The Quest For Universal Healthcare In Afghanistan: Challenges And Prospects

Afghanistan does not have universal health care. However, the country has made significant progress in introducing primary health care across the country over the last fifteen years. In 2018, a total of 3,135 health facilities were functional, which ensured access to almost 87% of the population within a two-hour distance.

Afghanistan's National Health Policy 2015-20 has five policy areas: governance, institutional development, public health, health services, and human resources. The country has also developed a National Health Strategy 2016-2020.

Despite these advancements, Afghanistan still faces challenges in extending access to basic health services, particularly for rural populations. Additionally, there is a shortage of female healthcare providers, and the quality of healthcare services remains poor.

Afghanistan's health system progress

Afghanistan's health system has been steadily progressing over the last 17 years, with increasing coverage of health services throughout the country. In 2018, there were 3,135 functional health facilities, ensuring access to almost 87% of the population within a two-hour distance. The country's health system has faced several challenges, including persistent insecurity, conservative social norms, weak public financing, and reducing donor aid. Despite these obstacles, Afghanistan has made notable advancements in introducing primary healthcare across the nation.

The right to health is recognised as a fundamental human right, and Afghanistan has committed to achieving the Sustainable Development Goals (SDGs), which include universal health coverage. This entails providing access to essential healthcare services and medicines for all. Afghanistan's National Health Policy 2015-2020 outlines five key areas: governance, institutional development, public health, health services, and human resources.

One of the significant steps taken by the country was the implementation of the Basic Package of Health Services (BPHS) by the Ministry of Public Health. This package focuses on interventions that have the greatest impact on common health issues, such as maternal and newborn health, child health, immunisations, nutrition, communicable diseases, mental health, disability, and pharmaceutical supply. The BPHS services are intended to be free of cost, but indirect costs like transportation and informal payments at private facilities contribute to high out-of-pocket expenditures.

Afghanistan has also established mobile health teams in 12 provinces to provide better access to basic health services for nomadic populations. Additionally, a Public-Private Partnership (PPP) model has been introduced to offer reproductive health and immunisation services in remote and insecure districts of six provinces. These efforts aim to expand the reach of preventive and curative healthcare functions.

While Afghanistan has made progress in some areas, there are still challenges to be addressed. For instance, less than half of the children are fully immunised, and the country is one of the last to eliminate wild poliovirus. Obstetric care also remains inadequate, with only about half of women delivering in a health facility and having access to skilled attendants at birth.

The country's level of public sector financing for health is relatively low compared to other low-income nations. Out-of-pocket expenditures are high, placing a significant burden on households. However, international donors provide a substantial portion of total health expenditure.

To achieve universal health coverage, Afghanistan needs both innovative access models and improved healthcare financing. Primary healthcare remains the focus, and the country has implemented a selective healthcare model, offering a limited number of basic, life-saving interventions. Governance and stewardship are critical challenges that need to be addressed to ensure effective BPHS services.

Overall, Afghanistan's investments in primary healthcare create a solid foundation for further improvements. By focusing on quality governance, stronger public sector administration, and provider accountability, Afghanistan can make strides towards universal health coverage and improved health outcomes for its citizens.

Primary health care

Afghanistan has been making efforts to improve its primary healthcare system, but it still faces many challenges.

In 2001, the country implemented a series of reforms to increase financial and geographic access to primary care services through partnerships with NGOs and the removal of user fees. The Basic Package of Health Services(BPHS) was introduced to provide essential primary healthcare services to all Afghans. The BPHS includes key interventions for all population groups, with a focus on maternal and child health. It covers maternal and newborn health, child health and immunisations, public nutrition, communicable diseases, and regular supply of essential drugs. Mental health and disability services are also available at select BPHS facilities.

However, there are several obstacles to the full implementation of these programmes. These include a lack of security, hospitals, medical equipment, basic diagnostic and treatment services, poor management, limited financial resources, and a shortage of healthcare workers, especially female healthcare workers.

To address these issues, the Afghan government needs to build hospitals in remote areas, allocate more funds for the health sector in rural areas, and provide training for female healthcare workers. The long-term goal of quality primary healthcare for all Afghans will require a combination of factors, including foreign aid, physician specialties, and time.

Innovative access models

Afghanistan's healthcare system has been steadily improving over the last 17 years, with increasing coverage of health services throughout the country. However, the country still has some of the worst levels of coverage of basic health interventions in the world. Innovative access models are required to achieve universal health coverage (UHC) in Afghanistan.

• Investment in mobile health teams: Establishing mobile health teams in 12 provinces to provide nomadic populations with better access to basic health services.
• Outreach from fixed centres: Establishing a call centre to support individuals' concerns on health issues.
• Improving literacy and incentives or salaries for community health workers: Training community health workers to assess disabilities, address stigma associated with disability, and increase referrals and provision of free transportation and access to hospitals.
• Strengthened governance of the 'contracting out' model of non-governmental organisations: The Ministry of Public Health has instituted a number of key policies, including the 'contracting out' model, where they purchase or contract with non-governmental organisations (NGOs) to deliver a package of primary health care services.
• Monitoring through the new citizen charter movement: This movement seeks to expand the preventive and curative functions of the health system based on empirical evidence, as well as expand its geographic reach.

