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Knowledge Partnership Programme

Healthcare in Afghanistan: Scenario and perspectives

Introduction The Ministry of Public Health (MoPH), Afghanistan is in charge of healthcare governance in the

country and endeavors to improve the health and nutritional status of the people of in an

equitable and sustainable manner through quality HCSs Provision (HCSP) and the promotion of

a healthy environment and living conditions along with living healthy life styles.

In 2003, MoPH developed a set of cost-effective and high impact interventions called the Basic

Package of Health Services (BPHS), that would be available to all Afghans with special focus on

those living in remote and underserved areas. Later on, in 2005, the MoPH developed the

Essential Package of Hospital Services (EPHS), which defined the role and services of the

hospital sector, specifically for the district, provincial and regional hospitals and aims to reduce

high maternal and childhood mortality rates.1

The key donors that focus mainly on funding BPHS and EPHS and support the health and

nutrition sector are- the USAID, the World Bank and the European Commission (EC). The main

UN Agencies that support health sector are UNICEF, WHO, UNFPA, UNODC and UNAIDS. Also,

the Global Alliance for Vaccine and Immunization (GAVI) and the Global Fund to Fight AIDS,

Tuberculosis and Malaria provide substantial assistance to the health sector. Many other health

stakeholders are supporting health sectors and they are governments like, Saudi Arabia, Italy,

Germany, France, Spain, Iran, Pakistan, India, United Arab Emirates, Canada, Turkey,

Turkmenistan, South Korea, Japan, USA, New Zealand, Estonia and Norway.2

Afghanistan’s young and fast-growing population serves as both a resource and a challenge. It

has become one of the youngest countries in the world, with 60% of the population of an

estimated 27.5 million under 20 years of age, and nearly 70% under age 25. With a population

growth rate estimated at between 2.2 and 2.8% per year and low life expectancy during the

1 http://moph.gov.af/en/tender/reoi-for-consultancy-services-for-third-party-monitoring-and-evaluation-of-the-bphs-and-

ephs-under-sehat-project 2 http://moph.gov.af/Content/Media/Documents/HNSS-Report-ENG-v4-1281220101156987.pdf


period of prolonged conflict, this “youth bulge” will keep growing for several years. These

demographics offer important prospects for renewal and growth. However, the country

remains hard-pressed to provide adequate, equitable, and sustainable health and education

services to meet the growing demand, or to find ways of creating jobs for an estimated 400,000

new labour market entrants each year.

In addition, life expectancy has risen from 42 years in 1990 to 49 years by 2012. Nevertheless,

these outcomes remain well below averages for countries in even the lowest category of

human development. Due to the Afghanistan’s geography, there are many pockets of

population that are beyond the reach of public health facilities. In addition, the movement of

patients, especially women and children, and health workers is significantly restricted by road

insecurity and in many places by cultural norms, combing to adversely affect maternal and child

health. Capacity development for the provision of sustainable quality health services by

government in all provinces requires coordinated collaboration of all partners, as critical

services are also provided by NGOs and development partners.

Afghanistan continues to experience deep poverty and inequality as well as one of the weakest

human development outcomes in the world, ranking 175 out of 187 countries in UNDP’s 2013

Human Development Report. GIRoA’s most recent report on progress toward the Millennium

Development Goals (MDGs), issued in 2010, suggests that positive developments are greatest in

the areas of education and child and maternal health, but there is little prospect for the country

to achieve most of the MDGs, even within the longer period through 2020 afforded to

Afghanistan, as a late entrant into the MDG process.


