
In addition to public facilities private health care facilities operate in parts of the country.
Where available, in general, people prefer to use private facilities for outpatient care and
public facilities for in-patient care (Central Statistics Organization, 2016-2017).
Considering the composite index for access and quality of health care defined by the Global
Burden of Diseases (GBD), Afghanistan is positioned 191st among 195 countries. Women
and girls in Afghanistan face significant barriers in accessing healthcare and other social
services (UNDP, 2020). In 2018, Afghanistan Gender Development Index (GDI), which
measures access to health services, empowerment, and economic status indicators, was
recorded at 0.723, ranking the country 170th out of 189 countries and territories (UNDP,
2020). However, with the onset of the Taliban's second regime, this index declined 14%
further to 0.622, placing Afghanistan 183rd out of 193 countries (UNDP, 2022). Even during
the democratic government, the participation of women in decision-making processes in
Afghanistan was notably low, ranging from 10% in private and government institutions to
20% in NGOs. With the Taliban’s ban on women’s education beyond grade six, coupled with
restrictions on all forms of women's participation in social life, these figures have further
deteriorated.
Health Workforce
Provision of the right combination of health services in appropriate quantities to address
health needs in a specific type of health facility, depends on the deployment and retention
of the right mix of healthcare providers with the right mix of skills. Initial training for Human
Resources for Health (HRH) is undertaken by both public and private universities, while
Elgar Companion to Health and the SDGs – pre publication proof
medical, nursing, and midwifery councils are responsible for the regulation of HRH.
Refresher training and continuous medical education are provided by different institutions,
including the MoPH, the Ministry of Higher Education (MoHE), and NGOs. Information on
the number, qualifications, skills, and deployment of HRH is scattered and is being compiled
by medical, midwifery, and nursing councils, recently established in 2016 and 2018,
respectively.
Overall, it is estimated that 47,000 healthcare providers are working in the health sector,
out of whom two-thirds are professional staff, while one-third are categorized as support
staff (MoPH, 2020). Medical doctors, nurses, midwives, and technicians constitute 27%,
28%, 13%, and 13% of the total healthcare providers, respectively. Females accounted for
only 32% of the total healthcare providers in 2020 (MoPH, 2020). Reportedly there are
provinces with no female medical doctor, which hampers the access of females and children
to primary healthcare services. On average, there are less than 10 professional staff
(medical doctors, nurses, midwives, technicians, etc.) per 10,000 population, which is much
below the WHO threshold of 44.5 per 10,000 population for universal health coverage
(WHO, 2016). Minimal information is available on the distribution of staff across the country
(Najibullah Safi et al., 2018). MoPH estimates indicate that a substantial portion of staff are
concentrated in large cities, and up to 50% of the professional staff are working only in
Kabul, the capital (MoPH, 2020). Panjshir province has the highest density, with 21 doctors,
nurses, and midwives per 10,000 population, compared to Paktika province, with the lowest
density of 2.3 per 10,000 population (MoPH, 2020). Balanced Score Card (BSC) 2018 reports
that only 35% of the basic primary health (BPHS) and 72% of hospital (EPHS) facilities
deployed the recommended number of staff (KIT the Royal Tropical Institute (KIT), 2018). In
general, staff salaries remain low. However, NGOs provide much higher salaries and benefits
compared to the government.
Health Systems Financing
In 2021, Afghanistan spent nearly US$ 3 billion on health (US$ 97.80 per capita). This
represents 22% of the Gross Domestic Product (GDP). A large portion (77.20%) of the total
health expenditures is paid by families at the point of service delivery as out-of-pocket
expenditures, followed by donors (19.30%) and the government of Afghanistan
(3.30%)(MoPH, 2023). Over the last decade, the Current Health Expenditures (CHE) followed
the same trend: government contribution remained low at 3% – 6 %, donors funding at 18–
23%, and out-of-pocket expenditures consistently remained high at over 77%. The CHE as a
percentage of the GDP (22%) is the highest in the region, while government spending on
health as a percentage of GDP remains the lowest (less than 1%) in the region (MoPH,
2020). In general, total health expenditures have grown from US$ 1.04 billion in 2008 to US$
2.6 billion in 2017 and to US$ 3 billion in 2021(MoPH, 2023).
