Afghanistan's health system is under duress, but has not collapsed

Abstract

Afghanistan's political crisis in August, 2021 triggered economic turmoil and a humanitarian emergency. Widespread hunger threatens the lives of children.1Cousins S Afghanistan's health crisis deepens under the Taliban.Lancet. 2022; 399: 1290-1291Google Scholar Media stories relay the dire situation of some medical facilities—mostly hospitals in Kabul and other urban centres—without funds for staff salaries or medicine. However, although there are real challenges, the resilience exhibited by the health system has been largely overlooked. Since 2002, the provision of public health care in Afghanistan has relied on non-governmental organisation service providers to deliver most health services nationally. These service providers were awarded contracts by the former government (using predominantly donor funds) to provide free-of-charge primary and secondary health services. Service providers also negotiated with armed opposition groups to gain access to and deliver services in areas under their control. Starting in 2019, expanded managerial autonomy for service providers, coinciding with a shift to linking payments to service volume, resulted in increased service coverage despite the worsening security situation.2Andersen CT Ahmadzai H Rasekh AW et al.Improving health service delivery in conflict-affected settings: lessons from a nationwide strategic purchasing mechanism in Afghanistan.J Glob Health. 2021; 1104049Google Scholar After August, 2021, international aid was temporarily paused. However, within 6 weeks, funding resumed and was channelled to pre-existing service providers to maintain primary and secondary health services nationwide. Short-term financing commitments were provided by The Global Fund to Fight AIDS, Tuberculosis and Malaria, the United Nations Central Emergency Response Fund, and the Afghanistan Reconstruction Trust Fund (ARTF). UNICEF and WHO provided oversight for service provider contracts. This support enabled more than 2300 health facilities, including 96 hospitals, to continue providing services. Afghanistan's Health Management Information System contains data submitted by service providers and verified by an independent third-party monitor; both data submission and verification continued after August, 2021 (appendix). Although services declined, on average, by 15% from the first to the second half of 2021, between January and June, 2022 they rebounded by 7%. Furthermore, service delivery volume for all services between January and June, 2022 is above that of between January and June, 2019—when the former government was in place and before the COVID-19 pandemic. International funding is essential to maintain primary and secondary health services under prevailing conditions, even after the December, 2022 announcement by the Taliban banning women from working for non-governmental organisations.3Samad D Naem AJ Feroz F Afghanistan: health sector gains in peril.Lancet. 2021; 3981127Google Scholar Female health workers continue to provide life-saving work, although future changes are uncertain.3Samad D Naem AJ Feroz F Afghanistan: health sector gains in peril.Lancet. 2021; 3981127Google Scholar Funding to continue support for the provision of basic health services has been approved by the Asian Development Bank (US$100 million to support services from January, 2022, to December, 2024) and The World Bank using ARTF ($314 million) and Global Financing Facility funds ($19 million for July, 2022, to December, 2023). Bilateral donors, such as the USA and the EU, also continue to provide substantial resources directly to the health sector. Despite real challenges since August, 2021—particularly at major hospitals—continuing donor and UN support has enabled the primary and secondary health system of Afghanistan to endure. All authors are involved in the financing or implementation of health programmes in Afghanistan with their organisations. Download .pdf (.09 MB) Help with pdf files Supplementary appendix