Selected Health Indicators

S.N. Indicator Afghanistan Mortality Survey, 2010

1 Infant mortality rate 77 per 1000 live births 2 Under 5 mortality rate 97 per 1000 live 3 Maternal mortality ratio (MMR) 372 per 100 000 live births 4 Antenatal care coverage 68% 5 Deliveries by skilled birth attendants 34% 6 Full immunization coverage Not available MICS data is

keenly debated 7 Access to primary health services

(within 1 or 2 h using normal mode of transport)

90% (goal)

The Strategic Plan for the Ministry of Public Health 2011–20153 puts forth ten emerging actionable directions-

1. Improve the nutritional status of the Afghan population

2. Strengthen human resource management and development

3. Increase equitable access to quality health services

4. Strengthen the stewardship role of MoPH and governance in the health sector

5. Improve health financing

6. Enhance evidence-based decision making by establishing a culture that uses data for

improvement

7. Support regulation and standardization of the private sector to provide quality

health services

8. Support health promotion and community empowerment

9. Advocate for and promote healthy environments

10. Create an enabling environment for the production and availability of quality

pharmaceuticals.

3 MoPH Strategic Plan. http://moph.gov.af/en/page/579


Public Healthcare Delivery System

Basic Package of Health Services (BPHS) The BPHS4 are offered at four standard types of health facilities, ranging from outreach by

Community Health Workers (CHWs), to outpatient care at basic health centers, to inpatient

services at comprehensive health centers and district hospitals.

At the community level, basic health services will be delivered by CHWs from their own homes,

which will function as community health posts and have a catchment area of 1,000–1,500

people, which is equivalent to 100–150 families. The BHC is a small facility offering the same

services as a health post but with more complex outpatient care and covers a population of

15,000–30,000, depending on the local geographic conditions and the population density. The

Comprehensive health center (CHC) covers a larger catchment area of 30,000–60,000 people

and offers a wider range of services than does the BHC.

There are seven healthcare elements of the BPHS and their components have been provided at a glance in the table below:

S.N. Health Service Areas Components

1 Maternal and Newborn Health • Antenatal care • Delivery care • Postpartum care • Family planning • Care of the newborn

2 Child Health and Immunization Expanded Program on Immunization (EPI) services • Integrated Management of Childhood Illnesses (IMCI)

3 Public Nutrition • Prevention of malnutrition • Assessment of malnutrition • Treatment of malnutrition

4 Communicable Disease Treatment and Control

• Control of tuberculosis • Control of malaria • Control of HIV

5 Mental Health • Mental health education and awareness • Case detection • Identification and treatment of mental illness

4 A Basic Package of Health Services for Afghanistan. http://moph.gov.af/Content/Media/Documents/BPHS-2005-

FINAL29122010162945969.pdf


6 Disability Services • Disability awareness, prevention, and education • Assessment • Referrals

7 Regular Supply of Essential Drugs Listing of all essential drugs needed

The Essential Package of Hospital Services for Afghanistan

The Essential Package of Hospital Services (EPHS)5 has three purposes: (1) to identify a

standardized package of hospital services at each level of hospital, (2) to provide a guide for the

MOPH, private sector, nongovernmental organizations (NGOs), and donors on how the hospital

sector should be staffed, equipped, and provided materials and drugs, and (3) to promote a

health referral system that integrates the BPHS with hospitals. The EPHS puts forth all the

necessary elements of services, staff, facilities, equipment, and drugs for each type of hospital

in Afghanistan. The EPHS identifies the following elements for each level of hospital so that the

inputs or resources needed at each level may be is well stratified and comparable:

1. Diagnostic and Treatment Services For Various Conditions

2. Diagnostic Tests

3. Staffing

4. Equipment And Supplies

5. Essential Drugs

Health Infrastructure and Human Resource For Health

Decades of war has dilapidated Afghanistan’s health infrastructure and the country's capacity

to deliver health services. There are nine types of Health Facilities at multi- levels of health care

delivery, including the Health Post, Sub Centre, Basic Health Centre (BHC), Comprehensive

Health Centre (CHC) mentioned above. Additionally, there are:

5 The Essential Package of Hospital Services for Afghanistan http://moph.gov.af/Content/Media/Documents/EPHS-2005-

FINAL29122010164126629.pdf


- Comprehensive Health Centre plus (CHC+): This type of health facilities aim to provide

maternal health care services particularly Comprehensive Emergency obstetrics Care

services. These facilities have 10 beds.