In 2017, around 90% of the out-of-pocket expenditures were consumed by medical goods
and diagnostic services (MoPH, 2019). Forty-four percent and 25% of the households spent
more than 10% and 25% of their total expenditures on health, respectively. This pushes 14%
of households under the national poverty line every year (MoPH, 2020).
Elgar Companion to Health and the SDGs – pre publication proof
The BPHS and EPHS were financed by key health sector donors (USAID, WB, EU, Canada)
through a pool fund called Afghanistan Reconstruction Trust Fund (ARTF). In addition to
ARTF, donors directly financed many projects in the health sector through off-budget
support1. The average cost of EPHS and BPHS is estimated at US$ 6.9 per capita per year,
while it varies from US$ 3.27 in Herat province to US$ 18.87 in Nuristan province. The
provincial differences are due to harsh geographical terrain, scattered population, and to
some extent, prevalent inequities. Almost half of the development budget of the health
sector, which was US$ 269 million in 2018, was allocated to BPHS and EPHS. Off-budget
support mainly finances immunization, including polio eradication and vertical disease
control programs for TB, Malaria, and HIV/AIDS, and salaries of technical assistance (MoPH,
2020).
As reported in successive National Health Accounts (NHA), pharmaceutical expenditures
have been gradually increasing and reached 42% of the CHE in 2021. At the same time, 6.2%
and 14% of the CHE are linked with hospital services and public health interventions,
respectively (MoPH, 2023). Medical tourism, primarily to neighbouring countries, remains a
substantial portion of total health expenditures, accounting 13% of out-of-pocket
expenditures in 2017. This shows a substantial decline from 26% in 2012 (MoPH, 2019).
There has been no updated figure since the Taliban's return to power. However, due to visa
restrictions for Afghans imposed by many countries, including common medical tourism
destinations, these figures may have changed.
Access to medicines and medical products
This is an essential part of the health system. It focuses on regulation, quality control, supply
chain management, financing medicines, essential supplies, and information management
system. The Afghanistan Food and Drug Authority (AFDA) is the responsible entity for
licensing both institutions and individuals, evaluation and registration, quality control of
imported and locally produced medicines, and inspection of the pharmaceutical institutions
from production to drug-selling outlets (MoPH, 2020).
The regulation of medicines includes pre-market interventions, which focus on assessing the
required infrastructure and licensing of staff and institutions. Afghanistan has 19 local
manufacturers, 600 importers, and more than 15,000 pharmacies. Overall, 9,550 medicines
and 2,454 medical products are registered. However, due to widespread corruption, and
porous borders, large quantities of medicines and medical products are illegally imported to
the country on a regular basis. A recent assessment indicated that only 57% of the
pharmacies were able to provide some evidence of registration of the products they sold,
and only 7% were able to provide some evidence of inspection by AFDA (Management
Sciences for Health (MSH), 2015). At the same time, AFDA attempted to set prices for
medicines, and only in 2019 were 6,357 items of medicine and 234 items of medical
products finally priced. However, the widespread corruption and limited inspection capacity
1 Off-budget support: the fund is directly channelled to the implementers, mainly UN agencies and
international NGOs, and it is not reflected in the national health budget.
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prevent enforcement of these set prices (Afghanistan Food and Drug Authority (AFDA),
2019).
Quality control is undertaken by the national quality control laboratory. In 2019, 18,000
teams of medicines were tested, and only 3-4 % did not meet the national standards.
However, a reference laboratory in India cross-checked the initial result and found that
around 15% of the medicines do not meet the required standards. The result confirms the
absence of the required capacity for quality control in the country (KIT the Royal Tropical
Institue (KIT), 2015) and associated corruption. The AFDA does not have the required staff
and resources to ensure effective post-marketing surveillance. Their activities are mainly
limited to the Capital, Kabul. In addition, the capacity for pharmacovigilance is limited, and
only 22 national hospitals, one private, and four district hospitals reported Adverse Drug
Reactions (ADR) after post-marketing. In 2019, only 110 episodes of ADR were recorded.
