Abstract
Afghanistan is one of the most fragile and conflict-affected countries in the world. It has experienced almost uninterrupted conflict for the last thirty years, with the present conflict now lasting over a decade. With no history of a functioning healthcare system, the creation of the Basic Package of Health Services (BPHS) in 2003 was a response to Afghanistan’s dire health needs following decades of war. Its objective was to provide a bare minimum of essential health services, which could be scaled up rapidly through contracting mechanisms with Non-Governmental Organisations (NGOs). The central thesis of this article is that, despite the good intentions of the BPHS, not enough has been done to overcome the barriers to accessing its services. This analysis, enabled through a review of the existing literature, identifies and categorises these barriers into the three access dimensions of: acceptability, affordability and availability. As each of these is explored individually, analysis will show the extent to which these barriers to access are a critical issue, consider the underlying reasons for their existence and evaluate the efforts to overcome these barriers. Understanding these barriers and the policies that have been implemented to address them is critical to the future of health system strengthening in Afghanistan.
Highlights
A global literature review of both peer reviewed and grey literature was conducted in 2016 to assess the barriers to accessing the Basic Package of Health Services (BPHS) for civilians in Afghanistan
The highest ever documented maternal mortality ratio was recorded in the Badakshan province of Afghanistan between 1999 and 2002 [33]
Health services targeting women and children in Afghanistan must be sensitive to religious and cultural barriers that prevent women from accessing services. It is culturally unacceptable in many areas of Afghanistan for a female patient to be seen by a male health professional [32]
Summary
Afghanistan’s history is blighted by conflict, a repetitive cycle of externally and internally driven warfare with only brief periods of peace. The package was adapted for the needs of the Afghani population and was designed to tackle the priority areas of maternal and newborn health, child health, public nutrition, and communicable diseases [13]. This was further expanded in 2005 to include disability and mental health services [11]. This paper contributes to the field of health care strengthening in post-conflict settings by considering the barriers to accessing healthcare faced by the Afghani people and reflecting on how this has changed over time since the introduction of the BPHS in 2003. The critical analysis that follows will consider these access dimensions individually, examining the extent to which they affect access to healthcare services and the reasons behind their existence in order to understand what can be done to achieve Universal Health Coverage (UHC) in Afghanistan [25]
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