- District Hospital (DH): At the district level, the DH will handle all services in the BPHS,

including the most complicated cases. The hospital will be staffed with doctors including

female obstetricians / gynaecologists; a surgeon, an anaesthetist and a paediatrician;

midwives; lab and X-ray technicians; a pharmacist; and a dentist and dental technician.

Each DH will cover an approximate population of 100,000-300,000 people in one to four

districts.

- Provincial Hospital (PH): The PH is the referral hospital for the Provincial Public Health

(PPH) Care System. In essence, the PH is not very different from a DH: it offers the same

clinical services and possibly a few additional specialties. In most cases, the PH is the last

referral point for patients referred from the districts. In some instances, the PH can refer

patients to higher levels of care to the regional hospital or to a specialty hospital (SH) in

Kabul.

- Regional Hospital (RgH): The RgH is primarily a referral hospital with a number of

specialties for assessing, diagnosing, stabilizing and treating, or referring back to a lower

level hospital. The RgH provides professional inpatient and emergency services at a

higher level than is available at DHs and PHs, yet the overall objective remains the

reduction of the high MMR, IMR, and U5MR, and of other diseases and conditions

responsible for Afghanistan’s high mortality and morbidity.

- National Hospitals (NH): NHs are referral centers for tertiary medical care and are

located primarily in Kabul. They provide education and training for HCWs and act as

referral hospitals for the PHs and RgHs.

The ratio of health workers to population is 1.08 to 1000. Female workers make up 28% of the

workforce (including unqualified support staff). Other than 100% midwives and 50% community

health workers being female, only vaccinators and university educated groups of doctors,


dentists and pharmacists have about 20% female. There are 16.7 public health workers

(including unqualified support staff) in rural areas, compared with 36 per 10,000 in urban areas.

Most qualified private health workers are in urban areas. Only 22.6% of the population lives in

urban areas, and most provinces are 90% rural.6

Community Level service provision Is through Family Health House scheme. There is a qualified

Community Mid wife, which provides basic package as well as conduct delivery. She also have

support from Community Health workers in her area as well as have Health Shouras, kind of

village councils for supporting health activities. In addition there are mobile health units is

most in accessible areas to provide services.

The under-five mortality rate in Afghanistan has been reduced from 176 per 1,000 live births in

1990 to 99 in 2012, a 44% decrease. The infant mortality rate was also significantly reduced,

from 120 per 1,000 live births in 1990 to 71 in 2012.

There are improvements in the supply and utilization of the health services. For example, the

number of births at health facilities increased from 6% in 2003, to 19% in 2005 and to 32.4% in

20117 and the percentage of facilities with female skilled health personnel (doctors, nurses or

midwives) increased from 39% in 2004 to 76% in 2006.8 The utilization rate of antenatal care

(ANC) and skilled birth attendance (SBA) has increased, respectively, from 31% and 24% (NRVA

2007/8) to 60% and 34% (AMS 2010).

Despite these encouraging trends, Afghan mothers and children’s mortality remains among the

highest in the region. It is unlikely that the MDG4 target of reducing under-five mortality to 59

6 Afghanistan National Health Workforce Plan 2012-16, 2011.

http://www.who.int/workforcealliance/countries/Afghanistan_HRHplan_2012_draft_wlogos.pdf 7LoLordo, A., Increase in skilled midwives saving lives in Afghanistan. 2013.

8 UNICEF(2008), Afghanistan’s community midwives. Context and challenge: Insufficient resources, poor maternal health

outcomes, political instability.


per 1,000 live births by 2020 will be attained.9 According to the most recent global targets,10

Afghanistan needs to reach an under-five mortality rate of 20 and a neonatal mortality rate of

10 by 2035. This would require an Annual Average Rate of Reduction (AARR) of 6.5% in the

under-five mortality rate compared with the current rate of 2.7%. For neonatal mortality, the

task ahead is even more daunting – the 2011 neonatal mortality rate is 36, so the current AARR

of 0.1% would need to increase to 5.2% in order to meet the target.