Required medicines can be purchased from local manufacturers or imported from outside.
Expanding local production through Public Private Partnership (PPP) was a national priority
before the Taliban retune in 2021. The supply chain system is fragmented. Each contracted
NGO in thirty-one provinces manages its own supplies, while the three provinces under the
strengthening mechanism are supplied by UNICEF. The MoPH pool procurement
mechanisms only cover national and reform hospitals (MoPH, 2020). The purchased items
are stored in the central medical stock and based on need, distributed to different health
facilities. Supplies for the vertical programs of immunization, public nutrition, and diseases
control programs (TB, Malaria, and HIV) are purchased and funded by health development
partners, stored in the central medical store, and distributed from there according to the
need. Since 2022, when UNICEF assumed responsibility for the contract management of
BPHS and EPHS, it has been procuring the necessary medicines and supplies for health
facilities. Meanwhile, the International Committee of the Red Cross (ICRC) handles the
procurement of supplies for provincial and national hospitals. Availability of medicines is
monitored by BSC and Health Management and Information System (HMIS); both share a
description of availability which is based on the presence of any quantity of medicines in a
health facility at the time of verification. This could be misleading and unable to capture
accurate stock-outs. Stockouts are more common in hospitals. Only 20% reported a
complete set of medicines for the Outpatient Department (OPD), as compared to 80% in
primary healthcare facilities (KIT the Royal Tropical Institute (KIT), 2018). Medicines remain
the largest part of out-of-pocket expenditures on health and represented 41% of the CHE
(US$ 1.2 billion) in 2021(MoPH, 2023).
Health Information Systems
A health information system is one of the most important building blocks of the health
system as everyone uses the data to monitor the trends of disease, make decisions, or
contribute to generating information and knowledge. Health Management and Information
System (HMIS) constitutes the largest component of HIS. Other components include vital
statistics, disease surveillance, research, and monitoring and evaluation.
Elgar Companion to Health and the SDGs – pre publication proof
The Afghan HMIS consists of data collection, compilation, analysis, reporting, and feedback
to service providers. Data is primarily generated in communities or health facilities. Monthly
paper-based compiled data is sent to the provincial public health directorate, where it’s
entered into an Access database. All the information is reviewed in the monthly meeting of
the provincial health directorates and sent to MoPH on a quarterly basis. After quality
control and necessary adjustment, data is uploaded to District Health Information Software-
2 (DHIS-2), where standard indicators are calculated, and pre-designed dashboards are
generated. DHIS-2 data are made available to data users within and outside the MoPH. Data
are also used to produce quarterly, semi-annual, and annual reports. Through the DHIS-2
platform, several databases such as tuberculosis, malaria, expenditure management
information system, human resources, and pharmaceuticals have been integrated and are
available for HMIS users.
The HMIS produces several indicators, ranging from coverage and utilization to access,
availability, and quality. Population-related indicators, where population estimates are the
denominator, are systematically different and higher than the same estimates obtained
through household surveys. Thus, for example, coverage of the Penta-3 vaccine estimated in
the HMIS 2018 is 92%, 98% for first antenatal care (ANC), and 67% for institutional
deliveries, while the same indicators obtained from the Afghanistan Health Survey 2018 are
61%, 65%, and 56%, respectively(Afghanistan National Statitics and Information Authories
(NSIA) KIT the Royal Tropical Institue (KIT), and Ministry of Public Health, April 2019; MoPH,
2020).
One of the reasons for this discrepancy may be the inadequacy of population estimates.
Since the latest census was conducted in 1979, population data have been estimated and
projected based on assumptions of growth and migration. For 2020, the Afghanistan
population estimate used by HMIS is 30.57 million, while the UN estimate –based on the
2017 remote census and satellite imagery data—exceeds 37.6 million. As a result, the HMIS
may have its limitations for the comparison between administrative divisions, but it is very
useful to assess the evolution over time of the same division (MoPH, 2020).