Health financing reform

Afghanistan has made significant progress in introducing primary healthcare across the country over the last 15 years. However, it is one of the most challenging contexts to achieve universal healthcare (UHC) due to persistent insecurity, conservative social norms, weak public financing, and reducing donor aid.

The right to health is considered a fundamental human right, and UHC has gained prominence globally as a goal for countries in the Sustainable Development Goals (SDGs). UHC is defined by the World Health Organization (WHO) as:

> "access to key promotive, preventive, curative, and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in access. A key element is cost, and the principle of financial-risk protection which ensures that the cost of care does not put people at risk of financial catastrophe. A related objective of health-financing policy is equity in financing: households contribute to the health system on the basis of ability to pay."

Current Status and Progress of Universal Health Coverage in Afghanistan

In 2016, the Government of the Islamic Republic of Afghanistan (GoIRA) committed to achieving the SDGs, with leadership for coordination, implementation, and reporting assigned to its Ministry of Economy. Target 3.8 commits Afghanistan to:

> "achieving universal health coverage, access to quality essential health-care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all."

This target will be measured by indicators, including the coverage of tracer interventions (e.g., child full immunization, antiretroviral therapy, tuberculosis treatment, hypertension treatment, skilled attendant at birth) and the proportion of the population protected against catastrophic/impoverishing out-of-pocket health expenditure.

Although Afghanistan has made progress in some areas, the country still has some of the worst levels of coverage of basic health interventions in the world. For example, less than half of the children (45.7%) are fully immunized, and obstetric care remains poor, with only half of all women delivering at a health facility (48.1%) and only half having a skilled attendant (50.5%).

Possible Approaches to Achieving Universal Health Coverage in Afghanistan

Given that Afghanistan has already implemented an evidence-based package of primary healthcare services, it now needs both innovative access models and improved healthcare financing to expand coverage. There is general agreement that primary healthcare must be the focus of UHC in Afghanistan. However, there are differing views on the best approach to achieving universal coverage of primary healthcare services.

A traditional approach is to promote a limited number of basic, life-saving interventions to the population, called the selective healthcare model. Another approach used by low- and middle-income countries (LMICs) involves structural adjustments, including increasing private insurance schemes and user fees, reorganizing the health system with decentralization to lower levels, staff layoffs, streamlined health administration, altering the pharmaceutical sector towards more marketization, and privatizing and out-contracting health services. However, structural adjustments have not been attempted in Afghanistan due to difficulties with centralized governance and monitoring.

Afghanistan can build upon its investments in primary healthcare and improve strategies to bring it closer to UHC. It should also focus on areas such as the quality of governance, stronger public sector administration and provider accountability, committing to UHC, improving the quality of services, and ensuring a fairer distribution of access to care and health outcomes.

Afghanistan is among the most challenging places to build a well-functioning health system and introduce UHC. At the same time, it has technical and financial resources from many development partners and reforms to improve governance. While it is a challenging time for the country, it is also a window of opportunity to plan for and start implementing and monitoring new ways to extend affordable care to more people, particularly in conflict-affected and other hard-to-reach areas.

Health worker shortages

Afghanistan has the second-lowest health worker density in the Eastern Mediterranean Region, with a ratio of 4.6 medical doctors, nurses, and midwives per 10,000 people. This is well below the threshold for a critical shortage of 23 health care professionals per 10,000. The country's health worker density breaks down to 1.2 doctors, 2.1 nurses, and 1.3 midwives per 10,000 people. However, these figures vary widely when comparing provinces. For example, the density of doctors is eight times greater in Kabul than in Kunar.

Afghanistan has introduced a number of interventions to tackle its health worker shortage and maldistribution. These include:

• Expanding training institutions in remote provinces and introducing new cadres of community-based health practitioners
• Targeted recruitment and deployment to rural areas
• Financial incentives and family support

These interventions have increased the availability of health workers in rural areas, resulting in improved service delivery and health outcomes. Despite these efforts, challenges still persist, including:

• Limited female health worker mobility
• Retention of volunteer community-based health workforce
• Competition from the private sector
• Challenges of expanding the scope of practice of new cadres

Afghanistan's critical health workforce shortage is a result of historic underinvestment in education and training, migration, lack of infrastructure and equipment, and poor remuneration. Other challenges include a lack of opportunities for career advancement, staff absenteeism, moonlighting, and weak management. Ongoing insecurity, harsh geographical terrain, cultural and socioeconomic barriers have also contributed to the overall shortage, as well as gender and geographic imbalances in the health workforce.

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