Healthcare Financing and Insurance

The out of pocket expenditure accounts for nearly three-quarters of all health spending (73.6%)

whereas the central government financed around 5.6 percent (USD 84,148,093) of health

expenditures in 2011-12. International donor funding accounted for the remaining 20.8 percent

(USD 312,468,367) of total health expenditure. These direct out-of-pocket (OOP) payments

made by households are extremely inequitable for the poorest households. The central

government should consider increasing its role as health financier and enlist the private sector

to take a more active role as well.

Afghanistan’s public and private insurance sectors are underdeveloped. An operational social

health insurance scheme does not exist despite small-scale programs during the 1960s and

1970s. The role of private insurance providers and employers in the financing of health services

is emerging but remains extremely limited.11

As per the current Health Financing Policy document there is no community based health

insurance implemented in the country.12

9 Levels & Trends in Child Mortality Report 2012; Estimates developed by the UN Inter-agency Group for Child Mortality

Estimation. Special provision was made for Afghanistan, which started the Millennium Development Goals process five years later than other countries and therefore has targets to be reached by 2020 rather than 2015. 10

APR document [full citation needed]. 11

Afghanistan National Health Accounts with Subaccounts for Reproductive Health 2011–2012. http://www.healthpolicyproject.com/pubs/262_AfghanistanNHAReportFINAL.pdf 12

Health Financing Policy 2012 – 2020. Islamic Republic of Afghanistan, Ministry of Public Health.

http://moph.gov.af/Content/Media/Documents/HealthFinancingPolicy2012-2020EnglishFinal174201313301319553325325.pdf


Private Health Care Sector:

The MoPH's private sector policies and strategies facilitate the strengthening and growth of

private health sector organizations and improvements in the quality of the health services and

products they provide. A dispersed and uncoordinated private health sector will not be able to

effectively deliver health services and will not be able to influence policies that are favorable for

the overall growth of the sector which any strong sector and civil society aims to achieve.

Minimum investment in facilitating the structuring of the private health sector has huge return

on investment due to a coordinated approach in health services delivery, towards the joint

health goals of the health sector. The private health sector has seen improvement on this front,

through the creation and evolving of the Afghanistan Private Hospitals Association (APHA) and

the National Medicines Services Organization (ANMSO). These associations serve as a reference

point through which the MoPH could establish working relationships with all members of these

associations. However, much more is needed. The MoPH seeks to increase the impact that

private spending has on the health of the Afghan population by positively influencing the types

and quality of services and products provided by private health organizations. Consequently, in

recent years, the private health sector has experienced rapid growth. Currently, there are

approximately 220 private hospitals, 100 private drug producers and importers, tens of private

diagnostic centers, and around 20 private educational institutes actively involved in health

service provision and production in Afghanistan. In addition, household health expenditures

represent 73 percent of total health expenditures, of which 62 percent are spent at private

health facilities.13

Pharmaceutical Market

In Afghanistan, there are legal provisions establishing the powers and responsibilities of the

Medicines Regulatory Authority (MRA). The MRA is responsible to regulate the medicines

system both in public and in private sector and as well as in the medicine system of NGOs and

other government departments, but the enforcement of the regulations is very poor in the

13

National Health Accounts 2011-12; World Health Statistics, 2007, WHO.


country. In Afghanistan only pharmaceutical companies are registered, medicines are not

registered. There are no legal provisions requiring the MRA to make the list of registered

pharmaceutical products publicly available and update it regularly. Regulations exist to allow

for inspection of imported pharmaceutical products at authorized ports of entry, but due to

lack of human and financial resources the inspection at the ports of entry are often not

performed. Legal provisions exist requiring manufacturers (both domestic and international) to

comply with Good Manufacturing Practices (GMP), but currently the GMPs are required only

for the International manufacturers and not for the domestic manufacturers, because the GDPA

has not developed GMP for the manufacturers yet. 14

Key issues:

The country faces high out of pocket expenditure for obtaining healthcare and has to

address challenges in Human resources for health availability and deployment especially

in conflict affected provinces. Given the growth trajectory in future and likelihood of

increasing GOIRA revenues, public financing for health is likely to increase which can be

optimally used for creating health infrastructure.