The disease surveillance system is part of the routine information system. It is based on
periodic weekly reports notified by more than 600 focal persons deployed at health
facilities. Notification is done with Short Message Service (SMS) for urgent cases and is
paper-based for longer periods. The surveillance system targets 20 notifiable
diseases(MoPH, 2020).
The monitoring and evaluation function is contracted out to an independent third party, the
Royal Tropical Institute of Amsterdam (KIT). KIT undertakes an annual balanced scorecard,
which reports on a variety of agreed indicators of resource availability, efficiency, and
quality; semi-annual HMIS and health facility functionality assessments, annual drug quality
assessment, and periodic national health survey (MoPH, 2020).
Comprehensive HIS assessment (2018) emphasizes the need for agreed monitoring and
evaluation (M&E) indicators, data sources, and annual targets; improving death reporting
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and its causes; birth and death notification; census and undertaken periodic performance
review (Comprehensive assessment of Afghanistan's health information system 2018, 2018).
Governance and leadership
Health governance is not always easy to define, as its interpretation may vary. Leadership
and governance in building a health system entail the existence of strategic policy
frameworks combined with effective oversight, coalition-building, regulation, and
accountability (WHO, 2022). For some, good governance means a system fulfilling its
mandate, and for others, it may be divided in several components which have the common
feature that they all influence the whole health system (MoPH, 2020).
Prior to the collapse of government on 15th August 2021, the MoPH in Afghanistan was
responsible for policymaking, regulation, financing, coordination, supervision, and
monitoring, while the responsibility of the health services provision was mainly contractedout
to NGOs(Ministry of Public Health (MoPH), 2021). Following the political transition of
August 2021, NGOs continue to provide health services across the country, while contracts
are managed by UNICEF and financed by ARTF/WB. The role of MoPH under the de facto
government is evolving and not well defined. In early 2021, the MoPH revised the national
health policy 2021 – 2030, which is expected to provide strategic direction to the health
sector. However, the development partners formulated the health sector transitional
strategy for 2022 -2025, which guides the provision of health services and clarify the role
and responsibilities of partners. Official engagement of development partners with the de
facto MoPH is limited to information sharing. All activities in the health sector are
coordinated through the Health Sector Transitional Working Group (H-STWG), which is
comprised of key donors, UN agencies, and the International Committee of the Red Cross
(ICRC).
Achievements and challenges by mid-2021
The last two decades have witnessed impressive developments in the Afghanistan health
sector, resulting in expanded coverage and improved health status. The health system has
also shown substantial resilience in the face of political and economic turmoil over the
years.
More than 90% of the Afghan population now lives within a reasonable distance of a health
facility (Afghanistan National Statitics and Information Authories (NSIA) KIT the Royal
Tropical Institue (KIT), and Ministry of Public Health, April 2019). Health outcomes for
women and children have steadily improved over the past two decades. Afghanistan’s
average life expectancy increased by 17 percent between 2000 and 2020. These successes
are the result of a series of long-term health reforms including the introduction of BPHS in
2003 and EPHS in 2005, which have constituted the backbone of the health sector in the
country. The BPHS and EPHS are contracted out to national and international NGOs which
are financed through ARTF. The contracted services are complemented by off-budget
projects by UN agencies, bilateral donors, and humanitarian actors.
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The progress achieved is maybe best illustrated with the significant reductions in morbidity
and mortality, with particularly substantial improvements in infant, child, and maternal
health that Afghanistan has witnessed. The Afghanistan Health Survey (AHS) 2018 reports
that 59% of deliveries were attended by a skilled professional, and 61% of the children were
completely immunized. Despite the relatively good coverage of public health facilities,
people prefer to visit private providers. Sixty percent of OPDs and 53% of antennal care
(ANC) visits take place in private clinics (Afghanistan National Statitics and Information
Authories (NSIA) KIT the Royal Tropical Institue (KIT), and Ministry of Public Health, April
2019). However, in regional and global comparison, Afghanistan’s health indicators remain
worrisome. The following table compares the key health indicators in 2002 and 2021.
Table 1 Comparison of health indicators 2002 vs. 2021
No Indicators 2002§ 2021¥
1 Maternal mortality ratio per 100,000 live births 1,700 638
2 Under 5 years old mortality per 1,000 live births 275 62
3 Infant mortality per 1,000 live births 165 48
4 Life expectancy at birth, women 42 62
5 Life expectancy at birth, men 47 64
6 Total fertility rate 7 5.1
Sources: §(L. A. Bartlett et al., 2005; K. Viswanathan et al., 2010); ¥(DHS, 2017; Afghanistan Mortality Survey
2010., 2010)
As evident, maternal mortality declined substantially over the last two decades. However,
the national lifetime risk of maternal mortality is still significantly higher than the global
average: 1 in 33 compared with 1 in 190 globally (UNICEF, 2021).
Sustaining gains and preventing excessive maternal morbidity and mortality
There is clear progress, but it is necessary to take immediate action to tackle the causes of
deaths among women while simultaneously focusing on health system strengthening and
addressing the broader social determinants of health. Tackling obstetric hemorrhage, infection,
and unsafe abortion can result in an immediate decline in maternal mortality. In addition,
addressing pre-existing conditions that are exacerbated by pregnancy, such as hypertensive
disorders and maternal anemia, will also assist in lowering maternal mortality.
In addition, maternal health problems often correlate with physical and sexual violence.
Violence in pregnancy poses a threat to the life, wellbeing, and health of both the mother
and the foetus and is associated to miscarriage, stillbirth, premature labour, and low birth
weight (Alhusen, 2015). Gender-based violence, economic exclusion, child marriage, and
lack of appropriate and affordable reproductive health services are common problems that
women face in Afghanistan. Child marriage is common and at least one in three girls get
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married before they become 18 years old. However, it is not well studied and gaps in
knowledge regarding prevalence, practice, and drivers remain (GoIRAF, 2018).
Further, only 23% of married women aged 15-49 are using family planning. Religious beliefs,
family opposition, and concerns about the methods are among the common causes of the
poor use of family planning ("National family planning summit; Renewing commitment to
the family planning program ", 2019). Unequal power relationships and the minimal role of
women in decision-making for health constrain their access to health services. Most Afghan
women lack control over their own fertility, which is instead determined by their spouses
and by sociocultural norms and practices (Kathiva van Egmond et al., 2004). Overall, it is
critical to improve respectful maternity care, women’s autonomy, dignity, choices, and
preferences for addressing preventable maternal and newborn morbidity and mortality
(Gausman J Jolivet RR, Kapoor N, Langer A, Sharma J, Semrau KEA., 2021).
Factors contributing to constrained access to health services after the political transition
The political transition in mid-August 2021 prompted by the sudden withdrawal of the US
and its allies ushered in a period of major uncertainty for the future of the health sector in
Afghanistan. The policies and restrictions placed on women and girls by the de facto
authorities will inevitably lead to a re-emergence of major health challenges for them. This
is aggravated by the limitations placed on the operations of NGOs for instance with the
recent government prohibition of women in their workforce.
But beyond the critical area of access to sexual and reproductive rights and health and
access to education for women and girls resulting from the change of government,
Afghanistan faces a range of health sector challenges that had not been resolved despite all
the progress over the last 20 years. These factors arguably further deepen the trouble the
health system is in.
While the burden of non-communicable diseases (NCDs) and injuries are growing,
communicable disease continues to account for a large portion of the overall disease
burden. Afghanistan remains one of the two polio endemic countries in the world. The
country recurrently experiences outbreaks of multiple diseases. The COVID-19 pandemic
severely affected the health system while the outbreaks of malaria, dengue, and measles
were ongoing.