The main source of essential medicines is the local market for private pharmacies and

nongovernmental organizations implementing health programmes. Most of the

essential medicines are imported from neighboring countries with little or no control.

Afghanistan's capacity to certify imported medicine through quality control checks is

weak.15

The situation of healthcare in Afghanistan needs updated scoping and assessment for

Private Sector involvement, capacity building and training of human resource for health,

health information technology, health insurance and access to medicines &

contraception. There is increasing recognition of need for MoPH stewardship and

regulatory mechanisms for pvt health care sector.

14

Afghanistan Pharmaceutical Country Profile, 2011.

http://www.who.int/medicines/areas/coordination/AfghanistanPSCPnarrative.pdf 15

Essential medicines and pharmaceutical policies; WHO Afghanistan. http://www.emro.who.int/afg/programmes/emp.html

http://www.who.int/medicines/areas/coordination/AfghanistanPSCPnarrative.pdf


Access to family planning services is still a challenge and this could reduce maternal

deaths if contraception use reaches around 60%. Also factors like numbers of skilled

birth attendants, reliable transport and availability/quality of emergency obstetrical care

facilities vary greatly within Afghanistan, so there is a need to study and prioritize

contextual interventions that will bring forth the evidenced impacts in attaining

health.16

Improving healthcare will require continued investments in developing technical

capacity in health technology and access to medicines arenas; fostering cross learning of

best practices with other developing countries; health infrastructure; a focus on

improving health-worker performance through training, material support.

Human Resources for Health is one major health systems component needs

strengthening in a major way. Country needs to invest in setting up more medical

schools and nursing/paramedical training centre, regulatory structures such as Afghan

Medical and Nursing Councils as well as offering structured in service training

programmes. Use of e learning plate forms for capacity building needs to be further

explored.

Afghanistan is one of the three polio endemic countries left. Though WHO has invested

in establishing surveillance systems and mass vaccination drives, much more needs to

be done in mobilizing support from community especially Taliban. Indian experiences in

reaching out to resistance communities can be considered leading to fine tuning of

outreach BCC strategies.

16

Carvalho N, Salehi SA, and Goldie JS. National and sub-national analysis of the health benefits and cost-effectiveness of strategies to reduce maternal mortality in Afghanistan. Health Policy Plan. (2012)doi: 10.1093/heapol/czs026


Authors: Dinesh Agarwal and Raghavendra Madhu. The views expressed in this paper are entirely those

of the authors and have been developed as a part of the Knowledge Partnership Programme, IPE Global.

The note may be freely quoted or reprinted but acknowledgement is kindly requested.

Key Indicators Year & Data Source

Total Population (million) 26,000,000 2012 CSO Life Expectancy at Birth, males (year) 62-64 2010 AMS Total Fertility Rate 5.1 2010 AMS % Population with sustainable access to improved water source

57 2011 AMICS

% Household using improved sanitation facilities 31 2011 AMICS % Population within one hour walking distance from a public health facility

57.7 2008 NRVA

Total expenditure on health as % of GDP (2012) 8% 2012 NHA Out-of pocket expenditure as % of total health expenditure 73% 2012 NHA Government health expenditure as % total government expenditure (2011-12)

4.2% 2012 NHA

No. of health facilities 2,096 2013 HMIS No. of health posts 13,200 2013 HMIS No. of PHC Center/ 10,000 population (2012) 0.8 2012 NHA No. of hospital beds / 10,000 population (2012) 4.2 2012 NHA No. of consultation per person per year 1,600,000 2013 HMIS Total health personnel of public sector (2012) 24,224 2013 HMIS

Annexure: List of Key Indicators-Afghanistan

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