Despite the implementation of corrective measures (e.g., strengthening Infection
Prevention and Control; training of staff on IPC, case management and ICU care; provision of
additional supplies and oxygen, expansion of lab network, deployment of rapid response
teams, strengthening surveillance particularly at the point of entry, provision of home-based
care for mild patients etc.), the pandemic has revealed various deficiencies in Afghanistan’s
health system. Weak surveillance, limited testing capacity, shortage of equipment and
supplies, inadequate ICU capacity and poor oxygen supply, and misinformation about
COVID-19 were among the Key challenges that the country faced (Ahmad Shah Salehi &
Rahimi, Ahmad Omid, 2022). Overall, the country reported more than 200,000 cases and
close to 8,000 deaths. Considering the surveillance and testing capacity, these numbers are
Elgar Companion to Health and the SDGs – pre publication proof
severely underreported. As of December 2022, 54% of the estimated target population has
been fully vaccinated against COVID-19, with 63% having received at least one dose of the
vaccine (MoPH, 2022).
Along with a rapidly growing population, NCDs and injuries exert substantial pressure on the
financing and provision of health services (K. M. I. Saeed, 2013). At the same time, poverty,
and food insecurity, which are important causes of malnutrition and maternal and child
mortality, continue to negatively affect the health of Afghans. More than 20 million people
are estimated to need food assistance. Contributing to these challenges is a severe
economic crisis. Estimates suggest that more than 90% of Afghans live below the poverty
line (Integrated Food Security Phase Classification (IPC), 2021; Shoba Suri & Mona, 2021).
The country is dealing with rising food prices, persistent conflict, severe drought, and
natural disasters, including the 2022 earthquake and recurrent flash floods. Long-term
consequences of these disruptions are likely to lead to a deterioration in many health
indicators, particularly for women, children, and other vulnerable groups (N. Safi et al.,
2022).
The health sector in Afghanistan suffers from chronic geographical, skill, and mixed
imbalances in human resources for health (HRH). In addition of the civil service commission,
the newly established medical and nursing counsels are playing a key role in regulating HRH.
Staff deployment and retention in hardship and remote areas is one of the main challenges
of HRH management. Several initiatives such as recruiting staff from the same area, and
financial incentives have obtained relative success, but the reality is that the situation of
staff availability in many places is described as “fluid” (Najibullah Safi et al., 2018). According
to the BSC 2018, only around 35% of BPHS facilities have the complete recommended team
(KIT the Royal Tropical Institute (KIT), 2018). Ultimately, the solution will require peace and
socio-economic development, both beyond the capacity of health managers. The
concentration of the health workforce in major urban areas widens the inequity in coverage
and access to health services in remote and underserved areas. Other factors such as poor
infrastructure, and unavailability of required equipment and supplies also contribute to
increased inequity in accessing primary health services in remote areas.
The health financing in Afghanistan is characterized by low government health expenditure,
reliance on donor funding, and extremely high OOP expenditure, mostly on medicines,
diagnostics, and treatment abroad (MoPH, 2020, 2021). After the August 2021 transition,
donor funding is confined only to humanitarian response and no investment is made in the
development of health system.
The Pharmaceutical sector has executed the split between regulatory and management
functions. The National Medicines and Health Regulatory Authority (NMHRA) oversees preand
post-market regulation as well as quality control. However, limited implementation
capacity, shortage of inspectors and other staff, and scarce capacity to enforce issued
regulations have reduced the potential impact. Substantial investments over the next few
years will be necessary to increase the NMHRA regulatory capacity to an acceptable level
(MoPH, 2020). The supply chain management of the Afghanistan health sector is completely
Elgar Companion to Health and the SDGs – pre publication proof
fragmented. Each of the NGOs involved in the delivery of BPHS/EPHS runs its own system.
The drug quality assessment 2015 found that up to 15% of samples collected at BPHS/EPHS
facilities failed to pass the quality test, while stockouts could reach up to 25% of essential
drugs(KIT the Royal Tropical Institue (KIT), 2015).
In the last few years, most entities related to gathering, treating, and releasing information
have been placed under the General Directorate of Health Information System (HIS). The HIS
generates quarterly, semi-annual, and annual reports covering different building blocks of
the health system with a key focus on service delivery. The DHIS-2 has become the platform
for integrating sub-sector information systems and making data available remotely to
interested actors. This is overall a positive development. However, reports still lack analysis
and explanations of the events identified through the existing systems (MoPH, 2020). Also,
other challenges in information systems include incomplete data, inaccurate and outdated
population estimates, and delays in releasing various reports. The absence of a functional
feedback mechanism to service providers continues to remain a persistent concern.
Post transition – what next for Afghanistan’s health system?
Following the political transition of 2021, the health sector in Afghanistan finds itself at a
critical inflection point. Discontinuation of support for the provision of BPHS and EPHS will
impose additional risk to the life of every Afghan and results in deaths of eight additional
women, forty-three additional neonates and eighty-four additional children every single day
(Najibullah Safi et al., 2023).
Despite the rule of the Taliban, after a short disruption in services provision the NGOs have
continued to provide health services under the contracting-out arrangements managed by
UNICEF and financed by ARTF/WB, the role of MoPH however, remains unclear and is
evolving. The de facto authorities need to define the governance and leadership function of
MoPH, provide strategic guidance, establish functional coordination structures, invest more
domestic resources in the social sector including health and ensure synergy with donors’
investment.
Corruption continues to remain a major governance challenge. According to the latest
Corruption Perception Index report (2021) by Transparency International, Afghanistan ranks
174 out of 180 countries(International Transparency, 2021)
Improvement of public health requires a multi-sectoral approach (Salunke, 2017).
Achievement of health system goals requires sound governance and adequate resources.
Neither of these conditions is currently being met. The recent ban on women’s education
and employment widens inequities in accessing health services for women and children. In
addition, the maldistribution of health facilities and the health workforce also led to
inequities in the health sector. Furthermore, women, particularly adolescents who
constitute 40% of the population, face enormous challenges in meeting their sexual
reproductive health needs (HeRAMS, 2022). In 2022 Afghanistan ranked the lowest in
Gender Gap Index (146th out of 146 countries) (Global Gender Gap Report 2022;
KhamaPress, 2023) reflecting high levels of inequities in reproductive health, women’s
empowerment, and economic activity. This affects their ability to reach their full potential
Elgar Companion to Health and the SDGs – pre publication proof
and contributes to the high maternal mortality ratio and poor maternal and child health
indicators.
Sustaining the current level of health services delivery is crucial to avoid excessive morbidity
and mortality, particularly in vulnerable population groups, including women and children
(Safi, 2023). In the long term, the allocation of domestic resources is key for sustaining
healthcare delivery and ensuring country ownership. Co-financing mechanisms and other
strategies will be needed to increase domestic resources to health. At the same time, in the
short term, continuous support from the international community is crucial for maintaining
the provision of health services and minimizing the impacts of the severe humanitarian crisis
in Afghanistan (N. Safi et al., 2022). Resuming the universities and training of female health
care providers will play a critical role in sustaining health care delivery in the long term.
Considering the ongoing humanitarian and political crisis, the surge in the burden of
communicable diseases and multiple outbreaks, increasing poverty, ongoing sanctions, and
the growing restriction on women’s mobility, employment and education, Afghanistan is
unlikely to achieve any of the health-related SDGs. Crucially, this is not just a matter of
achieving indicators in a framework. The consequences for access to health for Afghan
people are very significant, with the greatest impact on women and children.
The international allies of Afghanistan, who left the country in August 2021 have an ethical
obligation to continue using different strategies to sustain support to the country and
facilitate positive changes that could lead to a better future for Afghans. The global
community needs to closely work with local communities, community shuras and other
community-based organizations in Afghanistan to support efforts that seek to ensure the
protection of human rights, especially for women and girls, and equal access to health care,
education, work, adequate food, and shelter for all Afghanistan’s people. At the same time
the international community, particularly Islamic countries and organizations must use
every single opportunity to influence the Taliban and foster positive changes for respecting
the basic human rights of all Afghans.
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